What is the recommended initial management for bilateral hand pruritus?

Initial Management of Bilateral Hand Pruritus

Start with intensive emollient therapy using petroleum-based products applied at least twice daily combined with a moderate-potency topical corticosteroid (hydrocortisone 2.5% or clobetasone butyrate) applied 3-4 times daily for at least 2 weeks to restore the disrupted stratum corneum barrier and control inflammation. 1, 2

First-Line Topical Therapy

The cornerstone of management addresses the underlying barrier dysfunction that characterizes hand pruritus:

• Apply high-lipid content emollients or petroleum-based products (such as petrolatum/Vaseline) at least twice daily to all affected areas, as these are highly effective at restoring hydration and repairing the stratum corneum barrier 1, 2, 3

• Add a moderate-potency topical corticosteroid such as hydrocortisone 2.5%, clobetasone butyrate 0.02%, or triamcinolone acetonide 0.1% applied 3-4 times daily for at least 2 weeks to control inflammation 1, 4, 5

• For more severe cases with significant inflammation, medium- to high-potency topical steroids (triamcinolone 0.1% or higher) may be used on the hands, though avoid prolonged use due to risk of skin atrophy 6, 7, 5

• Topical corticosteroids containing menthol 0.5% or lotions with urea or polidocanol may provide additional antipruritic relief 6, 1

Essential Skin Care Measures

• Use mild soaps with neutral pH (pH 5) and warm water, avoiding hot water and excessive soap use which worsen barrier disruption 1, 2

• Keep nails short to minimize scratch damage 1

• Avoid irritants including harsh soaps, detergents, and frequent hand washing, as water itself acts as an irritant when barrier function is compromised 6, 2

• Wear protective gloves (rubber or polyvinyl chloride with cotton liners) when exposed to water or irritants, but remove them regularly to prevent occlusion-induced worsening 6

Second-Line Systemic Therapy (If No Improvement After 2 Weeks)

• Prescribe non-sedating antihistamines such as fexofenadine 180 mg daily or loratadine 10 mg daily for symptomatic relief 6, 1, 3

• Never use sedating antihistamines (hydroxyzine, diphenhydramine) as they carry increased risk of falls, confusion, and potential dementia association, particularly in elderly patients 1, 8

Third-Line Therapy for Refractory Cases

• Gabapentin 900-3600 mg daily or pregabalin 25-150 mg daily are specifically recommended for pruritus that fails topical and antihistamine therapy 6, 1

• Consider topical calcineurin inhibitors (tacrolimus, pimecrolimus) as steroid-sparing alternatives for chronic management 3, 4

• UV phototherapy may be beneficial for refractory hand dermatitis 4

Critical Diagnostic Considerations

Before assuming simple irritant or atopic hand dermatitis, evaluate for:

• Contact dermatitis (allergic or irritant) - consider patch testing if the distribution suggests allergen exposure or if first-line therapy fails 6, 2, 4

• Systemic causes including iron deficiency, renal disease, hepatic disease (especially cholestasis), thyroid dysfunction, or hematologic disorders if pruritus is generalized beyond just the hands 1, 9

• Drug-induced pruritus - review all medications, as opioids, SSRIs, and other agents commonly cause pruritus 1, 9

• Neuropathic pruritus if the distribution is localized and asymmetric 9

Critical Pitfalls to Avoid

• Do not use crotamiton cream - it has been proven ineffective in controlled studies (Level B recommendation) 1, 7

• Avoid topical capsaicin for generalized or hand pruritus, as there is no evidence of efficacy except in uremic pruritus 1

• Do not use calamine lotion for hand pruritus of unknown origin 1, 7

• Avoid systemic corticosteroids except for temporary relief of severe, refractory cases, as they should only be used very infrequently 6, 4

Reassessment and Referral Criteria

• Reassess after 2 weeks of first-line therapy; if no improvement or worsening occurs, proceed to second-line therapy 6, 1

• Refer to dermatology if no improvement after 2-4 weeks of appropriate therapy, if diagnostic uncertainty exists, or if patch testing is needed to identify contact allergens 6, 1, 2

• Consider allergy referral for comprehensive patch testing in cases where allergic contact dermatitis is suspected 2