What are the management options for pruritus?

Management of Pruritus

For generalized pruritus without an underlying dermatosis, start with emollients and a short course of non-sedating antihistamines as first-line therapy, followed by targeted treatments based on underlying cause if identified. 1, 2

Initial Assessment and Management

• Determine if pruritus is generalized or localized, as 20-30% of generalized pruritus cases may have a significant underlying cause 2
• Review medication history, as certain drugs can trigger pruritus 2
• Recommend self-care measures including keeping fingernails short to minimize skin damage and using emollients regularly 2
• Prescribe emollients as the foundation of treatment for all patients with pruritus 1
• For elderly patients, moisturizers with high lipid content are preferred 1

First-Line Pharmacologic Interventions

• Add a short course of non-sedating antihistamine (e.g., fexofenadine 180 mg or loratadine 10 mg daily) if initial measures are insufficient 1, 2
• Avoid sedating antihistamines in elderly patients due to increased risk of falls and cognitive impairment 1, 2
• Topical treatments that may provide relief include:
  • Topical doxepin (limited to 8 days, 10% of body surface area, maximum 12 g daily) 1
  • Topical clobetasone butyrate or hydrocortisone for temporary relief 1, 3
  • Menthol-containing preparations for counter-irritant effect 1

Treatment Based on Underlying Cause

For Generalized Pruritus of Unknown Origin (GPUO)

• After excluding underlying causes, use emollients and avoid soaps and physical triggers like wool clothing 1
• Do not use crotamiton cream, topical capsaicin, or calamine lotion as they lack efficacy 1

For Specific Secondary Causes

• Iron deficiency: Iron replacement 1
• Iron overload: Venesection or desferrioxamine infusion 1
• Lymphoma-associated pruritus: Consider cimetidine, carbamazepine, gabapentin, or mirtazapine 1
• Polycythemia vera: Consider cytoreductive therapy, aspirin, interferon-α, SSRIs, phototherapy, cimetidine, or atenolol 1
• Solid cancers: Paroxetine, mirtazapine, granisetron, or aprepitant may provide relief 1
• Uremic pruritus: Ensure adequate dialysis, normalize calcium-phosphate balance, use emollients, consider capsaicin cream, topical calcipotriol, or oral gabapentin 1
• Hepatic pruritus: Consider rifampicin as first-line treatment, followed by cholestyramine and sertraline 1

Phototherapy Options

• Broadband UVB (BB-UVB) is effective for many patients with uremic pruritus 1
• Narrowband UVB (NB-UVB) may benefit patients with pruritus associated with non-Hodgkin lymphoma 1
• Phototherapy (NB-UVB, BB-UVB, PUVA) may help relieve itch in polycythemia vera and aquagenic pruritus 1

Special Considerations for Elderly Patients

• Initially treat with emollients and topical steroids for at least 2 weeks to exclude asteatotic eczema 1
• Consider gabapentin for persistent pruritus in the elderly 1
• Avoid sedating antihistamines due to risk of adverse effects 1
• Be aware that pruritus in the elderly can rarely be the presenting feature of bullous pemphigoid 1

Alternative Approaches for Refractory Cases

• Consider acupuncture or acupressure for uremic pruritus 1
• Aromatherapy may provide benefit in uremic pruritus 1
• For drug-induced pruritus (e.g., opioid-induced), consider ondansetron, droperidol, mirtazapine, or gabapentin 1

Referral Guidelines

• Refer to secondary care if there is diagnostic uncertainty or if symptoms persist despite appropriate primary care management 1, 2
• Regular follow-up is important as underlying systemic causes may not be initially evident 1

Common Pitfalls to Avoid

• Don't assume all pruritus is due to dry skin or allergies; 20-30% of cases have significant underlying causes 2
• Avoid long-term use of sedating antihistamines except in palliative care settings 1
• Don't use gabapentin in hepatic pruritus 1
• Recognize that topical treatments alone are often insufficient for systemic causes of pruritus 4