Approach to managing itch in palliative care

Twycross, 2003Wilcock A, 2020

Generalised persistent itch (pruritus) is a common symptom in patients with an advanced life-limiting illness, and can be as distressing as pain. Itch can be multifactorial; common causes include:

  • dry skin
  • uraemia due to advanced chronic kidney disease
  • cholestasis due to biliary obstruction, intrahepatic disease, cirrhosis or adverse drug effects
  • cancer
  • opioid analgesics.

Use a stepwise approach to manage itch; see Approach to managing itch in palliative care.

Evidence for drugs used to treat itch in palliative care is limited, and drugs are usually prescribed on a trial basis.

Itch in patients with palliative care needs can also be caused by a concomitant condition unrelated to their life-limiting illness; see the Dermatology guidelines for possible causes. Consider the potential benefits and burdens of each intervention, and the patient’s prognosis, preferences and goals of care—see Principles of symptom management in palliative care.

Table 1. Approach to managing itch in palliative care

Step 1. Discuss possible cause(s) and treatment options with the patient

Explain that it may not be possible to treat the cause of the itch, but that it can often be managed using general measures and, if necessary, drug therapy.

Step 2. Address the cause of itch if possible

Consider stopping or reducing the dose of drugs and avoiding known irritants that may be causing itch.

Look for skin infection and treat if appropriate.

Treat dermatitis with emollients and topical corticosteroids (see the Dermatology guidelines).

Consider biliary drainage or stenting for cholestatic itch.

Step 3. Use general skincare measures and topical therapy

Good skincare is essential and may avoid the need for systemic drug therapy, particularly when dry skin causes or exacerbates itch; see General skincare measures in palliative care.

Consider topical preparations (eg menthol 1% in aqueous cream).

Step 4. Consider systemic drug therapy if itch persists and is distressing

Consider the impact of itch on the patient’s quality of life, and the potential benefits and harms of systemic drug therapy. For advice on drug therapy for itch, see:

Step 5. Seek specialist advice

If itch persists, seek specialist advice.