How should I manage pruritus in a patient with psoriasis?

Management of Pruritus in Psoriasis

Start with regular emollient application combined with medium-to-high potency topical corticosteroids as first-line therapy for pruritus in psoriasis, applying emollients liberally multiple times daily and topical steroids once or twice daily to affected areas. 1

First-Line Topical Management

Emollients as Foundation

• Apply emollients with high lipid content multiple times daily to maintain skin hydration and reduce pruritus 2, 3
• Use emollients on damp skin immediately after bathing for optimal absorption 3
• Continue emollient use even when combining with other treatments, as they enhance efficacy and reduce irritation from active agents 1

Topical Corticosteroids

• Use medium-to-high potency topical corticosteroids (such as triamcinolone acetonide 0.1% cream or betamethasone dipropionate) for active psoriatic lesions with pruritus 1, 2
• Apply once or twice daily to affected areas 1
• For mild pruritus, hydrocortisone 1% may be applied up to 3-4 times daily 4

Combination Therapy

• Calcipotriene/betamethasone combination products are highly effective for reducing both psoriasis severity and associated pruritus 1
• The combination ointment or suspension can be used once daily 1
• In pediatric studies, 65% of patients experienced pruritus at treatment initiation, which decreased to only 10% by trial end with combination therapy 1
• Use emollients at different times of day from calcipotriene to reduce irritation while maintaining efficacy 1

Practical Application Strategy

Daily Regimen

• Morning: Apply emollient to all affected areas on damp skin after brief, lukewarm bathing 3
• Midday: Reapply emollient as needed for comfort 3
• Evening: Apply topical corticosteroid or calcipotriene/betamethasone combination to active lesions, followed by emollient to surrounding areas 1

Bathing Modifications

• Reduce bathing frequency and use lukewarm (not hot) water, as hot water exacerbates pruritus 3
• Keep bath/shower duration as brief as practical 3
• Avoid harsh soaps; consider moisturizing soap bars instead 5

Steroid-Sparing Rotational Therapy

To avoid long-term corticosteroid adverse effects, implement rotational therapy alternating between different topical agents 1:

• Rotate between topical vitamin D analogues (calcipotriene), topical corticosteroids, and emollients 1
• After achieving control with combination therapy, transition to vitamin D analogue monotherapy 1
• This approach reduces potential adverse effects from overreliance on topical steroids 1

Adjunctive Measures for Refractory Pruritus

Phototherapy

• Consider UVB phototherapy for severe pruritus not responding to topical therapy 1
• PUVA (psoralen plus UVA) is another option for refractory cases 1

Systemic Options for Severe Cases

• Oral antihistamines (non-sedating preferred such as fexofenadine or loratadine) may provide symptomatic relief, though evidence is limited 2
• Avoid long-term sedating antihistamines, especially in elderly patients, due to dementia risk 6
• For truly refractory pruritus, consider gabapentin, pregabalin, or mirtazapine 1

Critical Pitfalls to Avoid

Common Mistakes

• Do not use hot water for bathing, as this dramatically worsens pruritus despite temporary relief 3
• Avoid applying topical corticosteroids to more than 10% body surface area with high-potency agents to prevent systemic absorption 1
• Do not discontinue emollients when starting active treatments—they work synergistically 1
• Avoid friction from rough clothing or washcloths on affected areas 3

Environmental Modifications

• Keep room temperatures cool and humidity as high as practical 3
• Limit exposure to soap, detergents, and solvents 3
• Keep fingernails short to minimize trauma from scratching 6

When to Escalate Care

Refer to dermatology or consider systemic therapy if 1:

• Pruritus persists despite 4-6 weeks of appropriate topical therapy 6
• Body surface area involvement exceeds 30% 1
• Pruritus significantly limits activities of daily living 1
• Signs of secondary infection develop 6

Special Considerations

Scalp Psoriasis

• Calcipotriene/betamethasone suspension is specifically effective for scalp psoriasis with associated pruritus 1
• In pediatric studies (ages 12-17), 58% achieved clearance with once-daily application for 8 weeks 1

Monitoring

• Assess for HPA axis suppression if using high-potency topical corticosteroids over large body surface areas or for prolonged periods 1
• Monitor for skin atrophy with long-term corticosteroid use, necessitating rotational therapy 1