Iron deficiency without anaemia

Editor – We read with interest the article from Al-Nassem and colleagues.¹ The points about diagnosis and management of iron deficiency without anaemia (IDWA) were most informative and will affect our practice. As a learning point, we would like to add a comment about the dermatological manifestations of IDWA. Their Fig 3 begins with ‘Effects of iron deficiency on the human body'; we would like to point out a very common presentation of iron deficiency has not been mentioned: ie pruritus. The authors have mentioned dry skin and hair loss that we see in dermatology (iron deficiency can cause chronic telogen effluvium), but other well-recognised manifestations of iron deficiency include angular cheilitis, koilonychia and pruritus.

Pruritus is a common presenting complaint to general medics, general practitioners and dermatologists, and iron deficiency is a commonly regarded cause of this symptom, even in the absence of anemia.² In some cases, iron replacement leads to complete cessation of pruritus very shortly after commencement of therapy, thus resolving what may otherwise be a debilitating and frustrating condition.³

In a previously conducted prospective case-control study, the most common cause of generalised pruritus in patients with underlying systemic disease was found to be iron deficiency anaemia (25% of all patients with pruritus with systemic disease). Based on this study, the British Association of Dermatologists guidelines recommended that full blood count and ferritin levels should be checked in all patients with chronic generalised pruritus without rash.³

As such, we would like to remind our colleagues to remember that the itchy (rash free) patient can be a classic presentation of iron deficiency (with or without anaemia).