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Pruritis

Introduction

Pruritis can cause discomfort, frustration, poor sleep, anxiety and depression. Itch may be localised or due to systemic disease. Pruritis in systemic disease is often worse at night.

Persistent scratching, and the ‘itch-scratch-itch’ cycle leads to skin damage excoriation and thickening.

Patients with itch usually have dry skin.

Most medication can cause pruritic rash.

Assessment

Take a careful patient history:

  • offer skin examination looking for local and systemic causes; the cause may be multifactorial
  • primary skin disease (e.g. atopic dermatitis, contact dermatitis or psoriasis)
  • infection – candidiasis, lice, scabies, fungal infection
  • consider medication – opioids in particular morphine and diamorphine, selective serotonin re-uptake inhibitors (SSRIs), ace inhibitors, statins, chemotherapeutic drugs, cytokines and monoclonal antibodies (refer to specific drug information)
  • consider investigations (full blood count, ferritin, c-reactive protein, urea and electrolytes, liver function tests, bone profile, thyroid function tests, blood glucose and chest X-ray).

Systemic diseases that can cause itch include:

Cholestatic jaundice

Chronic kidney disease

Iron deficiency +/-anaemia

Hepatitis

Thyroid disease

Lymphoma

Hepatoma

Diabetes

Leukaemia

Primary biliary cirrhosis

Mycosis fungoides

Multiple myeloma

Paraneoplastic syndrome

 

Polycythaemia

Management

  • Where possible treatment should be cause specific

  • Treat underlying cause(s). Review medication to exclude a drug reaction

  • Use an emollient frequently as a moisturiser. Use liberally and frequently

  • Add an emollient to bath water and use emollient as a soap substitute (see local guidelines)

  • Consider a sedating antihistamine such as hydroxyzine 25mg at night.

 Topical agents

  • Emollients or emollient with active ingredient (for example, menthol 1%)
  • Crotamiton 10% cream (Eurax) or capsaicin (0.025%) cream for localised itch
  • Topical corticosteroid (mild to moderate potency); apply sparingly once daily for 2 to 3 days if the area is inflamed but not infected.  Review after 7 days
  • Lidocaine patches, review benefit after 3 days.

Non pharmacological management

  • UVB phototherapy: may help in uraemic pruritis
  • Biliary stenting may relieve symptoms in cholestatic jaundice.

Medication

Pharmacological management – for systemic disease

The following table contains medication that may be recommended by a specialist. Please seek advice before initiating treatment.

Cause

Treatment 1st line

2nd line

3rd line

Cholestasis

(In cholestasis there is no evidence of one drug being more effective than another so the choice will depend on individual circumstances and local guidance.)

Rifampicin
300 to 600mg once daily

Sertraline
50 to 100mg once daily

Cholestyramine 4g up to four times daily

 

N/A

N/A

Uraemia

Gabapentin
100 to 300mg (following dialysis)

Naltrexone 50mg  daily

 

Lymphoma

Prednisolone
10 to 20mg three times daily

Cimetidine 400mg twice daily

Mirtazapine
15 to 30mg at bedtime

Systemic opioid-induced pruritis

Chlorphenamine 4–12mg (if benefit 4mg three times daily)

If no benefit switch opioid

Ondansetron 8mgtwice daily

Paraneoplastic

Paroxetine
5 to 20mg once daily

Mirtazapine
15 to 30mg at bedtime

 

Unknown

Chlorphenamine 4 to 12mg (if benefit 4mg three times daily)

Paroxetine
5 to 20mg once daily daily

Mirtazapine
7.5 to 15mg at bedtime

  

Practice Points

  • Avoid topical antihistamines as they can cause allergic contact dermatitis.

  • Systemic treatment is often unnecessary if skin care improves symptoms.

  • Avoid vasodilators such as caffeine, alcohol, spices, hot water.

Patient Advice points

  • Keep nails short and clean.  Avoid scratching

  • Wear loose clothing, preferably cotton.  Avoid irritating fabrics such as wool

  • Maintain cool environment, avoid prolonged bathing in hot water; bathe in tepid water

  • Dry skin by patting rather than rubbing; always apply emollients after bathing or showering

  • Avoid lanolin and perfumed products: consider baking soda in bathwater.

Resources

Websites

Textbooks

  • Twycross et al (2009) Symptom management in Advanced cancer 4th edition Ch11 321-329 Palliativedrugs.com Ltd

  • Palliative Care Formulary (PCF4) 4th edition (2011) pallitaivedrugs.com Ltd

References