A constant and prolonged itch without any visible rash on the skin may not always be just an allergic reaction. It could be an indicator of an underlying liver condition such as hepatic cholestasis (caused by reduced secretion of bile juice).
Itching, one of the primary symptoms of liver complications, could start on the palm or soles of the feet and then slowly spread to the rest of the body.
Link between itching and liver health
Dr Chetan Kalal, program director, transplant medicine, Nanavati Max Super Speciality Hospital, Mumbai, says the medical term for itching is pruritis and it is caused by an excess build-up of bile salts in the skin. This occurs when the liver is unable to clear toxins and excess salts from the body.
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“Itching (pruritus) can occur in the early stages of liver conditions like primary biliary cholangitis [in which the bile ducts are slowly destroyed], primary sclerosing cholangitis [bile ducts become inflamed, scarred and get blocked] and even in intrahepatic cholestasis of pregnancy [a liver complication that develops during pregnancy],” says Dr Sudeep Khanna, senior consultant, gastroenterologist, Indraprastha Apollo Hospitals, New Delhi.
People with already existing liver conditions may also experience an incessant itching and require treatment.
Another reason for itching could be obstructive jaundice, in which the bile duct gets blocked and bile is unable to flow from the liver to the small intestines.
Science behind the itching signs
According to a research article published in the August 2015 edition of Clinical Medical Journal, the disruption in the expulsion of bile from the liver triggers the release of pruritogens (that cause itching). These pruritogens accumulate in the blood plasma and other tissues that stimulate neural itch fibres in the skin. These neural fibres then transmit the stimulus to the spinal cord. The stimulus is decoded by the brain and makes people reach out and scratch the spot where they feel the itch.
Dr Kalal says the pathological mechanism for itching is not fully understood. “Usually, this itching is caused due to changes in the nerve signal pattern due to the underlying liver disease, altered immune response and high levels of enzymes like alkaline phosphatase (ALP) and lysophosphatidic acid (LPA),” he says. Excess of ALP and LPA indicates impaired liver function.
Symptoms of liver-related pruritus
Unlike other skin conditions, itching related to liver disease is different, says Dr Kalal. He adds that other skin-related conditions with itching usually present themselves with rashes or skin lesions, but in the case of itching triggered by liver damage there will not be any external marks.
According to Dr Khanna, cholestatic pruritus can affect the day-to-day life of people with the condition. “Most people with pruritus experience this incessant itch at night, which also affects and disturbs their sleep,” he says.
Pruritus and liver conditions
- Primary biliary cirrhosis: This chronic inflammation in the liver can cause bile duct damage and irreversible scarring of liver tissue (cirrhosis) which may progress into liver failure.
- Primary sclerosing cholangitis: This is a chronic liver disease in which the bile ducts of the liver become inflamed and scarred and get narrowed or blocked. “When this happens, bile builds up in the liver and causes further liver damage,” says Dr Kalal.
- Intrahepatic cholestasis of pregnancy: Many hormonal changes take place in the female body during pregnancy. Sometimes high estrogen and progesterone levels can cause salts in the bile to build up and enter the bloodstream. “This can cause severe bouts of itching,” says Dr Kalal.
- Benign recurrent intrahepatic cholestasis is a condition in which different episodes of liver dysfunction occur and the liver is unable to produce bile. “These episodes can happen of and on, last from weeks to months and are typically seen in young adults and adolescents. [They] usually begin with severe itching.”Â
- Progressive familial intrahepatic cholestasis: Pruritus is also seen in another hereditary disorder called progressive familial intrahepatic cholestasis that causes progressive liver disease.
- Sometimes viral hepatitis A and hepatitis E can also present with itching when they reach cholestatic state, although it is very rare.
- Drug-induced liver injury: This is usually triggered as a result of a severe adverse reaction to either natural or synthetic liver medicines and supplements.
Treatment
“Typically, the treatment involves addressing the underlying liver problem and methods to reduce the build-up of bile salts under the skin,” says Dr Kalal. Though anti-itch medication and antibiotics are given for relief from skin abrasions, liver conditions should be addressed without fail.
Sometimes UV light therapy is also given in cases of unmanageable itching. “By exposing the affected area of the skin to light we can convert these insoluble toxic bile salts into more soluble bile salts, and these could be expelled into urine, thereby reducing the itching,” says Dr Kalal.
Using topical creams and moisturisers, apart from maintaining good hydration, helps the skin. The affected people are also asked to avoid hot showers. “After a shower the affected person should make it a point to pat the skin dry and not rub it with a towel,” cautions Dr Kalal.
Intake of alcohol should be limited or completely avoided.
It is most important to go for a liver test and get the diagnosis of the underlying condition.
“The improvement of liver function through treatment of underlying liver disease can often alleviate itching symptoms,” says Dr Khanna.
Dr Kalal says plasma exchange therapy or plasmapheresis is also used as a rescue therapy which helps remove the bile salts, pruritogens, chemical mediators or other toxins responsible for itching.
Takeaways
Intense itching (pruritus) sensation without any rash on the skin could be one of the earliest signs of liver trouble, according to experts. This is mainly caused due to the inability of the liver to clear out bile. This causes accumulation of bile salts in the skin, triggering an itching sensation. Hepatologists say that it is essential to get a liver function test done to ascertain whether liver failure is the cause of the itch.
