Itching (pruritis) is a rare but distressing symptom. Intense itch is a form of pain.

Causes include:

  1. Eczema or allergy

  2. Candidiasis

  3. Drug reactions

  4. Cholestasis

  5. Malignant skin infiltration

  6. Generalized non-specific

  Itching is made worse by anxiety or boredom.

1. Eczema or skin allergies can still occur in terminally ill patients, and respond to topical steroids. There is usually a past history.

2. Candidiasis causes soreness as well as itch. Damp macerated skin (in groin, gluteal cleft, under breasts) can become infected with candida because maceration (excessive water in the keratin layer of the skin) breaks the protective barrier of keratin and allows infection to enter. Treat with an antifungal lotion, miconazole nitrate 2%, to allow evaporation and drying of the skin.

3. Drug reactions are usually obvious, with rash or urticaria. Some drugs (chlorpromazine, for example) cause cholestasis. Epidural morphine can cause itching which can respond to antihistamines.

4. Cholestasis causes itching due to bile-salt retention in the skin. In the early stages jaundice may not be obvious. (see Jaundice)

Management options include:

  • Cholestyramine 4g every 6 to 8 hours

  • Aluminum hydroxide 1.5ml every 6 hours

  • Antihistamines

  • Biliary stent (see Jaundice)

  • Radiotherapy to nodes at the porta hepatis

  • High dose steroids to relieve biliary pressure

Cholestyramine binds to bile-salts and reduces absorption. It is unpleasant to take. Aluminum hydroxide also reduces bile-salt absorption but is less effective. Antihistamines will reduce bile-salt itching in some patients. The non-specific measures discussed below can also help.

5. Malignant skin infiltration around a breast cancer sometimes causes pricking pain and itch which can respond to an anti-prostaglandin such as naproxen 250mg to 500mg 2 times a day.

6. Non-specific itch may be reduced by one or more of the following measures:

  • Avoid heat

  • Treat dry skin

  • Apply calamine lotion

  • Apply 10% crotamiton cream

  • Antihistamines

  • Night sedation

  • Methyltestosterone

  • Apply topical steroids

  • Plasma exchange

Overheating increases itching. Avoid hot baths and use cotton clothes to reduce sweating.

Dry skin can contribute to all forms of itching. Skin hydration often reduces itch. In normal skin a layer of grease (from the sebaceous glands) keeps the keratin layer hydrated and firm. With dry skin, keratin flakes off and exposes deeper layers causing inflammation and itch. Generous use of aqueous cream as a soap substitute and bland bath oils can restore skin hydration.

Calamine lotion is soothing. It cools by evaporation and leaves a fine coating of powder.

10% crotamiton cream has an anti-pruritic action, but avoid the eyes.

Antihistamines can reduce all forms of itch. They are successful for some patients but not for others. Terfenadine 60mg 2 times a day is useful because it is not sedating. A sedative antihistamine (oral promethazine 75mg, for example) can be useful at bedtime.

Methyltestosterone 25mg 3 times a day occasionally reduces severe itching, despite its known tendency to cause cholestasis. The mode of action is unknown. It takes 7 to 10 days for maximum effect. It is contraindicated in cancers of the prostate or male breasts.

Topical steroid cream may be necessary if there is secondary inflammation from scratching.

Plasma exchange has been used as a last resort to relieve intense itch.

The author and publisher have taken precautions to ensure that the information in this book is error-free. However, readers must be guided by their own personal and professional standards of good practice in evaluating and applying recommendations made herein. The contents of this book represent the views and experience of the author, and not necessarily those of the publisher.

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