What is the treatment for full body pruritus?

Treatment of Full Body Pruritus

Start with emollients applied at least once daily to the entire body, then escalate systematically through non-sedating antihistamines (fexofenadine 180 mg or loratadine 10 mg), followed by gabapentin/pregabalin or antidepressants if needed, while simultaneously investigating for underlying systemic causes. 1, 2

Initial Management and Investigation

Before treating symptomatically, investigate potential underlying causes including systemic diseases (hepatic, renal, thyroid, hematologic disorders), medications, infections, iron deficiency, or malignancies—particularly in older patients with chronic generalized pruritus. 1, 3

• Consider stopping suspected causative medications when the risk-benefit ratio is acceptable. 1
• Diagnostic workup should include complete blood count with differential, creatinine/BUN, liver function tests, iron studies, fasting glucose or A1C, and thyroid-stimulating hormone. 3
• Additional testing may include erythrocyte sedimentation rate, HIV screening, hepatitis serologies, and chest radiography based on clinical findings. 3

Stepwise Treatment Algorithm for Generalized Pruritus of Unknown Origin

First-Line: Emollients and Topical Therapies

• Apply emollients at least once daily to prevent xerosis, using oil-in-water creams or ointments; avoid alcohol-containing lotions. 2
• For elderly patients, select moisturizers with high lipid content. 1, 2
• Add topical clobetasone butyrate or menthol 0.5% preparations for symptomatic relief. 1, 2
• Topical doxepin can be used but limit to 8 days maximum, covering less than 10% body surface area, not exceeding 12g daily. 1, 2
• Moderate-to-high potency topical steroids (mometasone furoate 0.1% ointment, betamethasone valerate 0.1% ointment) for localized areas, but avoid prolonged use beyond 2 weeks to prevent skin atrophy. 2

Second-Line: Oral Antihistamines

• Fexofenadine 180 mg or loratadine 10 mg daily as first-choice systemic therapy. 1, 2
• Cetirizine 10 mg (mildly sedative) can be used as an alternative. 1, 2
• Critical pitfall: Avoid long-term sedating antihistamines except in palliative care settings due to potential dementia risk. 1, 2

Third-Line: Neuromodulators and Antidepressants

• Gabapentin 900-3600 mg daily or pregabalin 25-150 mg daily for patients failing antihistamines. 2
• Paroxetine, fluvoxamine, or mirtazapine as alternative third-line options. 1, 2
• Naltrexone or butorphanol can also be considered at this stage. 1

Cause-Specific Treatment Approaches

Hepatic Pruritus

• Rifampicin is first-line treatment for hepatic pruritus. 1, 2
• Cholestyramine as second-line treatment. 1
• Sertraline as third-line treatment. 1
• Avoid gabapentin in hepatic pruritus. 1

Uremic Pruritus (Chronic Kidney Disease)

• Optimize dialysis parameters, normalize calcium-phosphate balance, control parathyroid hormone levels, and correct anemia. 1, 2
• BB-UVB phototherapy is highly effective (Strength of recommendation A). 1, 2
• Use emollients as adjunctive therapy. 1

Drug-Induced Pruritus

• Naltrexone is first-line for opioid-induced pruritus if opioid cessation is not possible; methylnaltrexone is an alternative. 1
• Diclofenac 100 mg rectally for postoperative pruritus. 1

Elderly Patients

• Initial treatment with emollients and topical steroids for at least 2 weeks to exclude asteatotic eczema. 1
• Prioritize moisturizers with high lipid content. 1

Adjunctive and Alternative Therapies

• Behavioral interventions, relaxation techniques, and cognitive restructuring for patients with suspected psychological contributors. 1, 2
• Phototherapy (BB-UVB or NB-UVB) for specific conditions like uremic pruritus or lymphoma-associated pruritus. 2
• Patient support groups can be beneficial for chronic pruritus management. 1

Key Clinical Pitfalls

• Antihistamines have limited efficacy beyond urticaria and drug-induced reactions—don't rely on them as monotherapy for most causes of generalized pruritus. 4
• Avoid overlooking systemic causes, particularly in older patients with chronic generalized pruritus where malignancy evaluation is warranted. 3
• Don't use crotamiton cream or calamine lotion as they are ineffective for generalized pruritus. 2
• Limit water exposure and avoid coarse fabrics against the skin as exacerbating factors. 5