Treatment of Generalized Itching

Initial Management

The British Journal of Dermatology recommends starting with emollients and self-care advice as first-line therapy for all patients with generalized pruritus, then escalating treatment based on the underlying cause using a systematic algorithmic approach 1, 2
Emollients with high lipid content should be used to maintain skin hydration and restore the skin barrier, as recommended by the British Journal of Dermatology 1, 3
Self-care advice, including avoidance of hot water, irritants, and triggers, is also recommended by the British Journal of Dermatology 1, 4

Topical doxepin may be used, with a limit of 8 days, maximum 10% body surface area, and 12g daily maximum, as recommended by the British Journal of Dermatology 1, 3
Topical clobetasone butyrate or menthol preparations may be used as alternatives, according to the British Journal of Dermatology 1, 3
The British Journal of Dermatology recommends against using crotamiton cream (Strength B recommendation against) 1, 2
The British Journal of Dermatology also recommends against using topical capsaicin or calamine lotion 1, 2

Non-sedating H1 antagonists, such as fexofenadine 180 mg or loratadine 10 mg daily, are preferred as second-line therapy, as recommended by the British Journal of Dermatology 1, 3
The British Journal of Dermatology suggests considering combining H1 and H2 antagonists (e.g., fexofenadine plus cimetidine) for enhanced effect 1, 2
Sedative antihistamines, such as hydroxyzine, should only be used short-term or in palliative settings due to dementia risk, particularly in elderly patients, as recommended by the British Journal of Dermatology 1, 3, 4

For hepatic pruritus, the British Journal of Dermatology recommends a strict hierarchy of treatment, starting with rifampicin (Strength A recommendation) 5, 3
For uremic pruritus, the British Journal of Dermatology recommends optimizing dialysis parameters first, including normalizing calcium-phosphate balance and controlling parathyroid hormone, and using BB-UVB phototherapy (Strength A recommendation) 5, 3, 4
For drug-induced pruritus, the British Journal of Dermatology recommends naltrexone as first choice if opioid cessation is impossible (Strength B) 1, 2, 3

The British Journal of Dermatology recommends a mandatory initial approach for elderly patients, including a 2-week trial of emollients plus topical steroids to exclude asteatotic eczema 1, 3, 4
High lipid content moisturizers are preferred for elderly patients, as recommended by the British Journal of Dermatology 1, 3
Gabapentin may be beneficial for elderly patients if initial therapy fails, according to the British Journal of Dermatology 1
Sedative antihistamines should be absolutely avoided in elderly patients due to dementia risk (Strength C recommendation against), as recommended by the British Journal of Dermatology 1, 3