What are the treatment options for widespread itching in pregnancy?

From the Guidelines

Ursodeoxycholic acid (10-15mg/kg/day) is the recommended treatment for widespread itching in pregnancy, particularly in cases of intrahepatic cholestasis of pregnancy, as it has been shown to improve maternal symptoms and reduce the risk of adverse perinatal outcomes. The treatment of widespread itching during pregnancy should begin with non-medication approaches, including wearing loose cotton clothing, taking cool baths with colloidal oatmeal, using mild unscented soaps, and applying moisturizers frequently 1. For mild to moderate symptoms, topical treatments are preferred, including calamine lotion, menthol 1% in aqueous cream, or low-potency corticosteroids like hydrocortisone 1% cream applied sparingly to affected areas twice daily for up to two weeks. If these measures are insufficient, oral antihistamines may be used, with first-generation options like diphenhydramine (25-50mg every 4-6 hours) or chlorpheniramine (4mg every 4-6 hours) being considered safest, though they may cause drowsiness. Second-generation antihistamines like cetirizine (10mg daily) or loratadine (10mg daily) have less sedation but less pregnancy safety data.

Some key points to consider when treating widespread itching in pregnancy include:

• Identifying and treating any underlying causes of itching, such as cholestasis, pemphigoid gestationis, or pruritic urticarial papules and plaques of pregnancy (PUPPP) 1.
• Using ursodeoxycholic acid (10-15mg/kg/day) as the first-line treatment for intrahepatic cholestasis of pregnancy, as it has been shown to improve maternal symptoms and reduce the risk of adverse perinatal outcomes 1.
• Considering alternative treatments, such as S-adenosyl-methionine or cholestyramine, for patients who cannot take ursodeoxycholic acid or who have continued symptoms on the maximum dosage 1.
• Monitoring patients with severe or persistent itching for potential complications, such as preterm birth or stillbirth, and considering early delivery in cases where the risk of adverse outcomes is high 1.

It's essential to note that the treatment of widespread itching in pregnancy should be individualized and based on the severity of symptoms and the presence of any underlying conditions. Severe or persistent itching warrants medical evaluation as it may indicate a condition requiring specific treatment or monitoring for maternal and fetal well-being.

From the Research

Treatment Options for Widespread Itching in Pregnancy

• The treatment of pruritus in pregnancy requires prudent consideration due to potential effects on the fetus 2, 3.
• Topical and systemic treatments depend on the underlying aetiology of pruritus and the stage and status of the skin 2, 3.
• Emollients, topical anti-pruritics, and topical corticosteroids appear to be the safest options for localized forms of pruritus in pregnancy 2.
• Systemic treatments, such as systemic corticosteroids and a restricted number of antihistamines, may be administered in severe cases 2, 3.
• Ursodeoxycholic acid has been shown to be effective and safe in treating intrahepatic cholestasis of pregnancy, a condition characterized by intense pruritus 4, 5, 6.
• UV phototherapy may be used in severe and generalized forms of pruritus in pregnancy, but with caution due to potential long-term effects 2, 3.

Specific Treatments for Intrahepatic Cholestasis of Pregnancy

• Ursodeoxycholic acid has been shown to reduce pruritus, improve biochemical abnormalities, and improve fetal outcomes in patients with intrahepatic cholestasis of pregnancy 5, 6.
• The dosage of ursodeoxycholic acid used in studies ranged from 8-10 mg/kg body weight daily to 1 g per day orally 5, 6.
• Cholestyramine has also been used to treat intrahepatic cholestasis of pregnancy, but ursodeoxycholic acid has been shown to be more effective and safer 5.

Considerations for Treatment

• The severity of the underlying disease and the potential effects on the fetus must be considered when selecting a treatment for pruritus in pregnancy 2, 3.
• Systemic treatments should be used with caution and under close monitoring due to potential risks to the fetus 2, 3.
• Topical treatments are generally considered safer, but may not be effective for severe or generalized pruritus 2.