What are non-antihistamine medications for treating itch?

Non-Antihistamine Medications for Treating Itch

Topical corticosteroids are the first-line non-antihistamine treatment for itch, with other options including topical calcineurin inhibitors, topical PDE-4 inhibitors, menthol-based preparations, and systemic medications like gabapentin, pregabalin, and mirtazapine depending on the cause of pruritus. 1, 2

Topical Treatments

First-Line Options

• Topical Corticosteroids

  • Hydrocortisone 1% cream (available over-the-counter) 3
  • Higher potency prescription options like mometasone furoate 0.1% or betamethasone valerate 0.1% for moderate to severe cases 2
  • Provides rapid itch relief, with studies showing significant reduction in pruritus within 1-2 days 4
  • Caution: Low-potency corticosteroids (0.2-1% hydrocortisone) may not be effective for Toxicodendron dermatitis (poison ivy/oak) 1

• Emollients and Moisturizers

  • Essential for all pruritic conditions to maintain skin barrier function 1, 2
  • High lipid content moisturizers preferred for elderly patients 1
  • Should be applied regularly to prevent skin dryness 2

Second-Line Topical Options

• Topical Calcineurin Inhibitors (tacrolimus, pimecrolimus)

  • Effective for atopic dermatitis and other inflammatory skin conditions 5
  • Particularly useful for sensitive areas where corticosteroids may cause atrophy 2

• Topical PDE-4 Inhibitors

  • Crisaborole ointment approved for mild to moderate atopic dermatitis 1
  • Steroid-sparing alternative with effectiveness in patients aged 3 months and above 1
  • Most common side effect is stinging/burning at application site 1

• Topical Anesthetics and Coolants

  • Menthol-containing preparations provide cooling sensation and itch relief 1, 2
  • Pramoxine hydrochloride 1% provides rapid and long-lasting itch relief 6
  • Topical doxepin (limited to 8 days, 10% body surface area, 12g daily maximum) 1

• Not Recommended Topical Treatments

  • Crotamiton cream (not effective) 1
  • Topical capsaicin (potentially harmful) 1
  • Calamine lotion (lack of evidence for effectiveness) 2
  • Long-term topical antibiotics (risk of resistance and sensitization) 1
  • Topical antihistamines (risk of contact dermatitis) 1

Systemic Treatments

For Generalized Pruritus of Unknown Origin

• Gabapentin (900-3600 mg daily)

  • Effective for neuropathic and uremic pruritus 2
  • Requires dose titration based on efficacy and side effects 2

• Pregabalin (25-150 mg daily)

  • Alternative to gabapentin with similar mechanism 2
  • May have better side effect profile for some patients 2

• Mirtazapine (30 mg daily)

  • Particularly effective for lymphoma-associated pruritus 2
  • Also useful for generalized pruritus of unknown origin 1

• Selective Serotonin Reuptake Inhibitors

  • Paroxetine, fluvoxamine, sertraline can be effective 1, 2
  • Sertraline (100 mg/day) recommended as third-line for cholestatic pruritus 2

For Specific Causes of Pruritus

• Opioid-Induced Pruritus

  • Naltrexone (50 mg/day) - first choice if opioid cessation impossible 1
  • Methylnaltrexone, ondansetron, droperidol as alternatives 1

• Cholestatic Pruritus

  • Cholestyramine (4-16 g/day) - first-line treatment 2
  • Rifampicin (300-600 mg/day) - second-line (monitor liver function) 2
  • Sertraline (100 mg/day) - third-line 2
  • Naltrexone (50 mg/day) - fourth-line 2

• Post-Operative Pruritus

  • Diclofenac (100 mg rectally) 1, 2

Physical Treatments

• Phototherapy

  • BB-UVB or NB-UVB phototherapy highly effective for chronic pruritus 2
  • Reduces epidermal nerve fibers and normalizes axon guidance molecules 5
  • Particularly useful for uremic pruritus and atopic dermatitis 2

• Other Physical Approaches

  • Transcutaneous electrical nerve stimulation for hepatic pruritus 1
  • Cool compresses for symptomatic relief 1

Special Considerations

• Elderly Patients

  • Avoid sedative antihistamines due to increased risk of adverse effects 1, 2
  • High lipid content moisturizers preferred 1
  • Consider gabapentin for persistent pruritus 1

• Atopic Dermatitis

  • Topical corticosteroids and calcineurin inhibitors as first-line 5
  • Crisaborole as steroid-sparing alternative 1
  • Consider dupilumab for severe cases 5

• Toxicodendron Dermatitis (Poison Ivy/Oak)

  • Immediate washing with soap and water most effective 1
  • High-potency topical corticosteroids may be needed 1

By addressing the underlying cause of pruritus and selecting appropriate non-antihistamine treatments, most patients can achieve significant itch relief and improved quality of life.