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Pruritus

Key sources
The following summarized guidelines for the evaluation and management of pruritus are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2023; 2022), the Japanese Dermatological Association (JDA 2021), the European Academy of Dermatology and Venereology (EADV/EDF 2019), and the British Association of Dermatologists (BAD 2018).
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Guidelines

1.Diagnostic investigations

History and physical examination
As per AAFP 2022 guidelines:
Obtain a complete dermatologic assessment during the physical examination for pruritus.
B
Differentiate lesions as primary to pruritus or secondary (such as excoriations and scarring), recognizing that primary skin lesions indicate skin disease.
B
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  • Skin testing

  • Laboratory tests

  • Evaluation for infection

  • Hemato-oncologic evaluation

2.Medical management

Topical therapy, corticosteroids, AAFP: offer topical corticosteroids for initial symptomatic therapy in patients with pruritus.
B

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  • Topical therapy (capsaicin)

  • Topical therapy (calcineurin inhibitors)

  • Topical therapy (mast cell inhibitors)

  • Topical therapy (anesthetics)

  • Topical therapy (other agents)

  • Systemic therapy (H1-antihistamines)

  • Systemic therapy (corticosteroids)

  • Systemic therapy (gabapentin and pregabalin)

  • Systemic therapy (antidepressants)

  • Systemic therapy (opioid antagonists)

  • Systemic therapy (serotonin receptor antagonists)

  • Systemic therapy (neurokinin receptor-1 antagonists)

  • Systemic therapy (thalidomide)

  • Systemic therapy (immunosuppressants)

  • Systemic therapy (monoclonal antibodies)

  • Systemic therapy (other agents)

3.Nonpharmacologic interventions

Moisturizers and emollients: as per AAFP 2022 guidelines, encourage liberal use of emollients and limiting water exposure to reduce dry skin.
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  • Vitamin D supplements

  • Psychotherapy

  • Physical therapy

  • Acupuncture

4.Therapeutic procedures

Ultraviolet phototherapy: as per JDA 2021 guidelines, consider offering BB-UVB phototherapy for generalized pruritus in patients with renal dysfunction.
C

5.Specific circumstances

Pregnant patients: recognize that first- and second-generation H1RAs are safe to use throughout pregnancy.
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  • Elderly patients

  • Patients with uremic pruritus

  • Patients with hepatic pruritus

  • Patients with drug-induced pruritus

  • Patients with HIV infection

  • Patients with lymphoma

  • Patients with polycythemia vera

  • Patients with paraneoplastic syndrome

  • Patients with psychogenic pruritus

  • Patients with aquagenic pruritus

6.Patient education

General counseling: as per AAFP 2022 guidelines, counsel patients with a history of irritant or allergic contact dermatitis to avoid contact irritants and other triggers (such as rough textiles, detergents, perfumes, chemicals, dyes).
B