From the Guidelines
Ursodeoxycholic acid (UDCA) is the most effective treatment for pruritus, particularly in cases of intrahepatic cholestasis of pregnancy, with a typical starting dose of 10-15 mg/kg per day, divided into 2 or 3 daily doses 1. When considering treatment options for pruritus, it's essential to evaluate the underlying cause and severity of the condition. For mild to moderate itching, over-the-counter antihistamines like cetirizine (Zyrtec) 10mg daily or loratadine (Claritin) 10mg daily can provide relief, as suggested by the Society for Immunotherapy of Cancer (SITC) toxicity management working group 1.
Treatment Options
- Over-the-counter antihistamines: diphenhydramine (Benadryl) 25-50mg every 4-6 hours, cetirizine (Zyrtec) 10mg daily, or loratadine (Claritin) 10mg daily
- Topical treatments: hydrocortisone cream 1% applied to affected areas 2-3 times daily for up to two weeks, calamine lotion as needed, or menthol-containing lotions like Sarna
- Prescription options: stronger corticosteroid creams, gabapentin 300mg starting dose (increasing as needed), or prescription antihistamines
- Ursodeoxycholic acid (UDCA) for intrahepatic cholestasis of pregnancy: 10-15 mg/kg per day, divided into 2 or 3 daily doses 1
Key Considerations
- Identifying and addressing the underlying cause of itching is crucial, as persistent symptoms may indicate a condition requiring specific treatment
- Moisturizing regularly with fragrance-free lotions helps maintain skin barrier function, which prevents itching
- Cold compresses can provide temporary relief
- Alternative treatments, such as S-adenosyl-methionine and cholestyramine, can be considered for patients who cannot take UDCA or have continued symptoms on the maximum dosage 1
From the FDA Drug Label
For use in the management of pruritus due to allergic conditions such as chronic urticaria and atopic and contact dermatoses and in histamine-mediated pruritus: adults, 25 mg t.i.d. or q.i.d. ; children under 6 years, 50 mg daily in divided doses; children over 6 years, 50 to 100 mg daily in divided doses. Clobetasol propionate topical solution, USP is indicated for short-term topical treatment of inflammatory and pruritic manifestations of moderate to severe corticosteroid-responsive dermatoses of the scalp.
The medications used to treat pruritus are:
- Hydroxyzine (PO), with dosages of 25 mg t.i.d. or q.i.d. for adults and 50 mg daily in divided doses for children under 6 years, and 50 to 100 mg daily in divided doses for children over 6 years 2
- Clobetasol (TOP), for short-term topical treatment of inflammatory and pruritic manifestations of moderate to severe corticosteroid-responsive dermatoses of the scalp 3
From the Research
Medications for Pruritus
- Antihistamines, such as non-sedating antihistamines, are commonly used to treat pruritus, although their efficacy is limited in many diseases with pruritus and prurigo 4
- High-dose non-sedating antihistamines may be effective in treating chronic pruritus, with a retrospective case series showing efficacy in treating chronic pruritus 4
- First-generation antihistamines, such as hydroxyzine and diphenhydramine, may be used to treat pruritus, but their use is often limited by sedating effects and other side effects 5, 6
- Corticosteroids, cyclosporine, and Omalizumab may be effective in treating antihistamine-resistant chronic spontaneous urticaria, with response rates close to 75% for cyclosporine and Omalizumab 5
Limitations and Side Effects
- Antihistamines may not be effective in treating pruritus in many diseases, as the histamine receptor does not play a decisive role in the pathogenesis of pruritus 4, 7
- Hydroxyzine can worsen contact dermatitis in patients with sensitivities to phenothiazines and/or ethylenediamines, due to cross-reactivity between hydroxyzine and ethylenediamine 8
- Second-generation antihistamines, such as terfenadine, astemizole, loratadine, and cetirizine hydrochloride, may be associated with cardiovascular side effects, although these are rare and dose-related 6