What is the recommended dosage and usage of hydroxyzine for treating anxiety and itching?

Hydroxyzine Dosage and Usage for Anxiety and Itching

For treating anxiety and itching, hydroxyzine is recommended at 25 mg three times daily for adults with pruritus and 50-100 mg four times daily for anxiety, with lower doses for elderly patients and children.

Dosage Recommendations

For Pruritus (Itching)

• Adults: 25 mg three times daily or four times daily 1
• Children under 6 years: 50 mg daily in divided doses 1
• Children over 6 years: 50-100 mg daily in divided doses 1

For Anxiety

• Adults: 50-100 mg four times daily 1
• Children under 6 years: 50 mg daily in divided doses 1
• Children over 6 years: 50-100 mg daily in divided doses 1

Treatment Algorithm for Pruritus

First-Line Treatment

1. Mild or localized pruritus:

   • Hydroxyzine 25 mg three times daily 1
   • Apply emollients with cream or ointment-based, fragrance-free products 2
   • Consider topical corticosteroids:
     • Class I (clobetasol propionate, halobetasol propionate, betamethasone dipropionate) for body
     • Class V/VI (aclometasone, desonide, hydrocortisone 2.5%) for face 2

2. Moderate pruritus (widespread, intermittent):

   • Continue hydroxyzine 25 mg three to four times daily 1
   • Add topical moderate/high-potency steroids 2
   • Consider non-sedating antihistamines (cetirizine/loratadine 10 mg daily) during daytime 2

3. Severe pruritus (intense, widespread, constant):

   • Increase hydroxyzine dosage (up to recommended maximum)
   • Consider GABA agonists (pregabalin 25-150 mg daily or gabapentin 900-3600 mg daily) as second-line treatment 2
   • Consider dermatology referral 2

Treatment Algorithm for Anxiety

First-Line Treatment

1. Mild to moderate anxiety:

   • Start with hydroxyzine 50 mg four times daily 1
   • Adjust dosage according to response (up to 100 mg four times daily) 1

2. Moderate to severe anxiety:

   • Hydroxyzine 50-100 mg four times daily 1
   • Consider psychiatric referral if symptoms persist despite adequate treatment

Clinical Pearls and Considerations

Efficacy

• Hydroxyzine has demonstrated superior efficacy compared to placebo for generalized anxiety disorder, with significant improvement beginning in the first week of treatment 3, 4
• For pruritus, hydroxyzine is effective for histamine-mediated itching conditions such as chronic urticaria and allergic dermatoses 1

Side Effects and Monitoring

• Common side effects: Sedation/drowsiness (28% vs 14% with placebo), dry mouth (14% vs 5%), and weight gain (12% vs 10%) 3
• Sedation typically appears during the first week and progressively diminishes with continued treatment 3
• Monitor for excessive sedation, especially when initiating therapy or increasing dosage

Special Populations

• Elderly patients: Use lower doses (25 mg 2-3 times daily) due to increased sensitivity to anticholinergic effects and sedation
• Patients with hepatic impairment: Consider dose reduction
• Pregnant women: Use only when benefits clearly outweigh risks

Common Pitfalls to Avoid

1. Overlooking underlying causes: Always look for physical causes of pruritus before attributing it to psychogenic factors 2

2. Inadequate duration of treatment: Continue treatment for at least 4 weeks to achieve maximum benefit for anxiety 3, 4

3. Abrupt discontinuation: While hydroxyzine does not cause withdrawal symptoms like benzodiazepines, gradual tapering may be preferred for patients on long-term treatment 3

4. Drug interactions: Be cautious when combining with other CNS depressants, which may potentiate sedative effects

5. Overuse in elderly: Hydroxyzine has anticholinergic properties that may cause confusion or urinary retention in elderly patients

Hydroxyzine provides effective relief for both anxiety and pruritus with an acceptable side effect profile. The most common side effect is transient sedation, which typically improves with continued use. For anxiety, it offers an alternative to benzodiazepines without the risk of dependence.