SOCIO-DEMOGRAPHIC INFORMATIONS

1

Gender

1. Female 2. Male

/__/

2

Age

In years

/__/__/

3

Marital status

1. Single 2. Married 3. Divorced 4. Widow (er) 5. Not applicable

/__/

4

Profession/Occupation

1. Unemployed 2. Pupil /Student 3. Civil servant 4. Trader 5. Farmer 6. Worker/artisan 7. Self-employed person 8. Retired 9. Other to be specified (___) 10. Not applicable

/__/

5

Place of residence

1. Urban 2. Peri-urban 3. Rural

/__/

6

Religion

1. Christian 2. Muslim 3. Endogenous 4. Atheist 5. Other

/__/

7

Ethnic group

1. Fon and related 2. Dendi 3. Bariba and related 4. Yorouba and related 5. Peulh 6. Ditamari and related 7. Mina 8. Adja and related 9. Unspecified 10. Other (______________)

/__/

SOCIOECONOMIC INFORMATIONS, LIFESTYLE AND MEDICAL HISTORY

8

Alcohol consumption

1. Yes 2. No

/__/

9

Tobacco consumption

1. Yes 2. No

/__/

10

Number of body washes per day

1. Once 2. Twice 3. Thrice 4. More than three times

/__/

11

Towel change interval

1. At one week 2. >one week and ≤at one month 3. >at one month

/__/

12

Bedding change interval

1. At one week 2. >one week and ≤at one month 3. >at one month

/__/

13

Clothes change interval

1. Every day 2. Every two days 3. Every three days 4. After a week

/__/

14

Regular medication use

1. Yes 2. No If yes which

/__/

15

Use of water for bath

1. Well water 2. Borehole water 3. SONEB water 4. Others ( )

/__/

16

Temperature of water used for bath

1. Hot 2. Cold 3. Lukewarm

17

Type of sponge used for bath

1. Toilet net 2. Glove towel 3. Traditional net

/__/

18

Medical history

1. No medical history 2. Diabetes 3. AHT 4. Drépanocytose 5. Hemodialysis 6. HIV 7. Others ( )

/__/

19

History of itchy skin or systemic conditions

Yes / / No / / if yes which (urticaria, lichen planus, prurigo, contact eczema, atopic dermatitis, varicella, bullous pemphigoid, dermatitis herpetiformis, psoriasis, toxidermitis, leucémia, others)

20

Notion of atopy

1. Yes 2. No

/__/

21

If yes which

1. Asthma 2. Sinusitis 3. Allergic rhinitis 4. Allergic conjunctivitis 5. Others ( )

22

Family history

1. No family history 2. AHT 3. Rhinitis 4. Sinusitis 5. Asthma 6. Diabetes 7. HIV 8. Drépanocytose 9. Other (_______________)

/__/

23

Recent deworming

1. Yes 2. No

/__/

DATA RELATED TO THE USE OF COSMETICS

24

Use of body milk

1. Yes 2. No

/__/

25

If yes which

1. Depigmenting body milk 2. Perfumed body milk 3. Unscented body milk 4. Body cream 5. Body ointment 6. Body balm 7. Others ( ) 8. Unspecified

/__/

26

Use of body soap

1. Yes 2. No

/__/

27

If yes which

1. Detergent 2. Antiseptic 3. Superfatted 4. Enlightening 5. Marseilles 6. Neutral 7. Others ( ) 8. Unspecified

/__/

28

Perfume

1. Yes 2. No

/__/

29

Nail polish

1. Yes 2. No

/__/

30

Use of depigmenting products

1. Yes 2. No

/__/

INTERROGATION AND PHYSICAL EXAMINATION

Patient

1. Case; 2. Control

if case continue ; if control end of filling

31

Duration of symptoms

1. six weeks

/__/

32

Spawn mode

1. Progressive 2. Sudden

/__/

33

Evolution mode

1. Permanent 2. Intermittent 3. occasional

/__/

34

Schedule of pruritus

1. Diurnal 2. Nocturnal 3. Without schedule

/__/

35

Nocturnal upsurge

1. Yes 2. No

36

Period of onset of symptoms

1. Dry season 2. Rainy season

/__/

37

Intensity

1. Light 2. Moderate 3. Severe

/__/

38

Existence of factors that can cause pruritus

Yes / / No/ / if yes which ( medication intake, food, cosmetic application, water, toilet net, heat, cold, sun exposure, physical exercise, others)

39

Aggravating factors

1. Medication intake 2. Food 3. Cosmetic application 4. Water 5. Toilet net 6. Heat 7. Cold 8. Sun exposure 9. Physical exercise 10. Others ( )

40

Calming factors (cite)

41

Background of familial pruritus

1. Yes 2. No

/__/

42

Accompanying signs

1. Weight loss 2. Asthenia 3. Anorexia 4. Diarrhea 5. Abdominal pain 6. Insomnia 7. Fever 8. Pallor 9. Icterus 10. Dehydration folds 11. Malnourishment folds 12. Hepatomegaly 13. Splenomegaly 14. Adenopathies 15. None 16. Others

/__/

43

Previous treatment

1. Antihistamines 2. Dermocorticoid 3. Corticosteroids 4. None 5. others

/__/

44

Prescribed by

1. Self-medication 2. Physician/Nurse 3. Dermatologist 4. Unspecified

45

Presence of scratch marks

1. Yes 2. No

/__/

46

If yes which

1. Punctiform excoriation 2. Linear streaks 3. Lichenification 4. Impetiginization

/__/

Complementary examinations

NB: P = positive, Neg = negative, N = normal, AN = abnormal, B = Low, E = High

47

Complete blood count

RBC…. WBC…. Hb…. Platelets….

48

Blood sugar

49

Hepatic transaminases

ALT… AST…

50

Blood creatinine

51

Gamma glutamyl transferase

52

Alkaline phosphatase

53

Bilirubin

54

Liver markers

Anti-HBs / / Anti-HCV/ /

55

HIV serology

56

Thyroid hormones

TSH… T3… T4…

57

Protein electrophoresis

58

Calcemia

59

Skin biopsy

60

Others

ETIOLOGICAL DIAGNOSIS OF GENERALIZED PRURITUS SINE MATERIA

61

General infectious diseases

HIV infection / / Viral hepatitis / /

62

Metabolic, endocrine and neuropsychiatric causes

CKD/ / Diabetes mellitus/ / Hepatic cholestasis/ / Hyperthyroidism/ / Hypothyroidism/ / Thyrotoxicosis/ / Hyperparathyroidism/ /Neurogical disease/ / Anxiety or depression/ / Others/ / Specify

63

Blood disorders

Polycythaemia/ / Iron deficiency/ / Hodgkin’s disease/ /Hématological malignancies/ /

64

Neoplasia

Yes/ / No/ /

65

Drug-induced pruritus

Yes/ / No/ /

66

Cosmetic-induced pruritus

Yes/ / No/ /

67

Pruritus due to professional substances

Yes/ / No/ /

68

Pruritus due to climate change

Yes/ / No/ /

69

Aquagenic pruritus

Yes/ / No/ /

70

Senile pruritus

Yes/ / No/ /

71

Internal parasites

Yes/ / No/ /

72

Idiopathic generalized pruritus sine materia

Yes/ / No/ /