Aquagenic pruritus

Aquagenic pruritus
Aquagenic pruritus
Specialty	Dermatology

Aquagenic pruritus is a skin condition characterized by the development of severe, intense, prickling-like epidermal itching without observable skin lesions and evoked by contact with water.^[1]^[2]

Presentation

Presentation varies from person to person. Some people have discrete attacks, which can last between 10 and 120 minutes^[3] while others are symptomatic almost constantly due to atmospheric humidity levels and/or sweating. Itching most frequently occurs on the legs, arms, chest, back, and abdomen, though it can also occur elsewhere.^[4]

Itching on contact with water that also includes hives is known as aquagenic urticaria.

Pathogenesis

The exact mechanism of the condition is unknown. Some studies have suggested the itching occurs in response to increased fibrinolytic activity in the skin,^[5]^[6] inappropriate activation of the sympathetic nervous system,^[7] increased activity of acetylcholinesterase,^[8]^[9] or an increase in mast cell degranulation that releases histamine and other chemicals into the body.^[10]

Diagnosis

No definitive medical test is known for aquagenic pruritus. Rather, diagnosis is made by excluding all other possible causes of the patient's itching, including polycythemia vera. Since pruritus is a symptom of many serious diseases, it is important to rule out other causes before making a final diagnosis.^[11]

Treatment

Beta-Alanine, a nonessential amino acid and freely available as a nutritional supplement in many countries, has been found to suppress or significantly reduce the symptoms in many cases.^[12] Anecdotal evidence indicates that it is commonly consumed in doses of 750 mg to 2 grams before water contact.^[13] A study found that a dose of 2 grams twice per day led to a "dramatic and sustained improvement" of symptoms in a 13-year-old male patient, allowing him to comfortably shower, exercise, and swim.^[12]

Other treatment is usually focused on topical itch management. This can be effected by the application of hot water at the end of a bath or shower, antipruritic lotions or creams such as lotion containing capsaicin, using phototherapy, or the application of hot or cold packs to the skin after water contact.^[14] Paradoxically, hot baths or showers help many patients, possibly because heat causes mast cells in the skin to release their supply of histamine and to remain depleted for up to 24 hours afterward.^[15]^[16]

H1 and H2 blockers, such as loratadine, doxepin, or cimetidine, have historically been the first line of pharmacological treatment, but not all people find relief with these medications. When antihistamines do work, loratadine seems to be the most effective for mild cases and doxepin most effective for more severe cases.

Naltrexone, hydrocortisone, or propranolol may relieve itching for some people.^[17]^[7]

Sertraline or other Selective serotonin reuptake inhibitors (SSRIs) is also a line of treatment. Gabapentin is very helpful.

Etymology

The name is derived from Latin: aquagenic, meaning water-induced, and pruritus, meaning itch.

References

^ Freedberg IM, Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI, eds. (2003). Fitzpatrick's Dermatology in General Medicine (6th ed.). McGraw-Hill. p. 401. ISBN 978-0-07-138066-9.
^ James WD, Berger TG, Elston DM (2005). Andrews' Diseases of the Skin: Clinical Dermatology (10th ed.). Saunders. p. 56. ISBN 978-0-7216-2921-6.
^ Steinman HK, Greaves MW (July 1985). "Aquagenic pruritus". Journal of the American Academy of Dermatology. 13 (1): 91–96. doi:10.1016/S0190-9622(85)70149-1. PMID 2411768.
^ "Aquagenic pruritus". U.S. Department of Health and Human Services.
^ Sekar CS, Srinivas CR, Jacob S (July 2011). "Aquagenic pruritus: beneath water "lies"". Indian Journal of Dermatology. 56 (4): 446–447. doi:10.4103/0019-5154.84734. PMC 3179019. PMID 21965864.
^ Lotti T, Steinman HK, Greaves MW, Fabbri P, Brunetti L, Panconesi E (October 1986). "Increased cutaneous fibrinolytic activity in aquagenic pruritus". International Journal of Dermatology. 25 (8): 508–510. doi:10.1111/j.1365-4362.1986.tb00863.x. PMID 3771051. S2CID 41847126.
^ ^a ^b Nosbaum A, Pecquet C, Bayrou O, Amsler E, Nicolas JF, Bérard F, Francès C (November 2011). "Treatment with propranolol of 6 patients with idiopathic aquagenic pruritus". The Journal of Allergy and Clinical Immunology. 128 (5): 1113. doi:10.1016/j.jaci.2011.05.001. PMID 21616525.
^ Bircher AJ, Meier-Ruge W (January 1988). "Aquagenic pruritus. Water-induced activation of acetylcholinesterase". Archives of Dermatology. 124 (1): 84–89. doi:10.1001/archderm.1988.01670010048020. PMID 3337547.
^ Kligman AM, Greaves MW, Steinman H (February 1986). "Water-induced itching without cutaneous signs. Aquagenic pruritus". Archives of Dermatology. 122 (2): 183–186. doi:10.1001/archderm.1986.01660140073021. PMID 3947125.
^ "Aquagenic pruritus | Genetic and Rare Diseases Information Center (GARD) – an NCATS Program". rarediseases.info.nih.gov. Retrieved 2020-12-03.
^ Butler DF (Aug 17, 2018). James WD (ed.). "Pruritus and Systemic Disease". Medscape.
^ ^a ^b Friedlander MS, Admani S (January 2021). "Aquagenic pruritus in an adolescent effectively managed with β-alanine supplementation". Pediatric Dermatology. 38 (1): 320–321. doi:10.1111/pde.14440. PMID 33170524. S2CID 226297428.
^ https://www.facebook.com/groups/230640150306723/ ^{[user-generated source]}
^ Holme SA, Anstey AV (January 2001). "Aquagenic pruritus responding to intermittent photochemotherapy". Clinical and Experimental Dermatology. 26 (1): 40–41. doi:10.1046/j.1365-2230.2001.00757.x. PMID 11260176. S2CID 7564543.
^ People's Pharmacy (2012-06-18). "Hot Water for Itches". Retrieved 25 July 2012.
^ Sulzberger MB (1961). Dermatology: Diagnosis and Treatment (2nd ed.). Chicago: Year Book Publishers. p. 94. ISBN 978-0801648083. Retrieved 11 September 2018.
^ Ingber S, Cohen PD (October 2005). "Successful treatment of refractory aquagenic pruritus with naltrexone". Journal of Cutaneous Medicine and Surgery. 9 (5): 215–216. doi:10.1007/s10227-005-0144-x. PMID 16502200. S2CID 24439125.