Can liver conditions such as fatty liver or cirrhosis cause itching all over the body?

Liver Disease and Generalized Pruritus

Yes, liver conditions such as fatty liver disease and cirrhosis can cause itching all over the body, particularly in cholestatic liver diseases where bile flow is impaired. This itching (pruritus) is a common and often distressing symptom that significantly impacts quality of life.

Liver Conditions Associated with Pruritus

• Cholestatic liver diseases are most commonly associated with generalized pruritus, including:

  • Primary biliary cholangitis (PBC) 1
  • Primary sclerosing cholangitis (PSC) 1
  • Intrahepatic cholestasis of pregnancy 1
  • Biliary obstruction from any cause 1

• Other liver conditions that may cause pruritus:

  • Cirrhosis (of any etiology) 1
  • Viral hepatitis 1
  • Alcoholic liver disease 1
  • Nonalcoholic fatty liver disease (NAFLD) - less commonly associated with significant pruritus compared to cholestatic conditions 1

Pathophysiology of Liver-Related Pruritus

The exact mechanism of liver-related pruritus remains incompletely understood, but several factors have been implicated:

• Bile acid accumulation - traditionally thought to be the main cause, though recent evidence suggests a more complex mechanism 2
• Lysophosphatidic acid (LPA) and its forming enzyme autotaxin (ATX) - levels correlate with itch intensity in cholestatic patients 3, 2
• Endogenous opioids - may play a central role in mediating itch perception 3, 4
• Sulfated progesterone metabolites - particularly relevant in intrahepatic cholestasis of pregnancy 2

Clinical Characteristics of Liver-Related Pruritus

• Often worse at night 1
• In cholestatic conditions, pruritus commonly affects the palms and soles but can be generalized 1
• May precede other symptoms of liver disease 1
• Typically not associated with a primary rash, though excoriations from scratching may be present 1
• Can be severe and debilitating, significantly impacting quality of life 3

Treatment Approaches

For hepatic pruritus, the British Association of Dermatologists guidelines recommend a stepwise approach:

1. First-line treatment: Rifampicin (Strength of recommendation A) 1

   • Starting dose 150 mg twice daily, can be increased up to 600 mg twice daily
   • Monitor for hepatotoxicity

2. Second-line treatment: Cholestyramine (Strength of recommendation D) 1

   • Binds bile acids in the gut lumen
   • Must be separated from other medications by at least 2 hours
   • May exacerbate vitamin K deficiency in cholestatic patients 1

3. Third-line treatment: Sertraline (SSRI) 1

4. Fourth-line treatment: Naltrexone or nalmefene (opioid antagonists) 1

5. Fifth-line treatments for refractory cases 1:

   • Systemic dronabinol, phenobarbitone, propofol
   • Topical tacrolimus ointment
   • Extracorporeal dialysis techniques
   • Nasobiliary drainage
   • Liver transplantation (in extreme cases)

6. Additional therapies:

   • Broadband UVB phototherapy can provide temporary relief 1
   • Transcutaneous electrical nerve stimulation 1

Important Considerations

• Do not use gabapentin for hepatic pruritus (Strength of recommendation D) 1
• Avoid long-term sedative antihistamines except in palliative care settings, as they may predispose to dementia 1
• Vitamin K supplementation may be needed in patients with cholestasis, especially if using cholestyramine 1
• Treatment of the underlying liver condition is essential for long-term management 1
• In fatty liver disease, lifestyle modifications including weight loss and exercise may improve both the liver condition and associated symptoms 1

When to Seek Medical Attention

• Generalized pruritus without a rash should prompt evaluation of liver function 1
• New-onset pruritus in patients with known liver disease may indicate disease progression 1
• Intractable pruritus despite treatment may require specialist referral 1