What is the recommended treatment for itching in elderly patients?

Management of Pruritus in Elderly Patients

Elderly patients with pruritus should initially receive emollients and topical steroids for at least 2 weeks to treat any asteatotic eczema, with high lipid content moisturizers being preferred. 1

First-Line Treatment Approach

Initial Management

1. Self-care advice and emollients:

   • Keep fingernails short to prevent excoriation
   • Apply emollients liberally at least twice daily 2
   • Use high lipid content moisturizers specifically for elderly skin 1
   • Avoid hot water; use warm water for bathing
   • Limit bathing frequency and soap use (only for axillary, anal, and pubic areas) 3

2. Topical treatments (if emollients alone are insufficient):

   • Apply topical steroids for at least 2 weeks to treat any asteatotic eczema 1
   • Consider hydrocortisone for temporary relief of itching associated with minor skin irritations 4
   • Topical menthol preparations can provide cooling relief 2

Second-Line Treatment Options

1. Non-sedating antihistamines:

   • Consider a short course of non-sedating antihistamines such as fexofenadine 180 mg or loratadine 10 mg 1, 2
   • Mildly sedative agents such as cetirizine 10 mg may be considered 1

2. Gabapentin:

   • May benefit elderly patients with persistent pruritus 1, 5
   • Particularly useful for neuropathic pruritus 6

Important Cautions

1. Avoid sedating antihistamines:

   • Elderly patients should NOT receive sedating antihistamines due to increased risk of side effects and potential dementia risk 1, 2

2. Ineffective treatments to avoid:

   • Crotamiton cream (ineffective) 1
   • Topical capsaicin or calamine lotion (limited evidence) 1, 2

Special Considerations for Elderly Patients

1. Rule out underlying causes:

   • Systemic diseases (hepatic, renal, hematological disorders)
   • Medication-induced pruritus (particularly calcium channel blockers and hydrochlorothiazide) 6
   • Neuropathic causes (especially in diabetic patients) 6
   • Dermatological conditions more common in elderly (scabies, bullous pemphigoid) 6

2. Age-related factors contributing to pruritus:

   • Impaired skin barrier function
   • Immunosenescence
   • Neuronal changes and neuropathies 7
   • Poor hydration 8

When to Refer to Secondary Care

Refer elderly patients with pruritus to secondary care if:

• Diagnostic doubt exists
• Primary care management fails to relieve symptoms
• Signs of systemic disease are present 1, 2

Follow-up

Regular follow-up is essential as the underlying cause of pruritus may not be evident initially 1. Reassess patients who have not responded to initial treatment after 2 weeks 1.

Treatment Algorithm

1. Start with emollients (high lipid content) + self-care advice
2. Add topical steroids for 2 weeks if skin shows signs of inflammation
3. If inadequate response, add non-sedating antihistamine
4. Consider gabapentin for persistent or neuropathic pruritus
5. Refer to secondary care if no improvement or diagnostic uncertainty

Remember that pruritus in the elderly can significantly impact quality of life and requires prompt, effective management with careful consideration of age-related factors and potential medication side effects 7, 8.