Cholestatic jaundice Chronic kidney disease Iron deficiency +/-anaemia. Hepatoma Diabetes Leukaemia

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1 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 Copyright 2014 NHS Scotland Page 1 of 5

2 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 QT 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. Copyright 2014 NHS Scotland Page 2 of 5

3 Medication 1 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 1 st line 2 nd line 3 rd 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 Naltrexone 100 to 300mg (following dialysis) 50mg daily Lymphoma Prednisolone Cimetidine 400mg 10 to 20mg three times daily twice daily 15 to 30mg at Systemic opioid-induced pruritis Chlorphenamine 4 12mg (if benefit 4mg three times daily) If no benefit switch opioid QT Ondansetron 8mg twice daily Paraneoplastic Paroxetine 5 to 20mg once daily 15 to 30mg at Unknown Chlorphenamine 4 to 12mg (if benefit 4mg three times daily) Paroxetine 5 to 20mg once daily daily 7.5 to 15mg at 1 Indicates this use is off licence QT Indicates this medication is associated with QT prolongation Copyright 2014 NHS Scotland Page 3 of 5

4 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 Information from Macmillan Textbooks Twycross et al (2009) Symptom management in Advanced cancer 4th edition Ch Palliativedrugs.com Ltd Palliative Care Formulary (PCF4) 4th edition (2011) pallitaivedrugs.com Ltd References European Association for the Study of The, L EASL Clinical Practice Guidelines: Management of cholestatic liver diseases. Journal of Hepatology, 51(2), pp Map of Medicine Pruritis [Online]. Available: [Accessed 10 December 2013]. National Institute for Health and Care Excellence Clinical Knowledge Summaries: Itch - widespread [Online]. Available: [Accessed 10 December 2013]. Palliativedrugs.Com Ltd Palliativedrugs.com [Online]. Available: [Accessed 10 December 2013]. Copyright 2014 NHS Scotland Page 4 of 5

5 The Primary Care Dermatology Society Pruritus (without a rash) [Online]. Available: [Accessed 10 December 2013]. Twycross, R. G. and Wilcock, A Palliative Care Formulary (PCF4). 4th ed. Nottingham: Palliativedrugs.com Ltd. Twycross, R. G., Wilcock, A. and Toller, C. S Symptom Management in Advanced Cancer. 4th ed. Nottingham: Palliativedrugs.com Ltd. Xander, C., Meerpohl Joerg, J., Galandi, D., Buroh, S., Schwarzer, G., Antes, G. and Becker, G Pharmacological interventions for pruritus in adult palliative care patients. Cochrane Database of Systematic Reviews [Online]. Available: Copyright 2014 NHS Scotland Page 5 of 5