What is the treatment for pruritus or itchiness all over the body, specifically using Avil (hydroxyzine) and hydrocot (hydrocortisone)?

Management of Generalized Pruritus with Hydroxyzine (Avil) and Hydrocortisone

For generalized pruritus (itchiness all over the body), a combination of hydroxyzine (Avil) and topical hydrocortisone can be effective, with hydroxyzine providing systemic relief while hydrocortisone addresses localized symptoms. 1

First-Line Approach

Systemic Treatment

• Hydroxyzine (25-50 mg daily) is recommended as a sedative antihistamine for short-term or palliative treatment of generalized pruritus, particularly useful for nighttime relief due to its sedative properties 1
• Start with lower doses (25 mg) in elderly patients to avoid oversedation and confusion 2
• Monitor for potential side effects including drowsiness, dizziness, dry mouth, and sedation 3

Topical Treatment

• Hydrocortisone cream can be applied to affected areas 2-3 times daily for up to 7 days 1, 4
• Limit application to less than 10% of body surface area 4
• Do not use in genital areas if there is vaginal discharge, and avoid use in diaper rash without medical consultation 4

Treatment Algorithm

Step 1: Initial Management

• Begin with emollients to address any underlying skin dryness 5
• Apply topical hydrocortisone to affected areas (avoid eyes, rectum, and limit to 7 days of use) 4
• Start hydroxyzine 25 mg at bedtime for adults (reduce dose in elderly) 2

Step 2: For Inadequate Response After 2 Weeks

• Increase hydroxyzine dose if needed (up to 50 mg daily) 1
• Consider adding non-sedating antihistamines during daytime (fexofenadine 180 mg or loratadine 10 mg) 1, 5
• Consider combination of H1 and H2 antagonists (e.g., fexofenadine and cimetidine) 1

Step 3: For Refractory Cases

• Consider alternative agents such as gabapentin, pregabalin, or paroxetine 1, 5
• Refer to dermatology for consideration of phototherapy (BB-UVB) 1

Special Considerations

Underlying Causes

• Investigate for potential underlying causes including systemic diseases (liver, kidney, hematologic disorders), infections, or drug reactions 1
• Consider specific treatments based on underlying cause:
  • For hepatic pruritus: rifampicin as first-line 1
  • For uremic pruritus: ensure adequate dialysis and consider gabapentin 1

Important Cautions

• Hydroxyzine may cause QT prolongation - use with caution in patients with cardiac risk factors 2
• Avoid hydroxyzine in patients with known sensitivity to ethylenediamine compounds due to risk of systemic contact dermatitis 6, 7, 8
• Limit hydrocortisone use to 7 days; if symptoms persist or worsen, reevaluation is necessary 4
• Avoid driving or operating machinery while taking hydroxyzine due to sedative effects 2
• Long-term use of sedative antihistamines may predispose to dementia and should be avoided except in palliative care 1

Efficacy Evidence

• In a real-world observational study, hydroxyzine significantly improved symptoms of pruritus and quality of life over 12 weeks 3
• In a randomized clinical trial, hydroxyzine 25 mg/day showed greater efficacy than cetirizine 10 mg/day in controlling chronic pruritus symptoms 9

This approach provides both immediate symptomatic relief through hydroxyzine's antihistamine effects and localized anti-inflammatory action through hydrocortisone, addressing the dual components of generalized pruritus while monitoring for potential adverse effects.