| Abstract|| |
Uremic pruritus is an uncomfortable feeling of discomfort in the skin. When it becomes severe, pruritus leads to sleep disorders, anxiety, depression, and social dysfunction, affecting the quality of life of patients. Pruritus is experienced by approximately 50%–90% of hemodialysis (HD) patients. The main objective of the study was to evaluate the effectiveness of baby oil therapy for uremic pruritus in HD patients and to determine the association between severity of uremic pruritus and selected demographic variables of HD patients. The research design adopted for this study was an experimental, pretest and posttest control group design. The population was HD patients in the age-group of 40–60 years. The conceptual framework of this research was based on the general system theory model. Purposive sampling technique was used and the sample size was 120 HD patients. Results showed that pruritus score was reduced up to 23.7% among experimental group HD patients with pruritus, whereas in the control group, the reduction score was only about 1.3%. It shows the effectiveness of massage with baby oil on uremic pruritus among patients undergoing HD treatment.
|How to cite this article:|
Singh VS, Vinayadev V. Effectiveness of Baby Oil Therapy for Uremic Pruritus in Hemodialysis Patients. Saudi J Kidney Dis Transpl 2021;32:163-9
|How to cite this URL:|
Singh VS, Vinayadev V. Effectiveness of Baby Oil Therapy for Uremic Pruritus in Hemodialysis Patients. Saudi J Kidney Dis Transpl [serial online] 2021 [cited 2021 Jul 31];32:163-9. Available from: https://www.sjkdt.org/text.asp?2021/32/1/163/318518
| Introduction|| |
Dialysis is the process used to remove fluid and uremic waste products from our body when the kidneys are unable to do so. Hemodialysis (HD) is the most commonly used method of dialysis. Vivekhanand Jha, the Executive Director of The George Institute for Global Health reported that worldwide about 2.4 million people are on dialysis. Every year, estimated new patients develop the end-stage renal disease (ESRD). In India, it is about 200,000. Although 70%–80% of kidney patients actually start dialysis, among them about two-thirds of the starters withdraw from treatment and are condemned to death, due to limited resources. When compared to the US (6%) and other countries (8%), India’s demand for dialysis is increasing at a rate of 31%.
Uremic pruritus is also known as chronic kidney disease (CKD) associated pruritus (CKD-associated pruritus). When both kidneys stop working (renal failure), the blood urea level will be increased which is referred to as uremia. The common problem for patients with chronic renal failure or ESRD is pruritus or itch, which affects about one-third of dialysis patients. Patients on HD are more common than those on continuous ambulatory peritoneal dialysis. Uremic pruritus is not associated with gender, age, ethnicity, duration of dialysis, or cause of renal failure and it does not arise when uremia is due to acute renal failure.
| Incidence and Prevalence of Chronic Kidney Disease, Dialysis and Uremic Pruritus|| |
Varma in his published paper reported that the prevalence of CKD in India is between 8% and 10% of the adult population, the prevalence rate of CKD patients in stage three is about 6.3%. Modi and Jha reported that 229 per million population are at an age-adjusted incidence of end-stage kidney disease. This is more than double 100 per million over a long time. Agarwal et al conducted a study among the south Delhi urban population with CKD and reported stage 3 prevalence of 0.785%. A screening and early evaluation of kidney disease study by Singh et al reported that the mean age of the population was 45.22 ± 15.2 years.
Global Burden of Disease study reported that during 1990 CKD was ranked 27th in the list of causes of the total number of deaths worldwide and it rose to 18th in 2010. Worldwide, more than two million people receive treatment with dialysis or a kidney transplant to stay alive, yet this statistics may only represent 10% of people who actually need treatment to survive. Only 20% of kidney failure patients among two million people are treated in about 100 developing countries that make up over 50% of the world population.
The typical feature of uremic pruritus is bouts of itching that tend to worsen at night and may lead to sleep disturbances. The itch may be generalized or localized to one area, mainly the back, abdomen, head and/or arms, the pruritus is lowest the day after dialysis and peaks two days afterward in HD patients. The skin of the HD patients may appear normal or dry (xerosis), with few to numerous scratch marks and/or picked sores. Uremic pruritus is considered to be due to a combination of factors including dryness of skin, reduced sweating, abnormal metabolism of calcium and phosphorus, elevated parathyroid hormone, accumulation of toxins, sprouting of new nerves, systemic inflammation, co-existing medical problems, particularly diabetes mellitus, and liver disease. Some patients may have acquired perforating collagenosis.
The first step in the treatment of uremic pruritus is to make the best of dialysis efficacy. Dry skin can be treated by using nonsoap cleansers and applying emollients such as sorbolene cream or petrolatum several times daily. Menthol and camphor can also be added to an emollient to cool the skin and relieve the itch. Frequent applications of topical capsaicin may reduce localized itch if tolerated. Ultraviolet B phototherapy is the treatment of choice for severe uremic pruritus. Oral antihistamines and systemic steroids are not effective. Several treatments that have been reported to help some individuals include gabapentin and pregabalin, nalfurafine (opioid agonist), activated charcoal, thalidomide, cholestyramine, ondansetron, etc. Many natural external applicators are also available to reduce the itching in pruritus.
| Background of the Study|| |
Uremic pruritus is a regular incapacitating problem in patients on HD, and its prevalence has been reported to be between 30% and 90% in different studies. Uremic pruritus affects 50%–90% of HD patients, it is one of the most common medical problems in this population. Pruritus can create skin infection, desquamation, pathological skin change, sleep disorder, anxiety, depression, and social dysfunction.
The role of inflammation and pro-inflammatory factors in the development of pruritus, specify that uremic pruritus may be a systemic phenomenon due to dysfunctional regulation of immunologic parameters. Between 30% and 60% of patients with ESRD have inflammatory status of varied etiology, and the presence of inflammation can be confirmed by C-reactive protein levels.
Uremic pruritus in HD patients is associated with a 17% increase in mortality. Research showed that using emollients, phototherapy, and acupuncture significantly helps in reducing uremic pruritus. Nonpharmacological interventions are effective for HD patients with uremic pruritus. Emollients were very effective, readily available, and cost-effective intervention in comparison to other methods to improve pruritus symptoms.
Baby oil is an excellent product formulated for baby’s sensitive skin. Baby oil is nothing but perfumed mineral oil, which has a long and rich history, with many changes over the years. Baby oil is not just for babies, it is actually very useful to all. The composition of regular baby oil includes mineral oil (this is liquid paraffin obtained from petroleum which is actually fine for the skin), aloe vera extract (this is a concentrated form of aloe vera gel). It may be processed to remove out certain chemicals which might be allergic to baby’s skin. Vitamin E (Vitamin E is a great antioxidant and protects the skin from free radical damage). Vitamin A is used to treat common skin problems like dry skin and chapped lips. Honey is mainly used for its antiseptic properties. There are many other ingredients in smaller proportions such as natural and artificial aromatic compounds, emollients, and other substances.
A recent review article reported that in few reviews, they have tested an aloe-containing aqueous gel application twice a day, and shown that it has an effective improvement on patient’s pruritus, dryness, and scratches. However, after two weeks, only the improvement in the scratches was maintained. Another study conducted in Taiwan reported that commercially available baby oil applied once daily, even baby oil was applied at various temperatures (10°C–15°C and 24°C–25°C), was effective in improving the patients’ pruritus.
From the literature reviews and by the researcher’s own observation, they found that the application of baby oil once a day is very effective in reducing the itching in uremic pruritus and improved their sleep quality. In the context of relation between uremic pruritus and dialysis, few studies have been performed. The objective of this study was to evaluate the effectiveness of baby oil therapy on reducing uremic pruritus, in patients on HD.
| Objectives of the Study|| |
We aimed to evaluate the effectiveness of baby oil therapy for uremic pruritus in HD patients, both experimental and control groups, and to determine the association between severity of uremic pruritus and selected demographic variables of HD patients in these groups.
| Methods|| |
The main focus of this study was to assess the effectiveness of baby oil therapy on pruritus among HD patients. The research design adopted was an experimental pre-test and post-test control group design. Sixty patients in the intervention group and 60 patients in the control group were selected by purposive sampling technique. Only patients who have pruritus itch because of HD were included in this study. During the research period, medicines prescribed only for itch were stopped unless in an emergency, and regular medication was allowed. Descriptive and inferential statistics were used to analyze the data and to test the study hypothesis.
The numerical rating scale was used to assess the severity of pre- and post-uremic pruritus itch. It is a standardized tool. The scoring key is given in [Table 1].
This study was conducted in a reputed Hospital at Coimbatore, Tamil Nadu, India. The data collection was done in the selected ward and nephrology outpatient department (OPD) every week from Monday to Saturday after getting informed consent from the patients. The objective of the study was explained to the medical officer and other paramedical personnel. Based on the criteria for sample selection, 12 subjects a day from the experimental group were selected and the intervention was given for 10 days.
Adequate privacy was provided. On the 1st day of data collection, the demographic data and preassessment of itch score (NRS for pruritus) of the subjects were assessed. After thorough hand washing, the patient were placed in a comfortable position, commercially available baby oil with mineral oil and Vitamin E was applied only in the itchy area and gentle massage was also given. The quantity of baby oil used was according to the affected area and it was different for each patients. Baby oil massage was applied for 15 min (once in a day) for 10 consecutive days. The same baby oil was used for all the patients in the experimental group and it was supplied to the patient by the investigator. The post-assessment of pruritus itch score was obtained at the end of the 10th day. The opinion questionnaire regarding the intervention was also tested at the end of the 10th day. The present study was limited to four weeks and thus the data collection period was only for 10 days.
| Results|| |
Among experimental group
In preassessment, none of them were having no itch, 23.3% of them had mild itch, 53.4% of them had the moderate itch and 23.3% of them had severe itch. After the massage with baby oil, 20% of the patients had no itch, 56.7% of them had mild itch, 23.3% of them had moderate itch and, none of them had severe/ unbearable itch [Figure 1]. Statistically, there was a significant difference. Statistical significance was calculated using the Chi-square test [Table 2].
|Figure 1: Comparison of pre- and post-test level of itch score among study participants.|
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|Table 2: Preassessment and postassessment level of pruritus score in experimental and control group.|
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Among control group
In preassessment, none of them had no itch, 23.3% of them had mild itch, 60% of the study participants had moderate itch and 16.7% of them had severe itch. In posttest, none of them had no itch, 23.3% of them had mild itch, 66.7% of them had moderate itch and 10.0% of them had severe itch [Figure 1]. Statistically, there was no significant difference. Statistical significance was calculated using the Chi-square test [Table 2].
Experimental group HD patients who had uremic pruritus had reduction in pruritus score of about 23.7% (2.37), whereas, in the control group, patients had reduced pruritus score of only about 1.3% (0.13) [Figure 2] and [Table 3].
Differences between preassessment and postassessment score were analyzed using proportion with 95% confidence interval (CI) and mean difference with 95% CI. It shows the effectiveness of massage with baby oil on uremic pruritus among patients undergoing HD treatment.
The association between postassessment level of pruritus itch and patient’s demographic variables was assessed. Elders (χ2 = 10.26, P = 0.01), lesser duration of itch (χ2 = 9.14 P = 0.03, and patients having sleep disturbances (χ2 = 8.10, P =0.04 had greater reduction of itch than others. Statistical significance was calculated using the Chi-square test. Hence, the hypothesis (H2) was accepted.
| Discussion|| |
Pruritus is caused by chronic renal failure and it is the most common internal systemic cause of itching. It is the most frustrating and disabling symptom in the skin with a negative impact on patients’ quality of life including sleeplessness and mood disturbances, worsening prognosis, and increasing the risk of death and the cost of health-care. More or less, 50%–90% of HD patients experienced trouble with pruritus. Uremic pruritus is caused by uremic toxins. Zucker et al indicated that 61% of uremic patients experience sleeplessness because of pruritus, and 44% have their sleep disrupted by itchy sensations, in some cases leading to emotional anxiety and depression.
Drug therapy is a common clinical treatment method for HD associated pruritus. The treatment includes antihistamines, capsaicin, opioids, and pramoxine. HD modification is also used in some patients. Common alternative therapy to drug treatment includes the application of emollients, ultraviolet irradiation, and acupuncture. The main focus of this study is to assess the effectiveness of baby oil therapy on pruritus among HD patients at male and female surgical ward and nephrology OPD in selected hospitals.
In our study, in the experimental group in pretest, patients had 4.97 pruritus itch score and in posttest they had 2.60 pruritus itch score, with a difference of 2.37. This difference is statistically significant. It was confirmed using student paired t-test. This is also supported by a study conducted by Lin et al, who reported that baby oil therapy is effective for uremic pruritus in HD patients. The study participants in both experimental groups 1 and 2 were treated with chilled and un-chilled baby oil, respectively, for 15 min at least once in a day for three weeks. No intervention and only standard care were given to the control group. There was significantly larger anti-pruritic effect in subjects treated with either chilled or un-chilled baby oil than in those who received routine standard care. This study validated that chilled or non-chilled baby oil therapy is effective in relieving pruritus among HD patients.
This nursing intervention is a health promotion activity which the patient and the community can afford. Low-cost treatment is an economic advantage in developing counties like India. There is role for prevention; long-term care and follow up, hence such preparations have to be taught to the HD patients having itch and their family members to practice and to benefit from the long-standing effects in combating pruritus itch. Hence, nurses have to realize their responsibility in creating awareness regarding complimentary alternative medicine. The inferences from the present study can be considered by the nursing health professionals and this intervention can be applied as an alternative therapy for the pruritic itch.
| Conclusions|| |
There was an association between the levels of pruritus itch and duration, age and sleep quality of the patients with the selected demographic variables. Justification for undertaking this study was to relieve the clients from pruritus itching by massage with baby oil at least once a day for 15 min and to determine its effectiveness so that this baby oil therapy can be used in future for all HD patients with pruritus itch for health promotion.
Applying baby oil is a simple, safe, inexpensive, and easily administered treatment for itchy skin in HD patients. By preventing or reducing uremic pruritus, baby oil treatment may also improve the quality of life in this patient group. The application of baby oil for pruritus itch is safe and inexpensive. By preventing or reducing uremic pruritus, baby oil therapy has a great impact on the quality of life in HD patients with uremic pruritus.
Conflict of interest: None declared.
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Vimala Suryanarayan Singh
Syed Sadiq General Practitioner Clinic, Dubai
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]