Chronic Itching (Pruritus)

What is Chronic Itching?

Chronic itching is itch that lasts six weeks or longer. It is common: about one in five people has it at some point in life, and it accounts for roughly 1 percent of physician visits.^[1] Chronic itch is a symptom of many conditions, so the first task is to find out why it is happening.^[2]

Common symptoms

The main symptom is an itch that keeps returning and makes you want to scratch. Scratching can leave marks, thickened skin or sores, and these can in turn keep the itch going.^[3]

• Itch that is limited to one area or spread over the whole body
• Dry, red, scaly or rough skin, or skin that looks normal
• Poor sleep because of itching at night
• Anxiety, low mood or avoiding social situations^[4]

Causes and risk factors

About 60 percent of chronic itch comes from inflammatory skin disease such as eczema, psoriasis or seborrheic dermatitis. About 25 percent is neuropathic or mixed, meaning the nerves that carry itch signals are involved, as in postherpetic neuralgia. The remainder comes from systemic illness such as kidney or liver disease, from medicines, or from infections such as scabies.^[1]

Age and other factors matter too. Itch is more common in older adults and can accompany diseases of the kidney, liver, thyroid or blood.^[4]

How it is diagnosed and treated conventionally

Diagnosis starts with a history and skin examination. When there are few skin changes, doctors often order blood tests such as a blood count, kidney, liver and thyroid tests to look for an underlying illness.^{[1, 4]}

Treatment aims at the underlying disease, the skin and the itch itself. First-line care for inflammatory itch is a topical anti-inflammatory such as a corticosteroid or tacrolimus ointment. Neuropathic itch may be treated with topical agents such as menthol or pramoxine, or with medicines such as gabapentin or certain antidepressants. Dermatology referral is considered if topical care fails.^[1] Guidelines also advise treating sleep problems and, where needed, anxiety or depression.^[3]

Why Chronic Itching calls for a whole-person approach

Chronic itch rarely has a single driver. The skin, the nerves that signal itch, the immune system, and the state of the mind and body all influence it, which is why guidelines call for a stepwise, multimodal approach.^[2]

Care that addresses stress, sleep and skin comfort alongside medical treatment of the cause is therefore a reasonable addition, though it cannot replace finding the cause.

Skin inflammation

Inflammation is the most common cause of chronic itch, so controlling it is central to treatment.^[1] Anything that keeps the skin inflamed, including repeated scratching, can prolong the problem.^[3]

Nerve signaling

In a quarter of patients the main problem is nerve dysregulation, either in the skin or along the nerve pathway, and this type often responds poorly to skin creams alone.^[1]

Stress and anxiety

Stress makes itch worse, and itch in turn raises stress, creating a vicious cycle. A review links this to activation of the stress hormone axis and the sympathetic nervous system, which act on skin mast cells and on nerves.^[5]

Sleep and quality of life

Chronic itch is associated with disturbed sleep and a lower quality of life.^[4] Guidelines include sleep promotion as part of care.^[3]

Acupuncture for Chronic Itching

What the research shows

Research suggests acupuncture may reduce itch in some settings, but the evidence is limited and mostly concerns itch in people on dialysis. A 2023 meta-analysis of 7 trials with 504 patients with uremic pruritus found acupuncture more effective than conventional treatment overall (though comparable to anti-itch medicines in a subgroup), and combined with hemodialysis it worked better than hemodialysis alone.^[6] A larger 2022 meta-analysis of 40 trials with 2,735 patients found that acupuncture and ear acupressure improved uremic itch, while asking for larger and longer studies.^[7] Another meta-analysis of 12 trials found ear acupressure lowered itch scores in people on dialysis, but the authors advised caution because the included studies were of low quality.^[8]

Outside kidney disease the findings are small. In one placebo-controlled crossover trial of 30 adults with atopic eczema, acupuncture at specific points reduced itch from a skin allergy test more than no acupuncture, and in some measures more than acupuncture at non-specific points. This was a laboratory-style trial of short-term itch, not of everyday chronic itch.^[9] A sham-controlled trial of 30 women found that acupuncture did not prevent itch caused by spinal morphine after cesarean delivery.^[10]

An updated review of acupuncture in dermatology concluded that results were promising for uremic itch, atopic dermatitis, urticaria and itch, but that larger sham-controlled trials are needed.^[11]

How acupuncture may work

Researchers propose that acupuncture needling produces signals in skin and muscle that interact with cells and nerve fibers, change mediators and receptors, and reduce the transmission of itch signals in the nerves and brain.^[12] Stress reduction may also play a part, since stress feeds itch.^[5] These are proposed explanations, not settled facts, and the same review notes that acupuncture for itch was not recommended in recent clinical guidelines.^[12]

What treatment involves

Treatment uses fine, sterile, single-use needles placed at points chosen for you, often on the arms, legs and ears, and usually left in place for about 20 to 40 minutes. A course of several visits is typical, with reassessment along the way.

In prospective studies, about 9 in 100 patients had a minor reaction such as bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[13] Tell the practitioner first if you have a bleeding disorder, take blood thinners, are pregnant, or have a pacemaker (relevant to electroacupuncture). If your itch comes from kidney disease or liver disease, we ask that your treating team knows you are receiving acupuncture.

Ayurvedic medicine for Chronic Itching

The Ayurvedic view

Ayurveda describes itch under the name Kandu, and it is linked to several skin conditions in the classical texts. In this traditional framework, itching is often described as an imbalance of Kapha, sometimes with Pitta, and related to impaired digestion and the buildup of ama (undigested material). These are traditional categories used to choose treatment, not biomedical diagnoses.

Therapies that may be used

Care is chosen for the individual and traditionally combines:

• Diet and daily routine, for example avoiding foods a person finds trigger flare-ups and keeping regular meals and sleep
• Soothing oil applications for dry skin
• Herbs such as turmeric (Curcuma longa) and neem, traditionally used for skin conditions; turmeric has also been studied in trials for itch^[14]
• Transdermal medication therapy, meaning an herbal preparation applied to the skin, where an individually chosen preparation is appropriate

Panchakarma, a set of traditional cleansing procedures, is not appropriate during pregnancy, acute illness or frailty, and it is not suited to people with kidney or liver disease unless their physician agrees.

What the research shows

We found no clinical trials of Ayurvedic treatment for chronic itch as a whole, only individual case reports of Ayurvedic care for skin conditions. Research on Ayurvedic herbs for itch is therefore limited to single ingredients, mainly turmeric, described below.^{[14, 15]}

Herbal medicine for Chronic Itching

Herbs and formulas that have been studied

A review of 17 clinical trials of herbal and complementary treatments for chronic itch listed turmeric, Fumaria parviflora, oat (Avena sativa), capsaicin, sweet almond oil, peppermint oil, violet oil and vinegar applied to the skin, along with aromatherapy, ear acupressure and acupuncture.^[14] In uremic itch, Chinese herbal medicine has been tested as an add-on to dialysis and standard antiitch care.^[16]

What the research shows

The evidence is limited. The review of 17 trials found that several of these remedies were effective, but noted that few studies exist and more are needed.^[14] A meta-analysis of 50 trials with 3,311 dialysis patients found that adding Chinese herbal medicine improved overall response and lowered itch scores, without a higher rate of reported adverse events, although the comparison groups received hemodialysis alone or with standard anti-itch treatment rather than a placebo herb.^[16]

A systematic review of curcumin trials for skin disease graded the recommendation for pruritus as grade B and described the safety profile in trials as excellent; it also called for larger trials to determine optimal treatment.^[15] In a trial of 100 adults with post-burn itch, curcumin added to standard care modestly lowered total itch intensity compared with standard care alone, although individual itch measures did not differ significantly.^[17]

Safety and herb-drug interactions

Herbs are active substances and can interact with medicines. Case reports describe bleeding when warfarin was combined with herbs including dang gui (Angelica sinensis), dan shen (Salvia miltiorrhiza), ginger, ginseng and Boswellia.^[18] People taking blood thinners need a practitioner's review before using herbs.

Some herbal products can harm the liver, and liver injury is itself a cause of itch. A case series of ashwagandha supplements described jaundice with prolonged itching.^[19] Because liver disease is itself a cause of itch, anyone with liver or kidney disease, or who is pregnant or breastfeeding, should have herbs reviewed with their physician first.

About one fifth of Ayurvedic medicines bought online contained detectable lead, mercury or arsenic.^[20] Herbs should come from tested sources and be prescribed individually. Stop any herb and contact your physician if itch worsens or your skin or eyes turn yellow.

Translating traditional medicine into modern biological language

The links drawn here are interpretation, not equivalence. Chinese medicine often describes chronic itch as wind, heat or dryness in the skin, sometimes with blood deficiency. Researchers studying acupuncture for itch measure things that loosely parallel this picture: the activity of itch-sensing nerve fibers, mast cells and inflammatory signaling, and the way the brain processes itch.^[12]

Ayurveda's account of imbalance and ama has no direct biomedical counterpart. The nearest ideas researchers study are skin inflammation and the effect of stress on the nervous and immune systems.^[5] No study has shown that a dosha or a pattern corresponds to a specific biological process.

How this care fits with your medical care

Integrative care for chronic itch is complementary. Chronic itch can signal kidney, liver, thyroid or blood disease, so it should be medically evaluated before or alongside any complementary care.^[4] Keep your physician or dermatologist, and do not stop or change prescribed medicines without your prescriber. We do not diagnose the cause of itch.

Please bring your diagnosis, recent blood test results, a full list of medicines, creams and supplements, and notes on what makes your itch better or worse.

When to seek urgent medical care

Some symptoms point to a serious cause and need prompt medical attention.^[4]

• Itch with yellow skin or eyes, dark urine or pale stools
• Itch with unexplained weight loss, night sweats, fever or swollen glands
• Itch that began recently and is widespread, especially after age 60
• Swelling of the lips, tongue or face, or trouble breathing after a new medicine or food
• Skin that is spreading red, hot, painful, oozing or blistering, which may be infected

If you have trouble breathing or swelling of the face or throat, call 911 or go to the nearest emergency department.