What alternative treatments can be given to a patient with extensive excoriation and rash that does not improve with steroids or Benadryl (diphenhydramine)?

Management of Extensive Excoriation and Rash Unresponsive to Steroids and Diphenhydramine

For patients with extensive excoriation and rash that has not responded to steroids or diphenhydramine, gabapentin, pregabalin, or mirtazapine should be considered as next-line treatment options.

Alternative Treatment Options

First-line alternatives:

1. Oral antihistamines

   • Try non-sedating antihistamines if not already attempted:
     • Cetirizine 10 mg daily
     • Loratadine 10 mg daily
     • Fexofenadine 180 mg daily 1
   • Consider combination H1 and H2 antagonists:
     • Add cimetidine to existing antihistamine regimen 2

2. Topical treatments

   • Topical doxepin (limited to 8 days, 10% body surface area, maximum 12g daily) 2
   • Menthol-containing preparations for counter-irritant effect 2, 1
   • Polidocanol-containing lotions to soothe pruritus 2

Second-line options for moderate-to-severe cases:

1. Neuromodulators

   • Gabapentin (100-300 mg TID) 2
   • Pregabalin (start at 75 mg BID, titrate as needed) 2

2. Antidepressants

   • Mirtazapine (15-30 mg at bedtime) - particularly effective for excoriation disorder due to its antihistaminergic effects 3
   • Paroxetine or fluvoxamine 2

3. Other agents

   • Aprepitant (80 mg daily) - neurokinin receptor 1 antagonist 2
   • Naltrexone or butorphanol - opioid antagonists 2
   • Ondansetron 2

For severe, refractory cases:

1. Immunosuppressants

   • Cyclosporine - FDA approved for severe psoriasis, effective for recalcitrant pruritus 4
   • Azathioprine - shown to reduce pruritus in generalized pruritus of unknown origin 2, 5

2. Dermatology referral

   • Same-day consultation for severe cases 2
   • Consider skin biopsy to rule out underlying conditions 2

Monitoring and Management Algorithm

1. Initial assessment

   • Rule out infection or other underlying causes:
     • Complete blood count with differential
     • Comprehensive metabolic panel 2
   • Assess body surface area affected and impact on activities of daily living

2. Treatment selection based on severity

   • Mild (affecting <10% BSA): Try alternative antihistamines
   • Moderate (10-30% BSA): Add neuromodulators (gabapentin/pregabalin)
   • Severe (>30% BSA): Consider mirtazapine, immunosuppressants, and immediate dermatology referral

3. Supportive care

   • Apply emollients with cream or ointment-based, fragrance-free products 2, 1
   • Avoid hot water, alcohol-containing lotions, and skin irritants 2, 1
   • Use soap-free shower gels and bath oils 2, 1

4. Follow-up and monitoring

   • Reassess after 2 weeks of treatment 2
   • If no improvement, escalate to next treatment option
   • Monitor for adverse effects of medications

Special Considerations

• Infection risk: Rule out secondary infection before intensifying immunosuppression 6
• Elderly patients: Start with lower doses of medications and monitor renal/hepatic function 1
• Chronic excoriation: May require multidisciplinary approach including psychiatric evaluation 3
• Atopic dermatitis: Consider crisaborole or dupilumab for refractory cases if available 7
• Upadacitinib: Newer JAK inhibitor showing promise for excoriation in atopic dermatitis 8

Pitfalls to Avoid

• Continuing ineffective treatments without escalation
• Missing secondary infection that may worsen outcomes
• Prolonged use of high-potency topical steroids causing skin atrophy
• Inadequate moisturization essential for barrier repair
• Overlooking psychological components of chronic excoriation

By following this algorithm and considering these alternative treatments, you can effectively manage extensive excoriation and rash that has not responded to conventional steroid and diphenhydramine therapy.