Uraemic pruritus is an itch affecting large bilateral surface areas with no associated primary skin lesion. It can be generalised or localised to the back, face and arms, and occurs on a near-daily basis.
General management advice
Assess for non-uraemic causes of itch such as allergic or drug reactions, psoriasis, atopic eczema, fungal infections, scabies, delusional parasitosis etc.
Good skin care is essential as dry skin exacerbates itch:
- Avoid soap and substitute with QV lotion /non-soap based products
- Moisturise (eg with sorbolene) immediately after showering while skin is still wet
- Assess for broken skin and cut fingernails
- Liberal application of moisturiser such as QV cream or sorbolene
- If dry skin persists, substitute for an oil-based moisturiser or Baby oil
- For localised itch, trial Capsaicin 0.025% (can cause burning and may not be tolerated)
Combining with Menthol 3% can ease burning: either as separate creams or by compounding pharmacy
- Gabapentinoids (gabapentin or pregabalin)
- Commence gabapentin 100mg or pregabalin 25mg alternate nights for non-dialysis (eGFR<15ml/min) and peritoneal dialysis patients, or 3x weekly post-dialysis for haemodialysis patients. Additional dose post APD if excessive daytime symptoms.
- Up-titration if limited efficacy without side effects: to gabapentin 100mg nocte and then 100mg bd or pregabalin 25mg nocte and then 25mg bd
- Main side effects include drowsiness, ataxia, clumsiness, blurred vision
- These drugs are used in restless legs syndrome and neuropathic pain
- Evening Primrose Oil (over-the-counter) 1-2 capsules bd. No known side effects
- Sertraline (second line) 50mg daily
- Doxepin (second line): commence at 10mg nocte, up-titration to 10mg bd
Ultra-Violet B therapy
For refractory patients this can be considered, and requires a referral to Dermatologist
If treatment is ineffective at any stage, reconsider alternative non-uraemic causes of itch.
Simonsen E, Komenda P, Lerner B, Askin N, Bohm C, Shaw J, Tangri N, Rigatto C. Treatment of uremic pruritus: a systematic review. American Journal of Kidney Diseases. 2017 Nov 1;70(5):638-55.
Brennan F. The pathophysiology of pruritus–A review for clinicians. Progress in Palliative Care. 2016 May 3;24(3):133-46.