Management of Bilateral Pruriginous Erythematous Papules on the Lower Legs Refractory to Initial Treatment

Diagnostic Considerations

• The American Academy of Dermatology recommends considering fungal infection if lesions cover more than 10% of the body surface area, and treating with systemic antifungal therapy such as terbinafine or itraconazole orally 1
• The British Medical Journal suggests that emollients should be applied after bathing to retard water loss from the skin 4

Symptomatic Management

• The Praxis Medical Insights guideline recommends using a non-sedating antihistamine such as fexofenadina 180 mg once daily or cetirizina 10 mg daily for symptomatic relief of pruritus 2
• The Praxis Medical Insights guideline also suggests using a sedating antihistamine such as hidroxizina 25-50 mg before bedtime if pruritus interrupts sleep 3, 2

Treatment of Refractory Pruritus

• The Praxis Medical Insights guideline recommends using gabapentina 100-300 mg three times daily for neuropathic pruritus 2
• The Praxis Medical Insights guideline also suggests using pregabalina 25-150 mg daily for severe and constant pruritus 3, 2

Referral Criteria

• The Praxis Medical Insights guideline recommends urgent referral (same day) if lesions cover more than 30% of the body surface area or if there is no response after 2-3 weeks of topical treatment 1
• The Praxis Medical Insights guideline also suggests non-urgent referral if lesions cover more than 10% of the body surface area with uncertain diagnosis 1