What Is Cholestatic Pruritus?

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Cholestatic pruritus is a symptom of cholestatic liver disease. It is a constant, severe, and sometimes debilitating itching sensation on various parts of the body. Over 80% of people with cholestatic liver disease develop cholestatic pruritus.

This article discusses the symptoms, causes, and treatment options for people with cholestatic pruritus. 

Waking up with itchy skin

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Cholestatic Pruritus Symptoms

For people with cholestatic liver disease accompanied by cholestatic pruritus, the first and foremost symptom is an intense itch that doesn’t go away with scratching.

Other issues that can arise from cholestatic pruritus include:

  • Secondary rashes or lesions caused by excessive scratching
  • Sleep deprivation due to preoccupation with itching
  • Depression or suicidal ideation (in people with particularly stubborn cholestatic pruritus)

Symptoms of Cholestatic Liver Disease

In some cases, a person might not be aware they have a liver disease. Aside from itching, other signs of cholestatic liver disease may include:

  • Jaundice (yellowing of the skin or eyes)
  • Urine that is darker than normal
  • Pale stool
  • Abdominal pain
  • Fatigue
  • Nausea

Causes

The main cause of cholestatic pruritus is cholestatic liver disease, which develops when liver cells are unable to secrete bile (digestive fluid) or when there is a bile blockage in the biliary system. When this happens, bile can build up within the liver, which may further injure or damage the liver.

Various diseases that result in cholestatic liver disease may also cause cholestatic pruritus, including:

Itching develops because various substances, including bile acid, lysophosphatidic acid, endogenous opiates, and progesterone derivatives, build up within the body and end up in the skin.

However, there may be other, unknown pruritogens involved. Pruritogens are substances that cause itching and the urge to scratch after they make their way into the skin.

When Cholestatic Liver Disease Is Left Untreated

If left untreated, cholestatic itching will worsen. However, more severe consequences may occur, such as chronic liver failure.

Diagnosis

Diagnosing cholestatic pruritus is simple if a person has already been diagnosed with cholestatic liver disease. Since the symptom is present in the majority of cases, experiencing the itch is typically enough to make a diagnosis.

If a person has not yet been diagnosed with any type of liver disease, a healthcare provider will note the itching and then take a full health history and review of other symptoms. Then they will develop a treatment plan for both the disease and symptoms like cholestatic pruritus.

How to Test for Cholestatic Liver Disease

To diagnose cholestatic liver disease, a medical provider will examine a person for any signs of the condition, such as jaundice or lesions from scratching. Imaging of the liver and bile duct will be performed to look for functional issues or structural damage. Other imaging tests may be used to get a better look if results come back inconclusive.   

Treatment

Treatment for cholestatic pruritus can be challenging because there are various factors at play.

The first-line treatment for cholestatic pruritus is to treat the underlying condition, if possible. This might include a procedure to remove the obstruction or place a stent to drain the bile, or stop a medication if the cause is drug-induced.

For mild itching, simple skin care using lotions or emollients (moisturizers) may be enough. If these measures are not possible or don’t help, cholestyramine, a type of resin medication that can bind bile acid, might help to remove excess bile from the body.

If cholestyramine doesn't work, there are other treatment options to consider, such as:

  • Rifampicin: Rifadin (rifampicin) is an antibiotic typically used to treat tuberculosis (TB) that may work to relieve cholestatic pruritus by lowering levels of lysophosphatidic acid. However, side effects such as kidney and liver problems may limit its usefulness in people with liver disease.
  • Opioid antagonists: These are designed to block the action of certain opioid substances that can cause itching sensations to occur.
  • Sertraline: Zoloft (sertraline) is a type of serotonin-reuptake inhibitor that is typically used to treat depression by increasing serotonin levels within the brain. In cholestatic pruritus, it is used as a last resort option because of its ability to change how the itch pathways in the brain work.
  • Phototherapy: Phototherapy uses ultraviolet light to help address the itching sensation in the skin by suppressing the action of certain cells that cause the itching to occur.
  • Dronabinol: The cannabinoid dronabinol is thought to act as a blocker for certain substances that cause the itching.
  • Ursodeoxycholic acid: For pregnant patients with itching due to intrahepatic cholestasis of pregnancy, Ursodiol (ursodeoxycholic acid), a bile acid drug, may provide relief.

Invasive Treatments for Cholestatic Pruritus

In the event that none of the aforementioned treatment options provide relief to people with cholestatic pruritus, other, more invasive treatments may be explored. They can include:

  • The surgical removal of blood plasma that contains pruritogens
  • A surgical process that drains the bile ducts
  • Using activated charcoal in a way similar to dialysis to help filter the blood of any pruritogens

What Treatment Is Right for You?

No single treatment is right for everyone who deals with cholestatic pruritus. To determine which one will work for you, talk to your healthcare provider about your options.

Coping

Coping with cholestatic pruritus can be difficult, if not debilitating. In some cases, the itching can be so severe that it substantially affects your quality of life. A person can even develop secondary depression or suicidal ideation as a result.

The best way to cope is to work with your healthcare provider to identify the best treatment option. Since many of the aforementioned treatments work in many people with cholestatic pruritus, it’s likely that one of them will help provide you with relief.

Summary

Cholestatic pruritus is characterized as an extreme and debilitating itching sensation caused by cholestatic liver disease. Since it is a symptom of a larger health issue, other symptoms may accompany it, such as jaundice, fatigue, or dark-colored urine.

If you already know that you have cholestatic liver disease and want to relieve the itching, talk to your healthcare provider about treatment options, including various medications and phototherapy. There are both noninvasive and invasive options available to you.

A Word From Verywell

Feeling itchy all the time can be frustrating and bothersome. When you are so preoccupied by a severe itch, it can be hard to focus on anything else. Know that cholestatic pruritus is simply a side effect of something larger, and the main priority is treating the underlying liver disease. Talk to your healthcare provider about treatment options for both the disease and its symptoms.

Frequently Asked Questions

  • How do you treat cholestatic itching?

    There are several viable treatment options available for liver disease-induced itching. The first is medication. Medications tend to work for most people with cholestatic itching. However, other, more invasive options can be explored if medications do not work. 

  • How common is cholestatic itching?

    Roughly 80% to 100% of people with cholestatic liver disease will develop cholestatic itching. In some cases, it is one of the most obvious symptoms of cholestatic liver disease. Jaundice is also often present with cholestatic itching.

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