What are the treatment options for itching?

Treatment Options for Itching

The most effective treatment for itching depends on the underlying cause, with first-line options including topical treatments such as emollients, moderate to high-potency topical corticosteroids, and antihistamines for specific conditions. 1

Initial Approach to Itching

• Patients with generalized pruritus without rash (GPUO) should receive self-care advice and emollients as first-line treatment 1
• Topical treatments should be selected based on the underlying cause and severity of itching 1
• For mild or localized itching, topical moderate/high-potency steroids are recommended 1

Topical Treatment Options

Corticosteroids

• Topical corticosteroids are effective for inflammatory causes of itching 1, 2
• Hydrocortisone can temporarily relieve itching associated with minor skin irritations, inflammation, and rashes due to eczema, poison ivy, insect bites, and other causes 2
• For adults and children 2 years and older, apply hydrocortisone to affected area no more than 3-4 times daily 2
• Medium to high-potency topical steroid formulations are recommended for body areas, while low-potency hydrocortisone should be used on the face to avoid skin atrophy 1

Other Topical Agents

• Topical menthol may provide relief for generalized pruritus of unknown origin 1
• Patients with GPUO may benefit from topical clobetasone butyrate 1
• Topical doxepin can be prescribed for GPUO, but treatment should be limited to 8 days, 10% of body surface area, and 12g daily 1
• Topical pramoxine hydrochloride (1%) provides both rapid and long-lasting relief of itching 3

Treatments to Avoid

• Crotamiton cream should not be used for GPUO (Strength of recommendation B) 1
• Topical capsaicin or calamine lotion are not recommended for GPUO 1
• Topical antihistamines might increase the risk of contact dermatitis 1

Systemic Treatment Options

Antihistamines

• For GPUO, consider non-sedative antihistamines (H1 antagonists) such as fexofenadine 180 mg or loratadine 10 mg, or mildly sedative agents such as cetirizine 10 mg orally 1
• Consider H1 and H2 antagonists in combination, for example fexofenadine and cimetidine 1
• Non-sedating, second-generation antihistamines (such as loratadine, 10 mg daily) are recommended as first choice for systemic therapy during daytime 1
• First-generation antihistamines (diphenhydramine 25-50 mg daily or hydroxyzine 25-50 mg daily) may be considered for nighttime due to their sedative properties 1
• Sedative antihistamines should be used only in the short-term or palliative setting 1
• Sedative antihistamines should not be prescribed for elderly patients with pruritus 1

Other Systemic Medications

• For intense or widespread itching that limits self-care activities, consider GABA agonists (pregabalin/gabapentin) 1
• For GPUO, consider paroxetine, fluvoxamine, mirtazapine, naltrexone, butorphanol, gabapentin, pregabalin, ondansetron or aprepitant orally 1
• Naltrexone is effective in treating opioid-induced generalized pruritus and is the first-choice recommendation if cessation of opioid therapy is impossible 1

Condition-Specific Treatments

Hepatic Pruritus

• Consider rifampicin as first-line treatment for hepatic pruritus 1
• Cholestyramine as second-line treatment and sertraline as third-line treatment 1
• Do not use gabapentin in hepatic pruritus 1

Uremic Pruritus

• Ensure adequate dialysis, normalize calcium-phosphate balance, control parathyroid hormone levels, correct anemia with erythropoietin, and use simple emollients 1
• Consider capsaicin cream, topical calcipotriol, or oral gabapentin 1
• BB-UVB is an effective treatment for many patients with uremic pruritus 1
• Auricular acupressure or aromatherapy may be beneficial 1

Drug-Induced Pruritus

• A trial of cessation of medications should be undertaken if the risk vs. benefit analysis is acceptable 1
• For chloroquine-induced pruritus, consider prednisolone 10 mg, niacin 50 mg, or a combination 1

Special Considerations

Elderly Patients

• Patients with pruritus in elderly skin should initially receive emollients and topical steroids for at least 2 weeks to exclude asteatotic eczema 1
• Moisturizers with high lipid content are preferred in the elderly 1
• Gabapentin may benefit elderly patients with pruritus 1
• Sedative antihistamines should not be prescribed for elderly patients 1

When to Refer

• Patients with GPUO should be referred to secondary care if there is diagnostic doubt or if primary care management does not relieve symptoms 1
• Patients with neuropathic pruritus should be referred to the relevant specialist for treatment 1

Pitfalls and Caveats

• Topical corticosteroids applied to sites of positive immediate-type allergy skin tests do not provide relief of itching 4
• Long-term use of sedative antihistamines may predispose to dementia and should be avoided except in palliative care 1
• Cetirizine is not effective in uremic pruritus 1
• The application of corticosteroid cream to sites of positive immediate-type allergy skin tests does not provide relief of itching and should be abandoned 4