From the Guidelines
The best treatment for pruritus is bezafibrate, which has been shown to be effective in alleviating moderate to severe itch in people with primary sclerosing cholangitis (PSC) and primary biliary cholangitis (PBC) 1.
Treatment Options
When considering treatment for pruritus, it's essential to identify the underlying cause. For mild to moderate itching, simple self-care advice, such as keeping nails short, and emollients can be used, followed by a short trial of a nonsedating antihistamine, if warranted 2.
- For cholestasis-associated pruritus, bezafibrate is recommended as the first-line pharmacological treatment, due to its sustained antipruritic effect and strong additive anticholestatic effects in PSC and PBC 1.
- Rifampicin can be used as a second-line treatment, but it may induce drug-induced hepatitis after 4-12 weeks in up to 12% of cholestatic patients 1.
- Naltrexone, an oral opioid antagonist, can be considered as a third-line treatment, starting at a low dose of 12.5 mg to avoid early side effects resembling an opioid withdrawal syndrome 1.
General Recommendations
General recommendations for patients suffering from cholestasis-associated pruritus include:
- Using emollients to prevent dryness of skin
- Avoiding hot baths or showers
- Using cooling gels (e.g., menthol gels) for affected skin areas
- Keeping nails shortened It's crucial to note that the molecular pathogenesis of cholestatic pruritus has not been fully unravelled, and more research is needed to understand the underlying mechanisms and develop effective treatments 1. In cases where pruritus is associated with uraemic conditions, ensuring adequate dialysis, normalizing calcium-phosphate balance, controlling PTH to accepted levels, correcting any anaemia with erythropoietin, and using emollients for xerosis are essential before using other treatment strategies 3.
From the FDA Drug Label
CLINICAL STUDIES ... More ELIDEL patients (57%) had mild or no pruritus at 6 weeks compared to vehicle patients (34%) Directions for itching of skin irritation, inflammation, and rashes: adults and children 2 years of age and older: apply to affected area not more than 3 to 4 times daily
The best treatment for pruritus is not explicitly stated in the provided drug labels. However, based on the available information:
- Pimecrolimus (TOP) cream reduced pruritus in patients with atopic dermatitis, with 57% of patients having mild or no pruritus at 6 weeks 4.
- Hydrocortisone (TOP) is indicated for itching of skin irritation, inflammation, and rashes, but the label does not provide specific efficacy data for pruritus 5. It is essential to note that these treatments may be effective for specific conditions, such as atopic dermatitis, but may not be the best treatment for pruritus in general.
From the Research
Treatment Options for Pruritus
- Topical corticosteroids are the first-line treatment for atopic dermatitis flare-ups, which often cause pruritus 6
- Pimecrolimus and tacrolimus are topical calcineurin inhibitors that can be used in conjunction with topical corticosteroids as first-line treatment for atopic dermatitis 7, 8, 6
- Pimecrolimus cream 1% has been shown to be effective and well tolerated in pediatric patients with mild to moderate atopic eczema, reducing pruritus and erythema within 48 hours of initiating treatment 8
- Ultraviolet phototherapy is a safe and effective treatment for moderate to severe atopic dermatitis when first-line treatments are not adequate 6
- Newer medications approved by the U.S Food and Drug Administration, such as crisaborole and dupilumab, are effective in treating atopic dermatitis but are currently cost prohibitive for most patients 6
Vehicle Preferences for Topical Treatments
- Ointment preparations are not necessarily the best vehicle for psoriasis treatment, as they can be messy and may lead to poor adherence to treatment 9
- Non-ointment topical corticosteroid products exhibit excellent efficacy in clinical practice, and treatment outcomes may be improved by discussing vehicle preferences with patients 9