Palmar Itching in Chronic Pancreatitis: A Case of Mistaken Association
Palmar itching is not a characteristic feature of chronic pancreatitis itself—if present, it suggests concurrent cholestatic liver disease, which must be actively investigated.
The Critical Distinction
The question conflates two separate conditions. Chronic pancreatitis does not directly cause palmar pruritus. However, patients with chronic pancreatitis may develop cholestatic liver disease through several mechanisms, and cholestatic pruritus characteristically affects the palms and soles 1, 2.
When Palmar Itching Occurs: Cholestatic Complications
Primary Mechanism
- Cholestatic pruritus peaks in the evening and early night, predominantly affecting the palms of hands and soles of feet 2.
- The pathophysiology involves multiple pruritogens including bile salts, lysophosphatidic acid (LPA), autotaxin, and altered opioid signaling that affect both peripheral sensory nerves and central nervous system pathways 3.
How Chronic Pancreatitis Leads to Cholestasis
- Intrapancreatic bile duct stricturing occurs as a complication of chronic pancreatitis due to progressive fibrosis and inflammation compressing the common bile duct as it passes through the pancreatic head 4.
- Pancreatic head enlargement from inflammation or pseudocysts can cause mechanical obstruction of biliary drainage 5.
- This obstruction creates secondary cholestasis, which then produces the characteristic palmar itching pattern 1.
Diagnostic Approach
Immediate Evaluation Required
- Obtain liver biochemistries including alkaline phosphatase, bilirubin, and GGT to assess for cholestasis when a chronic pancreatitis patient reports palmar itching 1.
- Perform cross-sectional imaging (CT or MRI/MRCP) to evaluate for bile duct stricturing or obstruction 5, 6.
- Consider ERCP with brushings if a dominant stricture is identified, as this requires exclusion of cholangiocarcinoma 1.
Critical Pitfall
Do not dismiss palmar itching as a "typical" symptom of chronic pancreatitis—it signals a complication requiring intervention 1.
Management Algorithm
First-Line: Address the Obstruction
- If imaging reveals a relevant bile duct stricture causing cholestasis, endoscopic balloon dilation (or stenting if dilation alone is insufficient) is the primary intervention 1.
- Relieving mechanical obstruction addresses the root cause rather than merely treating symptoms 1.
Pharmacological Management of Cholestatic Pruritus
When obstruction cannot be fully relieved or while awaiting intervention:
First-line: Bezafibrate is now recommended as first-line pharmacological treatment for moderate to severe cholestatic pruritus based on the FITCH trial, which demonstrated clear benefit over placebo 1.
Second-line: Rifampicin (150-300 mg daily) remains highly effective but carries a 12% risk of drug-induced hepatitis after 4-12 weeks, requiring monitoring 1.
Third-line: Naltrexone (starting at 12.5 mg) should be initiated at very low doses to avoid opioid withdrawal-like symptoms 1.
Cholestyramine is no longer first-line for sclerosing cholangitis-related pruritus due to limited evidence and interference with other medications, though it remains first-line for primary biliary cholangitis 1.
Supportive Measures
- Use emollients to prevent skin dryness, avoid hot baths/showers, apply cooling menthol gels to affected areas, and keep nails shortened 1.
The Bottom Line
Palmar itching in a patient with chronic pancreatitis is a red flag for biliary obstruction from pancreatic inflammation or fibrosis compressing the bile duct. This requires urgent evaluation with liver biochemistries and imaging to identify and treat the underlying cholestatic complication 1, 4. The itching itself is not from the pancreatitis but from the secondary cholestasis, and treatment must address both the mechanical obstruction and the cholestatic pruritus 1.