What is the initial management for an elderly male with a history of colostomy presenting with chronic generalized pruritus?

Management of Chronic Generalized Pruritus in an Elderly Male with Colostomy

The initial management for an elderly male with a history of colostomy presenting with chronic generalized pruritus should begin with emollients with high lipid content and a mild topical steroid such as 1% hydrocortisone for at least 2 weeks. 1, 2

Initial Assessment and First-Line Treatment

• Evaluate for xerosis (dry skin), which affects over 50% of elderly patients and is a common cause of pruritus in this population 3
• Apply emollients with high lipid content as the cornerstone of initial therapy, focusing on thorough coverage of the entire body, including the peristomal area 1, 2
• Use mild topical steroids such as 1% hydrocortisone for at least 2 weeks to exclude asteatotic eczema 1, 2
• Ensure proper colostomy care and assess the peristomal skin for irritation, which may contribute to generalized pruritus 1
• Consider topical clobetasone butyrate or menthol preparations for additional relief 2

Second-Line Treatment Options

• If no improvement after 2 weeks of topical therapy, consider non-sedating antihistamines such as fexofenadine 180 mg or loratadine 10 mg 2
• Consider combination of H1 and H2 antagonists, such as fexofenadine with cimetidine 2
• Gabapentin may be beneficial for elderly patients with persistent pruritus not responding to topical treatments 2, 4
• For localized pruritus around the colostomy site, consider topical doxepin, limiting treatment to 8 days and 10% of body surface area 2

Diagnostic Workup

• Check full blood count and ferritin levels to rule out iron deficiency or iron overload, which can cause generalized pruritus 2
• Perform liver function tests, urea and electrolytes to exclude hepatic and renal causes 2
• Consider thyroid function tests if clinical features suggest thyroid disease 2
• Evaluate medication list for potential pruritus-inducing drugs, particularly calcium channel blockers and hydrochlorothiazide 3

Important Considerations for Elderly Patients with Colostomy

• Avoid sedating antihistamines (including hydroxyzine) in elderly patients as they may increase risk of dementia and cause excessive sedation 2, 5
• Do NOT use crotamiton cream as it has been shown to be ineffective for generalized pruritus 2
• Avoid topical capsaicin or calamine lotion as they are not recommended for elderly skin pruritus 2
• Reassess if symptoms don't improve after initial treatment 2
• Consider referral to secondary care if there is diagnostic doubt or if primary care management does not relieve symptoms 2

Special Considerations for Colostomy Patients

• Assess for contact dermatitis related to colostomy appliances or adhesives 1
• Evaluate for fungal infections around the stoma site that may trigger generalized pruritus 1
• Consider modification of colostomy care routine, including gentle cleansing and use of barrier products 1

When to Refer to Secondary Care

• If pruritus persists despite primary care management 2
• If there is diagnostic uncertainty or suspicion of underlying systemic disease 2
• If there are signs of secondary skin changes due to chronic scratching 6
• If quality of life is significantly impacted despite initial management 4