Guideline of the month - managing adult pruritus without rash
Get up to date with this month's must-know guideline
The British Association of Dermatologists has published a new guideline on identifying and managing generalised pruritus in adults without an underlying skin condition.
Key points for GPs
- FBC and ferritin levels should be checked in all patients with chronic generalised pruritus without a rash.
- Patients with generalised pruritus and no obvious underlying cause. should receive self-care advice and emollients, followed by a short course of non-sedating antihistamines. GPs should follow up these patients.
- Over-65s should receive emollients and topical steroids for at least two weeks to treat any asteatotic eczema, and reassessed if they do not respond.
- Elderly patients may benefit from gabapentin.
- Medications that can be considered for relieving itch include paroxetine, fluvoxamine, mirtazapine, naltrexone, butorphanol, gabapentin, pregabalin, ondansetron or aprepitan.
- Patients should be referred to secondary care if there is diagnostic uncertainty or if symptoms cannot be managed in primary care.
BAD recommends non-sedating rather than sedating antihistamines due to the potential association with dementia. The NICE CKS on widespread itch, however, suggests a short course of sedating antihistamine for over-18s, as these drugs are likely to be effective via sedative rather than antipruritic properties. GPs will therefore need to assess benefits and risks when making a decision.
Dr Nigel Stollery, a GPSI in dermatology in Leicestershire, said: ‘With the fear of a serious underlying condition, such as malignancy, pruritus is a common and challenging condition for GPs to manage. This guideline provides a summary of serious and benign causes and sets out a systematic approach to investigations, management and referral in primary care, including a helpful summary of drug choices and easy-to-use tables. It will be a helpful reference for busy GPs.’
British Association of Dermatologists. Guidelines for the investigation and management of generalised pruritus in adults without an underlying dermatosis, 2018. London; BAD:2018