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Dr. Zirwas Lecture Rewind: Handling the Patient that is Itchy and Scratchy with no Rash?

At last month’s 9th Annual Fall Conference in Orlando, we had the opportunity to listen to Dr. Matthew Zirwas share his thoughts on the following topic: “What do we do with patient that is itchy and scratchy, but has no rash?”  
Here is just a short snapshot from Dr. Zirwas’ session.  Stay tuned for the entire audio podcast of Dr. Zirwas’ lecture series on Dermcast!
As Derm PAs and MDs, we’ve all been there, and we’ve wanted to run and hide. Inevitably, a patient will come in complaining of horrible itching, but they have no visible rash.  Dr. Zirwas encourages us to always step back and let the patient tell their story.  As Derm PAs, sometimes we even have to schedule in extra time in order to give such patients ample time to talk.  
Dr. Zirwas notes that SSRIs and SNRIs can sometimes be effective in treating the “mystery itching” symptoms of a patient with no rash.  
Let’s review some general points about SSRIs and SNRIs:
+ SNRIs are typically good for anxiety and to probe for decreasing abnormal sensations.
+ SSRIs tend to be more helpful if we are just trying to reduce anxiety (except paroxetine which seems to have specific anti-pruritic effects).
+ Remind patients being treated with SNRIs and SSRIs that they may experience withdrawal symptoms if suddenly stopped.  These symptoms may be unpleasant but are not typically dangerous.
But what if we feel our patient should see a therapist?  How do we handle this?
Dr. Zirwas notes that we should never tell a patient that their brain is giving them a skin problem, even if we suspect that their symptoms may be related to a psychological problem.  The approach we should pursue is simply this: “I see a lot of patients like you and it causes so much stress, anxiety, and depression. If this isn’t really bothering you, it’s almost abnormal!  I think it would really help for you to see a therapist.”  
[image by takomabibelot]

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