What are the treatment options for pruritus (itching) in patients with Chronic Kidney Disease (CKD)?

Treatment of Pruritus in Chronic Kidney Disease

Start with optimizing dialysis adequacy (target Kt/V ~1.6), normalizing calcium-phosphate balance, controlling parathyroid hormone, correcting anemia with erythropoietin, and providing emollients before escalating to pharmacologic therapy. 1

Initial Management: Optimize Underlying CKD Parameters

Before initiating specific antipruritic medications, address these fundamental issues that directly contribute to uremic pruritus:

• Ensure adequate dialysis with a target Kt/V of approximately 1.6, as pruritus is significantly more common in underdialyzed patients 2, 1
• Normalize calcium-phosphate balance and control parathyroid hormone levels to accepted targets, since secondary and tertiary hyperparathyroidism frequently accompany ESRD and contribute to pruritus 2, 1
• Correct anemia with erythropoietin if present 1
• Provide emollients as supportive care to address xerosis (dry skin), which is the most common cutaneous sign in dialysis patients and lowers the threshold for itch 1

First-Line Pharmacologic Treatment: Gabapentin

Gabapentin 100-300 mg after each dialysis session (three times weekly) is the most effective medication for chronic uremic pruritus in hemodialysis patients. 1

• These doses are substantially lower than those used in non-ESRD populations due to reduced renal clearance 1
• Multicentre, double-blind, placebo-controlled trials demonstrate good response rates with significant reduction in visual analogue ratings 1
• Common side effects include mild drowsiness 1
• This represents the strongest evidence-based systemic treatment option 3

Second-Line Treatment: Topical Capsaicin

For patients who cannot tolerate or fail gabapentin, topical capsaicin 0.025% cream applied four times daily to affected areas is highly effective. 1, 4

• Randomized trials show 14 out of 17 patients reporting marked relief, with 5 achieving complete remission 1
• Acts by depleting neuropeptides including substance P in peripheral sensory neurons 1
• FDA labeling recommends applying a thin film to affected areas and rubbing in until fully absorbed, 3-4 times daily 4
• Wash hands thoroughly with soap and water immediately after application unless treating hands 4

Third-Line Treatment: Phototherapy

Broad-band UVB (BB-UVB) phototherapy is effective for many patients with uremic pruritus when first-line treatments fail. 2, 1

• This carries a Strength of recommendation A from the British Association of Dermatologists 2
• Particularly useful for patients with widespread pruritus 1

Additional Treatment Options

Topical Doxepin (Short-term Use Only)

• Can be considered for severe cases, but treatment must be strictly limited to 8 days, 10% of body surface area, and maximum 12 g daily 1
• Complete resolution reported in 58% of patients versus 8% on placebo 1
• Caution advised due to potential drowsiness 1

Topical Calcipotriol

• Can be used for localized areas of pruritus 1

Alternative Complementary Approaches

• Auricular acupressure or aromatherapy may be considered 2

Critical Pitfalls to Avoid

Do NOT use cetirizine for uremic pruritus—it is specifically ineffective for this condition despite efficacy in other pruritic disorders. 2, 1

• This is a common mistake, as cetirizine works well for other types of pruritus 1

Avoid long-term sedative antihistamines except in palliative care settings, as they may predispose to dementia. 2, 1

Do NOT use the following topical agents:

• Calamine lotion (no supporting literature) 1
• Crotamiton cream (shown ineffective versus vehicle control) 1

Definitive Treatment

Renal transplantation is the only definitive cure for uremic pruritus, showing excellent outcomes in most cases, but is not always feasible. 2, 1, 3

Clinical Presentation to Recognize

CKD-associated pruritus typically presents as:

• Bilaterally symmetrical, non-dermatomally distributed itching 5
• Commonly affects the back, limbs, chest, and head 5
• Approximately 50% of patients report generalized pruritus 1, 5
• May worsen during summer, at night, or during/after dialysis 1
• Secondary skin lesions may include excoriation, crusts, lichenifications, and prurigo 5
• Xerosis (dry skin) is commonly present 5