The Management of Chronic Pruritus in the Elderly

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The Management ofChronic Pruritus in theElderly

Tejesh Patel, MD1

and Gil Yosipovitch,

MD2,3

1. Division of Dermatology, Department of

Medicine, University of Tennessee Health

Science Center, Memphis, TN, USA

2. Department of Dermatology, Wake Forest

University School of Medicine, Winston-Salem,

NC, USA

3. Department of Neurobiology and Anatomy,

Wake Forest University School of Medicine,

Winston-Salem, NC, USA

ABSTRACT

The elderly in North America represent the

fastest growing segment of the population

and the most common skin complaint in this

age group is pruritus. The multitude of

variables that come with advanced age

means that the management of pruritus in

the elderly poses a particular therapeutic

challenge. Pruritus in advanced age may

result from a variety of etiologies, although

xerosis is the most common. In addition,

certain cutaneous and systemic diseases that

are associated with pruritus are more

prevalent in the elderly. At present, there is

no universally accepted therapy for pruritus.

Currently, management of pruritus in the

elderly must take an individualistically

tailored approach with consideration of the

patients general health, the severity of

symptoms, and the adverse effects of

treatment. Physical and cognitive limitations,

multiple comorbid conditions, and

polypharmacy are some aspects that can

influence the choice of treatment in this age

group.

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Key Words:

aging skin, comorbidity, itch, pruritus,

xerosis

Pruritus is the most common skin complaint in

patients over the age of 65 years.1,2 This

often neglected symptom can have a profound

impact on the quality of life in the elderly,

especially through sleep deprivation. Given

the multitude of variables that come with

advanced age, the management of pruritus in

the elderly poses a particular clinical

challenge.

Pathophysiology

Pruritus in advanced age may result from a

variety of etiologies. Xerosis (dry skin), which

increases with age, is probably the mostcommon cause of pruritus in the elderly.

3,4As

skin ages, the integumentary and vascular

systems undergo atrophy, leading to

suboptimal moisture retention. However,

many elderly patients have pruritic skin

without xerosis. Other skin changes in

advanced aged patients that may contribute

to itch include decreased skin surface lipids

and clearance of transepidermally absorbed

materials from the dermis, reduced sweat and

sebum production, as well as diminishedbarrier repair.

4

A decline of normal immune function that

occurs with aging also produces a higher

incidence of autoimmune skin disorders that

can induce pruritus, such as bullous

pemphigoid and postherpetic neuralgia.

Additional factors may also play a role, such

as age-related changes in nerve fibers and

polypharmacy. Certain cutaneous and

systemic disorders that are associated withpruritus are also more prevalent in advanced

aged patients (as discussed below). However,

in many instances, no apparent cause is

found.

Clinical Features

A detailed history, review of systems, and

physical examination are of prime importance

in guiding antipruritic treatment of senescent

skin. Once cutaneous and systemic causes of

itch are excluded, idiopathic itch of the elderly

may be considered. However, if an underlying

cause is discovered, it should be addressed,

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as this frequently leads to symptomatic

improvement. Certain pruritic cutaneous

diseases are more prevalent in the elderly

population, such as xerosis, nummular

dermatitis, and seborrheic dermatitis. The

later is especially common in patients with

dementia and Parkinsons disease. Systemic

diseases that are associated with pruritus,

such as chronic kidney disease, hepatic

dysfunction, and endocrine disorders, are also

more prevalent in the elderly. Notably,

infectious etiologies of pruritus, including

scabies and lice, may be more common in this

age group especially within institutionalized

care settings. In addition, medications

frequently used in the elderly increase the

possibility of drug-induced pruritus (e.g.,

aspirin, opioids, and angiotensin converting

enzyme inhibitors). Another serious

consideration in this cohort is that chronic

pruritus may be a presenting sign of

underlying malignancy (e.g., low grade

lymphoma, multiple myeloma, and

myleodysplastic syndromes), and thus, any

case with a high index of suspicion

necessitates a thorough work-up.5

Psychogenic and neuropathic disorders are

also common causes in this age group.6

General Principles

The management of pruritus in the elderly

poses a particular challenge. Physical and

cognitive impairments may make application

of topical treatments impossible and

compliance an issue. Comorbid conditions, especially those involving the liver

and kidney, as well as the frequent polypharmacy in this age group, confers a

greater risk of adverse drug reactions. At present, there is no universally

accepted therapy for itch. Instead, management of pruritus, especially in the

elderly, requires an individualistically tailored approach with consideration of the

patients general health, the severity of symptoms, and the adverse effects ofavailable treatments. Some of the treatments discussed are unlicensed for use

in pruritus and should be administered under a specialist setting.

There are a number of general measures that may be useful in the

management of pruritus in the elderly, irrespective of the underlying cause

(Table 1). Patient education is central to the management of pruritus.7

Identifying and removing aggravating factors are often the initial steps in

effective treatment. Breaking the itch-scratch cycle is critical and patients

should be informed of the increased cutaneous inflammation that scratching

causes. Simple measures, such as keeping finger nails short, may help to

interrupt this vicious cycle. The sensation of pruritus is often heightened bywarmth, thus, where appropriate, measures such as tepid showering, wearing

light clothing, and the use of air conditioning should be undertaken to keep the

skin cool. Wherever possible, simple topical regimens are preferable in order to


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maximize compliance and limit potential adverse drug reactions.

General Measures to Reduce Pruritus

Using moisturizers or barrier creams regularly (ideally with low pH)

Applying moisturizers immediately following bathing will ensure a higher

retention of moisture

Keeping finger nails short

Wearing light and loose clothing

Maintaining a comfortable temperature

Using a humidifier in the winter

Using an air conditioner in the summer

Restricting time in the shower or bathtub

Showering/bathing in cool or lukewarm water, as hot water can be drying

Avoiding cleansers with a high pH or those containing alcohol

Table 1. General measures for the management of pruritus

Topical Treatments

Moisturizers, Emollients and Barrier Creams

Moisturizers, emollients, and barrier repair creams are the mainstay of pruritus

treatment in the elderly, especially in cases associated with xerosis. These

nonpharmacologic compounds reduce pruritus through improving barrier

function by helping to prevent transepidermal water loss and possibly

preventing the entry of irritants and other itch-causing agents. Topical therapies

with a low pH may be especially useful in optimizing the skin barrier function

through their maintenance of the normal acidic pH of the skin surface. In

addition, low pH topical therapies may be of further benefit through their

reduction in the activity of serine proteases, such as mast cell tryptase, which is

known to activate protease-activating receptor 2 (PAR2) on skin nerve fibers.

This notion stems from recent studies suggesting serine proteases, via PAR2

located on C fiber terminals, may play an important role in mediating

pruritus.8,9

Topical Corticosteroids

Topical corticosteroids do not directly exert antipruritic effects, instead their

therapeutic benefits are derived from their anti-inflammatory properties.

Therefore, they should only be used to provide relief of itching that is associated

with inflammatory skin diseases, such as nummular dermatitis or psoriasis.

Topical corticosteroids should not be used to treat generalized chronic itch or for

prolonged periods. Of note, the elderly are particularly vulnerable to the

adverse effects (especially skin thinning) from the excessive use of topical

corticosteroids.10

Topical Immunomodulators

The topical calcineurin inhibitors, tacrolimus and pimecrolimus, have been

shown to be effective in reducing pruritus in conditions such as chronic irritant

hand dermatitis, seborrheic dermatitis, graft-versus-host disease, lichen

sclerosis, anogenital pruritus, and prurigo nodularis.11

The antipruritic effects of

topical calcineurin inhibitors may be mediated via TRPV1, a member of the

transient receptor potential (TRP) family of excitatory ion channels, located on


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nerve fibers. Although the recognized side-effects of these agents include

transient burning and stinging sensations, they are particularly useful in the

elderly as there is no associated risk of skin atrophy.

Menthol

Menthol, a naturally occurring cyclic terpene alcohol of plant origin, is frequently

used as a topical antipruritic at concentrations of 1-3%. It has been shown that

menthol elicits the same cooling sensation as low temperature through the

TRPM8 receptor.12

Both cooling the skin and menthol use result in the relief of

experimentally induced itch, although the latter is not associated with a

decrease in skin temperature. Of note, elderly patients who report a reduction

in pruritus with cooling may especially benefit from topical therapies containing

menthol.12

Capsaicin

Capsaicin has been reported to have a beneficial effect in chronic, localized

pruritic disorders, particularly those of neuropathic origin, which are common in

the elderly (e.g., postherpetic neuralgia, notalgia paresthetica, and

brachioradial pruritus).13,14

The TRPV1 receptor has recently been implicated in

the pathogenesis of pruritus and may be the target through which capsaicin

exerts its antipruritic effect.15

A recognized side-effect is an initial intense

transient burning sensation at the application site, which may lead to poor

compliance, particularly in the elderly.

Local Anesthetics

Pramoxine, a local anesthetic, reduces itch by interfering with transmission of

impulses along sensory nerve fibers and has been shown to reduce pruritus in

adult hemodialysis patients in a double-blinded study.16

Polidocanol is a

non-ionicsurfactant with both local anesthetic properties and moisturizingeffects. A combination of 5% urea and 3% polidocanol was found to significantly

reduce pruritus in patients with atopic dermatitis, contact dermatitis, and

psoriasis.17

Topical Salicylic Acid

Topical salicylic acid, a cyclooxygenase inhibitor, has been shown to significantly

reduce pruritus in patients with lichen simplex chronicus, possibly due to their

inhibitory effects on prostanoids.18,19

Of note, oral salicylates do not relieve

pruritus except in polycythemia vera.

Topical Cannabinoids

N-palmitoylethanolamine, a cannabinoid receptor CB2 agonist, has been

incorporated into creams and shown to reduce pruritus reported in patients with

atopic dermatitis, lichen simplex, prurigo nodularis, and chronic kidney disease-

associated itching.20-22

Systemic Treatments

Antihistamines

With the exception of chronic urticaria, antihistamines have little effect on

conditions associated with pruritus. Sedating (first generation) antihistamines

may have a role via their soporific effects on nocturnal pruritus, but in the

elderly caution must be taken to avoid causing excessive drowsiness.23

Antidepressants


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The serotonin-norepinephrine re-uptake inhibitor (SNRI), mirtazapine, has been

reported to relieve itch in patients with advanced cancers (e.g., leukemia and

lymphoma, including cutaneous lymphoma), chronic kidney disease, and

cholestasis.24-26

Mirtazapine may also be especially useful for the treatment of

nocturnal pruritus.25

Additionally, selective serotonin re-uptake inhibitors

(SSRIs) may have antipruritic effects. The SSRIs, paroxetine and fluvoxamine,

have been shown to reduce chronic pruritus, with the most favorable responsesseen in patients with pruritus due to atopic dermatitis, systemic lymphoma, and

solid carcinoma; whilst sertraline has been shown to be an effective treatment

for pruritus associated with chronic liver disease.27,28

Although the antiprurituc mechanism of antidepressants is unclear, medications

interfering with neuronal re-uptake of neurotransmitters, such as serotonin and

norepinephrine, may act through the cerebral cortex to reduce the perception of

pruritus.29

Antidepressants may be particularly useful in elderly patients with

psychogenic causes of pruritus. Of note, it may be prudent to start with lower

doses of antidepressants in the elderly and then taper up cautiously to avoid

the significant side-effects associated with these medications.

Opioid Agonists and Antagonists

An imbalance of the endogenous opioidergic system may have a role to play in

the pathophysiology of pruritus. Itch is induced by both -opioid receptor

agonists and -opioid receptor antagonists, while -receptor antagonists and

-receptor agonists can reduce it. Studies have shown the antipuritic effects of

-opioid receptor antagonists, such as naltrexone (in patients with cholestasis,

end-stage renal disease, burns, and atopic dermatitis) and nalmefene (in

patients with cholestasis, atopic dermatitis, and urticaria).30-34

Drug ClassMedication &Suggested Dose

Notes/Adverse Effects

Sedating

Antihistamines

Hydroxyzine: startat 25 mg daily andtaper up to 75 mgqd as tolerated

No direct effect on pruritusexcept in urticaria; sedatingantihistamines are usefulthrough their soporific effects;beware of excessive drowsinessespecially in the elderly

Antidepressants Recommend starting at lowdoses in the elderly and taperingup to avoid side-effects

SNRIsMirtazapine 7.5-15mg PO qhs

May cause increased weight,appetite, and somnolence

SSRIs

Paroxetine 10-40mg PO qdFluvoxamine25-150 mg PO qdSertraline 75-100mg PO qd

Useful in cholestatic pruritus

-opioid

Receptor

Antagonists

Naltrexone 25-50mg PO qd

Useful in patients withcholestatic and CKD-associated

pruritus; may cause nausea,vomiting, and drowsiness;recommend use in the elderlyunder specialist supervision


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-opioid Receptor

Agonists

Butorphanol 1-4mg intranasally qd

Useful in nocturnal andintractable pruritus; may causenausea, vomiting, anddrowsiness; recommend use inthe elderly under specialistsupervision

Nalfurafine 2.5-5 gPO qd

Useful in CKD-associated

pruritus; may cause insomnia;approved in Japan only;recommend use in the elderlyunder specialist supervision

Neuroleptics

Gabapentin100-2400 mg POqd

Useful in neuropathic pruritus;start at low doses and taper upin the elderly; may causedrowsiness, weight gain, and legswelling

Pregabalin 25-150

mg PO qd

Start at low doses and taper upin the elderly; should not be

stopped abruptly due to the riskof withdrawal symptoms

Table 2. Systemic treatments of pruritus CKD = Chronic kidney disease

The -opioid receptor agonists, butorphanol and nalfurafine, appear to have an

antipruritic effect in patients with chronic intractable itch and chronic kidney

disease, respectively.35,36

Due to the potential adverse effects associated with

opioid agonists and antagonist, treatment is advisable under specialist

supervision and at lower initial doses, especially in the elderly.

Neuroleptics

The neuroleptics, gabapentin and pregablin, are structural analogs of the

neurotransmitter -aminobutyric acid (GABA). The exact mechanisms of their

antipruritic effects are not clear, but they may be related to inhibition of central

itch pathways. Neuroleptics may be particularly useful in the elderly for

neuropathic pruritus related to conditions such as brachioradial pruritus,

postherpetic neuralgia, and notalgia paresthetica.6,14

Gabapentin has been

shown to reduce pruritus in patients with chronic kidney disease and lymphoma,

but treatment can actually worsen the itching in patients with cholestasis.26,37

Of note, it has been suggested that using a lower dose of gabapentin with slow

upward titration may reduce the risk of gabapentin-induced neurotoxicityand/or coma in patients with reduced renal function, a problem that may be

more prevalent in the elderly.38

Additionally, treatment with pregabalin should

not be stopped abruptly due to the risk of withdrawal symptoms.39

Physical Treatment

Phototherapy

Ultraviolet A (UVA), broadband ultraviolet B (BB-UVB), and narrowband UVB

(NB-UVB)-based phototherapies have been used for over three decades to treat

various pruritic dermatoses. This mode of treatment may be particularly

suitable in the elderly as it avoids the risk of adverse drug reactions (although

the risk of phototoxicity is increased) and overcomes challenges such as

physical and cognitive limitations that can lead to noncompliance.


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Conclusion

The multitude of variables that come with advanced age means that the

management of pruritus in the elderly continues to pose a particular diagnostic

and therapeutic challenge. Physical and cognitive limitations, multiple comorbid

conditions, and polypharmacy are some aspects that can influence choice of

treatment in this age group. Management of pruritus in the elderly must take anindividualistically tailored approach with consideration of the patients general

health, the severity of symptoms, and the adverse effects of treatment.

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In this issue:

Nanodermatology: A Bright Glimpse Just Beyond the Horizon - Part I1.

The Management of Chronic Pruritus in the Elderly2.

Update on Drugs and Drug News: September 20103.

All content 2005-2012 SkinThearpyLetter | Last modified: Thursday, 21-Jun-2012 16:53:33 MDT


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The Management of Chronic Pruritus in the Elderly