Generalized Pruritus Management

Initial Diagnostic Workup

The British Journal of Dermatology recommends liver function tests to assess for hepatic causes of pruritus, and urea and electrolytes to evaluate renal function 2, 3
The British Journal of Dermatology suggests considering bile acids and antimitochondrial antibodies if liver disease is suspected, and HIV and hepatitis A, B, and C serology if risk factors are present 3, 4
A medication review is necessary to identify potential drug-induced pruritus, as recommended by the British Journal of Dermatology 4

The American College of Dermatology recommends emollients to maintain skin hydration, topical doxepin, and topical clobetasone butyrate or menthol preparations as first-line therapies 1
Non-sedating antihistamines, such as fexofenadine or loratadine, are recommended as second-line therapies by the American College of Dermatology 1
Paroxetine, fluvoxamine, or mirtazapine may be considered as third-line therapies, as suggested by the British Journal of Dermatology 1, 5

The British Journal of Dermatology recommends rifampicin as a first-line treatment, and cholestyramine as a second-line treatment 4, 6
Sertraline may be considered as a third-line treatment, and naltrexone or nalmefene as fourth-line treatments, as suggested by the British Journal of Dermatology 4
The British Journal of Dermatology advises against using gabapentin in hepatic pruritus 4, 6

The British Journal of Dermatology recommends optimizing dialysis parameters, normalizing calcium-phosphate balance, and controlling parathyroid hormone levels as initial management 6
BB-UVB phototherapy is recommended as an additional treatment, with a strength of recommendation A, by the British Journal of Dermatology 4, 6
The British Journal of Dermatology advises against using cetirizine and long-term sedative antihistamines in uremic pruritus, except in palliative care settings 6

The British Journal of Dermatology recommends iron replacement therapy for iron deficiency, and venesection or desferrioxamine infusion for iron overload 3, 5
Cytoreductive therapy, aspirin, interferon-α, SSRIs, cimetidine, or atenolol may be considered for polycythemia vera, as suggested by the British Journal of Dermatology 3, 6

The British Journal of Dermatology recommends cimetidine, carbamazepine, gabapentin, or mirtazapine, and oral corticosteroids for incurable lymphoma 3, 6
BB-UVB phototherapy is recommended for Hodgkin lymphoma, and NB-UVB for non-Hodgkin lymphoma, as suggested by the British Journal of Dermatology 3, 6

The British Journal of Dermatology recommends paroxetine, mirtazapine, granisetron, or aprepitant, as suggested by the British Journal of Dermatology 3, 6

The British Journal of Dermatology recommends a trial of medication cessation if risk-benefit analysis is acceptable, and naltrexone for opioid-induced pruritus if cessation is not possible 1, 4

The American College of Dermatology recommends excluding asteatotic eczema with a 2-week trial of emollients and topical steroids in elderly patients 1
The British Journal of Dermatology advises against long-term use of sedative antihistamines except in palliative care settings due to potential dementia risk 1, 6
The British Journal of Dermatology suggests considering skin biopsy to confirm small fiber neuropathy if suspected in neuropathic pruritus 3, 4