What is the initial management for patients presenting with pruritus?

Initial Management of Pruritus

For patients presenting with pruritus, the initial management should include self-care advice and emollients, followed by a short trial of a non-sedating antihistamine if warranted. 1

Assessment and Initial Management Algorithm

Step 1: Initial Assessment

• Determine if pruritus is generalized or localized to help guide diagnosis 1, 2
• Consider that 20-30% of generalized pruritus cases may have a significant underlying cause 1
• Review medication history, as certain drugs can cause pruritus 1
• Assess for risk factors of underlying systemic disease 1

Step 2: First-line Management

• Provide self-care advice:
  • Keep fingernails short to minimize skin damage from scratching 1
  • Avoid hot water and harsh soaps that can exacerbate dry skin 3
  • Use emollients regularly to maintain skin hydration 1
• Prescribe emollients as the foundation of treatment 1
• For elderly patients (>65 years), use moisturizers with high lipid content 1

Step 3: Pharmacologic Intervention

• If initial measures are insufficient, add a short course of non-sedating antihistamine:
  • Options include fexofenadine 180 mg or loratadine 10 mg daily 1
  • Mildly sedating agents such as cetirizine 10 mg may also be considered 1
• For elderly patients, avoid sedating antihistamines due to risk of adverse effects 1
• Consider combination of H1 and H2 antagonists (e.g., fexofenadine and cimetidine) in refractory cases 1

Special Populations

Elderly Patients

• Initially treat with emollients and topical steroids for at least 2 weeks to exclude asteatotic eczema 1
• Prefer moisturizers with high lipid content 1
• Consider gabapentin for persistent pruritus 1
• Avoid sedating antihistamines due to increased risk of falls and cognitive impairment 1

Patients with Inflammatory Causes

• Apply topical anti-inflammatory therapies such as hydrocortisone 2.5% or triamcinolone 0.1% 3
• For elderly patients with asteatotic eczema, use topical steroids for at least 2 weeks 1

Patients with Neuropathic Pruritus

• Consider topical agents such as menthol, pramoxine, or lidocaine 3, 2
• For persistent cases, consider gabapentin, particularly in elderly patients 1, 3

When to Refer to Secondary Care

• Refer patients when there is diagnostic uncertainty 1
• Refer if symptoms persist despite appropriate primary care management 1
• Consider referral if pruritus is significantly impacting quality of life 1, 3

Common Pitfalls and Caveats

• Don't assume all pruritus is due to dry skin or allergies; 20-30% of cases have significant underlying causes 1
• Avoid sedating antihistamines (like hydroxyzine) except for short-term use or in palliative settings 1, 4
• Don't overlook the need for regular follow-up, as the underlying cause may not be initially evident 1
• Be aware that pruritus in the elderly can rarely be the presenting feature of bullous pemphigoid 1
• Remember that chronic pruritus (>6 weeks) significantly impacts quality of life and sleep, requiring more aggressive management 3

Alternative Approaches for Refractory Cases

• Consider topical doxepin (limited to 8 days, 10% of body surface area, and 12 g daily) 1
• Topical menthol or clobetasone butyrate may provide relief 1, 2
• Avoid crotamiton cream, topical capsaicin, or calamine lotion due to limited efficacy 1
• For persistent cases, consider medications such as paroxetine, mirtazapine, naltrexone, gabapentin, pregabalin, ondansetron, or aprepitant 1, 3
• Acupuncture may be considered as a second-line therapy 1