Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point-of-care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors and editors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

Choose from the list below to learn more about subscriptions for a:


Subscribers log in here


Pruritus: Overview of management

INTRODUCTION

Pruritus is a common symptom that occurs in a wide variety of clinical settings, such as dermatologic disorders, neuropathic disorders, and systemic or psychiatric disease. In addition to physical effects (eg, skin injury, secondary infections, scarring, and loss of sleep), pruritus can contribute to emotional disturbances such as agitation and depression [1]. In severe cases, pruritus can be incapacitating.

The inciting factor for pruritus and the extent and severity of symptoms influence the approach to treatment. While in some patients amelioration of pruritus is easily attained, treatment is extremely challenging in other individuals.

A wide variety of therapies have been used for pruritus; however, data are limited on the efficacy of many treatment options (table 1A-B). The therapies used for pruritus and the approach to the management of pruritus will be discussed here. Inciting factors for pruritus and the evaluation of patients with pruritus are reviewed separately. (See "Pruritus: Etiology and patient evaluation".)

THERAPEUTIC OPTIONS

Both nonpharmacologic and pharmacologic therapies may be beneficial in the treatment of pruritus. Topical therapies are commonly used for localized forms of pruritus; systemic agents are typically needed for patients with generalized symptoms. (See 'Local pharmacologic therapies' below and 'Systemic therapies' below.)

Nonpharmacologic interventions — The elimination of aggravating factors for pruritus is an important component of symptom management. Interventions that may be beneficial include:

                          

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Aug 2014. | This topic last updated: Jun 25, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
References
Top
  1. van Os-Medendorp H, Ros WJ, Eland-de Kok PC, et al. Effectiveness of the nursing programme 'Coping with itch': a randomized controlled study in adults with chronic pruritic skin disease. Br J Dermatol 2007; 156:1235.
  2. Gieler U, Niemeier V, Brosig B, Kupfer J. Psychosomatic aspects of pruritus. In: Itch: Basic Mechanisms and Therapy, Yosipovitch G, Greaves MW, Fleischer AB Jr, McGlone F (Eds), Marcel Dekker, New York 2004. p.343.
  3. Yamamoto Y, Yamazaki S, Hayashino Y, et al. Association between frequency of pruritic symptoms and perceived psychological stress: a Japanese population-based study. Arch Dermatol 2009; 145:1384.
  4. Yosipovitch G, Goon A, Wee J, et al. The prevalence and clinical characteristics of pruritus among patients with extensive psoriasis. Br J Dermatol 2000; 143:969.
  5. Yosipovitch G, Goon AT, Wee J, et al. Itch characteristics in Chinese patients with atopic dermatitis using a new questionnaire for the assessment of pruritus. Int J Dermatol 2002; 41:212.
  6. Pfab F, Huss-Marp J, Gatti A, et al. Influence of acupuncture on type I hypersensitivity itch and the wheal and flare response in adults with atopic eczema - a blinded, randomized, placebo-controlled, crossover trial. Allergy 2010; 65:903.
  7. Kim KH, Lee MS, Choi SM. Acupuncture for treating uremic pruritus in patients with end-stage renal disease: a systematic review. J Pain Symptom Manage 2010; 40:117.
  8. Tuerk MJ, Koo J. A practical review and update on the management of pruritus sine materia. Cutis 2008; 82:187.
  9. Bingham LG, Noble JW, Davis MD. Wet dressings used with topical corticosteroids for pruritic dermatoses: A retrospective study. J Am Acad Dermatol 2009; 60:792.
  10. Devillers AC, de Waard-van der Spek FB, Mulder PG, Oranje AP. Treatment of refractory atopic dermatitis using 'wet-wrap' dressings and diluted corticosteroids: results of standardized treatment in both children and adults. Dermatology 2002; 204:50.
  11. Papoiu AD, Yosipovitch G. Topical capsaicin. The fire of a 'hot' medicine is reignited. Expert Opin Pharmacother 2010; 11:1359.
  12. Cassano N, Tessari G, Vena GA, Girolomoni G. Chronic pruritus in the absence of specific skin disease: an update on pathophysiology, diagnosis, and therapy. Am J Clin Dermatol 2010; 11:399.
  13. Knotkova H, Pappagallo M, Szallasi A. Capsaicin (TRPV1 Agonist) therapy for pain relief: farewell or revival? Clin J Pain 2008; 24:142.
  14. Gooding SM, Canter PH, Coelho HF, et al. Systematic review of topical capsaicin in the treatment of pruritus. Int J Dermatol 2010; 49:858.
  15. Knight TE, Hayashi T. Solar (brachioradial) pruritus--response to capsaicin cream. Int J Dermatol 1994; 33:206.
  16. Barry R, Rogers S. Brachioradial pruritus--an enigmatic entity. Clin Exp Dermatol 2004; 29:637.
  17. Wallengren J, Klinker M. Successful treatment of notalgia paresthetica with topical capsaicin: vehicle-controlled, double-blind, crossover study. J Am Acad Dermatol 1995; 32:287.
  18. Leibsohn E. Treatment of notalgia paresthetica with capsaicin. Cutis 1992; 49:335.
  19. Makhlough A, Ala S, Haj-Heydari Z, et al. Topical capsaicin therapy for uremic pruritus in patients on hemodialysis. Iran J Kidney Dis 2010; 4:137.
  20. Lotti T, Teofoli P, Tsampau D. Treatment of aquagenic pruritus with topical capsaicin cream. J Am Acad Dermatol 1994; 30:232.
  21. Breneman DL, Cardone JS, Blumsack RF, et al. Topical capsaicin for treatment of hemodialysis-related pruritus. J Am Acad Dermatol 1992; 26:91.
  22. Ständer S, Luger T, Metze D. Treatment of prurigo nodularis with topical capsaicin. J Am Acad Dermatol 2001; 44:471.
  23. Yosipovitch G, Maibach HI, Rowbotham MC. Effect of EMLA pre-treatment on capsaicin-induced burning and hyperalgesia. Acta Derm Venereol 1999; 79:118.
  24. Fleischer AB Jr, Boguniewicz M. An approach to pruritus in atopic dermatitis: a critical systematic review of the tacrolimus ointment literature. J Drugs Dermatol 2010; 9:488.
  25. Ständer S, Schürmeyer-Horst F, Luger TA, Weisshaar E. Treatment of pruritic diseases with topical calcineurin inhibitors. Ther Clin Risk Manag 2006; 2:213.
  26. Pereira U, Boulais N, Lebonvallet N, et al. Mechanisms of the sensory effects of tacrolimus on the skin. Br J Dermatol 2010; 163:70.
  27. Yosipovitch G, Maibach HI. Effect of topical pramoxine on experimentally induced pruritus in humans. J Am Acad Dermatol 1997; 37:278.
  28. Shuttleworth D, Hill S, Marks R, Connelly DM. Relief of experimentally induced pruritus with a novel eutectic mixture of local anaesthetic agents. Br J Dermatol 1988; 119:535.
  29. Gal-Oz A, Rogowski O, Swartzon M, Kivity S. Ethyl chloride as an antipruritic agent: a double-blind placebo-controlled prospective study. Dermatology 2010; 221:373.
  30. Young TA, Patel TS, Camacho F, et al. A pramoxine-based anti-itch lotion is more effective than a control lotion for the treatment of uremic pruritus in adult hemodialysis patients. J Dermatolog Treat 2009; 20:76.
  31. Kopecky EA, Jacobson S, Bch MB, et al. Safety and pharmacokinetics of EMLA in the treatment of postburn pruritus in pediatric patients: a pilot study. J Burn Care Rehabil 2001; 22:235.
  32. FREEMAN CW. A new topical remedy useful in the management of pruritus. J Natl Med Assoc 1961; 53:151.
  33. Layton AM, Cotterill JA. Notalgia paraesthetica--report of three cases and their treatment. Clin Exp Dermatol 1991; 16:197.
  34. Freitag G, Höppner T. Results of a postmarketing drug monitoring survey with a polidocanol-urea preparation for dry, itching skin. Curr Med Res Opin 1997; 13:529.
  35. Eschler DC, Klein PA. An evidence-based review of the efficacy of topical antihistamines in the relief of pruritus. J Drugs Dermatol 2010; 9:992.
  36. Metz M, Ständer S. Chronic pruritus--pathogenesis, clinical aspects and treatment. J Eur Acad Dermatol Venereol 2010; 24:1249.
  37. Greene SL, Reed CE, Schroeter AL. Double-blind crossover study comparing doxepin with diphenhydramine for the treatment of chronic urticaria. J Am Acad Dermatol 1985; 12:669.
  38. O'Donoghue M, Tharp MD. Antihistamines and their role as antipruritics. Dermatol Ther 2005; 18:333.
  39. Yosipovitch G, Bernhard JD. Clinical practice. Chronic pruritus. N Engl J Med 2013; 368:1625.
  40. Klein PA, Clark RA. An evidence-based review of the efficacy of antihistamines in relieving pruritus in atopic dermatitis. Arch Dermatol 1999; 135:1522.
  41. Raap U, Ständer S, Metz M. Pathophysiology of itch and new treatments. Curr Opin Allergy Clin Immunol 2011; 11:420.
  42. Phan NQ, Bernhard JD, Luger TA, Ständer S. Antipruritic treatment with systemic μ-opioid receptor antagonists: a review. J Am Acad Dermatol 2010; 63:680.
  43. Penning JP, Samson B, Baxter AD. Reversal of epidural morphine-induced respiratory depression and pruritus with nalbuphine. Can J Anaesth 1988; 35:599.
  44. Peer G, Kivity S, Agami O, et al. Randomised crossover trial of naltrexone in uraemic pruritus. Lancet 1996; 348:1552.
  45. Pauli-Magnus C, Mikus G, Alscher DM, et al. Naltrexone does not relieve uremic pruritus: results of a randomized, double-blind, placebo-controlled crossover study. J Am Soc Nephrol 2000; 11:514.
  46. Yuan CS, Foss JF, O'Connor M, et al. Efficacy of orally administered methylnaltrexone in decreasing subjective effects after intravenous morphine. Drug Alcohol Depend 1998; 52:161.
  47. Moss J, Rosow CE. Development of peripheral opioid antagonists' new insights into opioid effects. Mayo Clin Proc 2008; 83:1116.
  48. Dawn AG, Yosipovitch G. Butorphanol for treatment of intractable pruritus. J Am Acad Dermatol 2006; 54:527.
  49. Kumagai H, Ebata T, Takamori K, et al. Effect of a novel kappa-receptor agonist, nalfurafine hydrochloride, on severe itch in 337 haemodialysis patients: a Phase III, randomized, double-blind, placebo-controlled study. Nephrol Dial Transplant 2010; 25:1251.
  50. Wang H, Yosipovitch G. New insights into the pathophysiology and treatment of chronic itch in patients with end-stage renal disease, chronic liver disease, and lymphoma. Int J Dermatol 2010; 49:1.
  51. Davis MP, Frandsen JL, Walsh D, et al. Mirtazapine for pruritus. J Pain Symptom Manage 2003; 25:288.
  52. Hundley JL, Yosipovitch G. Mirtazapine for reducing nocturnal itch in patients with chronic pruritus: a pilot study. J Am Acad Dermatol 2004; 50:889.
  53. Demierre MF, Taverna J. Mirtazapine and gabapentin for reducing pruritus in cutaneous T-cell lymphoma. J Am Acad Dermatol 2006; 55:543.
  54. Sheen MJ, Ho ST, Lee CH, et al. Prophylactic mirtazapine reduces intrathecal morphine-induced pruritus. Br J Anaesth 2008; 101:711.
  55. Ständer S, Böckenholt B, Schürmeyer-Horst F, et al. Treatment of chronic pruritus with the selective serotonin re-uptake inhibitors paroxetine and fluvoxamine: results of an open-labelled, two-arm proof-of-concept study. Acta Derm Venereol 2009; 89:45.
  56. Mayo MJ, Handem I, Saldana S, et al. Sertraline as a first-line treatment for cholestatic pruritus. Hepatology 2007; 45:666.
  57. Browning J, Combes B, Mayo MJ. Long-term efficacy of sertraline as a treatment for cholestatic pruritus in patients with primary biliary cirrhosis. Am J Gastroenterol 2003; 98:2736.
  58. Yesudian PD, Wilson NJ. Efficacy of gabapentin in the management of pruritus of unknown origin. Arch Dermatol 2005; 141:1507.
  59. Duval A, Dubertret L. Aprepitant as an antipruritic agent? N Engl J Med 2009; 361:1415.
  60. Ständer S, Siepmann D, Herrgott I, et al. Targeting the neurokinin receptor 1 with aprepitant: a novel antipruritic strategy. PLoS One 2010; 5:e10968.
  61. Vincenzi B, Fratto ME, Santini D, Tonini G. Aprepitant against pruritus in patients with solid tumours. Support Care Cancer 2010; 18:1229.
  62. Vincenzi B, Tonini G, Santini D. Aprepitant for erlotinib-induced pruritus. N Engl J Med 2010; 363:397.
  63. Mir O, Blanchet B, Goldwasser F. More on aprepitant for erlotinib-induced pruritus. N Engl J Med 2011; 364:487.
  64. Booken N, Heck M, Nicolay JP, et al. Oral aprepitant in the therapy of refractory pruritus in erythrodermic cutaneous T-cell lymphoma. Br J Dermatol 2011; 164:665.
  65. Torres T, Fernandes I, Selores M, et al. Aprepitant: Evidence of its effectiveness in patients with refractory pruritus continues. J Am Acad Dermatol 2012; 66:e14.
  66. Patel T, Yosipovitch G. Therapy of pruritus. Expert Opin Pharmacother 2010; 11:1673.
  67. Rivard J, Lim HW. Ultraviolet phototherapy for pruritus. Dermatol Ther 2005; 18:344.
  68. Hammes S, Hermann J, Roos S, Ockenfels HM. UVB 308-nm excimer light and bath PUVA: combination therapy is very effective in the treatment of prurigo nodularis. J Eur Acad Dermatol Venereol 2011; 25:799.
  69. Bruni E, Caccialanza M, Piccinno R. Phototherapy of generalized prurigo nodularis. Clin Exp Dermatol 2010; 35:549.
  70. Tamagawa-Mineoka R, Katoh N, Ueda E, Kishimoto S. Narrow-band ultraviolet B phototherapy in patients with recalcitrant nodular prurigo. J Dermatol 2007; 34:691.
  71. Ada S, Seçkin D, Budakoğlu I, Ozdemir FN. Treatment of uremic pruritus with narrowband ultraviolet B phototherapy: an open pilot study. J Am Acad Dermatol 2005; 53:149.
  72. Gilchrest BA, Rowe JW, Brown RS, et al. Relief of uremic pruritus with ultraviolet phototherapy. N Engl J Med 1977; 297:136.
  73. Ko MJ, Yang JY, Wu HY, et al. Narrowband ultraviolet B phototherapy for patients with refractory uraemic pruritus: a randomized controlled trial. Br J Dermatol 2011; 165:633.
  74. Madkan VK, Bandow GD, Koo JY. Resolution of pruritus secondary to polycythemia vera in a patient treated with narrow-band ultraviolet B phototherapy. J Dermatolog Treat 2005; 16:56.
  75. Baldo A, Sammarco E, Plaitano R, et al. Narrowband (TL-01) ultraviolet B phototherapy for pruritus in polycythaemia vera. Br J Dermatol 2002; 147:979.
  76. Ozden MG, Aydin F, Sentürk N, et al. Narrow-band ultraviolet B as a potential alternative treatment for resistant psychogenic excoriation: an open-label study. Photodermatol Photoimmunol Photomed 2010; 26:162.
  77. Pérez-Pérez L, Allegue F, Fabeiro JM, et al. Notalgia paresthesica successfully treated with narrow-band UVB: report of five cases. J Eur Acad Dermatol Venereol 2010; 24:730.
  78. Hsu MM, Yang CC. Uraemic pruritus responsive to broadband ultraviolet (UV) B therapy does not readily respond to narrowband UVB therapy. Br J Dermatol 2003; 149:888.
  79. Gambichler T, Hyun J, Sommer A, et al. A randomised controlled trial on photo(chemo)therapy of subacute prurigo. Clin Exp Dermatol 2006; 31:348.
  80. Patel T, Yosipovitch G. The management of chronic pruritus in the elderly. Skin Therapy Lett 2010; 15:5.
  81. Sonkoly E, Muller A, Lauerma AI, et al. IL-31: a new link between T cells and pruritus in atopic skin inflammation. J Allergy Clin Immunol 2006; 117:411.
  82. Grimstad O, Sawanobori Y, Vestergaard C, et al. Anti-interleukin-31-antibodies ameliorate scratching behaviour in NC/Nga mice: a model of atopic dermatitis. Exp Dermatol 2009; 18:35.
  83. Bigliardi PL, Stammer H, Jost G, et al. Treatment of pruritus with topically applied opiate receptor antagonist. J Am Acad Dermatol 2007; 56:979.
  84. Eberlein B, Eicke C, Reinhardt HW, Ring J. Adjuvant treatment of atopic eczema: assessment of an emollient containing N-palmitoylethanolamine (ATOPA study). J Eur Acad Dermatol Venereol 2008; 22:73.
  85. Ständer S, Reinhardt HW, Luger TA. [Topical cannabinoid agonists. An effective new possibility for treating chronic pruritus]. Hautarzt 2006; 57:801.
  86. Arai I, Takaoka A, Hashimoto Y, et al. Effects of TS-022, a newly developed prostanoid DP1 receptor agonist, on experimental pruritus, cutaneous barrier disruptions and atopic dermatitis in mice. Eur J Pharmacol 2007; 556:207.
  87. Engelhardt H, Smits RA, Leurs R, et al. A new generation of anti-histamines: Histamine H4 receptor antagonists on their way to the clinic. Curr Opin Drug Discov Devel 2009; 12:628.
  88. Dunford PJ, Williams KN, Desai PJ, et al. Histamine H4 receptor antagonists are superior to traditional antihistamines in the attenuation of experimental pruritus. J Allergy Clin Immunol 2007; 119:176.
  89. White-Chu EF, Reddy M. Dry skin in the elderly: complexities of a common problem. Clin Dermatol 2011; 29:37.
  90. Boccanfuso SM, Cosmet L, Volpe AR, Bensel A. Skin xerosis. Clinical report on the effect of a moisturizing soap bar. Cutis 1978; 21:703.
  91. Abbas S, Goldberg JW, Massaro M. Personal cleanser technology and clinical performance. Dermatol Ther 2004; 17 Suppl 1:35.
  92. Steinhoff M, Neisius U, Ikoma A, et al. Proteinase-activated receptor-2 mediates itch: a novel pathway for pruritus in human skin. J Neurosci 2003; 23:6176.
  93. Lodén M. The clinical benefit of moisturizers. J Eur Acad Dermatol Venereol 2005; 19:672.
  94. Draelos ZD. Active agents in common skin care products. Plast Reconstr Surg 2010; 125:719.
  95. Clinical Dermatology: A Color Guide to Diagnosis and Therapy, 4th ed, Habif TP (Ed), Mosby, St. Louis 2004. p.60.
  96. Yosipovitch G, Sugeng MW, Chan YH, et al. The effect of topically applied aspirin on localized circumscribed neurodermatitis. J Am Acad Dermatol 2001; 45:910.
  97. Gencoglan G, Inanir I, Gunduz K. Therapeutic hotline: Treatment of prurigo nodularis and lichen simplex chronicus with gabapentin. Dermatol Ther 2010; 23:194.
  98. Aymard JP, Lederlin P, Witz F, et al. Cimetidine for pruritus in Hodgkin's disease. Br Med J 1980; 280:151.
  99. Zylicz Z, Krajnik M, Sorge AA, Costantini M. Paroxetine in the treatment of severe non-dermatological pruritus: a randomized, controlled trial. J Pain Symptom Manage 2003; 26:1105.
  100. Etter L, Myers SA. Pruritus in systemic disease: mechanisms and management. Dermatol Clin 2002; 20:459.
  101. Saini KS, Patnaik MM, Tefferi A. Polycythemia vera-associated pruritus and its management. Eur J Clin Invest 2010; 40:828.
  102. Osterman PO. Paroxysmal itching in multiple sclerosis. Br J Dermatol 1976; 95:555.
  103. Yamamoto M, Yabuki S, Hayabara T, Otsuki S. Paroxysmal itching in multiple sclerosis: a report of three cases. J Neurol Neurosurg Psychiatry 1981; 44:19.
  104. Yosipovitch G, Samuel LS. Neuropathic and psychogenic itch. Dermatol Ther 2008; 21:32.
  105. Wallengren J. Brachioradial pruritus: a recurrent solar dermopathy. J Am Acad Dermatol 1998; 39:803.
  106. Heyl T. Brachioradial pruritus. Arch Dermatol 1983; 119:115.
  107. Poterucha TJ, Murphy SL, Davis MD, et al. Topical amitriptyline-ketamine for the treatment of brachioradial pruritus. JAMA Dermatol 2013; 149:148.
  108. Bueller HA, Bernhard JD, Dubroff LM. Gabapentin treatment for brachioradial pruritus. J Eur Acad Dermatol Venereol 1999; 13:227.
  109. Winhoven SM, Coulson IH, Bottomley WW. Brachioradial pruritus: response to treatment with gabapentin. Br J Dermatol 2004; 150:786.
  110. Kanitakis J. Brachioradial pruritus: report of a new case responding to gabapentin. Eur J Dermatol 2006; 16:311.
  111. Mataix J, Silvestre JF, Climent JM, et al. [Brachioradial pruritus as a symptom of cervical radiculopathy]. Actas Dermosifiliogr 2008; 99:719.
  112. Wood GJ, Akiyama T, Carstens E, et al. An insatiable itch. J Pain 2009; 10:792.
  113. Abbott LG. Neuropathic pruritus. Australas J Dermatol 1998; 39:198.
  114. Crevits L. Brachioradial pruritus--a peculiar neuropathic disorder. Clin Neurol Neurosurg 2006; 108:803.
  115. Tait CP, Grigg E, Quirk CJ. Brachioradial pruritus and cervical spine manipulation. Australas J Dermatol 1998; 39:168.
  116. Binder A, Fölster-Holst R, Sahan G, et al. A case of neuropathic brachioradial pruritus caused by cervical disc herniation. Nat Clin Pract Neurol 2008; 4:338.
  117. Metz M, Krause K, Maurer M, Magerl M. Treatment of notalgia paraesthetica with an 8% capsaicin patch. Br J Dermatol 2011; 165:1359.
  118. Savk E, Bolukbasi O, Akyol A, Karaman G. Open pilot study on oxcarbazepine for the treatment of notalgia paresthetica. J Am Acad Dermatol 2001; 45:630.
  119. Loosemore MP, Bordeaux JS, Bernhard JD. Gabapentin treatment for notalgia paresthetica, a common isolated peripheral sensory neuropathy. J Eur Acad Dermatol Venereol 2007; 21:1440.
  120. Weinfeld PK. Successful treatment of notalgia paresthetica with botulinum toxin type A. Arch Dermatol 2007; 143:980.
  121. Goulden V, Toomey PJ, Highet AS. Successful treatment of notalgia paresthetica with a paravertebral local anesthetic block. J Am Acad Dermatol 1998; 38:114.
  122. Maari C, Marchessault P, Bissonnette R. Treatment of notalgia paresthetica with botulinum toxin A: a double-blind randomized controlled trial. J Am Acad Dermatol 2014; 70:1139.
  123. Savk E, Savk O, Sendur F. Transcutaneous electrical nerve stimulation offers partial relief in notalgia paresthetica patients with a relevant spinal pathology. J Dermatol 2007; 34:315.
  124. Raison-Peyron N, Meunier L, Acevedo M, Meynadier J. Notalgia paresthetica: clinical, physiopathological and therapeutic aspects. A study of 12 cases. J Eur Acad Dermatol Venereol 1999; 12:215.