What is the treatment for pruritus?

Treatment for Pruritus

The treatment for pruritus should follow a stepwise approach, starting with topical therapies and antihistamines, then progressing to systemic therapies for refractory cases, with the primary goal of reducing symptoms and improving quality of life. 1

Initial Assessment and General Measures

• Determine if pruritus is localized or generalized
• Rule out underlying dermatoses or secondary causes (hematological, renal, hepatic, etc.)
• For all types of pruritus:
  • Use emollients and moisturizers to maintain skin barrier function 1
  • Avoid frequent bathing and use of soaps that can dry the skin 1
  • Avoid physical triggers such as wool clothing 2

Topical Treatments

First-line options:

• Topical corticosteroids:
  • Hydrocortisone can be applied to affected areas up to 3-4 times daily for adults and children over 2 years 3
  • Particularly effective for inflammatory causes of pruritus
  • Clobetasone butyrate may benefit patients with generalized pruritus of unknown origin (GPUO) 2

Other topical options:

• Menthol-containing preparations: Provide cooling sensation and itch relief 1, may benefit GPUO patients 2
• Topical doxepin: Can be used for GPUO but limited to 8 days, 10% of body surface area, and maximum 12g daily due to risk of allergic contact dermatitis 2, 1
• Topical calcineurin inhibitors (tacrolimus, pimecrolimus): Effective for atopic dermatitis and inflammatory conditions, especially in sensitive areas 1

Not recommended:

• Crotamiton cream: No significant antipruritic effect compared to vehicle 2
• Calamine lotion: No literature support for use in GPUO 2
• Topical capsaicin: Not recommended except in uremic pruritus 2
• Topical antihistamines: Risk of contact dermatitis 1

Systemic Treatments

Antihistamines:

• Non-sedating antihistamines: Fexofenadine 180mg or loratadine 10mg daily as second-line treatment 1
• Mildly sedating antihistamines: Cetirizine 10mg may be considered for nighttime pruritus 1
• Caution: Elderly patients should avoid sedative antihistamines due to increased risk of adverse effects 1

For refractory cases:

• Mirtazapine: Particularly effective for lymphoma-associated pruritus and GPUO, recommended dose 30mg daily 1
• Gabapentin (900-3600mg daily) or Pregabalin (25-150mg daily): Second-line treatments for persistent pruritus 1
• Selective serotonin reuptake inhibitors (paroxetine, fluvoxamine, sertraline): Can be effective though evidence is limited 1

Special Considerations

For specific causes:

• Opioid-induced pruritus: Naltrexone is first choice if opioid cessation is impossible 1
• Cholestatic pruritus: Cholestyramine (4-16g/day) is first-line, with rifampicin (300-600mg/day) and sertraline (100mg/day) as alternatives 1
• Uremic pruritus: Optimize dialysis, normalize calcium-phosphate balance, and control PTH levels 1

Phototherapy:

• BB-UVB phototherapy: Strong evidence-based treatment for pruritus (recommendation grade A) 1

Common Pitfalls and Caveats

• Failure to identify and treat underlying causes can lead to persistent symptoms
• Overuse of topical corticosteroids can lead to skin atrophy and other adverse effects
• Topical doxepin should be strictly limited in duration and area due to sensitization risk 2, 1
• Sedating antihistamines should be avoided in the elderly and those operating machinery
• Many patients self-medicate with proprietary emollients despite lack of objective evidence for efficacy 2
• Continuous reassessment is necessary as GPUO may later develop identifiable causes requiring specific treatment 2