Differential Diagnosis for Itchy Lower Legs with No Visible Skin Changes and Burning when Showering

• Single most likely diagnosis
  • Dry skin (xerosis): This is a common condition that can cause itchiness, especially on the lower legs, without any visible skin changes. The burning sensation when showering could be due to the harsh soap or hot water stripping the skin of its natural oils, exacerbating the dryness.
• Other Likely diagnoses
  • Eczema (atopic dermatitis): Although it often presents with visible skin changes, mild cases might not have noticeable alterations. The itch and burning could be symptoms of eczema, especially if the individual has a history of atopic diseases.
  • Contact dermatitis: This could be due to an allergic reaction or irritant from soaps, detergents, or other substances coming into contact with the skin. The lack of visible changes might indicate a mild reaction.
  • Folliculitis: An inflammation of the hair follicles, which can cause itchiness and burning, especially after shaving or when the skin is exposed to hot water.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed)
  • Neuropathic itch: Certain neurological conditions can cause itching without skin changes. Conditions like multiple sclerosis, neuropathy, or nerve damage could be underlying causes.
  • Internal diseases: Liver or kidney disease, thyroid disorders, and certain types of cancer can cause itching without visible skin changes. These conditions are critical to identify early for appropriate management.
• Rare diagnoses
  • Aquagenic pruritus: A rare condition characterized by intense itching after contact with water, without any visible skin changes. It can be associated with underlying hematological disorders.
  • Polycythemia vera: A rare blood disorder that can cause itching, particularly after exposure to water, due to the release of histamine from basophils.