Itch Management in the Elderly.

Itch is a common symptom in the elderly population over 65 years old, and is often a chronic condition lasting more than 6 weeks. As in all age groups, but especially in the elderly, there can be a significant effect on the general health status and quality of life, with impaired daily activities and lack of sleep, which can also lead in some cases to depression or anxiety. The cause of chronic itch in the elderly is often multifactorial due to physiological changes in the aging skin, including impaired skin barrier function, and also due to decline in immunological (immunosenescence), neurological, and psychological changes associated with age. Common causes of chronic pruritus in the aging skin include xerosis (dry skin), dermatological disorders (eczema, psoriasis, lichen planus), and systemic (renal, hepatic, endocrine), neurodegenerative, and psychological diseases. Comorbidities in the elderly population lead to polypharmacy, increasing the potential risk of drug side effects, which can result in causing or exacerbating itch in the elderly patient. It is essential to obtain a detailed history, including drugs, as well as a thorough clinical examination with appropriate subsequent investigations. Management of the elderly patient with chronic pruritus should include treatment with topical therapies such as emollients as well as other agents for symptomatic relief. Systemic therapies should be directed at any underlying cutaneous or systemic diseases. Often the cause of itch in the elderly cannot be found and some systemic treatments can be used for symptomatic control of the itch, including antihistamines, gabapentin, and selective antidepressants. A holistic approach needs to be taken on an individual basis to relieve chronic pruritus, as the management of itch in the elderly can be a challenge.

Current topical and systemic therapies for itch.

Itch is a common distressing symptom which may be caused by multifactorial aetiologies including inflammatory skin diseases, systemic diseases, neuropathic conditions and psychogenic disorders. Itch is a term used synonymously with pruritus and is defined as acute if it lasts less than 6 weeks or chronic if it persists for more than 6 weeks. It can have the same impact on the quality of life as chronic pain and shares many of the same pathophysiological pathways. Depending on the aetiology of the itch, different pathogenic mechanisms have been postulated with a number of mediators identified. These include histamine, leukotrienes, proteases, neuropeptides, cytokines and opioids, which may activate peripheral itch-mediating C-fibres via receptors on the nerve terminals and central neuronal pathways. Therefore, there is no single universally effective anti-itch treatment available. First-line treatments for itch include topical therapies, such as emollients, mild cleansers (low pH), topical anaesthetics, steroids, calcineurin inhibitors and coolants (menthol). Treatment with systemic therapies can vary according to the aetiology of the chronic itch. Non-sedating antihistamines are helpful in conditions such as urticaria where the itch is primarily histamine mediated. Although the itch of eczema is not mediated by histamine, sedating antihistamines at night are helpful to break the itch-scratch cycle. Chronic itch may also be treated with other systemic therapies, such as anticonvulsants, antidepressants as well as mu-opioid antagonists, kappa-opioid agonists and phototherapy, depending on the cause of the itch. This article summarises the topical and systemic therapies available with our current understanding of the pathophysiology of itch.