As the cold weather sets in, one common complaint that I tend to receive is – pruritus, or otherwise known as itch. Pruritus can be due to many reasons including allergic contact dermatitis, atopic dermatitis, bullous pemiphigoid, psorasis and scabies. In addition, pruritus can be a complication from other conditions such as cholestasis or chronic kidney failure (e.g. from uremic pruritus).
Ideally, a thorough evaluation should be conducted to identify the cause as it can direct the most appropriate management strategy. For example, pruritus from bullous pemiphigoid is primarily managed with steroid therapy, dialysis for uremic pruritus or cholesteryamine for pruritus from cholestasis.
However in a nursing home setting where residents may have cognitive impairment, it may be difficult to carry out any investigations. Often people jump to prescribe either diphenhydramine or hydroxyzine to manage the itchy symptoms. These two agents are not ideal as they are associated with anticholinergic properties and many side effects including dizziness, dry mouth, constipation and urinary retention. In addition, Health Canada has also recently released a new warning on the potential risk of QT prolongation with hydroxyzine and has lowered the dose limit to 100mg/day for adults and 50mg/day for the geriatric population.
Yet we often omit to realize that the itchy skin can be due to plain simple dry skin or xerotic eczema. So something as simple as adding a humidifier, reducing the frequency of bath or offering a topical lubricating lotion or cream may do the trick. Lotions or creams that are urea-based may be best as they tend to help trap in the water to keep the skin hydrated. This is where I wish a decent urea-based lotion or cream is available as a government stock item for residents to use at no additional cost to the family.
So next time before you jump to write a new prescription for diphenhydramine or hydroxzine, try to write a non-drug order to add a humidifier, reduce bath frequency or add a urea-based lotion or cream. It may just be the solution you need for the itchy scratchy resident.