How to control pruritus in lymphoma?

Management of Pruritus in Lymphoma

Patients with lymphoma-associated pruritus should be treated with cimetidine, gabapentin, carbamazepine, mirtazapine, or phototherapy as first-line options, with oral corticosteroids reserved for incurable cases. 1

Pathophysiology and Clinical Presentation

• Pruritus is a common symptom in lymphoma, particularly in Hodgkin's disease, and can be severe enough to significantly impact quality of life 2, 3
• Itching at night associated with weight loss, fevers, and night sweats is highly suggestive of lymphoma 1
• The symptom may precede other clinical manifestations of lymphoma and can be an early warning sign of disease 4, 5

Treatment Algorithm

First-Line Options:

• Cimetidine: An H2-receptor antagonist that can help relieve lymphoma-associated pruritus 1
• Gabapentin: An anticonvulsant that can effectively manage neuropathic components of lymphoma-related itch 1
• Carbamazepine: Another anticonvulsant option that may provide relief for lymphoma-associated pruritus 1
• Mirtazapine: An antidepressant with antihistaminic properties that can help control pruritus 1
• Phototherapy: UVB phototherapy can be effective for managing lymphoma-associated pruritus 1

For Incurable Lymphoma:

• Oral corticosteroids: High-dose oral corticosteroids are recommended for palliation and symptomatic relief of pruritus in patients with incurable lymphoma 1

Additional Options:

• Antihistamines: Hydroxyzine may be used at doses of 25 mg three to four times daily for histamine-mediated pruritus 6
• Targeted therapies: For cutaneous T-cell lymphomas, romidepsin (a histone deacetylase inhibitor) has shown efficacy in relieving intractable pruritus 7
• Neurokinin-1 receptor antagonists: Aprepitant has shown promise in case reports for managing paraneoplastic pruritus in Hodgkin's lymphoma 4

Monitoring and Follow-up

• Regular assessment of pruritus severity using visual analog scales can help track treatment efficacy 4
• Monitor for side effects of medications, particularly sedation with antihistamines and metabolic effects with corticosteroids 8
• Reassess treatment efficacy regularly and adjust therapy as needed 8

Important Considerations

• Definitive treatment: Curative treatment of the underlying lymphoma is the most effective approach and invariably resolves associated pruritus 1
• Symptomatic management: While awaiting or during definitive lymphoma treatment, symptomatic management of pruritus is essential for quality of life 1
• Refractory cases: For pruritus that persists despite standard therapies, consider novel agents like aprepitant or romidepsin in consultation with oncology 7, 4
• Avoid long-term sedative antihistamines: Except in palliative care settings, due to potential cognitive side effects 8

Pitfalls and Caveats

• Pruritus may be the presenting symptom of lymphoma, so unexplained persistent itching warrants thorough investigation 5
• Treatment-refractory "eczema" or generalized pruritus without visible primary skin lesions should raise suspicion for underlying lymphoma 5
• Pruritus may recur with disease progression or relapse, serving as a potential marker for treatment response 4
• The evidence for most treatments is limited to case reports and small case series, highlighting the need for more robust clinical trials 1, 3