What is the recommended management for senile pruritus?

Management of Senile Pruritus

For elderly patients with senile pruritus, initial treatment should consist of emollients with high lipid content and mild topical steroids for at least 2 weeks to treat any underlying asteatotic eczema. 1, 2

First-Line Treatment

• Apply emollients with high lipid content as the foundation of treatment to restore skin barrier function and reduce xerosis (dry skin), which is present in over 50% of elderly patients 2, 3
• Use mild topical steroids such as 1% hydrocortisone for at least 2 weeks, applied to affected areas no more than 3-4 times daily 1, 2
• Implement simple self-care advice such as keeping nails short to prevent excoriation and secondary infection 1, 4
• Consider topical menthol preparations for their cooling effect alongside emollients 2, 5

Second-Line Treatment

• If pruritus persists after initial treatment, reassess the patient to rule out underlying conditions 1, 2
• Add a short course of non-sedating antihistamines such as fexofenadine or loratadine 1, 2
• Consider gabapentin for elderly patients with persistent pruritus that doesn't respond to topical treatments and antihistamines 1, 2

Treatments to Avoid

• Sedating antihistamines should NOT be prescribed for elderly patients due to increased risk of adverse effects (Strength of recommendation C; Level of evidence 2++) 1, 2
• Crotamiton cream is not recommended for elderly skin pruritus 2
• Calamine lotion is not recommended as it may further dry the skin 2, 4

Referral Criteria

• Refer to secondary care if there is diagnostic doubt or if primary care management does not relieve symptoms 1
• Consider referral if pruritus is severe and affecting quality of life despite treatment 1, 6
• Refer if suspecting rare conditions such as bullous pemphigoid, which can present initially as pruritus without blisters in the elderly 1, 3

Special Considerations

• Pruritus in the elderly (Willan's itch) is very common and often associated with dry skin, but may also be caused by underlying systemic conditions in 20-30% of cases 1, 6
• Always consider medication-induced pruritus, particularly from calcium channel blockers and hydrochlorothiazide 3, 7
• Neuropathic pruritus should be considered, especially in patients with diabetes mellitus 3, 5
• Regular follow-up is essential as the underlying cause may not be evident initially 1, 4

Treatment Algorithm

1. Start with emollients and topical steroids for 2 weeks 1, 2
2. If no improvement, add non-sedating antihistamines 1, 2
3. For persistent symptoms, consider gabapentin 1, 2
4. If still unresponsive, refer to secondary care 1

Remember that xerosis treatment should be included in the initial therapy for all elderly patients with pruritus, as it is present in more than half of these patients 2, 3. The therapeutic approach should carefully balance efficacy against potential adverse effects, particularly given the high rates of comorbidities and polypharmacy in this population 6, 7.