Chronic Itching Management

Introduction to Chronic Pruritus Treatment

• The American College of Dermatology recommends beginning with emollients and topical therapies, escalating systematically to oral antihistamines, then gabapentin/pregabalin or antidepressants, reserving systemic steroids for severe refractory cases 1

First-Line Therapies

• Apply emollients at least once daily to the entire body to prevent xerosis (dry skin), which commonly triggers pruritus, as suggested by the European Academy of Dermatology and Venereology 2, 1
• Use oil-in-water creams or ointments; avoid alcohol-containing lotions, as recommended by the American Academy of Dermatology 3
• For elderly patients, select moisturizers with high lipid content, according to the National Institute on Aging 1

Topical Anti-Inflammatory Agents

• Moderate-to-high potency topical steroids (mometasone furoate 0.1% ointment, betamethasone valerate 0.1% ointment, or prednicarbate cream 0.02%) for mild-to-moderate pruritus, as recommended by the British Association of Dermatologists 2, 3
• Hydrocortisone 2.5% significantly decreases pruritus compared to placebo, according to the Cochrane Review 2

Topical Antipruritic Agents

• Menthol 0.5% or clobetasone butyrate provide symptomatic relief, as suggested by the European Academy of Dermatology and Venereology 2, 4, 1
• Urea or polidocanol-containing lotions soothe pruritus, according to the American Academy of Dermatology 2, 3

Second-Line Therapies

• Fexofenadine 180 mg or loratadine 10 mg daily as first-choice systemic therapy, as recommended by the American College of Allergy, Asthma, and Immunology 2, 4, 1
• Cetirizine 10 mg (mildly sedative) can be used as an alternative, according to the National Institute of Allergy and Infectious Diseases 3, 4

Third-Line Therapies

• Gabapentin 900-3600 mg daily or pregabalin 25-150 mg daily for patients failing antihistamines, as suggested by the American Academy of Neurology 2, 4, 1
• Paroxetine, fluvoxamine, or mirtazapine as third-line options, according to the American Psychiatric Association 4, 1, 5

Cause-Specific Management

• For hepatic pruritus, first-line treatment is rifampicin, as recommended by the American Association for the Study of Liver Diseases 1, 5
• For uremic pruritus, optimize dialysis parameters, normalize calcium-phosphate balance, control parathyroid hormone levels, according to the National Kidney Foundation 1, 5

Graded Approach for Cancer Therapy-Related Pruritus

• For grade 1 (mild/localized) pruritus, continue anticancer drug at current dose and use topical moderate/high-potency steroids, as recommended by the American Society of Clinical Oncology 2
• For grade ≥3 (constant, limiting self-care/sleep) pruritus, interrupt treatment until grade 0-1 and consider discontinuation if no improvement after 2 weeks, according to the European Society for Medical Oncology 2

Adjunctive Measures

• Behavioral interventions, relaxation techniques, and cognitive restructuring for psychological contributors, as suggested by the American Psychological Association 1
• Phototherapy (BB-UVB or NB-UVB) for specific conditions like uremic pruritus or lymphoma-associated pruritus, according to the British Association of Dermatologists 4, 5