Pruritus in palliative care

Severe pruritus may be seen as a rare complication in some cancer patients (although mild pruritus may occur as a result of dry skin, candida infections or local inflammation).

In majority of patients severe pruritus can be attributed to cholestasis but other causes of itch in cancer patients include:

• paraneoplastic itch – typically, suppression of the tumor growth will arrest pruritus and in some instances it may precedes diagnosis of cancer by months (or sometimes by years) e.g. – lymphomas
• neuropathic itch – due to the damage caused by localized growth of the tumor (1)

Pruritus associated with obstructive jaundice often responds to simple measures such as emollients.

In cases of obstuctive jaundice, further measures include:

• cholestyramine
• rifampicin
• naltrexone (1)
• an anabolic steroid such as danazol (2)
• antihistamines: chlorphenamine (piriton) 4mg 3 times/day may sedate - loratadine 10mg daily does not usually sedate

In paraneoplastic itch, patients may respond to paroxetine or sertraline therapy (1).

For neuropathic itch, Gabapentin may be useful (1).

Reference:

• (1) Zylicz Z, Krajnik M. Treatment of pruritus in malignant diseases. Adv. Pall. Med. 2009; 8,1: 7–12
• (2) Twycross R et al. Itch: scratching more than the surface. Q J Med 2003; 96: 7-26