What is a good antihistamine (anti-histamine) for pruritus (itching)?

From the Guidelines

For pruritus (itching), the most effective antihistamine is fexofenadine 180 mg, loratadine 10 mg, or cetirizine 10 mg, as they are recommended by the British Association of Dermatologists' guidelines for the investigation and management of generalized pruritus in adults without an underlying dermatosis 1.

Key Considerations

• Nonsedative antihistamines such as fexofenadine and loratadine are generally preferred due to their efficacy and safety profile.
• Cetirizine, a mildly sedative agent, can be considered as an alternative option.
• Sedative antihistamines like hydroxyzine may be used in the short-term or palliative setting, but their use should be limited due to potential side effects.

Treatment Approach

• Antihistamines should be taken regularly, rather than as needed, to achieve maximum effectiveness.
• It is essential to allow 1-3 days for the antihistamines to take effect.
• If the itching persists beyond a week, is severe, or is accompanied by other symptoms, consultation with a healthcare provider is necessary to determine the underlying cause and appropriate treatment.

Additional Options

• Other medications such as paroxetine, fluvoxamine, mirtazapine, naltrexone, butorphanol, gabapentin, pregabalin, ondansetron, or aprepitant may be considered for the treatment of pruritus, but their use should be guided by the British Association of Dermatologists' guidelines and individual patient needs 1.
• The Society for Immunotherapy of Cancer (SITC) toxicity management working group also recommends the use of antihistamines, such as cetirizine or loratadine, for the management of pruritus associated with immune checkpoint inhibitors 1.

From the FDA Drug Label

PRINCIPAL DISPLAY PANEL-500'S COUNT Rising® 16571-402-50 Original Prescription Strength Cetirizine Hydrochloride Tablets USP 10 mg 6 yrs & older Antihistamine ALLERGY Indoor & Outdoor Allergies 24 Hour Relief of: •Sneezing •Runny Nose •Itchy, Watery Eyes •Itchy Throat or Nose PRINCIPAL DISPLAY PANEL - 28.4 g Tube Carton TopCare health ™ MAXIMUM STRENGTH • OUR PHARMACISTS RECOMMEND • NDC 36800-099-02 Hydrocortisone 1% Cream ANTIPRURITIC (ANTI-ITCH) Intensive Healing Formula † NET WT 1 OZ (28.4 g)

Cetirizine and Hydrocortisone can be used for itching.

• Cetirizine is an oral antihistamine that provides 24-hour relief of itching associated with allergies 2.
• Hydrocortisone is a topical cream that is used as an antipruritic (anti-itch) for intensive healing 3.

From the Research

Antihistamines for Pruritus

• Antihistamines are often used to treat pruritus associated with atopic dermatitis (AD) despite lack of evidence for their efficacy 4
• The American Academy of Dermatology does not recommend the general use of antihistamines in the management of AD, although the value of short-term sedating antihistamine use for insomnia secondary to itch is recognized 4

Effective Antihistamines

• Loratadine is a long acting antihistamine which has a high selectivity for peripheral histamine H1-receptors and lacks the central nervous system depressant effects often associated with some of the older antihistamines 5
• Cetirizine has proven to be effective in the treatment of various forms of urticaria and it reduces the pruritus of atopic eczema 6
• Cetirizine is a safe second generation antihistamine, effective especially in the treatment of urticaria and reduces significantly the pruritus of atopic dermatitis 6

Dosage and Administration

• Loratadine is usually administered at a dose of 10mg once daily 5
• Cetirizine has been recommended at doses higher than 10 mg (up to 40 mg) to achieve the best benefit in the treatment of atopic eczema 6
• An individual dosage should be chosen based on the severity of symptoms 6

Limitations and Controversies

• There is no high-level evidence to suggest that nonsedating antihistamines reduce itch in patients with AD or that sedating antihistamines provide benefit in controlling AD symptoms (except perhaps sleep and AD comorbidities, such as allergic rhinitis) 4
• The evidence for the use of antihistamines in the treatment of atopic dermatitis is inconclusive 7
• More clinical trials examining the therapeutic efficacy of antihistamines, especially with the newer nonsedating antihistamines, are necessary to elucidate their role in the treatment of AD 7