What is the treatment for psychogenic itching?

Treatment for Psychogenic Itching

For psychogenic itching (functional itch disorder), the most effective approach is a combination of psychosocial interventions including education, relaxation techniques, cognitive restructuring, and behavior modification, along with appropriate pharmacotherapy targeting underlying psychological factors. 1

Diagnosis of Psychogenic Itching

Before initiating treatment, confirm the diagnosis using the French Psychodermatology Group criteria:

Compulsory criteria (all required):

• Chronic pruritus (>6 weeks)
• No somatic cause (cutaneous or systemic)
• Predominance during rest or inaction

Optional criteria (at least 3 required):

• Generalized pruritus
• Variations in intensity associated with stress
• Chronological relationship with psychological events
• Pruritus worse at night
• Associated psychological disorder
• Improvement with psychotropic drugs or psychological therapy

Treatment Algorithm

First-Line Treatments:

1. Self-care and skin protection:

   • Regular application of emollients to prevent skin dryness
   • Avoiding irritating factors (hot water, harsh soaps, tight clothing)
   • Maintaining cool ambient temperature 1, 2

2. Psychosocial and behavioral interventions:

   • Education on trigger avoidance and treatment application
   • Relaxation techniques to reduce stress-induced pruritus
   • Cognitive restructuring to address catastrophizing thoughts
   • Habit reversal training for scratch control 1, 3

3. Topical treatments:

   • Topical doxepin (limited to 8 days, 10% body surface area, 12g daily)
   • Topical clobetasone butyrate or menthol for symptomatic relief 4

Second-Line Treatments:

1. Antihistamines:

   • Non-sedating: fexofenadine 180mg or loratadine 10mg
   • Mildly sedating: cetirizine 10mg 4

2. Patient support groups:

   • Engage with others experiencing similar symptoms
   • Share coping strategies 1

3. Narrow-band UVB phototherapy:

   • May benefit patients with functional itch disorder 1

Third-Line Treatments:

1. Psychotropic medications:

   • Selective serotonin reuptake inhibitors (SSRIs): paroxetine, sertraline, fluoxetine, fluvoxamine
   • Tricyclic antidepressants: doxepin
   • Tetracyclic antidepressants: mirtazapine
   • Antipsychotics: pimozide (for delusional subtypes)
   • Anticonvulsants: gabapentin, pregabalin, topiramate
   • Benzodiazepines: alprazolam (short-term use only) 4, 2, 5

2. Specialist referrals:

   • Psychiatric consultation for medication management
   • Psychological therapy (cognitive-behavioral therapy)
   • Social work support for broader psychosocial issues 1

Important Clinical Considerations

• Avoid labeling as "psychogenic" prematurely: Always rule out physical causes before diagnosing psychogenic pruritus 1, 5

• Neurophysiological factors: Stress activates neural circuits in the hippocampus and subcortical structures that can trigger or worsen pruritus 1

• Psychological comorbidities: Up to one-third of patients with chronic pruritus develop anxiety or depressive disorders 1

• Sleep disruption: Address sleep disturbances as they can exacerbate both itch and psychological symptoms 1

• Treatment pitfalls to avoid:

  • Long-term use of sedative antihistamines (risk of dementia)
  • Ineffective treatments like crotamiton cream or calamine lotion
  • Inadequate treatment duration
  • Monotherapy when combination approaches are more effective 1, 4

Monitoring and Follow-up

• Regular assessment of itch intensity and frequency
• Evaluation of psychological symptoms
• Monitoring for medication side effects
• Adjustment of treatment based on response

The management of psychogenic itching requires patience and a strong therapeutic alliance. Success often depends on addressing both the physical symptoms and underlying psychological factors simultaneously 5, 6.