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.’