What is the recommended treatment for an adult patient with itching and no significant medical history?

Treatment for Itching in Adults Without Significant Medical History

For an adult patient with generalized itching and no significant medical history, start with emollients applied liberally and frequently, combined with a trial of non-sedating antihistamines such as fexofenadine 180 mg or loratadine 10 mg daily. 1

Initial Approach and First-Line Treatment

Begin with self-care measures and emollients before any pharmacologic intervention. 1 The British Association of Dermatologists emphasizes that patients with generalized pruritus of unknown origin (GPUO) should receive:

• Emollients with high lipid content applied liberally and frequently to restore skin barrier function 1
• Keep nails short to minimize skin damage from scratching 2
• Non-sedating antihistamines such as fexofenadine 180 mg or loratadine 10 mg orally, or mildly sedative cetirizine 10 mg if needed 1

Important Caveat About Topical Steroids

For localized itching, 1% hydrocortisone cream applied 3-4 times daily can be effective 3. However, topical steroids should be used cautiously and limited to 2-3 weeks to minimize adverse effects 4.

Second-Line Topical Options

If emollients and antihistamines fail:

• Topical menthol preparations provide cooling relief 1, 4
• Topical clobetasone butyrate (mild corticosteroid) may benefit persistent pruritus 1, 4
• Topical doxepin can be prescribed but must be limited to 8 days, 10% body surface area, and 12 g daily maximum 1

Second-Line Systemic Options

For refractory cases not responding to first-line treatment:

• Combination H1 and H2 antagonists (e.g., fexofenadine with cimetidine) may provide enhanced effect 1
• Gabapentin is recommended for persistent generalized pruritus 1
• SSRIs (paroxetine or fluvoxamine), mirtazapine, pregabalin, naltrexone, or ondansetron/aprepitant may be considered for refractory cases 1

Critical Treatments to AVOID

Do NOT use the following treatments:

• Sedative antihistamines (e.g., hydroxyzine) should be avoided except in short-term or palliative settings, as long-term use may predispose to dementia 1
• Crotamiton cream should not be used (Strength of recommendation B) 1
• Topical capsaicin or calamine lotion are not recommended 1

Essential Diagnostic Workup

Before assuming this is simple pruritus of unknown origin, rule out systemic causes with basic laboratory testing. 2 The most common treatable cause is iron deficiency, accounting for 25% of cases with underlying disease. 2

Obtain:

• Complete blood count and ferritin levels (iron deficiency is the #1 systemic cause) 2
• Liver function tests (cholestatic disease causes pruritus) 2
• Renal function tests (uremic pruritus) 2
• Thyroid-stimulating hormone 2

When to Refer

Refer to secondary care if:

• Diagnostic doubt exists 1, 4
• Primary care management does not relieve symptoms after appropriate trial 1, 4
• Patient remains distressed despite initial treatment 2

Common Pitfalls to Avoid

• Do not prescribe sedating antihistamines due to familiarity—they carry significant risks in all age groups, particularly dementia risk with long-term use 1, 5
• Do not skip the diagnostic workup—iron deficiency is highly treatable and the most common systemic cause 2
• Do not apply topical corticosteroids indefinitely—limit to 2-3 weeks to prevent adverse effects 4
• Do not assume all itching is benign—always consider systemic causes including malignancy, liver disease, and renal disease 2, 6