What Part of the Body Itches with Liver Damage? Evidence-Based Guide

If you have liver damage, one of the questions you may be asking is “what part of the body itches with liver damage?” Liver damage has encompassing effects. If it cannot process substances effectively, it results in the accumulation of these substances in the body. These substances include bile salts and other chemical substances. The accumulation of these substances, particularly under the skin, produces a distinctive pattern of itching. The itching intensifies at night and is deeper and more persistent than typical skin itching.

This post helps you understand where the liver-related itching occurs. You will also recognize accompanying symptoms so you can seek appropriate and timely care.

Key Takeaways

• Itching from liver damage typically occurs on the palms and soles, but can be widespread

• Typically occurs at nighttime or in heat

• The primary cause is buildup of bile salts

• Other factors like histamine and hormonal changes are likely contributing

• Research suggests it is more common in primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC) than in alcohol-related or non-alcoholic fatty liver disease (NAFLD)

• Diagnosis involves blood tests (e.g., ALP, bilirubin) and imaging

• Treatment includes medication like cholestyramine and lifestyle changes

• Seek medical attention for persistent itching or symptoms like jaundice or fatigue as early diagnosis is crucial

Why Does Liver Damage Cause Itching?

Liver damage causes itching because bile salt accumulates in the skin. When your liver is not working properly, it can’t process bile salts effectively.

This condition is called cholestasis. It happens when the bile flow from your liver gets blocked or is reduced due to other forms of obstruction. Your liver normally produces bile that helps in digestion, specifically fats. But when this organ gets damaged, these bile salts are not adequately processed.

As a result, the bile salts accumulate in your blood and eventually reach the skin tissue. This buildup stimulates the nerve endings under your skin, creating uncomfortable itching sensations.

There are also several chemical compounds that likely contribute to liver-related itching more than bile salt depositions. Your body produces several pruritogens, which are substances that induce itching. It includes, but not limited to:

• Histamine

• Serotonin

• Opioid peptides

Pruritogens are released when the liver struggles to filter toxins from the blood properly.

Research shows that about 70% of patients with PBC experience itchiness over their lifetime. And, nearly 35% of these patients have itchiness that does not respond to medications (refractory pruritus).

The itching sensation becomes more intense during nighttime, which can significantly impact sleep quality and daily activities.

What role do bile salts play in itching?

Bile salts are the natural detergents of the body (emulsifier) for breaking down dietary fats during digestion.

Your liver produces about 700-1200 ml of bile per day. But when your liver function declines, these bile salts can’t flow properly through the bile ducts to the small intestine.

Instead of flowing as it should through the bile ducts, they can accumulate in the blood. The kidneys filter out some of these bile salts. But they won’t be able to deal with the excess load. The unfiltered bile salts circulate throughout the body until they get deposited in your skin tissue.

The deposited bile salts irritate the nerve endings called mechano-sensitive C-fibers. This sends itch signals to the brain. However, the correlation between the amount of bile salt depositions and the intensity of the itchiness is quite poor or no correlation at all.

The amount of bile salts can be determined through blood works, which measure bile salt. If the results are elevated, it can confirm that the liver isn’t processing these substances properly. The diagnosis will be discussed in-depth in another subsection.

Are there other factors that contribute to itching in liver disease?

There are several other factors more than bile salts contribute to liver disease pruritus:

• Histamine

• Opioid peptides

• Serotonin imbalance

• Hormonal changes

• Inflammatory cytokines

The combination of these factors can explain why liver-related itchiness feels different than any typical skin disease. Often, it feels deeper, more persistent, and sometimes does not respond to regular anti-itch treatments like topical creams or anti-histamines.

Which Parts of the Body Are Most Commonly Affected?

Itchiness from liver disease starts on the palms and soles, which can spread to the arms and legs.

These parts of the body are rich in nerve endings that respond to these chemical irritants circulating in your bloodstream. Your palms and soles also have more sweat glands and blood vessels on their surface, which makes them more sensitive to accumulation of bile salts.

Often the itchiness starts at nighttime or after a warm bath, especially when circulation increases in the skin.

Pattern of Itchiness:

• Starts in hands and feet

• Spreads on arms and legs

• May become generalized in time as the disease advances, which will affect the entire body including the back, chest, and even face

During medical history, your doctor will ask you specifically where it started and the locations affected. It helps in evaluating the severity of the pruritus and the type of liver condition you may have. The pattern offers invaluable clues about your underlying liver function.

Nonetheless, patients will have their own unique manifestation and patterns. It varies in both intensity and location. The sensation is often described as “something crawling under the skin” or “tiny pricks of needles” on the palms and soles.

Does the location of itching indicate the severity of liver damage?

The location of itching does not indicate the severity of liver damage — at least not directly.

However, persistent or severe pruritus requires immediate medical consultation and evaluation. The pattern in pruritus mentioned earlier, however, gives clues about your condition.

Localized itching or pruritus that stays on the hands and feet may indicate that the condition is at its early-stage (early stage liver dysfunction or mild cholestasis). But when the itchiness becomes generalized or affects multiple body parts, it often suggests a more advanced condition or severe bile flow disruption.

Severe itchiness often disrupts quality of sleep or even daily activities, which affects overall quality of life. This is regardless of the location of itchiness on your body.

Any severe pruritus that lasts two weeks or more should prompt you to consult your doctor. Early detection and diagnosis is important to ensure that treatment is started on time, which can prevent progression to more severe liver problems.

What Are the Symptoms Associated with Itching in Liver Disease?

Aside from itchiness, symptoms that are related to liver disease may include the following:

• Jaundice

• Fatigue

• Abdominal pain (particularly on the right upper part)

• Dark-colored urine

These symptoms appear together with itchiness because of the liver’s decreased capacity to process bile salts, toxins, and inability to produce essential proteins.

Jaundice is the yellowish discoloration of the skin and whites of the eyes due to deposition of bilirubin. Bilirubin is a waste product that the liver normally processes and eliminates. When the liver function is reduced, bilirubin accumulates in the blood and gets deposited in tissues.

Fatigue in liver disease is different from the usual tiredness. It is a persistent, almost overwhelming feeling of exhaustion that does not improve even with adequate rest. This happens because the liver is the primary organ for energy production, so when it gets damaged, your body cannot convert nutrients to usable energy.

Abdominal pain, specifically at the right upper side, suggests liver involvement. The pain is characterized as dull but constant or sharp and intermittent. Liver swelling (hepatomegaly) often produces a symptom of discomfort and feeling of fullness.

Dark-colored urine occurs because the kidneys try to eliminate the excess bilirubin that the liver cannot process. The urine may appear as tea-colored, amber, or outright brown. Conversely, your stools may become pale or clay-colored because less bilirubin gets into the intestines, which normally gives your stool a brown color.

Some additional symptoms also include:

• Loss of appetite resulting in unintentional weight loss

• Nausea and vomiting especially after consuming fatty foods

• Swelling on the ankles, legs, or abdomen due to fluid retention

• Easy bruising and bleeding because of decreased protein production

• Altered mental status like confusion or difficulty concentrating in more advanced cases

However, itching alone is distressing enough for many patients more than fatigue or pain.

How Is Itching from Liver Disease Diagnosed?

Doctors diagnose itching from liver disease through blood tests, imaging, and sometimes liver biopsy.

The process often starts with a complete medical history and physical examination to identify signs that point to the liver as the culprit.

The physical examination often involves, checking for:

• Liver enlargement

• Abdominal tenderness

• Skin changes

• Scratch marks

• Jaundice

• Other abnormalities that may indicate liver disease

Blood tests are one of the cornerstones of diagnosing liver disease. Key tests include:

Liver Function Tests

• Alkaline phosphatase (ALP) - elevated levels often suggest bile duct problems

• Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) - indicate liver damage

• Bilirubin levels - show how well your liver functions in processing waste products

• Albumin and total protein - measures how well your liver produces essential proteins

Specialized Tests

• Bile acid levels - directly measures the substances that cause the pruritus

• Gamma-glutamyl transferase (GGT) - helps identify bile duct disorders

• Prothrombin time (PT) - evaluates your liver’s ability to produce clotting factors

Imaging Modalities

• Ultrasound - typically the first imaging test; it is non-invasive and can detect the following:

• Liver enlargement

• Gallstones

• Bile duct dilatation (widening)

• CT (computed tomography)

• MRI (magnetic resonance imaging)

Liver Biopsy

A procedure where the doctor will obtain a tissue sample from the liver and examine it under the microscope. It involves inserting a thin needle through the skin on your abdomen directly to your liver, which is often guided by ultrasound.

Biopsies help diagnose underlying liver conditions and evaluate the degree of liver damage. The diagnostic process typically takes several days to weeks. But this depends on the test results and the need for further testing. 

Your healthcare team will help coordinate what tests you need to minimize inconvenience for you, ensuring thorough evaluation.

 

What Treatments Are Available for Itching Caused by Liver Damage?

Treatments for itching caused by liver damage include cholestyramine and lifestyle changes like cool showers.

However, it depends on the underlying liver condition and the intensity of your pruritus.

Pharmacological Treatments

• Cholestyramine is the first-line medication for liver-associated pruritus.

The medication works by binding to bile salts in your intestines, preventing their reabsorption to your blood. The recommended initial dose is at 4g/day, which may be increased up to 16g/day. Research shows that the medication can reduce itchiness by 50% in patients.

• Rifampicin is another medication, which is an antibiotic, used for itchiness associated with liver disease.

It works by targeting the enzymes that process bile salts in the liver. Dosing recommendation ranges from 4-10mg/kg/day.

• Ursodeoxycholic acid (UDCA) does not only use underlying liver conditions but also reduces pruritus in many patients. Research shows that UDCA resolved pruritus in 40% of patients in PBC.

• Naltrexone is an opioid receptor blocker that significantly reduces pruritus severity. However, this medication requires careful monitoring because it can worsen itching before it can provide relief.

Non-Pharmacological Treatments

• Cool or lukewarm baths

• Fragrance-free, gentle moisturizers

• Loose-fitting, breathable cotton clothing

• Keep home cool and use fans

• Trim fingernails short

• Apply cold compresses on itchy areas

Advanced Treatment Options

• Phototherapy is one of the advanced treatment options, which use ultraviolet B light that can reduce itchiness in some patients. It requires specialized equipment and professional supervision.

• Plasmapheresis filters blood to remove bile salts is another treatment. However, this is reserved for severe cases.

You can find support groups that offer useful resources and coping strategies that work for them. There are also educational materials that you can read so you can deal with your pruritus.

When Should You See a Doctor for Itching Related to Liver Problems?

See your doctor immediately if the itchiness persists or if it’s accompanied by other symptoms like jaundice, fatigue, or abdominal pain. Early medical assessment can help identify liver problems that may lead to serious consequences.

Red Flag Symptoms: Seek Medical Attention Right Away

• Jaundice

• Dark urine or stools

• Severe abdominal pain (right upper region)

• Unintention weight loss or loss of appetite

• Swelling in legs, abdomen, or ankles

• Easy bruisability or bleeding

• Mental confusion or difficulty concentrating

• Persistent nausea or vomiting

Self-Assessment Checklist

• Has the itchiness been going on for more than two weeks?
• Does the itchiness worsen at nighttime or affect your sleep quality?
• Have you noticed any color change in your skin and whites of eyes (e.g., yellow discoloration)?
• Do you experience unusual fatigue that does not improve with rest?
• Does your family have a history of liver disease?
• Have you been exposed to  hepatitis?
• Are you taking medications that may affect your liver?
• Is itchiness localized to the palms and soles only or is it generalized?

Timeline for Seeking Care

Seek emergency care if you suddenly develop severe abdominal pain associated with itching, especially if it is accompanied by fever and vomiting. These symptoms may indicate serious complications that require immediate intervention.

Schedule a doctor’s appointment within a few days if you notice persistent pruritus with jaundice. Mild jaundice requires prompt evaluation since it suggests significant liver dysfunction.

Plan to have a medical evaluation in 1-2 weeks if you have persistent pruritus but are not accompanied by other symptoms. Your doctor will evaluate your liver through laboratory tests, such as liver function and will determine if further testing is required.

Remember, early detection will lead to early intervention. And, early intervention can lead to better outcomes. It will prevent further progression of the disease and other serious complications.

Quick Summary:

• Liver-related itching typically starts on palms and soles, then spreads to arms and legs

• Bile salt buildup under the skin is the primary cause of liver disease itching

• Up to 80% of people with primary biliary cholangitis experience significant itching

• The itching often worsens at night and doesn't respond to typical anti-itch treatments

• Persistent itching with yellowing skin requires immediate medical evaluation

• Treatment options include bile acid sequestrants, rifampin, and lifestyle modifications

For related resources, see the following:

What is an Echogenic Liver? Understanding Ultrasound Findings

Hepatic Parenchymal Disease: Conditions, Symptoms, And Treatment

Frequently Asked Questions

Why does liver disease cause itching?

Liver disease-related itching is brought by the buildup of bile salts that are inadequately processed by the liver. These bile salts are not eliminated properly so they accumulate in the blood. These get deposited on skin tissues, where they irritate the nerve endings and send signals to the brain, creating a sensation of deep, persistent itch characteristic of liver disease.

How is itching from liver disease treated?

The first-line of treatment is cholestyramine, which binds salt. Rifampicin goes next if the first one does not effectively reduce the itchiness. Lifestyle changes can also be applied such as cold showers, moisturizing, and even wearing loose clothing. There are also advanced therapies like phototherapy, which is done under medical supervision.

When should I see a doctor for itching related to liver disease?

You should see a doctor if itching persists for more than two weeks. And, especially if the itching is accompanied by yellowing of skin or eyes, dark urine, unexplained fatigue, or abdominal pain. Any itching that interferes with sleep or daily activities warrants medical evaluation.

 

Written by Jaclyn P. Leyson-Azuela, RMT, MD, MPH
Jaclyn P. Leyson-Azuela, RMT, MD, MPH, is a licensed General Practitioner and Public Health Expert. She currently serves as a physician in private practice, combining clinical care with her passion for preventive health and community wellness.

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