What heart failure medications can cause dry skin and prurigo?

Heart Failure Medications That Cause Dry Skin and Pruritus

Thiazide diuretics, particularly hydrochlorothiazide, are the most common heart failure medications causing dry skin and pruritus through photosensitivity reactions, while loop diuretics like furosemide can cause pruritus and rashes as direct adverse effects. 1, 2, 3

Primary Culprits: Diuretics

Thiazide Diuretics

• Hydrochlorothiazide is the most frequently implicated agent, especially when combined with amiloride (5 mg hydrochlorothiazide/50 mg amiloride combination), which has the highest recorded adverse drug reactions among diuretics, with 59% being dermatological and half presenting as phototoxic eczema 3
• Thiazides trigger multiple cutaneous reactions including phototoxic/photoallergic eruptions, vasculitis, erythema multiforme, and eczema 3
• These reactions occur through drug-induced photosensitivity when the drug is present in skin exposed to ultraviolet or visible radiation 1

Loop Diuretics

• Furosemide directly causes pruritus and rash as listed adverse effects in its FDA labeling, along with purpura, photosensitivity, urticaria, and bullous eruptions in rare cases 2, 3
• The mechanism involves direct dermatologic-hypersensitivity reactions rather than solely photosensitivity 2

Secondary Offenders: Other Heart Failure Medications

Amiodarone (if used for arrhythmias in HF patients)

• Causes drug-induced photosensitivity in >50% of treated patients, presenting as burning, tingling sensation, and erythema on sun-exposed skin 1
• Can induce distinctive blue-grey pigmentation on sun-exposed sites in 1-2% of patients after long-term exposure 1

ACE Inhibitors

• Captopril induces pruritus in up to 15% of patients and skin eruptions in 2% 3
• Other ACE inhibitors used in heart failure may have similar but less well-documented dermatologic effects 3

Mineralocorticoid Receptor Antagonists (MRAs)

• Spironolactone can cause skin reactions, though the primary concern is gynecomastia in males rather than pruritus 1

Important Clinical Context

Pruritus from Heart Failure Itself

• Recent evidence shows that pruritus in CHF patients correlates with NYHA class severity (31.2% in NYHA III+IV vs 21.1% in NYHA I+II), independent of medication effects 4
• The British Association of Dermatologists notes that generalized pruritus associated with chronic heart failure is currently thought to be related to treatment rather than the cardiac condition itself 1
• This creates diagnostic complexity: is the pruritus from the disease or the drugs? 1, 4

Prevalence Data

• 40% of CHF patients experience itching at some point over 3 months, with 13.6% experiencing weekly itching without rash 5
• Patients with CHF describe their pruritus as more disturbing than patients with coronary artery disease 5

Practical Management Algorithm

Step 1: Identify the Medication

• Review all diuretics first (thiazides > loop diuretics > potassium-sparing agents) 3
• Check for amiodarone if patient has atrial fibrillation 1
• Consider ACE inhibitors, particularly captopril 3

Step 2: Assess Sun Exposure Pattern

• If pruritus/rash occurs primarily on sun-exposed areas (face, arms, upper chest), suspect photosensitivity from thiazides or amiodarone 1, 3
• Advise seeking shade during midday, wearing protective clothing, broad-brimmed hats, and broad-spectrum sunscreen SPF 30+ 1

Step 3: Medication Adjustment Strategy

• For thiazide-related photosensitivity: Switch to loop diuretic if clinically appropriate for volume management 1
• For furosemide-related pruritus: Consider dose reduction if patient is euvolemic, or trial of alternative loop diuretic (bumetanide, torsemide) 1, 2
• For spironolactone in males with skin issues: Switch to eplerenone 1
• For captopril: Switch to alternative ACE inhibitor (enalapril, lisinopril) which have lower reported dermatologic adverse effect rates 3

Step 4: Rule Out Other Causes

• Verify patient is not taking NSAIDs (can worsen both heart failure and cause rash) 1
• Check for stasis dermatitis (associated with pruritus in CHF patients) 4
• Assess for xerosis (dry skin from volume depletion with excessive diuresis) 1

Critical Pitfalls to Avoid

• Do not assume all pruritus in CHF is from xerosis alone—medication-induced photosensitivity is a distinct and common mechanism requiring different management 1, 3
• Do not discontinue diuretics without ensuring adequate alternative volume management, as fluid overload itself worsens outcomes 1
• Avoid prescribing topical corticosteroids without identifying the underlying cause, as photosensitivity reactions require sun protection and possible medication change rather than just symptomatic treatment 1
• Remember that combination diuretic therapy (e.g., loop + thiazide) increases risk of all adverse effects including dermatologic reactions 1, 3