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PubMed2006

[Pruritus--causes, diagnostics and treatment].

Diagnosis and treatment of pruritus is still a great problem. The pathophysiologic principles are mostly unknown, however the progress in neurosciences also added several new neurophysiologic explanations for pruritus. There exist several different types of pruritus and also the treatment of the different forms varies. The treatment of chronic pruritus is not the same as the treatment of acute pruritus. Usually more than one pathological disorder leads to severe pruritus and therefore the diagnostic of the different forms of pruritus and the treatment needs an interdisciplinary approach. One of the major causes of itch is dry skin, this is true for elderly persons and also for patients with atopic dermatitis. Therefore, the treatment of the dry skin is one of the most important measures against pruritus.

Humans↗
PubMed1991

Halofantrine-induced pruritus amongst subjects who itch to chloroquine.

The incidence and nature of pruritus induced by chloroquine and halofantrine were studied in 82 patients with acute malaria and in 40 healthy subjects, using a visual analogue scale for quantitating pruritus. Results showed that the proportion of patients with acute malaria manifesting itch to halofantrine was significantly lower than the proportion manifesting itch to chloroquine. Furthermore, the intensity and duration of halofantrine-induced pruritus were significantly lower than those of chloroquine-induced pruritus. The few patients who itched to halofantrine all had a history of itching to chloroquine. The incidence and intensity of chloroquine-induced pruritus were significantly higher in patients with malaria than in healthy subjects. By contrast, there was no significant difference between malaria patients and healthy subjects as regards halofantrine-induced pruritus. These results suggest that itchers to halofantrine may constitute a small group within the population of itchers to chloroquine. Malaria infection appears to enhance chloroquine-induced pruritus but not halofantrine-induced pruritus and this may be of therapeutic importance.

Acute Disease↗
PubMed1989

Uremic pruritus. Clinical and experimental studies.

The aim of the study was to investigate clinical aspects of pruritus in maintenance hemodialysis patients and to evaluate factors of putative pathogenic importance. 60-65% of the patients in a maintenance hemodialysis program during a two-year period suffered from itching. Patients with pruritus tended to have been on dialysis treatment longer than those without pruritus (p = 0.05), otherwise there was no difference in clinical data or routine laboratory tests. Measurement of itch intensity continuously over one week in 28 patients using a computerized method showed that itching peaked at night after two days without dialysis, was relatively high during treatment and lowest during the day following dialysis. Our results suggest that the accumulation of pruritogens between dialysis sessions influences the intensity of itching. Most patients had "dry" skin. Recording of the stratum corneum water content by measurement of electrical capacitance, in 31 patients (19 with pruritus) and 12 controls, disclosed no significant difference between dialysis patients and controls, but a tendency that pruritic patients had a lower water content than the other subjects. In different body areas, there was a positive correlation in all groups between the clinical estimation of xerosis and hydration. Serum concentrations of parathyroid hormone (PTH) were significantly higher in dialysis patients with pruritus than in those without, but there was no correlation between the degree of symptoms and the PTH level. Indirect immunohistochemistry revealed no immunoreactivity for different parts of the PTH molecule in skin biopsies from uremic patients. Intradermal injections of PTH fragments did not evoke itching or other cutaneous reactions in patients or controls. Our results do not support PTH as a peripheral mediator of uremic itching. Flare reactions induced by intradermal histamine injections were significantly smaller in 26 dialysis patients (18 with pruritus) than in 9 healthy subjects. However, the itch responses were greater in patients with pruritus than in the other subjects, indicating an augmented sensitivity to pruritogens. Repeated histamine injections induced tachyphylaxis in both uremic patients and controls. Indirect immunohistochemistry revealed neuron-specific enolase (NSE) immunoreactive nerve fibers sprouting throughout the layers of the epidermis in 12 dialysis patients (9 with pruritus) but in none of 15 controls. This finding suggests that hemodialysis patients develop an abnormal pattern of cutaneous innervation.

Adult↗
PubMed1998

[Pruritus and the hepatitis C virus. The MULTIVIRC Unit].

OBJECTIVE: Determine the characteristics of pruritus in a selected population of patients with positive hepatitis C virus serology. PATIENTS AND METHODS: In a retrospective study, we re-examined outpatient reports for patients who consulted for pruritus from January 1993 to April 1996 and were followed in a hepatology unit for hepatitis C infection. The following data were collected: age, sex, risk factors, HIV and HBV serologies, duration of pruritus and diagnosis, ALAT, gamma GT and total bilirubin, METAVIR score, HCV RNA PCR, search for cryoglobulins, antiviral and dermatology treatments. There were 1,060 patients followed in the hepatology unit during this period, including 327 with cirrhosis. RESULTS: Twenty-seven patients were retained for study, 16 men and 11 women, mean age 53 years. None of the patients had HIV infection, 7 had a past history of hepatitis B infection (positive for anti-Hbc antibodies). Median duration of pruritus prior to consultation was 3 months (95 p. 100 CI: 3 months-2 years). Pruritus was associated with non-specific lesion in 19 cases (70 p. 100: 95 p. 100 CI: 51-85 p. 100). There were excoriated eczema-like lesions in 11 cases (41 p. 100: 95 p. 100 CI: 15-49 p. 100). Other causes were urticaria in 5 cases (18 p. 100: 95 p. 100 CI: 7-36 p. 100), including 1 case of urticarial vasculitis with cryoglobulinemia, 2 cases with atopic dermatitis, and 1 case of primary biliary cirrhosis. In four cases, lichen planus was associated. Skin biopsies were obtained in 10 patients and showed eczema-like alterations in 9 and urticarial vasculitis in 1. Mean ALAT and gamma GT levels were 2.6 N (95 p. 100 CI: 1.9 N-3.3 N) and 2.2 N (95 p. 100 CI: 1.4 N-3 N) respectively, including 11 cases without cholestasis (normal gamma Gt). PCR was positive in 13 cases out of 15. Cryoglobulinemia was found in 10 cases out of 24. At consultation, 3 patients were given ursolvan, 7 interferon, 1 ursolvan with ribavirin, and 3 an interferon-ribavirin combination. Dermatology treatment associated antihistamine agents, emollients, and corticosteroids. This population of hepatology patients referred for pruritus comprised 2.5 p. 100 of all patients (95 p. 100 CI: 1.7-3.6 p. 100). Among them, 1.8 p. 100 (95 p. 100 CI: 1.1-2.7 p. 100) had eczema-like lesions associated with cutaneous xerosis. DISCUSSION: Pruritus in our patient population was generally associated with non-specific excoriations, prurigo or xerosis in 19 cases (70 p. 100). As only ambulatory patients were retained for analysis, this is not a comprehensive population and the percentage of non-specific pruritus, evaluated at 1.8 p. 100, is probably an underestimation. Cholestasis cannot explain alone these manifestations since 11 patients had normal gamma GT levels. Several etiologies could be involved: a direct effect of HCV, interferon. A prospective study should allow an estimation of frequency, risk factors and possible impact on quality of life.

Female↗
PubMedDate not supplied

Pruritus in diabetes mellitus: investigation of prevalence and correlation with diabetes control.

Three hundred diabetic and 100 nondiabetic hospital outpatients (both groups of comparable age and sex distribution) were assessed for the presence of generalized and localized pruritus. Pruritus vulvae was significantly more common in diabetic women (18.4%) than in controls (5.6%) and was significantly associated with poor diabetes control (mean glycosylated hemoglobin level less than 12%). Other forms of localized pruritus were equally common in diabetic and nondiabetic patients, regardless of glycosylated hemoglobin levels. Generalized pruritus was present in 14 diabetic patients, but in 5 cases the symptom was ascribed to intercurrent illness or drug administration. Thus, generalized pruritus without apparent cause was present in only 8 diabetic patients (2.7%) and was not significantly more common than in nondiabetic patients. It is doubtful if diabetes mellitus per se should be regarded as a cause of generalized or localized pruritus, other than pruritus vulvae.

Adolescent↗
PubMed1985

The mycotic flora in proctological patients with and without pruritus ani.

The perianal mycotic flora was studied in proctological patients with and without pruritus ani, as well as in control subjects. Four groups of patients underwent perianal mycoculture. In Group 1, 53 patients with anal pruritus were treated for benign anorectal disease. In Group 2, 24 patients with no underlying disease presented with anal pruritus. Both of these groups underwent concomitant chemical and parasitical examination of the faeces and an oral glucose tolerance test. In Group 3, 50 patients without pruritus ani at present or in the past were treated for benign anorectal diseases. In Group 4, 47 surgical patients without pruritus ani were treated for benign (9) and malignant (38) non-proctological diseases. In Group 1 the mycoculture was positive in 24/53 patients (Candida albicans 14, dermatophytes 10). In Group 2 fungal infections were seen in 16/24 patients (C. albicans 7, dermatophytes 9). No parasites or diabetes were found in either group. In Group 3 C. albicans was isolated in 14/50 patients. In Group 4 C. albicans was found in 11/47 cases (2 in benign, 9 in malignant diseases). Infection by C. albicans was observed in all groups studied, independent of the presence of disease or anal pruritus. The presence of dermatophytes was always associated with pruritus ani.

Adolescent↗
PubMed2006

Gabapentin in patients with the pruritus of cholestasis: a double-blind, randomized, placebo-controlled trial.

Pruritus is defined as the second order of nociception, the first being pain; thus, there is a rationale to study gabapentin, a drug that increases the threshold to experience nociception. The aim of this double-blind, randomized, placebo-controlled trial was to study the effect of gabapentin on the perception of pruritus and its behavioral manifestation, scratching, in cholestasis. The participants were 16 women with chronic liver disease and chronic pruritus. Hourly scratching activity (HSA) was continuously recorded for up to 48 hours at baseline and on treatment for at least 4 weeks in an inpatient setting. The perception of pruritus was assessed by interviews and by a visual analog score (VAS) of pruritus recorded every hour while patients were awake. Patients were randomized to the study drug (gabapentin or placebo) at a starting dose of 300 mg orally per day in divided doses to a maximum of 2,400 mg or until relief from pruritus. Gabapentin was associated with an increase in mean HSA, in contrast to the placebo, which was associated with a decrease. The mean VAS decreased significantly among those taking the placebo and in some patients on gabapentin. In conclusion, gabapentin did not provide a significant therapeutic advantage over the placebo; in fact, it was associated with an increase in the perception of pruritus and in HSA in some patients.

Adult↗
PubMed1998

Open-label trial of oral nalmefene therapy for the pruritus of cholestasis.

The aims of this study were to determine whether long-term oral administration of the opiate antagonist nalmefene is associated with any beneficial effects in patients with pruritus secondary to cholestatic liver disease and to assess the safety of long-term administration of this drug to these patients. Fourteen patients with unrelieved chronic pruritus of cholestasis were studied. Scratching activity, independent of limb movements, was recorded continuously for 24-hour periods before and during treatment with an initial ameliorating dose of nalmefene. Simultaneously, during these periods, visual analogue scores (VASs) of pruritus were recorded every 4 hours while patients were awake. The dose of nalmefene, which initially was 2 mg orally twice daily, was increased during the study, usually until a satisfactory clinical response was achieved. Five patients experienced a transient opioid withdrawal-like reaction that did not preclude continuing with nalmefene therapy. Serum biochemical indices of cholestasis did not change appreciably during treatment. Thirteen patients reported amelioration of the perception of pruritus on nalmefene. In 5 patients, exacerbations of pruritus occurred approximately 4 weeks after an initial ameliorating dose had been reached; these exacerbations were managed by increasing the dose. Baseline mean values for VAS and scratching activity were higher than corresponding means during nalmefene therapy in 13 (P = .002) and 12 (P = .013) patients, respectively. Possible tolerance to nalmefene occurred in 3 patients. Three patients experienced marked exacerbation of pruritus after nalmefene therapy was suddenly discontinued. Blood levels of nalmefene were consistent with normal pharmacokinetics of the drug. These results suggest that nalmefene may have a favorable risk-to-benefit ratio when it is administered orally long-term to patients with the pruritus of cholestasis.

Administration, Oral↗
PubMed2004

Treatment of refractory cholestatic pruritus after liver transplantation with albumin dialysis.

Albumin dialysis has been shown to improve the outcome in patients with cholestatic liver failure caused by chronic liver disease. This study reports 7 liver transplant recipients who were treated with albumin dialysis for intractable pruritus of different origin (ductopenic graft rejection, non-anastomotic strictures, and recurrence of hepatitis C). Treatment with histamine (H1) blockers, opioid antagonists, and cholestyramine had not been effective. The Molecular Adsorbent Recirculating System (MARS; Teraklin, Rostock, Germany) was used for albumin dialysis. All patients presented with numerous scratch marks, 6 of whom had a pronounced icterus. Six patients (86%) responded to 3 consecutive treatments with significant reduction of pruritus. The mean pruritus score, which was quantified by a visual analog scale (VAS), decreased from 9.7 +/- 0.5 to 3.7 +/- 0.8 (SD). The mean duration of 1 treatment was 15.6 hours. The procedure was well tolerated by all patients. The mean total serum bilirubin in patients who responded to therapy declined from 19.11 +/- 16.96 mg/dL (SD) before MARS therapy to 9.24 +/- 3.52 mg/dL after treatment. The mean serum concentration of 3 alpha-hydroxy bile acids decreased from 192.67 +/- 58.12 micromol/L (SD) to 42.33 +/- 31.58 micromol/L (SD). Follow-up in 3 cases showed sustained improvement of pruritus lasting for more than 3 months. In 3 patients, however, pruritus relapsed. One patient, who showed severe pruritus, without relevant elevation of serum bile acids before treatment, did not respond to albumin dialysis. Our data indicate that MARS is an effective therapeutic option for patients with intractable cholestatic pruritus.

Aged↗
PubMed1991

Treatment of pruritus of primary biliary cirrhosis with rifampin.

Pruritus can be a debilitating symptom in patients with chronic cholestasis. Based on previous reports of its efficacy, we evaluated the impact of rifampin on the pruritus associated with primary biliary cirrhosis. Fourteen patients were included in a randomized, crossover study. After a 15-day washout period, subjects were followed for three weeks. During the first and third week, patients received 600 mg of rifampin or placebo; no treatment was administered during the second week. Pruritus was subjectively scored on a scale from 0 to 100. With rifampin, pruritus disappeared in 11 patients and partially improved in three; with placebo, only two had a partial response (P less than 0.001). Six patients with a prior poor or no response to cholestyramine improved with rifampin. No changes in biochemical tests or side effects were observed during this period. We conclude that short-term administration of rifampin relieves pruritus in primary biliary cirrhosis. When administered over a period of eight months in an open study, the relief of pruritus was maintained, while one individual developed an allergic reaction. Rifampin appears to be a safe drug in the management of the pruritus of primary biliary cirrhosis.

Adult↗
PubMed1997

Treatment of intrathecal morphine-induced pruritus following caesarean section.

PURPOSE: To compare both the efficacy and cost of nalbuphine and diphenhydramine in the treatment of intrathecal morphine-induced pruritus following Caesarean section. METHODS: Eighty patients, undergoing elective Caesarean section under spinal anaesthesia, were randomized, in a prospective, double-blind trial, to receive either nalbuphine (Group NAL) or diphenhydramine (Group DIP) for the treatment of SAB morphine-induced pruritus. All patients received an intrathecal injection of 10-12 mg hyperbaric bupivacaine 0.75% and 200 micrograms preservative free morphine. Postoperative pruritus was assessed, using a visual analogue scale (VAS), for 24 hr. Pruritus treatment was administered upon patient request and by a nurse blinded to the treatment given. Patients who failed to respond to three doses of the study drug were deemed treatment failures. Patient satisfaction was assessed with a questionnaire given 24 to 48 hr after surgery. Direct drug costs were calculated based on the pharmacy provision costs as of April 1996. RESULTS: Eighty patients were enrolled and 45 requested treatment for pruritus. Patients treated with NAL (n = 24) were more likely to achieve a VAS score of zero with treatment (83% vs 43%, P < 0.01), had a higher delta VAS following treatment (4 +/- 2 vs 2 +/- 2, P < 0.003), and experienced fewer treatment failures (4% vs 29%, P < 0.04), than those treated with DIP (n = 21). Group NAL patients were also more likely to rate their pruritus treatment as being good to excellent (96% vs 57%, P < 0.004). Direct drug costs were higher for NAL than for DIP ($6.4 +/- 3.1 vs $1.7 +/- 0.7, respectively, P < 0.0001). CONCLUSION: Nalbuphine is more effective than diphenhydramine in relieving pruritus caused by intrathecal morphine and the cost differences are small.

Adult↗
PubMed2005

[Pruritus in pregnancy. A frequent diagnostic and therapeutic challenge].

Pruritus is the leading dermatological symptom during pregnancy. Besides preexisting or acquired dermatoses, there are a number of pregnancy-specific dermatological diseases such as PEP (polymorphic eruption of pregnancy, previously named PUPPP), pemphigoid (herpes) gestationis, and pruritus gravidarum that are accompanied by severe itching and scratching. Because of potential effects on the fetus, the treatment of pruritus in pregnancy requires prudent consideration. The use of topical and systemic treatments depends on the underlying aetiology of pruritus and the stage and status of the skin. In general, emollients, topical anti-pruritics and topical corticosteroids appear to be the safest options for localised forms of pruritus in pregnancy whereas systemic treatments and/or UV phototherapy are adequate for generalized pruritus. Systemic corticosteroids and a restricted number of antihistamines may be administered in severe cases. This paper highlights the major aetiologies of pruritus during pregnancy and points out the cornerstones of antipruritic therapy in recognition of our own clinical experiences and the current literature.

Administration, Topical↗
PubMed1981

Pruritus in cholestasis: no direct causative role for bile acid retention.

Discrepancies have existed regarding the correlation between raised bile acid levels in cholestasis and the presence of pruritus. Nevertheless, the prevalent view is that bile acids have a direct etiologic role. To resolve the issue, we quantified separately all naturally-occurring bile acid species detectable in serum and skin, and on the skin surface of 13 patients with pruritus associated with cholestasis, 10 patients with cholestasis who did not have pruritus, three patients with uremia and generalized pruritus and in 10 controls. We were unable to find any correlations between the presence of pruritus and bile acid levels from the various sources. We did find great overlap in these same values with data from the group with cholestasis but without pruritus. As expected, the symptomatic (uremic) and asymptomatic control groups showed comparable levels. The results of the present study together with those of a similar recent study provide strong evidence against the hypothesis of a direct causative role for retained bile acids in pruritus associated with cholestasis.

Adult↗
PubMed2004

[Hereditary cholestasis, an unusual etiology of pruritus in the infant].

INTRODUCTION: Pruritus in the infant is predominantly related to common dermatosis. General causes remain exceptional. We report two cases of pruritus in infants revealing anicteric cholestasis. OBSERVATIONS: Case no 1. A thirteen month-old boy had exhibited pruritus since the age of 2 months. The clinical examination was non-specific. Biological explorations revealed an isolated and moderate rise in total bilary acids. The search for mutations in the genes of a familial fibrogenic cholestasis was negative. The diagnosis retained was hypercholanemia. Treatment combined ursodesoxycholic acid and rifampicine, which controlled the pruritus and normalized the bilary acid levels. Case no 2. A twenty-one month-old boy had exhibited pruritus since the age of 2 months and delayed growth. The clinical examination was unspecific. The biological explorations revealed cholestasis with normal delta GT, moderate cytolysis and liposoluble vitamin deficiency. The hepatic biopsy was normal. The diagnosis retained was familial fibrogenic cholestasis. Treatment combined ursodesoxycholic acid and rifampicine, which controlled the pruritus and normalized the hepatic parameters. DISCUSSION: Non-dermatological isolated pruritus is rare in infants. These two observations illustrate two abnormalities in bilary acid transport. Hypercholanemia is a faulty canalization of bilary acids by the hepatocyte. Familial fibrogenic cholestasis is a default in the elimination of these bilary acids. Such pathologies must be evoked because specific treatment will treat the symptoms and avoid the evolution of familial fibrogenic cholestasis towards cirrhosis.

Cholestasis↗
PubMed1986

A review of pruritus.

This article reviews the neurophysiology of pruritus and presents evidence that itch is a separate modality from pain, rather than a submodality of pain. The numerous suggested pruritogens are reviewed, and evidence supporting each one is critically examined. The systemic causes of generalized pruritus are reviewed, with detailed review of the literature on uremic pruritus, cholestatic pruritus, and the pruritus associated with polycythemia vera. The specific treatments used for each of these conditions are reviewed, as well as the use of antihistamines in generalized pruritus. An approach to the workup of a patient with pruritus is suggested.

Antipruritics↗
PubMed1994

Treatment of aquagenic pruritus with topical capsaicin cream.

BACKGROUND: Aquagenic pruritus is characterized by pruritus after contact with water; there are no objective cutaneous changes. Capsaicin, which induces the release of neuropeptides from A delta and C cutaneous nerve fibers, has been successfully used in the treatment of several dermatoses associated with pruritus. Among the many different neuropeptides present in human skin, the undecapeptide substance P has been shown to cause pruritus. OBJECTIVE: We evaluated the clinical effect and searched for alterations in cutaneous neuropeptidergic fibers before and after treatment with capsaicin cream. METHODS: Five patients with aquagenic pruritus were treated with capsaicin cream 0.025%, 0.5% or 1.0% three times daily for 4 weeks. Direct immunofluorescence (DIF) was performed before and after treatment to evaluate the storage of neuropeptides in the A delta and C type cutaneous nerve fibers. RESULTS: Before treatment (when by DIF the neuropeptidergic fibers appeared filled with neuropeptides), contact with water consistently provoked itching. After capsaicin treatment (when by DIF the neuropeptidergic fibers were depleted of neuropeptides), contact with water did not evoke pruritus. Areas of skin treated with the vehicle alone showed no clinical improvement or change in neuropeptide content. CONCLUSION: This study suggests that neuropeptides, including substance P, may contribute to mediating the itch in aquagenic pruritus.

Administration, Topical↗
PubMed2004

An approach to the management of the pruritus of cholestasis.

The cause of the pruritus of cholestasis is unknown. It is inferred that pruritus results from the accumulation in plasma of substances that are made in the liver and excreted in bile under physiologic conditions. The idea of neurotransmitters as important mediators in the pruritus of cholestasis has evolved over the past several years. There is evidence to suggest that endogenous opioids contribute to the pruritus of cholestasis and, for the first time, specific treatment for the pruritus has been instituted. The deficiency of studying pruritus with subjective methodology alone has been overcome with the development of objective methodology to study the behavioral manifestation of pruritus, scratching behavior. The use of this tool allows the definition of clear objective end-points, scratching activity, for inclusion in clinical trials.

Antipruritics↗
PubMed2001

Pharmacological control of opioid-induced pruritus: a quantitative systematic review of randomized trials.

BACKGROUND AND OBJECTIVE: Numerous drugs have been used to prevent or to treat opioid-induced pruritus in the surgical setting. Their relative efficacy is not well understood. METHODS: The methods employed involved the systematic search (MEDLINE, EMBASE, Cochrane library, bibliographies, without language restriction, up to June 2000) for full reports of randomized comparisons of any intervention which is thought to be anti-pruritic (active) compared with placebo or no treatment (control) in surgical (including labour) patients receiving opioids. The number of patients who had no pruritus were analysed using relative risk and number-needed-to-treat with 95% confidence interval. RESULTS: Twenty-two trials (1477 patients) were analysed. Two trials (66 patients), both with low-dose propofol, were on treatment of established pruritus; propofol had no anti-pruritic effect compared with Intralipid. In prophylaxis trials, the average incidence of pruritus with control was 59% (range, 10% to 100%). Most mu-receptor antagonists were efficacious: intravenous naloxone 0.25-2.4 microg kg-1 h-1, relative risk 2.31 (95% confidence interval, 1.5 to 3.54), number-needed-to-treat to prevent pruritus compared with control 3.5; oral naltrexone 9 mg, relative risk 2.80 (1.35-5.80), number-needed-to-treat 1.7; naltrexone 6 mg was less effective and 3 mg did not work; different intravenous and epidural nalbuphine regimens, relative risk 1.71 (1.12-2.62), number-needed-to-treat 4.2. Intravenous nalmefene 0.5 or 1 mg was not anti-pruritic. Intravenous (but not epidural) droperidol 2.5 mg was efficacious, relative risk, 1.71 (1.28-2.29), number-needed-to-treat 4.9. There was a lack of evidence for any anti-pruritic efficacy with prophylactic propofol, epidural or intrathecal epinephrine, epidural clonidine, epidural prednisone, intravenous ondansetron, or intramuscular hydroxyzine. CONCLUSION: Naloxone, naltrexone, nalbuphine and droperidol are efficacious in the prevention of opioid-induced pruritus; minimal effective doses remain unknown. There is a lack of valid data on the efficacy of interventions for the treatment of established pruritus.

Analgesics, Opioid↗