Topical Treatment for Urticaria in Dialysis Patients
Critical Distinction: True Urticaria vs. Uremic Pruritus
The approach depends entirely on whether you are treating true urticaria (wheals/hives) or uremic pruritus (generalized itching without wheals), as these are distinct conditions requiring different treatments. 1
For TRUE URTICARIA (Wheals/Hives)
First-Line Topical Approach
There are no specific topical treatments recommended for true urticaria in dialysis patients—systemic antihistamines are the mainstay. 1, 2 However, supportive topical measures include:
- Hydrocortisone cream 0.5-1% applied to affected areas 3-4 times daily for temporary relief of inflammation and itching 3
- Pramoxine topical preparations for temporary relief of itching associated with minor skin irritations 4
Systemic Treatment (Primary Management)
- Fexofenadine 180 mg daily is the preferred antihistamine, requiring no dose adjustment in renal impairment 1, 5
- Can be updosed to 720 mg daily (4-fold increase) if inadequate response, with minimal increase in somnolence 1
- Avoid cetirizine and levocetirizine in severe renal impairment (CrCl <10 mL/min) 1, 5
- Avoid long-term sedating antihistamines (diphenhydramine, hydroxyzine) except in palliative care due to dementia risk 6, 1, 5
For UREMIC PRURITUS (Generalized Itching Without Wheals)
Optimize Dialysis Parameters First
Before any topical treatment, ensure: 6, 1, 7
- Adequate dialysis with Kt/V target of approximately 1.6 6, 1, 7
- Normalized calcium-phosphate balance and controlled parathyroid hormone levels 1, 7
- Correction of anemia with erythropoietin if present 1, 7
First-Line Topical Treatment
Emollients are essential foundational therapy for xerosis (dry skin), which is the most common cutaneous manifestation in dialysis patients and lowers the threshold for itch 1, 7
Second-Line Topical Treatment
Capsaicin 0.025% cream applied four times daily is the most effective topical agent for uremic pruritus, with 14 of 17 patients reporting marked relief and 5 achieving complete remission in randomized trials 6, 1, 7
- Capsaicin works by depleting neuropeptides including substance P in peripheral sensory neurons 7
- Patients should be warned about initial burning sensation that typically diminishes with continued use
Alternative Topical Options
- Topical calcipotriol can be considered for localized areas 6, 7
- Topical doxepin for severe cases, but limit to 8 days, 10% body surface area, and 12 g daily due to systemic absorption risk 7
Most Effective Systemic Treatment (Not Topical)
Gabapentin 100-300 mg after each dialysis session (three times weekly) is the most effective medication for uremic pruritus, with significantly lower doses than non-ESRD populations due to reduced renal clearance 6, 1, 7
- A multicentre, double-blind, placebo-controlled trial showed visual analogue ratings falling in excess of 50% compared with placebo 6
- Common side effects include mild drowsiness 7
Phototherapy Option
Broad-band UVB phototherapy is effective for many patients with uremic pruritus when topical treatments are insufficient 1, 7
Critical Pitfalls to Avoid
- Do not use cetirizine for uremic pruritus—it is specifically ineffective despite efficacy in other conditions 6, 1, 7, 5
- Avoid long-term sedating antihistamines except in palliative care due to dementia risk 6, 1, 5
- Antihistamines have limited efficacy for uremic pruritus compared to gabapentin 5
- Renal transplantation is the only definitive treatment for uremic pruritus but is not always feasible 6, 7