Problem refinement

At this point it would be prudent to ask about any constitutional symptoms she may have noticed such as weight changes, fatigue, night sweats, temperature intolerances and polyuria or polydipsia, as this might point to thyroid dysfunction, diabetes, Sjögren’s syndrome, renal disease or malignancy. Mrs Morris says she is tired all the time but has put that down to her poor sleep quality. 

Finally, you ask about her general wellbeing and personal life to look for any changes in mood or disproportionate worries that might suggest a psychological cause for the itch. She reports nothing untoward.

The diagnosis still seems to point to dry skin as the cause but her tiredness could be a sign of underlying systemic illness and requires further investigation. Tests that should be conducted are full blood count (anaemias) and measurement of thyroid-stimulating hormone (thyroid disorders), fasting glucose (diabetes), alkaline phosphatase, bilirubin, creatinine and blood urea nitrogen (liver disorders).

Red flags

She shows no unexplained weight loss (cancer or renal failure) or neurological deficit (MS).

Management: self-care options

Strategies to keep the skin from drying out should be tried. Time in the shower or bath should be minimised and moisturising creams applied immediately after. Irritants, if known, should be avoided. Emollients should be given to help the itching and moisturise the skin.

Safety netting

You tell Mrs Morris that you believe her dry skin is part of the natural ageing process and that emollients should control her symptoms. However, she should make an appointment with her doctor as you cannot be 100 per cent certain that the itching is not due to something else.