Pruritus—itching for a cause and relief?
P. C. A. KAM
P.C.A. Kam, FRCA, FANZCA, FFARCSI, Senior Lecturer, K.H. Tan, MBBS , Provisional Fellow in Anaesthesia, Department of Anaesthesia, Royal Prince Alfred Hospital, Missenden Road, Camperdown, N.S.W. 2050, Australia.
Search for more papers by this authorK. H. TAN
P.C.A. Kam, FRCA, FANZCA, FFARCSI, Senior Lecturer, K.H. Tan, MBBS , Provisional Fellow in Anaesthesia, Department of Anaesthesia, Royal Prince Alfred Hospital, Missenden Road, Camperdown, N.S.W. 2050, Australia.
Search for more papers by this authorP. C. A. KAM
P.C.A. Kam, FRCA, FANZCA, FFARCSI, Senior Lecturer, K.H. Tan, MBBS , Provisional Fellow in Anaesthesia, Department of Anaesthesia, Royal Prince Alfred Hospital, Missenden Road, Camperdown, N.S.W. 2050, Australia.
Search for more papers by this authorK. H. TAN
P.C.A. Kam, FRCA, FANZCA, FFARCSI, Senior Lecturer, K.H. Tan, MBBS , Provisional Fellow in Anaesthesia, Department of Anaesthesia, Royal Prince Alfred Hospital, Missenden Road, Camperdown, N.S.W. 2050, Australia.
Search for more papers by this authorSummary
The mechanisms of pruritus, an unpleasant irritation on the skin that provokes an urge to scratch, are reviewed. Whilst symptomatic treatment is only partially effective, antihistamines remain the first choice of treatment. However, recent novel treatment using opiate antagonists, propofol (subhypnotic doses) and serotonin antagonists offer attractive alternatives.
References
- 1 Savin J. Itching. In: Rook A, Savin J. eds. Recent Advances of Dermatology No 5 edn. Edinburgh : Churchill-Livingstone, 1980: 221–35.
- 2 Ganong WF. Cutaneous, deep and visceral sensation. In: Ganong WF ed. Review of Medical Physiology 12th edn. Los Alto CA : Lange, 1985: 110.
- 3 Arthur RP, Shelley WB. The innervation of human epidermis. Journal of Investigative Dermatologv 1959; 32: 397–411.
- 4 Ballantyne JC, Loach AB, Carr DB. Itching after epidural and spinal opiates. Pain 1988; 33: 149–60.
- 5 Lorrette G, Valiant L. Pruritus: current concepts in pathogenesis and treatment. Drugs 1990; 39: 218–23.
- 6 Misch KJ, Greaves MW, Black AK. Histamine and the skin. British Journal of Dermatology 1983; 109: 10–3.
- 7 Lowitt MH, Bernhard JD. Pruritus. Seminars in Neurology 1992; 12: 374–84.
- 8 Hokfelt T, Kerthell JO, Nilssong, Pernau B. Substance P: localisation in the central nervous system and in some primary sensory neurons. Science 1975; 190: 889–90.
- 9 Lembeck F. Substance P and related peptides: cellular and molecular physiology. Annals of New York Academy of Science 1991; 632: 490–3.
- 10 Wallengren J, Hakanson R. Effects of capsaicin, bradykinin and prostaglandin E2 in the human skin. British Journal of Dermatology 1992; 126: 111–7.
- 11 Guyton AC. Somatic sensations II: Pain, Headache and thermal sensations. In: Guyton AC. ed. Textbook of Medical Physiology, 8th edn. Philadelphia : W.B. Saunders, 1991: 520–3.
- 12 Wall PD. The gate control theory of pain mechanisms. A re-examination and re-statement. Brain 1978; 101: 1–18.
- 13 Bickford RG. Experiments relating to the itch sensation, its peripheral mechanism and central pathways. Clinical Science 1937; 3: 377–86.
- 14 Hagabarth KE, Kerr DIB. Central influence on spinal afferent conduction. Journal of Neurophysiology 1954; 17: 295–307.
- 15 Koenigstein II. Experimental study of itch stimuli in animals. Archives of Dermatology 1948; 57: 828–49.
- 16 Bradford FK. Ablations of frontal cortex in cats with special reference to enhancement of the scratch reflex. Journal of Neurophysiology 1939; 2: 192–201.
- 17 Khandelwal M, Malet PF. Pruritus associated with cholestasis. A review of pathogenesis and management. Digestive Diseases and Sciences 1994; 39: 1–8.
- 18 Schoenfield LJ, Sjovall J, Penman E. Bile acids on the skin of patients with pruritic hepatobiliary disease. Nature 1967; 213: 93–4.
- 19 Beregasa NV, Jones EA. The pruritus of cholestasis: potential pathogenic and therapeutic implications of opioids. Gastroenterology 1995; 108: 1582–8.
- 20 Thornton JR, Losowsky MS. Plasma leucine enkephalin is increased in liver disease. GUT 1989; 30: 1392–5.
- 21 Thornton JR, Losowsky MS. Opioid peptides and primary biliary cirrhosis. British Medical Journal 1988; 297: 1501–4.
- 22 Schworer, H, Ramadori G. Improvement of cholestatic pruritus with ondansetron. Lancet 1993; 341: 1277.
- 23 Raderer M, Muller C, Scheithauer W. Ondansetron for pruritus due to cholestasis. New England Journal of Medicine 1994; 330: 1540.
- 24 Stahle-Backdahl M, Hagermark O, Lins ME, Torring O, Hillages M, Johansson O. Experimental and immunohistocompatability studies in the role of parathyroid hormone in uraemic pruritus. Journal of Internal Medicine 1989; 225: 411–5.
- 25
Francos GC.
Uremic pruritus.
Seminars in Dialysis
1988; 1: 209–12.
10.1111/j.1525-139X.1988.tb00730.x Google Scholar
- 26 Gilchrest BA, Stern RS, Steinman TI, Arndt KA. Clinical features of pruritus among patients undergoing maintenance hemodialysis. Archives of Dermatology 1982; 118: 154–6.
- 27 Carmichael AJ, Dickinson F, Mchugh MI, Martin AM, Farrow M. Magnesium free dialysis for uraemic patients. British Medical Journal 1988; 297: 1584–5.
- 28 Yatzidis H, Digenis P, Forutas P. Hypervitaminosis A accompanying advanced chronic renal failure. British Medical Journal 1975; 3: 352–3.
- 29 Marchi SD, Cecchin E, Villalta D, Sepiacci G, Santini G, Bartoli E. Relief of pruritus and decreases in plasma histamine concentrations during erythropioetin therapy in patients with uremia. New England Journal of Medicine 1992; 326: 969–74.
- 30 Greaves MW. New pathophysiologica! and clinical insights into pruritus. Journal of Dermatology 1993; 20: 734–40.
- 31 Osterman PO. Paroxysmal itching in multiple sclerosis. British Journal of Dermatology 1976; 95: 555–8.
- 32 Andrew VC, Petov I. Skin manifestations associated with tumours of the brain. British Journal of Dermatologv 1975; 92: 675–8.
- 33 Massey EW. Unilateral neurogenic pruritus following stroke. Stroke 1984; 15: 901–3.
- 34 Sullivan MJ, Drake ME. Unilateral pruritus and nacardia brain abscess. Neurology 1984; 34: 828–9.
- 35 Liddell K. Post herpetic pruritus. British Medical Journal 1974; 4: 168–9.
- 36 Layton AM, Cotterrill JA. Notalgia paraesthica-report of three cases and their treatment. Clinical and Experimental Dermatology 1991; 16: 197–8.
- 37 Chaney MA. Side effects of intrathecal and epidural opioids. Canadian Journal of Anaesthesia 1995; 42: 891–903.
- 38 Ready LB, Loper KA, Nessley M, Wild L. Postoperative epidural morphine is safe on surgical wards. Anesthesiology 1991; 75: 452–6.
- 39 Palacois QT, Jones MM, Hawkin JL, Adenwala JN, Longmire S, Hess KR, Skjonsby BS, Morrow DH, Joyce TH. Caesarean section analgesia; comparison of epidural butor-phanol and morphine. Canadian Journal of Anaesthesia 1991; 38: 24–30.
- 40 Caldwell LE, Rosen MA, Shnider SM. Subarachnoid morphine and fentanyl for labor analgesia. Efficiency and adverse effects. Regional Anesthesia 1994; 19: 2–8.
- 41 Camman WR, Minzter BH, Denney DA, Datta S. Intrathecal sufentinil for labor analgesia. Effects of added epinephrine. Anesthesiology 1993; 78: 870–4.
- 42 Fuller JG, Mcmorland GH, Douglas MJ, Palmer L. Epidural morphine for analgesia after caesarean section—a report of 4880 patients. Canadian Journal of Anaesthesia 1990; 37: 636–40.
- 43 Bailey PJ, Rhondeau S, Schafer PG. Dose response pharmacology of intrathecal morphine in human volunteers. Anesthesiology 1993; 79: 49–59.
- 44 Rawal N, Arner S, Gustafsson LI, Allvin R. Present state of extradural and intrathcal opioid analgesia in Sweden. British Journal of Anaesthesia 1987; 59: 791–9.
- 45 Labella FS, Kim RS, Templeton J. Opiate receptor binding activity of 17-alpha estrogenic steroids. Life Science 1978; 23: 1797–1804.
- 46 Scott PV, Fischer HBJ. Spinal opiate analgesia and facial pruritus: a neural theory. Postgraduate Medical Journal 1982; 58: 531–5.
- 47 Rieselback RE, Di Chio G, Freirech EJ, Ral DP. Subarach-noid distribution of drugs after lumbar injection. New England Journal of Medicine 1962; 267: 1273–8.
- 48 Gall H, Kaufman R, Vonehr M, Schumann K, Sterry W. Persistent pruritus after hydroxylethyl starch infusion: retrospective long term study of 266 cases. Hautarzt 1993; 44: 713–6.
- 49 Hosburg E. Pruritus secondary to hydroxyurea therapy in woman with polycythemia vera. American Journal of Hematology 1992; 41: 70.
- 50 Barbara A, Gilcherst MD, Rowe JW, Brown RS, Steinman TI, Arndt KA. Relief of uremic pruritus with ultraviolet phototherapy. New England Journal of Medicine 1977; 297: 136–8.
- 51 Bernstein JE, Swift R. Relief of intractable pruritus with naloxone. Archives of Dermatology 1979; 115: 1366–7.
- 52 Borgeat A, Wilder-Smith OHG, Meutha G. Subhypnotic doses of propofol relieve pruritus associated with liver disease. Gastroenlerology 1993; 104: 244.
- 53 Borgeat A, Wilder-Smith OHG, Saiah M, Rifat K. Subhypnotic doses of propofol relieve pruritus induced by epidural and intrathecal morphine. Anesthesiologv 1992; 76: 510–2.
- 54 Schworer H, Ramadori G. Treatment of pruritus: a new indication for serotonin type 3 receptor anagonists. Clinical Investigation 1993; 71: 659–62.