Can hydroxyzine help with itching from atopic dermatitis?

Hydroxyzine for Itching in Atopic Dermatitis

Hydroxyzine can help with itching from atopic dermatitis, particularly for nighttime use due to its sedative properties, but should not be used as a primary treatment and is best reserved for short-term management of severe pruritus. 1

Efficacy and Role in Treatment

• First-generation antihistamines like hydroxyzine (25-50 mg daily) are primarily beneficial for their sedative properties and may be considered for patients suffering from pruritus during nighttime 1
• Hydroxyzine's therapeutic value in atopic dermatitis resides principally in its sedative effects, making it useful as a short-term adjuvant to topical treatment during relapses associated with severe pruritus 1
• The FDA has approved hydroxyzine for management of pruritus due to allergic conditions including atopic dermatitis at doses of 25 mg three to four times daily for adults 2

Treatment Algorithm

First-line approach:

• Focus on topical treatments (corticosteroids, calcineurin inhibitors) as the primary therapy for atopic dermatitis 1
• Address skin dryness with moisturizers and emollients to reduce pruritus 1

When to add hydroxyzine:

• For patients with Grade 2 or 3 pruritus (intense or widespread itching that limits activities or sleep) 1
• When sleep disturbance due to itching is significant 1
• During acute flares with severe pruritus 1

Dosing Considerations

• Adults: 25 mg three to four times daily for pruritus management 2
• Children under 6 years: 50 mg daily in divided doses 2
• Children over 6 years: 50-100 mg daily in divided doses 2
• In pediatric patients, a dose of 0.7 mg/kg three times daily has shown similar efficacy with less sedation compared to higher doses 3

Limitations and Precautions

• There is insufficient evidence to recommend the general use of antihistamines as part of the routine treatment of atopic dermatitis 1
• Non-sedating antihistamines have little to no value in atopic dermatitis unless there is concurrent urticaria or allergic rhinoconjunctivitis 1
• Tachyphylaxis (diminishing response) may occur with continued use, reducing the value of antihistamines over time 1
• Hydroxyzine should not be substituted for proper management of atopic dermatitis with appropriate topical therapies 1

Adverse Effects

• Sedation is the most common side effect and may be beneficial at night but problematic during the day 1, 3
• Other potential side effects include anticholinergic symptoms (dry mouth, blurred vision, tachycardia) 1
• In rare cases, hydroxyzine may worsen contact dermatitis in patients with sensitivities to ethylenediamines 4
• School performance in children may be negatively affected by sedating antihistamines, requiring attention to dosing schedule 1

Special Considerations

• Daytime use should generally be avoided due to sedative effects 1
• For pediatric patients, hydroxyzine at 0.7 mg/kg three times daily has demonstrated significant pruritus suppression with less sedation than higher doses 3
• Loratadine (a non-sedating antihistamine) has shown antipruritic effects in atopic dermatitis without the central nervous system effects of hydroxyzine, making it potentially preferable for daytime use when antihistamines are needed 5
• Effective control of itching can significantly contribute to controlling the eruption itself and improve the patient's physical and emotional well-being 6