Treatment of Lymphoma-Associated Pruritus
For patients with lymphoma experiencing severe itchiness, first-line symptomatic treatment should include cimetidine, gabapentin, carbamazepine, mirtazapine, or UVB phototherapy, while definitive treatment of the underlying lymphoma remains the most effective approach to resolve pruritus. 1
Definitive Treatment Priority
- Curative treatment of the lymphoma invariably resolves the associated pruritus, making disease-directed therapy the ultimate goal 2
- Symptomatic management is essential for quality of life while patients await or undergo definitive lymphoma treatment 1
- The severity of itch correlates with disease stage in Hodgkin lymphoma, reinforcing the importance of treating the underlying malignancy 3
First-Line Symptomatic Therapies
The British Journal of Dermatology guidelines recommend the following as first-line options 1:
- Cimetidine (H2-receptor antagonist) can help relieve lymphoma-associated pruritus 1
- Gabapentin effectively manages neuropathic components of lymphoma-related itch 1
- Carbamazepine provides another anticonvulsant option for relief 1
- Mirtazapine (antidepressant with antihistaminic properties) can control pruritus 1
- UVB phototherapy can be effective for managing lymphoma-associated pruritus 1
Corticosteroids for Palliation
- High-dose oral corticosteroids are reserved for incurable cases and provide symptomatic relief from itching 2, 1
- Corticosteroids are frequently used in the treatment and palliation of patients with lymphoma and can provide symptomatic relief 2
- Monitor for metabolic side effects when using corticosteroids 1
Clinical Recognition Features
Look for these specific red flags suggesting lymphoma 2:
- Itching at night associated with weight loss, fevers, and night sweats is highly suggestive of lymphoma 2, 1
- Aquagenic pruritus (intense itching triggered by water contact without skin lesions) is characteristic of polycythemia vera 2
- Enlarged lymph nodes or masses warrant referral for excision or ultrasound-guided core biopsy 2
Important Diagnostic Considerations
- Pruritus is most commonly associated with Hodgkin lymphoma but is unusual in non-Hodgkin lymphoma 2
- Patients may rarely present with pruritus and normal-appearing skin who subsequently prove to have cutaneous lymphoma on biopsy 2
- Consider skin biopsy from the trunk in persistent, unexplained pruritus to rule out cutaneous lymphoma 2
Initial Laboratory Workup
When lymphoma is suspected, obtain 2:
- Full blood count and blood film
- Lactate dehydrogenase
- Erythrocyte sedimentation rate
- Ferritin levels
Monitoring and Reassessment
- Monitor for medication side effects, particularly sedation with antihistamines and metabolic effects with corticosteroids 1
- Reassess treatment efficacy regularly and adjust therapy as needed 1
- Avoid long-term sedative antihistamines except in palliative care settings due to potential cognitive side effects and dementia risk 1, 4
Critical Caveats
- The evidence for most symptomatic treatments is limited to case reports and small case series, highlighting the need for more robust clinical trials 1
- Pruritus in cutaneous T-cell lymphomas is particularly severe and difficult to treat, especially in Sézary syndrome 5, 6
- In polycythemia vera, pruritus can persist despite normalization of blood counts with venesection or cytoreductive therapy 2
- Aspirin 300 mg daily has shown effectiveness in relieving pruritus in some patients with polycythemia vera 2