What are the treatment options for pruritus?

Treatment Options for Pruritus

Treatment of pruritus should follow a stepwise approach based on severity, with topical moderate/high-potency steroids as first-line therapy for mild to moderate cases, followed by oral antihistamines and GABA agonists for more severe or persistent cases. 1

Initial Assessment and Classification

Pruritus can be categorized by:

• Severity: Mild (localized), moderate (widespread, intermittent), or severe (widespread, constant)
• Etiology: Inflammatory (60%), neuropathic (25%), or systemic disease-related (15%) 2
• Duration: Acute (<6 weeks) or chronic (≥6 weeks) 2

First-Line Treatments

For Mild (Grade 1) Pruritus:

• Topical moderate/high-potency steroids 1
  • Examples: mometasone furoate 0.1% ointment or betamethasone valerate 0.1% ointment
  • Apply to affected areas up to 3-4 times daily 3
• Topical antipruritic agents:
  • Menthol 0.5% preparations 1
  • Lotions containing urea or polidocanol 1
  • Hydrocortisone 2.5% (significantly decreases pruritus compared to placebo) 1, 2

For Prevention and Skin Protection:

• Regular application of emollients to prevent skin dryness 4
• Avoid irritating factors and maintain cool ambient temperature 4

Second-Line Treatments

For Moderate (Grade 2) Pruritus:

• Continue topical treatments AND add:
• Oral antihistamines 1:
  • Non-sedating, second-generation antihistamines (e.g., loratadine 10 mg daily) for daytime use 1
  • First-generation antihistamines (e.g., diphenhydramine 25-50 mg, hydroxyzine 25-50 mg) for nighttime use 1
  • Caution: Long-term use of sedative antihistamines may predispose to dementia 1, 4

Third-Line Treatments

For Severe (Grade 3) or Intolerable Grade 2 Pruritus:

• Interrupt any causative treatment until improvement to Grade 0/1 1
• GABA agonists 1:
  • Pregabalin (25-150 mg daily)
  • Gabapentin (900-3600 mg daily)
  • Note: Avoid gabapentin in hepatic pruritus 1, 4
• Antidepressants:
  • Doxepin (potent histamine antagonist) in both topical and oral forms 1
  • SSRIs (paroxetine, sertraline) 1, 4, 2
  • Mirtazapine 1, 4

Disease-Specific Treatments

For Uremic Pruritus:

1. Optimize dialysis, normalize calcium-phosphate balance, control PTH levels 1
2. BB-UVB phototherapy (strongest evidence, recommendation A) 1
3. Consider capsaicin cream, topical calcipotriol, or oral gabapentin 1

For Hepatic Pruritus:

1. Rifampicin (first-line) 1
2. Cholestyramine (second-line) 1
3. Sertraline (third-line) 1
4. Naltrexone or nalmefene (fourth-line) 1
5. Consider BB-UVB or combined UVA/UVB phototherapy 1

For Lymphoma-Associated Pruritus:

• Cimetidine, carbamazepine, gabapentin, or mirtazapine 1
• Oral corticosteroids for incurable lymphoma 1
• BB-UVB for Hodgkin lymphoma; NB-UVB for non-Hodgkin lymphoma 1

For Psychogenic Pruritus:

• Combination of psychosocial interventions and pharmacotherapy 4
• Relaxation techniques, cognitive restructuring, and behavior modification 4
• SSRIs, tricyclic antidepressants, or anticonvulsants 4

Treatment Pitfalls to Avoid

1. Long-term use of sedative antihistamines (may predispose to dementia) 1, 4
2. Ineffective treatments like crotamiton cream 4
3. Using gabapentin in hepatic pruritus 1, 4
4. Inadequate treatment duration (reassess after 2 weeks; if no improvement, proceed to next step) 1
5. Failure to address underlying causes (systemic diseases, medications, etc.) 2

Monitoring and Follow-up

• Reassess after 2 weeks of treatment 1
• If reactions worsen or do not improve, proceed to next treatment step 1
• For severe cases that don't respond to therapy, consider discontinuation of causative agents 1
• Regular assessment of itch intensity, psychological symptoms, and medication side effects 4

By following this stepwise approach and tailoring treatment to the severity and underlying cause of pruritus, most patients can achieve significant symptom relief and improved quality of life.