From the Guidelines
Managing neuropathic itch requires a multi-faceted approach targeting the underlying nerve dysfunction, with first-line treatments including topical medications such as lidocaine 5% patches or creams, capsaicin 0.075-0.1% cream, or compounded formulations containing amitriptyline 2%, ketamine 0.5%, and lidocaine 5%. For oral medications, anticonvulsants like gabapentin (starting at 300mg daily, gradually increasing to 300-600mg three times daily) or pregabalin (starting at 75mg twice daily, increasing as needed to 150-300mg twice daily) are often effective, as supported by recent studies 1. Tricyclic antidepressants such as amitriptyline (10-25mg at bedtime, increasing gradually if needed) can also help.
Some key points to consider in the management of neuropathic itch include:
- The use of topical capsaicin, which has been found to relieve neuropathic pain 1
- The potential benefits of gabapentin and pregabalin in treating neuropathic pain, as supported by multiple high-quality studies 1
- The importance of a thorough evaluation to identify the underlying cause of neuropathic itch and to rule out other conditions that may be contributing to the symptoms
- The need for a multidisciplinary approach, involving multiple specialties, to manage the condition holistically, as suggested by recent guidelines 1
Non-pharmacological approaches, such as applying cool compresses, wearing loose cotton clothing, maintaining skin hydration with fragrance-free moisturizers, and avoiding hot showers, can also be beneficial. Cognitive behavioral therapy and mindfulness techniques may help break the itch-scratch cycle. These treatments work by modulating nerve signal transmission, reducing neuronal hyperexcitability, or blocking inflammatory mediators that trigger itch sensations. Treatment often requires patience and may need adjustment over time, as neuropathic itch can be challenging to completely resolve.
From the Research
Management of Neuropathic Itch
To manage neuropathic itch, several treatment options are available, including:
- General antipruritic measures
- Local or systemic pharmacotherapy
- Various physical modalities
- Surgery, in cases of spinal or cerebral mass, abscess, or hemorrhagic stroke, and may provide decompression in entrapment neuropathies 2
Treatment Options
Some specific treatment options for neuropathic itch include:
- Anticonvulsants such as gabapentin and pregabalin, which are commonly used to relieve itching in patients with chronic kidney disease (CKD) stages 4 and 5 3
- Topical anesthetics and capsaicin, which have been shown to have antipruritic effects 2, 4
- Local treatment agents such as doxepin, tacrolimus, and botulinum toxin A, which may also provide relief from neuropathic itch 2
Diagnosis and Treatment Approach
Diagnosis of neuropathic itch is often difficult and depends on patient history, imaging, and neurophysiologic studies, and other causes of chronic itch should be excluded 4 A holistic approach to treatment, including collaboration with a neurologist, is recommended to determine the best course of treatment for each individual patient 2 The management of neuropathic itch can be demanding, and the majority of interventions are not curative, but symptomatic treatment can provide relief in many cases 4, 5