Zusammenfassung
Chronischer Pruritus tritt bei zahlreichen internistischen Erkrankungen auf. Im Gegensatz zu Pruritus bei Hauterkrankungen liegen bei Patienten mit internistischen Erkrankungen keine primären Hautveränderungen vor. Allerdings kann intensives Kratzen zu sekundären Hautveränderungen wie Erosionen, Exkoriationen, Krusten, Prurigo nodularis und als Folge sogar zu Narbenbildung führen. Die häufigsten internistischen Ursachen für chronischen Pruritus stellen die chronische Niereninsuffizienz, Leber- und Gallengangserkrankungen, hämatoonkologische Erkrankungen sowie Medikamentennebenwirkungen dar. Seltener tritt dieses Symptom bei Patienten mit endokrinen oder metabolischen Störungen, Malassimilationssyndromen, Infektionskrankheiten sowie soliden Tumoren auf. Die Pathogenese des Pruritus bei internistischen Erkrankungen ist noch weitgehend ungeklärt, erste Erkenntnisse liegen für den urämischen und cholestatischen Pruritus vor. Die antipruritische Behandlung ist daher meist symptomatisch und kann eine klinische Herausforderung darstellen. Bei chronischer Niereninsuffizienz ist die Wirksamkeit der Kalziumkanalblocker Gabapentin und Pregabalin am besten belegt. In Japan ist der κ‑Opioid-Rezeptor-Agonist Nalfurafin zugelassen. Eine UVB-Lichttherapie kann ebenfalls Linderung bringen. Bei hepatobiliären Erkrankungen ist neben dem Gallensalzbinder Colestyramin der Enzyminduktor Rifampicin effektiv. Ebenfalls kommen μ‑Opioid-Rezeptor-Antagonisten und Sertralin zum Einsatz. Für die Behandlung anderer internistischer Erkrankungen liegen dagegen keine randomisierten kontrollierten Studien vor, und die Behandlung richtet sich auf eine effektive Therapie der Grunderkrankung.
Abstract
Chronic pruritus is a symptom of various internal disorders. In contrast to dermatological diseases, pruritus does not present with primary skin alterations in these patients. However, intense scratching may cause secondary skin changes such as abrasion, excoriation, prurigo nodularis, or in rare cases even scaring. The most common internal medicine causes for chronic pruritus are chronic kidney disease, hepatobiliary and hematological disorders as well as adverse drug reactions. Pruritus is less commonly seen in patients with endocrine or metabolic diseases, malabsorption syndromes, infectious diseases and solid tumors. The pathogenesis of pruritus in these disorders remains largely elusive, albeit preliminary insights have been gained for uremic and cholestatic pruritus. Antipruritic treatment is therefore symptomatic in most cases and may represent a clinical challenge. The calcium channel blockers gabapentin and pregabalin have the best proven efficacy in chronic kidney disease-associated pruritus. In Japan nalfurafine, a κ-opioid receptor agonist, has been licensed for this indication. UVB light may also attenuate uremic symptoms. In patients suffering from hepatobiliary disorders the sequestrant cholestyramine and the enzyme inducer rifampicin are effective. Furthermore, μ‑opioid receptor antagonists and sertraline may be used to ameliorate cholestatic pruritus. So far, no randomized controlled trials have been performed for chronic itch in other internal medicine disorders. Antipruritic treatment is mainly based on effective therapy of the underlying disease.
Literatur
EASL Clinical Practice Guidelines (2009) Management of cholestatic liver diseases. J Hepatol 51:237–267
Afifi Y, Aubin F, Puzenat E, Degouy A, Aubrion D, Hassam B, Humbert P (2004) Pruritus sine materia: a prospective study of 95 patients. Rev Med Interne 25:490–493
Bergasa NV, Mehlman JK, Jones EA (2000) Pruritus and fatigue in primary biliary cirrhosis. Baillieres Best Pract Res Clin Gastroenterol 14:643–655
Berger TG, Shive M, Harper GM (2013) Pruritus in the older patient: a clinical review. JAMA 310:2443–2450
Beuers U (2006) Drug insight: Mechanisms and sites of action of ursodeoxycholic acid in cholestasis. Nat Clin Pract Gastroenterol Hepatol 3:318–328
Beuers U, Kremer AE, Bolier R, Elferink RP (2014) Pruritus in cholestasis: facts and fiction. Hepatology 60:399–407
Chen YC, Chiu WT, Wu MS (2006) Therapeutic effect of topical gamma-linolenic acid on refractory uremic pruritus. Am J Kidney Dis 48:69–76
Geenes V, Williamson C (2009) Intrahepatic cholestasis of pregnancy. World J Gastroenterol 15:2049–2066
Gobbi PG, Attardo-Parrinello G, Lattanzio G, Rizzo SC, Ascari E (1983) Severe pruritus should be a B‑symptom in Hodgkin’s disease. Cancer 51:1934–1936
Johannesdottir SA, Farkas DK, Vinding GR, Pedersen L, Lamberg A, Sorensen HT, Olesen AB (2014) Cancer incidence among patients with a hospital diagnosis of pruritus: a nationwide Danish cohort study. Br J Dermatol 171:839–846
Jones EA, Bergasa NV (2000) Evolving concepts of the pathogenesis and treatment of the pruritus of cholestasis. Can J Gastroenterol 14:33–40
Kilic A, Gul U, Soylu S (2007) Skin findings in internal malignant diseases. Int J Dermatol 46:1055–1060
Kimmel M, Alscher DM, Dunst R, Braun N, Machleidt C, Kiefer T, Stulten C, van der Kuip H, Pauli-Magnus C, Raub U, Kuhlmann U, Mettang T (2006) The role of micro-inflammation in the pathogenesis of uraemic pruritus in haemodialysis patients. Nephrol Dial Transplant 21:749–755
Kremer AE, Martens JJ, Kulik W, Rueff F, Kuiper EM, van Buuren HR, van Erpecum KJ, Kondrackiene J, Prieto J, Rust C, Geenes VL, Williamson C, Moolenaar WH, Beuers U, Oude Elferink RP (2010) Lysophosphatidic acid is a potential mediator of cholestatic pruritus. Gastroenterology 139:1008–1018
Kremer AE, Bolier R, van Dijk R, Oude Elferink RP, Beuers U (2014) Advances in pathogenesis and management of pruritus in cholestasis. Dig Dis 32:637–645
Kumagai H, Ebata T, Takamori K, Muramatsu T, Nakamoto H, Suzuki H (2010) Effect of a novel kappa-receptor agonist, nalfurafine hydrochloride, on severe itch in 337 haemodialysis patients: a phase III, randomized, double-blind, placebo-controlled study. Nephrol Dial Transplant 25:1251–1257
Kuypers DR, Claes K, Evenepoel P, Maes B, Vanrenterghem Y (2004) A prospective proof of concept study of the efficacy of tacrolimus ointment on uraemic pruritus (UP) in patients on chronic dialysis therapy. Nephrol Dial Transplant 19:1895–1901
Mesa RA, Niblack J, Wadleigh M, Verstovsek S, Camoriano J, Barnes S, Tan AD, Atherton PJ, Sloan JA, Tefferi A (2007) The burden of fatigue and quality of life in myeloproliferative disorders (MPDs): an international Internet-based survey of 1179 MPD patients. Cancer 109:68–76
Mettang T, Kremer AE (2015) Uremic pruritus. Kidney Int 87:685–691
Pauli-Magnus C, Klumpp S, Alscher DM, Kuhlmann U, Mettang T (2000) Short-term efficacy of tacrolimus ointment in severe uremic pruritus. Perit Dial Int 20:802–803
Pisoni RL, Wikstrom B, Elder SJ, Akizawa T, Asano Y, Keen ML, Saran R, Mendelssohn DC, Young EW, Port FK (2006) Pruritus in haemodialysis patients: International results from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Nephrol Dial Transplant 21:3495–3505
Reich A, Stander S, Szepietowski JC (2009) Drug-induced pruritus: a review. Acta Derm Venereol 89:236–244
Strumia R, Varotti E, Manzato E, Gualandi M (2001) Skin signs in anorexia nervosa. Dermatology (Basel) 203:314–317
Vannucchi AM, Antonioli E, Guglielmelli P, Rambaldi A, Barosi G, Marchioli R, Marfisi RM, Finazzi G, Guerini V, Fabris F, Randi ML, De Stefano V, Caberlon S, Tafuri A, Ruggeri M, Specchia G, Liso V, Rossi E, Pogliani E, Gugliotta L, Bosi A, Barbui T (2007) Clinical profile of homozygous JAK2 617V〉F mutation in patients with polycythemia vera or essential thrombocythemia. Blood 110:840–846
Weiss M, Mettang T, Tschulena U, Passlick-Deetjen J, Weisshaar E (2015) Prevalence of chronic itch and associated factors in haemodialysis patients: a representative cross-sectional study. Acta Derm Venereol 95:816–821
Weisshaar E, Weiss M, Mettang T, Yosipovitch G, Zylicz Z (2015) Paraneoplastic itch: an expert position statement from the Special Interest Group (SIG) of the International Forum on the Study of Itch (IFSI). Acta Derm Venereol 95:261–265
Wu HY, Peng YS, Chen HY, Tsai WC, Yang JY, Hsu SP, Pai MF, Lu HM, Chiang JF, Ko MJ, Wen SY, Chiu HC (2016) A comparison of uremic pruritus in patients receiving peritoneal dialysis and hemodialysis. Medicine (Baltimore) 95:e2935
Yamaoka H, Sasaki H, Yamasaki H, Ogawa K, Ohta T, Furuta H, Nishi M, Nanjo K (2010) Truncal pruritus of unknown origin may be a symptom of diabetic polyneuropathy. Diabetes Care 33:150–155
Yue J, Jiao S, Xiao Y, Ren W, Zhao T, Meng J (2015) Comparison of pregabalin with ondansetron in treatment of uraemic pruritus in dialysis patients: a prospective, randomized, double-blind study. Int Urol Nephrol 47:161–167
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Interessenkonflikt
A.E. Kremer und T. Mettang geben an, dass kein Interessenkonflikt besteht.
Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.
Rights and permissions
About this article
Cite this article
Kremer, A.E., Mettang, T. Pruritus bei systemischen Erkrankungen. Hautarzt 67, 606–614 (2016). https://doi.org/10.1007/s00105-016-3826-y
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00105-016-3826-y