Please be aware - this information is for healthcare professionals

Itch, also called pruritis, can be a very uncomfortable and frustrating symptom at the end of life. Scratching may cause breaks in the skin, bleeding and infection. For some people, itching can interrupt sleep. And it can lead to depression and anxiety.

In extreme cases, itch can have a negative effect on a person’s quality of life. Understanding the patient’s medical history, and the cause of the itching, will help you provide more effective care and support.

What is causing the itching?

Although there are some simple steps you can suggest to try to ease itching, it’s important that you try to find the cause. You may find it helpful to ask the patient, their family member or friend, these questions, which may help to establish a cause for the itching.

  • When did it start? (It could be related to a change in treatment)
  • Did it start gradually or come on quickly? (Sudden onset means the itch is more likely to have been caused by a drug, an allergic reaction to an irritant or an infestation)
  • Is it new or have you had it before?
  • If you’ve had it before, has anything helped or made it worse?
  • Did you change anything recently, such as your soap or washing powder?
  • Is the rash local to a particular area of the body, or general? (Local itching is more likely to be caused by an irritant or allergy)
  • Is anyone else in the house affected? Are there pets in the house? (Could the itch be caused by an infestation?)

Itching can be a very common complaint. There is a huge range of potential causes, and it is often due to more than one factor. Senile itch, which has no identifiable cause, can affect more than half of people aged over 70. Other possible causes are listed here.

Skin causes

  • dry skin
  • prickly heat
  • infection – for example, candidiasis, fungal infection
  • dermatitis – for example, eczema (atopic dermatitis) or contact dermatitis
  • psoriasis
  • insect bites, for example – scabies, lice, bed bugs and fleas
  • allergy.

Causes from other areas of the body

  • anaemia and iron deficiency
  • hormone imbalance – for example, hyperthyroidism, hypothyroidism, diabetes
  • cancer-related itch
  • blocked bile duct
  • renal failure
  • liver disease – for example, cholestatic jaundice, hepatitis, hepatoma or primary biliary cirrhosis (a liver disease that causes damage to the bile ducts in the liver)
  • polycythaemia (high concentration of red blood cells)
  • chronic kidney disease.

Psychological causes

  • anxiety
  • depression.

Medicines that can cause itch

  • opioids, particularly morphine and diamorphine
  • aspirin
  • antibiotics
  • hormone treatments
  • selective serotonin re-uptake inhibitors (SSRIs) – such as citalopram, fluoxetine, paroxetine and mirtazapine
  • ace inhibitors (commonly prescribed to people after a heart attack and also used to treat heart failure and high blood pressure ) – such as enalapril, ramipril
  • statins – such as atorvastatin, simvastatin, pravastatin
  • chemotherapy drugs
  • monoclonal antibodies (a type of cancer treatment).

Can itching be a sign of something serious?

Itching can sometimes be a sign of a serious problem that needs quick action. For example, if the underlying cause is a blocked bile duct or liver or kidney disease, it may be possible to resolve these issues if they are dealt with quickly. Reactions to medicines may also need urgent attention. For example, a GP may be able to change a morphine prescription to oxycodone.

Any of these issues should be reported to the GP, district nurse or specialist nurse immediately. Read more about palliative emergencies on our page recognising emergencies.

What can I do to help?

Make sure you know the patient’s full medical history and keep your own record of symptoms and treatments. You may also find it helpful to ask them, their carer, or family or friend, to keep a symptom diary. This may help to identify what might be causing it, when symptoms are worse, and whether anything seems to help.

Where possible, the treatment for itching should depend on the cause. However, the most important thing is to maintain skin integrity and keep it clean and moisturised. It is also worth suggesting to the patient that they keep their nails short to reduce damage to the skin.

Using topical treatments on the skin can sometimes be effective and give relief.

  • Apply moisturiser liberally and often to keep the skin supple and moist. Simple creams and ointments can be tried, as well as topical corticosteroids. . There are also emollients with anti-itch or cooling ingredients
  • Encourage the patient to use warm, not hot, water for bathing , and to bath less often. They can also consider adding something soothing to their bath, such as sodium bicarbonate or colloidal oatmeal. Some people find having cool or lukewarm baths or showers soothing
  • Avoid soaps, shower gels and bubble baths, which dry skin out by washing away natural oils. Use an emollient or soap substitute instead
  • Avoid irritating fabrics. Where possible, cotton and silk can be cooler and less irritating than manmade fabrics.

There are also more general steps you may consider suggesting to the patient before asking the GP about prescribing medication.

  • Remind the patient that scratching can make the itch worse and create a vicious cycle
  • Wearing gloves at night may be helpful
  • Pressing, tapping or drumming the skin, rather than scratching, can help
  • Avoid or cut down on anything that can cause vasodilation (when the blood vessels in the skin dilate) – these include caffeine, alcohol, spices and hot water
  • Heat can make an itch worse, which can affect sleep.Try to make sure the patient is not too warm in bed
  • A cool damp flannel or towel laid onto the skin may help
  • Oral antihistamines may help, but mainly when itching is due to hives or insect bites – these involve histamine production. Antihistamines won’t be effective for most skin diseases or systemic causes. Some antihistamines can cause drowsiness which may be a problem during the day but help at night
  • Distraction techniques, such as music, relaxation or positive imagery may help to take the mind off the itch.

If a medicine is thought to be the cause, you can discontinue it for a few weeks to see if the symptoms improve. This needs to be tried under medical direction and only when it is safe to stop the medicine.  

It is important to consider whether the patient has a condition that affects their ability to consent to care, for example they may have dementia. Care includes cutting their nails or putting mittens on them. If they cannot consent to care, you will need deprivation of liberty safeguards (DoLS) in place.

If the itching is caused by an insect infestation (for example, scabies, lice, bed bugs or fleas), their home or place of care will need fumigating. Consult your clinical commissioning group or district nurse policy for details on the appropriate organisation to deal with the infestation. The person will generally be required to leave the premises during fumigation and this should be considered when getting their consent and planning what to do.

Who else should I talk to?

  • The patient’s GP
  • A district nurse
  • The specialist palliative care team
  • Community pharmacist (for advice on topical treatments).

Points to remember

  • To treat itch effectively, it’s important to find the cause
  • Itch can have a negative impact on a person’s life and wellbeing
  • Cleanliness and skin integrity is important
  • Itch can be a symptom of serious underlining causes. Speak to a GP, specialist nurse or district nurse if you are concerned
  • If infestation is suspected, a local policy should be in place to provide support and advice.

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