About all

Hands and feet itch liver: The request could not be satisfied

Содержание

Itch and liver: management in primary care

Br J Gen Pract. 2015 Jun; 65(635): e418–e420.

Vinod S Hegade, MRCP, Clinical research fellow and hepatology registrar

Institute of Cellular Medicine, Newcastle University and Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne.

Stuart FW Kendrick, MRCP PhD, Consultant physician and hepatologist

GlaxoSmithKline Research and Development, Stevenage and Cambridge University Hospitals NHS Foundation Trust, Cambridge.

Jahangir Rehman, MRCP, ST3, Trainee in general practice

Westcliffe Medical Practice, Bradford.

David EJ Jones, PhD FRCP, Dean of research & innovation and consultant hepatologist

Institute of Cellular Medicine, Newcastle University and Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne.

Address for correspondence Vinod Hegade, Institute of Cellular Medicine, Faculty of Medical Sciences, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK. E-mail: [email protected]

Received 2015 Jan 30; Revisions requested 2015 Feb 6; Accepted 2015 Mar 9.

Copyright © British Journal of General Practice 2015This article has been cited by other articles in PMC.

INTRODUCTION

Pruritus can be defined as ‘an unpleasant sensation that causes the need to scratch.’1 Although it is most commonly seen in skin diseases it can occur as a consequence of systemic conditions and the possibility of the presence of such conditions should be considered in any patient presenting with pruritus in the absence of rash. Pruritus can be a feature of renal failure, haematological diseases (including lymphoma, leukaemia, and myeloproliferative disorders),2 and of liver diseases in which there is an element of cholestasis (impaired bile secretion). Pruritus in liver diseases can often be a debilitating symptom causing significant impairment in quality of life. Not all patients with liver disease develop pruritus and its prevalence varies depending on the underlying cause of liver disease. It is more common in conditions characterised by bile duct inflammatory destruction than in those characterised by hepatocellular injury.3 For example, the prevalence of pruritus is high in autoimmune liver diseases such as primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC), and biliary obstructive diseases secondary to benign (stones/strictures) or malignant diseases (for example, carcinoma of head of pancreas). It can also be seen in patients with chronic viral hepatitis (mainly hepatitis C) and drug-induced liver injury (DILI). In comparison, pruritus is relatively uncommon in alcohol-induced liver diseases (ALD) and non-alcoholic fatty liver disease (NAFLD).

Patients with pruritus often seek treatment from their GPs but studies have shown there is lack of awareness among clinicians in relation to pruritus associated with liver diseases.4 GPs are able to initiate treatments recommended by the guidelines so they and their patients would benefit from a knowledge of the condition and the understanding of currently available therapies.

PRESENTATION

Pruritus can develop at any stage of cholestatic liver disease and it should be particularly noted that severity of cholestatic itch is independent of the duration, biochemical severity, and histological stage of the underlying liver disease. In PBC, the liver condition most typically associated with pruritus, patients with pruritus typically have biochemical abnormality characterised by chronically (>6 months) elevated serum alkaline phosphatase (ALP). However, it is possible to see pruritus in patients with early PBC with completely normal liver function tests (LFT). Healthcare providers should be mindful of this lack of correlation between itch and biochemical abnormality and a potential liver diagnosis should not be dismissed in a symptomatic patient with normal LFT. In patients with itch and normal LFT a positive antimitochondrial antibody (AMA) test should raise the suspicion of PBC.

Pruritus in cholestasis has a number of unique features that should prompt appropriate investigations and diagnosis, which will help alert the clinician to a liver aetiology (as opposed to dermatological or other systemic causes). It tends to be generalised, predominantly affecting limbs and in particular palms and soles (palmoplantar pruritus). It is typically worse late in the evening and at night, and usually exacerbated by heat (including hot baths), menstrual period, hormone replacement therapy, early pregnancy, and contact with wool.5 Classical histamine-induced skin changes such as erythema, urticaria, and flares are not seen in patients with cholestatic pruritus. Characteristically, there is absence of skin lesions but intense scratching can result in secondary skin lesions including excoriations, folliculitis, and lichenification, which can occasionally lead to the mistaken interpretation of primary skin aetiology.

DIAGNOSIS AND TREATMENT

Clinical examination of a patient with cholestatic pruritus may be completely normal. Jaundice is absent in the majority of patients and its presence usually suggests advanced stage of underlying liver disease or severe biliary obstruction. shows a suggested approach to the assessment and management of cholestatic pruritus by GPs.

A suggested approach to management of cholestatic pruritus in primary care.

Cholestatic biochemistry (raised serum ALP), especially in female patients, should prompt checking of the liver autoimmune profile (particularly AMA) and serum immunoglobulins. In all cases of suspected cholestatic pruritus it is essential to perform a transabdominal ultrasound scan to assess liver and biliary architecture to rule out biliary obstruction (obstructive cholestasis). Presence of intrahepatic duct dilatation on ultrasound usually suggests biliary obstruction and, as such, the patient should be referred to secondary care (gastroenterology, hepatology, or surgery) for further investigations (computed tomography, magnetic resonance imaging, or magnetic resonance cholangiopancreatography) as well as treatment (management usually involves endoscopy and/or interventional radiology and/or surgery depending on the aetiology and level of biliary obstruction). If malignancy is suspected (for example, unexplained weight loss) to be the cause of biliary obstruction patients should be referred on an urgent 2-week-wait (2WW) referral pathway.

Empirical treatment with guideline recommended antipruritic medications should be started early while appropriate investigations and referrals are being arranged. This is mainly because cholestatic itch rarely improves spontaneously and if left untreated it may become persistent and severe and could impact on sleep and mood, contributing to anxiety, depression, fatigue, and impaired quality of life. Contrary to common practice among clinicians, antihistamines (such as chlorphenirmine, cetirizine, loratadine, fexofenadine, and hydroxyzine) have not been shown to be effective in cholestatic pruritus.5 Antihistamines worsen fatigue and sicca symptoms (dry mouth and dry eyes) of PBC. However, due to their sedative properties some antihistamines may temporarily alleviate pruritus by inducing sleep. The use of moisturisers, emollients, and other topical preparations has not been submitted to studies in patients with the pruritus of cholestasis; however, their use should be encouraged to keep skin healthy.3 Our standard practice is to encourage all patients with pruritus to use topical application of aqueous cream with 1% menthol (for its coolant effect). This treatment may suffice in patients with mild and localised itch.

For moderate to severe, or generalised itch guideline recommended first-line therapy is with oral cholestyramine (colestyramine, Questran® Bristol-Myers Squibb). It is a non-absorbable anion exchange resin which is thought to act by removing potential pruritogens (bile salts) from the enterohepatic circulation by binding with them and enhancing faecal excretion. It is licenced for use in cholestatic pruritus. Although it is generally well tolerated, its unpleasant taste affects adherence (which may be improved by mixing with fruit juice). Adverse effects can include anorexia, constipation, diarrhoea, abdominal discomfort, or bloating. Colesevelam, a novel resin, is generally better tolerated and although evidence of its efficacy in cholestatic pruritus is equivocal, it should be offered to those who benefit from colestyramine but are intolerant to its taste or side effects. Use of both colestyramine and colesevelam in primary care is safe and does not need monitoring. In a retrospective review of 92 patients with PBC and itch treated between 2007 and 2011 at our centre in Newcastle, 61% of patients treated with colestyramine (mean dose 8 g/day, median duration 24 weeks) had complete or partial resolution of their itch. There are no data on the use of topical treatments or colesevelam at the centre.

Rifampicin (150–600 mg/day) and naltrexone (up to 50 mg/day), given orally are the guideline recommended second- and third-line drugs for those unresponsive to colestyramine/colesevelam. In our experience complete or partial resolution of itch can be achieved with rifampicin in up to 80% of patients, and with naltrexone in up to 50% of patients. These results are consistent with published studies and meta-analyses of rifampicin and opiate antagonists in cholestatic pruritus.6 However due to their side-effect profile, rifampicin and naltrexone need regular monitoring and should ideally be initiated in secondary care. Serious side effects associated with rifampicin include hepatitis, haemolytic anaemia, thrombocytopenia, and renal impairment. Rifampicin-induced hepatotoxicity is of serious concern and it is most likely to occur in the first 2 months of starting therapy. Therefore close monitoring of LFT every fortnight in the first 2 months of therapy, and at least once monthly thereafter is strongly recommended. Although uncommon, hepatitis can also be associated with naltrexone, therefore regular monitoring of LFT is recommended. Long-term use of both rifampicin and naltrexone is safe and effective in treating cholestatic itch and monitoring of blood tests can be done in primary care. In patients developing abnormal LFT, treatment should be immediately discontinued and referred to secondary care.

Notes

Funding

Cholestatic pruritus research at Newcastle University is supported by the National Institute for Health Research (NIHR) though our Biomedical Research Unit (Funding reference number: Bh234330/PD0203).

Provenance

Freely submitted; externally peer reviewed.

Competing interests

The authors have declared no competing interests.

Discuss this article

Contribute and read comments about this article: bjgp.org/letters

REFERENCES

1. Misery L. Pruritus: considerable progress in pathophysiology [French] Med Sci (Paris) 2014;30(12):1123–1128. [PubMed] [Google Scholar]2. Yosipovitch G, Bernhard JD. Clinical practice. Chronic pruritus. N Engl J Med. 2013;368(17):1625–1634. [PubMed] [Google Scholar]3. Bergasa NV. Frontiers in neuroscience pruritus of cholestasis. In: Carstens E, Akiyama T, editors. Itch: mechanisms and treatment. Boca Raton, FL: CRC Press/Taylor & Francis Group; 2014. [Google Scholar]4. Rishe E, Azarm A, Bergasa NV. Itch in primary biliary cirrhosis: a patients’ perspective. Acta Derm Venereol. 2008;88(1):34–37. [PubMed] [Google Scholar]5. Lindor KD, Gershwin ME, Poupon R, et al. Primary biliary cirrhosis. Hepatology. 2009;50(1):291–308. [PubMed] [Google Scholar]6. Tandon P, Rowe BH, Vandermeer B, Bain VG. The efficacy and safety of bile acid binding agents, opioid antagonists, or rifampin in the treatment of cholestasis-associated pruritus. Am J Gastroenterol. 2007;102(7):1528–1536. [PubMed] [Google Scholar]

Cholestasis – Liver and Gallbladder Disorders


  • If blood test results are abnormal, an imaging test, usually ultrasonography


A doctor suspects cholestasis in people who have jaundice and tries to determine whether the cause is within or outside the liver on the basis of symptoms and the results of a physical examination.

Recent use of drugs that can cause cholestasis suggests a cause within the liver. Small spiderlike blood vessels visible in the skin (called spider angiomas), an enlarged spleen, and accumulation of fluid within the abdomen (ascites)—which are signs of chronic liver disease—also suggest a cause within the liver.

Findings that suggest a cause outside the liver include certain kinds of abdominal pain (such as intermittent pain in the upper right side of the abdomen and sometimes also in the right shoulder) and an enlarged gallbladder (felt during the physical examination or detected by imaging studies).

Some symptoms (such as loss of appetite, nausea, and vomiting) do not indicate whether the cause is within or outside the liver.

Typically, blood tests are done to measure levels of two enzymes (alkaline phosphatase and gamma-glutamyl transpeptidase) that are very high in people with cholestasis. However, if the level of alkaline phosphatase is very high but the level of gamma-glutamyl transpeptidase is normal, the cause of the high level of alkaline phosphatase is probably not cholestasis. A blood test that measures the level of bilirubin indicates the severity of the cholestasis but not its cause.

An imaging study, usually ultrasonography, is almost always done if blood test results are abnormal. Computed tomography (CT) or sometimes magnetic resonance imaging (MRI) may be done in addition to or instead of ultrasonography. If the cause appears to be within the liver, a liver biopsy may be done and usually establishes the diagnosis.

If the cause appears to be blockage of the bile ducts, more precise images of these ducts are usually needed. Typically, one of the following is done:

  • Endoscopic retrograde cholangiopancreatography (ERCP): A flexible viewing tube (endoscope) is inserted through the mouth and into the small intestine, and a radiopaque contrast agent (which can be seen on x-rays) is injected through the tube into the bile and pancreatic ducts. Then, x-rays are taken.

  • Magnetic resonance cholangiopancreatography (MRCP): MRCP is MRI of the bile and pancreatic ducts, with specialized techniques that are used to make the fluid in the ducts appear bright and the surrounding tissues appear dark.

  • Endoscopic ultrasonography: Images are obtained via an ultrasound probe inserted with a flexible viewing tube (endoscope) through the mouth and into the small intestine.

Successful Treatment of Intractable Palmoplantar Pruritus With Ondansetron | Dermatology | JAMA Dermatology

A 61-year-old woman presented with a 2-year history of intense itching of her palms and soles. The irritation was relieved only by plunging her hands and feet into cold water. She would awaken at least 4 times per night to rub her hands and feet for 15 minutes before falling asleep again. Her symptoms were more marked in the summer compared with the winter. Her medical history included chronic obstructive pulmonary disease, hiatal hernia, nasal polyps, and 3 previous deep vein thrombi. She took sulfalene tablets and ipratropium bromide, albuterol, and beclomethasone dipropionate aerosol inhalers during the winter for her bronchitis.

On examination, her hands and feet appeared healthy. There were no color changes, dryness, or abnormal neurologic symptoms. Investigation showed that the results of a complete blood cell count, electrolyte levels, liver function tests, immunoglobulin profile, total IgE level, and autoantibody profile all were within normal limits. A biopsy of the palm showed a mild chronic inflammatory infiltrate of the upper dermis, mild acanthosis, and no spongiosis. These changes were nonspecific and consistent with rubbing of the skin. A psychological assessment by a clinical psychologist showed no evidence for a psychosomatic cause of her pruritus.

The following treatments were tried for several months per treatment, one after another: 0.5% to 2% menthol in aqueous cream (BP cream, Hillcross Pharmaceuticals, Briercliff, England), 30% emulsifying ointment in purified water, various emollients, oral antihistamines, 10% crotamiton cream twice per day (Emla cream, Astra, Westboro, Mass), 2.5% lignocaine hydrochloride and 2.5% prilocaine hydrochloride cream twice per day, 0.05% clobetasol propionate cream under occlusion twice per day, oral doxepin hydrochloride, 75 mg/d, carbamazepine, 200 mg twice per day, and topical 0.07% capsaicin cream twice per day, all without beneficial effect. She also underwent a twice-weekly course of local UV-B phototherapy for 6 weeks and a twice-weekly course of UV-A phototherapy with topical psoralen paint for 10 weeks, but both of these treatments were ineffective.

The degree of discomfort experienced by the patient and the failure of a wide range of therapeutic approaches often considered useful for intractable pruritus made us search for other treatments.

Ondansetron hydrochloride is a competitive and selective antagonist of serotonin receptors. These receptors are widely distributed throughout the body, including in the peripheral and central nervous systems.1 Intravenous ondansetron has been used successfully to treat postoperative pruritus following administration of perioperative intravenous morphine2 and perioperative intrathecal morphine sulfate.3 Oral ondansetron has been used effectively to treat refractory pruritus in cholestatic jaundice4,5 and in chronic renal insufficiency.5 These reports suggest that ondansetron is an effective agent for pruritus arising from different causes. In our patient, ondansetron hydrochloride was started at 8 mg/d and within a few hours of starting the treatment, her pruritus stopped. She has remained free of pruritus for 1 year with a regimen of 8 mg taken on alternate days during the summer and 8 mg/wk during the winter, without adverse effects and with no change in her liver function test results.

Itch is a skin sensation that leads to a desire to scratch. Soluble mediators found in itchy inflamed skin can cause itching when injected intradermally.1 These mediators include histamines, opioids, serotonin, interleukin 2, and substance P. Specific antagonists or interventions designed to deplete these mediators will ease or abolish pruritus. Itching of healthy-looking skin in the absence of systemic disease is common. No specific mediators have been identified to explain this phenomenon. One hypothesis suggests that a local intermittent stimulation of a few afferent sensory nerve fibers will produce itch, while a prolonged stimulation of more afferent fibers will generate inhibition by activation of inhibitory circuits within the spinal cord. Disorders or unusual settings of this central inhibitory mechanism may produce itching without the need for a sensory input from the periphery.

The efficacy of ondansetron in treating different types of pruritus suggests an effect on a common nociceptive pathway, such as the inhibition of serotonin receptors on peripheral nerves or in the spinal cord. Oral ondansetron is rapidly absorbed and has a terminal elimination half-life of between 2.5 and 5.4 hours.2 Ondansetron is a well-tolerated drug, with adverse effects limited to headaches, dizziness, drowsiness, and occasional abnormal results of liver function tests. Oral ondansetron is rapidly absorbed with a large volume of distribution, including the central nervous system.

Ondansetron is an established treatment for vomiting induced by cancer chemotherapy and radiotherapy and in the prevention of postoperative nausea and vomiting. Blockade of serotonin receptors and dopamine release within the central nervous system are possible mechanisms to explain its effectiveness.2 Preliminary data have shown ondansetron to have clinical benefit in patients with some pain and neurologic disorders, such as alcohol dependency, opiate withdrawal, intractable vertigo, cerebellar tremor, and Parkinson disease treatment–related psychosis.2 As in pruritus, many of these claims have been documented as case reports only. The mechanisms by which ondansetron produces its clinical effects in these novel applications are not understood. Serotonin causes pruritus1,4 and a serotonin antagonist, such as ondansetron, would appear to block the generation of pruritus.3-6 There has been just 1 placebo-controlled trial assessing the efficacy of ondansetron in cholestatic pruritus resistant to other antipruritic agents.6 This trial showed at least a 50% reduction of itching in all 10 patients.

Itching can only be assessed subjectively. This creates difficulty in interpreting the effectiveness of a given treatment. We believe that our patient had tried multiple treatments without success but has responded to oral ondansetron, and that the success of ondansetron was not placebo related because the response has been maintained for more than 1 year. Although the drug is expensive ($564 for thirty 8-mg tablets), in conditions in which the degree of pruritus is debilitating and cheaper alternatives have been unsuccessful, it should be considered.

2.Wilde
 MIMarkham
 A Ondansetron: a review of its pharmacology and preliminary clinical findings in novel applications.  Drugs. 1996;52773- 794Google ScholarCrossref 3.Schworer
 HHartmann
 HRamadori
 G Relief of choleostatic pruritus by a novel class of drugs: 5-hydroxytryptamine type 3 (5-HT3) receptor antagonists: effectiveness of ondansetron.  Pain. 1995;6133- 37Google ScholarCrossref 4.Arai
 LStayer
 SSchwartz
 RDorsey
 A The use of ondansetron to treat pruritus associated with intrathecal morphine in two paediatric patients.  Paediatr Anaesth. 1996;6337- 339Google ScholarCrossref 5.Schworer
 HRamadori
 G Improvement of choleostatic pruritus by ondansetron [letter].  Lancet. 1993;3411277Google ScholarCrossref 6.Schworer
 HRamadori
 G Treatment of pruritus: a new indication for serotonin type 3 receptor antagonists.  Clin Invest Med. 1993;71659- 662Google Scholar

Cholestasis of Pregnancy | Cedars-Sinai

Not what you’re looking for?

What is cholestasis of pregnancy?

Cholestasis of pregnancy is a liver problem. It slows or stops the normal flow of
bile from the gallbladder. This causes itching and yellowing of your skin, eyes, and
mucous membranes (jaundice). Cholestasis sometimes starts in early pregnancy. But
it is more common in the second and third trimesters. It most often goes away within
a few days after delivery. The high levels of bile may cause serious problems for
your developing baby (fetus).

What causes cholestasis of pregnancy?

Healthcare providers don’t know
what causes cholestasis of pregnancy. They do know that this happens:

  • Your liver makes bile. Bile helps break down fats during digestion.
  • The gallbladder stores the bile.
  • The hormones your body releases during pregnancy change the way the gallbladder works. This
    may cause bile to slow or stop flowing.
  • Bile builds up in the liver and spills into the bloodstream.

What are the symptoms of cholestasis of pregnancy?

The main symptom of cholestasis of pregnancy is severe itching. This is sometimes
called pruritus. It may be all over the body. But it is more common on the palms of
the hands and soles of the feet. It may also be worse at night. Other symptoms may
include:

  • Pain in the belly (abdomen), although this is not common
  • Light color of stool (bowel movements)
  • Yellow color of skin, eyes, and mucous membranes (jaundice), although this is not
    common

The symptoms of cholestasis sometimes look like other health conditions. Always see
your healthcare provider for a diagnosis.

How is cholestasis of pregnancy diagnosed?

Your healthcare provider is likely to think you have cholestasis of pregnancy if you
have severe itching. Lab tests will help to confirm the diagnosis. You may have these
tests:

  • Liver function tests, including the amount of bile acid in the blood. This test result
    is high in cholestasis of pregnancy.
  • Other lab tests, including prothrombin time. This checks how well your blood clots.

You may also have other tests such as an ultrasound exam of the tubes that carry bile
(bile ducts). 

How is cholestasis of pregnancy treated?

You and your healthcare provider
will discuss the best treatment for you based on:

  • Your pregnancy
  • Your overall health and health history
  • How sick you are
  • How well you can handle certain medicines, procedures, or therapies

The goals of treating cholestasis of pregnancy are to relieve the itching and prevent
complications. Treatment may include:

  • Medicine. To help relieve itching and help lower the level of bile.  
  • Measuring serum total bile acid. The level of bile in your blood may be checked. This helps your healthcare provider
    figure out treatment.
  • Fetal monitoring. The healthcare provider may check your developing baby for any problems.
  • Early delivery. You may deliver your baby early, between 37 to 38 weeks of pregnancy. This will lessen
    the risk to your baby. This may be by vaginal delivery with medicine to start labor.
    Or you may have a cesarean delivery. Your healthcare provider may decide that you
    should deliver even earlier, depending on your symptoms, test results, and pregnancy
    history.

What are possible complications of cholestasis of
pregnancy?

There is a serious risk of complications in your developing baby if you have cholestasis
of pregnancy. The complications include:

  • Fetal distress. This means your developing baby is not doing well. For example, the baby may not
    be getting enough oxygen.
  • Preterm birth. You may be at greater risk for giving birth too early.
  • Meconium in amniotic fluid. This means your baby has a bowel movement before birth. This may cause very serious
    breathing problems.
  • Breathing (respiratory) problems. Your baby may have breathing problems as a newborn.

Cholestasis of pregnancy can also lead to vitamin K deficiency. This will need to
be treated before you give birth, because it can cause you to bleed too much.

When should I call my healthcare provider?

Call your healthcare provider if you have:

  • Severe itching
  • Yellow coloring of your eyes, skin, or mucous membranes (jaundice)

Key points about cholestasis of pregnancy

  • Cholestasis of pregnancy is a condition that slows or stops the normal flow of bile
    in the gallbladder.
  • It can cause severe itching. This is the most common symptom.
  • The goals of treating cholestasis of pregnancy are to relieve itching and prevent
    complications for your developing baby.
  • Babies of women with cholestasis are often delivered early (usually around 37 weeks)
    because of the risks.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

  • Know the reason for your visit and what you want to happen.
  • Before your visit, write down questions you want answered.
  • Bring someone with you to help you ask questions and remember what your provider tells
    you.
  • At the visit, write down the name of a new diagnosis, and any new medicines, treatments,
    or tests. Also write down any new instructions your provider gives you.
  • Know why a new medicine or treatment is prescribed, and how it will help you. Also
    know what the side effects are.
  • Ask if your condition can be treated in other ways.
  • Know why a test or procedure is recommended and what the results could mean.
  • Know what to expect if you do not take the medicine or have the test or procedure.
  • If you have a follow-up appointment, write down the date, time, and purpose for that
    visit.
  • Know how you can contact your provider if you have questions.

Medical Reviewer: Irina Burd MD PhD

Medical Reviewer: Donna Freeborn PhD CNM FNP

Medical Reviewer: Heather Trevino

© 2000-2021 The StayWell Company, LLC. All rights reserved. This information is not intended as a substitute for professional medical care. Always follow your healthcare professional’s instructions.

Not what you’re looking for?

Can Itchy Skin Be a Symptom of Cancer?

Itchy skin (also called pruritis) can be a symptom of cancer or even the first sign of cancer, though other causes of itching are certainly much more common. Cancers commonly associated with itching include some leukemias and lymphomas, gallbladder cancer, and liver cancer. However, a number of other cancers may be implicated as well.

Itching may occur due to direct irritation of the skin (such as with skin cancer or skin metastases), through the build-up of bile salts, or due to substances secreted by a tumor or by the body in response to a tumor.

Though it can be difficult to differentiate itching due to cancer from itching due to benign causes, there are a few clues that should raise suspicion. What should you know about the link between cancer and itching?

Illustration by Brianna Gilmartin, Verywell

Incidence

It’s uncertain exactly how often itching occurs as a symptom or first symptom of cancer, but it’s thought that an underlying systemic (body-wide) disease is present in 10 percent to 25 percent of people who develop generalized itching without a rash.

In one study looking at almost 17,000 people, those who had generalized itching were more likely to have an underlying cancer (5.76 times more likely) than those who did not experience itching. The cancers that were most commonly associated included liver cancer, gallbladder cancer, bile duct cancer, blood-related cancers such as lymphomas and leukemias, and skin cancer.

In this study, Black people were more likely to have skin cancer, soft tissue cancers (such as sarcomas), and blood-related cancers as the underlying cause of their itching, whereas white people were more likely to have liver cancer, lung cancer, digestive tract cancers, and cancers of the female reproductive tract such as ovarian cancer.

Among the participants with newly diagnosed with cancer, 30 percent of those with Hodgkin lymphoma, 15 percent with non-Hodgkin lymphoma, 5 percent with leukemia, and over 50 percent of those with myeloproliferative disorders had significant itching.

Is Cancer Causing the Itching?

Itching related to cancer is sometimes identical to itching related to skin conditions or other benign causes, but there are some characteristics that may differ.

Characteristics of cancer-related itching may include:

  • Itching in response to water (aquagenic pruritis)
  • The absence of a rash or hives (though sometimes a rash occurs due to repeated scratching)
  • The presence of other symptoms such as jaundice (a yellowish discoloration of the skin), and the B symptoms of lymphoma (fever, weight loss, and drenching night sweats)

In addition, itching associated with cancer tends to feel the worst on the lower legs and chest and may be associated with a burning sensation.

How Does Cancer Cause Itching?

There are a number of mechanisms by which cancer can lead to itching. The body contains nerve endings that cause itching (similar to pain receptors). In general, anything that irritates these nerve endings can cause itching.

Direct Inflammation

Cancers that involve the skin or mucous membranes in some way are the most obvious cause of itching. This may include the different types of skin cancer, breast cancers such as inflammatory breast cancer, Paget’s disease of the nipple, and certainly any cancer that spreads (metastasizes) to the skin.

Direct inflammation may also give rise to the itch associated with vulvar and anal cancers.

Build-Up of Bile Salts

Obstruction of the bile ducts or the breakdown of red blood cells can both lead to the build-up of bile salts in the skin. This often leads to severe itching.

This may occur with leukemias and lymphomas (due to the breakdown of cells), abdominal cancers such as those of the liver and gallbladder, and any cancer that spreads to the liver (such as breast, lung, colon, and more).

Sometimes the build-up of bile salts is associated with jaundice (a yellowish appearance to the skin), though not always.

Secretion of Chemicals

Substances secreted by tumors (which cause paraneoplastic symptoms), or substances released by the body in response to a tumor, may lead to itching. This itching is often most severe in the legs. In some cases, paraneoplastic symptoms such as itching may precede by weeks or months the diagnosis of cancers such as non-small cell lung cancer or lymphomas.

Some of the chemicals that have been implicated in this effect include cytokines (inflammatory chemicals released from immune cells often in response to lymphomas), substance P, neuropeptides, prostaglandins, and more.

Some of these chemicals act directly on the nerve endings to cause itching, whereas others may cause the release of histamine by mast cells and other mechanisms.

Itching as a paraneoplastic symptom may occur alone, or may be associated with rashes such as erythroderma, acanthosis nigricans, dermatomyositis, Grover’s disease, or eruptive seborrheic keratosis.

Hormonal Changes

Hormonal changes related to cancer or cancer treatments can lead to itching in a few ways. Menopause in women (whether natural, surgical, or medically induced such as with breast cancer) can cause dryness. Hormonal changes may also lead to hot flashes. These hot flashes, often followed by sweats, can easily lead to itching.

Other Mechanisms

There are a number of other ways in which cancer may cause itching. For example, mast cells (which are responsible for allergic reactions and release histamine) may become overactive with some cancers, especially when exposed to hot water, such as during a hot shower. This is most common with blood-related cancers and myeloproliferative disorders.

Cancers That May Cause Itching

As noted earlier, there are some cancers that are more likely to present with symptoms of itching than others. Sometimes the itching is severe, whereas other times it may occur intermittently or only after taking a hot bath or shower.

Leukemias, Lymphomas, and Multiple Myeloma

Any type of blood-related cancer may present with itching, but the most common culprits include Hodgkin’s lymphoma, leukemia, and cutaneous T cell lymphoma (such as mycosis fungoides and Sezary syndrome).

With cutaneous T cell lymphomas, the cancer can cause itching both due to direct skin involvement and due to the secretion of inflammatory substances such as interleukin-31.

Myelodysplastic disorders such as polycythemia vera also commonly present with itching.

With both T cell lymphomas and myeloproliferative disorders, itching of the skin due to the exposure to water may even be present for years before the cancer is diagnosed.

Skin Cancer

Skin cancer is the most common type of cancer to cause itching. Itching is more common with basal cell carcinoma and squamous cell carcinoma than with melanoma.

Vulvar Cancer and Anal Cancer

Itching in the vulvar and vaginal region or anal region is more likely due to another cause, but this is still sometimes seen with cancers in these regions.

Breast Cancer

Itching as a symptom of breast cancer isn’t common, but it may occur. Unlike the more common types of breast cancer, inflammatory breast cancer often looks like a rash or breast infection (mastitis) initially.

Sometimes, symptoms begin with itching and a small rash that could even be dismissed as a bug bite before it worsens. Paget’s disease of the breast may also present with itching that is often associated with a dry, scaly rash of the nipple.

Liver, Bile Duct, Pancreatic, and Gallbladder Cancers

Any cancer that interferes with the bile ducts can lead to obstruction and the consequent build-up of bile salts in the skin. With pancreatic cancer specifically, this is most common with cancers located in the head of the pancreas. Other symptoms may include jaundice, abdominal pain, ascites (the build-up of fluid in the abdomen), and abdominal pain.

Metastatic Cancer

Metastatic cancer to the skin (skin metastases) may present with itching. In women, breast cancer is the most common source of skin metastases; in men, lung cancer is most common. Other cancers may also spread to the skin, such as colon cancer and more.

Liver metastases may also lead to itching, similar to the itching associated with primary liver cancers. The most common cancers to spread to the liver include lung cancer, breast cancer, colon cancer, and melanoma.

Itching Due to Cancer Treatments

There are many cancer treatments that can lead to itching. The most common include some targeted therapies and some immunotherapy drugs, especially interferon and interleukin-2. Many medications can also cause allergic reactions or inflammation of the liver, which in turn, can lead to itching.

Radiation therapy commonly causes itching, especially later on in treatment when the skin begins to heal.

Diagnosis

Unexplained itching should be evaluated by your doctor. The first step in diagnosis includes a careful history and physical examination looking for any obvious causes of itching.

Laboratory work may include a complete blood count and liver function tests. If leukemia, lymphoma, or a myeloproliferative disorder is suspected, a bone marrow test is often needed to either confirm or rule out a problem.

Imaging tests may be needed as well. Paraneoplastic symptoms are not uncommon with lung cancer, and evaluation may include a chest CT scan (chest X-rays can miss up to 25% of lung cancers). If an abdominal cancer is a possibility, an abdominal CT scan as well as other imaging tests may be needed.

Even if the evaluation is negative, careful follow-up is necessary if a cause is not found. As noted earlier, itching may occur weeks to months before other symptoms with lung cancer, and itching may appear years before the diagnosis of a T cell lymphoma is made.

If an obvious underlying medical cause is not determined (either benign or cancerous), keeping a symptom diary is sometimes helpful, as well as letting your doctor know if any new symptoms arise.

Management

Managing itching with cancer is very important in improving quality of life, especially when itching is severe such as with liver metastases or T cell lymphomas.

Often times, treatment of the underlying cancer reduces itching. However, this isn’t always possible, for example, with advanced cancers. It can take some time to resolve the itching.

Lifestyle Measures

Simple measures for managing itchy skin due to cancer treatment can include:

  • Staying well hydrated
  • Using quality lotions and creams (avoiding any scented products)
  • Applying baking soda or oatmeal mixtures to the skin
  • Using a humidifier if the air is dry in your home
  • Avoiding shaving
  • Bathing in lukewarm rather than hot water
  • Try to limit bathing to every few days rather than daily, and avoid sitting in a tub more than 30 minutes
  • Allowing your skin to dry naturally after bathing rather than rubbing your skin with a towel
  • Wearing comfortable and loose clothing
  • Avoiding clothing that creates friction or rough clothing such as wool; cotton and linen are preferable to synthetic garments
  • Keeping the thermostat down or the air conditioning up to decrease sweating (sweating can greatly aggravate itching)
  • Using distraction, such as conversations, music, or anything to help you get your mind off of the itching
  • Keeping your fingernails short to avoid scratching when you are sleeping
  • Using insect spray when spending time outside to avoid additional causes of itching
  • Avoiding your personal triggers for itching (sometimes keep a symptom diary can help you determine what makes the itching worse and what helps the most)
  • Reducing stress, as emotional stress can make itching more severe

Avoiding scratching, is of course, important, but often easier said than done. To relieve the itch you may try patting the area, massage, gentle pressure, or vibration as alternatives to scratching. Cold compresses are helpful for some people.

Medications

A number of different medications have been used to help relieve itching. Before using any over-the-counter (OTC) preparations, however, make sure to talk to your oncologist. Some medications can interfere with cancer treatments.

For example, Benadryl (diphenhydramine) counteracts the effects of the breast cancer drug tamoxifen. Options include:

  • Antihistamines
  • Topical or oral steroids
  • The anti-nausea drug Zofran
  • Questran (a bile acid sequestrant that may be helpful for people who have itching due to liver metastases or tumors that are causing bile duct obstruction)
  • Serotonin reuptake inhibitors such as Paxil (paroxetine)
  • Serotonin-norepinephrine reuptake inhibitors such as Cymbalta (duloxetine)
  • Neurontin (gabapentin), a seizure drug, or Remeron (mirtrazapine), an atypical antidepressant which may be helpful for the severe itching associated with T cell lymphomas
  • Emend (aprepitant), a medication often used to prevent nausea and vomiting associated with chemotherapy. The medication is a substance P antagonist.
  • Tagamet (cimetidine) with or without aspirin may help with itching related to Hodgkin lymphoma

A Word From Verywell

Most often, itching is due to something other than cancer. However, it can be a symptom or even the first sign of several types of cancer in certain cases. If you have itching that is not otherwise explained, it’s important to make an appointment to see your doctor to determine the underlying cause.

In addition to cancer, there are other medical conditions ranging from liver disease to kidney disease that could be a factor, and treatment of many of these conditions—just as it is with cancer—is often most successful when the condition is discovered earlier rather than later.

Finally, even though it may be considered a “nuisance symptom” by some, itching can seriously reduce your quality of life. Talking to your doctor may help you determine both the underlying cause, and find relief.

Unexplained Itching and Fatigue? Time to Get Your Liver Checked

Imagine having itchy skin and fatigue with no explanation or diagnosis for your symptoms. This is what happened to Minnesota native Nishele, 44, who received a primary biliary cholangtis (PBC) diagnosis after years without any answers. Her journey, unfortunately, is like many others who have PBC.

“By the time I was diagnosed, I had actually had elevated liver enzymes for about four years that they just ignored,” Nishele says. Her frustration grew steadily until she was sent to a gastrointestinal (GI) doctor who ran liver tests and made the PBC diagnosis.

PBC, a rare autoimmune disease that affects the bile ducts in the liver, can sometimes take years to present symptoms. In fact, many symptoms are common to other diseases, so misdiagnosis—or no diagnosis, as in Nishele’s case—is common.

“I was relieved that I finally knew what was going on,” Nishele says.

It is important to be evaluated by a doctor with experience in liver diseases to make an accurate diagnosis of PBC in a timely fashion.

Patient empowerment is key to maintaining health. It’s important to ask your health care professional questions and advocate for important evaluations, such as routine liver function tests, whether you’re experiencing symptoms or not.

“I know it sounds kind of cliché, but you have to be your own patient advocate,” says Nishele. “You know when there’s something wrong. You can’t just take their word for it and not push the issue. You have to insist things are followed up on.”

Advocacy is particularly important for females. Women are nine times more likely than men to develop PBC, meaning that women make up about 90 percent of PBC cases. The disease most often develops during middle age and is usually diagnosed in people between the ages of 35 and 60 years. There appears to be a genetic predisposition to developing PBC, because it’s more common among siblings and in families where PBC or other autoimmune disease has affected one or more members.

Genetics may have played a role in Nishele’s PBC. About a year after she was diagnosed, her mother received the same diagnosis. She now assists her mom by sharing important information and encouraging her to work closely with her health care professionals to manage the condition.

If you think you or someone you love may have PBC, it’s important to talk with your health care professional about testing and treatment. The most common initial symptoms are fatigue and itching of the skin (pruritis). Other symptoms may include abdominal pain, darkening of the skin, dry mouth and eyes, and bone, muscle and joint pain. Learn more about the liver and PBC by visiting http://healthywomen.org/PBC.

“I think you just have to be determined and just be proactive about it,” says Nishele. “I consistently research as much information as I can and try to find the answers. I think knowledge is power.”

This resource was created with support from Intercept Pharmaceuticals, Inc.

Intrahepatic cholestasis of pregnancy

What is intrahepatic cholestasis of pregnancy?

Intrahepatic cholestasis of pregnancy (also called ICP or cholestasis of pregnancy) is the most common liver condition that happens during pregnancy. The liver is the largest organ in your body. It helps your body digest (break down and use) food, store energy and remove poisons. The liver makes a fluid called bile that helps your body break down fats and helps the liver get rid of toxins (poisonous substances) and waste. ICP slows the normal flow of bile, causing bile to build up in your liver. This buildup can cause chemicals called bile acids to spill into your blood and tissues, leading to severe itching.

ICP is most common during the third trimester, but some women with ICP have severe itching earlier in pregnancy. ICP affects about 1 to 2 in 1,000 pregnant women (less than 1 percent) in the United States, and it’s more common in Latina women. About 5 in 100 Latina women (5 percent) in this country have ICP.

What problems can ICP cause during pregnancy and after birth?

If you have ICP, you and your baby are at increased risk of having of complications, including:

  • Premature birth. This is birth that happens too soon, before 37 weeks of pregnancy. Babies born this early may have more health problems or need to stay in the hospital longer than babies born later.
  • Fetal distress. This is when a baby isn’t getting enough oxygen in the womb. Signs of fetal distress include reduced fetal movement (when your baby moves less often than usual), changes in your baby’s heart rate and your baby passing meconium. Meconium is your baby’s first bowel movement. A baby usually passes meconium after birth, but a baby in fetal distress may pass meconium into the amniotic fluid that surrounds him in the womb before or during labor and birth.
  • Stillbirth. This is when a baby dies in the womb after 20 weeks of pregnancy.
  • Meconium aspiration. This is when a baby has breathing problems after he breathes in amniotic fluid with meconium. If your baby breathes in meconium during birth, it can block his airways.
  • Respiratory distress syndrome (also called RDS). RDS is a breathing problem that happens in newborns whose lungs have not yet fully developed. Babies with RDS have don’t have enough surfactant, a slippery substance that helps the lungs fill with air and keeps the small air sacs in the lungs from collapsing. RDS is common in premature babies.
  • Postpartum hemorrhage (also called PPH). This is heavy bleeding after giving birth. It’s a serious but rare condition. 

What causes ICP? 

We’re not sure what causes ICP, but genes and pregnancy hormones may play a role. Genes are part of your body’s cells that stores instructions for the way your body grows, looks and works. Genes are passed from parents to children. During the third trimester of pregnancy, your body makes more of the pregnancy hormones estrogen and progesterone. The increase in these hormones may slow the flow of bile out of your liver. 

More women are diagnosed with ICP during the winter than other times of the year, but experts aren’t sure why. We need more research on ICP to find out more about it and why women get it.  

You may be at an increased risk for ICP if you:

  • Had ICP before. More than half of women who have ICP have it again in another pregnancy.
  • Have a family history of ICP. ICP is more common in some families, so tell your health care provider if your mother or sister had ICP. Fill out the March of Dimes family health history form to record health information about your family and share the form with your provider.
  • Have a history of liver disease, like hepatitis C. Hepatitis C is a disease caused by the hepatitis C virus (also called HVC) that makes your liver swollen. Hepatitis C usually spreads though infected blood. It also can spread through unprotected sex with an infected person or from mom to baby during childbirth.
  • Have ABCB11 or ABCB4 gene changes (also called mutations). These genes help the body make and use bile. A gene change is a change to instructions that are stored in a gene. A person’s gene can change on its own, or a changed gene can be passed from parents to children.
  • Are pregnant with multiples (twins, triplets or more). If you’re pregnant with multiples, your estrogen levels may be higher than if you were pregnant with just one baby. 

What are signs and symptoms of ICP? 

Signs of a condition are things someone else can see or know about you, like you have a rash or you’re coughing. Symptoms are things you feel yourself that others can’t see, like having a sore throat or feeling dizzy.

Signs and symptoms of ICP can range from mild to severe and may begin in your second or third trimester. Call your provider if you have signs and symptoms of ICP, including:

  • Severe itching. Itchy skin is the most common symptom of ICP. You may itch all over your body, but it may be most severe on the palms of your hands and the bottom of your feet. Itching may be the worst at night, and it may wake you up or make it hard to sleep.
  • Dark urine or light-colored bowel movements
  • Jaundice. This is a condition that makes your eyes and skin look yellow. It happens when your liver isn’t working well and there’s too much of a substance called bilirubin in the blood.
  • Loss of appetite (not hungry)
  • Nausea (feeling sick to your stomach) or pain in the upper right belly

To check you for ICP, your health care provider may give you a physical exam and a blood test. The blood test checks the amount of bile acids and other chemicals in your blood that show how well your liver is working. 

How is ICP treated? 

Talk to your provider about treatment for ICP. Your provider may give you prescription medicine called ursodiol (brand names Actigall® and Urso®). A prescription is an order for medicine given by a health care provider. Ursodiol helps lower the amount of bile acids in your blood, relieves itchy skin and may help reduce your baby’s risk of having complications caused by ICP. Don’t take any prescription medicine during pregnancy without talking to your provider first.

Don’t use medicines like antihistamines or corticosteroid creams or lotions to help relieve itching. You can buy these medicines over the counter without a prescription. Antihistamines are medicines that treat allergy symptoms, like skin rashes or itchy eyes. They often don’t work, and they may harm your baby during pregnancy. Corticosteroid creams and lotions don’t relieve itching caused by ICP, and they may harm your baby during pregnancy. Soaking in a bath with lukewarm water may help you feel better. Don’t take any over-the-counter medicine during pregnancy without talking to your provider first. 

If you have ICP, your provider may monitor your baby with tests, like:

  • Amniocentesis. This is a test that takes some amniotic fluid from around your baby in the uterus (also called womb). The test checks for birth defects and genetic conditions in your baby. Your provider may use ultrasound to check your baby’s amniotic fluid for meconium or find out if your baby’s lungs are developed for birth. Ultrasound uses sound waves and a computer screen to show a picture of your baby inside the womb.
  • Fetal heart rate monitoring (also called a nonstress test or NST). This test checks your baby’s heart rate in the womb and sees how the heart rate changes when your baby moves. Your provider uses this test to make sure your baby’s getting enough oxygen.
  • Biophysical profile (also called BPP). This test combines a nonstress test with an ultrasound. Your provider can use BPP to find out how much amniotic fluid is in your womb and check your baby’s muscle tone and movements.

If you have ICP, your provider may recommend inducing labor to help prevent complications like stillbirth. Inducing labor is when your provider gives you medicine or breaks your water (amniotic sac) to make your labor begin. The American College of Obstetricians and Gynecologists (ACOG) suggests women may need to have their baby before 37 weeks and 7 days of pregnancy. If your baby needs to be delivered before 39 weeks, ask your provider about the type of care your baby may need.

Does ICP cause problems after you give birth?

Itching should stop within a few days of giving birth. Your provider may recommend blood tests after giving birth to check your bile acid levels and make sure your liver is working well. 

Last reviewed: July 2020

Influence of liver diseases on skin condition

Prashnova Maria Konstantinovna

Doctor, gastroenterologist, hepatologist, Ph.D.

100.5 thousand views

A familiar phrase: “Beauty comes from the inside”? It’s true. To maintain beauty on the outside, you need to create health inside. Today we will talk about why the treatment of skin diseases, cleansing and other cosmetic procedures should start with the liver and gallbladder.

First – 3 real stories of our patients

Story 1: weight loss, expensive creams and gallbladder

Patient P., 36 years. At the new workplace – high requirements for appearance. The patient went on a strict diet, went in for sports and lost 8 kg in a month. However, the rash on the skin intensified – areas of redness, peeling, acne appeared. Treatment by a beautician did not help, and even expensive skin products did not work.

On the advice of another dermatologist, the patient came to a gastroenterologist-hepatologist for examination. At the reception, the patient recalled that while playing sports, she sometimes felt a tingling sensation in her right side, but did not pay attention.The doctor prescribed an ultrasound scan, which revealed changes in the gallbladder: due to irregular nutrition, he was spasmodic, thick bile began to accumulate, and this slowed down intestinal motility. The doctor prescribed treatment, and recommended food 4-5 times a day in small portions. Gradually, the skin condition improved, the pain stopped bothering me.

Conclusion: competent cosmetologists know how the condition of the skin is connected with the work of internal organs. Therefore, it is often advised to consult a gastroenterologist for problem skin.Listen, beautiful skin starts with health inside.

Story 2: Skin rashes and hepatitis

Patient K, 34 years old. I have never suffered from allergies. Suddenly, urticaria-type rashes appeared, which began to recur regularly. The patient consulted an allergist and hematologist on several occasions. Antiallergic drugs did not help at all. It got to the point that the rashes began to appear for no apparent reason at all. The condition worsened, added weakness, drowsiness, fatigue.

Noticing this, the patient came to a gastroenterologist for examination. The supervisor doctor prescribed tests, ultrasound with elastography. Diagnosis: chronic hepatitis C, genotype 1a, stage 2 fibrosis. Upon further examination, lamblia was found – it was they who caused the rash on the skin. The patient underwent an appropriate course of treatment and antiviral therapy, the rash disappeared.

Conclusion: if you have a rash, do not rush to buy expensive medicines and go on a strict diet. Often the reason is different. Check your liver and gallbladder.

Story 3: pruritus and cirrhosis of the liver

Patient O., 54 years old, turned to the “Polyclinic EXPERT” on the recommendation of a dermatologist with complaints of itching. Long-term treatment by a dermatologist was ineffective, and a consultation with a gastroenterologist-hepatologist was prescribed.

The doctor found out that a few years before the onset of itchy skin, changes were revealed in the biochemical blood test due to problems with the production and excretion of bile from the liver. The patient has been working with chemical fertilizers for many years.In addition, the gynecologist prescribed hormonal contraceptives to her to normalize the menstrual cycle, which she took for a long time.

The patient was fully examined according to one of the complex diagnostic programs, including a liver biopsy. Excluded toxic and drug hepatitis. All this helped to establish the final diagnosis: primary biliary cirrhosis of the liver. The patient was prescribed bile acid preparations and treatment of itchy skin. Now the patient feels satisfactory, the skin itching has disappeared, the biochemical parameters of the liver are normal.

Conclusion: if your liver has been overloaded – you have been in contact with toxic substances, take medications for a long time – get periodically examined. This way you can identify a potentially dangerous disease at an early stage.

What does the skin have in common with the liver?

One of the many tasks of the liver is to remove metabolic products from the body. If for some reason the liver cells stop doing this work, the secretion increases through the skin. This is manifested by rashes, changes in skin color, etc.p.

Check the liver if you see:

  • early age-related changes – fatty hepatosis, hepatitis of various origins
  • blood dew (Tuzhilin syndrome) – a sign of a number of diseases of the liver, gall bladder and pancreas (photo # 1)
  • vesicles and papules – often appear during an autoimmune process in the liver and viral hepatitis (photo # 2)
  • acne – fatty degeneration of the liver and inflammation of cells – non-alcoholic steatohepatitis
  • spider veins (i.e.n. spiders) – frequent signs of hepatitis, cirrhosis, fatty hepatosis, acogolic liver disease (photo # 3)
  • jaundice is a sign of the release of bile pigments into the blood due to mechanical obstruction of the outflow of bile or damage to liver cells (photo # 4)
  • hepatic palms – appears due to the accumulation of estrogen in cirrhosis
  • excoriation – scratching due to itching of the skin with hepatitis and cirrhosis
  • urticaria – although it is not directly related to the liver, but may indirectly indicate an increased allergy provoked by a disease in this organ
  • bruises without visible trauma – a sign of blood clotting disorders, pancreatic diseases
  • white spots on the nails, cracks in the corners of the mouth – a sign of vitamin deficiency, anemia, bowel diseases
  • stretch marks (striae) – often appear with the accumulation of fluid and an increase in the volume of the abdominal cavity with cirrhosis
  • enlargement of the abdomen and “head of medusa” – ascites and enlargement of the subcutaneous veins of the abdominal cavity – signs of liver cirrhosis and portal hypertension, also occurs in oncological diseases of the internal organs (photo №5).

What if you notice changes in your skin?

Step 1. Consult a doctor and get an individual examination plan – biochemical tests – ALT, AST, bilirubin, alkaline phosphatase, GGTP, markers of viral hepatitis, immunological tests, ultrasound, and others, according to the doctor’s recommendations.
Step 2. Find out the test results, diagnosis and prognosis of the disease.
Step 3. Get a treatment plan based on comorbid conditions.

Do not wait for the skin condition to deteriorate.Check your liver. In the early stages, recovery can be achieved. And the specialists of the Polyclinic EXPERT – hepatologists and dermatologists with extensive experience – will be happy to help. Health and beauty of your skin!

To scratch or not to scratch, that is the question. Scientists Answer

Photo Credit, Getty Images

There is not much scientific knowledge about itching and scabies, but this underrated area of ​​medicine can reveal surprising facts about the human brain.

We have collected 12 facts that will make you scratch your head.

1. You scratch about 97 times a day

Photo by Getty Images

According to research, each of us itches about 100 times a day. Probably, you have something itching right now. Scratch it, nobody will notice.

2. The urge to scratch is caused by toxins left on the skin by animals or plants

Photo Credit, Getty Images

Toxins trigger the release of histamine, which is part of the body’s immune response.As a result, nerve fibers begin to send “itchy” signals to the brain. The simplest example is meeting a jellyfish.

3. Scratching has its own nervous system

Photo author, Getty Images

itching is answered by certain nerve fibers.

4. Signals that itching somewhere are transmitted very slowly

Photo author, Getty Images

Nerve fibers have different speeds:

  • Touch signal transmission speed – 321 km / h
  • ” quick pain “(which you experience if, for example, you accidentally touch a hot plate) is transmitted at a speed of 128 km / h
  • the desire to scratch” crawls “at a speed of 3.2 km / h – slower than you are walking

five.The urge to scratch is contagious

Photo author, Getty Images

Scientists have proven this by showing groups of mice videos of other mice scratching themselves. The watching group also began to scratch themselves.

6. The suprachiasmatic nucleus is responsible for infectious scratching

Photo by, Getty Images

Neuroscientists do not yet know how a tiny part of our brain called the “suprachiasmatic nucleus” is involved in observing scratching and arousing the desire to scratch.

7. The urge to scratch is the best way to deal with itching caused by insects or plants

Photo Credit, Getty Images

This helps to get rid of all pesky insects or poisonous plants, and also dilates blood vessels, allowing leukocytes and plasma to wash away toxins. It is because of this flush that the skin becomes red and blotchy.

8. Scratching is pleasant because it releases serotonin in the brain as a result

Serotonin is a neurotransmitter to which scientists attribute feelings of well-being and happiness.The more serotonin circulates throughout the body, the happier you feel. Unsurprisingly, it’s sometimes hard to stop itching.

9. The nicest place to scratch is the ankle …

Photo by Getty Images

At least according to a study published in the British Journal of Dermatology in 2012.

Results showed that itching is felt most intensely on the ankle, but it is also the place where the pleasure of scratching is felt the most and lasts the longest.

Have you just scratched your ankle to test the findings of the British scientists? Honestly.

10. The more you scratch, the more it itches

When you scratch your skin, histamine is released into the bloodstream and more itchy signals are sent to the brain.

11. The cycle of scratching and combing is dangerous for people with skin conditions

Photo Credit, Getty Images

These patients suffering from eczema, psoriasis and other skin conditions are often prescribed antihistamines to try to reduce the intensity of itching sensations.

12. Chronic itching is as debilitating as chronic pain

Photo Credit, Getty Images

Scientists have found that people suffering from persistent itching experience the same levels of discomfort and depression as those with chronic diseases …

According to a study published in the Archives of Dermatology, people who suffer from itching for weeks, months, or even years feel as bad as those who suffer from chronic pain.

In fact, the study authors say that chronic itching is the skin’s equivalent of pain.

Moreover, persistent itching should not be ignored, chronic itching can be associated with many diseases such as liver disease and lymphoma.

Interventions to treat cholestasis during pregnancy

Obstetric cholestasis is a liver disorder during pregnancy that most often occurs in the third trimester of pregnancy. The main symptom of this condition is itchy skin, which can be very painful for a pregnant woman.Bile acids accumulate in the liver and blood levels also rise. The signs and symptoms of this condition resolve spontaneously within the first few days after delivery or within two to three weeks. The condition has been associated with preterm birth and is thought to be associated with complications such as miscarriage and stillbirth. Most doctors deliver early to reduce the risk of stillbirth. Treatments such as ursodeoxycholic acid (UDCA) and S-adenosylmethionine (SAM) detoxify bile acids or alter their solubility.Some agents (activated charcoal, guar gum, cholestyramine) were used to bind bile acids in the intestine and remove them. Some of these drugs have potential adverse effects on mothers by reducing the vitamin K levels needed for blood clotting.

We included 21 randomized controlled trials with a total of 1197 participants in this review. The risk of bias in most clinical trials was moderate to high. Compared to placebo, UDCA reduced pruritus in five clinical trials (228 women), no benefit was seen in one clinical trial (16 women), and another trial reported improvement only in women with severe disease. (94 women).Five clinical trials (304 women) reported unborn child distress or asphyxiation symptoms, and although there were fewer cases of fetal distress in the UDCA groups compared with placebo, the differences were not statistically significant. Results from four clinical trials comparing SAM and placebo were conflicting. Two trials (48 women) reported a reduction in pruritus with SAM compared to placebo, and two trials (34 women) reported no significant difference between groups in terms of relief of pruritus.

Comparisons of guar gum, activated charcoal, dexamethasone, cholestyramine, sage, Yinchenghao, Danxioling or Yiganling decoctions (used in Chinese medicine for their hepatoprotective properties) with placebo or with each other were based on data from a single clinical trial. Further clinical trials are needed before any convincing conclusions can be drawn about their effectiveness.

One clinical trial (63 women) compared early delivery with expectant management.There were no stillbirths or neonatal deaths in any of the groups. There were no significant differences in the frequency of caesarean section, meconium-stained amniotic fluid, and neonatal intensive care unit admissions.

Memorial Sloan Kettering Cancer Center

This document, provided by Lexicomp ® , contains all the information you need to know about the drug, including the indications, route of administration, side effects and when you should contact your healthcare provider.

Trade names: USA

Soltamox

Trade names: Canada

APO-Tamox; Nolvadex D; TEVA-Tamoxifen

Warning

  • This drug may increase the risk of very bad and sometimes deadly side effects, such as stroke, blood clots, endometrial cancer, or uterine cancer.

What is this drug used for?

  • Used to treat breast cancer.
  • The drug is used to reduce the likelihood of breast cancer in people at increased risk of developing this disease. It may reduce the likelihood of cancer developing in the other breast after cancer in one breast has developed.
  • This medicinal product can be used for other indications. Consult your doctor.

What do I need to tell my doctor BEFORE taking this drug?

  • If you are allergic to tamoxifen or any of the other ingredients of this medicine.
  • If you are allergic to this drug, any of its ingredients, other drugs, foods or substances. Tell your doctor about your allergy and how it manifested itself.
  • For blood clots or blood clots in the past.
  • If you are being treated with any of the following drugs: anastrozole, letrozole, or warfarin.
  • If you are taking any of these medicines: carbamazepine, phenobarbital, phenytoin, rifabutin, rifampin, or St. John’s wort.
  • If you are breastfeeding. Do not breast-feed while taking this drug or for 3 months after your last dose.

This list of drugs and diseases that may be adversely associated with this drug is not exhaustive.

Tell your doctor and pharmacist about all medicines you take (both prescription and over-the-counter, natural products and vitamins) and your health problems.You need to make sure that this drug is safe for your medical conditions and in combination with other drugs you are already taking. Do not start or stop taking any drug or change the dosage without your doctor’s approval.

What do I need to know or do while taking this drug?

  • Tell all healthcare providers that you are taking this drug.These are doctors, nurses, pharmacists and dentists.
  • Perform blood tests as directed by your healthcare practitioner. Please consult your doctor.
  • This drug may interfere with some lab tests. Tell all healthcare providers and laboratory staff that you are taking this drug.
  • Cases of decreased blood cell count have been reported during treatment with this drug. A marked decrease in the number of blood cells can lead to bleeding, infection, or anemia.See your doctor right away if you develop symptoms of an infection such as high fever, chills, or sore throat; any unexplained bruising or bleeding; or when you are very tired or weak.
  • Call your doctor right away if you have signs of thrombosis, such as pain or tightness in your chest; coughing up blood; dyspnea; swelling, warmth, numbness, discoloration, or pain in your leg or arm; Difficulty speaking or swallowing.
  • This drug may increase the risk of cataracts or the need for cataract surgery.Consult your doctor.
  • You need regular breast examinations. Your doctor will tell you how often this test needs to be done. It is also necessary to carry out a breast self-examination in accordance with the instructions of your doctor. Check with your doctor.
  • Get regular gynecological examinations. Your doctor will tell you how often this test needs to be done.
  • Other malignancies have been diagnosed with this drug.It is not known if this drug has caused other malignancies. If you have any questions, please consult your doctor.
  • This drug may keep your period from coming on for some time. This is not a method of contraception.
  • Potential adverse effects of this drug on the fetus. Before you start taking this drug, you will have a pregnancy test to confirm that you are NOT pregnant.
  • Use non-hormonal contraceptives such as condoms. Follow this rule for the entire duration of this drug and for 2 months after stopping it.
  • If you become pregnant while taking this drug or within 2 months after your last dose, call your doctor right away.

What side effects should I report to my doctor immediately?

WARNING. In rare cases, some people with this drug can have serious and sometimes deadly side effects. Call your doctor or get medical help right away if you have any of the following signs or symptoms, which may be associated with serious side effects:

  • Signs of an allergic reaction such as rash, hives, itching, reddened and swollen skin with blistering or scaling, possibly associated with fever, wheezing or wheezing, tightness in the chest or throat, difficulty breathing, swallowing or speaking, unusual hoarseness, swelling in the mouth, face, lips, tongue, or throat.
  • Symptoms of increased calcium levels such as weakness, confusion, fatigue, headache, nausea, vomiting, constipation, or bone pain.
  • Signs of a urinary tract infection, including blood in the urine, burning or painful sensations when urinating, frequent or immediate urge to urinate, fever, pain in the lower abdomen or pelvis.
  • Weakness on one side of the body, difficulty speaking or thinking, trouble maintaining balance, drooping one side of the face, or blurred vision.
  • Change in vision.
  • Lump in the breast or breast tenderness.
  • Depression.
  • Swelling of the hands or feet.
  • Any change in the skin.
  • Severe headache.
  • Unusual burning, numbness, or tingling sensations.
  • Treatment with this drug in rare cases was accompanied by liver disorders. These include several cases of liver cancer. Sometimes these liver problems have resulted in death.Call your doctor right away if you have symptoms of liver problems such as dark urine, increased fatigue, lack of appetite, nausea or abdominal pain, lightened stool, vomiting, yellowing of the skin or eyes.
  • If you are a woman, see your doctor right away if you have pain when urinating, pain or pressure in the pelvic area, or changes in your period (period) such as missing your period, vaginal bleeding that is not common, or vaginal discharge.
  • Some men have had sexual problems with this drug. These included decreased interest in sex and lack of erection. If you have any sexual dysfunction while taking this drug, call your doctor right away.

What are some other side effects of this drug?

Any medicine can have side effects. However, many people have little or no side effects.Call your doctor or get medical help if these or any other side effects bother you or do not go away:

  • Tides.
  • Nausea or vomiting.
  • Weight gain or loss.
  • Feeling dizzy, tired, or weak.
  • Pain in the back, bones, joints or muscles.
  • Diarrhea or constipation.
  • Sleep disorders.
  • Anxiety.

This list of possible side effects is not exhaustive.If you have any questions about side effects, please contact your doctor. Talk to your doctor about side effects.

You can report side effects to the National Health Office.

You can report side effects to the FDA at 1-800-332-1088. You can also report side effects at https://www.fda.gov/medwatch.

What is the best way to take this drug?

Use this drug as directed by your healthcare practitioner.Read all the information provided to you. Follow all instructions strictly.

All forms of issue:

  • Take this medication with or without food.
  • Continue taking this drug as directed by your doctor or other healthcare professional, even if you feel well.
  • If you are able to get pregnant, start this drug during your period (period).If in doubt about the time to start treatment, consult your doctor.

Tablets:

  • Should be swallowed whole with some water or other beverage.

Liquid:

  • Use only the measuring container supplied with the liquid preparation.

What should I do if a dose of a drug is missed?

  • Take the missed dose as soon as you can.
  • If it is time for your next dose, do not take the missed dose and then return to your normal dose schedule.
  • Do not take 2 doses at the same time or an additional dose.
  • If you miss a dose and are not sure what to do, contact your doctor.

How do I store and / or discard this drug?

Pills:

  • Store at room temperature in a dry place.Do not store in the bathroom.

Liquid:

  • Store at room temperature. Do not place in refrigerator or freezer.
  • Store in a dry place. Do not store in the bathroom.
  • Store in primary container.
  • The lid must be tightly closed.
  • Throw away all unused portions of this medicine 90 days after opening the package.

All forms of issue:

  • Do not expose to heat and light.
  • Store all medicines in a safe place. Keep all medicines out of the reach of children and pets.
  • Dispose of unused or expired drugs. Do not empty into toilet or drain unless directed to do so. If you have any questions about the disposal of your medicinal products, consult your pharmacist. Your area may have drug recycling programs.

General information on medicinal products

  • If your health does not improve or even worsens, see your doctor.
  • You should not give your medicine to anyone and take other people’s medicines.
  • Some medicines may come with other patient information sheets. If you have questions about this drug, talk with your doctor, nurse, pharmacist, or other healthcare professional.
  • A separate patient instruction sheet is attached to the product. Please read this information carefully. Reread it every time you replenish your supply. If you have questions about this drug, talk with your doctor, pharmacist, or other healthcare professional.
  • If you think an overdose has occurred, call a Poison Control Center immediately or seek medical attention. Be prepared to tell or show which drug you took, how much and when it happened.

Use of information by consumer and limitation of liability

This information should not be used to make decisions about taking this or any other drug. Only the attending physician has the necessary knowledge and experience to make decisions about which drugs are suitable for a particular patient. This information does not guarantee that the drug is safe, effective, or approved for the treatment of any disease or specific patient.Here are only brief general information about this drug. It does NOT contain all available information on the possible use of the drug with instructions for use, warnings, precautions, information about interactions, side effects and risks that may be associated with this drug. This information should not be construed as a treatment guide and does not replace information provided to you by your healthcare professional. Check with your doctor for complete information on the possible risks and benefits of taking this drug.Use of this information is governed by the Lexicomp End User License Agreement available at https://www.wolterskluwer.com/en/solutions/lexicomp/about/eula.

Copyright

© UpToDate, Inc. and its affiliates and / or licensors, 2021. All rights reserved.

90,000 Vitamins in Dermatology. Review article – FSBI “NMITs TPM” of the Ministry of Health of Russia

Vitamins include a group of organic compounds that are present in small quantities in cells and catalyze various chemical reactions.It is known that almost all hypovitaminosis is accompanied by one or another change in the skin and its appendages. In dermatovenerology, vitamins and their various complexes are used for non-specific immunomodulatory therapy, which changes the body’s relationship with etiopathogenetic factors and drugs used to treat this disease.

Vitamins are divided into two classes:

  • water-soluble: thiamine, riboflavin, nicotinic acid, pantothenic acid, pyridoxine, folic acid, cobalamin, ascorbic acid, biotin,
  • fat-soluble: retinol, calciferol, tocopherol, phylloquinone.

Water-soluble vitamins

Thiamine (vitamin B 1 ) controls the most important processes of energy production and biosynthesis of living cell substances. This vitamin is involved in the metabolism of carbohydrates, nucleic acids, proteins, lipids. The action of thiamine is characterized as hyposensitizing, analgesic, antipruritic, anti-inflammatory; it stimulates the detoxification function of the liver, has a beneficial effect on the state of the central nervous system.Thiamine stimulates melanogenesis, as well as the synthesis of connective tissue elements. It is reported about a change in lipid peroxidation with a deficiency in the body of thiamine; in particular, an increase in the permeability of the lysosomal and plasma membranes of leukocytes was found. There are observations about the participation of thiamine in immunological reactions. The action of this vitamin is realized by activating the biosynthesis of nucleic acids and proteins, which underlies the proliferation of both thymocytes and bone marrow cells.With thiamine deficiency, both cellular and humoral immunity is inhibited.

Thiamine is recommended for eczema, psoriasis, lupus erythematosus, for diseases with photosensitization – photodermatosis: porphyrin disease, lupus erythematosus, pellagra; as well as neurodermatitis, pruritus, chronic urticaria, pruritus, seborrhea, lichen planus, when the peripheral nervous system is involved in the pathological process in patients with shingles, leprosy, as well as in the complex treatment of vitiligo, circular and seborrheic hair loss, chills, cheilitis , acne vulgaris, pyoderma, candidiasis.

On the other hand, a dermatologist in his practice may encounter negative effects of vitamin B 1 , caused by allergic reactions: urticaria, pruritus, Quincke’s edema, erythroderma. A manifestation of hypersensitivity to thiamine in the conditions of its production is contact dermatitis.

Riboflavin (vitamin B 2 ) participates in the processes of energy metabolism. It is part of the enzymes of tissue respiration, affects the exchange of nucleic acids, proteins, carbohydrates, lipids.This vitamin has a beneficial effect on the processes of growth, regeneration and trophism of tissues, is closely related to the exchange of a number of other vitamins, stimulates phagocytosis, melanogenesis.

With a deficiency in the body of riboflavin, wounds and trophic ulcers do not heal well.

Riboflavin preparations are effective in combination with other drugs for cheilitis, angular and aphthous stomatitis, glossitis, cracked lips, seborrheic dermatitis, alopecia, rosacea, photodermatosis, psoriasis, eczema, neurodermatitis, pruritus, acne vulgaris, streptoderma.Vitamin B 2 is indicated for long-term use of antibiotics, sulfonamides, hormones, antimalarial drugs, which are often used in dermatology. The stimulating effect of riboflavin in trophic disorders in tissues, as well as its participation in the regeneration process, make it possible to use this vitamin for the treatment of burns.

Nicotinic acid (vitamin PP or B 3 ) is part of the enzymes of redox reactions, affects the metabolism of carbohydrates, lipids, proteins, reduces blood glucose, improves the functional state of the central nervous system, liver and stomach, participates in reparative processes of the skin …

With a lack of nicotinic acid, pellagra develops (Italian pelle – skin, agro – rough). The main manifestations of pellagra are photodermatitis and inflammatory lesions of the oral mucosa and tongue. Dermatitis is found mainly in open areas. Erythematous in the acute period, accompanied by itching or burning. Then, within 2 to 3 weeks, it becomes dry and scaly, the skin thickens. Casal’s collar is a term used to describe sharply delineated skin lesions that form around the neck, resembling a necklace.Skin lesions also occur in areas of bony protrusions and on the face. The skin symptoms of pellagra, when nicotinic acid is added to the diet, quickly disappear in a centrifugal manner. A decrease in the content of nicotinic acid in the body was found in psoriasis, eczema, photodermatosis.

Due to the vasodilating effect of nicotinic acid, it is successfully used for the treatment of chills, chronic atrophic acrodermatitis, Raynaud’s disease and scleroderma, and due to its beneficial effect on the state of the nervous system and liver function – for the treatment of eczema, neurodermatitis, pruritus, lichen planus, psoriasis.The photodesensitizing effect of vitamin PP allows it to be used for photodermatosis, and a beneficial effect on the functional state of the digestive tract – for red acne. Due to the ability of this vitamin to prevent and reduce toxic effects, it is recommended to prescribe it with prolonged use of high doses of antibiotics, sulfonamides, antimalarial drugs, as well as in combination with other drugs – for cheilitis, stomatitis. The use of nicotinic acid has a good effect on sluggish healing wounds and ulcers.Nicotinic acid is prescribed to obtain the phenomenon of inflammation in the diagnosis of syphilitic roseola and erythema leprosy.

Patients suffering from allergic dermatoses, during the period of a pronounced allergic state (allergic dermatitis, eczema, urticaria), should not be prescribed the drug. Side effects include redness of the skin of the face and upper half of the body, an increase in skin temperature, sometimes itching and urticarial elements.

Pantothenic acid (vitamin B 5 ).It was found that pantothenic acid takes part in the metabolism of carbohydrates, fats, proteins, participates in redox processes, in melanogenesis.

Pantothenic acid is used in dermatological practice as a dermatoprotector, since it has a regenerating and anti-inflammatory effect. It is used in the treatment of atopic dermatitis, eczema, trophic ulcers, burns, herpes, alopecia and dermatoses of various etiologies.

Pyridoxine (vitamin B 6 ) catalyzes the processes that regulate the exchange of nucleic acids, proteins, fats, carbohydrates.

Pyridoxine deficiency leads to the development of anemia, functional changes in the central nervous system, seborrheic dermatitis, glossitis, cheilitis, hair loss.

Vitamin B 6 is used to treat dermatoses, in which a significant lack of pyridoxine in the body is determined – seborrhea, stomatitis, psoriasis, scleroderma, shingles, photodermatosis, atopic dermatitis.

The drug is indicated for patients suffering from neurodermatitis, eczema. Pyridoxine prevents and reduces toxic effects in persons taking long-term high doses of antibiotics, antimalarial and anti-tuberculosis drugs.

A positive clinical effect was established in patients with acne vulgaris, for the treatment of whom a cosmetic cream containing 0.5% pyridoxal phosphate was used.

The use of the drug in dermatological practice for psoriasis, eczema, neurodermatitis is associated with its ability to stimulate metabolic processes in the skin and mucous membranes. In patients with psoriasis, the use of pyridoxal phosphate is pathogenetically justified by a deficiency of pyridoxine and a violation of tryptophan metabolism at the level of B 6 -dependent enzyme.

Possible allergic reactions to pyridoxine – itching, urticaria, toxicoderma.

Folic acid (vitamin B 9 ). Folic acid plays an important role in the exchange of serine, glycine, histidine, and the biosynthesis of DNA and RNA molecules. It is also essential for the normal course of growth, development, tissue proliferation, and melanogenesis.

Prescribing folic acid is accompanied by a clinical effect in psoriasis, solar urticaria, pruritus, late cutaneous porphyria, rosacea, cheilitis, hyperkeratosis, dermatitis herpetiformis, pyoderma, acne, radiation lesions of the skin, as well as with prolonged use of cytostatics, antibiotics.Thus, the combination of methotrexate with folic acid in the treatment of patients with psoriasis significantly reduces the incidence of such serious side effects as anemia, leukopenia, and thrombocytopenia.

Folic acid is referred to as vitamins, which are characterized by severe toxicity, since even a single administration of it to a person at a dose of more than 100 mg causes symptoms resembling histamine poisoning – a sharp reddening of the face, itchy maculopapular rash, etc. Positive skin tests in some cases indicate the allergic nature of such phenomena.

Cobalamin (vitamin B 12 ). The ability of cobalamin to increase nonspecific resistance to bacterial infections has been established. One of the foundations of the mechanism of the immunomodulatory action of this vitamin is considered its effect on the exchange of nucleic acids and proteins.

Vitamin B 12 is successfully used in psoriasis, photodermatosis, dermatitis herpetiformis, neurodermatitis.

With the introduction of cobalamin, allergic reactions are possible in the form of urticaria and Quincke’s edema.The combined use of cobalamin with thiamine often causes the development of allergic reactions than the separate use. With a pronounced hyperergic state in the period of exacerbation of eczema and neurodermatitis, the appointment of cobalamin can increase allergic reactivity, therefore, in the acute stage of dermatoses, the use of this vitamin should be avoided. A similar tactic is advisable in the progressive stage of psoriasis, psoriatic erythroderma and its arthropathic form.

Ascorbic acid (vitamin C) is involved in the formation of connective tissue, the metabolism of proteins, carbohydrates, lipids, the synthesis of adrenal cortex hormones, nucleic acids, has a beneficial effect on regenerative processes, regulates pigment metabolism in the skin, stimulates the antitoxic function of the liver, the activity of the endocrine glands, promotes the adaptive abilities of the body.Ascorbic acid preparations are characterized by antitoxic, hyposensitizing, anti-inflammatory, anti-hyaluronidase action. In vitro, the bacteriostatic and bactericidal role of vitamin C in relation to staphylococcus and streptococcus was revealed.

Vitamin C deficiency leads to a violation of the T-system of immunity and less significant deviations of humoral immunity. The fact of melasma with C-avitaminosis is widely known. Disruption of collagen synthesis in vitamin deficiency is expressed in poor wound healing.

The positive effect of ascorbic acid was noted in inflammatory, degenerative and other pathological processes of the skin. Appointment of ascorbic acid is advisable for toxicoderma, allergic dermatitis, eczema, neurodermatitis, pruritus, chronic urticaria, lichen planus, photodermatosis, vasculitis, pemphigus, stomatitis, glossitis, chronic atrophic acrodermatitis, chronic pyoderma, obesity, and feet also with prolonged use of corticosteroid drugs and antimalarial drugs.In the treatment of diseases manifested by vascular skin pathology, the effectiveness increases with the combination of ascorbic acid and rutin.

Biotin (vitamin H) is an organic acid that participates in numerous carboxylation reactions. Biotin deficiency is accompanied by alopecia, dryness, scaly skin (seborrhea), skin hyperesthesia, swelling and atrophy of the papillae of the tongue.

It is used in the treatment of atopic dermatitis, psoriasis, eczema, alopecia, seborrhea. A good clinical effect was obtained in the treatment with high doses of biotin acne vulgaris.

Fat-soluble vitamins

Vitamin A (retinol). According to the variety of reactions in which retinol is involved, it ranks first among vitamins. Retinol affects the processes of reproduction and growth, redox processes, metabolism of proteins, carbohydrates, lipids, the synthesis of corticosteroids and sex hormones, nucleic acids. Retinol is involved in the regeneration of epithelial tissues, regulates the processes of keratogenesis. Such an important function of retinol has been established as maintaining the stability of plasma and subcellular membranes.At the same time, retinol hypervitaminosis leads to shifts in the activity of phospholipases, which play an important role in changes in the composition of biomembranes. The antioxidant properties of retinol have been established. The ability of the vitamin to have an immunomodulatory effect is noted. This vitamin causes a relative and absolute increase in the content of B-lymphocytes in the peripheral blood. With a deficiency of retinol, antibody production is inhibited. The ability of this vitamin to remove the immunosuppressive effect of glucocorticoids is known.

Deficiency of retinol in the body is naturally manifested by a violation of the processes of keratinization of the skin and mucous membranes, especially the oral cavity; brittle nails, hair loss, frinoderma (Greek Phrynos – toad) are noted – follicular keratosis, in which areas of keratosis are surrounded by a depigmentation zone on the skin of the upper arms and legs. Then it moves to the torso, back, abdomen and neck. Facial lesions may resemble comedones when the sebaceous glands of the hair follicles are inflamed.

The beneficial effect of retinol in inflammatory, degenerative and other pathological processes of the skin is the basis for its widespread use in dermatological practice.This vitamin is effective in diseases accompanied by hypertrophy of the stratum corneum of the epidermis (all forms of ichthyosis, follicular keratosis, hyperkeratosis of the palms and soles). It is used in the treatment of dermatoses, which are characterized by disturbances in the processes of keratinization (psoriasis), the secretory function of the sebaceous glands (seborrhea, seborrheic alopecia, acne vulgaris), with lesions of the mucous membranes (leukoplakia), nail dystrophy, hair growth disorders (dryness and increased fragility, monilethrix (lat.monile necklace + greek. thrix hair; – hereditary hair dystrophy, manifested by the alternation of fusiform thickening of the hair shaft with areas of thinning, dryness, brittleness and hair loss. In combination with other drugs, retinol is useful in the treatment of eczema, chronic ulcerative pyoderma, trophic ulcers, Raynaud’s disease. Taking into account the pronounced antioxidant properties of retinol, its combination with tocopherol acetate and 0.5% selenium ointment is successfully used in the treatment of psoriasis and baldness.

Hypervitaminosis A is also characterized by dermatological manifestations: rash, itching, pigmentation, yellow coloration of the skin of the palms and feet, delayed wound healing, hair loss. On the skin, there may be seborrheic rashes, bleeding of the mucous membranes of the mouth.

Retinoids, being synthetic derivatives of vitamin A, have significantly expanded the therapeutic possibilities for a number of dermatoses, including severe and resistant to other therapeutic agents.Synthetic retinol derivatives – aromatic retinoids – are hundreds of times less toxic than their natural precursor, so they can be used in the clinic in rather massive doses for a long time. Etretinate (tigazone) and 13-cis-retinoic acid (isotretioin) have found application in clinical practice.

The effect of retinoids is characterized by an amazing variety of biological effects. In practical terms, the most significant is their antitumor and immunostimulating action; with the appointment of these drugs in patients, the total number of lymphocytes in the blood and the number of T cells significantly increase.

Isotretinoin is used in the treatment of various forms of acne (the commercial name of the drug is “Roaccutane”), which has a sebostatic effect (inhibits the secretion of the sebaceous glands). Of the side effects during the period of taking maximum doses of roaccutane, in some cases, there is an increased dryness of the skin, especially around the mouth, mucous membranes of the oral cavity, as well as dermatitis of the facial skin, oozing, itching, reversible alopecia.

Another retinoid, tigazone, due to its antiproliferative effect, has been shown to be effective in the treatment of psoriasis.The effectiveness of treatment increases significantly when etretinate is combined with photochemotherapy. The authors recommend such an integrated approach in the treatment of patients with common, often recurrent psoriasis.

There is evidence of a favorable clinical result of the use of tigazone in the treatment of patients with lichen planus of the oral mucosa, subacute lupus erythematosus, hyperkeratotic eczema of the hands and feet, palmar-plantar hyperkeratosis, pustulosis of the palms and soles, ichthyosis of various forms.

Dry mucous membranes, itching, hair loss, profuse desquamation of palms and soles were noted among the most common complications of tigazone intake.

Calciferol (vitamin D). The skin plays an important role in the production of vitamin D, where it can be actively synthesized by keratinocytes, fibroblasts and macrophages under the influence of UV rays.

The action of the vitamin is realized by the regulation of phosphorus-calcium metabolism; it also has a regulating effect on the state of the autonomic nervous and vascular systems, enhances perspiration and sebum secretion, improves hair growth, and normalizes water metabolism in the skin.Many tissues contain receptors for calcitriol, so it is assumed to have a variety of functions not yet understood. So, recently, its active influence on cell differentiation in normal and tumor tissues has been established.

Due to the wide spectrum of biochemical activity of calciferols, they are used in the treatment of tuberculous lupus, scrofuloderma, chromomycosis. The literature describes a case when the administration of vitamin D for senile osteoporosis led to a regression of concomitant psoriasis in a patient, which served as the basis for the use of vitamin D in the treatment of this disease.

Calciferol can cause acute poisoning with symptoms of hemorrhagic vasculitis. With prolonged intake of high doses of vitamin, pustular and acne-like rash, general sweating may occur. These phenomena are reduced with the complex use of calciferol with retinol, thiamine and ascorbic acid.

Tocopherol (vitamin E) affects the metabolism of proteins, carbohydrates, nucleic acids and steroids, promotes the accumulation of retinol and other fat-soluble vitamins in the body, exhibits anti-inflammatory and antithrombotic effects, reduces the permeability of the vascular wall, plays the role of an antioxidant.Protecting lipids from peroxidation is one of the most studied functions of vitamin E. Since unsaturated lipids are a component of biological membranes, this function of tocopherol is very important for maintaining the structural integrity and functional activity of lipoprotein cell membranes and subcellular structures. The immunostimulating properties of tocopherol are realized by inhibition of the activity of T-suppressors. At the same time, vitamin E significantly increases the activity of natural killer cells.

Appointment of vitamin E is indicated for ichthyosis, dermatomyositis, scleroderma, Raynaud’s disease, photodermatosis, psoriasis, ulcerative stomatitis, poorly healing leg ulcers, X-ray ulcers, acne, seborrhea, nested hair loss, as well as dermatoses associated with genital gland dysfunctions …Good clinical results have been established with the combined administration of tocopherol acetate, retinol and 0.5% sodium selenite ointment to patients suffering from psoriasis and circular baldness.

Vitamin E is also used externally in dermatology – in the form of an oil concentrate, or an ointment containing 3% tocopherol acetate.

Vitamin K (phylloquinone) is involved in blood coagulation, enhances the anti-inflammatory effect of steroid hormones, affects tissue regeneration, increases resistance to infections, and has an analgesic effect.Lack of vitamin K leads to the development of hemorrhagic syndrome.

Appointment of vitamin K is indicated for burns and frostbites, radiation injuries, dermatoses with a hemorrhagic component, ulcerative stomatitis, gingivitis, dermatomyositis.

Vitamin-like compounds

Lipoic acid (vitamin F) is a part of the polyenzyme complex involved in the decarboxylation of pyruvic acid, exhibits a pronounced hepatotropic and weak hypoglycemic effect, activates the consumption of glucose and pyruvate by tissues, reduces the content of cholesterol and total lipids in the blood serum, stimulates phosphorylation and protein biosynthesis in the liver …

The effectiveness of lipoic acid in psoriasis, dermatoses, accompanied by impaired liver function and lipid metabolism has been established.

With prolonged use of lipoic acid, allergic skin reactions are possible.

Calcium pangamate (vitamin B 15 ) affects lipid and carbohydrate metabolism, increases the activity of respiratory chain enzymes, and therefore significantly increases the absorption of oxygen by tissues. Due to the lipotropic effect of the vitamin, the total content of lipids in the liver, as well as cholesterol, decreases, the production of glucocorticoids increases, and a detoxifying effect is observed.

Calcium Pangamate is successfully used in psoriasis, pruritus, pruritus, toxicoderma, and also to improve the tolerance of corticosteroid and sulfa drugs.

Rutin (vitamin P). The group of vitamin P includes a number of substances – bioflavonoids, which have the ability to reduce capillary permeability and fragility.

The physiological effect of the vitamin is realized through the endocrine glands, by influencing the enzyme systems involved in tissue respiration.Vitamin P preparations exhibit antihistaminic action and antioxidant properties. Rutin regulates free radical homeostasis through several mechanisms. Firstly, it neutralizes the most dangerous radicals (peroxynitrite and hydroxyl), and secondly, it controls the production of physiologically important radicals (superoxides) by cells. In addition, rutin stimulates the release of nitric oxide, the main stimulator of relaxation of the musculature of the vascular wall.

In case of vitamin P deficiency in the body, characteristic changes are noted in the form of small intradermal hemorrhages (petechiae), which occur spontaneously, especially in areas of pressure, and disappear after the administration of bioflavonoids.

The use of vitamin P is advisable in case of increased permeability of blood vessels and their fragility (hemorrhagic diathesis, capillarotoxicosis). The effectiveness of vitamin P has been noted in toxicoderma, allergic dermatitis, eczema, urticaria, vasculitis, exudative form of psoriasis, erythroderma, Dühring’s dermatosis, and radiation dermatitis.

Along with vitamin P, it is advisable to prescribe ascorbic acid.

Methylmethionine sulfonium chloride (vitamin U), being a donor of methyl groups, participates in the biotransformation of various xenobiotics, as well as histamine methylation, which provides an antihistamine effect.When studying the autoflora of workers engaged in the production of methyl methionine sulfonium chloride, a significant increase in the number of microbes, an increase in the number of hemolytic forms of microorganisms, yeast-like fungi were found. Such changes are regarded as evidence of the possibility of a nonspecific effect of the products of vitamin production on the general reactivity of the organism.

Vitamin U proved to be to a certain extent effective in the complex treatment of patients with psoriasis, especially patients with concomitant diseases of the gastrointestinal tract.

Material prepared by a dermatocosmetologist Lyshkanets S.N

Cirrhosis of the liver ›Diseases› DoktorPiter.ru

Liver cirrhosis is a progressive disease in which liver tissue is replaced by connective tissue. In economically developed countries, cirrhosis of the liver is among the top ten causes of death for people aged 35-60 years. Most often, this disease develops after 40 years. The ratio of men to women with cirrhosis is approximately 3: 1.About 300,000 people die from this disease in the world every year. And this figure is growing.

Features

Cirrhosis develops very slowly and often does not manifest itself in the initial stages. Many people with chronic liver disease may not even notice it. However, this disease can be suspected if a person constantly experiences weakness, fatigue, if he has lost his appetite and is losing weight. One of the symptoms of this disease is telangiectasia (spider veins).If you press on them, they turn pale, however, after a while they will be filled with blood again. Also, a person suffering from cirrhosis is worried about itching, especially at night, a tendency to bleeding and the formation of bruises. His skin and sclera are yellow, and his palms are red, as a lot of blood rushes to them. The language of such people is crimson, “lacquered”. The fingers are shaped like drumsticks. With cirrhosis, pain in the right hypochondrium or heaviness in the side after taking the “wrong” food or alcohol may disturb.

For cirrhosis, portal hypertension syndrome is characteristic. It develops due to an increase in pressure in the portal vein, which carries blood from the abdominal organs to the liver. With increased pressure in it, blood from the organs cannot flow to the liver and stagnates. The syndrome of portal hypertension manifests itself as varicose veins in the legs, hemorrhoids, edema of the veins, enlarged veins on the surface of the abdomen, and accumulation of fluid in the abdominal cavity (ascites).

In women, menstrual irregularities are possible.In men, erection may weaken, gynecomastia may develop. Hair loss is possible.

Description

Translated from the Greek “cirrhosis” means yellow. Indeed, with cirrhosis, both the color of the liver and the color of the skin change. The disease begins with the fact that a certain factor damages liver cells. The cells begin to pathologically regenerate (recover), but the result is not a full-fledged liver tissue, but connective tissue. This tissue disturbs the structure of the liver, and normal blood supply to the organ is no longer possible.The remaining healthy cells work at the limit of their capabilities for some time, but after a while they die. The liver ceases to perform its functions – it does not neutralize toxins, does not synthesize blood proteins, does not secrete bile acids, therefore digestion is disturbed, hemostasis cannot be maintained.

As the circulatory system of the liver is impaired, the portal vein becomes full of blood. The blood begins to look for other ways, flows through the veins of the esophagus and stomach, hemorrhoidal veins, and also along the superficial veins of the anterior abdominal wall, causing them to expand.

There are three stages in the development of this disease:

  • The stage of compensation, during which there are no symptoms yet, but some of the cells have already been replaced by connective tissue, and healthy ones work in an enhanced mode.
  • The stage of subcompensation, at which the first signs of the disease appear. At the same time, the liver can no longer function at full strength.
  • The stage of decompensation, in which liver failure appears.It is at this time that the disease poses a threat to human life.

Many people think that cirrhosis of the liver is a disease of alcoholics. But this is not so, cirrhosis can develop in a child who has never even tried alcohol. Causes of the disease:

In about 20 out of 100 cases, the cause of cirrhosis cannot be established at all. This cirrhosis is called cryptogenic.

Many who have a reason to see a doctor for cirrhosis make the big mistake of ignoring the advice of doctors or turning to them too late.After all, cirrhosis cannot be cured, you can only stop the pathological process and slow down the development of life-threatening complications:

  • bleeding from the veins of the esophagus;
  • accession of infection;
  • the development of liver cancer;
  • hepatic coma.

The main causes of death in cirrhosis are hepatic coma and gastrointestinal bleeding.

Those with cirrhosis are assigned a disability.In most cases, they have limited working capacity. With decompensated cirrhosis and with complications, they are disabled.

Diagnostics

To diagnose cirrhosis, you need to contact a gastroenterologist or hepatologist. He will order further research. You will need a general and biochemical blood test, a general urine test, a coagulogram, tests for viral infections in the blood.

You will also need to do an ultrasound examination of the abdominal organs, gastroscopy to assess the condition of the esophageal veins and the likelihood of gastrointestinal bleeding.In some cases, additional studies are carried out – computed tomography, liver scintigraphy, liver biopsy.

Treatment

With cirrhosis, hepatoprotectors are prescribed. In autoimmune disease, glucocorticoid hormones are indicated. To eliminate portal hypertension, antihypertensive drugs and diuretics are prescribed. If the cause of the disease is a virus, antiviral drugs are prescribed. To improve digestion, enzyme preparations are prescribed.

It is imperative to follow a diet (table 5a).

In the case of an advanced disease, treatment is aimed at eliminating unpleasant symptoms and slowing the development of complications.

If the liver does not cope with the neutralization of toxins, plasmapheresis is indicated.

In some cases, surgical intervention is indispensable. Usually, paracentesis is done – a puncture of the anterior abdominal wall. This procedure removes fluid from the abdominal cavity.This procedure has to be done more than once, since the abdominal cavity is quickly re-filled with blood.

To reduce the pressure in the portal vein, in some cases bypass surgery is performed, that is, a new bloodstream is formed.

In some cases, liver transplantation is indicated.

The life expectancy of those suffering from cirrhosis of the liver depends on the stage at which treatment is started.

Lifestyle

A person suffering from cirrhosis should limit physical and mental stress.However, if his general condition is satisfactory, walking and therapeutic exercises are indicated. But you need to rest at the first sign of fatigue.

In cirrhosis, it is forbidden to lift weights, as this can cause gastrointestinal bleeding.

It is imperative to normalize the bowel function.

Those with cirrhosis should limit their fluid intake. Weigh ourselves daily and measure the abdominal circumference at the level of the navel.This will help to notice ascites in a timely manner.

To control damage to the nervous system, some doctors recommend starting a notebook in which you need to write the same phrase every morning. If you change your handwriting, you should consult a doctor.

Contraindicated in liver cirrhosis:

  • alcohol;
  • salt;
  • mineral water containing sodium;
  • pickles;
  • ham, bacon, canned fish and meat;
  • Foods containing baking powder and baking soda.

When there are concomitant diseases, additional restrictions are introduced.

Prevention

Prevention of cirrhosis of the liver consists in the timely diagnosis and proper treatment of diseases leading to cirrhosis.

Also, for the prevention of this disease, it is worth giving up alcohol.

© Dr. Peter

90,000 causes, symptoms, diagnosis and treatment

Lymph nodes in the human body act as a biological and mechanical filter.The lymph collects harmful substances and bacteria, which are then destroyed by the lymph nodes. There are about 500 of them in the body. Cancer of the lymph nodes is a fairly rare disease, which occupies 4% of all types of oncology. It develops in the form of an independent pathology or with the spread of metastases from a tumor of another localization.

Classification of lymph node cancer

If there is any inflammatory or infectious process in the body, the lymph nodes react to it with an increase, and sometimes even soreness.If this condition does not go away for a long time, then this is a reason to consult a doctor, since it is important to detect pathology at an early stage.

Lymph node cancer can develop in one of two forms:

  • Hodgkin’s lymphoma (lymphogranulomatosis). The most common variant of the development of cancer of the lymph nodes, occurs in 1/3 of cases of detection of such oncology in both adults and children. Hodgkin’s lymphoma is considered a more favorable form in terms of healing.Even at the 4th stage of the disease, the survival rate is 65%;
  • non-Hodgkin’s lymphoma. This is a more serious form of lymph node cancer, occurring in 2/3 of cases. The disease progresses rapidly, metastases appear early and spread throughout the body.

Causes and risk factors

Lymph node cancer has several age peaks, in which the disease is diagnosed more often. This is the period from 15 to 30 years, and people over 50 are also at risk.It is during this time that the risk of developing lymphoma is higher. The exact causes of the onset of the disease are unknown. Doctors cite only risk factors that increase the likelihood of developing lymphoma:

  • long-term interaction with harmful substances;
  • HIV infection and other types of immunodeficiency;
  • 90,049 smoking and alcohol abuse;

  • radiation exposure;
  • 90,049 living in an unfavorable environment;

    90,049 pregnancy over the age of 35;

  • Epstein-Bar virus;
  • genetic inheritance.

Stages

Different types of lymphomas can have different degrees of spread throughout the body. With this in mind, there are 4 stages of lymph node cancer.

  • First. Only one area is affected, cancer of the lymph nodes develops in the armpit, in the neck, etc.
  • Second. The tumor process already spreads to 2 or more groups of lymph nodes.
  • Third. In addition to the lymph nodes, the diaphragm and one organ outside the lymphatic system are affected.
  • Fourth. At the last stage, tissues outside the lymphatic system are affected, and in several parts of the body at once. The disease invades vital organs, so treatment becomes less effective.

Types of lymph node cancer

In addition to the division according to the type of lymphoma, lymph node cancer is classified according to the location of the lesion. According to this criterion, oncology of different types of lymph nodes is distinguished:

  • axillary;
  • 90,049 cervical;

    90,049 pulmonary;

    90,049 ileum;

  • supraclavicular;
  • inguinal.

In percentage terms, cancer of the lymph nodes most often occurs in the groove area (35%), then on the neck (31%) and armpits (28%). Other localizations of oncology account for 6%. The most favorable prognosis is observed for cancer of the nodes in the groin, armpits and under the jaw.

Symptoms and signs of lymph node cancer

Lymph node cancer can manifest itself in different ways depending on the form of the disease that develops in the patient. With lymphogranulomatosis, the following symptoms are observed:

  • Strong enlargement of the lymph nodes above the collarbone and in the neck;
  • enlargement of the mediastinal nodes with a specific cough, shortness of breath and swelling of the veins in the neck;
  • Painful sensations in the lumbar region, most often manifested at night.

The disease causes different symptoms when a specific group of lymph nodes is affected. If the pathology develops in an acute form, then the patient immediately has an increased degree of sweating and a sharp increase in body temperature. There is also a lot of weight loss, which progresses over time. With the development of the disease, more characteristic symptoms of lymph node cancer appear:

  • febrile condition;
  • severe itching of the skin;
  • weakness;
  • lesions of a red or dark shade on the skin;
  • diarrhea, tendency to belch;
  • frequent migraines, dizziness;
  • Soreness in the epigastric region and navel.

When to see a doctor

Cancer of the lymph nodes requires timely detection at the earliest stage, since the prognosis of recovery depends on this. In the presence of risk factors or symptoms of the disease, you should immediately consult a doctor for appropriate diagnostic measures. In the case of oncology of the lymphatic system, the patient needs the help of an oncologist. In our oncology center “Sofia” on the 2nd Tverskoy-Yamskiy per. house 10 employs the best specialists who specialize in the diagnosis and treatment of various types of oncology.

Diagnosis of cancer of nodes in the oncology center

If lymph node cancer is suspected, the doctor begins with a general examination to detect characteristic signs of the disease. It is very important to answer all the questions of a specialist, since any complaints and manifestations, as well as previous illnesses, can give the doctor the necessary information base to prescribe a successful treatment in the future.

An important stage of the examination is palpation of the lymph nodes, which makes it possible to identify their enlargement and soreness.Also, the Sofia Cancer Center practices all modern diagnostic methods that allow to identify the disease with 100% accuracy. The patient may be assigned:

  • scintigraphy;
  • PET / CT;
  • magnetic resonance imaging;
  • lymphography;
  • blood test for onokmarkers;
  • vacuum aspiration biopsy of neoplasm tissues;
  • SPECT (single photon emission computed tomography).

Lymph node cancer treatment

The treatment regimen for lymphoma depends on many factors: the location of the tumor, its spread throughout the body, size and presence of metastases in other tissues and organs. The best results are obtained with an integrated approach that combines several methods of treatment.

Chemotherapy

Lymph node metastases in cancer require mandatory chemotherapy. It is considered a versatile treatment and is used alone or in combination with other methods.The essence of chemotherapy is the intravenous administration of special anticancer drugs that destroy cancer cells. Such drugs also act on healthy tissues, which leads to the appearance of side effects, but when metastases spread, this is the only way of treatment.

Surgery

Treatment of lymph node cancer with a surgical method consists in their complete removal. This method is also considered to be quite effective, since it minimizes the risk of recurrence of the disease.Surgery for lymph node cancer is performed with resection of several regional-type nodes, which is necessary to reduce the likelihood of recurrent oncology.

Cervical, submandibular, inguinal and axillary lymph nodes are removed under local anesthesia, and deeper ones under general anesthesia. The excised parts can be used for histology and correct diagnosis.

Radiation therapy

The use of radiation therapy is recommended in conjunction with surgical treatment.This method allows you to destroy cancer cells that may have remained after surgery. Also, radiation therapy is used at an early stage in preparation for surgery to reduce the size of the tumor.

Bone marrow transplant

Today, another new method is used in the treatment of lymph node cancer – donor bone marrow transplantation. This operation allows for very optimistic predictions, especially at an early stage of the disease.

Treatment projections

The prognosis for cancer of the lymph nodes is quite favorable. With this disease, treatment is extremely successful in 70-83% of cases in which there is a 5-year survival rate. The number of relapses is 30-35%. More often, the disease recurs in men, which is explained by more difficult working conditions and bad habits. In general, the prognosis depends on how early the disease was diagnosed and treatment started. The age of the patient is of no less importance.

How to make an appointment with a specialist at the Sofia Cancer Center

To get a consultation with a specialist in our cancer center, you need to use any convenient way to register.