Table 1.

Treatment options for pruritus secondary to advanced disease in palliative care

TREATMENTMECHANISM OF ACTIONINDICATION(S)CONSIDERATIONS
POSITIVENEGATIVE
Nonpharmacologic
General skin care2,5,7,20
  • Emollients

  • Minimize bathing

  • Tepid water

  • Mild, unscented soap

  • Loose, nonirritating clothing

  • Avoid fragrant topical agents

  • Cool, humidified environment

Soothes inflamed skin and prevents futher abrasions, eruptions, or irritationsDry skinDry skin is associated with many other causes of pruritusNA
UVB light therapy5,21Decreases the number of mast cells and free nerve endings in the skinCholestasis
Uremia
Malignant skin infiltration
NAProcedure often required 3 times/wk; impractical at end of life
Biliary stenting5,6,8,9,18Relieves obstruction in the bile ductsCholestasis due to biliary obstructionMight negate need for pharmacotherapyNA
Pharmacologic
Lidocaine 2.5% cream (topical anesthetic)18Anesthetizes sensory nerve endingsLocalized areas of itchAppropriate regardless of cause of pruritusLarge quantities of cream can cause toxicity when absorbed
Paroxetine (antidepressant)5,10,11,21,225-HT3 reuptake inhibitionCholestasis
Uremia
Opioid-induced pruritus
Malignancy
Effects within 24 to 48 h
Few side effects
NA
Mirtazapine (antidepressant)10,11,21,225-HT2, 5-HT3, and H1 receptor antagonistsCholestasis
Uremia
Opioid-induced pruritus
Malignancy
EffectiveSedation
Weight gain
Ondansetron (antiemetic)5,14,15,17,225-HT3 receptor antagonistCholestasis
Uremia
Opioid
NAExpensive
Constipation
Dipenhydramine (antihistamine)5,7,8,9H1 receptor antagonistAllergy
Histamine-mediated pruritus
InexpensiveSedation
Rarely effective
Naloxone or naltrexone (opioid antagonist)5,16,17,22μ-Opioid receptor antagonistCholestasis
Uremia
Opioid-induced pruritus
NAReverses analgesia
Expensive
  • 5-HT—5-hydroxytryptamine (serotonin), H1—histamine–type 1, NA—not applicable, UVB—ultraviolet B.