What is the best course of treatment for an elderly male patient presenting with pruritus (itching) of the ears?

Treatment of Itchy Ears in an Elderly Male

Start with liberal application of high lipid-content emollients combined with 1% hydrocortisone ointment applied 3-4 times daily for at least 2 weeks to address the xerosis and asteatotic eczema that commonly causes ear pruritus in elderly patients. 1, 2

Initial Treatment Approach

The British Association of Dermatologists specifically addresses pruritus in elderly patients (defined as over 65 years) and emphasizes that dry skin (xerosis) is the most common underlying cause. 1

First-line therapy consists of:

• High lipid-content moisturizers/emollients applied liberally and frequently to the affected ear area, as elderly skin has impaired barrier function and increased transepidermal water loss 1, 2
• 1% hydrocortisone ointment applied to the itchy ear area 3-4 times daily to treat any underlying asteatotic eczema (age-related eczematous changes) 1, 2, 3
• Continue this regimen for at least 2 weeks before reassessing, as this duration is necessary to adequately treat asteatotic eczema 1, 2

Essential self-care measures:

• Keep fingernails short to minimize trauma from scratching 1, 2

Second-Line Options if No Improvement After 2 Weeks

If the initial approach fails, the patient should be reassessed for other causes. 1

Consider adding:

• Non-sedating antihistamines such as fexofenadine 180 mg or loratadine 10 mg daily, though evidence is stronger for generalized pruritus 1, 2
• Gabapentin starting at low doses (100-300 mg at bedtime) for persistent pruritus in elderly patients, as this has specific evidence in this population 1, 2

Critical Safety Considerations

Avoid sedating antihistamines (diphenhydramine, hydroxyzine) in elderly patients due to increased risk of falls, confusion, and cognitive impairment. 1, 2 This is a Level 2++ recommendation from the British Association of Dermatologists. 1

Do not use:

• Crotamiton cream (proven ineffective in controlled studies) 2
• Topical capsaicin or calamine lotion (not recommended for elderly skin pruritus) 2

When to Investigate Further

Consider underlying systemic causes if:

• Pruritus extends beyond the ears to become generalized 1, 2
• No response to initial treatment after 2-4 weeks 1
• The British Association of Dermatologists notes that 20-30% of generalized pruritus cases have significant underlying causes including malignancy, drug-induced pruritus, or systemic disease 1

Appropriate investigations include:

• Complete blood count with differential 2, 4
• Liver and renal function tests 2, 4
• Thyroid function and glucose screening 2, 4
• Ferritin level 4

Special consideration: Pruritus can rarely be the sole presenting feature of bullous pemphigoid in elderly patients, which may require skin biopsy and immunofluorescence testing if suspected. 1

Referral Criteria

Refer to secondary care (dermatology or ENT) if: 1, 2

• Diagnostic uncertainty exists
• Symptoms persist despite 4-6 weeks of appropriate primary care management
• Visible skin changes suggest underlying dermatosis
• Patient is significantly distressed by symptoms

Common Pitfalls

• Do not assume all ear itching is simply "dry skin" without proper assessment, as underlying causes exist in a significant minority of cases 1
• Ensure regular follow-up as the underlying cause may not be initially evident 1
• Remember medication review as drug-induced pruritus is common in elderly patients on multiple medications 1, 5