What is the recommended treatment for pruritus in an inpatient?

Treatment of Pruritus in Inpatients

For inpatient pruritus management, emollients and topical steroids should be used as first-line therapy, with specific systemic treatments added based on the underlying cause. 1

Initial Assessment and First-Line Treatment

First-Line Topical Therapy

• Emollients: Apply skin-type-adjusted moisturizers at least once daily to the whole body 1
• Topical steroids:
  • Hydrocortisone 1% cream for mild cases (apply to affected area not more than 3-4 times daily) 2
  • Clobetasone butyrate for more significant pruritus 1
• Topical menthol: Provides cooling sensation that can relieve itch 1, 3

Avoid These Topical Agents

• Do not use crotamiton cream (strong recommendation) 1
• Do not use topical capsaicin or calamine lotion in generalized pruritus 1
• Avoid alcohol-containing lotions or gels 1

Treatment Algorithm Based on Underlying Cause

1. Generalized Pruritus of Unknown Origin (GPUO)

• First-line: Emollients and topical steroids 1
• Second-line options:
  • Topical doxepin (limit to 8 days, 10% body surface area, 12g daily) 1
  • Non-sedative antihistamines: fexofenadine 180mg, loratadine 10mg, or cetirizine 10mg 1
  • Consider H1 and H2 antagonists in combination (e.g., fexofenadine and cimetidine) 1
• Third-line options:
  • Gabapentin, pregabalin, mirtazapine, paroxetine, fluvoxamine, naltrexone, ondansetron, or aprepitant 1, 3
  • Sedative antihistamines (e.g., hydroxyzine) only for short-term or palliative use 1, 4

2. Drug-Induced Pruritus

• Opioid-induced:
  • First-line: Naltrexone (if opioid therapy cannot be discontinued) 1
  • Alternatives: Methylnaltrexone, ondansetron, droperidol, mirtazapine, or gabapentin 1
• Postoperative pruritus: Diclofenac 100mg rectally 1
• Chloroquine-induced: Prednisolone 10mg, niacin 50mg, or combination; alternatively dapsone 1

3. Hepatic/Cholestatic Pruritus

• First-line: Rifampicin 1, 4
• Second-line: Cholestyramine 1, 4
• Third-line: Sertraline 1
• Fourth-line: Naltrexone or nalmefene 1
• Do not use gabapentin for hepatic pruritus 1

4. Uremic Pruritus

• First-line: Gabapentin 1, 4
• Second-line: UVB phototherapy 1
• Alternative options: Capsaicin cream, topical calcipotriol 4

5. Elderly Patients with Pruritus

• First-line: Emollients and topical steroids for at least 2 weeks (to exclude asteatotic eczema) 1
• Prefer: Moisturizers with high lipid content 1
• Consider: Gabapentin for persistent symptoms 1
• Avoid: Sedative antihistamines (may predispose to dementia) 1, 4

Special Considerations for Inpatients

• Secondary infections: Take bacterial swabs and start appropriate antibiotics if impetiginization occurs (commonly Staphylococcus aureus) 1
• Fissures: Treat with propylene glycol 50% in water under plastic occlusion, followed by hydrocolloid dressing; alternatively, antiseptic baths with potassium permanganate (1:10,000) 1
• Severe pruritus: Consider referral to dermatology if symptoms persist despite initial management 1

Pitfalls to Avoid

• Overtreatment: Excessive cleaning and multiple medications can worsen symptoms 4
• Long-term sedative antihistamines: May increase dementia risk except in palliative care 4
• Inadequate moisturization: Dry skin worsens pruritus and can lead to eczematous changes 1, 3

Remember that chronic pruritus significantly impacts quality of life 5, 3 and requires prompt, effective management in the inpatient setting to improve patient comfort and outcomes.