What is the best treatment for a 48-year-old male with pruritic skin lesions, previously treated with loratadine, now considering Zyrtec (cetirizine) and hydrocortisone cream?

From the Guidelines

I strongly recommend prescribing cetirizine (Zyrtec) 10 mg once daily and hydrocortisone cream 1% to be applied to affected areas twice daily for this patient with pruritic skin lesions, as this approach is supported by the most recent and highest quality evidence from the 2021 ESMO clinical practice guidelines 1. The patient's symptoms of itchy skin spots that break when scratched suggest a grade 1 or 2 dermatologic toxicity, according to the Common Terminology Criteria for Adverse Events (CTCAE) v5.0 1. Since loratadine was ineffective, switching to cetirizine is appropriate as it belongs to the same class of second-generation antihistamines but may provide better symptom control for some patients. The hydrocortisone cream will help reduce inflammation and itching directly at the affected sites. The patient should apply a thin layer of the cream to clean, dry skin and avoid covering treated areas with occlusive dressings unless directed. Treatment should continue for 1-2 weeks, and if symptoms persist beyond this period, the patient should return for reevaluation. Cetirizine works by blocking H1 histamine receptors, reducing the allergic response, while hydrocortisone suppresses inflammatory mediators locally. The patient should be advised that cetirizine may cause mild drowsiness and to avoid alcohol while taking this medication. Key considerations for management include:

• Monitoring for change in severity of symptoms
• Reassessing after 2 weeks to determine if the reaction has worsened or improved
• Proceeding to the next step in management if the reaction worsens or does not improve, which may include topical moderate/high-potency steroids, oral antihistamines, or GABA agonists 1.

From the FDA Drug Label

Warnings For external use only Do not use in the genital area if you have a vaginal discharge. Consult a doctor. for the treatment of diaper rash. Consult a doctor. When using this product avoid contact with eyes do not use more than directed unless told to do so by a doctor do not put directly into the rectum by using fingers or any mechanical device or applicator Stop use and ask a doctor if condition worsens, symptoms persist for more than 7 days or clear up and occur again within a few days, and do not begin use of any other hydrocortisone product unless you have asked a doctor rectal bleeding occurs Keep out of reach of children.If swallowed, get medical help or contact a Poison Control Center right away.

The patient can use hydrocortisone cream for itchy skin spots, but it is essential to follow the instructions and warnings provided, including:

• Using the cream for external use only
• Avoiding contact with eyes
• Not using more than directed unless advised by a doctor
• Stopping use and consulting a doctor if the condition worsens or symptoms persist for more than 7 days 2.

From the Research

Patient Complaints and Treatment

• The patient is a 48-year-old male with complaints of itchy skin spots that break when scratched.
• The patient had previously tried loratadine, which is an antihistamine, but its effectiveness is not clear in this case.
• The patient is now being prescribed Zyrtec (cetirizine) and hydrocortisone cream.

Relevant Studies

• A study on the approach to patients with chronic pruritus 3 discusses the different categories of itch-causing diagnoses and how to narrow down the differential diagnosis.
• Another study on the effect of betamethasone-loratadine combination therapy on severe exacerbations of allergic rhinitis 4 found that combination treatment with betamethasone and loratadine was significantly better in relieving symptoms of hayfever.
• A comparative study of antiallergic effects of second-generation H1-antihistamines ebastine, cetirizine, and loratadine 5 found that ebastine was more effective than cetirizine or loratadine in alleviating symptoms of seasonal allergic rhinitis.
• A review on the itch-scratch cycle from a neuroimmune perspective 6 highlights the complex mechanisms underlying chronic itch and the potential for novel therapeutic paradigms.
• The 2020 guidelines for the diagnosis and treatment of cutaneous pruritus 7 provide an updated framework for understanding and managing itch, including the use of antihistamines and other treatments.

Treatment Options

• The prescription of Zyrtec (cetirizine) and hydrocortisone cream may be effective in managing the patient's itchy skin spots, given the patient's previous experience with loratadine.
• The use of combination therapy with a corticosteroid and an antihistamine, as seen in the study on betamethasone-loratadine combination therapy 4, may be beneficial in relieving symptoms.
• Further evaluation and diagnosis may be necessary to determine the underlying cause of the patient's itch and to guide treatment, as outlined in the guidelines for the diagnosis and treatment of cutaneous pruritus 7.