Pruritis: Information for clinicians

This information is inspired by Dr Tony Duffy 

Pruritus/itch can be incredibly disruptive causing pain, insomnia and infection from excessive scratching.

Itch in palliative care falls into two groups – the cause will guide treatment:

  1. Histamine-induced: e.g. opioids or allergic dermatitis
  2. Non-histamine induced: e.g. cholestasis/jaundice or renal failure
Red flags

Don’t just prescribe an anti-histamine e.g. chlorphenamine, without thinking about the cause. This will cause sedation without helping the itch if it is not histamine-induced.

Key clinical features for a clinician to assess in the community
  • Review underlying diagnosis e.g. liver disease, renal failure, cancer.
  • Consider primary skin disease e.g. eczema or psoriasis
  • Medication review e.g. opioids can cause itch but any new medication could be the cause
  • Signs or symptoms of common infection – e.g. candidiasis, scabies
An initial approach to treatment
  • Stop offending drugs or reduce dose
  • For opioid-induced itch try an anti-histamine
  • Blood tests: full blood count, ferritin, c-reactive protein, urea and electrolytes, liver function tests, bone profile, thyroid function tests, blood glucose
  • Menthol 2%-5% in aqueous cream has the best evidence as counter-irritant but any emolient may help
  • Consider a sedating antihistamine, such as Hydroxyzine 25mg at night, if confident that the pruritis is mediated by histamine release
Specific treatments according to cause

Cause

Initial approach to treatment

Opioid induced itch mediated by histamine release

Other medicines e.g. antibiotics

Anti-histamine such as:

  • Chlorphenamine (Piriton) 4mg b.d.
  • Hydroxyzine 25mg at night (sedating)
  • Loratadine 10mg daily (less sedating)

Consider: switch to different opioid

Consider: Ondansetron up to 4-8mg b.d. (constipating)

Cholestatic jaundice

  • Sertraline 25mg-50mg
  • Mirtazepine 7.5mg-15mg
  • Steroids e.g. Dexamethasone 4mg-8mg (not long term)

Itch is not histamine related

Consider: Biliary stenting

Chronic kidney disease->uraemia

  • Gabapentin 100mg t.d.s. can be very effective
  • Sertraline 25mg-50mg
  • Mirtazepine 7.5mg-15mg

Itch is not histamine related

Lymphoma/leukaemia

Steroids can reduce lymphoma itch dramatically

Consider: Cimetidine 400mg b.d.

Paraneoplastic or Unknown

Localised:

  • Capsaicin cream
  • Menthol in aqueous cream (Dermacool)

Generalised:

  • Sertraline 25mg-50mg
  • Mirtazepine 7.5mg-15mg

If no better, try Chlorphenamine or Loratidine

If none of the above help, then speak to your local palliative care team for more ideas.

 

Recommended Resources

Isle of Wight Palliative Care Symptom Control Guidelines

Published 28th May 2021

JPSM Chronic Pruritus: Histamine Is Not Always the Answer

Published 1st May 2015

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