Dr. Constantino Costarangos P. Medicina Interna (St. Agnes Hospital, Baltimore, Md.) Dermatología...
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Transcript of Dr. Constantino Costarangos P. Medicina Interna (St. Agnes Hospital, Baltimore, Md.) Dermatología...
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EVALUACIÓN DEL PACIENTE CON PRURITO
Dr. Constantino Costarangos P.Medicina Interna
(St. Agnes Hospital, Baltimore, Md.)Dermatología
(The Johns Hopkins Hospital, Baltimore, Md.)
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PRURITO
Hormigueo o irritación de la piel al rascarse.
Es una sensación de naturaleza subjetiva.Prurito crónico , picazón de más de 6
semanas.Histamina, es el mediador más conocido.
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Condiciones Asociadas a Prurito1. INFLAMATORIAS
• Asteatosis (piel reseca)• Dermatitis atópica y seborreica.• Dermatitis de contacto (irritante/fibra de vidrio y alérgica).• Dermatografismo.• Lichen simplex crónicus.• Lichen planus.• Psoriasis.• Reacción o hipersensibilidad a medicamento.• Urticaria. • Mastositosis.• Quemadura solar.• Pititriasis rosadas.
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Condiciones Asociadas a Prurito
2. INFESTACIONES• Escabiosis.• Pediculosis.• Picaduras de insectos.• Parásitos.
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Condiciones Asociadas a Prurito
3. INFECCIONES• Impétigo.• Varicela.• Candidiasis• Dermatofitosis.• Foliculitis.
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Condiciones Asociadas a Prurito
4. NEOPLÁSICOS
• Linfoma cutáneo de célula T.
• Linfoma cutáneo de célula B.
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Condiciones Asociadas a Prurito
5. EMBARAZOS• Penfigoide gestacional.• Erupción polimórfica del embarazo.• Prurigo gestacional.
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Causas Sistémicas Asociadas a Pruritos
1. RENAL• Insuficiencia renal crónica.• Hemodiálisis crónica.
2. HEPATOBILIAR• Obstrucción biliar.• Cirrosis biliar primaria.• Colestasis durante el embarazo.• Enfermedad hepática.
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Causas Sistémicas Asociadas a Pruritos
3. ENDOCRINO• Diabetes mellitus.• Insuficiencia adrenal.• Hipotiroidismo.• Hipertiroidismo.• Prurito peri menopaúsico.
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Causas Sistémicas Asociadas a Pruritos
4. INFECCIOSO
• VIH• Exantema viral.
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Causas Sistémicas Asociadas a Pruritos
5. HEMATOLÓGICO• Policitemia vera.• Deficiencia de hierro.• Paraproteinemia.• Macroglobulinemia (Waldenstrom).
6. PSICOGÉNICA • Prurito psicogénico.• Escoriación neurótica. • Delusión parasitaria.
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Causas Sistémicas Asociadas a Pruritos7. MEDICAMENTOS• Opioides.• Simvastatina.• Hidroclortiacida, furosemida. • Estrógeno, progesterona, testosterona.• Alopurinol.• Complejo B (vitamina) / vitamina A.• Antimalarial.• Aspirina.• Hormonas anabólicas.• Inhibidores de la enzima convertidora de
angiotensina.• Fenotiacinas. • Sulfas / penicilina.• Amiodarona.
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Causas Sistémicas Asociadas a Pruritos
8. NEUROLÓGICOS
• Esclerosis múltiple.• Absceso.• Infarto.• Tumores.
9. PSIQUIÁTRICA
• Desordenes de ansiedad.• Depresión • Desorden obsesivo-compulsivo.
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Causas Anecdóticas de Pruritos • Anhidrosis.• Intoxicación de café.• Bananas.• Hemocromatosis .• Sarcoidosis.• Prurito premenstrual.• Síndrome de Sjögren.• Alergia al sudor.• Alergia al semen.
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DIAGNOSTICO
1. Historia.2. Revisión de sistemas.3. Examen físico.4. Laboratorios.
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1. Historia• Generalizado versus localizado.• Comienzo, diurno-nocturno.• Historia familiar de atopia.• Exposición (fibra de vidrio, polvo, químicos y a
otras personas con picazón).• Ocupación.• Medicamentos.• Historia sexual, transfusión y de medicamentos
intravenosos (VIH o Hepatitis).• Historia de estrés/psiquiatrica.
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2. Revisión de Sistemas• Salud general (fiebre, escalofrió y perdida de peso).• Piel (pigmentación, sudoración, asteatosis y
ictericia).• Ojos (exoftalmos).• Endocrino.• Gastrointestinal.• Genitourinario.• Hematopoyético. • Neurológico.• Mental.
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3. Examen físico• Escoriaciones.• Pápulas, nódulos y placas liquenificadas.• Ictericia.• Examen de la espalda (superior media).• Infestación parasitaria (escabiosis / piojos).• Examen de nódulos linfáticos, hígado y bazo.
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4. Laboratorios• Hemograma completo.• Creatinina / Nitrógeno de urea.• Anticuerpos a Hepatitis C.• Prueba funcionales hepáticas.• TSH / T4• Glicemia en ayunas / hemoglobina . • VIH.• Velocidad de eritrosedimentación.• Examen de heces (sangre oculta / parásitos).• Rayos X de tórax.• Papanicolau• Exámenes adicionales:
• Panel alérgico.• Biopsia de piel: de rutina y por inmunofluorescencia
(dermatitis herpetiformis / penfigoide); tinción especial para excluir mastocitosis.
• Ferritina sérica. Proteina e inmunofluorescencia sérica.• Endoscopia. • Tomografía computarizada.
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TRATAMIENTO1. Tópicos:
Humectantes. Esteroides tópicos. Antipruriticos.
2. Sistémicos: Antihistamínicos. Cortico esteroides. Antagonista del receptor opioide.
3. Fototerapia: Luz ultravioleta B / Luz ultravioleta A.
4. Misceláneos: Acupuntura.