Management of Flares and Pruritus in Pediatrics and Adults
Atopic Dermatitis Flares: Proactive Maintenance Strategy
For patients with recurrent atopic dermatitis flares, implement proactive twice-weekly application of mid-potency topical corticosteroids (fluticasone propionate or methylprednisolone aceponate) or topical calcineurin inhibitors (tacrolimus 0.03% in children, 0.1% in adults) to previously affected areas, combined with daily moisturizers to all skin—this reduces flare risk by 54% compared to reactive treatment alone. 1
Evidence-Based Flare Prevention Protocol
Apply mid-potency topical corticosteroids twice weekly to previously involved skin after achieving disease control, continuing for 16-20 weeks minimum—this approach reduces flare risk (pooled relative risk 0.46,95% CI 0.38-0.55) and extends time to relapse. 1
Alternative proactive regimen: Apply tacrolimus 2-3 times weekly to previously affected sites for 40-52 weeks, which decreases flare frequency (pooled relative risk 0.78,95% CI 0.60-1.00) and increases anti-inflammatory-free days. 1
Daily moisturizer application is mandatory across all skin surfaces regardless of which proactive strategy is chosen, as this addresses epidermal barrier dysfunction and independently lengthens time to first flare. 1
Critical Safety Considerations for Proactive Therapy
Monitor for adrenal suppression if using proactive topical corticosteroids beyond 16 weeks—abnormal cosyntropin stimulation testing occurred in 2 of 44 subjects after 44 weeks of intermittent treatment. 1
Avoid continuous daily topical calcineurin inhibitor use due to FDA black box warning; restrict to intermittent scheduled dosing (twice weekly or two consecutive days weekly) to minimize theoretical long-term risks. 1
Transition strategy unclear: No studies define when to switch from proactive topical corticosteroids to topical calcineurin inhibitors after 44 weeks, but prudent practice suggests considering this transition given steroid-related risks. 1
Acute Pruritus Management: Stepwise Approach
First-Line: Topical Anti-Inflammatory Therapy
Start with moderate-to-high potency topical corticosteroids applied 3-4 times daily for at least 2 weeks to exclude inflammatory causes—hydrocortisone 2.5%, clobetasone butyrate, or triamcinolone 0.1% are appropriate initial choices. 2, 3
For inflammatory pruritus (eczema, psoriasis, dermatitis): Apply hydrocortisone 2.5% or triamcinolone 0.1% to affected areas 3-4 times daily, combined with high-lipid content emollients applied at least once daily to entire body. 2, 4, 3
For scalp involvement: Clobetasol propionate 0.05% solution is FDA-approved for short-term treatment (maximum 2 consecutive weeks, not exceeding 50 mL/week) of moderate-to-severe corticosteroid-responsive dermatoses. 5
Pediatric considerations: Hydrocortisone topical is approved for children ≥2 years; clobetasol is not recommended under age 12 years. 5, 4
Second-Line: Oral Antihistamines
If topical therapy fails after 2 weeks, add non-sedating antihistamines—fexofenadine 180 mg daily, loratadine 10 mg daily, or cetirizine 10 mg daily—as first-choice systemic agents. 2, 6
Avoid sedating antihistamines (hydroxyzine, diphenhydramine) in elderly patients due to increased fall risk and potential dementia association (Strength C recommendation against use). 2
Exception for nighttime pruritus: Hydroxyzine 25-50 mg at bedtime may be used cautiously in non-elderly adults when sleep disruption is severe, but avoid long-term use. 6
Pediatric mastocytosis: H1 antihistamines (diphenhydramine, hydroxyzine, cetirizine) effectively decrease pruritus, flushing, and urticaria; combined H1/H2 antihistamine therapy controls severe pruritus and wheal formation. 1
Third-Line: Neuropathic Agents
For pruritus refractory to topical steroids and antihistamines after 2-4 weeks, escalate to gabapentin 900-3600 mg daily or pregabalin 25-150 mg daily—these are specifically effective for neuropathic and mixed-etiology chronic pruritus. 2, 6, 3
Gabapentin is the preferred neuropathic agent for elderly patients with refractory pruritus, with dosing titrated from 900 mg to 3600 mg daily based on response. 2
Alternative neuropathic agents include pregabalin 25-150 mg daily, or antidepressants such as sertraline or doxepin for neuropathic chronic pruritus. 3
Adjunctive Topical Therapies for Symptomatic Relief
Neuropathic Topical Agents
Menthol 0.5% preparations provide additional symptomatic relief for pruritus and can be combined with topical corticosteroids. 6, 3
Pramoxine or lidocaine are effective topical neuropathic agents that can be used alone or combined with immunomodulatory agents for mixed-etiology pruritus. 3
Ineffective Therapies to Avoid
- Do not prescribe crotamiton cream, topical capsaicin, or calamine lotion—these are ineffective or not recommended for generalized pruritus management. 2, 6
Special Population Considerations
Elderly Patients (≥65 Years)
Begin with high-lipid content emollients plus moderate-potency topical steroid (hydrocortisone 2.5% or clobetasone butyrate) for at least 2 weeks to exclude asteatotic eczema, the most common cause of pruritus in this age group. 2
Screen for systemic causes: Evaluate renal function, liver function, thyroid function, and hematologic malignancy, as 20-30% of elderly pruritus has underlying systemic disease. 2
Review all medications thoroughly—polypharmacy is common and drug-induced pruritus is a frequent culprit in elderly patients. 2
Pediatric Severe Atopic Dermatitis
Optimize topical therapy first: Use appropriate-potency topical corticosteroids during flares, combined with daily moisturizers containing barrier lipids (ceramides) to reduce flare frequency and extend time between flares. 7, 8
Proactive maintenance: Apply topical anti-inflammatory agents twice weekly to troublesome areas between flares to prevent recurrence. 9, 8
Systemic therapy for severe disease: Consider phototherapy, traditional immunosuppressants, or biologics (dupilumab approved for moderate-to-severe pediatric atopic dermatitis) when topical therapy is inadequate. 8
Pediatric Mastocytosis
Oral cromolyn sodium effectively controls diarrhea, abdominal pain, nausea, vomiting, and may help cutaneous symptoms including pruritus despite low absorption. 1
Water-soluble sodium cromolyn cream or lotion decreases pruritus and flaring of cutaneous mastocytosis lesions. 1
Psychosocial and Behavioral Interventions
In distressed patients with chronic pruritus, implement psychosocial interventions including education on trigger avoidance, lifestyle modifications, relaxation techniques, cognitive restructuring, and habit reversal training—chronic pruritus causes significant psychosocial morbidity in one-third of patients. 1
Consider referral to clinical psychology or psychiatry for patients with severe quality-of-life impairment, as chronic pruritus significantly reduces quality of life similar to chronic pain. 1
Patient support groups are beneficial and should be recommended as adjunctive therapy. 1
Screen for psychiatric comorbidity: Depression, anxiety disorder, obsessive-compulsive disorder, and substance abuse commonly coexist with chronic pruritus, but always exclude physical causes first. 1
Phototherapy for Refractory Cases
Narrowband UVB (NB-UVB) or broadband UVB (BB-UVB) provides temporary relief for pruritus associated with Hodgkin disease, non-Hodgkin lymphoma, polycythemia vera, aquagenic pruritus, and cholestatic pruritus. 1
UVB phototherapy is effective for HIV-associated pruritus when other treatments fail. 1
PUVA therapy (oral methoxypsoralen with UVA radiation) is effective for bullous diffuse cutaneous mastocytosis in children, particularly for non-hyperpigmented lesions. 1
Disease-Specific Pruritus Management
HIV-Associated Pruritus
Indomethacin 25 mg three times daily orally is more effective than sedating antihistamines for HIV-related pruritus, though gastric intolerance may occur. 1
Hypnosis significantly reduces HIV-related itch in case series. 1
Cholestatic and Hepatic Pruritus
- BB-UVB or combined UVA/UVB phototherapy relieves cholestatic pruritus associated with viral hepatitis (A, B, C, E). 1