Cholestatic pruritus: a knowledge update

Abstract

This review is focused on updating knowledge about cholestatic pruritus. It summarizes clinical-epidemiological characteristics, pathophysiology, diagnostic approach, and evidence-based therapeutic recommendations regarding this form of pruritus. Pruritus is a frequent symptom that accompanies several liver diseases, particularly cholestatic ones. The symptom may be mild and tolerable, but it can also dramatically reduce the quality of life. Although the exact pathophysiology of this form of pruritus remains unclear, current evidence supports a mixed origin. It is extremely important for dermatologists to have knowledge about cholestatic pruritus since they are usually the first physicians to be sought by the patient when they experience the symptom. In the absence of specific dermatological alterations, cholestasis must always be considered as a possible cause of pruritus. In addition to allowing an adequate diagnosis, a better pathophysiological understanding of hepatic pruritus provides the identification of new therapeutic targets and, consequently, optimization of the approach in patients with this condition.

Keywords: Cholestasis; Dermatology; Pruritus.

Figure 1

Classification of cholestasis according to its origin in the biliary system and corresponding examples. PBC, Primary Biliary Cholangitis; PSC, Primary Sclerosing Cholangitis; SSC, Secondary Sclerosing Cholangitis, IHCP, Intrahepatic Cholestasis of Pregnancy; PFIC, Progressive Familial Intrahepatic Cholestasis.

Figure 2

Pathophysiology of cholestatic pruritus. LPA, Lysophosphatidic Acid.

Figure 3

Algorithm for the treatment of cholestatic pruritus. UDCA, Ursodeoxycholic Acid; PBC, Primary Biliary Cholangitis; IHCP, Intrahepatic Cholestasis of Pregnancy; IBAT, Ileal Bile Acid Transporter; MARS, Molecular Adsorbent Recirculating System, PPARs, Peroxisome Proliferator-Activated Receptor Agonists; UVB, Ultraviolet radiation type B.