Douglas DiRuggiero, PA-C, elaborates on specific components from his lecture, Unraveling Chronic Itch , 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 Lisa Weiss, DiRuggiero walks through how he characterizes chronic itch: quantifying it over the past week (nights woken up, activities skipped, and the NRS 0-to-10 scale), using Dr. Zirwas's mosquito-bite and poison-ivy analogies to gauge severity, and tracing the history back to where it started and how it spread. He stresses that elderly skin is "super charged for itch" — worse barrier, changing pH, falling filaggrin — so these patients can itch for no reason or a thousand reasons, and he starts a workup based on chronicity and presentation, always keeping bullous pemphigoid "until proven otherwise" in the back of his mind as the most common cause of undiagnosed chronic itch in the elderly.
He addresses polypharmacy by correlating itch onset with new medications (calcium channel blockers, hydrochlorothiazide, ACE inhibitors) within about a month to six weeks, and reminds clinicians to ask about herbs, vitamins, supplements, and OTC products too. On treatment, he resists the temptation to simply hand out a biologic sample before putting on his "thinking cap" — noting workup and management can proceed simultaneously — and lays out his oral efficacy ladder (mirtazapine, then gabapentin, then trazodone, then doxepin/hydroxyzine), the opioid nasal spray butorphanol, and his enthusiasm for the OTC topical strontium (Dermeleve) as "the most fantastic over-the-counter medication" of his career.
- Quantify itch over a week, not just 24 hours — ask how many nights it woke them, whether it kept them from falling asleep, and what common errands they skipped, then use mosquito-bite/poison-ivy analogies to grade severity.
- Trace the history: ask where the itch started, how bad it was, where it spread, and how it changed — when patients say they itch everywhere, you lose the classic textbook clues.
- In elderly chronic itch, bullous pemphigoid — often in its early urticarial, non-bullous phase — is the most common undiagnosed cause; keep your "spidey senses up" and consider BP180/230 antibodies or DIF.
- For polypharmacy, correlate itch onset to a new drug started within a month to six weeks, ask about OTC herbs/vitamins/supplements, and coordinate a drug-free trial of at least four (preferably six) weeks with the prescriber before re-challenging.
- Oral efficacy ladder: mirtazapine (start 7.5 mg) > gabapentin (start 300 mg) > trazodone (start 25 mg) > doxepin/hydroxyzine — watch sedation, falls, and dementia risk in the elderly; consider butorphanol nasal spray and the OTC topical strontium Dermeleve.
