From the Guidelines
The most effective treatment for pruritus of unknown etiology is often a multi-faceted approach, but according to the British Association of Dermatologists' guidelines, rifampicin is considered a first-line treatment for hepatic pruritus with a strength of recommendation A 1.
Treatment Approaches
When considering treatment for pruritus of unknown etiology, it's crucial to rule out underlying conditions that may be causing the symptoms. The guidelines provide various treatment options based on the underlying cause:
- For generalized pruritus associated with iron deficiency, iron replacement is recommended with a strength of recommendation C 1.
- For patients with generalized pruritus associated with lymphoma, treatments such as cimetidine, carbamazepine, gabapentin, or mirtazapine may be effective, although the strength of recommendation is D 1.
- In cases of uraemic pruritus, ensuring adequate dialysis, normalizing calcium-phosphate balance, and controlling parathyroid hormone levels are essential before considering other treatment strategies, with a strength of recommendation D 1.
Key Considerations
It's essential to note that:
- Sedative antihistamines should be avoided long-term due to the risk of dementia, except in palliative care, with a strength of recommendation B 1.
- BB-UVB is an effective treatment for many patients with uraemic pruritus, with a strength of recommendation A 1.
- Rifampicin is considered a first-line treatment for hepatic pruritus, with a strength of recommendation A 1.
Lifestyle Modifications
In addition to these treatments, lifestyle modifications can play a crucial role in managing pruritus, including:
- Using lukewarm water for bathing
- Mild fragrance-free soaps
- Wearing loose cotton clothing
- Keeping fingernails short
- Maintaining a cool, humid environment These modifications can help alleviate symptoms and improve quality of life.
Referral to Specialist
If the pruritus persists or worsens despite these measures, referral to a dermatologist or relevant specialist is warranted for further evaluation and consideration of advanced treatments such as gabapentin, pregabalin, or phototherapy 1.
From the Research
Treatment Options for Pruritus of Unknown Etiology
- Various treatment options are available for pruritus of unknown etiology, including nonpharmacologic methods, emollients, tar preparations, topical agents, ultraviolet B therapy, and oral antihistamines or corticosteroids 2
- A new topical tricyclic agent is now available that adds a promising therapeutic approach 2
- Serlopitant, a neurokinin 1 receptor (NK1R) antagonist, may reduce pruritus intensity when compared with placebo, although the certainty of the evidence is low 3
- First-line treatment for inflammatory chronic pruritus includes topical anti-inflammatory therapies such as hydrocortisone (2.5%), triamcinolone (0.1%), or tacrolimus ointment 4
- Neuropathic topical treatments such as menthol, pramoxine, or lidocaine can be used either alone or in combination with immunomodulatory agents such as topical steroids 4
- Other effective therapies for neuropathic pruritus include gabapentin, antidepressants such as sertraline or doxepin, or opioid receptor agonist/antagonists such as naltrexone or butorphanol 4
Diagnosis and Treatment Approach
- Medical care of patients with chronic pruritus should include interdisciplinary diagnosis and therapy of the triggering underlying disease, therapy of the secondary symptoms of pruritus, and symptomatic antipruritic therapy 5
- A comprehensive and careful diagnostic workup is necessary to identify the underlying cause of chronic pruritus, and treatment approaches should be tailored to the individual patient's needs 6
- Device-based physical therapies, such as phototherapy, and medications that act on the itch-perception processing pathway may be effective treatment options for cutaneous pruritus 6