What treatment options are available for an elderly male with pruritus (itching) of the hands?

Treatment of Itchy Hands in an Elderly Male

Start with emollients containing high lipid content combined with 1% hydrocortisone cream applied 3-4 times daily for at least 2 weeks to treat the most common cause—asteatotic eczema (dry skin-related eczema). 1

Initial Management Algorithm

First-Line Treatment (Weeks 1-2)

• Apply emollients with high lipid content liberally and frequently to both hands, as elderly skin has impaired barrier function and increased dryness that drives itching 1

• Apply 1% hydrocortisone cream to itchy areas of the hands not more than 3-4 times daily for at least 2 weeks 1, 2

  • This combination addresses asteatotic eczema, which is the most common cause of pruritus in elderly patients 1
  • The 2-week trial is essential before escalating therapy 1, 3

• Provide self-care advice including keeping nails short to prevent excoriation 1

If No Improvement After 2 Weeks

• Reassess the patient to ensure proper application technique and rule out other causes 1

• Consider topical clobetasone butyrate (a mid-potency steroid) if 1% hydrocortisone was insufficient 4

• Add topical menthol preparations for additional symptomatic relief through cooling effects 4

Second-Line Oral Therapy

If topical therapy fails after 2-3 weeks:

• Gabapentin is the preferred oral medication specifically for elderly patients with pruritus 1, 3

  • This targets neuropathic itch mechanisms that occur with aging nerve fiber changes 1, 3

• Non-sedating antihistamines (fexofenadine 180 mg or loratadine 10 mg) may be tried, though evidence is weaker for localized hand itch 1, 4, 3

Critical Safety Considerations

• NEVER prescribe sedating antihistamines (like hydroxyzine or diphenhydramine) to elderly patients—they increase fall risk, cognitive impairment, and dementia risk 1, 3

• Avoid crotamiton cream—it has been proven ineffective 4, 3

• Avoid calamine lotion—not recommended for elderly skin 4, 3

• Limit topical steroid use to 2-3 weeks to minimize adverse effects like skin atrophy 4

When to Investigate Further

Look for specific clues that suggest causes beyond simple dry skin:

• Occupational exposures or contact with irritants/allergens that could cause contact dermatitis 5, 6

• Vesicular lesions suggesting dyshidrotic eczema or pompholyx 6

• Systemic symptoms (weight loss, fatigue, jaundice) suggesting underlying disease requiring blood work 7, 8

• Unilateral or asymmetric distribution raising concern for other diagnoses 8

Referral Indications

Refer to dermatology if:

• Diagnostic uncertainty exists about the cause of hand itching 1, 3

• Primary care management (topical therapy plus gabapentin if needed) fails to provide relief 1, 7, 3

• Concern for bullous pemphigoid, which can rarely present as pruritus alone in elderly patients 1

• Severe impact on quality of life despite treatment 1

Common Pitfalls to Avoid

• Don't skip the 2-week topical trial before starting oral medications—most elderly hand itch responds to proper moisturization and mild steroids 1, 3

• Don't reach for sedating antihistamines out of habit—they are contraindicated in the elderly despite being commonly prescribed 1, 3

• Don't forget to follow up—the underlying cause may not be evident initially and requires reassessment 1