What is the treatment for general pruritis?

Treatment of Generalized Pruritus

The treatment of generalized pruritus should first focus on identifying and treating the underlying cause, followed by a stepwise approach using topical therapies, systemic medications, and phototherapy based on the specific etiology and severity of symptoms. 1

Initial Approach

• Begin with a thorough investigation to identify potential underlying causes, including systemic diseases, medications, infections, or psychological factors 1
• Perform appropriate diagnostic testing based on clinical suspicion, which may include complete blood count, liver and renal function tests, thyroid studies, and screening for infections like HIV and hepatitis 1, 2
• A trial of medication cessation should be considered if drug-induced pruritus is suspected, when the risk-benefit ratio is acceptable 1

Treatment for Generalized Pruritus of Unknown Origin (GPUO)

First-line therapies:

• Provide self-care advice and prescribe emollients to maintain skin hydration 1
• Consider topical therapies:
  • Topical doxepin (limited to 8 days, 10% of body surface area, and 12g daily) 1
  • Topical clobetasone butyrate or menthol preparations 1
  • Avoid crotamiton cream, topical capsaicin, and calamine lotion as they are not recommended 1

Second-line therapies:

• Non-sedating antihistamines (H1 antagonists):
  • Fexofenadine 180 mg or loratadine 10 mg 1
  • Mildly sedative agents such as cetirizine 10 mg 1
  • Consider combination of H1 and H2 antagonists (e.g., fexofenadine and cimetidine) 1

Third-line therapies:

• Systemic medications:
  • Paroxetine, fluvoxamine, mirtazapine 1
  • Naltrexone, butorphanol 1
  • Gabapentin, pregabalin 1
  • Ondansetron or aprepitant 1
• Sedative antihistamines like hydroxyzine (25 mg three to four times daily for adults) should be used only short-term or in palliative settings due to potential risk of dementia with long-term use 1, 3

Alternative approaches:

• Consider acupuncture as a second-line therapy, potentially in combination with Chinese herbal remedies 1
• Referral to secondary care is recommended if there is diagnostic doubt or if primary care management fails to relieve symptoms 1

Specific Treatments Based on Underlying Causes

Hepatic pruritus:

• First-line: Rifampicin 1
• Second-line: Cholestyramine 1
• Third-line: Sertraline 1
• Fourth-line: Naltrexone or nalmefene 1
• Avoid gabapentin in hepatic pruritus 1
• Consider BB-UVB phototherapy or combined UVA and UVB for symptomatic relief 1

Uremic pruritus:

• Optimize dialysis, normalize calcium-phosphate balance, control parathyroid hormone levels, correct anemia, and use emollients 1
• Consider capsaicin cream, topical calcipotriol, or oral gabapentin 1
• BB-UVB phototherapy is highly effective (Strength of recommendation A) 1
• Avoid cetirizine as it is not effective in uremic pruritus 1

Drug-induced pruritus:

• For opioid-induced pruritus: Naltrexone is first-line if opioid cessation is not possible; methylnaltrexone is an alternative 1
• For postoperative pruritus: Diclofenac 100 mg rectally 1
• For chloroquine-induced pruritus: Prednisolone 10 mg, niacin 50 mg, or a combination; alternatively, dapsone 1

Pruritus in elderly patients:

• Initial treatment with emollients and topical steroids for at least 2 weeks to exclude asteatotic eczema 1
• Prefer moisturizers with high lipid content 1

Special Considerations

• Avoid long-term use of sedative antihistamines except in palliative care settings due to potential dementia risk 1
• For refractory cases, consider novel agents such as monoclonal antibodies, neurokinin-1 receptor antagonists, and opioid receptor modulators 4
• In cases of suspected psychological factors, consider behavioral interventions, relaxation techniques, and cognitive restructuring 1
• Patient support groups can be beneficial for chronic pruritus management 1