Itching (Pruritus): Drug Therapy

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.

  • Symptomatic therapy of chronic pruritus: topical or systemic 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]:
      1. 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).
      2. Stage: rifampicin (bactericidal antibiotic from the group of ansamycins) (expert opinion: most effective drug for hepatogenic pruritus).
      3. Stage: opioid antagonists: naloxone, naltrexone.
      4. 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

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: