What treatment options are available for pruritis (itching) in a 93-year-old female patient on prednisone (corticosteroid) for a skin condition?

Management of Pruritus in a 93-Year-Old Female on Prednisone

For a 93-year-old female on prednisone with pruritus, topical emollients and moderate-potency topical corticosteroids should be the first-line treatment, with oral non-sedating antihistamines as adjunctive therapy if needed. 1

Initial Assessment and First-Line Treatments

• Rule out other causes of pruritus, including drug effects, infections, or underlying systemic conditions 1
• Begin with topical treatments:
  • Emollients with high lipid content (preferred in elderly skin) 1
  • Moderate-potency topical corticosteroids (e.g., clobetasone butyrate) for at least 2 weeks to exclude asteatotic eczema 1
  • Topical menthol 0.5% can provide symptomatic relief 1

Second-Line Treatments

• If pruritus persists after initial topical treatments, consider:
  • Non-sedating antihistamines such as fexofenadine 180 mg or loratadine 10 mg, or mildly sedative agents such as cetirizine 10 mg 1
  • Combination of H1 and H2 antagonists (e.g., fexofenadine and cimetidine) 1
  • Topical anti-itch remedies such as refrigerated menthol and pramoxine 1

Important Considerations for Elderly Patients

• Avoid sedative antihistamines in elderly patients as they may increase risk of falls and cognitive impairment 1, 2
• Gabapentin may be beneficial for elderly patients with persistent pruritus, but start at lower doses and titrate slowly 1, 2
• Monitor for drug interactions due to polypharmacy common in elderly patients 2

For Severe or Refractory Pruritus

• Consider gabapentin or pregabalin if pruritus remains uncontrolled 1
• For pruritus without rash that is severe or limiting self-care activities:
  • Gabapentin (start at lower doses in elderly)
  • Pregabalin (25-150 mg daily)
  • Consider referral to dermatology 1

Monitoring and Follow-up

• Reassess after 2 weeks of treatment to evaluate response 1
• If symptoms worsen or don't improve, consider advancing to next treatment option 1
• Refer to secondary care if there is diagnostic doubt or if primary care management does not relieve symptoms 1

Cautions

• Prednisone itself can cause or exacerbate pruritus in some patients; consider if dose adjustment is possible 2
• Limit topical steroid use to avoid skin atrophy, especially in elderly skin 1
• Avoid long-term use of sedative antihistamines in the elderly except in palliative care settings 1
• Be cautious with systemic medications due to potential side effects in elderly patients 2