By Gary M. White, MD
This middle-aged man has been plagued for 8 months with intense itching on the left side of his scalp. He scratches incessantly causing some hair loss.
Itching or burning of the scalp is a very common skin complaint and most commonly is due to seborrheic dermatitis or psoriasis. Scalp dysesthesia or burning scalp syndrome is characterized by burning, itching and/or stinging of the scalp in the absence of any primary skin disorder. Stressful life events, anxiety and depression have been associated with scalp dysesthesia.
Pruritus of the scalp is a common complaint of older adults. As with any pruritus, physical examination should be performed to rule out any skin changes e.g. pustules, pediculosis, psoriasis, seborrheic dermatitis, allergic contact dermatitis and even lichen simplex chronicus.
Chronic severe scalp pruritus with or without excoriation in the absence of any other skin changes, especially in an elderly person has been termed scalp dysesthesia. In one report of 11 women with chronic severe burning, stinging or itching of the scalp, five of them had physician-diagnosed disorders including dysthymic disorder, generalized anxiety and somatization [AD 1998;134;327]. Cervical spine diseases (C5-6) has been associated with scalp dysesthesia. It may be that nerve impingement is causative, or that chronic muscle tension related to the cervical disease leads to cutaneous symptoms. Facial or brow lift is associated with chronic scalp pruritus and is thought due to surgical trauma to the superficial nerves.
Of note, androgenetic alopecia has been reported to cause scalp itching, burning, tenderness or other uncomfortable sensations in a small percent [AD 1960;81;108]. Rarely, temporal arteritis could be considered.
If no scalp changes are present, a mild case of seborrheic dermatitis may be considered. A potent topical steroid solution (e.g. clobetasol) bid should be tried. If this is unsuccessful, antihistamines, doxepin or a tricyclic antidepressant may be tried.
In the report concerning scalp dysesthesia, many of the patients responded to low-dose doxepin or amitriptyline. Gabapentin and tricyclic antidepressants may be tried.
One patient of mine with localized itch of the scalp, daily scratching and mostly excoriations on exam was cured after 3 weeks of not touching the area. Diagnosis: Habit and lichen simplex chronicus.
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