Therapeutic target
Elimination or improvement/relief of symptoms.
Therapy recommendations
- First search for the cause and adequate treatment of the same.
- General therapeutic measures: Basic therapeutics for pruritus (greasing and hydrating the skin in xerosis cutis/dry skin); the following classes are distinguished:
- Rehydrating
- Natural Moisturizing Factor (NMF; natural moisturizing factor): urea, lactic acid derivatives, pyrrolidone carboxylic acid (PCA), amino acids.
- Moisturizing factors (humectants) and swelling agents: glycosaminoglycans, hyaluronic acid, glyceryl glucoside (GG), glycols.
- Refatting: Naturally occurring oils: e.g. borage oil, evening primrose oil, almond oil.
- Soothing to the skin: dexpanthenol, glycyrrhetinic acid, oat extract, niacinamide.
- Pruritus relieving: menthol, menthoxypropanediol, N-palmitoylethanolamide, polidocanol.
Note: The basic therapy must be carried out throughout, ie, even in the relapse or symptom-free interval.
- Rehydrating
- Symptomatic therapy of chronic pruritus: topical or systemic therapy:
- Topical therapy (local therapy):
- Glucocorticoids
- Calcineurin inhibitors (very effective; have no atrophic side effect on the skin).
- Vanilloid alkaloid (capsaicin).
- Menthol, camphor (menthol has a cooling and analgesic effect; camphor develops its effect via a sensation of warmth and subsequent mild anesthesia after application).
- Local anesthetics (for localized pruritus).
- Systemic therapy:
- Nonsedating antihistamines (H1 antihistamines): if a single dose is not therapeutically sufficient, high-dose antihistamines (up to quadruple dose) can be administered. Note: antihistamines have very little effect in hepatobiliary disease!
- Aniconvulsants (gabapentinoids: gabapentin, pregabalin).
- Antidepressants (eg, paroxetine, amitriptyline, duloxetine, mirtazapine, sertraline).
- Opioid receptor antagonists (naltrexone, naloxone).
- Immunosuppressants (ciclosporin A, methotrexate, azathioprine).
- Physical therapy: UV phototherapy (see below “Further therapy”).
- Topical therapy (local therapy):
- Therapeutic options for different forms of pruritus according to the guidelines of the German Dermatological Society.
- Atopic eczema (neurodermatitis) – effective substances, tested in controlled trials (glucocorticoids, immunosuppressants, cytokines, calcineurin inhibitors).
- Hepatic (“liver-related”) and cholestatic (“biliary dust-related”) pruritus/pruritus in patients with hepatogenic jaundice [S3 guideline]:
- Step: cholestyramine (cholesterol resorption inhibitor) (is the only substance approved for the treatment of cholestatic pruritus); alternatively, colesevelam (binds bile acids in the intestinal lumen much better than colestyramine and is apparently also more tolerable than colestyramine).
- Stage: rifampicin (bactericidal antibiotic from the group of ansamycins) (expert opinion: most effective drug for hepatogenic pruritus).
- Stage: opioid antagonists: naloxone, naltrexone.
- Stage: sertraline (antidepressant from the group of selective serotonin reuptake inhibitors): if patients have depressive symptoms.
- Cutaneous pruritus – local therapy with glucocorticosteroids.
- Paraneoplastic pruritus – paroxetine (selective serotonin reuptake inhibitor).
- Pruritus senilis – lipid-replenishing basic care (see above) and lotions containing urea.
- Renal pruritus (“kidney-related pruritus)/uremic pruritus / nephrogenic pruritus – effective substances, tested in controlled studies (activated charcoal, anticonvulsants/central calcium channel blockers gabapentin and pregabalin, immunosuppressants, vanilloid alkaloid (capsaicin 0.025-0.1%; also applicable in non-histamine-induced pruritus; gamma-linolenic acid (GLA); UVB phototherapy).
- See also under “Further therapy“.
Further notes
- A meta-analysis demonstrated that administration of a placebo resulted in a significant reduction in chronic pruritus (in atopic dermatitis, psoriasis, or chronic idiopathic urticaria).
Active substances (main indication) for symptomatic therapy – Topical therapy
Active ingredient group | Active ingredients | Special features |
Glucocorticoids | Dexamethasone, e.g., 0.02%. | |
Vanilloid alkaloid | Capsaicin 0.025-0.1 % | Can also be used for non-histamine-induced pruritus |
Calcineurin inhibitors | Pimecrolimus 1% | Inhibition of cytokine releaseAdverse effects: Mast cell degranulation |
Tacrolimus 0.1 | Inhibition of cytokine releaseAdverse effects: Mast cell degranulation | |
Menthol | Menthol 3 % | |
Camphor | ||
Urea | Urea cream |
Agents (main indication) for symptomatic therapy – Systemic therapy
Active ingredient group | Active ingredients | Special features |
Antihistamines | Azelastine | Initial dose adjustment for renal/hepatic insufficiency. |
Cetirizine | Dose adjustment in renal insufficiency | |
Clemastine | No dose adjustment | |
Loratardin | Dose adjustment in severe hepatic insufficiency. | |
Terfenadine | Dose adjustment in severe renal insufficiency | |
Glucocorticoids | Prednisolone equivalent | For severe pruritusNot as continuous therapy. |
Opioid receptor antagonist | Naltrexone | Dose adjustment in renal/hepatic insufficiency. |
Therapeutic options for different forms of pruritus according to the guidelines of the German Dermatological Society
Renal pruritus / uremic pruritus – effective substances tested in controlled trials.
Drug group | Active ingredients | Special features |
Activated carbon | Activated carbon | |
Anticonvulsants | Gabapentin | 1st choiceDose adjustment in renal insufficiency. |
Pregabalin | 2nd choiceDose adjustment in renal insufficiency. | |
Immunosuppressants | Thalidomide | No information on dose adjustment |
Opioid receptor antagonist | Naltrexone | 3rd choiceDetraction-like symptoms: insidious dosing; pain, confusion. |
Vanilloid alkaloid | Capsaicin 0.025-0.1 % | Can also be used for non-histamine-induced pruritusNo information on dose adjustment. |
Gammalinolenic acid | ||
UVB phototherapy | + topical treatment |
Hepatic and cholestatic pruritus-effective agents tested in controlled trials (modified according to)
Drug group | Active ingredients | Special features |
Anion exchange resins | Colesevelam | Binds bile acids in the intestinal lumen significantly better than colestyramine and is apparently also more tolerable than colestyramine |
Colestyramine |
1st choice
Contraindications: primary biliary cholangitis (PBC, synonyms: nonpurulent destructive cholangitis; primary biliary cirrhosis). |
|
Ursodeoxycholic acid (UDCS). | No data on dose adjustmentIns. intrahepatic pregnancy cholestasis/pregnancy-related biliary retention | |
Antituberculous | Rifampicin (RMP) |
2nd choiceEvidence grade 1A.
Most effective drug for hepatogenic pruritus/liver-related pruritus (expert opinion)Dose adjustment for renal insufficiency and concomitant liver injuryKI for acute hepatic insufficiency/acute liver disease. Cave: hepatotoxicity (liver toxicity) after 4-12 weeks. |
Opioid receptor antagonist | Naltrexone | 3rd choiceEvidence level 1ADose adjustment for renal/hepatic insufficiency. |
Nalmefene | No data on dose adjustment | |
Anesthetics | Propofol | Dose adjustment in renal/hepatic insufficiency. |
Immunosuppressants | Thalidomide | No information on dose adjustment |
Andidepressants (SSRI) | Paroxetine | Insb.For paraneoplastic pruritus |
Sertraline | Insb. for cholestatic pruritus/gallbladder-related pruritus4. ChoiceDose adjustment in hepatic insufficiency. |
Atopic dermatitis-effective agents, tested in controlled trials
Active ingredient group | Active ingredients | Special features |
Glucocorticoids | Prednisolone equivalent | |
Immunosuppressants | Ciclosporin (cyclosporin A) | Dose adjustment in severe hepatic insufficiencyKI in renal insufficiency (except nephrotic syndrome). |
Cytokines | Interferon gamma | No information on dose adjustment |
Calcineurin inhibitor | Tacrolimus (cream preparation) | No systemic NW when used topically |
Pimecrolimus(cream preparation) | No systemic NW when used topically |
Supplements (dietary supplements; vital substances)
Suitable dietary supplements should contain the following vital substances:
- Vitamins (vitamin E)
- Trace elements (zinc)
- Fatty acids (omega-3 fatty acids: eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA); omega-6 fatty acids: gamma-linolenic acid (GLA)).