Pruritus: scratching the surface.

Abstract

Patients who are jaundiced have an accumulation of bile acids in the plasma, which can cause intense irritation. Pruritus associated with cholestasis is a difficult problem; the pathogenesis remains unknown. In severe cases, it can lead to sleep deprivation and contribute to significant psychological disturbances. Patients who have pancreatic cancer with unrelieved jaundice often say the itching is the worst symptom. Typically patients are prescribed Chlorpheniramine, an antihistamine, and Choleystiramine, which binds bile salts in the bowel and helps to facilitate their excretion. Choleystiramine only works if biliary obstruction is incomplete; it is not very palatable and can cause diarrhoea. A review of the literature revealed that certain drugs not intended for the treatment of pruritus associated with malignant cholestasis eased the symptoms considerably. There was very little relating to skin care in the majority of articles dealing with pruritus. Twycross (1997, Introducing Palliative Care, pp. 112-114) stated that most patients with advanced cancer and pruritus may never need an antihistamine if given appropriate skin care and that drugs are of little use in isolation. A regime of skin care was devised with the main aim of keeping the skin moist and cool. Factors were identified that would alleviate or aggravate the skin surface. With prompt treatment, symptoms were reduced and in some cases eradicated completely. The information gained has led to the planning of a trial to determine efficacy of skin care management and different drug therapies to relieve debilitating pruritus when established treatments fail. Key points include: (1) treatment of pruritus associated with malignant disease is directed towards effective management of the underlying cause; (2) given the subjective nature of pruritus, it is poorly understood and management presents a challenging problem; and (3) effective skin management can help to alleviate debilitating symptoms. Certain drugs not intended for treatment of pruritus associated with malignant cholestasis have proven to be effective.