What is the emergency treatment for pruritus?

Emergency Treatment for Pruritus

In an emergency setting, hydroxyzine is the first-line treatment for acute pruritus, administered at 25 mg three to four times daily for adults. 1

First-line Treatments

• Hydroxyzine (oral antihistamine) is the most effective immediate intervention for emergency pruritus management at 25 mg three to four times daily for adults 1
• For children under 6 years, hydroxyzine can be given at 50 mg daily in divided doses; for children over 6 years, 50-100 mg daily in divided doses 1
• Emollients should be provided as supportive care to address dry skin which can exacerbate pruritus 2

Cause-Specific Emergency Treatments

For Cholestatic/Hepatic Pruritus:

• Rifampicin is the first-line treatment for hepatic pruritus, starting at 150 mg with monitoring of liver function tests, which may be increased to a maximum of 600 mg daily 2
• Cholestyramine 4 g up to four times daily can be used as an alternative first-line treatment (should be spaced at least 4 hours from other medications) 2
• Do not use gabapentin in hepatic pruritus as it is ineffective 2

For Uremic Pruritus:

• Ensure adequate dialysis, normalize calcium-phosphate balance, and use emollients before other treatments 2
• Gabapentin 100-300 mg after dialysis (three times per week) is effective for uremic pruritus 2
• Broad-band UVB (BB-UVB) phototherapy is an effective treatment for many patients with uremic pruritus but not practical in emergency settings 2

For Drug-Induced Pruritus:

• For opioid-induced pruritus, naltrexone is the first-choice treatment if cessation of opioid therapy is impossible 2
• For postoperative pruritus, consider diclofenac 100 mg given rectally 2

Second-line Emergency Treatments

• For moderate-to-severe pruritus unresponsive to antihistamines, consider GABA agonists (pregabalin/gabapentin) except in hepatic pruritus 2
• Topical moderate/high-potency steroids can be used for localized pruritus 2
• Doxepin (tricyclic antidepressant with potent antihistamine properties) can be considered for severe cases 2

Monitoring and Follow-up

• Reassess after 2 weeks for mild-to-moderate cases; if reactions worsen or do not improve, proceed to next treatment step 2
• For severe pruritus (Grade ≥3 or intolerable Grade 2), interrupt any causative treatments until improvement to Grade 0-1 2
• If pruritus is associated with a systemic disease, emergency management should include addressing the underlying condition while providing symptomatic relief 2

Cautions and Pitfalls

• Long-term use of sedative antihistamines may predispose to dementia and should be avoided except in palliative care 2
• Always check for drug interactions, particularly with hydroxyzine which may potentiate meperidine and barbiturates 1
• Be aware that some treatments are contraindicated in specific conditions (e.g., gabapentin in hepatic pruritus) 2
• Recognize that pruritus may be a manifestation of a serious underlying condition requiring urgent investigation beyond symptomatic treatment 3