Treatment of Itching in Elderly Patients
Start with high-lipid emollients applied at least twice daily to all pruritic areas plus 1% hydrocortisone cream twice daily for 2 weeks, while completely avoiding sedating antihistamines which are contraindicated in the elderly. 1
Initial Management Algorithm
First-Line Topical Therapy (Weeks 1-2)
Apply high-lipid content emollients at least twice daily to all affected areas, as elderly skin has severely impaired barrier function and increased transepidermal water loss 1, 2
Apply 1% hydrocortisone cream 3-4 times daily for at least 2 weeks to exclude asteatotic eczema (xerosis-related eczema), which is the most common cause of pruritus in elderly patients 1, 3
Provide self-care advice: Keep nails short, avoid hot water bathing, avoid harsh soaps, and reduce bathing frequency to prevent worsening xerosis 1, 2
Adjunctive Oral Therapy
Add non-sedating antihistamines such as fexofenadine 180 mg daily or loratadine 10 mg daily for symptomatic relief if warranted 1, 2
Never prescribe sedating antihistamines (diphenhydramine, hydroxyzine, chlorpheniramine) in elderly patients due to increased risk of falls, confusion, urinary retention, constipation, and potential contribution to dementia (Strength of recommendation C) 1, 2
Reassessment at 2 Weeks
If no improvement after 2 weeks of emollients and topical steroids, the patient must be reassessed as this may not be simple elderly xerosis 1
Second-Line Options
Consider topical clobetasone butyrate or menthol preparations for additional relief 1, 4
Consider gabapentin starting at 100-300 mg at bedtime if pruritus persists after adequate topical therapy, as it has specific efficacy for elderly skin pruritus (Strength of recommendation D) 1, 2
Consider topical doxepin (limited to 8 days, 10% of body surface area, and 12 g daily maximum) 1
Alternative Systemic Options for Refractory Cases
Consider combination H1 and H2 antagonists (e.g., fexofenadine plus cimetidine) 1
Consider paroxetine, fluvoxamine, mirtazapine, naltrexone, pregabalin, ondansetron, or aprepitant for refractory generalized pruritus of unknown origin 1
Critical Pitfalls to Avoid
Do not use crotamiton cream (ineffective, Strength of recommendation B) 1
Do not use topical capsaicin or calamine lotion for generalized pruritus (Strength of recommendation D) 1
Avoid cetirizine as first-line as it may cause mild sedation (13.7% vs 6.3% placebo) at standard 10 mg doses 2
Do not dismiss potential underlying causes: In elderly patients with impaired renal function, investigate for uremia, hepatobiliary disease, hematologic disorders, thyroid dysfunction, or malignancy as these commonly cause pruritus 1, 2, 5, 6
Special Considerations for Renal Impairment
When prescribing for elderly patients with potential renal impairment:
Gabapentin requires dose adjustment based on creatinine clearance 5, 6
Avoid nitrofurantoin and adjust doses of renally-excreted medications appropriately 5, 6
Monitor for uremic pruritus if renal function is significantly impaired, which may require different management strategies 5, 6, 7
Referral Criteria
Refer to dermatology if:
No improvement after 2-4 weeks of first-line therapy 1, 2, 4
Skin biopsy is needed to exclude bullous pemphigoid (which can present with pruritus alone before skin lesions appear in elderly patients), cutaneous lymphoma, or other serious conditions 1, 2, 4
Patient is distressed by symptoms despite primary care management 1
Important Clinical Pearls
Pruritus in the elderly is often multifactorial due to xerosis, immunosenescence, neuronal changes, polypharmacy, and age-related comorbidities 5, 6, 7
Review all medications as calcium channel blockers and hydrochlorothiazide are important causes of pruritic skin eruptions in older patients 7
Consider neuropathic pruritus especially for localized genital itching or generalized truncal pruritus in patients with diabetes 7
Maintain high suspicion for scabies, bullous pemphigoid, transient acantholytic dermatosis, and mycosis fungoides which are more common in elderly patients 7