Table of Contents Purpose of This PDQ Summary Overview Etiology/Pathophysiology
Assessment Interventions Get More Information From NCI Changes to This Summary (08/14/2008) Questions or Comments About This Summary More Information
Purpose of This PDQ Summary
This PDQ cancer information summary provides comprehensive, peer-reviewed information for health professionals about the pathophysiology and treatment of pruritus. This summary is reviewed regularly and updated as necessary by the PDQ Supportive and Palliative Care Editorial Board.
Information about the following is included in this summary:
- Etiology.
- Assessment.
- Intervention.
This summary is intended as a resource to inform and assist clinicians and other health professionals who care for cancer patients during and after cancer treatment. It does not provide formal guidelines or recommendations for making health care decisions. Information in this summary should not be used as a basis for reimbursement determinations.
This summary is also available in a patient version, which is written in less technical language, and in Spanish.
Back to Top Overview
Pruritus (itching) is an unpleasant sensation that elicits the desire to
scratch. It is a distressing symptom that can cause discomfort and threaten
the effectiveness of the skin as a major protective barrier. Because of the
subjective nature of pruritus, the lack of a precise definition, and the lack
of suitable animal models, pruritus is a disorder that has not been researched
adequately.
The skin accounts for 15% of the body's total weight and is the largest organ of
the body. The skin has significant psychosocial and physical functions. Its
function as a protective mechanism is the skin's most important role. But skin
is also essential to self image and one's ability to touch and be touched,
thereby providing an important component of communication.
Symptoms of generalized itching, without rash or skin lesions, may be related
to anything from dry skin to an occult carcinoma, and the etiology of the
symptoms should be explored. Common nonmalignant etiologic factors include
drug reactions, xerosis, scabies, and primary skin diseases. Pruritus is one of
the most common complaints of the elderly patient, but estimates of the
significance of pruritic symptoms in the elderly population vary from 10% to
50%. The most common diagnosis related to pruritus in this population is
simply dry skin.[1]
Generalized pruritus is found in about 13% of all individuals with chronic
renal disease and about 70% to 90% of those undergoing hemodialysis for its
treatment.[2] Cholestatic liver disease with intrahepatic or posthepatic
obstruction, with or without increased serum levels of bile acids, is often
associated with pruritus.[3] Other etiologic factors include (but are not
limited to) primary biliary cirrhosis, cholestasis related to phenothiazines or
oral contraceptives, intrahepatic cholestasis in pregnancy, and posthepatic
obstruction.[3]
References
-
Duncan WC, Fenske NA: Cutaneous signs of internal disease in the elderly. Geriatrics 45 (8): 24-30, 1990.
[PUBMED Abstract]
-
Blachley JD, Blankenship DM, Menter A, et al.: Uremic pruritus: skin divalent ion content and response to ultraviolet phototherapy. Am J Kidney Dis 5 (5): 237-41, 1985.
[PUBMED Abstract]
-
Abel EA, Farber EM: Malignant cutaneous tumors. In: Rubenstein E, Federman DD, eds.: Scientific American Medicine. New York: Scientific American, Inc, Chapter 2: Dermatology, Section XII, 1-20, 1992.
Back to Top Etiology/Pathophysiology
Hematologic disorders that cause pruritus include polycythemia vera. Some
conditions that cause iron deficiency, including exfoliative skin disorder,
also cause pruritus. Diabetes and thyrotoxicosis are endocrine causes of
pruritus.[1]
Pruritus is a frequent clinical manifestation of people with AIDS, AIDS-related
Kaposi sarcoma, and AIDS-related opportunistic infections. Pruritus with or
without rash has been reported in approximately 84% of people with AIDS and
35.5% of those with AIDS-related Kaposi sarcoma. The incidence of pruritus
associated with AIDS-related opportunistic infections approaches 100%.[2]
Various malignant diseases are known to produce pruritus. Hodgkin lymphoma
causes pruritus in 10% to 25% of patients. In some instances, pruritus
precedes diagnosis of the lymphoma [1] and may be an indicator of a less
favorable prognosis when associated with significant fever or weight loss (“B”
symptoms).[3] Pruritus associated with Hodgkin lymphoma is characterized by
symptoms of burning and intense itching occurring on a localized skin area,
frequently on the lower legs. Other lymphomas and leukemias have been
associated with a less intense but more generalized pruritus. Adenocarcinomas
and squamous cell carcinomas of various organs (i.e., stomach, pancreas, lung,
colon, brain, breast, and prostate) sometimes produce generalized pruritus that
is more pronounced on the legs, upper trunk, and extensor surfaces of the upper
extremities.[1,3] Pruritus associated with malignant diseases has been
observed to diminish or disappear with eradication of the tumor and reappear
with recurrence of disease.[3]
Drugs associated with secondary pruritus include opium derivatives (cocaine,
morphine, butorphanol), phenothiazines, tolbutamide, erythromycin estolate,
anabolic hormones, estrogens, progestins, testosterone and subsequent
cholestasis, aspirin, quinidine and other antimalarials, biologics such as
monoclonal antibodies, and vitamin B complex. Subclinical sensitivity to any
drug may be related to pruritus.[3]
Hypothesized mechanisms of pruritus have been inferred from studies of pain,
since pain and itching share common molecular and neurophysiological
mechanisms.[4] Both itch and pain sensations result from the activation of a
network of free nerve endings at the dermal-epidermal junction. Activation may
be the result of internal or external thermal, mechanical, chemical, or
electrical stimulation. The cutaneous nerve stimulation is activated or
mediated by several substances including histamine, vasoactive peptides,
enkephalins, substance P (a tachykinin that affects smooth muscle), and
prostaglandins. It is believed that nonanatomic factors (such as psychological
stress, tolerance, presence and intensity of other sensations and/or
distractions) determine itch sensitivity in different regions of the body.
The itch impulse is transmitted along the same neural pathway as pain impulses,
i.e., traveling from peripheral nerves to the dorsal horn of the spinal cord,
across the cord via the anterior commissure, and ascending along the
spinothalamic tract to the laminar nuclei of the contralateral thalamus.
Thalamocortical tracts of tertiary neurons are believed to relay the impulse
through the integrating reticular activating system of the thalamus to several
areas of the cerebral cortex. Factors that are believed to enhance the
sensation of itch include dryness of the epidermis and dermis, anoxia of
tissues, dilation of the capillaries, irritating stimuli, and psychological
responses.[1,3-5]
The motor response of scratching follows the perception of itch. Scratching is
modulated at the corticothalamic center and is a spinal reflex. After
scratching, itching may be relieved for 15 to 25 minutes. The mechanism
through which the itch is relieved by scratching is unknown. It is
hypothesized that scratching generates sensory impulses that break circuits
in the relay areas of the spinal cord. Scratching may actually enhance the
sensation of itching, creating a characteristic itch-scratch-itch cycle. Other
physical stimuli such as vibration, heat, cold, and ultraviolet radiation
diminish itching and increase the release of proteolytic enzymes, potentially
eliciting the itch-scratch-itch cycle.
A pinprick near or in the same dermatome as an itchy point will abolish the
itch sensation.[3] It is known that hard scratching may substitute pain for
the itch, and in some instances, the patient might find pain the more tolerable
sensation. It is thought that spinal modulation of afferent stimuli (Gate
theory) and central mechanisms may play a role in the relief of itch.[3]
Hypothesized pathogenesis of pruritus associated with underlying disease states
are varied. Biliary, hepatic, renal, and malignant diseases are thought to
produce pruritus through circulating toxic substances. Histamine released from
circulating basophils and the release of leukopeptidase from white blood cells
may trigger pruritus associated with lymphomas and leukemias. Elevated blood
levels of kininogen in Hodgkin lymphoma, release of histamine or bradykinin
precursors from solid tumors, and release of serotonin in carcinoid may all be
related to pruritus.[1,6]
People receiving cytotoxic chemotherapy, irradiation, and/or biologic response
modifiers for treatment of malignancy are likely to experience pruritus. This
same population is quite likely to be exposed to many of the other etiologic
factors relating to pruritus ranging from nutritionally related xerosis (dry
skin) to radiation desquamation, chemotherapy and biologic agent–induced side
effects, antibiotic reactions, and other drug sensitivities.
Cytotoxic Chemotherapy
Each of the major classes of antineoplastic agents (alkylating agents,
antimetabolites, antibiotics, plant alkaloids, nitrosoureas, and enzymes)
include drugs capable of producing cutaneous reactions including pruritus.
Patients receiving antineoplastic drugs frequently report dry skin and scaling,
thought to be related to effects on sebaceous and sweat glands.[7,8] Many
problems are self-limiting and require no active intervention. Other problems
warrant anticipation and implementation of preventive measures.
Hypersensitivity to cytotoxic agents can be manifested by pruritus, edema,
urticaria, and erythema. Hypersensitivity reactions vary in symptomatology and
depend on the drug, the dosage, and the allergy history of the patient. The
agents most associated with hypersensitivities include doxorubicin,
daunorubicin, cytarabine, L-asparaginase, paclitaxel, and cisplatin. In most
reports, these reactions have been localized to the area of the vascular access
and dissipate within 30 to 90 minutes.[9,10] More dramatic and even
life-threatening reactions can occur, and the development of pruritus may
represent an early stage of serious hypersensitivity reactions.[11]
Radiation Therapy
Radiation therapy–related pruritus is usually associated with dry desquamation
of skin within the treatment field. Dryness and pruritus may occur at an
accumulated dose of 20 Gy to 28 Gy,[12] and is caused by obliteration of
sebaceous glands within the field. This is an acute phenomenon that correlates
with the depletion of actively proliferating basal cells in the epidermal layer
of the skin, a fixed percentage of which die with each dose fraction of
irradiation. Remaining basal cells undergo cornification and shed at an
increased rate, while nonproliferating basal cells are stimulated and their
cell cycle shortened. Subsequent peeling of the skin is defined as dry
desquamation. The skin becomes dry, and the patient may notice itching and
burning sensations.[12] Dry skin is susceptible to further injury through
scratching and/or formation of fissures, augmenting the risk of infection and
tissue necrosis.
If the desquamation process continues, the dermis will eventually be exposed, resulting in moist desquamation. This side effect increases the risk of
infection, discomfort, and pain, possibly necessitating interruption of a
treatment plan to allow for healing. This interruption can compromise the final outcome of
cancer therapy. For this reason, it is desirable to anticipate and prevent the
progression of skin reactions to this stage.[13]
External beam therapy with electrons may elicit more skin reactions than photon
therapy since the depth of penetration and linear energy transfer is closer to
the skin surface with electrons. Radiation delivery techniques (bolus doses
and tangential fields) also influence the degree of reaction. Fields that
include skin folds (i.e., the axilla, breast, perineum, and gluteus) are
anticipated to have increased reactions because of friction, higher moisture
content, and low aeration.[14,15]
Combination Therapy
Therapy combining radiation and chemotherapy plays a significant role in
state-of-the-art cancer therapy. The synergism of these cytotoxic modalities
enhances normal tissue reaction and can be expected to precipitate higher
complication rates.[7] The total combined effects of the drugs and irradiation
exceed the individual effects of either modality. Significant cutaneous
reactions are thought to occur more frequently when chemotherapy and
irradiation are administered concurrently.[16]
Biologic Response Modifiers
Biologic response modifiers used in the treatment of malignant disease are
associated with a wide variety of side effects and toxic effects. Pruritus has
been a side effect associated with several biologics but has been most
reported in patients receiving interferons.[17-20] Reports of
pruritus as a side effect of biologics are primarily anecdotal and have not
been a focus of attention.
Bone Marrow Transplantation
Graft-versus-host disease (GVHD) affects 25% to 50% of patients who live longer
than 100 days after bone marrow transplantation. The incidence of skin GVHD is
reported to be 80% to 90%, and symptoms vary in severity and type.[21] Reported
skin changes include dryness and pruritic, erythematous, maculopapular rashes.
Onset can be subtle or sudden; skin GVHD can progress to scleroderma and
contracture.[22]
Other Pharmacologic Support During Cancer Treatment
Many pharmacologic agents employed at any point during the cancer course,
whether in a primary treatment plan or incorporated into a symptom control or
supportive care program, are capable of eliciting a pruritic reaction. These
drugs include morphine, other opium derivatives, and aspirin used in pain
management; corticosteroids; antibiotics; phenothiazines; and, to a lesser
degree, hormonal agents (estrogen, progestins, and testosterone).[3]
Mechanisms of these reactions range from hypersensitivity to chemical
interference with neural pathways.[4]
Infection
Pruritus can be a symptom of infection. Pruritus involving anal or vulvar
areas might be caused by infections with Trichomonas or fungi, local tumors,
hemorrhoids, anal fissures, fistula discharge, wound effluent, or surgical
wound drainage.
References
-
Abel EA, Farber EM: Malignant cutaneous tumors. In: Rubenstein E, Federman DD, eds.: Scientific American Medicine. New York: Scientific American, Inc, Chapter 2: Dermatology, Section XII, 1-20, 1992.
-
Dangel RB: Pruritus and cancer. Oncol Nurs Forum 13 (1): 17-21, 1986 Jan-Feb.
[PUBMED Abstract]
-
Bernhard JD: Clinical aspects of pruritus. In: Fitzpatrick TB, Eisen AZ, Wolff K, et al., eds.: Dermatology in General Medicine. 3rd ed. New York, NY: McGraw-Hill, 1987, Chapter 7, pp 78-90.
-
Greaves MW: Pathophysiology of pruritus. In: Fitzpatrick TB, Eisen AZ, Wolff K, et al., eds.: Dermatology in General Medicine. 3rd ed. New York, NY: McGraw-Hill, 1987, Chapter 7, pp 74-78.
-
Duncan WC, Fenske NA: Cutaneous signs of internal disease in the elderly. Geriatrics 45 (8): 24-30, 1990.
[PUBMED Abstract]
-
Abel EA, Farber EM: Drug eruptions and urticaria. In: Rubenstein E, Federman DD, eds.: Scientific American Medicine. New York: Scientific American, Inc, Chapter 2: Dermatology, Section VI, 1-11, 1990.
-
Dunagin WG: Clinical toxicity of chemotherapeutic agents: dermatologic toxicity. Semin Oncol 9 (1): 14-22, 1982.
[PUBMED Abstract]
-
Hood AF: Cutaneous side effects of cancer chemotherapy. Med Clin North Am 70 (1): 187-209, 1986.
[PUBMED Abstract]
-
Gullo SM: Adriamycin extravasation versus flare. Oncol Nurs Forum 7(4): 7, 1980.
-
Barlock AL, Howser DM, Hubbard SM: Nursing management of adriamycin extravasation. Am J Nurs 79 (1): 94-6, 1979.
[PUBMED Abstract]
-
Weiss RB: Hypersensitivity reactions to cancer chemotherapy. In: Perry MC, Yarbro JW, eds.: Clinical Oncology Monographs: Toxicity of Chemotherapy. Orlando, Fla: Grune and Stratton, Inc., 1984, pp 101-123.
-
Hassey KM, Rose CM: Altered skin integrity in patients receiving radiation therapy. Oncol Nurs Forum 9 (4): 44-50, 1982 Fall.
[PUBMED Abstract]
-
Miaskowski C: Potential and actual impairments in skin integrity related to cancer and cancer treatment. Top Clin Nurs 5 (2): 64-71, 1983.
[PUBMED Abstract]
-
O'Rourke ME: Enhanced cutaneous effects in combined modality therapy. Oncol Nurs Forum 14 (6): 31-5, 1987 Nov-Dec.
[PUBMED Abstract]
-
Hassey KM: Skin care for patients receiving radiation therapy for rectal cancer. J Enterostomal Ther 14 (5): 197-200, 1987 Sep-Oct.
[PUBMED Abstract]
-
Phillips TL, Fu KK: Quantification of combined radiation therapy and chemotherapy effects on critical normal tissues. Cancer 37 (2 Suppl): 1186-1200, 1976.
[PUBMED Abstract]
-
Mayer DK, Smalley RV: Interferon: current status. Oncol Nurs Forum 10 (4): 14-9, 1983 Fall.
[PUBMED Abstract]
-
Krown SE: Interferons and interferon inducers in cancer treatment. Semin Oncol 13 (2): 207-17, 1986.
[PUBMED Abstract]
-
Spiegel RJ: Intron A (interferon alfa-2b): clinical overview and future directions. Semin Oncol 13 (3 Suppl 2): 89-101, 1986.
[PUBMED Abstract]
-
Irwin MM: Patients receiving biological response modifiers: overview of nursing care. Oncol Nurs Forum 14 (6 Suppl): 32-7, 1987 Nov-Dec.
[PUBMED Abstract]
-
Sullivan KM, Deeg HJ, Sanders JE, et al.: Late complications after marrow transplantation. Semin Hematol 21 (1): 53-63, 1984.
[PUBMED Abstract]
-
Nims JW, Strom S: Late complications of bone marrow transplant recipients: nursing care issues. Semin Oncol Nurs 4 (1): 47-54, 1988.
[PUBMED Abstract]
Back to Top Assessment
Pruritus is a symptom, not a diagnosis or disease. Generalized pruritus is a
“cardinal symptom of medical significance”[1] and should be taken seriously.
Assessment of pruritus must incorporate an accurate and thorough history and
physical examination. The history includes the following data:[2,3]
- Location, onset, duration, and intensity of itching.
- Previous history of pruritus.
- Previous history of malignant disease.
- Current malignant disease and treatment.
- Nonmalignant systemic diseases.
- Use of analgesics.
- Use of antibiotics.
- Use of other prescription and nonprescription drugs.
- Presence of infection.
- Nutritional and fluid level status.
- Current skin care practices.
- Existence of other pruritic risk factors.
- Review of relevant laboratory values (complete blood cell chemistry).
- Factors that relieve and aggravate itching.
- Patient's emotional state.
Physical examination will provide data from assessment of the following:
- All skin surfaces for signs of infection.
- All skin surfaces for signs of drug reaction.
- Environmental factors (temperature, humidity).
- Physical factors (tight, constrictive clothing).
- Evidence of scratching (erythema, dryness, excoriation).
- Skin turgor, texture, color, temperature, and lesions.
References
-
Bernhard JD: Clinical aspects of pruritus. In: Fitzpatrick TB, Eisen AZ, Wolff K, et al., eds.: Dermatology in General Medicine. 3rd ed. New York, NY: McGraw-Hill, 1987, Chapter 7, pp 78-90.
-
Lydon J, Purl S, Goodman M: Integumentary and mucous membrane alterations. In: Groenwald SL, Frogge MH, Goodman M, et al., eds.: Cancer Nursing: Principles and Practice. 2nd ed. Boston, Mass: Jones and Bartlett, 1990, pp 594-635.
-
Pace KB, Bord MA, McCray N, et al.: Pruritus. In: McNally JC, Stair JC, Somerville ET, eds.: Guidelines for Cancer Nursing Practice. Orlando, Fla: Grune and Stratton, Inc., 1985, pp 85-88.
Back to Top Interventions
Management of pruritus associated with neoplastic disease is directed toward
effective management of the underlying malignancy, elimination of actual or
potential alterations in skin integrity, and promotion of comfort. Given the
subjective nature of itching, the extent to which any therapy is effective may
be modified by psychological factors. Multiple approaches and combined efforts
may be needed to promote comfort and prevent alterations in the integrity of
the skin.
Treatment
Treatment of pruritus can be grouped into four categories:[1,2]
- Patient education and minimizing or eliminating provocative factors.
- Application of topical preparations.
- Systemic therapy.
- Physical treatment modalities.
Patient Education and Elimination of Provocative Factors
Patients and caregivers must be included in planning care and providing care to
the extent possible. Education is an important aspect of symptom control.
Skin care regimens incorporate protection from the environment, good cleansing practices, and internal and
external hydration.[3] The intensity of the regimen and the techniques
employed will vary according to etiologic factors and the degree of distress
associated with the pruritus.
Affected individuals (either patients or caregivers) should have a good
understanding of factors that promote or aggravate itching. Knowledge of
factors that alleviate symptoms provides rationale for the development and
implementation of effective and reasonable self-care interventions.
Adequate nutrition is essential to the maintenance of healthy skin. An optimal
diet should include a balance of proteins, carbohydrates, fats, vitamins,
minerals, and fluids. Daily fluid intake of at least 3,000 cc is
suggested as a guideline but may not be possible for some individuals.[4,5]
Aggravating factors should be avoided, including the following:
- Fluid loss secondary to fever, diarrhea, nausea and vomiting, or decreased
fluid intake.
- Use of ointments (e.g., petroleum, mineral oil).
- Bathing with hot water.
- Use of soaps that contain detergents.
- Frequent bathing or bathing for longer than ½ hour.
- Adding oil early to a bath.
- Genital deodorants or bubble baths.
- Dry environment.
- Sheets and clothing laundered with detergent.
- Tight restrictive clothing or clothing made of wool, synthetics, or other
harsh fabric.
- Emotional stress.
- Use of opium alkaloids, morphine, and antibiotics.
- Underarm deodorants or antiperspirants.
Alleviating factors should be promoted, as follows:
- Basic skin care.
- Application of emollient creams or lotions.
- Use of mild soaps or soaps made for sensitive skin.
- Limiting bathing to ½ hour daily or every other day.
- Adding oil at the end of a bath or adding a colloidal oatmeal treatment
early to the bath.
- Use of cornstarch to areas of irradiated skin following bathing.
- Maintenance of a humid environment (e.g., humidifier).
- Use of cotton flannel blankets if needed.
- Washing of sheets, clothing, and undergarments in mild soaps for infant
clothing (e.g., Dreft).
- Wearing of loose-fitting clothing and clothing made of cotton or other soft
fabrics.
- Use of distraction, relaxation, positive imagery, or cutaneous stimulation.
- Use of antibiotics if pruritus is secondary to infection.
- Use of oral antihistamines, with increased doses at bedtime.
- Use of topical mild corticosteroids (except for pruritus secondary to
radiation therapy).
Topical Skin Care
If pruritus is thought to be primarily related to dry skin, interventions to
improve skin hydration can be employed. The main source of hydration for skin
is moisture from the vasculature of underlying tissues. Water, not lipid,
regulates the pliability of the epidermis, providing the rationale for use of
emollients.[6] Emollients reduce evaporation by forming occlusive and
semiocclusive films over the skin surface, encouraging the production of
moisture in the layer of epidermis beneath the film (hence, the term
moisturizer).[3]
Knowledge of the ingredients of skin care products is essential, since many
ingredients may enhance skin reactions. Three main ingredients of emollients
are petrolatum, lanolin, and mineral oil. Both petrolatum and lanolin may
cause allergic sensitization in some individuals.[3]
Petrolatum is poorly absorbed by irradiated skin and is not easily removed. A
thick layer could produce an undesired bolus effect when applied within a
radiation treatment field.[7] Mineral oil is used in combination with
petrolatum and lanolin to create creams and lotions and may be an active
ingredient in bath oils. Other ingredients added to these products, such as
thickeners, opacifiers, preservatives, fragrances, and colorings, may cause
allergic skin reactions.
Product selection and recommendations must be made in consideration of each
patient's unique needs and should incorporate such variables as the
individual's skin, the desired effect, the consistency and texture of the
preparation, its cost, and acceptability to the patient.[3] Emollient creams
or lotions should be applied at least two or three times daily and after
bathing. Recommended emollient creams include Eucerin or Nivea or lotions such
as Lubriderm, Alpha Keri, or Nivea.[4] Gels with a local anesthetic (0.5%–2%
lidocaine) can be used on some areas, as often as every 2 hours if
necessary.[8]
Some topical agents including talcum powders, perfumed powders, bubble baths,
and cornstarch can irritate the skin and cause pruritus. Cornstarch has been
an acceptable intervention for pruritus associated with dry desquamation
related to radiation therapy, but it should not be applied to moist skin surfaces,
areas with hair, sebaceous glands, skin folds or areas close to mucosal
surfaces, such as the vagina and rectum.[9,10] Glucose is formed when
cornstarch is moistened, providing an excellent medium for fungal growth.[10]
Agents with metal ions (i.e., talcum and aluminum used in antiperspirants)
enhance skin reactions during external beam radiation therapy and should be
avoided throughout the course of radiation therapy. Other common ingredients
in over-the-counter lotions and creams that may enhance skin reactions include
alcohol and menthol. Topical steroids can reduce itching, but they reduce blood flow
to the skin, resulting in thinning of the skin and increased susceptibility to
injury.[11]
Skin Cleansing
The goal of skin cleansing is to remove dirt and prevent odor, but actual
hygienic practices are influenced by skin type, lifestyle, and culture.
Extensive bathing aggravates dry skin, and hot baths cause vasodilation, which
further promotes itching. Many soaps are salts of fatty acids with an alkali
base. Soap is a degreaser and can also irritate skin. Older adults or
individuals with dry skin should limit use of soaps to those areas with
apocrine glands. Plain water should suffice for other skin surfaces. Mild
soaps have less soap or detergent content. Superfatted soaps deposit a film of
oil on the skin surface, but there is no proof that they are less drying than
other soaps and they may be more expensive.
Tepid baths have an antipruritic effect, possibly resulting from capillary
vasoconstriction. The bath should be limited to a half hour every day or every
two days. Examples of mild soaps that can be recommended include Dove,
Neutrogena, and Basis. Oil can be added to the water at the end of the bath or
applied to the skin before towel drying.
Environment
Heat increases cutaneous blood flow and may enhance itching. Heat also lowers
humidity, and skin loses moisture when the relative humidity is less than 40%.
A cool, humid environment may reverse these processes.
Residue left by detergents used in laundering clothes and linens, as well as
fabric softeners and antistatic products, may aggravate pruritus. Detergent
residue can be neutralized by the addition of vinegar (1 teaspoon per quart
of water) to rinse water. Mild laundry soaps marketed for infant items may
offer a solution as well.
Loose-fitting, lightweight cotton clothes and cotton bed sheets are suggested.
The elimination of heavy bedcovers may alleviate itching by decreasing body
heat. Wool and some synthetic fabrics may be irritating. Distraction, music
therapy, relaxation, and imagery may be useful to relieve symptoms.[12]
Pharmacologic Therapy
If treatment of the underlying disease and/or control of other aggravating
factors provides inadequate relief of pruritus, topical and oral medications
may be useful. Topical steroids may provide relief when symptoms are related
to a steroid-responsive dermatosis, but anticipated benefits must be weighed
against the vasoconstrictive side effects. Topical steroids have no role in
the management of pruritus of unknown origin. Topical steroids should not be
applied to skin surfaces inside a radiation treatment field.
Systemic medications useful in the management of pruritus include those
directed toward the underlying disease or control of symptoms. Antibiotics can
reduce symptoms associated with infection. Oral antihistamines may provide
symptomatic relief in histamine-related itching. A higher dose of
antihistamines at bedtime may produce antipruritic and sedative effects.
Diphenhydramine hydrochloride, 25 mg to 50 mg every 6 hours, has demonstrated
effectiveness.[13] Hydroxyzine hydrochloride, 25 mg to 50 mg every 6 to 8
hours, or cyproheptadine hydrochloride, 4 mg every 6 to 8 hours, may provide
symptomatic relief.[14] Oral chlorpheniramine (4 mg) or hydroxyzine (10 mg or
25 mg) orally every 4 to 6 hours has been used with good results.[15] If one
antihistamine is ineffective, one of another class may provide relief.
Sedative or tranquilizing agents may be indicated, especially if relief is not
provided by other agents. Antidepressants can have strong antihistamine and
antipruritic effects.[15] Diazepam may be useful in some situations to
alleviate anxiety and promote rest.[16]
Sequestrant agents may be effective in relieving pruritus associated with renal
or hepatic disease through binding and removing pruritogenic substances in the
gut and reducing bile salt concentration. Cholestyramine is not always
effective and produces gastric side effects.[17]
Aspirin seems to have reduced pruritus in some individuals while increasing
pruritus in others. Thrombocytopenic cancer patients should be cautioned
against using aspirin. Cimetidine alone or in combination with aspirin has
been used with some effectiveness for pruritus associated with Hodgkin lymphoma and polycythemia vera.[18]
Physical Modalities
Alternatives to scratching for the relief of pruritus can help the patient
interrupt the itch-scratch-itch cycle. Application of a cool washcloth or ice
over the site may be useful. Firm pressure at the site of itching, at a site
contralateral to the site of itching, and at acupressure points may break the
neural pathway. Rubbing, pressure, and vibration can be used to relieve
itching.[2,12]
There are anecdotal reports of the use of transcutaneous electronic nerve
stimulators (TENS) and acupuncture in the management of pruritus.[1]
Ultraviolet phototherapy has been used with limited success for pruritus
related to uremia.[1]
References
-
Bernhard JD: Clinical aspects of pruritus. In: Fitzpatrick TB, Eisen AZ, Wolff K, et al., eds.: Dermatology in General Medicine. 3rd ed. New York, NY: McGraw-Hill, 1987, Chapter 7, pp 78-90.
-
Dangel RB: Pruritus and cancer. Oncol Nurs Forum 13 (1): 17-21, 1986 Jan-Feb.
[PUBMED Abstract]
-
Klein L: Maintenance of healthy skin. J Enterostomal Ther 15 (6): 227-31, 1988 Nov-Dec.
[PUBMED Abstract]
-
Lydon J, Purl S, Goodman M: Integumentary and mucous membrane alterations. In: Groenwald SL, Frogge MH, Goodman M, et al., eds.: Cancer Nursing: Principles and Practice. 2nd ed. Boston, Mass: Jones and Bartlett, 1990, pp 594-635.
-
Pace KB, Bord MA, McCray N, et al.: Pruritus. In: McNally JC, Stair JC, Somerville ET, eds.: Guidelines for Cancer Nursing Practice. Orlando, Fla: Grune and Stratton, Inc., 1985, pp 85-88.
-
Blank L: Factors which influence the water content of the stratum corneum. J Invest Dermatol 18(2): 133-139, 1952.
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For more information, U.S. residents may call the National Cancer Institute's (NCI's) Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237) Monday through Friday from 9:00 a.m. to 4:30 p.m. Deaf and hard-of-hearing callers with TTY equipment may call 1-800-332-8615. The call is free and a trained Cancer Information Specialist is available to answer your questions.
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