Chronic pruritus is itching that lasts for more than 6 weeks and is a common but underdiagnosed symptom in clinical practice. It can be a secondary symptom of primary dermatological disease, systemic disease, neurological dysfunction, psychiatric disorders, drug reactions, or may be idiopathic following evaluation. The International Forum for the Study of Itch classified chronic pruritus based on clinical presentation and underlying cause, and highlighted that it is a symptom with multiple etiologies and not a single disease entity [1].

Chronic pruritus is especially common in elderly people due to age-related changes in the skin, decreased epidermal barrier function, decreased lipid content, altered immune response, xerosis, multiple comorbidities, and polypharmacy. It is one of the most frequent causes of itch in older adults and can occur in conjunction with eczematous dermatitis, asteatotic eczema, stasis dermatitis, scabies, fungal infections and other inflammatory dermatoses [2,3]. Thus, in geriatric patients, pruritus can be caused by several overlapping factors, and clinical evaluation can be difficult.

Chronic pruritus is prevalent and has a significant disease burden in population-based studies. In a German population-based study, Matterne et al. found a point prevalence of 13.5%, 12-month prevalence of 16.4% and lifetime prevalence of 22.0% [4]. In older adults, more recent data from the Rotterdam Study revealed prevalences of current, 12-month and lifetime chronic pruritus of 8.6%, 10.5% and 18.6%, respectively, and associations with female sex, older age, smoking, atopic dermatitis, psoriasis, dry skin, asthma, steatotic liver disease, polyneuropathy, depressive symptoms, anxiety and poor sleep [5].

This symptom is also clinically significant in geriatric-specific studies. Günther et al. investigated 201 geriatric patients (mean age 83.5 years) and found chronic pruritus in 23.4% of patients, with a mean duration of 8 years and moderate to severe itch intensity. Legs and arms were frequently involved, and chronic pruritus was linked to depressive symptoms, daily medication use, impaired physical function and decreased itch-related quality of life [6]. This means that chronic pruritus in elderly patients is not a trivial symptom, but a chronic condition with physical, psychological and functional consequences.

Chronic pruritus in elderly patients has a wide etiological spectrum. Dermatological causes include xerosis, eczema, psoriasis, urticaria, lichen simplex chronicus, prurigo, infestations, fungal infections and malignancy associated dermatoses. Systemic causes include chronic kidney disease, cholestatic liver disease, diabetes mellitus, thyroid disorders, iron deficiency, hematological disorders, and malignancies. In older age groups, neuropathic causes like diabetic neuropathy, post-herpetic neuralgia, brachioradial pruritus and notalgia paresthetica are also relevant [7].

Psychogenic factors, depression, anxiety and sleep disturbance may exacerbate the perception of itch and contribute to the itch–scratch cycle.

Clinical and laboratory evaluation is important because chronic pruritus may be the presenting symptom of an underlying systemic disease. Aboeldahab et al. assessed elderly patients with pruritus and found that generalized itching was frequent and that dermatological and systemic associations could be found in many of these patients [8]. The work-up of an elderly patient should therefore be based on careful history, thorough skin examination, drug history, evaluation of comorbidities, and selected laboratory investigations based on clinical suspicion.

Chronic pruritus also significantly impacts quality of life. It can affect sleep, daily life, emotional health, focus and social interaction. The severity of itch, not just the presence of pruritus, seems to be an important factor in determining impairment of quality of life [4,5]. These effects may be exacerbated by frailty, decreased mobility, dependence, cognitive impairment, and multiple chronic conditions in older adults.

Although it is clinically relevant, there is still a lack of regional hospital-based data on chronic pruritus in elderly patients, particularly in tertiary care centers where patients frequently present with a combination of dermatological and systemic diseases. The aim of the present study was to estimate the prevalence of chronic pruritus and to identify the etiological factors. Knowledge of the clinical pattern and underlying causes may help to improve the diagnostic evaluation, targeted treatment and quality of life in elderly patients with chronic pruritus.

Study design and setting This prospective observational study was conducted at a tertiary care centre from 1 August 2025 to 1 May 2026. A total of 300 elderly patients were evaluated to determine the prevalence, clinical pattern, etiological profile, and associated factors of chronic pruritus. Study population Patients aged 60 years and above attending the tertiary care centre during the study period were included. Chronic pruritus was defined as pruritus persisting for more than six weeks. Patients were categorized into two groups: those with chronic pruritus and those without chronic pruritus. Patients with incomplete clinical evaluation or insufficient data for assessment of pruritus status, comorbidities, or etiological classification were excluded. Clinical assessment and data collection Demographic and clinical data were recorded, including age, sex, residence, comorbidities, medication count, polypharmacy, xerosis, diabetes mellitus, hypertension, chronic kidney disease, liver/cholestatic disease, thyroid disorder, iron deficiency anemia, neuropathy, and other relevant systemic conditions. Polypharmacy was defined as the use of five or more medications. Among patients with chronic pruritus, details regarding duration, distribution, severity, nocturnal predominance, winter aggravation, sleep disturbance, xerosis, excoriations, and lichenification were documented. Pruritus severity and quality-of-life assessment Pruritus severity was assessed using the Visual Analogue Scale (VAS) and classified as mild, moderate, or severe. Quality-of-life impairment was assessed using the Dermatology Life Quality Index (DLQI). Large or very large quality-of-life impairment was categorized according to DLQI severity interpretation. Etiological classification The probable etiology of chronic pruritus was assigned after clinical evaluation and relevant investigations. Etiologies were classified as dermatological, systemic, mixed, idiopathic, drug-related, neuropathic, or psychogenic. Xerosis was recorded separately because of its clinical relevance in elderly patients. Outcome measures The primary outcome was the prevalence of chronic pruritus among elderly patients. Secondary outcomes included etiological distribution, clinical pattern, pruritus severity, sleep disturbance, DLQI score, quality-of-life impairment, and factors independently associated with chronic pruritus. Statistical analysis Continuous variables were presented as mean ± standard deviation or median (interquartile range), and categorical variables as frequency and percentage. A 95% confidence interval was used to calculate the prevalence of chronic pruritus. Welch’s t-test was used for comparison of continuous variables between patients with and without chronic pruritus, and the chi-square test was used for categorical variables. For chronic pruritus cases, comparisons between severity groups were made using Kruskal–Wallis test for DLQI scores and chi-square test for categorical burden indicators. Pearson and Spearman correlation analyses were used to assess the association between VAS and DLQI scores. t-test and chi-square test were used for comparisons based on sleep disturbance for continuous and categorical variables, respectively. Independent factors associated with chronic pruritus were identified by multivariable logistic regression. Adjusted odds ratios with 95% confidence intervals were calculated. A p-value <0.05 was considered statistically significant. Ethical considerations The study was carried out with the approval of the Institutional Ethics Committee of the tertiary care centre. All participants signed informed consent forms and confidentiality of patient information was respected during the study.

Study cohort and prevalence

A total of 300 elderly patients were evaluated during the study period. Chronic pruritus was identified in 128 (42.7%) patients, with an estimated prevalence of 42.7% (95% CI 37.2%–48.3%). Baseline characteristics according to chronic pruritus status are summarized in Table 1. Patients with chronic pruritus were older and had a higher burden of xerosis, polypharmacy, diabetes mellitus, chronic kidney disease, and selected systemic comorbidities, while sex and residence were not significantly different between groups.

Table 1. Baseline characteristics according to chronic pruritus status

Values are presented as mean ± SD or n (%). Welch’s t-test was used for continuous variables and the chi-square test for categorical variables.

Clinical pattern and etiological profile of chronic pruritus

Clinical patterns among patients with chronic pruritus are presented in Table 2. Most patients had persistent symptoms for several months, with generalized distribution and moderate-to-severe intensity forming the dominant clinical pattern. Dermatological causes constituted the largest etiological group, followed by systemic and mixed etiologies; the etiological distribution is illustrated in Figure 1. Xerosis was a frequent accompanying finding and was commonly recorded either as a primary or contributory factor.

Table 2. Clinical pattern and etiological classification among patients with chronic pruritus

VAS, Visual Analogue Scale; DLQI, Dermatology Life Quality Index; QoL, quality of life.

Factors associated with chronic pruritus

Multivariable analysis is shown in Table 3. Increasing age, xerosis, polypharmacy, diabetes mellitus, and chronic kidney disease remained independently associated with chronic pruritus. Among these variables, xerosis and chronic kidney disease showed the strongest adjusted associations.

Table 3. Multivariable logistic regression for factors associated with chronic pruritus

Adjusted odds ratios were estimated using multivariable logistic regression. OR, odds ratio; CI, confidence interval.

Pruritus severity, sleep disturbance, and quality-of-life impairment

The clinical impact of chronic pruritus increased with symptom severity (Table 4). Higher pruritus severity was associated with higher DLQI scores, more frequent sleep disturbance, and greater quality-of-life impairment. A strong positive association was observed between VAS score and DLQI score, indicating that increasing itch intensity was closely linked to worsening quality of life (Figure 2).

Table 4. Clinical impact according to pruritus severity among chronic pruritus cases

DLQI was compared using the Kruskal–Wallis test; categorical variables were compared using the chi-square test.

Scatterplot showing the relationship between VAS pruritus score and DLQI score among patients with chronic pruritus. The fitted line demonstrates a positive association between itch severity and quality-of-life impairment.

Additional Predictive and Burden Analyses

To complement the main multivariable model, an additional clinically oriented regression analysis was performed using categorical exposure variables that are easier to interpret in routine practice, including age ≥75 years, comorbidities, polypharmacy, and xerosis. This analysis confirmed that older age, diabetes mellitus, chronic kidney disease, polypharmacy, and xerosis remained independently associated with chronic pruritus after adjustment for overlapping clinical factors (Table 5). In addition, exploratory burden analyses were performed among patients with chronic pruritus to quantify the relationship between itch intensity, sleep disturbance, scratch-related skin findings, and quality-of-life impairment. These findings are summarized in Table 6 and support the clinical relevance of assessing both symptom severity and associated functional burden.

Table 5. Multivariable predictors of chronic pruritus among elderly patients

Adjusted odds ratios were estimated using multivariable logistic regression.

Table 6. Clinical burden indicators among patients with chronic pruritus

VAS, Visual Analogue Scale; DLQI, Dermatology Life Quality Index.

In this prospective observational study of 300 elderly patients, chronic pruritus was found in 128 patients, with a prevalence of 42.7%. Patients with chronic pruritus were older and had significantly higher prevalence of xerosis, diabetes mellitus, hypertension, chronic kidney disease, liver/cholestatic disease, thyroid disorder, neuropathy, and polypharmacy. In chronic pruritus cases, symptoms were often persistent, generalized, nocturnal, and moderate to severe. The most common etiological group was dermatological, followed by systemic and mixed causes. There was a strong correlation between the severity of pruritus and sleep disturbance and quality of life impairment, and between VAS score and DLQI score.

The prevalence found in the present study is higher than that reported by Valdes-Rodriguez et al., who assessed 302 Hispanic geriatric patients with a standardized itch questionnaire and identified chronic itch in 25% of the patients. In their cohort, 69% of patients with chronic itch had xerosis, 96% had documented comorbidities, and diabetes mellitus was significantly associated with chronic itch (OR 2.3; 95% CI 1.3–3.9). They also reported worsening in the winter in 77% and at night in 65% of patients [10]. These findings are very similar to our results, in which xerosis, diabetes mellitus, winter aggravation, and nocturnal predominance were all prominent clinical features.’

The high prevalence in our tertiary-care cohort is also similar to that of dermatology-based clinical cohorts. Schut et al. investigated 3,530 dermatological patients and 1,094 healthy-skin controls in 13 European countries and found that 54.3% of dermatological patients reported itch, while 8.0% of healthy-skin controls did. Chronic itch was reported by 36.9% of patients and 4.7% of controls, and the mean itch intensity was greater in the dermatology patients [11]. Our prevalence of 42.7% is in between geriatric community-based and dermatology-clinic estimates, which is reasonable as elderly tertiary-care patients frequently have both cutaneous disease and systemic comorbidity.

A key finding in this study was the impairment of quality of life. The mean DLQI score for chronic pruritus patients was 13.7, with 78.1% having large or very large quality-of-life impairment. In a 13-country European cross-sectional study, Dalgard et al. found that itch was linked to depression, suicidal ideation, economic hardship, and worse generic health status. Patients with itch had lower EQ-5D visual analogue scores than patients without itch [12]. In our cohort, there was a strong correlation between increasing VAS score and DLQI score, and severe pruritus was associated with 100% large/very large quality-of-life impairment, which further supports the clinical relevance of itch beyond the symptom itself.

The high correlation between chronic kidney disease and chronic pruritus in the current study is in line with the literature on dialysis and CKD-associated pruritus. Pisoni et al. studied 18,801 haemodialysis patients in the DOPPS study and reported that 42% of prevalent haemodialysis patients had moderate-to-extreme pruritus. Pruritus was linked to poor sleep quality, physician diagnosed depression, lower mental and physical quality of life scores, and a 17% increased risk of mortality prior to sleep quality adjustment [13]. In our study, elderly patients were not only haemodialysis patients, but chronic kidney disease was one of the most powerful independent factors associated with chronic pruritus.

Mathur et al. further support the chronicity and quality of life burden of renal pruritus. In their longitudinal study of 103 haemodialysis patients with uraemic pruritus, 84% experienced itching daily or almost daily, 59% had symptoms for more than one year, and 83% had large, non-dermatomal areas with bilateral symmetry. They also identified strong relationships between itching intensity, severity, mood, social relations and sleep [14]. The median duration of pruritus in the present study was 9 months, generalized distribution was present in 62.5%, and sleep disturbance was present in 45.3%, which is similar in terms of persistence and functional impact.

Our findings on sleep and patient-reported burden are also supported by recent longitudinal evidence based on DOPPS. In a study of 7,976 haemodialysis patients in 21 countries, Sukul et al. reported that 51% of patients had moderate-to-severe CKD-associated pruritus at baseline or follow-up, and 22% had persistent moderate-to-severe pruritus at both assessments. Incident pruritus was linked to depression, restless sleep and feeling drained, while persistent pruritus was linked to higher risks of death, hospitalization and cardiovascular events [15]. Sleep disturbance was significantly more common in severe pruritus and correlated with higher VAS and DLQI scores, highlighting the need for repeated symptom assessment in elderly patients.

The correlation between diabetes mellitus and chronic pruritus in the present study is similar to previous diabetic pruritus data. Neilly et al. evaluated 300 diabetic and 100 non-diabetic hospital outpatients and found that pruritus vulvae was significantly more common in diabetic women than controls, with an association with poor glycaemic control [16]. Diabetes mellitus was found in 53.1% of patients with chronic pruritus and 22.1% without chronic pruritus and was independently associated with chronic pruritus in our study. This can be attributed to several diabetes-related factors such as xerosis, neuropathy, susceptibility to infection, autonomic dysfunction and renal involvement.

The impact of pruritus on psychological and skin-related quality of life has also been shown in haemodialysis cohorts. Suseł et al. examined 200 haemodialysis patients and found uraemic pruritus in 38% of them, with 64.5% of those with pruritus having impaired skin-related quality of life (DLQI) and a correlation between pruritus intensity and quality-of-life impairment and depressive symptoms [17]. In the current cohort, DLQI rose in a step-wise fashion from mild to severe pruritus, with all severe pruritus patients having large or very large quality-of-life impairment. This helps to justify the use of DLQI or other instruments in the regular evaluation of elderly patients with chronic pruritus.

The etiological pattern in our study highlights the multifactorial nature of chronic pruritus in elderly patients. Dermatological causes were 37.5%, systemic causes were 21.9%, mixed causes were 16.4% and idiopathic pruritus was 11.7%. In an internal medicine context, Silverberg et al. highlighted that itch is not uncommon outside of dermatology and that it has measurable quality-of-life impacts [18]. This is pertinent to the current study as a tertiary-care elderly population involves dermatological, metabolic, renal, hepatic, neurological and medication-related contributors. The high prevalence of mixed causes in our cohort suggests that a wide diagnostic approach should be taken and that a single cause should not be assumed.

Another important finding was polypharmacy. Polypharmacy ≥5 drugs was present in 39.8% of chronic pruritus patients and 8.7% of those without chronic pruritus and was independently associated with chronic pruritus. This association is clinically plausible because elderly patients are more likely to be taking multiple drugs, and drugs can cause itch directly, by xerosis, by cholestatic or renal effects, or by drug eruptions without obvious primary lesions. Drug-related pruritus was present in 5.5% of cases in the present study, and polypharmacy may have played a role in mixed or systemic etiologies.

There are some limitations in the study. It was carried out in one tertiary care centre and the prevalence may be higher in the community. Etiological classification was made on the basis of clinical evaluation and investigations available, and in some patients more than one cause may have been responsible. Causality cannot be inferred from cross-sectional assessment, especially for comorbidities and polypharmacy.

Overall in this study elderly patients had a high prevalence of chronic pruritus, which was significantly related to xerosis, chronic kidney disease, diabetes mellitus, polypharmacy, and age. Dermatological causes were most common, with systemic and mixed etiologies comprising a significant percentage. The high correlation between pruritus severity, sleep disturbance and DLQI impairment suggests that structured assessment and targeted management is warranted in elderly patients.

Chronic pruritus was common among elderly patients, with a prevalence of 42.7%. Xerosis, chronic kidney disease, diabetes mellitus, polypharmacy, and increasing age were independently associated with chronic pruritus. Dermatological causes were most frequent, followed by systemic and mixed etiologies. Greater pruritus severity was strongly linked to sleep disturbance and poorer quality of life, highlighting the need for structured evaluation and targeted management in elderly patients

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