In an 88‑year‑old woman with a two‑week history of generalized pruritus most pronounced on the face, periorbital area and upper extremities, minimal erythema, no new skin products, recent viral illness and a minor cough, and who is taking potassium chloride, mirtazapine, methocarbamol, tramadol, clobetasol‑lidocaine topical, lidocaine‑nystatin‑zinc ointment, metoprolol, trazodone, sertraline, and budesonide delayed‑release, what laboratory work‑up and medication adjustments (including use of antihistamines or famotidine) should be undertaken?

Management of Generalized Pruritus in an 88-Year-Old Woman

Start immediately with high-lipid content emollients applied liberally to the entire body at least once daily plus hydrocortisone 2.5% or clobetasone butyrate cream applied 3-4 times daily to affected areas for at least 2 weeks to treat asteatotic eczema, which is the most common cause of itching in elderly patients. 1

Immediate Treatment Plan

First-Line Topical Therapy (Start Today)

• Apply high-lipid content moisturizers/emollients to the entire body at least once daily, as elderly skin has impaired barrier function and increased transepidermal water loss 1, 2
• Add moderate-potency topical corticosteroid (hydrocortisone 2.5% or clobetasone butyrate) to face, periorbital areas, and arms 3-4 times daily for at least 2 weeks to exclude asteatotic eczema before pursuing other diagnoses 1, 3
• Advise keeping nails short to minimize scratch damage 1, 2

Medication Review (Critical)

Review her current medications for drug-induced pruritus, as polypharmacy is common in this age group and drug-induced pruritus is a frequent culprit 1. Her tramadol, sertraline, trazodone, and budesonide could all potentially contribute to pruritus 4, 5.

Antihistamine Decision: DO NOT prescribe hydroxyzine

Avoid sedating antihistamines like hydroxyzine in this 88-year-old patient, as they carry increased fall risk, confusion, cognitive impairment, and potential dementia association (Strength C recommendation against use) 1, 3, 2. If antihistamines are needed after the 2-week topical trial, prescribe non-sedating options: fexofenadine 180 mg daily, loratadine 10 mg daily, or cetirizine 10 mg daily 1.

Famotidine Consideration

Famotidine is reasonable to trial given her recent illness 4 weeks ago and minor persistent cough, though this addresses potential reflux rather than pruritus directly. There is no contraindication in elderly patients.

Laboratory Work-Up (Order Today)

Order the following screening tests to evaluate for systemic causes, as 20-30% of generalized pruritus cases have significant underlying causes including malignancy, drug effects, or systemic disease 2, 5:

• Complete blood count with differential (evaluate for eosinophilia, hematologic malignancy) 1, 5
• Comprehensive metabolic panel (renal and hepatic function) 1, 5
• Thyroid function tests (TSH, free T4) 1, 5
• Fasting glucose or HbA1c 1, 5
• Ferritin level (iron metabolism disorders) 3, 5

These labs are particularly important given her age >60 years and diffuse itch of 2 weeks duration, as there should be heightened concern for underlying malignancy in elderly patients with recent-onset generalized pruritus 5.

Differential Diagnosis Considerations

Most Likely: Asteatotic Eczema (Xerosis)

This is the most common cause of pruritus in patients over 65 years and explains the upper body predominance with minimal rash and erythema only from scratching 1, 3. The 2-week trial of emollients plus topical corticosteroids will confirm this diagnosis if symptoms resolve.

Alternative Considerations

• Drug-induced pruritus from her multiple medications, particularly opioids (tramadol), antidepressants (sertraline, trazodone, mirtazapine), or budesonide 4, 1
• Periorbital involvement raises consideration of allergic contact dermatitis from cosmetics, though she denies product changes 6
• Neuropathic itch is possible given the localized distribution, though typically more focal 7

Follow-Up Plan

If No Improvement After 2 Weeks

Add gabapentin starting at 100-300 mg at bedtime, which is specifically recommended for elderly pruritus that fails topical and antihistamine therapy 1, 3. Titrate to 900-3600 mg daily in divided doses as tolerated 1.

Referral Criteria

Refer to dermatology if:

• Symptoms persist despite 4-6 weeks of appropriate management 3, 2
• Laboratory abnormalities suggest systemic disease 1
• Visible skin changes suggest underlying dermatosis beyond simple xerosis 2
• Diagnostic uncertainty exists 2

Critical Pitfalls to Avoid

• Never use sedating antihistamines (hydroxyzine, diphenhydramine) in elderly patients due to fall risk and cognitive effects 1, 3, 2
• Do not prescribe crotamiton cream, which has been proven ineffective in controlled studies 1, 3
• Avoid topical capsaicin or calamine lotion for generalized pruritus in elderly patients 1, 3
• Do not dismiss this as simple dry skin without the 2-week therapeutic trial, as 20-30% have underlying systemic causes 2