What are alternative medications to hydroxyzine (antihistamine) for treating itching?

Alternative Medications for Itching Other Than Hydroxyzine

Second-generation antihistamines like cetirizine (10mg daily) are the preferred alternative to hydroxyzine for treating itching, offering similar efficacy with significantly less sedation and cognitive impairment. 1, 2

First-Line Alternatives

Non-Sedating Second-Generation Antihistamines

• Cetirizine 10mg daily - provides 24-hour relief of itching with minimal sedation, making it ideal for daytime use 1, 3
• Loratadine 10mg daily - effective for pruritus with minimal central nervous system effects 2
• Fexofenadine 180mg daily - offers relief of itching symptoms with negligible sedation 2, 4

Topical Options

• Moderate-potency topical corticosteroids (mometasone furoate 0.1% or betamethasone valerate 0.1%) for localized itching 2
• Emollients and lotions containing urea or polidocanol for soothing effect and preventing skin dryness 2
• Menthol creams for widespread itching (though efficacy may be limited) 5, 2

Second-Line Alternatives

For Refractory Itching

• Gabapentin (900-3600mg daily) - particularly effective for neuropathic itching 2
• Pregabalin (25-150mg daily) - alternative to gabapentin with similar mechanism 2
• Doxepin - a tricyclic antidepressant with potent antihistamine properties 2
• SSRIs such as paroxetine or sertraline - effective for certain types of pruritus 2

Condition-Specific Alternatives

• For cholestatic itching: Ursodeoxycholic acid (UDCA) at 10-15 mg/kg per day, which can be divided into 2-3 daily doses 5
• For hepatic pruritus: Rifampicin as first-line treatment 2
• For uremic pruritus: Capsaicin cream or topical calcipotriol 2

Clinical Considerations

Advantages of Second-Generation Antihistamines

• Less sedation and cognitive impairment compared to first-generation antihistamines like hydroxyzine 1, 6
• Comparable efficacy to first-generation antihistamines in relieving pruritus 6, 7
• Once-daily dosing improves compliance 6
• Minimal anticholinergic effects 6

Special Populations

• Elderly patients: Avoid first-generation antihistamines due to risk of cognitive impairment; prefer second-generation options 1, 2
• Pregnancy: Second-generation antihistamines may be safer than hydroxyzine, which is contraindicated in early pregnancy 1
• Renal impairment: Dose adjustments necessary for many antihistamines 1
• Liver disease: Avoid hydroxyzine and use alternatives with caution 1

Common Pitfalls

• Antihistamines primarily relieve histamine-mediated itching but may be less effective for non-histaminergic pruritus 8
• Long-term use of sedating antihistamines in elderly patients may increase risk of dementia 2
• Gabapentin should not be used in hepatic pruritus despite efficacy in other forms of pruritus 2
• Antihistamines alone may be insufficient for complex pruritus cases requiring combination therapy 2, 7

Treatment Algorithm

1. Start with non-sedating second-generation antihistamine (cetirizine, loratadine, or fexofenadine) for daytime relief 1, 2
2. If nighttime itching is problematic, consider low-dose first-generation antihistamine (diphenhydramine 25-50mg) for bedtime only 2
3. For inadequate response, consider:
   • Increasing antihistamine dose 2
   • Adding H2 antihistamines 2
   • Switching to alternative treatments like gabapentin or doxepin 2
4. For specific causes of pruritus, use targeted therapies (UDCA for cholestatic itching, rifampicin for hepatic pruritus) 5, 2