What is the treatment for pruritus?

From the Guidelines

Bezafibrate is recommended as the first-line pharmacological treatment for moderate to severe pruritus in patients with sclerosing cholangitis and other forms of fibrosing cholangiopathy, as it has shown a clear-cut benefit in alleviating moderate to severe itch in people with PSC and PBC treated with UDCA 1.

Treatment Options

• For patients with pruritus, the following treatments can be considered:
  • Bezafibrate as first-line treatment, which has been shown to be effective in alleviating moderate to severe itch in people with PSC and PBC treated with UDCA 1
  • Rifampicin as second-line treatment, which may induce drug-induced hepatitis after 4-12 weeks in up to 12% of cholestatic patients 1
  • Naltrexone as third-line treatment, starting at very low doses (12.5 mg) to avoid early side effects resembling an opioid withdrawal syndrome 1

Lifestyle Modifications

• General recommendations for patients suffering from cholestasis-associated pruritus include:
  • Using emollients to prevent dryness of skin
  • Avoiding hot baths or showers
  • Using cooling gels (e.g., menthol gels) for affected skin areas
  • Keeping nails shortened

Important Considerations

• The molecular pathogenesis of cholestatic pruritus has not been fully unravelled, but major pathophysiological insights have been achieved during the last decade 1
• Liver transplantation is effective, but should only be considered when all available interventions have proven ineffective 1
• It is essential to exclude relevant bile duct strictures in large duct sclerosing cholangitis as the cause of progressive pruritus, and if present and reachable, relevant strictures should be treated by endoscopic balloon dilation (or stenting, if balloon dilation alone is insufficient) after brushing 1

From the FDA Drug Label

Directions for itching of skin irritation, inflammation, and rashes: adults and children 2 years of age and older: apply to affected area not more than 3 to 4 times daily Uses temporarily relieves itching associated with minor skin irritations, inflammation, and rashes due to: eczema psoriasis poison ivy, oak, sumac insect bites detergents jewelry cosmetics soaps seborrheic dermatitis temporarily relieves external anal and genital itching

The treatment for pruritus is to apply hydrocortisone (TOP) to the affected area not more than 3 to 4 times daily for adults and children 2 years of age and older. For children under 2 years of age, a doctor should be consulted. Key points include:

• Application frequency: 3 to 4 times daily
• Age restrictions: children under 2 years of age should consult a doctor
• Uses: temporarily relieves itching associated with minor skin irritations, inflammation, and rashes due to various causes 2 2

From the Research

Treatment for Pruritus

The treatment for pruritus, also known as itch, can vary depending on the underlying cause of the condition. According to 3, first-line treatments for itch include:

• Topical therapies, such as emollients, mild cleansers, topical anaesthetics, steroids, calcineurin inhibitors, and coolants
• Systemic therapies, such as non-sedating antihistamines, sedating antihistamines, anticonvulsants, antidepressants, mu-opioid antagonists, kappa-opioid agonists, and phototherapy

Topical Treatments

Topical treatments are often used to manage pruritus, especially for inflammatory causes. As stated in 4, first-line treatment for inflammatory chronic pruritus includes:

• Topical anti-inflammatory therapies, such as hydrocortisone, triamcinolone, or tacrolimus ointment
• Topical neuropathic agents, such as menthol, pramoxine, or lidocaine, for neuropathic causes

Systemic Treatments

Systemic treatments may be necessary for more severe or chronic cases of pruritus. According to 3, systemic therapies can include:

• Non-sedating antihistamines, such as cetirizine or fexofenadine, for conditions like urticaria
• Sedating antihistamines, such as diphenhydramine, to help break the itch-scratch cycle
• Anticonvulsants, such as gabapentin, for neuropathic pruritus
• Antidepressants, such as sertraline or doxepin, for neuropathic pruritus
• Mu-opioid antagonists, such as naltrexone, for chronic pruritus

Efficacy of Treatments

The efficacy of different treatments for pruritus can vary. As reported in 5, a review of oral H1 antihistamines as 'add-on' therapy to topical treatment for eczema found:

• Fexofenadine probably leads to a small improvement in patient-assessed pruritus
• Cetirizine was no better than placebo in terms of physician-assessed clinical signs or patient-assessed symptoms
• Loratadine was not found to be more beneficial than placebo

Network Meta-Analysis

A network meta-analysis of topical anti-inflammatory treatments for eczema, as reported in 6, found:

• Potent topical corticosteroids, tacrolimus, and ruxolitinib were ranked as the most effective treatments
• Mild topical corticosteroids, roflumilast, and crisaborole were ranked as the least effective treatments
• Tacrolimus and crisaborole were found to be most likely to cause local application-site reactions
• No evidence was found for increased skin thinning with short-term use of topical corticosteroids, but an increase was found with longer-term use.