What can I prescribe for chronic itching in the elderly instead of Benadryl (diphenhydramine)?

Management of Chronic Itching in the Elderly: Alternatives to Diphenhydramine

For chronic itching in elderly patients, non-sedating antihistamines such as cetirizine, fexofenadine, or loratadine should be prescribed instead of Benadryl (diphenhydramine), along with high-lipid content emollients as first-line therapy. 1

First-Line Treatment Options

• Emollients with high lipid content should be the initial treatment for elderly skin, as they help restore the skin barrier and reduce dryness that commonly causes itching in older individuals 1, 2
• Topical steroids (such as 1% hydrocortisone) should be applied to affected areas for at least 2 weeks to exclude asteatotic eczema 1
• Non-sedating antihistamines are recommended for symptomatic relief:
  • Cetirizine 10 mg daily (mildly sedating but safer than diphenhydramine) 1, 3
  • Fexofenadine 180 mg daily 1
  • Loratadine 10 mg daily 1

Second-Line Treatment Options

• Consider combination of H1 and H2 antagonists (e.g., fexofenadine and cimetidine) for better control of symptoms 1
• Topical options that may provide benefit:
  • Topical clobetasone butyrate 1
  • Topical menthol preparations for cooling relief 2
• For refractory cases, consider gabapentin which has shown benefit specifically in elderly patients with pruritus 1

Treatments to Avoid in the Elderly

• Sedative antihistamines like diphenhydramine (Benadryl) should NOT be prescribed for elderly patients with pruritus due to increased risk of adverse effects 1
• Crotamiton cream is not recommended based on evidence 1
• Topical capsaicin and calamine lotion should be avoided 1

Important Considerations

• Chronic pruritus in the elderly is often multifactorial due to physiological changes in aging skin, including impaired skin barrier function and immunological changes 4
• Polypharmacy in elderly patients increases the risk of drug side effects that can cause or exacerbate itching 4
• Non-sedating antihistamines like cetirizine have been shown to provide similar efficacy to older sedating antihistamines but with significantly fewer central nervous system effects 5
• For difficult-to-treat cases, increasing the dose of non-sedating antihistamines up to 4-fold may improve symptoms without compromising safety 6
• Reassessment is necessary if symptoms don't improve after initial treatment 1
• Consider referral to secondary care if there is diagnostic doubt or if primary care management does not relieve symptoms 1

Treatment Algorithm

1. Start with high-lipid content emollients and topical steroids for 2 weeks
2. Add non-sedating antihistamine (cetirizine, fexofenadine, or loratadine)
3. If inadequate response, consider combination H1/H2 antihistamines
4. For persistent symptoms, consider gabapentin
5. Refer to dermatology if symptoms persist despite these interventions

Remember that chronic pruritus significantly affects quality of life in elderly patients, with impaired daily activities and sleep disturbances that can lead to depression or anxiety 4. Proper management focusing on non-sedating options is essential for improving outcomes.