Pruritis: Information for clinicians

Pruritus/itch can be incredibly disruptive causing pain, insomnia and infection from excessive scratching.

Itch in palliative care falls into two groups – the cause will guide treatment:

  1. Histamine-induced: for example opioids or allergic dermatitis
  2. Non-histamine induced: for example cholestasis/jaundice or renal failure
Red flags

Don’t just prescribe an anti-histamine e.g. chlorphenamine (Piriton), without thinking about the cause. This will cause sedation without helping the itch if it is not histamine-induced.

Key clinical features for a clinician to assess in the community
  • Review underlying diagnosis e.g. liver disease, renal failure, cancer
  • Consider primary skin condition e.g. eczema/psoriasis or new scars
  • Medication review e.g. opioids can cause itch but any new medication (e.g. antibiotics) could be the cause
  • Signs or symptoms of common infection – e.g. candidiasis, scabies
An initial approach to treatment
  • Stop offending drugs and consider alternative
  • For opioid-induced itch try an anti-histamine (see table below)
  • Blood tests: full blood count, ferritin, c-reactive protein, urea and electrolytes, liver function tests, bone profile, thyroid function tests
  • Menthol 2%-5% in aqueous cream has the best evidence as counter-irritant but any emollient may help
  • Consider a sedating antihistamine, such as Hydroxyzine 25mg at night, if confident that the pruritis is mediated by histamine release
Specific treatments according to cause

Cause

Initial approach to treatment

Opioid induced itch mediated by histamine release

Other medicines e.g. antibiotics

Anti-histamine such as:

  • Chlorphenamine (Piriton) 4mg b.d. (sedating)
  • Hydroxyzine 25mg at night (sedating)
  • Loratadine 10mg daily (non sedating)

Consider: switch to different opioid

Consider: Ondansetron up to 4-8mg b.d. (constipating)

Cholestatic jaundice

  • Sertraline 25mg-50mg
  • Mirtazepine 15mg
  • Steroids e.g. Dexamethasone 4mg-8mg (not long term)

Itch is not histamine related

Consider: Biliary stenting

Chronic kidney disease->uraemia

  • Gabapentin 100mg t.d.s. can be very effective
  • Sertraline 25mg-50mg
  • Mirtazepine 15mg

Itch is not histamine related

Lymphoma/leukaemia

Steroids can reduce lymphoma itch dramatically e.g. Dexamethasone 4mg-8mg

Consider: Cimetidine 400mg b.d.

Paraneoplastic 

Localised:

  • Capsaicin cream
  • Menthol 2% in aqueous cream (Dermacool)

Generalised:

  • Sertraline 25mg-50mg
  • Mirtazepine 15mg

Candida

Treat systemically or locally according to distribution

Unknown

Chlorphenamine or Loratidine

If none of the above help, then speak to your local palliative care team for more ideas.

 

Recommended Resources

Scottish Palliative Care Guidelines - Prutitis

Published 1st July 2025

Isle of Wight Palliative Care Symptom Control Guidelines

Published 1st August 2024

JPSM Chronic Pruritus: Histamine Is Not Always the Answer

Published 1st May 2015

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