Vol 10, No 1 (2024)
Review paper
Published online: 2024-02-01

open access

Page views 286
Article views/downloads 203
Get Citation

Connect on Social Media

Connect on Social Media

Pruritus in elderly patients: review of literature

Paula Mazan1, Aleksandra Lesiak12, Joanna Narbutt1
Forum Dermatologicum 2024;10(1):1-9.

Abstract

Pruritus is the most common symptom reported by dermatology patients, including the geriatric patient population. Due to population ageing, pruritus will be an increasingly common reason for medical consultations. Pruritus can involve both previously affected and unaffected skin, occurring as the only manifestation of the disease. Chronic pruritus lasting more than six weeks has a significant impact on patients’ quality of life, often resulting in sleep disorders and depressive-anxiety disorders. Mechanisms responsible for pruritus in the elderly include abnormal dermal-epidermal barrier, age-related changes in the immune system, and central and peripheral neuropathy. Xerosis is considered the most common cause of pruritus in geriatric patients. Chronic pruritus occurs in the course of many dermatological conditions, as well as Internal diseases, and neurological or psychiatric disorders. The treatment of chronic pruritus in elderly patients may sometimes be a therapeutic challenge due to comorbidities or the complexity of the mechanisms leading to its onset. Each patient needs an individual and often multidisciplinary approach, taking into account comorbidities and polypragmasia. In addition to emollient skincare — which is the basis of skin care — and topical anti-inflammatory preparations for inflammatory skin disorders, biologics are increasingly being used in the treatment of pruritus, as well as drugs with antidepressant and antiepileptic effects.

Article available in PDF format

View PDF Download PDF file

References

  1. Hawro T, Przybyłowicz K, Spindler M, et al. The characteristics and impact of pruritus in adult dermatology patients: A prospective, cross-sectional study. J Am Acad Dermatol. 2021; 84(3): 691–700.
  2. Valdes-Rodriguez R, Mollanazar NK, González-Muro J, et al. Itch prevalence and characteristics in a Hispanic geriatric population: a comprehensive study using a standardized itch questionnaire. Acta Derm Venereol. 2015; 95(4): 417–421.
  3. Silverberg JI, Hinami K, Trick WE, et al. Itch in the general internal medicine setting: a cross-sectional study of prevalence and quality-of-life effects. Am J Clin Dermatol. 2016; 17(6): 681–690.
  4. Dalgard F, Dawn AG, Yosipovitch G. Are itch and chronic pain associated in adults? Results of a large population survey in Norway. Dermatology. 2007; 214(4): 305–309.
  5. Matterne U, Strassner T, Apfelbacher CJ, et al. Measuring the prevalence of chronic itch in the general population: development and validation of a questionnaire for use in large-scale studies. Acta Derm Venereol. 2009; 89(3): 250–256.
  6. Ständer S, Schäfer I, Phan NQ, et al. Prevalence of chronic pruritus in Germany: results of a cross-sectional study in a sample working population of 11,730. Dermatology. 2010; 221(3): 229–235.
  7. Dalgard F, Svensson A, Holm JØ, et al. Self-reported skin morbidity in Oslo. Associations with sociodemographic factors among adults in a cross-sectional study. Br J Dermatol. 2004; 151(2): 452–457.
  8. Weisshaar E, Dalgard F. Epidemiology of itch: adding to the burden of skin morbidity. Acta Derm Venereol. 2009; 89(4): 339–350.
  9. Thaipisuttikul Y. Pruritic skin diseases in the elderly. J Dermatol. 1998; 25(3): 153–157.
  10. Beauregard S, Gilchrest BA. A survey of skin problems and skin care regimens in the elderly. Arch Dermatol. 1987; 123(12): 1638–1643.
  11. Yalçin B, Tamer E, Toy GG, et al. The prevalence of skin diseases in the elderly: analysis of 4099 geriatric patients. Int J Dermatol. 2006; 45(6): 672–676.
  12. Gunalan P, Indradevi R, Oudeacoumar P, et al. Pattern of skin diseases in geriatric patients attending tertiary care centre. J Evol Med Dent Sci. 2017; 6(20): 1566–1570.
  13. Key findings & advance tables, World population prospects 2017 Revision, United Nations. https://esa.un.org/unpd/wpp/Publications/Files/ WPP2017_KeyFindings.pdf (27.09.2017).
  14. Shevchenko A, Valdes-Rodriguez R, Yosipovitch G. Causes, pathophysiology, and treatment of pruritus in the mature patient. Clin Dermatol. 2018; 36(2): 140–151.
  15. Moniaga CS, Tominaga M, Takamori K. Mechanisms and management of itch in dry skin. Acta Derm Venereol. 2020; 100(2): adv00024.
  16. Candore G, Caruso C, Jirillo E, et al. Low grade inflammation as a common pathogenetic denominator in age-related diseases: novel drug targets for anti-ageing strategies and successful ageing achievement. Curr Pharm Des. 2010; 16(6): 584–596.
  17. Pawelec G, Larbi A, Derhovanessian E, et al. Senescence of the human immune system. J Comp Pathol. 2010; 142 Suppl 1: S39–S44.
  18. Ferrando-Martínez S, Franco JM, Hernandez A, et al. Thymopoiesis in elderly human is associated with systemic inflammatory status. Age (Dordr). 2009; 31(2): 87–97.
  19. Weiskopf D, Weinberger B, Grubeck-Loebenstein B. The aging of the immune system. Transpl Int. 2009; 22(11): 1041–1050.
  20. Berger TG, Steinhoff M. Pruritus in elderly patients — eruptions of senescence. Semin Cutan Med Surg. 2011; 30(2): 113–117.
  21. Berger TG, Shive M, Harper GM. Pruritus in the older patient: a clinical review. JAMA. 2013; 310(22): 2443–2450.
  22. Schmidt T, Sitaru C, Amber K, et al. BP180- and BP230-specific IgG autoantibodies in pruritic disorders of the elderly: a preclinical stage of bullous pemphigoid? Br J Dermatol. 2014; 171(2): 212–219.
  23. Haynes L, Maue AC. Effects of aging on T cell function. Curr Opin Immunol. 2009; 21(4): 414–417.
  24. Sandmand M, Bruunsgaard H, Kemp K, et al. Is ageing associated with a shift in the balance between Type 1 and Type 2 cytokines in humans? Clin Exp Immunol. 2002; 127(1): 107–114.
  25. Xu AZ, Tripathi SV, Kau AL, et al. Immune dysregulation underlies a subset of patients with chronic idiopathic pruritus. J Am Acad Dermatol. 2016; 74(5): 1017–1020.
  26. Beauregard S, Gilchrest BA. A survey of skin problems and skin care regimens in the elderly. Arch Dermatol. 1987; 123(12): 1638–1643.
  27. Polat M, Yalçin B, Calişkan D, et al. Complete dermatological examination in the elderly: an exploratory study from an outpatient clinic in Turkey. Gerontology. 2009; 55(1): 58–63.
  28. Paul C, Maumus-Robert S, Mazereeuw-Hautier J, et al. Prevalence and risk factors for xerosis in the elderly: a cross-sectional epidemiological study in primary care. Dermatology. 2011; 223(3): 260–265.
  29. White-Chu EF, Reddy M. Dry skin in the elderly: complexities of a common problem. Clin Dermatol. 2011; 29(1): 37–42.
  30. Yosipovitch G. Dry skin and impairment of barrier function associated with itch — new insights. Int J Cosmet Sci. 2004; 26(1): 1–7.
  31. Choi EH, Man MQ, Xu Pu, et al. Stratum corneum acidification is impaired in moderately aged human and murine skin. J Invest Dermatol. 2007; 127(12): 2847–2856.
  32. Choi EHo. Gender, age, and ethnicity as factors that can influence skin pH. Curr Probl Dermatol. 2018; 54: 48–53.
  33. Lambers H, Piessens S, Bloem A, et al. Natural skin surface pH is on average below 5, which is beneficial for its resident flora. Int J Cosmet Sci. 2006; 28(5): 359–370.
  34. Jensen JM, Förl M, Winoto-Morbach S, et al. Acid and neutral sphingomyelinase, ceramide synthase, and acid ceramidase activities in cutaneous aging. Exp Dermatol. 2005; 14(8): 609–618.
  35. Ali SM, Yosipovitch G. Skin pH: from basic science to basic skin care. Acta Derm Venereol. 2013; 93(3): 261–267.
  36. Andersen HH, Elberling J, Sølvsten H, et al. Nonhistaminergic and mechanical itch sensitization in atopic dermatitis. Pain. 2017; 158(9): 1780–1791.
  37. Seyfarth F, Schliemann S, Antonov D, et al. Dry skin, barrier function, and irritant contact dermatitis in the elderly. Clin Dermatol. 2011; 29(1): 31–36.
  38. Simon M, Bernard D, Minondo AM, et al. Persistence of both peripheral and non-peripheral corneodesmosomes in the upper stratum corneum of winter xerosis skin versus only peripheral in normal skin. J Invest Dermatol. 2001; 116(1): 23–30.
  39. Long CC, Marks R. Stratum corneum changes in patients with senile pruritus. J Am Acad Dermatol. 1992; 27(4): 560–564.
  40. Elias PM, Ghadially R. The aged epidermal permeability barrier: basis for functional abnormalities. Clin Geriatr Med. 2002; 18(1): 103–120, vii.
  41. Pappas A. Epidermal surface lipids. Dermatoendocrinol. 2009; 1(2): 72–76.
  42. Balato A, Balato N, Di Costanzo L, et al. Contact sensitization in the elderly. Clin Dermatol. 2011; 29(1): 24–30.
  43. Lima AL, Timmermann V, Illing T, et al. Contact dermatitis in the elderly: predisposing factors, diagnosis, and management. Drugs Aging. 2019; 36(5): 411–417.
  44. Theodosat A. Skin diseases of the lower extremities in the elderly. Dermatol Clin. 2004; 22(1): 13–21.
  45. Fenske NA, Lober CW. Structural and functional changes of normal aging skin. J Am Acad Dermatol. 1986; 15(4 Pt 1): 571–585.
  46. Thornton MJ, et al. Estrogens and aging skin. Dermatoendocrinol. 2013; 5(2): 264–270.
  47. Steinhoff M, Schmelz M, Szabó IL, et al. Clinical presentation, management, and pathophysiology of neuropathic itch. Lancet Neurol. 2018; 17(8): 709–720.
  48. Canavero S, Bonicalzi V, Massa-Micon B. Central neurogenic pruritus: a literature review. Acta Neurol Belg. 1997; 97(4): 244–247.
  49. Liao YH, Chen KH, Tseng MP, et al. Pattern of skin diseases in a geriatric patient group in Taiwan: a 7-year survey from the outpatient clinic of a university medical center. Dermatology. 2001; 203(4): 308–313.
  50. Liddell K. Letter: Post-herpetic pruritus. Br Med J. 1974; 4(5937): 165.
  51. Oaklander AL. Mechanisms of pain and itch caused by Herpes zoster (shingles). J Pain. 2008; 9(1 Suppl 1): S10–18.
  52. Yamaoka H, Sasaki H, Yamasaki H, et al. Truncal pruritus of unknown origin may be a symptom of diabetic polyneuropathy. Diabetes Care. 2010; 33(1): 150–155.
  53. Fitzpatrick JE. Common inflammatory skin diseases of the elderly. Geriatrics. 1989; 44(7): 40–46.
  54. Ward JR, Bernhard JD. Willan's itch and other causes of pruritus in the elderly. Int J Dermatol. 2005; 44(4): 267–273.
  55. Cömert A, Akbaş B, Kılıç EZ, et al. Psychiatric comorbidities and alexithymia in patients with seborrheic dermatitis: a questionnaire study in Turkey. Am J Clin Dermatol. 2013; 14(4): 335–342.
  56. Arsic Arsenijevic VS, Milobratovic D, Barac AM, et al. A laboratory-based study on patients with Parkinson's disease and seborrheic dermatitis: the presence and density of Malassezia yeasts, their different species and enzymes production. BMC Dermatol. 2014; 14: 5.
  57. Tanner C, Albers K, Goldman S, et al. Seborrheic Dermatitis and Risk of Future Parkinson's Disease (PD) (S42.001). Neurology. 2012; 78(1).
  58. Arlian LG, Estes SA, Vyszenski-Moher DL. Prevalence of Sarcoptes scabiei in the homes and nursing homes of scabietic patients. J Am Acad Dermatol. 1988; 19(5 Pt 1): 806–811.
  59. Hopper AH, Salisbury J, Jegadeva AN, et al. Epidemic Norwegian scabies in a geriatric unit. Age Ageing. 1990; 19(2): 125–127.
  60. Pereira MP, Ständer S. How to define chronic prurigo? Exp Dermatol. 2019; 28(12): 1455–1460.
  61. Kwon CD, Khanna R, Williams KA, et al. Diagnostic workup and evaluation of patients with prurigo nodularis. Medicines (Basel). 2019; 6(97).
  62. Balato A, Balato N, Di Costanzo L, et al. Contact sensitization in the elderly. Clin Dermatol. 2011; 29(1): 24–30.
  63. Seyfarth F, Schliemann S, Antonov D, et al. Dry skin, barrier function, and irritant contact dermatitis in the elderly. Clin Dermatol. 2011; 29(1): 31–36.
  64. Ozkaya E. Adult-onset atopic dermatitis. J Am Acad Dermatol. 2005; 52(4): 579–582.
  65. Kwon HH, Kwon InHo, Youn JIl. Clinical study of psoriasis occurring over the age of 60 years: is elderly-onset psoriasis a distinct subtype? Int J Dermatol. 2012; 51(1): 53–58.
  66. Grozdev I, Voorhees AV, Gottlieb A, et al. Psoriasis in the elderly: from the Medical Board of the National Psoriasis Foundation. J Am Acad Dermatol. 2011; 65(3): 537–545.
  67. Meeuwis KAP, van de Kerkhof PCM, Massuger LF, et al. Patients' experience of psoriasis in the genital area. Dermatology. 2012; 224(3): 271–276.
  68. Parsons JM. Transient acantholytic dermatosis (Grover's disease): a global perspective. J Am Acad Dermatol. 1996; 35(5 Pt 1): 653–66; quiz 667.
  69. Horn TD, Groleau GE. Transient acantholytic dermatosis in immunocompromised febrile patients with cancer. Arch Dermatol. 1987; 123(2): 238–240.
  70. Manteaux AM, Rapini RP. Transient acantholytic dermatosis in patients with cancer. Cutis. 1990; 46(6): 488–490.
  71. De Argila D, Ortiz-Frutos J, Vanaclocha F. Transient acantholytic dermatosis (Grover's disease) in a patient with gastric carcinoma. Acta Derm Venereol. 1997; 77(3): 245–246.
  72. Singer EM, Shin DB, Nattkemper LA, et al. IL-31 is produced by the malignant T-cell population in cutaneous T-Cell lymphoma and correlates with CTCL pruritus. J Invest Dermatol. 2013; 133(12): 2783–2785.
  73. Bigby M, Jick S, Jick H, et al. Drug-induced cutaneous reactions. A report from the Boston Collaborative Drug Surveillance Program on 15,438 consecutive inpatients, 1975 to 1982. JAMA. 1986; 256(24): 3358–3363.
  74. Raksha MP, Marfatia YS. Clinical study of cutaneous drug eruptions in 200 patients. Indian J Dermatol Venereol Leprol. 2008; 74(1): 80.
  75. Maleki K, Weisshaar E. Drug-induced pruritus. Hautarzt. 2014; 65(5): 436–442.
  76. Schmidt E, Zillikens D. Pemphigoid diseases. Lancet. 2013; 381(9863): 320–332.
  77. Försti AK, Jokelainen J, Ansakorpi H, et al. Psychiatric and neurological disorders are associated with bullous pemphigoid — a nationwide Finnish Care Register study. Sci Rep. 2016; 6: 37125.
  78. Meijer JM, Diercks GFH, de Lang EWG, et al. Assessment of diagnostic strategy for early recognition of bullous and nonbullous variants of pemphigoid. JAMA Dermatol. 2019; 155(2): 158–165.
  79. Lamberts A, Meijer JM, Jonkman MF. Nonbullous pemphigoid: a systematic review. J Am Acad Dermatol. 2018; 78(5): 989–995.e2.
  80. Bakker CV, Terra JB, Pas HH, et al. Bullous pemphigoid as pruritus in the elderly: a common presentation. JAMA Dermatol. 2013; 149(8): 950–953.
  81. Lamb PM, Abell E, Tharp M, et al. Prodromal bullous pemphigoid. Int J Dermatol. 2006; 45(3): 209–214.
  82. Zhang Yu, Luo Y, Han Y, et al. Non-bullous lesions as the first manifestation of bullous pemphigoid: A retrospective analysis of 181 cases. J Dermatol. 2017; 44(7): 742–746.
  83. Meijer JM, Lamberts A, Luijendijk HJ, et al. Prevalence of pemphigoid as a potentially unrecognized cause of pruritus in nursing home residents. JAMA Dermatol. 2019; 155(12): 1423–1424.
  84. Lamberts A, Meijer JM, Pas HH, et al. Nonbullous pemphigoid: Insights in clinical and diagnostic findings, treatment responses, and prognosis. J Am Acad Dermatol. 2019; 81(2): 355–363.
  85. Levine N. Pruritic lesions on extremities. Could this persistent eruption be related to hypertension medication? Geriatrics. 1997; 52(9): 89.
  86. Rinderknecht JD, Goldinger SM, Rozati S, et al. RASopathic skin eruptions during vemurafenib therapy. PLoS One. 2013; 8(3): e58721.
  87. Hodi FS, O'Day SJ, McDermott DF, et al. Improved survival with ipilimumab in patients with metastatic melanoma. N Engl J Med. 2010; 363(8): 711–723.
  88. Cao T, Tey HL, Yosipovitch G. Chronic pruritus in the geriatric population. Dermatol Clin. 2018; 36(3): 199–211.
  89. Misery L, Alexandre S, Dutray S, et al. Functional itch disorder or psychogenic pruritus: suggested diagnosis criteria from the French psychodermatology group. Acta Derm Venereol. 2007; 87(4): 341–344.
  90. Patel T, Yosipovitch G. The management of chronic pruritus in the elderly. Skin Therapy Lett. 2010; 15(8): 5–9.
  91. Yamaura K, Doi R, Suwa E, et al. Repeated application of glucocorticoids exacerbate pruritus via inhibition of prostaglandin D2 production of mast cells in a murine model of allergic contact dermatitis. J Toxicol Sci. 2012; 37(6): 1127–1134.
  92. Papier A, Strowd LC. Atopic dermatitis: a review of topical nonsteroid therapy. Drugs Context. 2018; 7: 212521.
  93. Ständer S, Schürmeyer-Horst F, Luger TA, et al. Treatment of pruritic diseases with topical calcineurin inhibitors. Ther Clin Risk Manag. 2006; 2(2): 213–218.
  94. Arana A, Pottegård A, Kuiper JG, et al. Long-Term risk of skin cancer and lymphoma in users of topical tacrolimus and pimecrolimus: final results from the extension of the cohort study protopic joint European Longitudinal Lymphoma and Skin Cancer Evaluation (JOELLE). Clin Epidemiol. 2021; 13: 1141–1153.
  95. Margolis DJ, Abuabara K, Hoffstad OJ, et al. Association between malignancy and topical use of pimecrolimus. JAMA Dermatol. 2015; 151(6): 594–599.
  96. Lam M, Zhu JW, Tadrous M, et al. Association between topical calcineurin inhibitor use and risk of cancer, including lymphoma, keratinocyte carcinoma, and melanoma: a systematic review and meta-analysis. JAMA Dermatol. 2021; 157(5): 549–558.
  97. Endo JO, Wong JW, Norman RA, et al. Geriatric dermatology: Part I. Geriatric pharmacology for the dermatologist. J Am Acad Dermatol. 2013; 68(4): 521.e1–521.e10.
  98. Gray SL, Anderson ML, Dublin S, et al. Cumulative use of strong anticholinergics and incident dementia: a prospective cohort study. JAMA Intern Med. 2015; 175(3): 401–407.
  99. Matsuda KM, Sharma D, Schonfeld AR, et al. Gabapentin and pregabalin for the treatment of chronic pruritus. J Am Acad Dermatol. 2016; 75(3): 619–625.e6.
  100. Legat FJ. [Importance of phototherapy in the treatment of chronic pruritus]. Hautarzt. 2018; 69(8): 631–640.
  101. Weisshaar E, Szepietowski JC, Darsow U, et al. European guideline on chronic pruritus. Acta Derm Venereol. 2012; 92(5): 563–581.
  102. Beck LA, Thaçi D, Deleuran M, et al. Dupilumab treatment in adults with moderate-to-severe atopic dermatitis. N Engl J Med. 2014; 371(2): 130–139.
  103. Simpson EL, Bieber T, Guttman-Yassky E, et al. SOLO 1 and SOLO 2 Investigators. Two phase 3 trials of dupilumab versus placebo in atopic dermatitis. N Engl J Med. 2016; 375(24): 2335–2348.
  104. Beck KM, Yang EJ, Sekhon S, et al. Dupilumab treatment for generalized prurigo nodularis. JAMA Dermatol. 2019; 155(1): 118–120.
  105. Mollanazar NK, Elgash M, Weaver L, et al. Reduced itch associated with dupilumab treatment in 4 patients with prurigo nodularis. JAMA Dermatol. 2019; 155(1): 121–122.
  106. Lee JK, Simpson RS. Dupilumab as a novel therapy for difficult to treat chronic spontaneous urticaria. J Allergy Clin Immunol Pract. 2019; 7(5): 1659–1661.e1.
  107. Machler BC, Sung CT, Darwin E, et al. Dupilumab use in allergic contact dermatitis. J Am Acad Dermatol. 2019; 80(1): 280–281.e1.
  108. Seidman JS, Eichenfield DZ, Orme CM. Dupilumab for bullous pemphigoid with intractable pruritus. Dermatol Online J. 2019; 25(11).
  109. Zhang Y, Xu Q, Chen L, et al. Efficacy and safety of dupilumab in moderate-to-severe bullous pemphigoid. Front Immunol. 2021; 12: 738907.
  110. Nemoto O, Furue M, Nakagawa H, et al. The first trial of CIM331, a humanized antihuman interleukin-31 receptor A antibody, in healthy volunteers and patients with atopic dermatitis to evaluate safety, tolerability and pharmacokinetics of a single dose in a randomized, double-blind, placebo-controlled study. Br J Dermatol. 2016; 174(2): 296–304.
  111. Guttman-Yassky E, Teixeira HD, Simpson EL, et al. Once-daily upadacitinib versus placebo in adolescents and adults with moderate-to-severe atopic dermatitis (Measure Up 1 and Measure Up 2): results from two replicate double-blind, randomised controlled phase 3 trials. Lancet. 2021; 397(10290): 2151–2168.
  112. Simpson EL, Sinclair R, Forman S, et al. Efficacy and safety of abrocitinib in adults and adolescents with moderate-to-severe atopic dermatitis (JADE MONO-1): a multicentre, double-blind, randomised, placebo-controlled, phase 3 trial. Lancet. 2020; 396(10246): 255–266.
  113. Saini SS, Bindslev-Jensen C, Maurer M, et al. Efficacy and safety of omalizumab in patients with chronic idiopathic/spontaneous urticaria who remain symptomatic on H1 antihistamines: a randomized, placebo-controlled study. [published correction appears in J Invest Dermatol. J Invest Dermatol. 2015; 135(1): 67–75.
  114. Kremer N, Snast I, Cohen ES, et al. Rituximab and omalizumab for the treatment of bullous pemphigoid: a systematic review of the literature. Am J Clin Dermatol. 2019; 20(2): 209–216.
  115. Seyed Jafari SM, Feldmeyer L, Bossart S, et al. Case report: combination of omalizumab and dupilumab for recalcitrant bullous pemphigoid. Front Immunol. 2021; 11(611549).
  116. Kapruvia European Medicines Agency. https://www.ema.europa.eu/en/medicines/human/EPAR/kapruvia (22.05.2022).
  117. Dawn AG, Yosipovitch G. Butorphanol for treatment of intractable pruritus. J Am Acad Dermatol. 2006; 54(3): 527–531.
  118. Patel P, Patel K, Pandher K, et al. The role of psychiatric, analgesic, and antiepileptic medications in chronic pruritus. Cureus. 2021; 13(8): e17260.
  119. Biondi M, Arcangeli T, Petrucci RM. Paroxetine in a case of psychogenic pruritus and neurotic excoriations. Psychother Psychosom. 2000; 69(3): 165–166.
  120. Patel P, Patel K, Pandher K, et al. The role of psychiatric, analgesic, and antiepileptic medications in chronic pruritus. Cureus. 2021; 13(8): e17260.
  121. Saguil A, Kane S, Mercado M, et al. Herpes zoster and postherpetic neuralgia: prevention and management. Am Fam Physician. 2017; 96(10): 656–663.
  122. Gunal AI, Ozalp G, Yoldas TK, et al. Gabapentin therapy for pruritus in haemodialysis patients: a randomized, placebo-controlled, double-blind trial. Nephrol Dial Transplant. 2004; 19(12): 3137–3139.
  123. Simonsen E, Komenda P, Lerner B, et al. Treatment of uremic pruritus: a systematic review. Am J Kidney Dis. 2017; 70(5): 638–655.