What are the treatment options for managing pruritis?

Management of Pruritus

Start with emollients and self-care measures for all patients, then escalate treatment based on the underlying etiology: use topical corticosteroids for inflammatory causes, topical neuropathic agents (menthol, pramoxine) for neuropathic causes, and specific targeted therapies for systemic disease-related pruritus. 1, 2

Initial Approach for All Patients

All patients with pruritus should receive emollients and basic skin care regardless of etiology. 1

• Apply emollients at least once daily to prevent xerosis, which commonly triggers pruritus 3
• Use oil-in-water creams or ointments; avoid alcohol-containing lotions 3
• Avoid physical triggers including wool clothing and harsh soaps 1
• Keep skin dry after bathing and use clean, separate towels 4

Generalized Pruritus of Unknown Origin (GPUO)

Topical Treatments (First-Line)

For GPUO, topical doxepin is the most evidence-based topical agent, but must be limited to 8 days, maximum 10% body surface area, and 12 grams daily due to contact dermatitis and toxicity risks. 1

• Topical clobetasone butyrate or menthol may provide benefit 1
• Do NOT use crotamiton cream (no significant antipruritic effect versus vehicle) 1
• Do NOT use topical capsaicin or calamine lotion (no evidence of efficacy in GPUO) 1

Systemic Treatments (Second-Line)

When topical treatments fail, start with nonsedative antihistamines before escalating to other systemic agents. 1

• First choice: Nonsedative antihistamines - fexofenadine 180 mg or loratadine 10 mg, or mildly sedative cetirizine 10 mg 1
• Second choice: Consider paroxetine, fluvoxamine, mirtazapine, naltrexone, butorphanol, gabapentin, pregabalin, ondansetron, or aprepitant 1
• Alternative approach: Combine H1 and H2 antagonists (e.g., fexofenadine with cimetidine) 1
• Short-term/palliative only: Sedative antihistamines like hydroxyzine 1

Refer to secondary care if primary management fails or diagnostic uncertainty exists. 1

Inflammatory Pruritus (Eczema, Psoriasis, Dermatitis)

Topical corticosteroids are first-line for inflammatory causes, with hydrocortisone 2.5% or triamcinolone 0.1% as effective options. 4, 2

• Apply moderate to high potency topical corticosteroids 3-4 times daily for up to 7 days maximum 4
• Options include hydrocortisone 2.5%, mometasone furoate 0.1%, or betamethasone valerate 0.1% 4
• Critical pitfall: Do not exceed 7 days to avoid cutaneous atrophy and increased trauma risk 4
• For refractory cases (approximately 10% of patients), refer to dermatology for systemic therapies like dupilumab or methotrexate 2

Neuropathic Pruritus

For neuropathic pruritus, topical neuropathic agents (menthol, pramoxine, lidocaine) are first-line, either alone or combined with topical steroids. 2

• Menthol 0.5% provides counter-irritant symptomatic relief 4
• For systemic treatment, use gabapentin 900-3600 mg daily or pregabalin 25-150 mg daily 4
• Antidepressants (sertraline, doxepin) or opioid receptor agonist/antagonists (naltrexone, butorphanol) are alternatives 2
• Refer neuropathic pruritus patients to relevant specialists for underlying condition treatment 1

Disease-Specific Pruritus

Hepatic/Cholestatic Pruritus

Rifampicin is the first-line treatment for hepatic pruritus (Strength A recommendation). 1

• Do NOT use gabapentin for hepatic pruritus 1
• Second-line: Cholestyramine 1
• Third-line: Sertraline before naltrexone or nalmefene 1
• Fifth-line options: Dronabinol, phenobarbitone, propofol, or topical tacrolimus 1
• Phototherapy: BB-UVB or combined UVA/UVB may relieve cholestatic itch 1

Uremic Pruritus (Renal Disease)

Ensure adequate dialysis, normalize calcium-phosphate balance, control parathyroid hormone, and correct anemia with erythropoietin as foundational management. 1, 3

• BB-UVB phototherapy is effective for many uremic pruritus patients 1, 3
• Consider auricular acupressure or aromatherapy 1
• Renal transplantation is the only definitive cure 1
• Topical capsaicin may have benefit specifically in uremic pruritus (unlike GPUO) 1

Opioid-Induced Pruritus

Naltrexone is the first-choice treatment for opioid-induced generalized pruritus when cessation is impossible (Strength B recommendation). 1

• Alternatives: Methylnaltrexone, ondansetron, droperidol, mirtazapine, or gabapentin 1
• For postoperative pruritus: Consider diclofenac 100 mg rectally 1

Polycythemia Vera

Treat with cytoreductive therapy, aspirin, interferon-α, SSRIs, PUVA, UVB phototherapy, cimetidine, or atenolol. 3

Chloroquine-Induced Pruritus

Consider prednisolone 10 mg, niacin 50 mg, or combination of prednisolone and niacin. 1

• Dapsone may also relieve chloroquine-induced itch 1

Psychogenic/Emotional Pruritus

For distressed patients with chronic pruritus of likely psychogenic origin, implement psychosocial and behavioral interventions. 1

• Education on trigger avoidance and treatment application 1
• Lifestyle interventions, relaxation techniques, cognitive restructuring 1
• Habit reversal training and behavior modification 1
• Patient support groups can be beneficial 1
• Refer to social workers, liaison psychiatry, or psychologists as needed 1
• NB-UVB phototherapy may benefit psychogenic pruritus 1

Vulvar Pruritus Specific Considerations

Identify and treat the underlying cause while providing symptomatic relief with topical corticosteroids. 4

• Most common cause: Candidiasis (80-90% cure with 7 days azole topical treatment) 4
• Trichomoniasis: 90-95% cure with oral metronidazole (treat partner) 4
• If topical treatment fails after 2 weeks, escalate to oral antihistamines (loratadine 10 mg or fexofenadine 180 mg daily) 4
• For nocturnal pruritus: Diphenhydramine 25-50 mg or hydroxyzine 25-50 mg at bedtime 4
• Third-line: Gabapentin 900-3600 mg daily or pregabalin 25-150 mg daily 4
• Do NOT use topical capsaicin for vulvar pruritus (lacks efficacy) 4

Mandatory Reevaluation

Reevaluate after 2 weeks if no improvement or worsening occurs to advance to next treatment step or investigate for underlying systemic disease. 4, 2

• For chronic pruritus lasting less than 1 year with few primary skin changes, obtain: complete blood count, complete metabolic panel, thyroid function tests 2
• Consider chest radiography and HIV testing in appropriate clinical contexts 5