What is the treatment for alcohol-induced pruritis (itching)?

Treatment of Alcohol-Induced Pruritus

For alcohol-induced pruritus, first-line treatment includes topical moderate/high-potency corticosteroids, menthol-containing preparations, and oral antihistamines, with GABA agonists like gabapentin or pregabalin as effective second-line options for persistent cases. 1

First-Line Treatments

Topical Therapies

• Topical moderate/high-potency steroids: Apply mometasone furoate 0.1% ointment or betamethasone valerate 0.1% ointment to affected areas 2, 1
• Topical antipruritic agents:
  • Menthol 0.5% preparations provide cooling relief 2, 1
  • Lotions containing urea or polidocanol can soothe itching 2
  • Consider refrigerated menthol and pramoxine for pruritus without rash 2

Oral Antihistamines

• Non-sedating antihistamines for daytime use:
  • Fexofenadine 180 mg daily
  • Loratadine 10 mg daily 2, 1
• Mildly sedating antihistamines for nighttime use:
  • Cetirizine 10 mg daily 2, 1
  • First-generation antihistamines (diphenhydramine 25-50 mg or hydroxyzine 25-50 mg) may be considered for nighttime pruritus due to their sedative properties 2

Second-Line Treatments

Neuromodulators

• GABA agonists:
  • Pregabalin (25-150 mg daily) 2, 1
  • Gabapentin (900-3600 mg daily) - dose titrate according to side effects and efficacy 2, 1
  • Note: Avoid gabapentin in hepatic pruritus 2, 1

Antidepressants

• Sertraline (100 mg daily) - titrate dose to symptoms and tolerance 2
• Mirtazapine - particularly for opioid-induced pruritus but may help with other types 2
• Doxepin - acts as a potent histamine antagonist in both topical and oral forms 2, 1

Treatment Algorithm

1. Start with topical therapies and antihistamines

   • Apply topical corticosteroids and menthol preparations
   • Begin oral antihistamines appropriate for time of day

2. Reassess after 2 weeks

   • If no improvement, proceed to next step 2

3. Add neuromodulators for persistent symptoms

   • Begin pregabalin or gabapentin (unless hepatic etiology)
   • Consider sertraline if neuromodulators ineffective

4. For severe or refractory cases

   • Consider referral to dermatology 2, 1
   • Evaluate for possible underlying causes (e.g., hepatic involvement)

Special Considerations

For Alcohol-Related Hepatic Pruritus

If alcohol consumption has led to liver damage with cholestatic pruritus:

1. Cholestyramine (4-16 g/day) - first choice for cholestatic pruritus 2, 3

   • Must be given 2-4 hours before or after other medications
   • Mix with orange squash and refrigerate overnight to improve palatability
   • Start at breakfast time if gallbladder is intact

2. Rifampicin (300-600 mg/day) as second-line therapy 2

   • Start at 150 mg once to twice daily and titrate upward
   • Monitor liver function tests after 2-4 weeks
   • Use caution in advanced liver disease

3. Sertraline (100 mg/day) as third-line treatment 2

4. Naltrexone (50 mg/day) as fourth-line treatment 2

   • Start at 12.5 mg/day and titrate slowly to avoid withdrawal symptoms

Non-Pharmacological Approaches

• Avoid triggers: Identify and avoid specific alcoholic beverages causing symptoms 4
• Emollients: Regular application to prevent skin dryness 2, 1
• Cool environment: Maintain cool ambient temperature to reduce itch sensation 1
• Habit reversal training: Break the itch-scratch cycle 1

Common Pitfalls and Caveats

• Avoid crotamiton cream as it has been shown to be ineffective 2, 1
• Limit use of sedative antihistamines in elderly patients due to risk of dementia with long-term use 1
• Consider allergen testing if symptoms suggest systemic contact dermatitis from specific components in alcoholic beverages (e.g., Balsam of Peru, cinnamon, vanilla) 4
• Monitor for hepatotoxicity when using rifampicin, especially in patients with existing liver disease 2

By following this structured approach to treating alcohol-induced pruritus, most patients should experience significant relief of symptoms. Treatment should be escalated if initial therapies fail to provide adequate relief after 2 weeks.