Itch in palliative care
Itch, also called pruritis, can be a very uncomfortable and frustrating symptom when someone has a terminal illness or is at the end of life. Scratching may cause breaks in the skin, bleeding and infection. Itch can disrupt sleep and have a negative effect on someone’s quality of life. It’s also associated with depression and anxiety.
On this page:
Please be aware - this information is for healthcare professionals.
You can use our My Learning form to reflect on how this page has helped with your continuing professional development.
Understanding itch
Itch is common in people living with a terminal illness, but it is not always diagnosed or treated properly. Itch produces the desire to scratch which can cause more damage to skin and more itching. This is called the itch-scratch-itch cycle.
What causes itch?
There are many causes of itch and a person may feel itchy because of more than one reason. Senile itch (itch in older people) has no obvious cause and can affect more than half of people aged over 70.
Skin causes of itch:
- dry skin
- infection – for example, candidiasis (thrush) or fungal infection
- eczema (atopic dermatitis) or
- allergic skin reaction (contact dermatitis)
- psoriasis
- insect infestation - for example, scabies, lice, bed bugs and fleas
- increased moisture caused by sweating or incontinence
- prolonged skin contamination from urine and/or faeces.
Causes of itch from other areas of the body:
- anaemia and iron deficiency
- high or low levels of thyroid hormone – thyroxine (hyperthyroidism or hypothyroidism)
- diabetes
- cholestasis (blocked bile duct)
- liver disease – for example, cholestatic jaundice, hepatitis, cancer or primary biliary cirrhosis
- polycythaemia (high concentration of red blood cells)
- chronic kidney disease or kidney (renal) failure
- leukaemia or lymphoma.
Medicines that can cause itch:
- opioids, particularly morphine and diamorphine
- aspirin
- antibiotics
- hormone treatments
- selective serotonin re-uptake inhibitors antidepressants (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 (immunotherapy).
Psychological causes of itch:
- anxiety
- depression
- hallucinations related to phobias or psychosis.
How can I assess someone with itch?
Although there are some simple steps you can suggest to try to ease itching, it’s important that you try to find the cause so the person can have the most appropriate treatment. You may find it helpful to ask them, or their friend or family member, these questions which can 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 itch localised to a particular area of the body, or all over? (Localised itching is more likely to be caused by an irritant or allergy.)
- Is anyone else in the house affected? (Could the itch be caused by an infestation?)
- Are there pets in the house? Is the person allergic to any animals? (Pets could also increase the chance of an infestation.)
You may also find it helpful to ask them to keep a symptom diary. Their carer, family or friend may be able to help with this. This may help to identify the cause, when symptoms are worse, and whether anything helps. Document the person’s answers and speak to their doctor or specialist nurse about getting the most appropriate treatment. Sometimes blood tests or other investigations may be needed to find out the cause. However, this might not be appropriate for every person, especially someone in the last days of life.
If assessing someone's itch is not part of your role, tell the patient's doctor or nurse that they are experiencing itch.
How can I support someone with itch?
An important thing to do is to ask a person if they have itch. People don’t always mention it themselves so it’s commonly underdiagnosed and undertreated.
Regardless of the cause of itch, there are lots of things you can do to help care for the person’s skin and make them feel less itchy.
Skin care
- Look for signs of damage, bleeding and infection.
- Apply moisturising emollients such as lotions and creams often to keep the skin supple and moist.
- Try emollients with anti-itch or cooling ingredients such as menthol to reduce itch.
- Consider corticosteroid creams, although they should not be used for long periods. Check with the person’s GP or pharmacist for advice.
Eating and drinking
- Encourage the person to drink water or suck on ice cubes to stay hydrated.
- Avoid or cut down on anything that can cause vasodilation (dilation of the blood vessels in the skin) – this includes caffeine, alcohol, spices and heat.
Bathing
- Encourage the person to use warm, not hot, water for bathing.
- Add sodium bicarbonate or oatmeal to the bath water.
- Avoid soaps, shower gels and bubble baths. These can dry skin out by washing away natural oils. Use an emollient soap substitute instead.
- Pat dry rather than rubbing after bathing.
Clothing and environment
- Avoid irritating fabrics for clothes and bed sheets. Some people find cotton and silk can be cooler and less irritating than synthetic fabrics.
- Keep the person’s room at a comfortable temperature and make sure they’re not too warm at night. Consider using a fan.
Managing scratching and itching
- Remind them that scratching can make the itch worse and create a vicious cycle.
- Suggest wearing gloves at night as this can reduce damage done to the skin by scratching.
- Encourage them to keep their nails short.
- Ask them if the itch is worse at night and stopping them from being able to sleep. If so, you should speak with their doctor who may consider a short-term trial of a sedating oral anti-histamine.
- Tell them that pressing, tapping or drumming the skin, rather than scratching, can help.
- Try distraction techniques, such as music, relaxation or positive imagery, as these may help to break the itch-scratch-itch cycle.
- Providing emotional support and reassurance can help with itch caused by anxiety.
When should I ask for help?
Be aware of the serious causes of itch such as liver and kidney disease and get urgent help from the person’s GP or hospital team. An operation to fit a stent in the bile duct may be required for people with itch caused by cholestasis.
Speak to the person’s GP, specialist nurse or district nurse if you are concerned about any other causes of itch. They can try to work out the underlying cause, or causes, and give the appropriate treatment. They will review the person’s medicines and change any that might be contributing to itching, for example they might change morphine to a different opioid. Also seek help if you think someone has a skin infection.
The best treatment will depend on the cause of the itching and might include:
- topical steroid creams
- topical lignocaine (anaesthetic) cream to numb the nerves in the skin and reduce the sensation of itch
- antidepressants paroxetine or mirtazapine
- antihistamine tablets (antihistamine creams don’t often work and can make itch worse)
- UVB light therapy
- acupuncture.
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 to be treated. Contact your local council for information on pest control services. The person will generally be required to leave the premises during treatment and this should be considered when getting their consent and planning what to do.
Useful resources
Key points
- Itch is a common symptom in palliative care and can be very frustrating and distressing.
- To treat itch effectively, it’s important to look for a cause to guide treatment.
- General skin care measures are important to keep skin intact and reduce itch.
- Itch can be a symptom of serious underlying causes. Speak to a GP, specialist nurse or district nurse if you are concerned.
Let us know what you think
Email your feedback to knowledgezone@mariecurie.org.uk
Did you find this page useful?
Help us be there for anyone with an illness they're likely to die from by telling us what you think.
If you are completing this survey using a desktop computer, hold down the Ctrl button to select multiple options.
Disclaimer
This information is not intended to replace any training, national or local guidelines, or advice from other health or social care professionals.
The Palliative Care Knowledge Zone is not intended for use by people living with a terminal illness or their family and friends, who should access our information for the public.
