FAQ: A message to health systems and payers: chronic itch is more than a skin problem

Chronic itch has often been dismissed as a minor skin complaint; however, experts view it as a warning sign of deeper disease and a driver of repeated health visits and rising costs. This FAQ explains why chronic itch and prurigo nodularis matter to managed care leaders and why many patients don’t always get the appropriate care.

FAQ 1: What is chronic itch?

Chronic itch is defined as itching that can last six weeks or longer that could occur with visible skin changes or with little to no rash at all, according to JAMA Network. While many people experience itch at some point, chronic itch can significantly disrupt sleep, daily functioning and mental health. Studies suggest nearly one in four adults experience chronic itch during their lifetime.

FAQ 2: Why is chronic itch so often misdiagnosed or undertreated?

According to Shawn Kwatra, M.D., chair of dermatology at the University of Maryland School of Medicine, chronic itch is commonly misdiagnosed because it’s still widely viewed as a benign dermatologic issue rather than a possible marker of serious disease.

When visible skin findings are small or absent, symptoms could be minimized by both patients and clinicians. This can delay appropriate evaluation and treatment, Kwatra noted, adding that chronic itch may reflect systemic inflammation neurologic disease or internal illness, not just a skin condition.

This delay can result in many patients cycling through topical treatments that do little to address the root cause.

FAQ 3: When is itch more than “just a skin problem”?

Persistent itch without a primary rash should raise red flags. Kwatra stressed that itch accompanied by sleep disruption, neuropathic sensations or other systemic symptoms should prompt further evaluation beyond dermatology.

Conditions that are commonly linked to chronic itch include:

1. Chronic kidney disease
2. Liver and biliary disease
3. Thyroid disorders
4. Hematologic disease including iron deficiency
5. Medication reactions
6. Neurologic injury or neuropathy

In these cases, itch may be one of the earliest or most persistent symptoms.

FAQ 4: What is prurigo nodularis, and why is it severe?

Prurigo nodularis is a chronic condition marked by intensely itchy firm nodules that usually appear on the arms, legs, back or trunk. Scratching worsens the lesions and reinforces a vicious itch-scratch cycle.

Research shows prurigo nodularis involves abnormal signaling between the immune system and the nervous system. Cytokines such as IL-31 play a direct role in triggering itch signals in the brain. This process of signaling explains why traditional medications or topical therapies tend to fail.

FAQ 5: Why does chronic itch drive repeated healthcare use?

Chronic itch affects much more than the skin. Patients often experience:

• Severe sleep disruption
• Anxiety and depression
• Difficulty working or concentrating
• Social withdrawal due to visible lesions

Kwatra pointed out that payers and health systems often underestimate the clinical and economic burden of chronic itch. Without coordinated care pathways, patients may bounce between primary care, urgent care dermatology and other specialties without a clear diagnosis or effective treatment plan.

This fragmented care contributes to delayed diagnosis, patient frustration and higher downstream costs.

FAQ 6: How is chronic itch evaluated?

Evaluation begins with a careful history and physical exam. If itch is widespread, persistent or has no clear cause, clinicians may order laboratory tests to assess for kidney, liver, thyroid or blood disorders.

For suspected prurigo nodularis, dermatologists may perform a skin biopsy to confirm the diagnosis and rule out other conditions.

FAQ 7: What treatments are available today?

Treatment depends on the underlying cause. General approaches include:

• Moisturizers and topical anti-inflammatory agents
• Treatment of underlying systemic disease
• Behavioral strategies to reduce scratching

For conditions such as prurigo nodularis, newer therapies target the immune and nerve pathways that drive itch. These advances may improve outcomes but also raise questions about access, coverage and cost management.

FAQ 8: What should payers and health systems take away?

Kwatra discussed that the absence of coordinated care pathways for chronic itch leads to missed diagnoses, delayed treatment and unnecessary utilization.

Key considerations include:

• Recognizing itch as a potential marker of serious disease
• Avoiding dismissal of symptoms when skin findings are minimal
• Improving referral pathways across specialties
• Preparing for emerging targeted therapies

Chronic itch exposes gaps in how health systems recognize and manage a significant amount of symptoms that cross specialties. Treating itch as a meaningful clinical warning sign rather than a minor complaint may improve outcomes, reduce fragmentation and lower long-term costs.

This FAQ was reviewed and approved for publishing by Kwatra.