Pruritus in older people is caused by a wide range of dermatological, systemic, neurological and psychogenic diseases. It can also be attributed to various cutaneous drug reactions. The dermatological, neurological and immunological changes associated with ageing predispose older people to pruritus of a wide range of aetiologies. The most common cause of pruritus in older people is xerosis, or dry skin. Regular use of emollients is the mainstay of treatment for pruritus of any cause, with general measures aiming to ensure optimal skin hydration and to prevent the itch–scratch cycle. Topical treatments are generally better tolerated for localized pruritus. Anti-histamines are the predominant agents to treat pruritus, but can be inadequate in many cases. Numerous other systemic agents have been demonstrated to alleviate pruritus depending on the cause, but may be limited by their adverse effects. This article reviews the current published literature on pruritus in older people, with a practical approach to its evaluation and management in non-specialist settings.

Opioids are the cornerstone medication for the treatment of moderate to severe pain. However, analgesic opioid requirements and the propensity to suffer from aversive opioid effects, including fatal respiratory depression and addiction, vary widely among patients. The factors underlying the substantial response variance remain largely unknown and need clarification for using opioids more effectively in appropriately selected patients. This ongoing study takes advantage of the twin paradigm to estimate the genetic and environmental contributions to inter-individual differences in opioid responses. Evidence of significant heritability will justify more detailed and extensive genomic studies. The enrollment target is 80 monozygotic and 45 dizygotic twin pairs who undergo a target-controlled infusion of the opioid alfentanil and saline placebo in sequential but randomized order. In a laboratory-type setting, well-defined pharmacodynamic endpoints are measured to quantify pain sensitivity, analgesic opioid effects, and aversive opioid effects including respiratory depression, sedation and reinforcing affective responses. First results obtained in 159 participants provide evidence for the feasibility and utility of this interventional study paradigm to estimate familial aggregation and heritability components of relevant drug effects. Areas highlighted in this report include recruitment strategies, required infrastructure and personnel, selection of relevant outcome measures, drug infusion algorithm minimizing pharmacokinetic variability, and considerations for optimizing data quality and quantity without hampering feasibility. Applying the twin paradigm to complex and potentially harmful studies comprehensively characterizing pharmacological response profiles is without much precedent. Methods and first results including heritability estimates for heat and cold pain sensitivity should be of interest to investigators considering similar studies.

Skin is among the first and most heavily damaged organs upon sulphur mustard (SM) exposure. Pruritus is the most common chronic skin complication of SM, which adversely affects the quality of life (QoL). However, current therapies for the management of SM-induced pruritus are very limited and associated with side effects. The present trial investigated the efficacy of curcumin in the alleviation of SM-induced chronic pruritic symptoms. A total of ninety-six male Iranian veterans (age 37–59 years) were randomised to receive either curcumin (1 g/d, n 46) or placebo (n 50) for 4 weeks. Serum concentrations of substance P and activities of antioxidant enzymes were measured at baseline and at the end of the trial. Assessment of pruritus severity was performed using the pruritus score, visual analogue scale (VAS) and scoring atopic dermatitis (SCORAD) index. QoL was evaluated using the Dermatology Life Quality Index (DLQI) questionnaire. Serum concentrations of substance P (P < 0·001) as well as activities of superoxide dismutase (P = 0·02), glutathione peroxidase (P = 0·006) and catalase (P < 0·001) were significantly reduced in the curcumin group, while no significant change was observed in the placebo group. Curcumin supplementation was also associated with significant reductions in measures of pruritus severity including the pruritus score (P < 0·001), VAS score (P < 0·001), overall (P < 0·001) and objective SCORAD (P = 0·009), and DLQI's first question (P < 0·001). None of these measures was significantly changed in the placebo group. As for the QoL, although DLQI scores decreased in both groups (P < 0·001 and P = 0·003 in the curcumin and placebo groups, respectively), the magnitude of reduction was significantly greater in the curcumin group (P < 0·001). In conclusion, curcumin may be regarded as a natural, safe, widely available and inexpensive treatment for the management of SM-induced chronic pruritus.

Summary

Background and objectives: This study was designed to investigate whether single epidural droperidol or continuous epidural droperidol inhibit pruritus and postoperative nausea and vomiting induced by postoperative continuous epidural fentanyl administration, and to identify the optimal method of administering epidural droperidol. Methods: 120 ASA I–II patients undergoing subtotal gastrectomy with general anaesthesia combined with epidural anaesthesia were randomly allocated into three groups: control (no droperidol), single injection (droperidol 2.5 mg) and continuous group (droperidol 2.5 mg 2 day−1). Postoperatively the frequency and severity of pruritus and postoperative nausea and vomiting in all groups were compared during 48 h. Results: The frequency and severity of pruritus was significantly lower in both single injection and continuous groups than control group after epidural fentanyl administration (P < 0.05). The frequency and severity of postoperative nausea and vomiting was significantly lower in single injection group than control group after epidural fentanyl administration (P < 0.05). Conclusion: Epidural continuous droperidol is effective for reducing pruritus, and single epidural droperidol injection is effective for reducing pruritus and postoperative nausea and vomiting induced by postoperative continuous epidural fentanyl analgesia.

Background and objective Numerous drugs have been used to prevent or to treat opioid-induced pruritus in the surgical setting. Their relative efficacy is not well understood.

Methods The methods employed involved the systematic search (MEDLINE, EMBASE, Cochrane library, bibliographies, without language restriction, up to June 2000) for full reports of randomized comparisons of any intervention which is thought to be anti–pruritic (active) compared with placebo or no treatment (control) in surgical (including labour) patients receiving opioids. The number of patients who had no pruritus were analysed using relative risk and number–neededto– treat with 95% confidence interval.

Results Twenty-two trials (1477 patients) were analysed. Two trials (66 patients), both with low-dose propofol, were on treatment of established pruritus; propofol had no anti-pruritic effect compared with Intralipid. In prophylaxis trials, the average incidence of pruritus with control was 59% (range, 10% to 100%). Most mu–receptor antagonists were efficacious: intravenous naloxone 0.25–2.4 μgkg−1 h−1, relative risk 2.31 (95% confidence interval, 1.5 to 3.54), numberneeded– to–treat to prevent pruritus compared with control 3.5; oral naltrexone 9 mg, relative risk 2.80 (1.35–5.80), number-needed-to-treat 1.7; naltrexone 6mg was less effective and 3mg did not work; different intravenous and epidural nalbuphine regimens, relative risk 1.71 (1.12–2.62), number-needed-to-treat 4.2. Intravenous nalmefene 0.5 or 1mg was not antipruritic. Intravenous (but not epidural) droperidol 2.5mg was efficacious, relative risk, 1.71 (1.28–2.29), number-needed-to-treat 4.9. There was a lack of evidence for any anti–pruritic efficacy with prophylactic propofol, epidural or intrathecal epinephrine, epidural clonidine, epidural prednisone, intravenous ondansetron, or intramuscular hydroxyzine.

Conclusion Naloxone, naltrexone, nalbuphine and droperidol are efficacious in the prevention of opioidinduced pruritus; minimal effective doses remain unknown. There is a lack of valid data on the efficacy of interventions for the treatment of established pruritus.

This study was designed to determine whether low doses of intrathecal morphine still result in itching and it evaluates the outcome of a standardized treatment using promethazine and – for intractable itch – naloxone. Patients (n = 143) scheduled for total hip surgery were allocated to four groups (in a double blind manner) with bupivacaine 20 mg in 4 mL but different doses of intrathecal morphine: Group I, 0.025 mg, Group II, 0.05 mg, Group III, 0.1 mg and Group IV, 0.2 mg. The presence or absence of itching was noted every three hours for a 24-h period. When required, standardized treatment was provided. The incidence of itching was: Group I: 14.3%; Group II: 21.6%; Group III: 48.6%; and, Group IV: 61.7%. Itch was treated by administering promethazine intramuscularly in 2.9% (Group I); 8.1% (Group II); 10.8% (Group III), and 8.9% (Group IV), respectively. Only in group IV there was a single patient who needed naloxone to treat itching. The incidence and severity of itching is a dose-related side-effect in the dose range of 0.025–0.2 mg of intrathecal morphine. Itching still occurs after the low doses of intrathecal morphine, but symptoms vanish after promethazine 25 mg intramuscularly.