Medications for Itching
Start with emollients and second-generation antihistamines for most cases of itching, escalating to gabapentin or pregabalin if antihistamines fail.
For general pruritus, begin with regular emollient application combined with non-sedating second-generation antihistamines like loratadine 10 mg daily or fexofenadine 180 mg daily during the day, reserving first-generation sedating antihistamines (diphenhydramine 25-50 mg or hydroxyzine 25-50 mg) for nighttime use only. 1, 2
Stepwise Treatment Algorithm
First-Line: Topical Therapy + Non-Sedating Antihistamines
Topical treatments:
- Apply emollients regularly to all affected areas to prevent and treat dry skin 1, 2
- For localized itching, use moderate-potency topical corticosteroids: mometasone furoate 0.1% or betamethasone valerate 0.1% ointment 1, 2
- Lotions containing urea or polidocanol provide additional soothing effects 1, 2
- Menthol 0.5% creams can be added for symptomatic relief through counter-irritant effects 2, 3
Systemic antihistamines:
- Daytime: Cetirizine 10 mg daily, loratadine 10 mg daily, or fexofenadine 180 mg daily 1, 2
- Nighttime: Diphenhydramine 25-50 mg or hydroxyzine 25-50 mg at bedtime to break the itch-scratch cycle 1, 2
Second-Line: Neuropathic Agents
If antihistamines fail after 2 weeks, escalate to:
- Gabapentin 900-3600 mg daily (particularly effective for neuropathic itching) 1, 2
- Pregabalin 25-150 mg daily as an alternative to gabapentin 1, 2
- Doxepin 10 mg twice daily (functions as both tricyclic antidepressant and potent H1/H2 histamine antagonist) 1
Third-Line: Additional Options
For refractory cases:
Cause-Specific Treatments
Opioid-Induced Pruritus
- First choice: Naltrexone if opioid cessation is impossible 1
- Alternatives: Methylnaltrexone, ondansetron, droperidol, mirtazapine, or gabapentin 1
Hepatic Pruritus
- First-line: Rifampicin 1, 2
- Second-line: Cholestyramine 1
- Third-line: Sertraline 1
- Avoid gabapentin in hepatic pruritus despite its efficacy elsewhere 1, 2
Uremic Pruritus (Dialysis Patients)
- Ensure adequate dialysis and normalize calcium-phosphate balance 1
- Doxepin 10 mg twice daily achieves complete resolution in 58% of patients (versus 8% with placebo) 1
- Alternatives: Capsaicin cream, topical calcipotriol, or oral gabapentin 1, 2
- Avoid long-term sedative antihistamines except in palliative care 1
Vulvar Pruritus
- Hydrocortisone 2.5%, mometasone furoate 0.1%, or betamethasone valerate 0.1% applied 3-4 times daily for up to 7 days 3
- For candidosis: Azole topical treatment for 7 days (80-90% cure rate) 3
- For trichomoniasis: Oral metronidazole (90-95% cure rate) 3
Atopic Dermatitis/Eczema
- Pimecrolimus 1% cream (topical calcineurin inhibitor) for patients 2 years and older with mild to moderate disease 4
- Apply twice daily to affected areas only; 35% of patients achieve clear or almost clear skin at 6 weeks 4
- Use for short periods with breaks between treatments 4
Critical Pitfalls to Avoid
Sedating antihistamines in elderly patients:
- Long-term use may predispose to dementia 1, 2
- Use second-generation antihistamines preferentially in elderly patients 2
Topical corticosteroid duration:
- Do not exceed 7 days of use to avoid cutaneous atrophy 3
- Topical doxepin limited to 8 days maximum, 10% body surface area, and 12 g daily due to allergic contact dermatitis risk 1
Gabapentin contraindication:
Pimecrolimus precautions:
- Do not use under 2 years of age 4
- Avoid sun exposure, tanning beds, and UV light therapy during treatment 4
- Long-term safety unknown; use only for short periods 4
Pregnancy considerations:
- Second-generation antihistamines may be safer than hydroxyzine, which is contraindicated in early pregnancy 2
When to Escalate or Reevaluate
Reevaluate after 2 weeks if:
Call physician if: