Lauren Madigan, MD, discusses highlights from the panel discussion Complex Medical Dermatology: Top Diagnoses You Can't Afford to Miss at the 2nd Annual Elevate-Derm Alliance Summer Conference at the Grand Hyatt Deer Valley in Park City, Utah.

In this video

In conversation with dermatology NP Veronica Richardson, Dr. Madigan tackles the patient with pruritus, noting that while excellent, fast-acting itch treatments now exist, clinicians shouldn't "jump the gun" before doing their due diligence. She frames itch "in boxes": itch with a rash (including cryptic or subclinical rashes like early pemphigoid or dermatographism), metabolic derangements such as thyroid or liver dysfunction, malignancies including lymphoma and other hematologic cancers, medications and illicit substances, psychological contributors, and neurologic itch — reminding that roughly one in five patients with chronic itch has a systemic cause.

She flags neurologic itch as its own big camp, with localized or patterned distributions in classic neural territories as a useful clue, and describes pursuing imaging or neurology referral when a patient has other symptoms — like the case presented with dysarthria and ataxia — or no known cause. Drawing on training under itch guru Tim Berger at UCSF, she urges considering DIF, ELISA, or serum studies for prebullous pemphigoid in older patients with new refractory itch, calling directed therapy "life-changing" for those cases. Her closing point: when a patient isn't responding as expected, put the thinking cap back on rather than reflexively moving to the next drug.

  • Itch without a rash deserves a long, thoughtful visit — full exam, careful history, and a solid review of systems — because for many patients itch is the presenting sign of systemic disease.
  • Roughly one in five patients with chronic itch has a systemic cause; think in boxes: cryptic rashes, metabolic derangements (thyroid, liver), malignancy/lymphoma, medications and illicit substances, psychiatric contributors, and neurologic itch.
  • In the first 12 months of new itch, ask about B symptoms and consider screening like chest x-ray to avoid missing lymphoma and other hematologic malignancies.
  • Consider biopsy for H&E and DIF — plus ELISA or serum studies — to catch invisible mycosis fungoides or prebullous pemphigoid, especially in older patients with new itch, where directed therapy can be life-changing.
  • Localized or patterned itch in classic neural distributions points toward neurologic causes; pursue imaging or neurology when there's no known cause or additional neurologic symptoms.
  • When a patient isn't responding as anticipated, pause and re-investigate the diagnosis rather than reflexively moving to the next treatment.