Of all the symptoms that seriously ill patients can have, itching can be one of the most disruptive and annoying. Medically referred to as pruritus, itching can cause severe emotional and physical anguish. In addition to the discomfort of itching, scratching an itch can lead to skin damage and infections.
Itching isn't a symptom that should be ignored or viewed as less important than other symptoms. Severe itching needs prompt assessment and treatment. Let's look at the many causes of itching and what you can do to help stop the itch.
Causes of Itching
There are many causes of itching. Some are easily identified and others may be more discreet. Here are some of the most common causes of itching.
- Medications - Opioid pain medications frequently cause itching, especially when they are first started or the dose is increased. Sensitivities or allergies to other medications can also cause severe itching.
- Kidney Failure - End-stage renal disease patients may develop uremia. There are several factors that may contribute to uremia, and the pruritus associated with it can be disabling. It's estimated that between 80% and 90% of end-stage renal disease patients experience this type of severe itching.
- Liver Disease - Liver disease can lead to the accumulation of bile salts in the system, which may cause itching.
- Dermatitis - Dermatitis is an irritation or inflammation of the skin. Skin reactions to soaps, creams, latex, and other chemicals can cause itching that is usually accompanied by a rash. Dry skin can cause flaking and itching. Fungal infections are more common in obese patients and those with compromised immune systems, and can be a source of intense itching.
- Sweating - Sweating can be a real problem, especially in bed-bound patients. It can cause skin irritation and itching, as well as lead to pressure sores that can cause pain and itching themselves.
- Other Illness - Neurological diseases and conditions, such as multiple sclerosis, brain tumors, and herpes zoster (shingles), can all cause pruritus. Other forms of cancer and metabolic diseases can also cause intense itching.
Stop the Itch: Treatment of Itching
Simple Steps You Can Take
There are some simple steps you can take now to prevent or treat itching. These include:
- Avoid excessive heat, which can dry out the skin.
- Use a humidifier in the patient's room to prevent dry skin.
- Use mild lotions liberally, especially after a bath or shower.
- Avoid skin irritants, such as wool, pet hair, harsh soaps, and perfumed lotions.
- Apply a cool compress to itchy areas. A cool washcloth may be enough to relieve itching. If you use an ice pack, be sure to use a barrier of cloth between it and the patient, and apply it no more often than 20 minutes every two hours.
- Wear loose fitting, 100% cotton clothing. Change clothing if it becomes saturated with sweat, urine, or water.
- Apply topical treatments as ordered by your physician.
Topical treatments are applied directly to the skin to treat itching.
- Dry Skin Treatment - Dry skin, also known as xerosis, can be treated with rehydration. The "soak and seal" technique can be highly effective at relieving the itching associated with dryness. To do this, the patient can soak in a warm bath for 15 to 20 minutes. If the patient is bed-bound, this can be modified by applying warm, soaked towels to the skin, refreshing and re-warming the towels as needed.
After soaking, gently pat skin dry and apply an occlusive cream. Good examples of occlusive creams include petroleum jelly, vegetable shortening (like Crisco), and heavy moisturizers that are alcohol and fragrance-free, such as Eucerin, Aquaphor, and Cetaphil. Avoid other moisturizers because they can be more irritating to the skin. It's important to apply the cream several times per day and dress in loose cotton clothing to avoid excess sweating.
- Skin Cleansing - Keeping the skin clean can reduce itching related to sweating and is important to reduce the risk of infections from scratching. It's important to use only soap that is mild and non-drying. Good examples include Dove, Oil of Olay, and Aveeno.
- Anti-histamine Creams - Calamine lotion, Benadryl cream, and other anti-itch creams contain antihistamines that can relieve itching.
- Pain Relief Creams - Lidocaine or morphine-based creams can provide relief for itching that is burning or painful in nature. Creams containing camphor, phenol, and menthol can cool the skin and calm a painful itch as well.
- Steroid Creams - Corticosteroid creams, such as Kenalog (triamcinolone), may be useful for short-term use to decrease inflammation and itching in certain conditions. Steroid creams shouldn't be used long-term because of side effects.
- Antifungal Creams - For fungal skin infections, antifungal creams are the first treatment of choice. These creams will cure a fungal infection and the itching associated with it.
Certain oral medications may be prescribed by your physician to treat pruritus, depending on the cause. These may include oral steroids, antihistamines, and antidepressants.
The Bottom Line
The bottom line is that you should never ignore itching. It can be just as distressing as pain for some patients and needs prompt assessment and treatment by your palliative care team. There are some simple things you can do to prevent or treat mild itching, but you should always alert your physician to your severe or chronic itching for professional advice.
Rhiner, M and Slatkin, N. Pruritis. Textbook of Palliative Nursing, Oxford University Press, 2006: 345-354.
Pittelkow MR, et al. Pruritis and sweating. Oxford Textbook of Palliative Medicine, 2nd edition. Oxford University Press, 2004: 573-587.