What is the management of pruritis?

From the Guidelines

The management of pruritus should start with identifying and treating any underlying conditions, and for immediate relief, non-pharmacological approaches such as using mild, fragrance-free soaps and applying moisturizers regularly should be used, followed by pharmacological treatments like topical corticosteroids or antihistamines as needed, according to the most recent guidelines 1.

Key Considerations

• Identify and treat underlying conditions such as dry skin, allergies, liver or kidney disease, or skin infections.
• Non-pharmacological approaches include:
  • Using mild, fragrance-free soaps
  • Applying moisturizers regularly
  • Taking lukewarm (not hot) showers
  • Wearing loose cotton clothing
  • Avoiding known irritants
• Pharmacological treatments:
  • Topical corticosteroids like hydrocortisone 1% cream for inflammatory conditions
  • Antihistamines such as diphenhydramine (25-50mg every 6 hours) or cetirizine (10mg daily) for allergic causes
  • Gabapentin (starting at 300mg daily and titrating up) or pregabalin for severe or persistent pruritus

Specific Recommendations

• For mild or localized pruritus, topical moderate/high-potency steroids or oral antihistamines may be used 1.
• For intense or widespread pruritus, topical moderate/high-potency steroid or oral antihistamines or GABA agonists (pregabalin/gabapentin) may be considered 1.
• Persistent pruritus warrants medical evaluation as it may indicate serious underlying conditions requiring specific treatment 1.

Important Considerations

• Scratching should be avoided as it can lead to skin damage, infection, and a worsening itch-scratch cycle.
• Patients with generalized pruritus should receive self-care advice and emollients, followed by a short course of nonsedating antihistamine if needed, and should be referred to secondary care if there is diagnostic doubt or if primary care management does not relieve symptoms 1.

From the FDA Drug Label

Uses temporarily relieves itching associated with minor skin irritations, inflammation, and rashes due to: eczema psoriasis poison ivy, oak, sumac insect bites detergents jewelry cosmetics soaps seborrheic dermatitis temporarily relieves external anal and genital itching Directions for itching of skin irritation, inflammation, and rashes: adults and children 2 years of age and older: apply to affected area not more than 3 to 4 times daily The management of pruritis includes applying hydrocortisone (TOP) to the affected area not more than 3 to 4 times daily for adults and children 2 years of age and older, and asking a doctor for children under 2 years of age or under 12 years of age for external anal and genital itching 2 2.

• For external anal and genital itching, clean the affected area with mild soap and warm water and rinse thoroughly before applying.
• Gently dry by patting or blotting with toilet tissue or a soft cloth before applying.

From the Research

Management of Pruritis

• The management of pruritis involves a combination of trigger avoidance, liberal emollient use, limiting water exposure, and administration of oral antihistamines and topical corticosteroids 3.
• In some cases, the use of H1-antihistamines in combination with topical corticosteroids may have a synergistic effect in treating pruritus, particularly in atopic dermatitis 4.
• For chronic pruritus, steroid-sparing agents such as azathioprine may be used to treat recalcitrant itch, especially in cases of urticarial dermatitis 5.
• A thorough skin examination and evaluation for systemic causes, including laboratory tests and imaging studies, are essential in determining the underlying cause of pruritus and guiding treatment 3, 6.
• In cases where the evaluation for multiple etiologies of pruritus is ambiguous, clinicians may consider psychogenic etiologies and consultation with a specialist 3.

Treatment Options

• Topical corticosteroids are commonly used to treat pruritus, especially in cases of atopic dermatitis 4.
• Oral antihistamines may be used to relieve pruritus, especially in cases of allergic reactions or urticarial dermatitis 3, 5.
• Device-based physical therapies, such as phototherapy, may be used to treat cutaneous pruritus 7.
• Medications that act on the itch-perception processing pathway, such as those targeting the skin, peripheral sensory nerves, spinal cord, or brain, may be used to treat cutaneous pruritus 7.

Diagnostic Approach

• A structured history and physical examination are essential in narrowing down the number of potential differential diagnoses for pruritus 6.
• Laboratory tests, such as complete blood count, liver function tests, and thyroid-stimulating hormone test, may be used to evaluate for systemic causes of pruritus 3.
• Imaging studies, such as chest radiography, may be used to evaluate for underlying conditions that may be causing pruritus 3.