What are the recommended treatments for itching?

Treatment of Itching

For generalized itching without an underlying skin condition, start with emollients and non-sedating antihistamines (fexofenadine 180 mg or loratadine 10 mg daily), then escalate to gabapentin or pregabalin if antihistamines fail, while avoiding calamine lotion and topical capsaicin which are ineffective. 1, 2

First-Line Approach: Emollients and Self-Care

• Apply emollients at least once daily to the entire body to prevent xerosis (dry skin), which commonly triggers pruritus 2
• Use oil-in-water creams or ointments; avoid alcohol-containing lotions 2
• For elderly patients specifically, select moisturizers with high lipid content 1, 2
• Patients should receive self-care advice alongside emollient therapy 1

Topical Therapies

Effective Topical Agents

• Topical doxepin may be prescribed but with strict limitations: maximum 8 days of treatment, apply to no more than 10% of body surface area, and use no more than 12 g daily due to risk of allergic contact dermatitis 1
• Topical clobetasone butyrate or menthol (0.5%) provide symptomatic relief 1, 2
• Moderate-to-high potency topical steroids (mometasone furoate 0.1% ointment, betamethasone valerate 0.1% ointment) for mild-to-moderate pruritus 2
• Hydrocortisone is FDA-approved for temporary relief of itching associated with minor skin irritations, inflammation, and rashes, applied 3-4 times daily 3

Ineffective Topical Agents to Avoid

• Do not use crotamiton cream - it has no significant antipruritic effect compared to vehicle control 1
• Do not use topical capsaicin or calamine lotion - there is no literature supporting their use in generalized pruritus 1

Systemic Antihistamine Therapy

First-Choice Systemic Agents

• Start with non-sedating antihistamines: fexofenadine 180 mg or loratadine 10 mg daily 1, 2
• Alternatively, use mildly sedative cetirizine 10 mg as a middle-ground option 1, 2
• Consider combining H1 and H2 antagonists (e.g., fexofenadine plus cimetidine) for enhanced effect 1

Important Caveat About Antihistamines

While antihistamines are widely recommended, their efficacy is limited in non-histamine-mediated itch. The evidence shows they work primarily through sedation rather than true antipruritic effects in many conditions 4, 5, 6. However, guidelines still recommend them as first-line systemic therapy due to their safety profile and occasional benefit 1.

Sedating Antihistamines: Limited Role

• Reserve sedating antihistamines (e.g., hydroxyzine) only for short-term use or palliative settings 1
• They should not be prescribed for elderly patients with pruritus due to safety concerns 1

Third-Line Systemic Therapies

When antihistamines fail, consider the following agents:

• Gabapentin 900-3600 mg daily or pregabalin 25-150 mg daily for antihistamine-resistant cases 1, 2
• Antidepressants: paroxetine, fluvoxamine, or mirtazapine 1, 2
• Opioid modulators: naltrexone or butorphanol 1
• Antiemetics: ondansetron or aprepitant (80 mg daily) 1

All of these carry a strength of recommendation D, reflecting limited evidence but clinical utility in refractory cases 1.

Cause-Specific Considerations

Drug-Induced Itch

• For opioid-induced pruritus: naltrexone is first-choice (strength of recommendation B); alternatives include methylnaltrexone, ondansetron, droperidol, mirtazapine, or gabapentin 1
• For chloroquine-induced pruritus: consider prednisolone 10 mg, niacin 50 mg, or their combination; alternatively dapsone 1

Elderly Patients

• Initially treat with emollients and topical steroids for at least 2 weeks to exclude asteatotic eczema 1
• Gabapentin may be beneficial in elderly patients with pruritus 1
• Avoid sedating antihistamines in this population 1

Referral Criteria

• Refer to secondary care if there is diagnostic doubt or if primary care management does not relieve symptoms 1
• This ensures appropriate investigation for underlying systemic causes and access to advanced therapies like phototherapy 1

Common Pitfalls

• Avoid using over-the-counter hydrocortisone for generalized pruritus expecting significant benefit - low-potency corticosteroids (0.2%-2.5% hydrocortisone) have not shown improvement in randomized trials for many pruritic conditions 1
• Do not continue ineffective antihistamines indefinitely; escalate therapy systematically 2
• Remember that antihistamines work primarily in histamine-mediated conditions like urticaria, not in most cases of generalized pruritus 4, 5