From the Guidelines
For first-line treatment of itching (pruritus), I recommend starting with a combination of systemic corticosteroids and high-potency topical corticosteroids, as this has been shown to reduce the duration of itching 1.
Key Considerations
- The use of low-potency corticosteroids is not associated with symptom improvement 1.
- Cool compresses and oatmeal baths may provide symptomatic relief, although evidence is limited 1.
- Oral antihistamines, such as cetirizine or diphenhydramine, may be helpful for nighttime itching or for patients with widespread itching, but their efficacy for itching is questionable 1.
Treatment Approach
- Apply topical corticosteroids, such as hydrocortisone 1%, to the affected area 2-3 times daily for up to 7 days.
- Use systemic corticosteroids, as prescribed by a healthcare professional, in combination with topical corticosteroids.
- Keep the skin moisturized with fragrance-free lotions or creams, applied immediately after bathing while skin is still damp.
- Use lukewarm water for bathing rather than hot water, which can worsen itching by triggering histamine release.
- Avoid scratching as this damages the skin barrier and creates a cycle of more inflammation and itching.
Special Considerations
- For patients with uraemic pruritus, ensure adequate dialysis, normalize calcium–phosphate balance, control parathyroid hormone to accepted levels, correct any anaemia with erythropoietin, and use simple emollients (for xerosis) before using other treatment strategies 1.
- For patients with cholestasis-associated pruritus, consider bezafibrate or rifampicin as first-line pharmacological treatment 1.
From the FDA Drug Label
Uses temporarily relieves itching associated with minor skin irritations, inflammation, and rashes due to: eczema psoriasis poison ivy, oak, sumac insect bites detergents jewelry cosmetics soaps seborrheic dermatitis temporarily relieves external anal and genital itching 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 first line treatment for pruritus (itching) is topical hydrocortisone 2, which can be applied to the affected area 3 to 4 times daily for adults and children 2 years of age and older 2.
- Key uses:
- Relieves itching associated with minor skin irritations and inflammation
- Relieves external anal and genital itching It is essential to follow the directions for use and consult a doctor for children under 2 years of age or under 12 years of age for external anal and genital itching 2.
From the Research
First-Line Treatment for Pruritus
The first-line treatment for pruritus (itching) includes:
- Topical therapies, such as emollients, mild cleansers (low pH), topical anaesthetics, steroids, calcineurin inhibitors, and coolants (menthol) 3, 4, 5, 6
- Topical glucocorticoids are commonly used as the first-line therapy in the management of atopic dermatitis (AD) and psoriasis patients 7
Topical Therapies
Topical therapies can be used to treat localized pruritus, as well as generalized pruritus when general measures are not effective, systemic drugs are contraindicated, and/or as an addition to causative or systemic therapy 4
- Symptomatic therapy includes substituting some other sensation by cooling, heating, and/or counterirritation, by anesthesia of sensory nerve endings with local anesthetics, blocking mediators of pruritus, and reducing inflammation of the skin with corticosteroids or topical immunomodulators 4
- Topical anti-itch preparations should be prescribed after the diagnosis is made and used as the first-choice treatment together with general measures 4
Systemic Therapies
Systemic therapies can vary according to the aetiology of the chronic itch, and may include non-sedating antihistamines, sedating antihistamines, anticonvulsants, antidepressants, mu-opioid antagonists, kappa-opioid agonists, and phototherapy 3