How should I evaluate and manage pruritus in an adult patient?

Evaluation and Management of Pruritus in Adults

Begin with high-lipid emollients applied at least once daily to the entire body and a moderate-potency topical corticosteroid (hydrocortisone 2.5% or clobetasone butyrate) applied 3-4 times daily for at least 2 weeks to exclude asteatotic eczema, the most common cause of generalized pruritus, especially in elderly patients. 1

Initial Clinical Assessment

History and Physical Examination:

• Determine whether primary skin lesions are present or if pruritus exists without underlying dermatosis 2
• Assess for secondary skin changes from scratching: excoriations, prurigo nodularis, lichenification, or scarring 3
• Review all current medications systematically, as drug-induced pruritus is extremely common, particularly in polypharmacy patients 1, 4
• In patients ≥80 years, specifically evaluate for opioids (tramadol), SSRIs (sertraline), atypical antidepressants (trazodone, mirtazapine), and inhaled corticosteroids (budesonide) 1
• Obtain travel history and assess risk factors for infectious causes 2, 4
• Evaluate for systemic symptoms suggesting malignancy, though routine extensive cancer screening is not recommended 2

First-Line Topical Management

Emollient Therapy:

• Apply high-lipid content moisturizers at least once daily to the entire body, ideally after a 10-minute warm bath 1, 5
• Petrolatum (Vaseline) is preferred for very dry areas due to superior occlusive properties 1
• Creams with polidocanol can provide additional antipruritic relief 1

Topical Corticosteroids:

• Apply moderate-potency corticosteroid (hydrocortisone 2.5% or clobetasone butyrate 0.02%) to affected areas 3-4 times daily for minimum 2 weeks 1, 5
• This trial is essential to exclude asteatotic eczema before pursuing systemic workup 1

Skin Care Measures:

• Use mild, fragrance-free cleansers with neutral pH (pH 5) in limited quantities 1, 5
• Avoid hot showers and excessive soap use 1
• Pat skin dry gently rather than rubbing 1
• Keep nails short to minimize scratch damage 1

Laboratory Screening for Generalized Pruritus Without Rash

Essential Initial Tests (20-30% of cases have significant underlying cause): 1

• Complete blood count and ferritin (iron deficiency is common) 2, 1
• Liver function tests (hepatic disease, iron overload) 2, 1
• Urea and electrolytes (uremic pruritus) 2, 1

Conditional Testing (only with suggestive clinical features): 2, 1

• Thyroid function tests: NOT routine; only if additional features suggest endocrinopathy, diabetes, or renal disease 2, 1
• Fasting glucose, lactate dehydrogenase, ESR: only when hematologic or metabolic disorders suspected 1
• Peripheral blood film and JAK2 V617F mutation: if polycythemia vera suspected (elevated hemoglobin/hematocrit) 2, 1, 4
• Bile acids and antimitochondrial antibodies: if cholestatic liver disease suspected 2, 1
• HIV and hepatitis A/B/C serology: only with relevant risk factors or travel history 2, 1

Second-Line Systemic Therapy

If pruritus persists after 2 weeks of adequate topical therapy:

Non-Sedating Antihistamines (first systemic option): 1, 5

• Fexofenadine 180 mg daily, OR
• Loratadine 10 mg daily, OR
• Cetirizine 10 mg daily

CRITICAL WARNING: Avoid sedating antihistamines (hydroxyzine, diphenhydramine) in elderly patients—they increase fall risk and may predispose to dementia (Strength C recommendation against use). 1, 5

Third-Line Therapy for Refractory Pruritus

Neuropathic Agents:

• Gabapentin 900-3600 mg daily is specifically recommended for elderly pruritus failing topical and antihistamine therapy 1
• Alternative: Pregabalin 25-150 mg daily 1, 4

Cause-Specific Management

Iron Deficiency:

• Iron replacement therapy 2

Uremic Pruritus:

• Ensure adequate dialysis 4
• Normalize calcium-phosphate balance and control parathyroid hormone 4
• Correct anemia with erythropoietin 4
• Gabapentin or pregabalin have best proven efficacy 3
• UVB phototherapy may attenuate symptoms 3
• Capsaicin 0.025% cream four times daily for 4 weeks (14/17 patients reported marked relief) 2

Cholestatic Pruritus:

• First-line: Rifampicin 4, 3
• Second-line: Cholestyramine 4, 3
• Third-line: Sertraline before naltrexone 4
• Alternative: Bezafibrate 3

Paraneoplastic Pruritus:

• Paroxetine, mirtazapine, granisetron, or aprepitant 2, 4
• Palliative care setting may include thalidomide 2

Opioid-Induced Pruritus:

• Naltrexone if cessation impossible 4

Drug-Induced Pruritus:

• Trial cessation of suspected medications if risk-benefit analysis acceptable 2

Indications for Skin Biopsy

Perform biopsy if: 1, 4, 5

• Lesions persist after 2 weeks of adequate topical treatment
• Persistent unexplained generalized pruritus (evaluate for cutaneous lymphoma)
• Suspected small-fiber neuropathy
• Suspected autoimmune bullous dermatosis or lichenoid reactions

Specialist Referral Criteria

Refer to hematology: 2, 1

• Suspected polycythemia vera or lymphoma

Refer to hepatology: 2, 1

• Significant hepatic impairment on laboratory testing

Refer to dermatology/neurology: 1

• Suspected neuropathic pruritus requiring expert management

Critical Pitfalls to Avoid

• Do NOT use crotamiton cream—proven ineffective in controlled studies 1
• Do NOT use topical capsaicin for generalized pruritus or xerosis—no evidence except in uremic pruritus 1
• Do NOT use calamine lotion—not recommended 1
• Do NOT perform routine extensive malignancy screening—investigations should be guided by thorough history and physical examination 2, 1
• Reevaluate thoroughly if no response to optimal management after 2 weeks—consider alternative diagnoses including cutaneous lymphoma, bullous pemphigoid, or undetected systemic causes 4, 5