Treatment
Patient Education and Elimination of Provocative Factors
Topical Skin Care
Skin Cleansing
Environment
Pharmacologic Therapy
Physical Modalities

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 of pruritus can be grouped into four categories:[1,2]

1. Patient education and minimizing or eliminating provocative factors.



2. Application of topical preparations.



3. Systemic therapy.



4. Physical treatment modalities.

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).

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]

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.

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]

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]

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

1. 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. 
   
   
2. Dangel RB: Pruritus and cancer. Oncol Nurs Forum 13 (1): 17-21, 1986 Jan-Feb.  [PUBMED Abstract]
   
   
3. Klein L: Maintenance of healthy skin. J Enterostomal Ther 15 (6): 227-31, 1988 Nov-Dec.  [PUBMED Abstract]
   
   
4. 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. 
   
   
5. 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. 
   
   
6. Blank L: Factors which influence the water content of the stratum corneum. J Invest Dermatol 18(2): 133-139, 1952. 
   
   
7. Hilderley L: Skin care in radiation therapy. A review of the literature. Oncol Nurs Forum 10 (1): 51-6, 1983 Winter.  [PUBMED Abstract]
   
   
8. De Conno F, Ventafridda V, Saita L: Skin problems in advanced and terminal cancer patients. J Pain Symptom Manage 6 (4): 247-56, 1991.  [PUBMED Abstract]
   
   
9. Hassey KM: Skin care for patients receiving radiation therapy for rectal cancer. J Enterostomal Ther 14 (5): 197-200, 1987 Sep-Oct.  [PUBMED Abstract]
   
   
10. Maienza J: Alternatives to cornstarch for itchiness. Oncol Nurs Forum 15 (2): 199-200, 1988 Mar-Apr.  [PUBMED Abstract]
    
    
11. Hassey KM, Rose CM: Altered skin integrity in patients receiving radiation therapy. Oncol Nurs Forum 9 (4): 44-50, 1982 Fall.  [PUBMED Abstract]
    
    
12. Yasko JM, Hogan CM: Pruritus. In: Yasko J, ed.: Guidelines for Cancer Care: Symptom Management. Reston, Va: Reston Publishing Company, Inc., 1983, pp 125-129. 
    
    
13. Geltman RL, Paige RL: Symptom management in hospice care. Am J Nurs 83 (1): 78-85, 1983.  [PUBMED Abstract]
    
    
14. Levy M: Symptom control manual. In: Cassileth BR, Cassileth PA, eds.: Clinical Care of the Terminal Cancer Patient. Philadelphia, Pa: Lea and Febiger, 1982, pp 214-262. 
    
    
15. Winkelmann RK: Pharmacologic control of pruritus. Med Clin North Am 66 (5): 1119-33, 1982.  [PUBMED Abstract]
    
    
16. Supportive Care. In: Casciato DA, Lowitz BB: Manual of Bedside Oncology. Boston, Mass: Little & Brown, 1983, pp 59-95. 
    
    
17. 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. 
    
    
18. Daly BM, Shuster S: Effect of aspirin on pruritus. Br Med J (Clin Res Ed) 293 (6552): 907, 1986.  [PUBMED Abstract]