Treatment of Neurological Pruritus
Patients with neuropathic pruritus should receive gabapentin 300-1200 mg daily as first-line systemic therapy, with referral to neurology or dermatology for underlying neurological evaluation. 1
Initial Management Approach
Refer to specialist for neurological evaluation after basic history and examination to identify the underlying cause (peripheral nerve entrapment, radiculopathy, small fiber neuropathy, CNS lesions). 2, 1 This is critical because neuropathic itch arises from dysfunction anywhere along the sensory pathway—from peripheral nerves (like notalgia paresthetica, brachioradial pruritus) to central lesions (stroke, multiple sclerosis). 3, 4
- Skin biopsy may be considered to confirm small fiber neuropathy if clinically suspected, though not routinely required. 1
- Targeted investigations should be guided by clinical findings rather than blanket testing. 1
Pharmacological Treatment Algorithm
First-Line Systemic Therapy
- Gabapentin 300-1200 mg daily is the primary systemic treatment for neuropathic pruritus. 1
- Titrate gradually based on response and tolerability, with maximum doses up to 600 mg daily in some contexts. 5
- Pregabalin is an alternative anticonvulsant option if gabapentin is not tolerated. 2, 3
Critical caveat: Do NOT use gabapentin for hepatic/cholestatic pruritus—it is explicitly contraindicated and ineffective in that context. 6, 5 This is a common pitfall since gabapentin works for neuropathic but not cholestatic mechanisms.
Topical Therapies
- Topical doxepin can be applied to affected areas, maximum 12 g daily for up to 8 days, covering no more than 10% body surface area. 1, 2
- Capsaicin cream applied 3-4 times daily may provide benefit in neuropathic itch, though evidence is limited and it is NOT recommended for generalized pruritus of unknown origin. 2, 3 The FDA label indicates use for adults and children ≥18 years. 7
- Topical tacrolimus, local anesthetics, and botulinum toxin A have been used in selected cases. 3
Alternative Systemic Options
If gabapentin/pregabalin fail or are not tolerated:
- Consider SSRIs (paroxetine, fluvoxamine) or mirtazapine. 2
- Naltrexone or other opioid receptor modulators may be tried. 2, 8
- These are the same agents used for generalized pruritus of unknown origin, with Strength D recommendations. 2
Important: Antihistamines and corticosteroids are largely ineffective for neuropathic itch and should be avoided long-term (except palliative care) due to dementia risk. 6, 3, 4
Non-Pharmacological Interventions
Physical Modalities
- Phototherapy (NB-UVB) may provide symptomatic relief in some cases. 2
- Transcutaneous electrical nerve stimulation (TENS) has shown value in selected patients. 3
- Physical therapy may be beneficial depending on the underlying neurological condition. 3
Behavioral and Psychosocial Support
- Incorporate behavioral interventions including education on trigger avoidance, relaxation techniques, cognitive restructuring, and habit reversal training for distressed patients. 2, 1
- Patient support groups can be beneficial. 2
- Referral to liaison psychiatry or psychology may help, as chronic neuropathic pruritus causes significant psychosocial morbidity in up to one-third of patients. 2, 1
Surgical Intervention
- Surgery is indicated for spinal/cerebral masses, abscesses, hemorrhagic stroke, or nerve entrapment syndromes causing the neuropathic itch. 3
- This addresses the underlying neuroanatomic pathology directly. 3