What is the initial management of pruritus?

Initial Management of Pruritus

The initial management of pruritus should include self-care advice and emollients, followed by a short course of non-sedating antihistamines if warranted. 1

Step-by-Step Management Algorithm

First-Line Approach

1. Self-care advice:

   • Keep fingernails short to minimize skin damage from scratching
   • Avoid trigger factors (hot environments, wool clothing, alcohol)
   • Use mild, fragrance-free soaps
   • Apply cool compresses for immediate relief

2. Emollients:

   • Apply liberally and frequently (at least twice daily)
   • Use high lipid content moisturizers, especially in elderly patients 1
   • Apply after bathing while skin is still slightly damp

3. Non-sedating antihistamines:

   • Consider fexofenadine 180 mg or loratadine 10 mg daily 1
   • Cetirizine 10 mg is an option for those who can tolerate mild sedation
   • Consider H1 and H2 antagonist combinations (e.g., fexofenadine with cimetidine) for enhanced effect

Second-Line Approach (if first-line fails)

1. Topical treatments:

   • Topical clobetasone butyrate (mild steroid) for short-term use 1
   • Topical menthol preparations for cooling effect
   • Topical doxepin (limited to 8 days, 10% of body surface area, and 12g daily) 1

2. Avoid ineffective treatments:

   • Crotamiton cream (evidence shows ineffectiveness) 1
   • Topical capsaicin or calamine lotion (limited evidence of benefit) 1
   • Sedating antihistamines (except in short-term or palliative settings) 1

Special Considerations

Elderly Patients

• Start with emollients and topical steroids for at least 2 weeks to treat any asteatotic eczema 1
• Use moisturizers with high lipid content 1
• Consider gabapentin for persistent pruritus 1
• Avoid sedating antihistamines in elderly patients due to increased risk of side effects and potential dementia risk 1, 2

When to Refer to Secondary Care

• Diagnostic uncertainty
• Failure to respond to primary care management
• Signs of systemic disease
• Significant impact on quality of life despite treatment 1

Pitfalls and Caveats

1. Underlying causes: Remember that generalized pruritus may have a significant underlying cause in 20-30% of cases 1. Consider systemic diseases such as:

   • Hepatic or cholestatic disease
   • Renal disease
   • Hematological conditions (especially polycythemia vera)
   • Malignancy
   • Endocrine disorders

2. Follow-up: Regular follow-up is essential as the underlying cause of pruritus may not be evident initially 1

3. Medication-induced pruritus: Always review the patient's medication list as many drugs can cause or exacerbate pruritus

4. Psychological factors: Consider psychological and emotional factors that may contribute to pruritus, especially in chronic cases

The evidence strongly supports a stepwise approach starting with simple measures before progressing to more complex interventions. While there is no universally accepted therapy for pruritus, the British Association of Dermatologists provides clear guidance on initial management strategies with good evidence supporting the use of emollients and non-sedating antihistamines as first-line treatments 1.