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Itch: A palliative care thread
As with Nausea and Vomiting the best approach is to identify the underlying cause if possible. Treatment can be targeted to best improve symptoms and reduce side-effects
Start with a good history as always
As with Nausea and Vomiting the best approach is to identify the underlying cause if possible. Treatment can be targeted to best improve symptoms and reduce side-effects
Start with a good history as always
History:
I approach this in a similar way to a pain history SOCRATES:
Site: often abdomen, palms, soles
Onset: local or generalised
Character: neuropathic pain?
Rash
Associated featues: sweating?
Timing (see below)
Exacerbating/alleviating factors
Severity
I approach this in a similar way to a pain history SOCRATES:
Site: often abdomen, palms, soles
Onset: local or generalised
Character: neuropathic pain?
Rash
Associated featues: sweating?
Timing (see below)
Exacerbating/alleviating factors
Severity
Timing: Anything that causes increased blood flow to the skin can exacerbate itch
Alcohol
Caffeine
Spicy food
Hot baths
And warm beds
Note these are common and pleasurable things: Itch can impact hugely on quality of life
Alcohol
Caffeine
Spicy food
Hot baths
And warm beds
Note these are common and pleasurable things: Itch can impact hugely on quality of life
Ask about
Medication : opioids, SSRI, ACE-i, chemotherapy
Cholestasis: steattorhoea, dark urine, pale stools
Systemic illness: Renal failure, polycythaemia, iron deficiency, thyroid disease, liver disease
Previous skin conditions: eczema and psoriasis, lichen planus
Medication : opioids, SSRI, ACE-i, chemotherapy
Cholestasis: steattorhoea, dark urine, pale stools
Systemic illness: Renal failure, polycythaemia, iron deficiency, thyroid disease, liver disease
Previous skin conditions: eczema and psoriasis, lichen planus
Don’t forget to ask about the downstream effects of itch. It can lead to
Insomnia
Depression
Anxiety
Social isolation
Body image concerns
And even suicidal ideation
Insomnia
Depression
Anxiety
Social isolation
Body image concerns
And even suicidal ideation
Examination:
Dry skin
Sweating
Rashes, blisters and excoriations: look for localised pattern to these
Superimposed infection
Nail and hair changes:psoriasis
Jaundice
Stigmata of liver disease
Signs of systemic disease such as thyroid disorders or iron deficiency
Dry skin
Sweating
Rashes, blisters and excoriations: look for localised pattern to these
Superimposed infection
Nail and hair changes:psoriasis
Jaundice
Stigmata of liver disease
Signs of systemic disease such as thyroid disorders or iron deficiency
General management
Make sure skin is well moisturised
Prescribe an emollient
Creams and lotions for most skin
Ointments for very dry skin
Add emollient to bath water such as Dermol wash
Stop offending medications if possible
Avoid strong perfumes, deodorants and sunburn.
Make sure skin is well moisturised
Prescribe an emollient
Creams and lotions for most skin
Ointments for very dry skin
Add emollient to bath water such as Dermol wash
Stop offending medications if possible
Avoid strong perfumes, deodorants and sunburn.
Itch in palliative care falls into two groups
Histamine induced: e.g opioids
Non-histamine induced: e.g. cholestasis or uraemic itch
Opioid and serotonin receptors play a role, remember itch shares similar peripheral receptors and spinal pathways with pain sensation.
Histamine induced: e.g opioids
Non-histamine induced: e.g. cholestasis or uraemic itch
Opioid and serotonin receptors play a role, remember itch shares similar peripheral receptors and spinal pathways with pain sensation.
Opioid induced itch
Mediated by histamine release
1st line : anti-histamine such as chlorphenamine (piriton) 4mg t.i.d
2nd line : change to a different opioid
3rd line: ondansetron up to 8mg b.d
Itch often felt around nose and face. Patients may reach for face when drowsy
Mediated by histamine release
1st line : anti-histamine such as chlorphenamine (piriton) 4mg t.i.d
2nd line : change to a different opioid
3rd line: ondansetron up to 8mg b.d
Itch often felt around nose and face. Patients may reach for face when drowsy
Cholestatic itch
Often palms and soles of feet
Worse at night
Can occur before jaundice
1st Line: Rifampicin: warn about change in colour of urine, tears and saliva (orange-red)
2nd: Sertraline or Danazol
3rd: Naltrexone (caution with opioids as will reduce analgesic effect)
Often palms and soles of feet
Worse at night
Can occur before jaundice
1st Line: Rifampicin: warn about change in colour of urine, tears and saliva (orange-red)
2nd: Sertraline or Danazol
3rd: Naltrexone (caution with opioids as will reduce analgesic effect)
Uraemic itch
Often on back and arms
Better day 1 after dialysis
1st line: UVB phototherapy or capsaicin 0.025% cream (if localised)
2nd line: Doxepin or Gabapentin
3rd line: Mirtazapine
Itch is not histamine related and newer therapies emerging https://www.nejm.org/doi/full/10.1056/NEJMoa1912770
Often on back and arms
Better day 1 after dialysis
1st line: UVB phototherapy or capsaicin 0.025% cream (if localised)
2nd line: Doxepin or Gabapentin
3rd line: Mirtazapine
Itch is not histamine related and newer therapies emerging https://www.nejm.org/doi/full/10.1056/NEJMoa1912770
Itch in Lymphoma/ leukaemia
Tends to be generalised itch
Often painful, intense.
1st line: Systemic corticosteroids
Do NOT start steroids without speaking to a haematologist first. Steroid may interfere with inital diagnosis.
2nd line: Cimetidine or Mirtazapine
Tends to be generalised itch
Often painful, intense.
1st line: Systemic corticosteroids
Do NOT start steroids without speaking to a haematologist first. Steroid may interfere with inital diagnosis.
2nd line: Cimetidine or Mirtazapine
Unknown paraneoastic itch
Localised: emollient, capsaicin cream or menthol im aqueous cream (Dermacool)
Generalised: paroxetine or sertraline
In resistant cases consider thalodomide. Highly effective but can cause neuropathy so consider quality of life
Localised: emollient, capsaicin cream or menthol im aqueous cream (Dermacool)
Generalised: paroxetine or sertraline
In resistant cases consider thalodomide. Highly effective but can cause neuropathy so consider quality of life
Specifics
Cholestasis: Itch is one of the indications to consider palliative biliary stenting.
Uraemia: Dialysis can give temporary relief. Renal transplant is usually definitive.
Oncological treatment of underlying malignancy. Steroids can reduce lymphoma itch dramatically
Cholestasis: Itch is one of the indications to consider palliative biliary stenting.
Uraemia: Dialysis can give temporary relief. Renal transplant is usually definitive.
Oncological treatment of underlying malignancy. Steroids can reduce lymphoma itch dramatically
Important!!
Speak to the patient’s oncology, surgical, haematology or renal team. They will have managed itch many times.
The thread above is an outline of approaches. Guidelines for Scotland below
https://www.palliativecareguidelines.scot.nhs.uk/guidelines/symptom-control/Pruritis.aspx
Speak to the patient’s oncology, surgical, haematology or renal team. They will have managed itch many times.
The thread above is an outline of approaches. Guidelines for Scotland below
https://www.palliativecareguidelines.scot.nhs.uk/guidelines/symptom-control/Pruritis.aspx
Final note
Dermatologists are fantastic!
I have had personal experience as a teenager who got Roaccutane. It transformed my late teens.
If there is a rash with itch, I’ve always found Dermatology review improves patient and staff journeys.
Dermatologists are fantastic!
I have had personal experience as a teenager who got Roaccutane. It transformed my late teens.
If there is a rash with itch, I’ve always found Dermatology review improves patient and staff journeys.
