Pruritus

KEYPOINTS

• Pruritus can be described as an unpleasant cutaneous sensation which produces the desire to scratch
• Pruritus is relatively uncommon in advanced disease but can be very unpleasant and difficult to treat
• General non-pharmacologic treatment can be very helpful

• Generalised itching (often the child repeatedly rubbing the nose-tip) due to opioids is more common in children than adults

ASSESSMENT

(see Foreword)

• History should include the times at which the itching occurs (whether continuous and whether at night or day) its nature (burning, itching, etc.), location and relevant medication history
• Examination should include review of dryness of skin, possible presence of scabies, possible presence of jaundice

MANAGEMENT

General Measures

• Pruritus is often caused by dry skin, so a good first measure is a simple moisturiser cream
• Keep patient cool and use cool clothing
• Tepid (around 37°C) baths and showers (avoiding detergents), followed by gentle drying and application of moisturiser cream
• Keep nails short (filed not cut)
• Avoidance of alcohol and spicy foods

Topical Agents

• Menthol 1% and camphor 1% compounded in aqueous cream can be used several times a day as needed

Cause Specific Therapy

• Cholestasis
  • Use general measures (see above)
  • HI and H2 receptor blockers likely to be ineffective
  • Place biliary stent (if possible and if patient’s general condition warrants this)
  • The burden of investigation and treatment should always be weighed against the prognosis, the likely benefit of treatment and the patient’s wishes
  • Cholestyramine 4 g 1-6 times/day PO to a maximum of 36 g/day

• Uraemia
  • Use general measures (see above)
  • HI and H2 receptor blockers likely to be ineffective
  • Capcaisin 0.025% or 0.075% cream applied 3-5 times daily is useful where there is localised pruritus. Do not apply to large body areas

• Hodgkins Lymphoma
  • Use general measures (see above)
  • HI and H2 receptor blockers likely to be ineffective
  • Radiation or chemotherapy where appropriate
  • Corticosteroids e.g dexamethasone 4-8 mg daily
  • If ineffective, substitute cimetidine 400 mg bid PO or ranitidine 150 mg bid PO

• Itch due to an opioid
  • Use general measures (see above)
  • HI and H2 receptor blockers likely to be ineffective
  • May be transitory lasting a few days
  • May be relieved by ‘switching opioids’
  • Paroxetine 5 mg/day PO to 20 mg/day can be helpful

PITFALLS/CONCERNS

• Potential side effects of antihistamines may be agitation or confusion

PALLIATIVE TIPS

• Itching of the skin is present without obvious cause in over 50% of patients over 70 years
• Itching associated with cholestasis often starts on palms and soles and the severity is unrelated to the level of bile acids in skin
• H1 receptor blockers are useful in histamine based itch such as a drug reaction or urticaria
• Ondansetron is helpful when spinal opioids cause itching
• Antihistamine creams may cause a contact dermatitis
• Lidocaine cream may cause a contact dermatitis and worsening of itching
• Calamine cream may cause drying of the skin and worsening of the itching

SOURCES/REFERENCES

1. Twycross R, Greaves MW, Handwerker H, Jones EA, Libretto SE, Szepietowski JC et al. Itch: scratching more than the surface. QJM 2003;96(1):7-26. http://www.ncbi.nlm.nih.gov/pubmed/12509645
2. Zylicz Z, Twycross R, Jones A, editors. Pruritus in advanced disease. Oxford: Oxford University Press; 2004.

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