AQUAGENIC PRURITUS: BENEATH WATER “LIES”
Aquagenic pruritus is a skin disease characterized by the development of severe itching on contact with water without observable skin lesions. The symptoms may be felt immediately after contact with water and can persist for an hour or longer. In some families, a tendency toward aquagenic pruritus appears to be hereditary. It may sometimes be a symptom of primary polycythemia or polycythemia vera. It has also been linked to several conditions such as juvenile xanthogranuloma, myelodysplastic syndrome, T-cell non-Hodgkin’s lymphoma, hepatitis C infection, drugs like bupropion and idiopathic hypereosinophilic syndrome. It can exert a psychological effect to the extent of abandoning bathing or developing phobia to bathing. We report this case as psychological factors played a role in inciting the condition.
A 38-year-old woman presented with a 6-year history of pruritus predominantly over the lower half of the body after bathing. The pruritus usually started within a minute and regressed after an hour. Itching was precipitated by cold water, and bathing in lukewarm water gave temporary relief. The pruritus was not associated with any urticarial wheals. The patient was not relieved with various antihistamines since 5 years. She had associated headache and breast tenderness more during the premenstrual period. Her complete blood count, liver and renal function tests were within normal limits. She was treated with antipruritic lotion (combination of menthol, calamine and camphor). Her symptoms improved the next day but exacerbated the following day. Since her symptoms were exaggerated and did not respond to conventional treatment, a psychiatric opinion was sought. The psychiatrist was able to elicit history of multiple premarital contacts few years back about which she felt guilty. She was married for 7 years. She was diagnosed to have venerophobia with hypochondriasis and severe depression. Venereal Disease Research Laboratory (VDRL) test, HIV I and II antibodies were negative. She was then started on Tab. Sertraline 50 mg and Tab. Quetiapine 200 mg and the patient improved. Patient was simultaneously started on psoralen ultraviolet A (PUVA) and antihistamines were continued. Visual analogue scale for pruritus was taken before and few days after the treatment and she showed marked improvement. The patient was discharged on PUVASOL and antidepressants. On follow-up, her symptoms had subsided.
Aquagenic pruritus is a distressing condition for both the patients and the treating physician. The exact pathogenesis of aquagenic pruritus is unknown. According to Greaves et al., pharmacological studies have shown that aquagenic pruritus is associated with local release of acetylcholine in the skin, mast cell degranulation, and raised blood histamine concentrations as well as with increased cutaneous fibrinolytic activity, both before and after contact with water, which could explain the lack of wheal formation in this condition. Cold is a widely recognized cause of degranulation of mast cells, whether in the skin or lungs or elsewhere, which may be a strong factor in this condition.
Various therapeutic modalities have been tried to relieve pruritus. Antihistamines are the mainstay of treatment. Greaves et al. have observed that H1 antihistamine with or without H2 antihistamine was effective in this disorder. Topical hyoscine has also been proven to be effective in relieving the pruritus. Wolf et al. reported that sodium bicarbonate added to bath water may also be helpful. Koh et al. have reported that UVB phototherapy along with PUVA therapy has been effective in this condition. Ingber et al. have treated a resistant case with naltrexone.
The psychological aspect as a cause in aquagenic pruritus is hitherto unexplored. Guilt is a cognitive or an emotional experience that occurs when a person realizes or believes that they have violated a moral standard, and is responsible for that violation. Our patient had premarital contacts which made her feel guilty. According to Sigmond Freud, “the sense of guilt makes itself noisily heard in consciousness resulting in diverse forms of self-punishment, the ‘moral masochism’”. Aquagenic pruritus could have been the somatic manifestation of the depressive disorder which improved with treatment.
We report this case primarily to highlight the fact that psychological disorders may present with features highly suggestive of known clinical entity.
Original Article: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3179019/