Pruritus in Obstructive Jaundice: Palmar and Plantar Distribution
Yes, pruritus in obstructive jaundice characteristically involves the palms and soles most severely, though it can become generalized. This distinctive distribution pattern is a hallmark clinical feature that helps distinguish cholestatic pruritus from other causes of generalized itching.
Clinical Presentation and Distribution
The hands and feet are often the worst-affected areas in hepatic pruritus, according to the British Association of Dermatologists 1. This palmar-plantar predominance is particularly characteristic of cholestatic conditions, including obstructive jaundice.
- In intrahepatic cholestasis of pregnancy (a related cholestatic condition), the classic symptom is generalized pruritus most severe in the palms and soles without an accompanying rash, with typical onset in the second or third trimester 1
- Cholestatic itching often peaks in the evening and early night, and mainly occurs on the palms of the hands and soles of the feet but can also occur more generalized 2
- The skin in hepatic pruritus is often generally hyperpigmented and excoriated, with the hands and feet being the worst-affected areas 1
Pathophysiology
The exact mechanism remains incompletely understood, though multiple factors contribute 3, 2:
- Bile acids accumulate in plasma and cause intense irritation 4
- Autotaxin (an enzyme producing lysophosphatidic acid) has been identified as a possible pruritogen in cholestasis 2
- Endogenous opioids, serotonin, and steroid metabolites all play roles 3
- There is poor correlation between pruritus severity and bile acid levels, suggesting other factors are relevant 1
Clinical Significance
Patients with pancreatic cancer and unrelieved jaundice often report that itching is their worst symptom, more distressing than the jaundice itself 4. The condition can lead to:
- Sleep deprivation and significant psychological disturbances 4
- Severe reduction in quality of life 2
- Excoriated, hyperpigmented skin particularly on the hands and feet 1
Treatment Approach
In patients with large bile duct obstruction, treatment is directed at restoration of biliary drainage, which is often associated with prompt resolution of symptoms 1. Surgical biliary bypass relieves pruritus in 88% of patients with malignant obstructive jaundice 5.
For medical management when drainage is not immediately possible:
- Rifampicin is first-line treatment (150 mg twice daily, increasing to 600 mg twice daily as needed) 1
- Cholestyramine is second-line (9 g daily orally), though it only works if biliary obstruction is incomplete 1, 4
- Sertraline is third-line 1
- Naltrexone or nalmefene are fourth-line options 1
Important Clinical Pitfall
Do not use gabapentin for hepatic pruritus—it is ineffective in this condition despite proven efficacy in uremic pruritus 1. This is a critical distinction, as gabapentin is highly effective for kidney disease-related itching but has no role in cholestatic pruritus.