Breaking Down the ‘4 Horsemen of Itch’

“Itch is one of the most, if not the most, frequent symptoms we manage,” said Charlotte Lanphear, MPAS, PA-C, as she opened her session titled “The 4 Horsemen of Itch: Neuropathic, Neurogenic, Psychogenic, Cutaneous” at the Dermatology Week 2025 conference. Lanphear emphasized that while the terminology may sound ominous, understanding these itch subtypes can significantly improve diagnosis and treatment.

The session outlined 4 primary subtypes of pruritus—neuropathic, neurogenic, psychogenic, and cutaneous—each with distinct mechanisms, presentations, and management strategies.

Lanphear began with neuropathic pruritus, caused by direct damage to the central or peripheral nervous system. She described conditions such as brachioradial pruritus, notalgia paresthetica, postherpetic itch, and scalp pruritus—highlighting their spontaneous nature and lack of visible dermatitis. She shared real-world insights from her clinic, noting promising results from occipital nerve bupivacaine injections and compounded topicals with lidocaine, gabapentin, or ketamine. Oral agents like gabapentin and pregabalin are also options, although negative side effects like drowsiness can limit use.

Next, she discussed neurogenic itch, which arises from nerve signaling but follows an indirect inflammatory cascade. “For a long time, we lumped this in with neuropathic itch,” she said, but clarified they are now understood as distinct. Conditions like inducible urticaria, such as dermatographism, and cholinergic urticaria fall into this category. Lanphear illustrated how neuropeptides like substance P activate mast cells, releasing pruritogenic factors such as histamine and IL-31—now a target for therapies like nemolizumab.

Lanphear highlighted psychogenic pruritus as perhaps the most misunderstood type. Often rooted in or contributing to mental health disorders such as anxiety or OCD, psychogenic itch includes presentations like excoriation disorder. “These patients often come in saying they’re crazy itchy—not that they see bugs,” she noted, distinguishing it from delusions of parasitosis. She stressed the need for sensitive history-taking and interdisciplinary care, including psychiatric support and potential anti-anxiety medication adjustments.

Finally, cutaneous itch—seen in conditions like atopic dermatitis, psoriasis, lichen planus, and contact dermatitis—was mentioned as the most common but not always the most straightforward. The hallmark is visible primary skin lesions, often with secondary signs like lichenification and post-inflammatory pigmentation. Still, Lanphear cautioned that these secondary features can also appear in other itch subtypes.

Lanphear wrapped up with a detailed overview of treatment advances. From topical agents, such as  menthol and pramoxine, to systemic therapies like dupilumab, omalizumab, and the emerging biologics lebrikizumab and nemolizumab, she encouraged providers to consider newer options—especially when patients plateau on existing regimens. She also shared clinical pearls, such as using in-office intramuscular corticosteroids diagnostically to assess subtype responsiveness.

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Reference
Lanphear C. The 4 horsemen of itch: neuropathic, neurogenic, psychogenic, cutaneous. Presented at: Dermatology Week; May 14–16, 2025; Virtual.