Guideline sources The following summarized guidelines for the evaluation and management of pruritus are prepared by our editorial team based on guidelines from the European Academy of Dermatology and Venereology (EADV/EDF/CP-EEG 2019). 1 Guidelines 1. Diagnostic investigations History and physical examination: Elicit a detailed history of any patient with chronic pruritus, including general characteristics of pruritus (duration, time course, localization, intensity, and quality), knowledge of the personal history, precise information on medication, and family history. E Obtain a complete dermatological examination. E 2. Medical management Topical therapy (anesthetics): offer topical anesthetics to patients with localized pruritus, and polidocanol for selected cases of generalized pruritus. E Topical therapy (corticosteroids): offer topical corticosteroids to patients with chronic pruritus associated with inflammatory dermatoses and chronic prurigo. Do not use topical https://web.pathway.md/diseases/recJUqdkgDd4Hx2lP 1/4 6/29/23, 11:33 PM Pruritus Pathway corticosteroids in patients with chronic pruritus with non-inflamed skin. Do not use long-term treatment with topical corticosteroids. E Topical therapy (capsaicin): consider topical capsaicin in patients with localized forms of chronic pruritus. E Topical therapy (calcineurin inhibitors): consider tacrolimus and pimecrolimus in patients with localized forms of chronic pruritus. E Topical therapy (mast cell inhibitors): do not use topical mast cell inhibitors in patients with chronic pruritus. D Topical therapy (acetylsalicylic acid): insufficient evidence to recommend topical acetylsalicylic acid in patients with chronic pruritus. I Systemic therapy (H1-antihistamines): offer non-sedating H1RAs for the treatment of patients with chronic pruritus in urticaria. Consider non-sedating H1RAs in patients with chronic pruritus in mastocytosis. Consider non-sedating and/or sedating H1RAs as an initial symptomatic therapy in patients with chronic pruritus. E Systemic therapy (corticosteroids): consider systemic corticosteroids as a short-term treatment in selected patients with refractory chronic pruritus, especially in paraneoplastic pruritus and palliative care. E Systemic therapy (opioid antagonists): consider mu-opioid receptor antagonists in patients with refractory chronic pruritus, especially in cholestatic pruritus. E Systemic therapy (gabapentin and pregabalin): offer gabapentin and pregabalin to patients with neuropathic chronic pruritus and in CKD-associated pruritus. Consider gabapentin and pregabalin in patients with refractory chronic pruritus and pruritus of undetermined origin. E Systemic therapy (antidepressants): offer selected antidepressants (paroxetine, mirtazapine, doxepin, amitryptiline) to patients with psychogenic chronic pruritus and refractory chronic pruritus, especially in malignant, cholestatic and CKD. E Systemic therapy (serotonin receptor antagonists): do not use serotonin receptor antagonists in patients with chronic pruritus. D Systemic therapy (thalidomide): consider thalidomide in selected patients with refractory chronic pruritus after informing the patient about teratogenicity and dose-related risk of neuropathy. E Systemic therapy (leukotriene receptor antagonists): do not use leukotriene receptor antagonists in patients with chronic pruritus. D Systemic therapy (immunosuppressants): consider cyclosporine, methotrexate, and azathioprine in patients with refractory chronic pruritus associated with inflammatory dermatoses and chronic prurigo. E Systemic therapy (neurokinin receptor-1 antagonists): consider neurokinin receptor-1 antagonists, such as serlopitant, in patients with refractory chronic pruritus and chronic prurigo. E Systemic therapy (monoclonal antibodies): consider omalizumab in patients with refractory chronic pruritus in chronic spontaneous urticaria and dupilumab in patients with refractory https://web.pathway.md/diseases/recJUqdkgDd4Hx2lP 2/4 6/29/23, 11:33 PM Pruritus Pathway chronic pruritus in atopic dematitis. Insufficient evidence to recommend monoclonal antibodies in patients with chronic pruritus of other origin. E Systemic therapy (mast cell inhibitors): do not use systemic mast cell inhibitors in patients with chronic pruritus. D 3. Nonpharmacologic interventions Moisturizers and emollients: advise patients with chronic pruritus to use moisturizers and emollients depending on the status of the skin. E Topical menthol, camphor and zinc: advise patients with chronic pruritus to use topical menthol and its derivatives. Consider advising patients with chronic pruritus to use topical camphor or zinc. E 4. Therapeutic procedures Physical treatment: insufficient evidence to recommend physical treatment in patients with chronic pruritus. I Ultraviolet phototherapy: consider UV A and UV B phototherapy in patients with refractory chronic pruritus in inflammatory skin diseases, cutaneous lymphoma chronic prurigo and selected cases of systemic pruritus (such as CKD-associated pruritus, cholestatic pruritus, aquagenic pruritus). Consider UV phototherapy in combination with topical and/or systemic treatment, with the exception of calcineurin inhibitors and immunosuppressant medications. E 5. Patient education Psychosomatic therapy: advise patients on educational programs. Consider relaxation and habit reversal techniques as a complementary treatment for managing chronic pruritus. E Studies 2023 LIBERTY-PN PRIME In adults with prurigo nodularis with 20 nodules and severe itch uncontrolled with topical therapies, dupilumab was superior to placebo with respect to reduction in Worst Itch NRS by 4- point at week 24. Gil Yosipovitch et al. Nat Med. 2023 May. 2023 LIBERTY-PN PRIME2 In adults with prurigo nodularis with 20 nodules and severe itch uncontrolled with topical therapies, dupilumab was superior to placebo with respect to reduction in Worst Itch NRS by 4- point at week 12. Gil Yosipovitch et al. Nat Med. 2023 May. https://web.pathway.md/diseases/recJUqdkgDd4Hx2lP 3/4 6/29/23, 11:33 PM Pruritus Pathway References 1. Elke Weisshaar, Jacek C Szepietowski, Florence J Dalgard et al. European S2k Guideline on Chronic Pruritus. Acta Derm Venereol. 2019 Apr 1;99 5 469 506. Open 2. Anand Padmanabhan, Laura Connelly-Smith, Nicole Aqui et al. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher. 2019 Jun;34 3 171 354. Open https://web.pathway.md/diseases/recJUqdkgDd4Hx2lP 4/4