Palliative Care Guidelines
Jimmy S Bilimoria Foundation



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 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


  • 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
CauseStep 1Step 2Step 3
CholestasisRifampicin 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 weeksNaltrexone 12.5 – 50mg PO OD
UraemiaCapsaicin 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
LymphomaPrednisolone 10 – 20mg PO tidCimetidine 800mg PO/24 hoursCarbamazepine 200mg PO bd
Systemic opioidsChlorphenamine 4 – 12mg PO stat; if any benefit after 2 – 3 hours, then 4mg PO tid or
Cetirizine 10mg PO hsod
Switch opioidOndansetron 8 mg PO bd
ParaneoplasticSertraline 50 to 100mg PO OD or
Paroxetine 5 – 20mg PO OD
Mirtazapine 15 – 30mg PO hsodThalidomide 100 – 200mg PO hsod
Unknown aetiologyChlorphenamine 4 – 12 mg PO stat; if any benefit after 2 – 3 hours, then 4mg PO tidParoxetine 5 – 20 mg PO ODMirtazapine 7.5 – 15mg PO hsod


  • 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 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)

Palliative Care Guidelines