What is the best treatment for itchiness?

Treatment of Itchiness

For generalized itching without a specific underlying cause, begin with emollients applied at least once daily to the entire body, followed by topical corticosteroids (hydrocortisone 2.5% for mild cases, medium-potency steroids like mometasone furoate 0.1% for moderate cases), and escalate systematically to oral antihistamines if topical therapy fails. 1

First-Line Approach: Emollients and Topical Therapy

Emollients as Foundation

• Apply emollients at least once daily to prevent xerosis (dry skin), which is a common trigger for pruritus 1
• Use oil-in-water creams or ointments; avoid alcohol-containing lotions that can worsen dryness 1
• For elderly patients, select moisturizers with high lipid content 1

Topical Corticosteroids

Hydrocortisone 2.5% significantly decreases pruritus and is FDA-approved for temporary relief of itching associated with minor skin irritations, inflammation, rashes, eczema, psoriasis, insect bites, and external anal/genital itching. 2, 3

• Apply to affected areas not more than 3-4 times daily 2
• Hydrocortisone 2.5% reduces itch duration by 32% and provides significant relief within minutes, with continued improvement over 8 hours 3
• For children under 2 years, consult a physician before use 2

For moderate-to-severe pruritus, escalate to medium-potency topical steroids (mometasone furoate 0.1% ointment, betamethasone valerate 0.1% ointment, or prednicarbate cream 0.02%). 1

Topical Antipruritic Agents

• Menthol 0.5% or clobetasone butyrate provide symptomatic relief 1
• Urea or polidocanol-containing lotions soothe pruritus 1
• Pramoxine 1% cream provides rapid relief (within 2 minutes) comparable to hydrocortisone 1%, with 58% reduction in itch severity after 8 hours 4

Second-Line: Oral Antihistamines

If topical therapy fails, initiate oral antihistamines with fexofenadine 180 mg or loratadine 10 mg daily as first-choice systemic therapy. 1

• Cetirizine 10 mg daily can be used as an alternative, though it is mildly sedative 1
• Antihistamines may provide symptomatic relief for itching in various conditions 5
• Important caveat: Sedative antihistamines long-term may predispose to dementia and should be avoided except in palliative care 5

Third-Line: Neuropathic Agents and Antidepressants

For patients failing antihistamines, escalate to gabapentin 900-3600 mg daily or pregabalin 25-150 mg daily. 1

• These agents are particularly effective for neuropathic pruritus 1
• Alternative third-line options include paroxetine, fluvoxamine, or mirtazapine 1

Condition-Specific Management

Hepatic Pruritus

Rifampicin is the first-line treatment for hepatic pruritus. 5, 1

Uremic Pruritus

• Optimize dialysis parameters, normalize calcium-phosphate balance, control parathyroid hormone levels, and correct anemia with erythropoietin before using other treatments 5, 1
• BB-UVB phototherapy is effective for many patients with uremic pruritus 5, 1
• Consider capsaicin cream, topical calcipotriol, or oral gabapentin 5
• Cetirizine is not effective in uremic pruritus 5

Lymphoma-Associated Pruritus

• Cimetidine, carbamazepine, gabapentin, or mirtazapine may resolve itch 5
• BB-UVB or NB-UVB phototherapy provides temporary relief 5

Polycythemia Vera

• Cytoreductive therapy, aspirin, interferon-α, SSRIs, PUVA, UVB phototherapy, cimetidine, or atenolol may relieve itch 5

Atopic Dermatitis

Topical corticosteroids are strongly recommended with overwhelming evidence supporting their use in atopic dermatitis. 5

• Medium-potency TCS (fluticasone propionate 0.05%) used intermittently twice weekly as maintenance therapy reduces disease flares by 7-fold 5
• High-potency steroids (betamethasone dipropionate) demonstrate 94.1% good/excellent clinical response with 86% improvement in severity scores 5
• Very high-potency TCS (clobetasol propionate) achieve clear/almost clear status in 67.2% of patients within 2 weeks 5

Grade I Acute GVHD

• Continue or restart immunosuppressive agents and administer topical skin-directed steroids (triamcinolone, clobetasol) and/or topical tacrolimus 5
• Use medium-to-high potency topical steroids except on the face where low-potency hydrocortisone is preferred to avoid skin atrophy 5
• Antihistamines may be used for symptomatic relief of itching 5

Important Caveats

Do not apply topical corticosteroids to sites of positive immediate-type allergy skin tests—this practice is ineffective and should be abandoned, as itching resolves spontaneously within 30 minutes without treatment. 6

• Minimize periocular steroid use due to unclear association with cataracts or glaucoma 5
• Hypothalamic-pituitary-adrenal axis suppression can occur with prolonged, continuous use of high-potency TCS on large surface areas 5