Emergency Treatment for Pruritus

First-line Treatments

Emollients should be provided as supportive care to address dry skin which can exacerbate pruritus, as recommended by the British Journal of Dermatology 1

For Cholestatic/Hepatic Pruritus, the British Journal of Dermatology recommends rifampicin as the first-line treatment, starting at 150 mg with monitoring of liver function tests, which may be increased to a maximum of 600 mg daily 1, 2
Cholestyramine 4 g up to four times daily can be used as an alternative first-line treatment for Cholestatic/Hepatic Pruritus, as suggested by the Journal of Hepatology, and should be spaced at least 4 hours from other medications 2
The British Journal of Dermatology advises against using gabapentin in hepatic pruritus as it is ineffective 1
For Uremic Pruritus, the British Journal of Dermatology recommends ensuring adequate dialysis, normalizing calcium-phosphate balance, and using emollients before other treatments 1
Gabapentin 100-300 mg after dialysis (three times per week) is effective for uremic pruritus, according to the British Journal of Dermatology 3, 4
Broad-band UVB (BB-UVB) phototherapy is an effective treatment for many patients with uremic pruritus, but not practical in emergency settings, as noted by the British Journal of Dermatology 1
For Drug-Induced Pruritus, the British Journal of Dermatology suggests naltrexone as the first-choice treatment for opioid-induced pruritus if cessation of opioid therapy is impossible 5
For postoperative pruritus, the British Journal of Dermatology recommends considering diclofenac 100 mg given rectally 5

For moderate-to-severe pruritus unresponsive to antihistamines, the Annals of Oncology suggests considering GABA agonists (pregabalin/gabapentin) except in hepatic pruritus 6
Topical moderate/high-potency steroids can be used for localized pruritus, as recommended by the Annals of Oncology 6
Doxepin (tricyclic antidepressant with potent antihistamine properties) can be considered for severe cases, according to the Annals of Oncology 6

The Annals of Oncology recommends reassessing after 2 weeks for mild-to-moderate cases; if reactions worsen or do not improve, proceed to next treatment step 6
For severe pruritus (Grade ≥3 or intolerable Grade 2), the Annals of Oncology advises interrupting any causative treatments until improvement to Grade 0-1 6
If pruritus is associated with a systemic disease, emergency management should include addressing the underlying condition while providing symptomatic relief, as recommended by the British Journal of Dermatology and the British Journal of Dermatology 1, 5

Long-term use of sedative antihistamines may predispose to dementia and should be avoided except in palliative care, as warned by the British Journal of Dermatology 1
The British Journal of Dermatology cautions that some treatments are contraindicated in specific conditions (e.g., gabapentin in hepatic pruritus) 1