Itch and liver: management in primary care.

IntroduCtIon Pruritus can be defined as ‘an unpleasant sensation that causes the need to scratch.’1 Although it is most commonly seen in skin diseases it can occur as a consequence of systemic conditions and the possibility of the presence of such conditions should be considered in any patient presenting with pruritus in the absence of rash. Pruritus can be a feature of renal failure, haematological diseases (including lymphoma, leukaemia, and myeloproliferative disorders),2 and of liver diseases in which there is an element of cholestasis (impaired bile secretion). Pruritus in liver diseases can often be a debilitating symptom causing significant impairment in quality of life. Not all patients with liver disease develop pruritus and its prevalence varies depending on the underlying cause of liver disease. It is more common in conditions characterised by bile duct inflammatory destruction than in those characterised by hepatocellular injury.3 For example, the prevalence of pruritus is high in autoimmune liver diseases such as primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC), and biliary obstructive diseases secondary to benign (stones/strictures) or malignant diseases (for example, carcinoma of head of pancreas). It can also be seen in patients with chronic viral hepatitis (mainly hepatitis C) and drug-induced liver injury (DILI). In comparison, pruritus is relatively uncommon in alcohol-induced liver diseases (ALD) and non-alcoholic fatty liver disease (NAFLD). Patients with pruritus often seek treatment from their GPs but studies have shown there is lack of awareness among clinicians in relation to pruritus associated with liver diseases.4 GPs are able to initiate treatments recommended by the guidelines so they and their patients would benefit from a knowledge of the condition and the understanding of currently available therapies.