Q J Med 2003; 96: 7-26
© 2003 Association of Physicians
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Itch: scratching more than the surface
From the 1 Sir Michael Sobell House, Churchill Hospital, Oxford, 2 St John's Institute of Dermatology, St Thomas' Hospital, London, UK, 3 Institute of Psychology/Experimental Pathophysiology, University of Erlangen-Nurnberg, Erlangen, Germany, 4 Department of Gastrointestinal and Liver Diseases, Academic Medical Center, Amsterdam, The Netherlands, 5 Janssen-Cilag Ltd, Saunderton, High Wycombe, UK, 6 Department of Dermatology and Venereology, University of Medicine, Wroclaw, Poland and 7 Hospice Rozenheuvel, Rozendaal, The Netherlands, and the Palliative Care Department, The Ludwik Rydygier University, Bydgoszcz, Poland
In origin, itch can be cutaneous (‘pruritoceptive’, e.g. dermatitis), neuropathic (e.g. multiple sclerosis), neurogenic (e.g. cholestasis), mixed (e.g. uraemia) or psychogenic. Although itch of cutaneous origin shares a common neural pathway with pain, the afferent C-fibres subserving this type of itch are a functionally distinct subset: they respond to histamine, acetylcholine and other pruritogens, but are insensitive to mechanical stimuli. Histamine is the main mediator for itch in insect bite reactions and in most forms of urticaria, and in these circumstances the itch responds well to H1-antihistamines. However, in most dermatoses and in systemic disease, low-sedative H1-antihistamines are ineffective. Opioid antagonists relieve itch caused by spinal opioids, cholestasis and, possibly, uraemia. Ondansetron relieves itch caused by spinal opioids (but not cholestasis and uraemia). Other drug treatments for itch include rifampicin, colestyramine and 17-
alkyl androgens (cholestasis), thalidomide (uraemia), cimetidine and corticosteroids (Hodgkin's lymphoma), paroxetine (paraneoplastic itch), aspirin and paroxetine (polycythaemia vera) and indometacin (some HIV+ patients). If the remedies specified fail, paroxetine and mirtazapine should be considered. Ultraviolet B therapy, particularly narrow-band UVB, may be superior to drug treatment for itch in uraemia.
Address correspondence to Dr R. Twycross, Sir Michael Sobell House, Churchill Hospital, Oxford, OX3 7LJ. e-mail: robtwy{at}yahoo.com
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