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Guideline of the month - managing adult pruritus without rash

Get up to date with this month's must-know guideline

The 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.

Practical issues

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.

Expert comment

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.’

The guideline

British Association of Dermatologists. Guidelines for the investigation and management of generalised pruritus in adults without an underlying dermatosis, 2018. London; BAD:2018

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Readers' comments (2)

  • this makes it sound easy but pruritus of old age is a nightmare to manage as nothing much works. Having a guideline is not going to alter that one bit. I suspect the consultants have done this in the hope of preventing referrals. Unfortunately referrals are usually necessary to prove to the patient that the GP is not 'holding out' on their misery and no one has any easy answers. I used to prescribe a combo of emulsifying ointment dermovate and coal tar solution (3%) which was given me by the late queens dermatologist and this worked better than anything else. but because it has coal tar in it which gives rats cancer it has to be made up by men in protective suits and costs over £250 for 300gm so is no longer usable. There would be a good business if someone can provide this on a named patient basis at a reasonable cost.....

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  • Rogue1

    I can see the logic in the creams. But I don't think any of the oral meds are licensed for pruritis? You are right, patients want to see the specialist to know there is nothing else they can do. But they still come back to the GP for answers after that. It is a common problem that keeps representing itself, and this isn't going to stop me referring

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