What is the first line treatment for a patient presenting with itchy skin?

First-Line Treatment for Itchy Skin

The first-line treatment for a patient presenting with itchy skin is emollients combined with self-care advice, applied at least once daily to the entire body. 1, 2, 3

Initial Management Approach

All patients with generalized pruritus should begin with emollients and self-care measures before escalating to other therapies. 1, 3 This recommendation comes from the British Association of Dermatologists' 2018 guidelines and represents the universal starting point regardless of the underlying cause.

Emollient Selection and Application

• Use oil-in-water creams or ointments with high lipid content to maintain skin hydration and restore the skin barrier 2, 3
• Avoid alcohol-containing lotions as these can worsen xerosis (dry skin) 2
• Apply at least once daily to the entire body to prevent dry skin, which commonly triggers pruritus 2
• For elderly patients specifically, select moisturizers with high lipid content 1, 2, 3

Self-Care Advice

• Avoid hot water, irritants, and known triggers 3
• Use soap substitutes and bath oils instead of traditional soaps 4

When to Add Topical Therapies

If emollients alone are insufficient after an appropriate trial, escalate systematically:

For Elderly Patients (Special Algorithm)

Elderly patients with pruritus must receive a mandatory 2-week trial of emollients PLUS topical steroids to exclude asteatotic eczema before considering other treatments 1, 3. This is a critical step that should not be skipped.

Topical Corticosteroids

• Hydrocortisone can be applied to affected areas 3-4 times daily for temporary relief of itching associated with minor skin irritations, inflammation, and rashes 5
• Moderate-to-high potency topical steroids (mometasone furoate 0.1% ointment, betamethasone valerate 0.1% ointment, or prednicarbate cream 0.02%) for mild-to-moderate pruritus 2
• Clobetasone butyrate or menthol 0.5% may provide symptomatic relief 1, 2

Alternative Topical Options

• Topical doxepin may be prescribed but must be limited to 8 days maximum, covering no more than 10% body surface area, with a maximum of 12g daily 1, 3
• Urea or polidocanol-containing lotions can soothe pruritus 2

Topical Agents to AVOID

Do NOT use crotamiton cream (Strength B recommendation against) 1, 3

Do NOT use topical capsaicin or calamine lotion 1, 3

When to Escalate to Systemic Therapy

If topical therapies fail after an appropriate trial, escalate systematically:

Second-Line: Non-Sedating Antihistamines

• Fexofenadine 180 mg or loratadine 10 mg daily as first-choice systemic therapy 1, 2, 3
• Cetirizine 10 mg daily (mildly sedative) can be used as an alternative 1, 2
• Consider combining H1 and H2 antagonists (e.g., fexofenadine plus cimetidine) for enhanced effect 1, 3

Critical Caveat About Sedating Antihistamines

Sedative antihistamines (such as hydroxyzine) should ONLY be used short-term or in palliative settings 1, 3

In elderly patients, sedative antihistamines should be absolutely avoided (Strength C recommendation against) due to dementia risk 1, 3

Third-Line: Neuromodulators or Antidepressants

• Gabapentin 900-3600 mg daily or pregabalin 25-150 mg daily for patients failing antihistamines 2
• Paroxetine, fluvoxamine, or mirtazapine as third-line options 1, 2

When to Refer to Secondary Care

Refer to secondary care if there is diagnostic doubt, or if primary care management does not relieve symptoms 1, 3

Common Pitfalls to Avoid

• Do not skip the emollient trial – this is the foundation of all pruritus management and must be attempted first 1, 2, 3
• Do not use sedating antihistamines long-term in elderly patients – the dementia risk outweighs benefits 1, 3
• Do not use crotamiton cream, capsaicin, or calamine lotion – these have evidence against their use 1, 3
• Do not prescribe topical doxepin for more than 8 days or exceed the body surface area/dose limits 1, 3