What is the treatment for pruritus?

Treatment for Pruritus

For pruritus treatment, start with emollients and topical steroids, then progress to oral antihistamines, and finally to neuromodulators like gabapentin or pregabalin if symptoms persist.

Initial Assessment and First-Line Therapy

Identify Underlying Cause

• Determine if pruritus is localized or generalized
• Look for underlying conditions:
  • Dermatological: Xerosis, eczema, contact dermatitis
  • Systemic: Renal disease, hepatic disease, hematologic disorders
  • Drug-induced: Opioids, anticancer agents
  • Psychological factors

First-Line Treatments

1. Topical therapies:
   • Emollients: Essential for all pruritus, especially with dry skin 1
   • Topical corticosteroids:
     • Moderate to high-potency steroids for localized pruritus 1
     • Hydrocortisone butyrate 0.1% for inflammatory and pruritic manifestations 2
     • Mometasone furoate 0.1% or betamethasone valerate 0.1% ointment 1
   • Menthol 0.5%: Provides cooling sensation and relief 1
   • Lotions with urea or polidocanol: Soothe pruritus 1

Second-Line Therapy

Oral Antihistamines

• Non-sedating (daytime use):

  • Fexofenadine 180 mg daily
  • Loratadine 10 mg daily
  • Cetirizine 10 mg daily (mildly sedating) 1

• Sedating (nighttime use):

  • Diphenhydramine 25-50 mg daily
  • Hydroxyzine 25-50 mg daily 1

Caution: Long-term use of sedative antihistamines may predispose to dementia and should be avoided except in palliative care 1

Combination Therapy

• Consider H1 and H2 antagonists together (e.g., fexofenadine and cimetidine) 1

Third-Line Therapy

Neuromodulators

• GABA agonists:
  • Pregabalin (25-150 mg daily)
  • Gabapentin (900-3600 mg daily) 1
  • Particularly effective for neuropathic pruritus

Other Systemic Options

• Antidepressants:

  • Paroxetine, fluvoxamine, mirtazapine 1
  • Doxepin (also a potent antihistamine) 1

• Opioid antagonists:

  • Naltrexone (especially for opioid-induced pruritus) 1

• NK-1 receptor antagonist:

  • Aprepitant (for refractory cases, especially in cancer patients) 1

Disease-Specific Approaches

Uraemic Pruritus

• Ensure adequate dialysis and normalize calcium-phosphate balance
• Consider capsaicin cream, topical calcipotriol, or oral gabapentin
• BB-UVB (broadband ultraviolet B) phototherapy is effective 1

Hepatic Pruritus

• Rifampicin as first-line treatment
• Cholestyramine as second-line treatment
• Sertraline as third-line treatment 1

Cancer-Related Pruritus

• Paroxetine, mirtazapine, granisetron, or aprepitant 1

Special Considerations

Elderly Patients

• Start with emollients and topical steroids for at least 2 weeks
• Prefer moisturizers with high lipid content 1

Drug-Induced Pruritus

• For opioid-induced pruritus: naltrexone, methylnaltrexone, ondansetron 1
• For chloroquine-induced pruritus: prednisolone 10 mg, niacin 50 mg 1

Treatment Algorithm Based on Severity

Mild (Grade 1)

• Continue any current medications
• Apply topical moderate/high-potency steroids
• Reassess after 2 weeks 1

Moderate (Grade 2)

• Continue any current medications
• Apply topical moderate/high-potency steroids OR
• Start oral antihistamines OR
• Consider GABA agonists
• Reassess after 2 weeks 1

Severe (Grade 3 or intolerable Grade 2)

• Interrupt causative treatment if applicable
• Apply topical moderate/high-potency steroids OR
• Use oral antihistamines OR
• Start GABA agonists
• Reassess after 2 weeks 1

Common Pitfalls to Avoid

• Failing to identify and treat the underlying cause
• Using sedating antihistamines long-term in non-palliative settings
• Overlooking skin barrier repair with emollients
• Using crotamiton cream or calamine lotion, which have limited evidence 1
• Neglecting psychological factors that may exacerbate pruritus

By following this structured approach to pruritus management, clinicians can effectively address this distressing symptom while minimizing adverse effects and improving patient quality of life.