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Guideline of the month – managing adult pruritus without rash



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