The evaluation of the pruritic patient can appear daunting at first glance. Itching can be a manifestation of an underlying disease, making a systematic approach to the itchy patient necessary. A general history and physical, along with key laboratory tests as guided by the history and physical, can yield clues to the diagnosis. Hepatobiliary, renal, endocrine and lymphoproliferative diseases are some of the most common underlying systemic causes of itch. Treatment should be guided by the diagnosis, and may include topical steroids, oral antihistamines, opioid antagonists and phototherapy. In this review we outline the steps to take when evaluating a patient with pruritus. In addition, we highlight some of the more common systemic causes of itch and discuss treatment options.