What is the best approach to manage pruritus in an adult patient?

Management of Pruritus in Adults

Begin with emollients and self-care advice as the foundation for all pruritic patients, then escalate systematically based on underlying cause and severity. 1, 2

Initial Assessment and Diagnostic Approach

Key History Elements

• Medication review is critical – 20-30% of generalized pruritus cases have drug-induced causes 3
• Document travel history, sexual history, and potential intravenous drug use 1
• Assess for trigger factors and timing of symptoms 1

Physical Examination Priorities

• Examine finger webs, anogenital region, nails, and scalp thoroughly 4
• Distinguish primary skin lesions (indicating dermatologic disease) from secondary lesions (excoriations from scratching) 3, 4
• Assess body surface area involved and presence of lichenification or secondary infection 3

Essential Laboratory Workup

For generalized pruritus without obvious dermatologic cause, obtain: 1, 4

• Complete blood count with differential
• Comprehensive metabolic panel (renal and liver function)
• Thyroid-stimulating hormone
• Ferritin and iron studies
• Erythrocyte sedimentation rate
• Fasting glucose or A1C

Consider additional testing based on clinical suspicion: 1

• HIV and hepatitis serologies
• Chest radiography (especially in older patients for occult malignancy)
• Serum bile acids for cholestatic disease

Treatment Algorithm by Clinical Scenario

Generalized Pruritus of Unknown Origin (GPUO)

First-Line Therapy:

• Liberal application of emollients – this is the cornerstone of all pruritus management 1, 2
• Topical doxepin (limit to 8 days, ≤10% body surface area, ≤12g daily) 1, 2
• Topical clobetasone butyrate or menthol preparations 1, 2

Avoid: Crotamiton cream, topical capsaicin, and calamine lotion are ineffective 1

Second-Line Therapy:

• Non-sedating antihistamines: fexofenadine 180 mg or loratadine 10 mg daily 1, 2
• Mildly sedating option: cetirizine 10 mg daily 1, 2, 5
• Consider combining H1 and H2 antagonists (e.g., fexofenadine + cimetidine) 1

Third-Line Systemic Therapy:

• SSRIs: paroxetine or fluvoxamine 1, 2
• Mirtazapine 1, 2
• Opioid antagonists: naltrexone or butorphanol 1, 2
• Anticonvulsants: gabapentin or pregabalin 1, 2
• Ondansetron or aprepitant 1

Critical Caveat: Sedative antihistamines (e.g., hydroxyzine) should only be used short-term or in palliative care settings due to dementia risk with long-term use 1, 3

Hepatic Pruritus (Cholestatic Disease)

Treatment Hierarchy: 1, 2

1. First-line: Rifampicin (Strength of recommendation A)
2. Second-line: Cholestyramine
3. Third-line: Sertraline
4. Fourth-line: Naltrexone or nalmefene
5. Fifth-line options: dronabinol, phenobarbitone, propofol, or topical tacrolimus

Important: Do NOT use gabapentin in hepatic pruritus 1, 2

Adjunctive therapies: 1

• Broadband UVB or combined UVA/UVB phototherapy
• Transcutaneous electrical nerve stimulation

Uremic Pruritus (Renal Disease)

Optimize underlying factors first: 2

• Maximize dialysis adequacy
• Normalize calcium-phosphate balance
• Control parathyroid hormone levels
• Correct anemia
• Apply emollients regularly

Most effective treatment: Broadband UVB phototherapy (Strength of recommendation A) 1, 2

Pharmacologic options: 1

• Gabapentin (oral or topical)
• Consider auricular acupressure or aromatherapy

Avoid: Cetirizine is not effective for uremic pruritus 1

Definitive treatment: Renal transplantation 1

Drug-Induced Pruritus

Opioid-induced pruritus: 1, 2

• First-line: Naltrexone (Strength of recommendation B) if opioid cessation is impossible
• Alternative: Methylnaltrexone 1, 2
• Other options: ondansetron, droperidol, mirtazapine, or gabapentin 1

Postoperative pruritus: 1

• Diclofenac 100 mg rectally

Chloroquine-induced pruritus: 1

• Prednisolone 10 mg, niacin 50 mg, or combination
• Alternative: dapsone

Pruritus in Elderly Patients

Initial approach: 1, 2

• Trial of emollients and topical steroids for at least 2 weeks to exclude asteatotic eczema
• Prefer moisturizers with high lipid content 1

If persistent: 1

• Consider gabapentin
• Avoid sedative antihistamines (Strength of recommendation C) due to dementia risk

Reassess if no response and refer to dermatology if diagnostic uncertainty or treatment failure 1

Pruritus with Skin Breakdown

Severity-based escalation: 3

Mild disease:

• Emollients applied liberally and frequently
• Mild-to-moderate potency topical corticosteroids 3-4 times daily

Moderate disease:

• Medium-to-high potency topical corticosteroids twice daily
• Oral antihistamines (fexofenadine 180 mg, loratadine 10 mg, or cetirizine 10 mg)

Severe disease:

• High-potency topical corticosteroids with emollients
• Systemic corticosteroids: prednisone 1 mg/kg/day, taper over ≥4 weeks

Wound care: Maintain skin hydration and protect broken skin from further trauma 3

Psychogenic and Behavioral Factors

For patients with suspected psychological contributions: 1, 2

• Psychosocial and behavioral interventions: education on trigger avoidance, lifestyle modifications, relaxation techniques
• Cognitive restructuring and habit reversal training
• Patient support groups can be beneficial
• Consider referral to liaison psychiatry or psychology in refractory cases

Referral Criteria

Refer to dermatology or specialist when: 1, 3

• Diagnostic uncertainty exists
• Primary care management fails after 4-6 weeks
• Symptoms worsen despite treatment
• Suspected systemic disease requiring specialist evaluation
• Neuropathic pruritus (refer to neurology) 1

Common Pitfalls to Avoid

• Do not use sedating antihistamines long-term except in palliative care – dementia risk outweighs benefits 1, 3
• Do not delay systemic workup in older patients with chronic generalized pruritus without skin findings – consider occult malignancy 3, 4
• Do not use cetirizine for uremic pruritus – it is ineffective 1
• Do not use gabapentin for hepatic pruritus – it is contraindicated 1, 2
• Do not assume antihistamines work for all pruritus – they are primarily effective only for urticaria and drug reactions 6