What is the recommended treatment for severe itching in adults?

Management of Severe Itching in Adults

For severe itching in adults, first-line treatment should include emollients and topical corticosteroids, with additional therapies based on the cause and response to initial treatment. 1, 2

Initial Assessment and First-Line Management

First-Line Treatments

• Emollients: Apply regularly to maintain skin hydration 1

  • Moisturizers with high lipid content are preferred, especially in elderly patients 2
  • Apply at least once daily 2

• Topical Corticosteroids:

  • Moderate to high-potency corticosteroids for initial management 2
  • Examples: mometasone furoate 0.1% ointment, betamethasone valerate 0.1% ointment 2
  • Apply once daily (evidence shows once-daily application is as effective as twice-daily for potent corticosteroids) 3
  • Avoid prolonged use on face and intertriginous areas to prevent skin atrophy 2

• Topical Antipruritic Agents:

  • Menthol 0.5% preparations can provide immediate relief 2
  • Topical doxepin can be used for localized areas (limit to 8 days, 10% of body surface area, and 12g daily) 1
  • Pramoxine 1% provides rapid and long-lasting relief 4

Second-Line Treatments

Oral Medications

• Non-sedating antihistamines:

  • Fexofenadine 180mg, loratadine 10mg, or cetirizine 10mg daily 1, 2
  • Consider combination of H1 and H2 antagonists (e.g., fexofenadine and cimetidine) 1

• Neuromodulators for neuropathic or refractory pruritus:

  • Gabapentin (900-3600mg daily) or pregabalin (25-150mg daily) 2, 5
  • Particularly beneficial in elderly patients with pruritus 1

• Other oral options for refractory cases:

  • Paroxetine, fluvoxamine, mirtazapine, naltrexone 1
  • Sedative antihistamines (e.g., hydroxyzine) only for short-term use or in palliative settings 1, 2
  • Avoid sedating antihistamines in elderly patients 1, 2

Treatment Based on Specific Causes

Inflammatory Pruritus (approximately 60% of cases) 5

• Focus on topical anti-inflammatory therapies
• Consider tacrolimus ointment for steroid-sparing approach in sensitive areas 5
• For patients not responding to topical therapies (~10%), consider referral to dermatology for systemic treatments 5

Neuropathic Pruritus (approximately 25% of cases) 5

• Topical agents: menthol, pramoxine, or lidocaine 5
• Oral medications: gabapentin, antidepressants, or opioid receptor modulators 5

Pruritus of Unknown Origin

• Start with self-care advice and emollients 1
• Add topical clobetasone butyrate or menthol 1
• Avoid: crotamiton cream, topical capsaicin, and calamine lotion 1

Special Considerations

Elderly Patients

• Start with emollients and topical steroids for at least 2 weeks to exclude asteatotic eczema 1
• Moisturizers with high lipid content are preferred 1
• Consider gabapentin for persistent pruritus 1
• Avoid sedative antihistamines 1

Refractory Cases

• Consider alternative therapies such as acupuncture (alone or with Chinese herbal remedies) 1
• NK-1 receptor antagonists like aprepitant may be beneficial 2
• Refer to secondary care if there is diagnostic doubt or if primary care management does not relieve symptoms 1

Monitoring and Follow-up

• Reassess patients who have not responded to initial treatment 1
• For persistent pruritus, consider laboratory evaluation: complete blood count, metabolic panel, and thyroid function tests 5
• Monitor for adverse effects of topical corticosteroids, particularly skin thinning (more common with higher potency steroids) 3

Remember that severe itching significantly impacts quality of life and sleep, making effective management crucial for patient wellbeing.