For the past ten months I have been plagued by chronic itching all over my upper body. It is very bad and I get white blotches under the skin when I scratch. My GP doesn’t know what it is and just prescribed menthol in aqueous cream. But this only cools the skin. I have tried brushing my skin vigorously and antihistamine tablets, which did not help. The itching started after I returned from a trip to Australia via Bangkok, where I suffered a severe nose bleed in the airport and was in hospital for three days having lost two pints of blood.
Stewart Fothergill, Wareham, Dorset.
Kidney disease, liver diseases, disorders of the bone marrow and hormonal disorders can all cause itching
Pruritus – the medical term for an itch – is a symptom rather than a disease and is a complaint we GPs see all the time. It’s a feature of a number of skin disorders.
Scabies (a tiny mite which lays its eggs in the skin) can cause itch, as can urticaria (also known as hives or nettle rash), atopic eczema (an inherited skin condition which can be triggered by allergy), and contact dermatitis (caused by direct exposure to a substance that triggers an immune response, resulting in itching).
As well as skin disorders, there are other conditions that can cause itching. These include kidney disease causing renal failure (unlikely without your knowledge), a number of liver diseases, several disorders of the bone marrow and the blood system, hormonal disorders including thyroid disease and diabetes, and a number of auto‑immune diseases. It can also occur following shingles.
Certain medicines, such as salicylates (which include aspirin) and morphine, can also trigger it. If itching is the only symptom, what you describe suggests it’s urticaria, as the rash is itchy rather than painful and the white blotches you describe are also typical of this condition.
Acute urticaria comes on quickly, lasts 24 to 48 hours and is often triggered by an allergy or heat.
However, chronic urticaria – which lasts for weeks or longer, as in your case – is rarely caused by an allergy and so will not usually respond to antihistamines.
Exactly what causes it is poorly understood. It may be that the immune system attacks healthy tissues, triggering the release of inflammatory chemicals in the skin.
Treatments to suppress this immune response, such as steroid tablets or cyclosporine, can help suppress the maddening itching. However, in your case the question is whether the severe nosebleed could be related.
This is why you should have a blood test to both check the cell counts in your blood and your liver function, in order to look for the possibility of bone marrow disorders or liver disease. Your GP may already have done this.
What you need is an exact diagnosis of the cause. On occasions, the specialist skill and experience of a dermatologist is necessary to unravel the possibilities.
I have a spur growing out of my lower spine which, in turn, is pressing down and trapping a nerve, which is very painful. I have had this problem for about six months. I have been doing stretching exercises to no avail. Would it be feasible to get a surgeon to remove it? Painkillers are not helping.
B. Eggby, Whitstable, Kent.
The complaint you describe is not uncommon. The spur of bone has grown out from the lower part of the spine and is irritating a nerve root.
If symptoms do not improve with conservative treatment – such as stretching and other physiotherapy techniques – then there is a surgical technique that can be used to remove the spur and relieve your pain.
The idea of spinal surgery may be daunting, but it is a minimally-invasive procedure which involves making just an inch‑long incision to allow the surgeon to remove the spur. You would be up and about the next day and home almost at once.
These spurs occur on the spine as part of the body’s effort to repair normal wear and tear damage, often referred to as degenerative disease.
The five large bones or vertebrae that form the lower, or lumbar, spine carry the greatest load.
As a result, over the years there may be a gradual degeneration. The shock-absorbing discs in between each vertebra may wear out, for example, or a disc may herniate (often called a slipped disc) which means part of it squeezes out and puts pressure on the nerves in the spinal cord.
Some people may have grumbling pain due to this degeneration – often characterised as lumbago – whereas others will have no symptoms despite advanced damage.
Yet, in the long run, the inflammation this process causes triggers a repair process that in some cases, like yours, may involve new bone formation.
It’s simply the body’s attempts to bolster and strengthen the weakening spine. These bony growths are often called spurs because that’s what they look like on an X-ray. Often, these don’t cause pain, as there is space for a lumbar nerve to pass by without pressure. However, in other cases, such as yours, a nerve becomes trapped and irritated by the spur, causing pain.
The site of the pain will vary according to which nerve is being pinched or trapped by the spur: it can be in the lower back, or radiate into the buttock or leg on that side – the course of the irritated nerve. There may also be muscle weakness in part of the leg on that side.
Surgery is normally suggested only if there is weakness or muscle wasting, but persistent pain also justifies it.
If you have suffered for six months, then you may soon be offered surgery, as nerve root impingement that has persisted for this long (and especially any associated muscle weakness) is unlikely to spontaneously improve; that bony spur is not going to spontaneously clear, and may continue to grow.
A specialist will arrange a scan – typically a MRI – to confirm what’s going on.
I hope that you will not have to wait too long for expert assistance and that 2014 will see resolution for you.
By the way… GPs have to waste too much time on admin
As someone who works in the private sector and who, like most GPs, is driven by vocation and a sense of duty, a 48-hour week is the absolute minimum.
Even so, an ever-growing proportion of my working week is spent satisfying the demands of regulation: answering a litany of emails; dealing with the inadequacies, incompetence and misleading behaviour of the private health insurance world; and organising the increasing complexities of running a medical practice – much or most of which is amplified by political correctness and official trivia.
I now hear that clinical staff – nurses and doctors – in the NHS also expect to spend a quarter of their average working week collecting and checking data, according to a recent report from the NHS Confederation (the umbrella organisation that commissions NHS services).
It’s possibly a similar picture for junior doctors. Although data here is sparse, in the U.S. – where the medics enjoy better technology, proper administration support and smarter systems than those available in the ailing and cost-cutting NHS – a study found junior hospital doctors spend just 12 per cent of their time in direct patient care.
But they spent 60 per cent of it in indirect care (reviewing medical records, lab results, writing up notes), 15 per cent of their time on educational activities (lectures, conferences), and 5 per cent of their time walking around the hospital.
These figures compared with 20 per cent of time spent with patients 25 years ago.
I am certain that the figures will not be too different in the UK, and may well be worse.
Certainly, as a GP who can control his fate, I find that only half of my 16-hour working day is spent with patients; every other moment is spent on bureaucracy.
No wonder GPs no longer can manage house calls and night or weekend work.
This is the corner into which we have been steered, general practitioners and hospital doctors alike.
I fear for the future, and most of all I fear for the quality of patient care.