Pruritis

• Pruritus can cause discomfort, frustration, poor sleep, anxiety and depression. Itch may be localised or due to systemic disease. Pruritus in systemic disease is often worse at night.
• Some causes of pruritus are independent of histamine (uraemic pruritus), therefore antihistamine medication is often ineffective.
• 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.

Take a careful patient history:

• offer skin examination looking for local and systemic causes as the cause may be multifactorial
• primary skin disease (for example atopic dermatitis, contact dermatitis or psoriasis)
• infection – candidiasis, lice, scabies, fungal infection
• consider medication – opioids in particular codeine, 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
• iron deficiency +/-anaemia
• chronic kidney disease
• hepatitis
• thyroid disease
• lymphoma
• hepatoma
• diabetes
• leukaemia
• primary biliary cirrhosis
• mycosis fungoides
• multiple myeloma
• paraneoplastic
• polycythaemia.

General advice

• Where possible treatment should be cause specific.
• Treat underlying cause(s). Review medication to exclude a drug reaction.
• Use an emollient liberally and frequently as a moisturiser.
• Add an emollient to bath water and use emollient as a soap substitute (refer to local guidelines). All emollients improve dry skin which consequently improves itch. Some emollients contain specific antipruritic agents (refer to topical agents below).
• Consider a sedating antihistamine, such as QThydroxyzine 25mg at night, if confident that the pruritic pathway is activated by histamine or if sleep disturbance remains despite other antipruritic measures.

Non pharmacological management

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

Pharmacological management – for systemic disease

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

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Topical agents

• Emollients or emollient with active ingredient (for example menthol 1%).
• Crotamiton 10% cream (for example 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.
• Be aware of the risk of fire when using emollients containing paraffin (refer to MHRA update).  

• Avoid topical antihistamines as they can cause allergic contact dermatitis.
• Systemic treatment is often unnecessary if skin care improves symptoms.
• Reserve systemic medication for patients who have persistent symptoms despite topical therapy.
• Avoid vasodilators such as caffeine, alcohol, spices and hot water.
• Ointments are better at relieving dry skin than creams or lotions, but take longer to be absorbed into the skin and may not be as well tolerated.

• NHS Inform: Itching
• Macmillan: Managing symptoms

Alshammay SA, Duraisamy BP, Alsuhail A. Review of management of pruritus in palliative care. J Health Spec. 2016;4(1):17-23.

Clinical Knowledge Summaries. Itch - widespread. 2015 [cited 2018 Oct 03]; Available from: https://cks.nice.org.uk/itch-widespread.

Davis MP, Frandsen JL, Walsh D, Andresen S, Taylor S. Mirtazapine for pruritus. J Pain Symptom Manage. 2003;25(3):288-91.

Elsaie LT, El Mohsen AM, Ibrahim IM, Mohey-Eddin MH, Elsaie ML. Effectiveness of topical peppermint oil on symptomatic treatment of chronic pruritus. Clin Cosmet Investig Dermatol. 2016;9:333-8.

European Association for the Study of the Liver. EASL Clinical Practice Guidelines: management of cholestatic liver diseases. J Hepatol. 2009;51(2):237-67.

Hundley JL, Yosipovitch G. Mirtazapine for reducing nocturnal itch in patients with chronic pruritus: a pilot study. J Am Acad Dermatol. 2004;50(6):889-91.

MHRA.  2018.  Emollients: new information about risk of severe and fatal burns with paraffin-containing and paraffin-free emollients.  Available: https://www.gov.uk/drug-safety-update/emollients-new-information-about-risk-of-severe-and-fatal-burns-with-paraffin-containing-and-paraffin-free-emollients [Accessed 21 Jan 2019]

Primary Care Dermatological Society. Pruritus (without a rash). 2018 [cited 2018 Oct 03]; Available from:http://www.pcds.org.uk/clinical-guidance/pruritus-without-a-rash

Siemens W, Xander C, Meerpohl JJ, Buroh S, Antes G, Schwarzer G, et al. Pharmacological interventions for pruritus in adult palliative care patients. 2016 [cited 2018 Oct 03]; Available from:https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008320.pub3/epdf/full

Twycross R, Wilcock A, Howard P. Palliative Care Formulary PCF6. 6th ed. England: Pharmaceutical Press; 2017.

Twycross R, Wilcock A, Toller CS. Symptom Management in Advanced Cancer. 4th ed. Nottingham: palliativedugs.com; 2009.