From the Guidelines
The best treatment option for this patient with diffuse pruritic papules and nodules is to first identify and address any underlying conditions that may be causing the symptoms, and then consider treatments such as nonsedative antihistamines, paroxetine, or gabapentin, as recommended by the British Association of Dermatologists' guidelines for the investigation and management of generalized pruritus in adults without an underlying dermatosis, 2018 1. The patient's symptoms of diffuse pruritic papules and nodules could be indicative of a variety of underlying conditions, including iron deficiency, lymphoma, polycythaemia vera, solid cancers, uraemia, liver disease, or neuropathy.
- It is essential to conduct a thorough investigation to determine the underlying cause of the symptoms, as treatment will depend on the specific condition.
- If the underlying condition is iron deficiency, iron replacement is recommended, as stated in the guidelines 1.
- If the underlying condition is lymphoma, treatment with cimetidine, carbamazepine, gabapentin, or mirtazapine may be effective in resolving the itch, as recommended by the guidelines 1.
- If the underlying condition is uraemia, BB-UVB is an effective treatment for many patients with uraemic pruritus, as stated in the guidelines 1.
- If the underlying condition is liver disease, rifampicin is considered a first-line treatment for hepatic pruritus, as recommended by the guidelines 1. In addition to addressing the underlying condition, the patient may also benefit from symptomatic relief with treatments such as:
- Nonsedative antihistamines, such as fexofenadine or loratadine, as recommended by the guidelines 2.
- Paroxetine, fluvoxamine, mirtazapine, naltrexone, butorphanol, gabapentin, pregabalin, ondansetron, or aprepitant, as recommended by the guidelines 2.
- Topical doxepin, clobetasone butyrate, or menthol, as recommended by the guidelines 3. It is crucial to note that the treatment of generalized pruritus can be complex and may require a multidisciplinary approach, involving dermatologists, specialists in the underlying condition, and other healthcare professionals.
- The patient should be referred to secondary care if there is diagnostic doubt or if primary care management does not relieve symptoms, as recommended by the guidelines 3.
- The patient should also receive self-care advice and emollients, as recommended by the guidelines 3.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION Adults and children Thoroughly massage Permethrin Cream, 5% into the skin from the head to the soles of the feet. Scabies rarely infests the scalp of adults, although the hairline, neck, temple, and forehead may be infested in infants and geriatric patients. PRECAUTIONS General Scabies infestation is often accompanied by pruritus, edema, and erythema.
The best treatment for a 60-year-old male with diffuse pruritic papules and nodules is Permethrin Cream, 5%.
- The patient should thoroughly massage the cream into the skin from the head to the soles of the feet.
- The cream should be removed by washing after 8 to 14 hours.
- One application is generally curative 4.
- Patients may experience persistent pruritus after treatment, but this is rarely a sign of treatment failure and is not an indication for retreatment 5.
From the Research
Treatment Options for Diffuse Pruritic Papules and Nodules
- The patient's symptoms suggest a possible diagnosis of scabies, a contagious and itchy parasitic infection of the skin 6.
- First-line treatment for scabies is typically permethrin 5% cream 7, 8, 6.
- However, recent studies have reported a decrease in the efficacy of permethrin 5% cream due to resistance 9, 10.
- An alternative treatment option is benzyl benzoate 25%, which has shown a higher cure rate compared to permethrin 5% in a recent double-blinded randomized controlled trial 10.
Considerations for Treatment
- The patient's age and symptoms should be taken into account when selecting a treatment option.
- Permethrin 5% cream is generally well-tolerated, but may not be effective in all cases due to resistance 9, 10.
- Benzyl benzoate 25% may be a suitable alternative, but can cause a burning sensation in some patients 10.
- It is essential to follow proper treatment protocols and hygiene measures to ensure effective treatment and prevent reinfection 6.
Application and Administration
- Topical permethrin 5% cream should be applied from neck to toes, and may also be applied to the scalp and head in some cases 8.
- Treatment should be repeated as necessary, and patients should be followed up to ensure resolution of symptoms 7, 9.
- Counseling on proper diagnosis, treatment, and hygiene measures is crucial to reducing the burden of scabies 6.