Pruritus Management

Introduction to Pruritus

• Pruritus can be localized or generalized, and determining the type is crucial for diagnosis and treatment, as recommended by the British Journal of Dermatology guidelines 1
• Primary skin lesions should be looked for, and if present, the dermatological condition should be treated, and if not, systemic causes should be investigated, as suggested by the British Journal of Dermatology 1

Diagnosis and Assessment

• First-line investigations for pruritus should include complete blood count, liver function tests, urea and electrolytes, and thyroid function tests, according to the British Journal of Dermatology 1
• A thorough skin assessment and psychiatric assessment are recommended to evaluate for depression, anxiety, obsessive-compulsive behaviors, delusional thinking, and suicidal ideation, which is present in up to 10% of patients with certain skin conditions, as recommended by the American Academy of Dermatology 2

Treatment Options

• Topical corticosteroids are the first-line treatment for mild to moderate pruritus, with hydrocortisone 1% cream being the most commonly recommended over-the-counter option, as recommended by the American College of Dermatology and the Annals of Oncology 3, 4
• Topical doxepin can be considered for localized areas of pruritus, limited to 8 days, 10% body surface area, maximum 12g daily, as recommended by the British Association of Dermatologists 1
• Non-sedating antihistamines such as fexofenadine 180mg, loratadine 10mg, or cetirizine 10mg daily can be used to treat pruritus, as recommended by the British Journal of Dermatology 1
• Gabapentin (900-3600mg daily) or pregabalin (25-150mg daily) can be particularly beneficial in elderly patients with pruritus, and should be considered for persistent pruritus, as recommended by the British Journal of Dermatology 1
• Systemic corticosteroids (0.5-2 mg/kg daily) can be used for temporary relief of severe pruritus, as recommended by the Annals of Oncology 3, 4

Special Considerations

• For pruritus in elderly skin, emollients and topical steroids, moisturizers with high lipid content, and considering gabapentin for persistent pruritus, and avoiding sedating antihistamines due to risk of falls and cognitive impairment, as recommended by the British Journal of Dermatology 1
• Cognitive Behavioral Therapy (CBT) as the first-line treatment for Body Dysmorphic Disorder (BDD) in young people, incorporating exposure with response prevention (ERP) and involving family or carers, adapted to the developmental level of young people, is recommended by the NICE guidelines 5
• Selective Serotonin Reuptake Inhibitors (SSRIs) are recommended as second-line treatment for moderate to severe BDD in young people aged 12-18 years who haven't responded adequately to CBT, as suggested by the NICE guidelines 5

Treatment Recommendations Summary

Follow-up and Referral

• Regular follow-up is recommended for patients with generalized pruritus, and reassessing patients who have not responded to initial treatment, and monitoring for adverse effects of treatments, as recommended by the British Journal of Dermatology 1
• Consider referral to secondary care if there is diagnostic doubt, primary care management does not relieve symptoms, or systemic disease is suspected but investigations are negative, as recommended by the British Journal of Dermatology 1
• Cetirizine is not effective for uremic pruritus, according to the British Journal of Dermatology guidelines 1
• The American College of Obstetricians and Gynecologists and the National Comprehensive Cancer Network recommend considering referral to gynecology or dermatology if suspicion of vulvar cancer exists, such as presence of mass or ulcer 6
• Long-term use of sedating antihistamines may predispose to dementia, except in palliative care, as stated by the British Journal of Dermatology guidelines 1