{"id":16106,"date":"2026-11-06T06:00:00","date_gmt":"2026-11-06T11:00:00","guid":{"rendered":"https:\/\/cov19longhaulfoundation.org\/?p=16106"},"modified":"2026-09-13T13:47:48","modified_gmt":"2026-09-13T17:47:48","slug":"the-itch-that-covid-19-left-behind","status":"publish","type":"post","link":"https:\/\/cov19longhaulfoundation.org\/?p=16106","title":{"rendered":"The Itch That COVID-19 Left Behind"},"content":{"rendered":"\n

For most people, an itch is an annoyance. A mosquito bite, dry skin or an allergic rash produces a familiar sensation, the hand scratches, and the episode ends.<\/em><\/p>\n\n\n\n

John Murphy, CEO The COVID-19 Long haul Foundation<\/p>\n\n\n\n

For some people after COVID-19, however, itching is something altogether different.<\/p>\n\n\n\n

It can burn, migrate across the body, appear in places that look completely normal and become sufficiently intense to interfere with sleep, concentration and ordinary life. Some patients describe the sensation as being underneath the skin rather than on its surface. Others experience simultaneous burning, tingling, electric sensations or numbness. In a small but increasingly recognizable group, the skin examination provides remarkably little explanation for the severity of the symptoms.<\/p>\n\n\n\n

Published medical reports now provide evidence that COVID-19 can be associated with several distinct forms of pruritus\u2014the medical term for itching\u2014including inflammatory skin disease, urticaria, post-viral immune dysfunction, cholestatic liver disease and, perhaps most intriguingly, neuropathic itch caused by abnormalities of cutaneous nerves<\/strong>. \ue201<\/p>\n\n\n\n

That last possibility changes the way the problem should be understood.<\/p>\n\n\n\n

If the nerve is generating the itch, putting another layer of moisturizer on the skin may accomplish very little.<\/p>\n\n\n\n

A symptom hiding in plain sight<\/h5>\n\n\n\n

Early in the pandemic, physicians had little information about COVID-related itching. A 2020 review in Dermatologic Therapy<\/em> noted that the prevalence of itch associated directly with SARS-CoV-2 infection was unknown and that the published literature consisted primarily of descriptions of skin eruptions rather than systematic investigations of pruritus. \ue201<\/p>\n\n\n\n

That literature nevertheless established that COVID could produce several itchy skin conditions, including urticaria and erythematous eruptions. One early review reported that cutaneous manifestations had been described in roughly 0.2% to 20.4% of patients in the studies available at the time, although the enormous range reflected differences in populations and ascertainment rather than a reliable prevalence estimate. \ue201<\/p>\n\n\n\n

Urticaria was particularly important because hives can be intensely pruritic.<\/p>\n\n\n\n

In one published case, a 39-year-old woman developed an intensely itchy eruption on her arms that subsequently spread to her trunk and face. She then developed headache, gastrointestinal symptoms, muscle and joint pain, loss of smell and other characteristic symptoms of COVID-19. Her SARS-CoV-2 PCR test was positive. An oral antihistamine was prescribed, and the eruption completely resolved within approximately a week. At two-week follow-up she was asymptomatic. \ue201<\/p>\n\n\n\n

For this patient, COVID-related itching was temporary.<\/p>\n\n\n\n

For others, it has been anything but temporary.<\/p>\n\n\n\n

When the skin looks normal<\/h5>\n\n\n\n

Perhaps the most illuminating evidence comes from a case series published in Clinical Case Reports<\/em> examining patients with persistent neuropathic skin symptoms after COVID-19.<\/p>\n\n\n\n

One patient was a 67-year-old woman who developed burning pain and itching late during her COVID-19 infection. The sensation began on her chest and spread irregularly to all four limbs, eventually involving her palms and soles. Yet when physicians examined her skin, the examination was negative<\/strong>. There was no obvious rash capable of explaining the severity of her symptoms. \ue201<\/p>\n\n\n\n

The investigators did something unusual: they biopsied the affected skin.<\/p>\n\n\n\n

Microscopic examination demonstrated abnormal nerve structures in the deeper dermis, including wavy and hypertrophic nerve ramifications. The findings suggested that the patient’s symptoms could have a neuropathic rather than purely dermatologic origin. \ue201<\/p>\n\n\n\n

Another patient in the same series, a 64-year-old man, developed generalized burning and itching two months after SARS-CoV-2 infection. His acute COVID pneumonia had resolved, but he was left with fatigue, shortness of breath and cognitive difficulties. His skin biopsy again demonstrated hypertrophic nerve bundles, without an inflammatory reaction. \ue201<\/p>\n\n\n\n

A fourth patient, a 35-year-old woman, developed persistent itching and stinging following hospitalization for COVID-associated pericarditis. Her biopsy demonstrated clusters of abnormal nerve bundles, and nerve-conduction testing showed reduced sensory nerve action-potential amplitude. \ue201<\/p>\n\n\n\n

These observations do not prove that SARS-CoV-2 caused the nerve abnormalities in every patient with post-COVID itching. Five or six cases cannot establish population-level causality.<\/p>\n\n\n\n

But they provide something that symptom questionnaires cannot: an anatomical correlate of the patient’s complaint.<\/strong><\/p>\n\n\n\n

The patient who says, \u201cMy skin itches terribly, but nobody can see anything,\u201d may not be imagining the problem.<\/p>\n\n\n\n

There may be pathology beneath the surface.<\/p>\n\n\n\n

Why would COVID cause an itch?<\/h5>\n\n\n\n

The sensation of itch is generated through a complicated network involving skin cells, immune mediators and specialized sensory neurons. It is not merely a superficial reaction of the skin.<\/p>\n\n\n\n

COVID-19 can disturb several components of this system.<\/p>\n\n\n\n

Inflammatory mediators can activate sensory nerve endings. Immune dysregulation can produce urticaria or dermatitis. Vascular abnormalities can affect the skin and underlying nerves. And SARS-CoV-2-associated neurological injury may alter sensory signaling.<\/p>\n\n\n\n

Research into COVID-associated skin lesions has also identified abnormalities in molecules involved in itch signaling. One study reported increased expression of TRPA1 and substance P in COVID-associated skin lesions and concluded that the itch observed in those lesions might be predominantly non-histaminergic<\/strong>. \ue201<\/p>\n\n\n\n

That finding has potentially important therapeutic implications.<\/p>\n\n\n\n

Histamine is responsible for much ordinary allergic itching. Consequently, antihistamines can be extremely effective when histamine is driving the process.<\/p>\n\n\n\n

But not every itch is histaminergic.<\/p>\n\n\n\n

A nerve can generate an itch through mechanisms that antihistamines do not adequately suppress.<\/p>\n\n\n\n

This may explain why one patient takes cetirizine and experiences substantial relief while another takes antihistamines day after day with little improvement.<\/p>\n\n\n\n

The 73-year-old man whose itching would not stop<\/h5>\n\n\n\n

One of the most striking published cases involves a 73-year-old man who developed chronic, severe pruritus after COVID-19.<\/p>\n\n\n\n

His experience is important because physicians attempted numerous conventional and unconventional treatments without adequate control. Eventually, he was treated with dupilumab<\/strong>, a monoclonal antibody that blocks signaling through interleukin-4 and interleukin-13.<\/p>\n\n\n\n

The response was substantial: the report describes a marked reduction in his pruritus and eventual disappearance of the symptoms. \ue201<\/p>\n\n\n\n

Dupilumab is not a conventional treatment for \u201cCOVID itch.\u201d It is an established biologic therapy for several type-2 inflammatory diseases, including atopic dermatitis.<\/p>\n\n\n\n

The significance of the case therefore lies less in the drug itself than in the possibility that some post-COVID patients develop a persistent immune-mediated dermatologic phenotype that can respond to targeted immunomodulation.<\/p>\n\n\n\n

A single case does not establish dupilumab as a standard treatment for post-COVID pruritus.<\/p>\n\n\n\n

It does, however, demonstrate why physicians should not assume that every case is simply dry skin.<\/p>\n\n\n\n

Hives can become chronic<\/h5>\n\n\n\n

Another group of patients develop urticaria\u2014hives\u2014which can persist well beyond the acute infection.<\/p>\n\n\n\n

In a published case series of chronic spontaneous urticaria, investigators found that SARS-CoV-2 infection could exacerbate preexisting disease and make control more difficult. Patients required escalation from standard treatment to second- and third-line therapies, and only one patient achieved adequate control under the treatment regimen described in the report. \ue201<\/p>\n\n\n\n

Another report described a 47-year-old man who developed pruritic urticaria after COVID-19. Scratching and hot showers triggered the lesions, and testing demonstrated dermatographism\u2014the phenomenon in which lightly scratching the skin produces raised wheals. Cetirizine 10 mg daily improved his symptoms. \ue201<\/p>\n\n\n\n

This distinction matters because urticaria has a reasonably well-established treatment pathway.<\/p>\n\n\n\n

For chronic spontaneous urticaria, modern management generally begins with a second-generation, nonsedating H1 antihistamine. When standard dosing fails, physicians may increase antihistamine dosing under appropriate supervision and consider biologic treatment such as omalizumab for persistent disease. Corticosteroids may sometimes be used briefly for severe flares but are generally not a satisfactory long-term solution.<\/p>\n\n\n\n

Why ordinary antihistamines sometimes fail<\/h5>\n\n\n\n

The temptation is to regard all itching as an allergic phenomenon.<\/p>\n\n\n\n

That is incorrect.<\/p>\n\n\n\n

Chronic pruritus can arise from dermatologic, neurologic, systemic and psychiatric mechanisms. Liver disease, kidney disease, iron deficiency, thyroid abnormalities, hematologic disorders, medications and neuropathy can all produce itching.<\/p>\n\n\n\n

COVID adds another potential cause to the diagnostic list.<\/p>\n\n\n\n

For a patient with persistent generalized itching after COVID, physicians should therefore ask a deceptively simple question:<\/p>\n\n\n\n

Is there actually a rash?<\/strong><\/p>\n\n\n\n

If there is, the appearance and distribution of the eruption can provide important diagnostic information.<\/p>\n\n\n\n

If there isn’t, the investigation should not end.<\/p>\n\n\n\n

Neuropathic itch should enter the differential diagnosis, particularly when the patient describes burning, tingling, electric sensations, crawling sensations, numbness or abnormal temperature perception.<\/p>\n\n\n\n

Treating the patient rather than the word \u201cCOVID\u201d<\/h5>\n\n\n\n

There is no single medication that treats COVID-related itching because there is no single mechanism.<\/p>\n\n\n\n

The treatment should follow the phenotype.<\/p>\n\n\n\n

For dry or irritated skin<\/strong>, frequent application of thick, fragrance-free moisturizers and avoidance of hot showers, harsh soaps and fragrances can restore the skin barrier. This sounds trivial until one remembers that a damaged skin barrier can perpetuate an itch-scratch cycle.<\/p>\n\n\n\n

For urticaria<\/strong>, nonsedating antihistamines such as cetirizine, loratadine or fexofenadine are generally first-line therapies. Persistent chronic urticaria may require specialist management and biologic treatment.<\/p>\n\n\n\n

For inflammatory dermatitis<\/strong>, topical corticosteroids or other anti-inflammatory topical therapies may be appropriate depending on the diagnosis. Long-term indiscriminate use of potent topical steroids, however, can damage the skin.<\/p>\n\n\n\n

For neuropathic itch<\/strong>, treatment may need to be directed at the nervous system rather than the skin. Gabapentin and pregabalin are recognized treatments for neuropathic pruritus in chronic-pruritus guidelines. \ue201<\/p>\n\n\n\n

Other therapies can be considered by specialists depending on the cause, including antidepressant-class neuromodulators, phototherapy, topical agents and, in selected refractory cases, other systemic therapies.<\/p>\n\n\n\n

For severe type-2 inflammatory disease<\/strong>, targeted biologics such as dupilumab may be considered when the clinical diagnosis supports their use. The remarkable response in the 73-year-old post-COVID case provides an intriguing example, but it remains a case report rather than a clinical trial. \ue201<\/p>\n\n\n\n

And when itching accompanies liver or bile-flow abnormalities<\/strong>, the treatment must address the underlying cholestatic disorder rather than simply suppressing the sensation.<\/p>\n\n\n\n

The liver can provide another explanation<\/h5>\n\n\n\n

COVID-19 can be associated with liver abnormalities, and post-COVID cholestasis has been described particularly in severely ill patients.<\/p>\n\n\n\n

This matters because cholestasis can produce extraordinarily intense generalized itching.<\/p>\n\n\n\n

A patient whose itching begins after COVID should therefore not necessarily be sent home with an antihistamine. Depending on the clinical situation, laboratory evaluation can include bilirubin, alkaline phosphatase, AST, ALT and other liver tests. If abnormalities suggest biliary obstruction or cholestatic disease, imaging and hepatologic evaluation may be appropriate.<\/p>\n\n\n\n

Likewise, kidney dysfunction can produce severe pruritus, and renal disease should be considered when the clinical history suggests it.<\/p>\n\n\n\n

The mistake is not failing to diagnose \u201cCOVID itch.\u201d<\/p>\n\n\n\n

The mistake is failing to determine what kind of itch the patient has.<\/strong><\/p>\n\n\n\n

A particularly important problem for older adults<\/h5>\n\n\n\n

Itching is common in older people even without COVID, largely because aging alters the epidermal barrier and increases susceptibility to dryness and other dermatologic conditions. The original COVID-era dermatology literature specifically noted that itch is particularly common in elderly populations. \ue201<\/p>\n\n\n\n

That makes post-COVID itching particularly difficult to interpret.<\/p>\n\n\n\n

An older person may have several simultaneous causes: dry skin, medication effects, renal disease, diabetes, neuropathy and a post-viral inflammatory or neurological disorder.<\/p>\n\n\n\n

Consequently, attributing every itch to COVID can be as problematic as dismissing COVID as irrelevant.<\/p>\n\n\n\n

Good medicine requires distinguishing coincidence from consequence.<\/p>\n\n\n\n

The psychological price of an itch that never stops<\/h5>\n\n\n\n

Chronic pruritus is not a cosmetic inconvenience.<\/p>\n\n\n\n

Persistent itching can destroy sleep. Sleep deprivation then increases fatigue, irritability, impaired concentration and sensitivity to pain. Scratching can produce excoriations, bleeding, skin thickening and secondary infection. The resulting damage creates additional sensory stimulation and can perpetuate the cycle.<\/p>\n\n\n\n

The 2020 review of itch during the COVID era emphasized the psychosocial consequences of chronic pruritus and noted that anxiety and stress can themselves amplify itching. \ue201<\/p>\n\n\n\n

This creates a particularly cruel feedback loop:<\/p>\n\n\n\n

COVID \u2192 itch \u2192 loss of sleep \u2192 stress \u2192 heightened sensory sensitivity \u2192 more itch.<\/strong><\/p>\n\n\n\n

A patient may consequently appear anxious because the patient has been unable to sleep for weeks, rather than the itching being \u201cpsychological.\u201d<\/p>\n\n\n\n

That distinction is clinically important.<\/p>\n\n\n\n

What is the prognosis?<\/h5>\n\n\n\n

For many patients, the prognosis is favorable.<\/p>\n\n\n\n

COVID-associated acute rashes and urticaria can resolve within days or weeks. The 39-year-old woman described earlier had complete resolution of her rash within seven days. \ue201<\/p>\n\n\n\n

But a minority of patients develop persistent symptoms.<\/p>\n\n\n\n

A 2024 review of post-COVID dermatologic complications reported pruritus among the persistent cutaneous manifestations described in Long COVID literature, with one synthesis reporting pruritus in approximately 25% of affected subjects in the studies it reviewed. The authors also described dermatitis, edema, pigmentation changes and other persistent abnormalities. The estimates should be interpreted cautiously because Long COVID cohorts differ substantially in their definitions and methods of ascertainment. \ue201<\/p>\n\n\n\n

Neuropathic cases may be particularly prolonged.<\/p>\n\n\n\n

The published nerve-biopsy series demonstrates that some patients had persistent burning and itching after their acute infection had resolved and that objective nerve abnormalities could remain when the skin itself looked normal. \ue201<\/p>\n\n\n\n

What remains unknown is how often these abnormalities eventually disappear.<\/p>\n\n\n\n

Longitudinal studies specifically designed to follow post-COVID pruritus are still remarkably sparse.<\/p>\n\n\n\n

That is an important scientific gap.<\/p>\n\n\n\n

The patient should not have to prove the itch<\/h5>\n\n\n\n

Perhaps the most important lesson is also the simplest.<\/p>\n\n\n\n

A patient can have severe itching without a visible rash.<\/p>\n\n\n\n

That does not make the symptom imaginary.<\/p>\n\n\n\n

The skin is a sensory organ. Its nerves communicate continuously with the spinal cord and brain. Damage or dysregulation anywhere along that pathway can produce sensations that have no obvious external correlate.<\/p>\n\n\n\n

COVID-19 has already demonstrated its ability to affect the nervous system, vascular system, immune system and skin. It should therefore not be surprising that some survivors report abnormal sensory experiences involving the skin.<\/p>\n\n\n\n

The challenge is proving precisely how often this occurs and determining which biological pathway is responsible in each patient.<\/p>\n\n\n\n

The emerging evidence suggests at least four broad possibilities: inflammatory skin disease, immune-mediated urticaria, systemic disease such as cholestasis or renal dysfunction, and neuropathic itch.<\/strong><\/p>\n\n\n\n

Each requires a different treatment.<\/p>\n\n\n\n

The next step: stop treating \u201citch\u201d as a diagnosis<\/h5>\n\n\n\n

The future of post-COVID medicine will depend increasingly upon phenotyping.<\/p>\n\n\n\n

Instead of recording simply \u201citching after COVID,\u201d clinicians should document whether the patient has hives, dermatitis, dry skin, neuropathic sensations, sensory loss, systemic abnormalities or completely normal skin.<\/p>\n\n\n\n

That information can determine the next diagnostic step.<\/p>\n\n\n\n

Blood testing may identify hepatic, renal, thyroid or hematologic abnormalities. Dermatologic examination may identify dermatitis or urticaria. Skin biopsy can occasionally provide information about inflammatory or neural pathology. Neurologic examination and nerve testing may be appropriate when neuropathic symptoms are prominent.<\/p>\n\n\n\n

Treatment can then become rational rather than empirical.<\/p>\n\n\n\n

The 73-year-old man who eventually responded to dupilumab demonstrates the potential benefit of this approach. The 67-year-old woman whose biopsy revealed abnormal dermal nerves demonstrates another. The patient whose hives disappeared after a conventional antihistamine demonstrates a third.<\/p>\n\n\n\n

They did not necessarily have the same disease.<\/p>\n\n\n\n

They had the same complaint.<\/p>\n\n\n\n

That distinction may be the key to helping the many COVID survivors for whom an itch that should have disappeared with the infection instead became another unwelcome component of life after COVID.<\/p>\n\n\n\n

The medical profession has become increasingly comfortable recognizing that SARS-CoV-2 can leave patients with persistent problems involving the lungs, heart, brain, autonomic nervous system and immune system. The skin deserves the same attention.<\/p>\n\n\n\n

Sometimes the evidence of disease is a rash.<\/p>\n\n\n\n

Sometimes it is a biopsy.<\/p>\n\n\n\n

And sometimes, when the skin looks perfectly normal, the evidence is hiding in the nerves beneath it.<\/p>\n","protected":false},"excerpt":{"rendered":"

For most people, an itch is an annoyance. A mosquito bite, dry skin or an allergic rash produces a familiar sensation, the hand scratches, and the episode ends. John Murphy, […]<\/p>\n","protected":false},"author":2,"featured_media":16190,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[779,151,846,266,533],"tags":[],"class_list":["post-16106","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-dermatosis","category-epithelium","category-itch","category-itching","category-skin-dermatology"],"_links":{"self":[{"href":"https:\/\/cov19longhaulfoundation.org\/index.php?rest_route=\/wp\/v2\/posts\/16106","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/cov19longhaulfoundation.org\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/cov19longhaulfoundation.org\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/cov19longhaulfoundation.org\/index.php?rest_route=\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/cov19longhaulfoundation.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=16106"}],"version-history":[{"count":1,"href":"https:\/\/cov19longhaulfoundation.org\/index.php?rest_route=\/wp\/v2\/posts\/16106\/revisions"}],"predecessor-version":[{"id":16107,"href":"https:\/\/cov19longhaulfoundation.org\/index.php?rest_route=\/wp\/v2\/posts\/16106\/revisions\/16107"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/cov19longhaulfoundation.org\/index.php?rest_route=\/wp\/v2\/media\/16190"}],"wp:attachment":[{"href":"https:\/\/cov19longhaulfoundation.org\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=16106"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/cov19longhaulfoundation.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=16106"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/cov19longhaulfoundation.org\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=16106"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}