Treatment of Generalized Pruritus

Initial Approach

• The British Journal of Dermatology recommends beginning with a thorough investigation to identify potential underlying causes, including systemic diseases, medications, infections, or psychological factors 1, 3
• A trial of medication cessation should be considered if drug-induced pruritus is suspected, when the risk-benefit ratio is acceptable 1, 4

Treatment for Generalized Pruritus of Unknown Origin (GPUO)

First-line therapies:

• The British Journal of Dermatology suggests providing self-care advice and prescribing emollients to maintain skin hydration 5, 6
• Topical doxepin (limited to 8 days, 10% of body surface area, and 12g daily) can be considered as a first-line therapy 5, 6
• Topical clobetasone butyrate or menthol preparations can also be used as first-line therapies 5, 4

Second-line therapies:

• Non-sedating antihistamines (H1 antagonists) such as fexofenadine 180 mg or loratadine 10 mg can be used as second-line therapies 5, 6
• Mildly sedative agents such as cetirizine 10 mg can be considered as second-line therapies 5, 4

Third-line therapies:

• Systemic medications such as paroxetine, fluvoxamine, mirtazapine can be used as third-line therapies 5, 6
• Naltrexone, butorphanol can also be considered as third-line therapies 5, 6
• Gabapentin, pregabalin can be used as third-line therapies, but gabapentin should be avoided in hepatic pruritus 5, 4

Specific Treatments Based on Underlying Causes

Hepatic pruritus:

• Rifampicin is recommended as a first-line treatment for hepatic pruritus 1, 7
• Cholestyramine can be considered as a second-line treatment for hepatic pruritus 7, 3
• Sertraline can be used as a third-line treatment for hepatic pruritus 7, 3

Uremic pruritus:

• Optimizing dialysis, normalizing calcium-phosphate balance, controlling parathyroid hormone levels, correcting anemia, and using emollients can help manage uremic pruritus 1, 8
• BB-UVB phototherapy is highly effective (Strength of recommendation A) for uremic pruritus 1, 8

Drug-induced pruritus:

• Naltrexone is recommended as a first-line treatment for opioid-induced pruritus if opioid cessation is not possible; methylnaltrexone is an alternative 5, 9
• Diclofenac 100 mg rectally can be used to manage postoperative pruritus 5, 9

Pruritus in elderly patients:

• Initial treatment with emollients and topical steroids for at least 2 weeks can help exclude asteatotic eczema 6, 9
• Moisturizers with high lipid content are preferred for elderly patients 9

Special Considerations

• Long-term use of sedative antihistamines should be avoided except in palliative care settings due to potential dementia risk 1, 8
• Behavioral interventions, relaxation techniques, and cognitive restructuring can be beneficial for patients with suspected psychological factors contributing to pruritus 9, 4
• Patient support groups can be beneficial for chronic pruritus management 9, 4