Treatment Options for Itchy Skin (Pruritus)
The first-line treatment for generalized pruritus should include self-care advice and emollients, with specific therapies tailored to the underlying cause when identified. 1
Initial Approach to Pruritus
- Identify and treat any underlying cause of pruritus, as treatment varies significantly depending on etiology 1
- For all types of pruritus, emollients and moisturizers should be applied at least once daily to the whole body as a foundation of treatment 1
- Avoid triggers that can worsen pruritus such as hot showers, excessive use of soaps, and alcohol-containing lotions 1
Treatment Options Based on Severity
Mild Pruritus (Grade 1)
- Apply topical treatments:
- For adults and children over 2 years, apply topical treatments no more than 3-4 times daily 2
Moderate Pruritus (Grade 2)
- Continue topical treatments as above
- Add oral antihistamines:
- Consider combination of H1 and H2 antagonists (e.g., fexofenadine and cimetidine) 1
Severe Pruritus (Grade 3 or intolerable Grade 2)
- Intensify topical treatments
- Consider GABA agonists such as pregabalin (25-150 mg daily) or gabapentin (900-3600 mg daily) 1
- Consider referral to dermatologist if no improvement after 2 weeks 1
Specific Treatment Based on Underlying Cause
Pruritus Due to Dry Skin (Xerosis)
- Apply oil-in-water creams or ointments rather than lotions 1
- For inflammatory conditions like eczema, use topical steroid preparations such as prednicarbate cream 1
- For severe cases, short-term oral systemic steroids may be needed 1
Pruritus Associated with Systemic Diseases
Uremic Pruritus
- Ensure adequate dialysis, normalize calcium-phosphate balance, and control parathyroid hormone levels 1
- Consider capsaicin cream, topical calcipotriol, or oral gabapentin 1
- Broad-band UVB (BB-UVB) phototherapy is effective (Strength of recommendation A) 1
- Avoid long-term sedative antihistamines except in palliative care 1
Hepatic Pruritus
- First-line: Rifampicin (Strength of recommendation A) 1
- Second-line: Cholestyramine 1
- Third-line: Sertraline 1
- Do not use gabapentin in hepatic pruritus 1
Pruritus Associated with Malignancy
- For lymphoma-associated pruritus: cimetidine, carbamazepine, gabapentin, or mirtazapine 1
- For solid tumor paraneoplastic pruritus: paroxetine, mirtazapine, granisetron, or aprepitant 1
- UVB phototherapy may provide temporary relief 1
Drug-Induced Pruritus
- If possible, discontinue the suspected medication (risk vs. benefit analysis) 1
- For opioid-induced pruritus: naltrexone or methylnaltrexone (Strength of recommendation B) 1
- For chloroquine-induced pruritus: prednisolone 10 mg, niacin 50 mg, or a combination 1
Pruritus of Unknown Origin (GPUO)
- Self-care advice and emollients as foundation therapy 1
- Topical options: doxepin (limited to 8 days, 10% of body surface area), clobetasone butyrate, menthol 1
- Avoid crotamiton cream (Strength of recommendation B), topical capsaicin, or calamine lotion 1
- Consider paroxetine, fluvoxamine, mirtazapine, naltrexone, gabapentin, pregabalin, ondansetron, or aprepitant 1
Special Considerations
Elderly Patients
- Use emollients and topical steroids for at least 2 weeks to exclude asteatotic eczema 1
- Prefer moisturizers with high lipid content 1
- Be cautious with sedating antihistamines due to potential cognitive side effects 1
Psychological Factors in Chronic Pruritus
- Consider psychosocial and behavioral interventions including relaxation techniques and cognitive restructuring 1
- Patient support groups can be beneficial 1
- Referral to mental health professionals may be helpful in individual cases 1
Common Pitfalls to Avoid
- Overuse of sedating antihistamines, especially in the elderly, may predispose to dementia 1
- Failing to identify and treat underlying systemic causes before focusing solely on symptomatic treatment 1
- Using alcohol-containing products that can worsen skin dryness 1
- Treating all pruritus the same way, when different etiologies require specific approaches 3