In this video blog, Aaron Ver Heul, MD, discusses highlights from his lecture, Case From My Career: Lessons Learned From My Itchy Patients, on July 27, 2024, during the inaugural Elevate-Derm Alliance Summer Conference at the Westin Copley Place in Boston, Massachusetts.

In this video

Dr. Ver Heul explains that itchy patients are usually straightforward when there's a clear rash pointing to atopic dermatitis or psoriasis, or an obvious systemic cause like a hemodialysis patient with uremic pruritus. The tricky cases are the ones where a rash isn't responding to typical dermatologic treatment, or where primary itch — systemic or idiopathic — leads to scratching and secondary lesions that are hard to distinguish from a primary dermatologic process, clinically or on biopsy. Because chronic itch patients skew older, he stresses a careful history and physical and a willingness to run a broad workup so as not to miss malignancy, worsening renal disease, or hepatic disease.

Coming at itch as an allergist — where "everything's probably mast cell mediated and histamine mediated" — he leans on the distinction between histaminergic and non-histaminergic itch. His first stop is having patients ramp up antihistamines: relief suggests an allergic, mast cell, or urticarial itch, while no response points him toward neuropathic or more T-cell/immune-pathway itch like atopic dermatitis. He also discusses weight-based dosing of omalizumab, noting that the urticaria trials used two fixed doses regardless of weight — likely a mistake — and that pushing the dose in higher-BMI non-responders is now one of his go-to strategies.

  • The hardest itch cases are the mixed ones — a rash plus systemic disease that isn't responding as expected, or primary itch complicated by secondary excoriations.
  • Older chronic itch patients warrant a broad workup: basic labs (CBC, CMP, LDH) to screen for malignancy and renal or hepatic disease, with history-driven testing like 24-hour mast cell urinary metabolites only when there's a specific clue.
  • Use antihistamine response as a first diagnostic step — relief suggests histaminergic (allergic/mast cell/urticarial) itch, while no response points toward neuropathic or immune-pathway itch.
  • Refer to an itch specialist when something doesn't add up — e.g., presumed atopic dermatitis whose itch isn't responding as it should — especially if you're not comfortable doing the workup yourself.
  • With omalizumab, higher-BMI patients who respond only partially to the fixed label dose often improve when the dose is pushed higher; growing case-report evidence supports weight-informed dosing beyond label.