INTRODUCTION

Pruritus or itch though not a common symptom seen in palliative care. Pruritus can be described as an unpleasant sensation of the skin that provokes the desire to scratch or rub. It is very distressing and adversely affects the quality of life. It can lead to frustration, mood disorders, lack of sleep and difficulty in activities of daily living.
The major causes of pruritus in advanced malignancy are:

• Dermatological
• Generalised skin problems – Psoriasis, atopic dermatitis, contact dermatitis, urticaria, xerosis (dry skin), candidiasis, lice, scabies, fungal infection
• Systemic
• Cholestatic jaundice
• Chronic kidney disease
• Haematological disorders – iron deficiency anaemia, polycythaemia rubravera, leukaemia, lymphoma
• Medications – opioids, selective serotonin re-uptake inhibitors (SSRIs), ACE inhibitors, chemotherapy
• Endocrine disorders – diabetes mellitus, thyroid dysfunction, hyperparathyroidism, hypoparathyroidism
• Neuropathic/neurogenic
• Neuroendocrine tumours, paraneoplastic tumours, multiple sclerosis, stroke, brain injury
• Psychogenic

ASSESSMENT

• Assessment must determine the underlying cause of pruritus, effectiveness of treatment and impact on quality of life for the patient and their family (refer to the Guideline – Symptom Assessment)
• A thorough skin examination should be done to try and identify local/systemic causes.
• Investigations (If appropriate)
• Renal function tests, liver function tests, urea and electrolytes, blood counts, blood glucose, thyroid function tests, ferritin, C-reactive protein

MANAGEMENT

• Correct the correctable
• Treat the underlying cause
• Atopic dermatitis – use a topical corticosteroid with an emollient
• Contact dermatitis – avoid the allergen and use topical corticosteroid
• Scabies – topical permethrin cream or malathion lotion
• Cholestatic jaundice – biliary stenting if appropriate
• Hodgkin’s lymphoma – radiotherapy and/or chemotherapy
• Review medications likely to be the cause of pruritus and prescribe alternative
• Non-pharmacological measures
• Avoid soap and talcum powder
• Frequent application of moisturizer
• Wear loose soft clothing, preferably cotton
• An ambient cooler room temperature
• Advise the patient to keep the nails short and to rub gently or pat rather than scratch
• Advise the patient to pat dry the skin with a soft towel after bathing
• Apply emollients after bathing
• Uraemia – UVB phototherapy
• Pharmacological measures
• Topical agents
• Corticosteroids – Anti-inflammatory; should be used for localised itch associated with inflamed, non-infected skin and for short-term use only
• Lidocaine 2.5% cream
• Emollients should be pH neutral and free of alcohol and fragrance
• Menthol 1-2%
• Capsaicin 0.025% for localized itch
• Systemic treatment

Cause	Step 1	Step 2	Step 3
Cholestasis	Rifampicin 300 – 600mg PO OD or Sertraline 50 – 100 mg PO OD or Cholestyramine 4g PO up to four times daily	Danazol 200 mg PO OD – tid; if effective titrate downwards (e.g. to thrice weekly) in two to three weeks	Naltrexone 12.5 – 50mg PO OD
Uraemia	Capsaicin 0.025 – 0.075% OD -qid or UVB phototherapy	Doxepin 10 mg PO bd or Gabapentin 100 – 400mg PO after dialysis	Sertraline 50 mg PO OD or Naltrexone 50 mg PO OD
Lymphoma	Prednisolone 10 – 20mg PO tid	Cimetidine 800mg PO/24 hours	Carbamazepine 200mg PO bd
Systemic opioids	Chlorphenamine 4 – 12mg PO stat; if any benefit after 2 – 3 hours, then 4mg PO tid or Cetirizine 10mg PO hsod	Switch opioid	Ondansetron 8 mg PO bd
Paraneoplastic	Sertraline 50 to 100mg PO OD or Paroxetine 5 – 20mg PO OD	Mirtazapine 15 – 30mg PO hsod	Thalidomide 100 – 200mg PO hsod
Unknown aetiology	Chlorphenamine 4 – 12 mg PO stat; if any benefit after 2 – 3 hours, then 4mg PO tid	Paroxetine 5 – 20 mg PO OD	Mirtazapine 7.5 – 15mg PO hsod

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REFERENCES

• Alshammary, S.A., Duraisamy, B.P., Alsuhail, A. Review of management of pruritis in palliative care. Journal of Health Specialities. (2016); 4(1): 17-23
• Bassari, R., and Koea, J. Jaundice associated pruritis: A review of pathophysiology and treatment. World Journal of Gastroenterology. (2015); 21(5): 1404-1413
• Nursing Practice Review – End of Life. Management of pruritis in palliative care. Retrieved online from https://www.nursingtimes.net/clinical-archive/end-of-life-and-palliative-care/management-of-pruritus-in-palliative-care/7005495.article on 17 January 2019
• Oxford Textbook of Palliative Medicine (pp. 724-739)
• Seccareccia, D., and Gebara, N. Pruritis in palliative care – Getting up to scratch. Canadian Family Physician. (2011); 57: 1010-1013
• Twycross, R., Wilcock, A., Howard, P. (2014). Drugs for Pruritis. Palliative Care Formulary 5. (pp. 939-947)