eMedicine Specialties > Dermatology > Internal Medicine

Pruritus and Systemic Disease: Treatment & Medication

Author: David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic
Coauthor(s): Jared J Lund, MD, Dermatology Resident, Department of Dermatology, Marshfield Clinic, St Joseph's Hospital
Contributor Information and Disclosures

Updated: Jan 22, 2009

Treatment

Medical Care

The treatment for pruritus of systemic disease varies depending on the underlying etiology. New therapies are based on advances in the understanding of the mechanisms that cause pruritus. However, without eradication of the underlying systemic disease, treatment is often palliative at best and can be frustrating for both the patient and physician.

Certain therapies, such as antihistamines and emollients, offer marginal benefit. Nevertheless, they should be tried because of their low cost and potential for providing relief. Sedating antihistamines may be effective in patients with nocturnal pruritus. Although antihistamines are partially effective in treating pruritus due to systemic disease, the effect is usually marginal and the relief is unsatisfactory. Doxepin, a tricyclic antidepressant (TCA) with antihistaminic properties, at dosages of 25-50 mg at bedtime may be quite helpful. Mirtazapine at 15-30 mg at bedtime has also been used to treat pruritus.7,8

  • Renal pruritus: Treatment can be physical, topical, or systemic.
    • Physical therapy with UV-B therapy is a treatment of choice. Patients have reported months of remission after 6-8 treatments. UV-B reduces cutaneous phosphorus, decreases the number of dermal mast cells, and reduces epidermal vitamin A levels. However, UV-B treatment increases the risk of nonmelanoma skin cancer.
    • Topical therapy is especially helpful in cases of localized pruritus.
      • Capsaicin 0.025% cream is effective for localized pruritus due to CRF, as has been shown in double-blinded, placebo-controlled studies. Topical application of a eutectic mixture of local anesthetics (eg, EMLA cream) before capsaicin treatment may reduce the burning sensation associated with capsaicin.9
      • Tacrolimus 0.03% ointment has shown promising results for localized renal pruritus in a prospective study, but randomized placebo-controlled studies are needed. Tacrolimus is a calcineurin inhibitor, it decreases the differentiation of type 1 helper T lymphocytes, and it reduces the production of interleukin 2.10
      • Topical gamma linolenic acid appears promising.11
      • Topical gabapentin cream (3-6%) has been reported to help vulvodynia and could potentially be used to treat localized areas of neurogenic pruritus such as pruritus vulvae, pruritus scroti, and notalgia paresthetica.12
    • Systemic therapy includes UV-B and activated charcoal, which are first-line treatments, along with ensuring effective dialysis.13,14,15,16,17,18 Narrow-band UV-B is particularly effective.
      • Oral activated charcoal is inexpensive, effective, and well tolerated; therefore, it is considered a reasonable treatment when UV therapy has failed. Activated charcoal is thought to prevent the absorption of an unknown pruritogen. Cholestyramine is not as effective and is associated with adverse effects, such as acidosis.
      • Efficient dialysis is helpful. Pruritus tends to become severe with insufficient dialysis.19
      • Thalidomide has been reported as effective but should be used with caution because of its adverse-effect profile.20 However, in the authors' experience, thalidomide is a valuable tool in cases unresponsive to conventional therapy.
      • Regarding opioid antagonists, studies of oral naltrexone have shown mixed results, with efficacy only in a small subset of patients.21,22
      • Erythropoietin has been studied,23,24 and one double-blinded, placebo-controlled study showed marked benefit in patients receiving small doses for up to 6 months. However, this effect could not be confirmed.
      • Other systemic therapies include nicergoline and free fatty acids (eg, those in primrose oil); these have shown positive results in reducing renal pruritus.
      • Gabapentin has been shown to be effective in the treatment of chronic uremic pruritus, but it has been shown to worsen cholestatic pruritus.25
      • Butorphanol, an opioid that displays mu antagonism and kappa agonism, has been shown to relieve uremic pruritus.26
  • Cholestatic pruritus: Cholestyramine is the first-line therapy, followed by rifampin and opioid antagonists. Ondansetron may also be tried.
    • Cholestyramine has only been show effective in a few randomized studies, but this drug is thought to be helpful in relieving pruritus. Because of its low cost, it should be tried before more expensive treatments are considered.
    • Rifampin, a hepatic enzyme inducer, is effective for pruritus of cholestasis. Caution should be used in patients with preexisting liver disease because of possible hepatotoxicity.27,28
    • Opioid antagonists, including naloxone, may relieve pruritus, but intravenous administration limits its use outside the hospital setting. Oral naltrexone is also effective.29,30,31,32 Oral nalmefene has been tested and is effective but may only be available in intravenous form.33 To prevent opioid withdrawal syndrome, low starting doses should be used. These drugs should not be used in patients in need of palliative opioid treatment. Butorphanol, which antagonizes the mu receptor but agonizes the kappa receptor, has been shown to be effective in suppressing cholestatic pruritus.26
    • Ursodeoxycholic acid and S-adenosyl-L-methionine have both been reported to decrease pruritus in women with cholestasis of pregnancy, but ursodeoxycholic acid may improve fetal outcomes and biochemical serum markers.34,35
    • Extracorporeal albumin dialysis may be considered when severe pruritus is refractory to other therapies.36,37
    • Ondansetron has limited effectiveness and, because it relieves opioid-induced pruritus, it appears to affect opioid pathways.
    • Stanozolol relieves pruritus; however, it worsens cholestasis and is not recommended.
    • Removal of the offending agent should be initiated in patients with drug-induced cholestasis.
    • Other therapies that may be effective are thalidomide, infused propofol, serotonin-selective reuptake inhibitors, UV-B, phenobarbital, dronabinol, and bright-light therapy indirectly reflected toward the eyes.
  • Hematologic pruritus
    • Iron deficiency responds to treatment with iron, which should be continued until ferritin levels are normalized. Correction of iron deficiency in persons with polycythemia vera may decrease the pruritus but worsen the polycythemia vera.
    • Patients with pruritus due to polycythemia vera may benefit from aspirin, which is considered the first-line therapy. Cimetidine, danazol, cholestyramine, UV-B light therapy, and psoralen with UV-A therapy have all been shown to help.38,39
    • Interferon-alfa may provide relief, but its adverse effects may decrease compliance.40
    • Treatment with paroxetine at 20 mg/d has been shown to be effective, but further clinical trials are needed.
  • Endocrine pruritus
    • The pruritus of hypothyroidism is secondary to xerosis and should be treated with emollients and thyroid hormone replacement.
    • Pruritus secondary to hyperthyroidism improves with the correction of thyroid function.
  • Chronic vaginal pruritus and lichen sclerosis et atrophicus: When these conditions cause pruritus of the vaginal area, treatment with topical pimecrolimus cream has been effective.
  • Nonspecific treatments
    • Topical cannabinoid agonist creams have been shown to relieve pruritus associated with certain chronic dermatoses.
    • Treating the underlying disorder is the mainstay of therapy for controlling pruritus.
    • Corticosteroids with palliative chemotherapy in late-stage Hodgkin disease often provide relief.
    • Nonspecific treatments for intractable pruritus, such as UV-B light therapy, cholestyramine, naloxone, and activated charcoal, should be considered.
    • Paroxetine relieves itch in patients with advanced cancer; however, the effect usually lasts only 4-6 weeks.

Surgical Care

  • Successful transplantation is the only definitive treatment for renal pruritus.
  • When pruritus is associated with obstructive malignancy of the biliary tract or other obstructive causes (eg, primary sclerosing cholangitis), placing a stent to relieve the obstruction also treats the pruritus.
  • Liver transplantation may be considered in patients who have pruritus associated with nonmalignant cholestasis that does not respond to medical therapy.

Consultations

  • Dermatologist: Always consult a dermatologist to rule out any primary cause of pruritus and to discuss UV-B or psoralen UV-A light therapy when it is considered in the treatment plan.
  • Gastroenterologist: A gastroenterologist should evaluate any patient with liver or biliary tract disease.
  • Hematologist/oncologist: These specialists should always be involved in the care of patients with pruritus due to hematologic or malignant causes.
  • Endocrinologist: Patients with endocrine pruritus should be evaluated for treatment of their thyroid disease, which often cures their itch.
  • Surgeon and/or transplant surgeon: Patients with CRF or chronic liver disease may need to be evaluated for kidney or liver transplantation, respectively. A surgeon should always be consulted in cases of malignant cholestasis.

Diet

A low-protein diet may help decrease pruritus in persons with CRF.

Medication

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Detoxifying agents

These agents are used to treat renal pruritus.


Activated charcoal (Charcodote)

DOC for initial treatment of renal pruritus. Mechanism of action unknown but thought to bind unknown pruritogen. Sorbitol and flavoring added to some forms to enhance palatability.

Adult

6 g PO qd

Pediatric

<1 year: Not recommended
>1 year: Administer as in adults

Decreases effectiveness of coadministered drugs; do not mix with sherbet, milk, or ice cream (decreases absorptive properties)

Documented hypersensitivity (including sorbitol); use of other medication within 2 h (may impair absorption)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Diarrhea may occur (some forms mixed with sorbitol); patients can expect stools to be black; constipation and vomiting (rare); adverse effects include electrolyte imbalance; GI obstruction; hypotension

Topical agents

Topical agents are used to treat localized renal pruritus.


Capsaicin 0.025% cream

Derived from plants of Solanaceae family. May render skin and joints insensitive to pain and pruritus by depleting substance P in peripheral sensory neurons, decreasing transmission of sensation. For localized pruritus only.

Adult

Cream: Apply to skin tid/qid for 3-4 wk and evaluate efficacy; not to exceed 4 applications qd

Pediatric

Administer as in adults

Documented hypersensitivity; broken or irritated skin

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

For external use only; avoid contact with eyes; do not use with tight bandage; discontinue if condition worsens or symptoms persist for 14-28 d; mild irritation, redness, or burning may occur at application site; pretreatment with EMLA cream may reduce adverse effects, but EMLA dose restrictions must be carefully followed

Immunomodulatory agents

Immunomodulatory agents are used to treat recalcitrant renal or cholestatic pruritus.


Thalidomide (Thalomid)

Thought to decrease T helper cells while inhibiting production of TNF-alpha, which may induce itch. Strong central depressant effect that may decrease pruritus. Because of adverse events, attempt other treatments first.

Adult

100 mg PO qd (may be best to start at night because of possible sedation); prescribing physician must enter STEPS program established by manufacturer

Pediatric

Not established

May increase sedation caused by alcohol, barbiturates, chlorpromazine, and reserpine; because of teratogenic effects, women must use 2 additional methods of contraception or abstain from intercourse; nonthalidomide interactions with hormonal contraceptives

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Perform pregnancy test within 24 h before therapy (then weekly during first month and monthly in women with regular menstrual cycles or q2wk in those with irregular cycles); sedation; peripheral neuropathy; hypotension; neutropenia; exacerbation of HIV; rash (including TEN); seizure disorder; bradycardia may occur; use protection (eg, sunscreens, protective clothing) against sunlight or UV light (eg, tanning beds)

Bile Acid Lowering Agents

These agents are used to treat cholestatic pruritus.


Cholestyramine (Prevalite, Questran)

Anion-exchange resin that binds bile acids in GI tract, interrupting their enterohepatic circulation; primarily used to lower cholesterol. Patients must have adequate bile flow for drug to be effective. Consider this therapy early in cases of hepatic cholestasis because it is inexpensive and may provide relief (within 1-3 wk). Pruritus returns within weeks of discontinuation.

Adult

4-16 g PO qd in divided doses (4 g before or after meals to coincide with gall bladder contraction); further increases may be given before midday and evening meals; not to exceed 16 g/d; do not take powder in dry form (mix with choice of beverage)

Pediatric

Not established for pruritus

Inhibits absorption of many drugs (eg, warfarin, thyroid hormone, amiodarone, NSAIDs, methotrexate, digitalis glycosides, glipizide, phenytoin, imipramine, niacin, methyldopa, tetracyclines, clofibrate, hydrocortisone, penicillin G); may increase effect of warfarin by impairing absorption of vitamin K
Concurrent administration with iopanoic acid reported to result in abnormal cholecystography

Documented hypersensitivity; complete biliary obstruction; hyperlipidemia types III, IV, or V; hypersensitivity to bile-sequestering resins

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

GI effects, especially constipation; caution if prior history of constipation and phenylketonuria (Questran Light contains aspartame); with long-term use, affects absorption of fat-soluble vitamins A, D, E, and K; may be unpalatable and nauseating; monitor serum electrolyte levels periodically; patients with renal pruritus who are not receiving HD may develop acidosis (chloride liberation); increases urinary calcium excretion and osteoporosis; some preparations may contain aspartame; use with caution in patients with phenylketonuria


Ursodeoxycholic acid/ursodiol (Actigall, Urso 250, Urso Forte)

Hydrophilic bile acid that alters hydrophilicity and distribution of total bile acids and increases excretion of hydrophobic bile acids. Decreases damage to hepatocyte membrane by decreasing uptake of hydrophobic bile acids at terminal ileum (and likely in hepatocytes). First-line treatment for patients with intrahepatic cholestasis of pregnancy; normalizes laboratory values and decreases morbidity and mortality to the fetus by reducing exposure to bile acids.

Adult

10-16 mg/kg/d until delivery

Pediatric

Not established

Bile-sequestering agents (eg, cholestyramine) and aluminum-based antacids may interfere with action

Documented hypersensitivity (bile acids); intolerance

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adverse events may include GI discomfort, including diarrhea

Hepatic enzyme inducing agents

These agents are used to treat cholestatic pruritus.


Rifampin (Rifadin)

Traditionally used as antibiotic with known mechanism of action of inhibiting RNA synthesis in bacteria. Also inhibits reuptake of hepatic bile acid and induces hepatic mixed-function oxidases, which may detoxify hepatic bile acids. Consider this drug when course of cholestyramine fails.

Adult

150 mg PO qd initially; can be increased to 300-600 mg/d

Pediatric

10 mg/kg/d; not to exceed 300 mg/d mg divided bid

Induces microsomal enzymes, which may decrease effects of acetaminophen, oral anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, oral contraceptives, corticosteroids, mexiletine, cyclosporine, digitoxin, disopyramide, estrogens, hydantoins, methadone, clofibrate, quinidine, dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, and digoxin; blood pressure may increase with coadministration of enalapril; coadministration with isoniazid or pyrazinamide may result in higher rate of hepatotoxicity than with either agent alone (discontinue 1 or both agents if LFT altered)

Documented hypersensitivity; history of liver disease or coadministration with other hepatotoxic agents (relative contraindication)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Obtain CBC counts and baseline clinical chemistry values before and throughout therapy; in liver disease, including porphyria, weigh benefits against risk of further liver damage; interrupted and high-dose intermittent therapy associated with thrombocytopenia and other more severe adverse reactions (former reversible if therapy discontinued as soon as purpura occurs); if treatment is continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur; long-term use may cause emergence of resistant organisms; may alter endogenous hormone levels (adrenal, thyroid, vitamin D)

Opioid antagonist agents

These agents are used to treat cholestatic pruritus.


Naloxone (Narcan)

Opioid antagonist is given IV; therefore, should only be used in emergency treatment of exacerbations of cholestatic pruritus in hospital setting. Low-dose infusion may be used for 24 h before oral naltrexone or nalmefene to avoid opioid withdrawal syndrome (sometimes seen in patients given PO opioid antagonists).

Adult

0.4 mg IV bolus then 0.2 mcg/kg/min IV infusion
Preparation for oral opioid antagonists: 0.002 mcg/kg/min IV, infusion rate doubled q3-4h if no withdrawal symptoms; continual increase to 0.2 mcg/kg/min at 24 h; may then start low-dose PO naltrexone

Pediatric

Not established

Decreases analgesic effects of narcotics; hypotensive and bradycardic effects of long-term clonidine administration may be temporarily attenuated by intravenous naloxone

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in cardiovascular disease; may precipitate opioid withdrawal–like symptoms (eg, anxiety, restlessness, hypertension, tremor, insomnia, mood change, hallucinations, nausea, vomiting, diarrhea, abdominal pain); reaction does not appear dangerous but may be alarming to patient and physician
Adverse reactions include cardiac dysrhythmia; hepatotoxicity; hypertension; hypotension; pulmonary edema


Naltrexone (ReVia, Vivitrol)

Naltrexone may also be considered if patients with cholestatic pruritus do not respond to cholestyramine and rifampin. Naltrexone can be administered PO and has a longer half-life than naloxone.

Adult

Initial: 12.5 mg PO qd (cut 50-mg pill) with or without previous naloxone infusion
Maintenance: 25-250 mg/d

Pediatric

Not established in patients with cholestatic pruritus

Inhibits effects of opiates; coadministration with yohimbine may increase symptoms of anxiety or nervousness

Documented hypersensitivity; acute hepatitis; liver failure

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hepatic impairment (metabolites may accumulate, decrease dose); hepatotoxicity may occur (check serum hepatic panels periodically during treatment); opioid withdrawal–like symptoms may occur but should improve within days of continued treatment (low-dose infusion with naloxone for 24 h may prevent these adverse effects); pruritus may recur during therapy due to up-regulation of opioid receptors (prevented by interrupting treatment 2 d/wk) Adverse effects include thromboembolic disorder, depression, hypersensitivity disorder, and eosinophilic pneumonia

Anti-inflammatory agents

Anti-inflammatory agents are used to treat polycythemia rubra vera.


Aspirin (Anacin, Ascriptin, Bayer Aspirin, Bayer Buffered Aspirin)

Appears to decrease platelet degranulation of serotonin and prostaglandins, which contribute to pruritus. First-line treatment for symptomatic control of pruritus related to polycythemia vera. Relief may last 12-24 h.

Adult

300-500 mg PO q8-24h

Pediatric

Not established

Effects may decrease with antacids and urinary alkalinizers; corticosteroids decrease salicylate serum levels; additive hypoprothrombinemic effects and increased bleeding time may occur with coadministration of anticoagulants; may antagonize uricosuric effects of probenecid and increase toxicity of phenytoin and valproic acid; doses >2 g/d may potentiate glucose-lowering effect of sulfonylurea drugs; concurrent administration with diltiazem or verapamil may prolong bleeding time

Documented hypersensitivity; liver damage; hypoprothrombinemia; vitamin K deficiency; bleeding disorders; asthma, rhinitis, or nasal polyps; use in children (<16 y) with chickenpox or flu symptoms (associated with Reye syndrome)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

May cause transient decrease in renal function and aggravate chronic kidney disease; avoid use with severe anemia, history of blood coagulation defects, or anticoagulation; increases risk of gastric ulcers
Adverse effects include angioedema, bronchospasm, and tinnitus (may suggest salicylate intoxication)
When acetaminophen measured by spectrophotometric methods, salicylates and metabolites cause false increases in apparent acetaminophen levels

Antidepressant agents

These drugs are used to treat generalized pruritus in patients with advanced cancer or polycythemia vera.


Mirtazapine (Remeron, Remeron SolTab)

Relatively new antidepressant, not as widely used as sertraline. Exhibits both noradrenergic and serotonergic activity. In cases of depression associated with severe insomnia and anxiety, has been shown superior to other SSRI drugs.

Adult

15 mg PO hs initially; may increase in 15-mg increments q1-2wk, not to exceed 45 mg hs

Pediatric

Not established

May increase effect of CNS depressants; concurrent administration with MAOI may trigger hypertensive crisis

Documented hypersensitivity; MAOI within 14 d

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May cause drowsiness; discontinue use if patient develops sore throat, fever, or other signs of infection; suicide ideation is inherent in depression and may persist until significant remission occurs; severe neutropenia reported in clinical trials
Cardiovascular or cerebrovascular disease or conditions that predispose patients to hypotension; orthostatic hypotension may occur; hepatic impairment may increase risk of drug toxicity and liver injury; phenylketonuria; PO disintegrating tab contains phenylalanine 2.6 mg per 15 mg tab, 5.2 mg per 30 mg tab, and 7.8 mg per 45 mg tab; renal impairment, owing to moderate or severe increased risk of drug toxicity; caution in patients with history of seizures


Paroxetine (Paxil, Paxil CR)

Potent selective inhibitor of neuronal serotonin reuptake. Mechanism of relieving pruritus unknown. Effects occur within few days but may last only 4-6 wk.

Adult

10-20 mg PO qd

Pediatric

Not established

Drugs metabolized by CYP 2D6 (including TCAs) and drugs that are highly protein bound (warfarin) increase levels of theophylline; phenobarbital and phenytoin decrease effects; alcohol, cimetidine, sertraline, phenothiazines, and warfarin increase toxicity; serotonin syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death) occurs with simultaneous use of other serotonergic agents (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan) so discontinue other serotonergic agents at least 2 wk before use of other SSRIs

Documented hypersensitivity; coadministration with MAOIs or in past 14 d; coadministration with thioridazine

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in history of seizures, mania, renal disease, or cardiac disease; nausea, fatigue, decreased libido, and sedation possible
Serious adverse effects include abnormal bleeding with concurrent use of NSAIDs, aspirin, or other drugs that affect coagulation; depression exacerbation, suicide, or hyponatremia may occur; hyponatremia, syndrome of inappropriate antidiuretic hormone secretion has occurred with paroxetine


Doxepin (Remeron, Remeron SolTab)

TCA that has potent H1-blocking activity, making it quite useful for urticaria. However, it has very potent sedative and anticholinergic effects. Can be quite effective if used at bedtime because the sedative effects can help a patient with pruritus sleep.

Adult

25-50 mg/d PO hs

Pediatric

<12 years: Not recommended
>12 years: 25-50 mg/d PO hs

Decreases antihypertensive effects of clonidine but increases effects of sympathomimetics and benzodiazepines; effects of desipramine increase with phenytoin, carbamazepine, and barbiturates; TCAs may increase half-life and bioavailability of oral anticoagulants; monitor serum TCA levels within first few days of starting or discontinuing cimetidine; concomitant use of a TCA and MAOI may cause seizure and serotonin syndrome (should be considered only with close monitoring and when clinical benefit outweighs potential risk)

Documented hypersensitivity; urinary retention; acute recovery phase following myocardial infarction; glaucoma

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in cardiovascular disease, conduction disturbances, seizure disorders, urinary retention, hyperthyroidism, and patients receiving thyroid replacement
Serious adverse effects include agranulocytosis, leukopenia, thrombocytopenia, pancytopenia, suicidal ideation and behavior, worsening depression (increased risk, particularly in children, adolescents, and young adults during first few months of therapy or following dosage changes), hypertension, hypotension, and tachyarrhythmia; increased risk of confusion and oversedation in elderly persons

Analgesic opioid agents

Agents with central analgesic action may be useful. May alter perception and response to varied stimuli.


Butorphanol (Stadol)

Mixed agonist-antagonist narcotic with central analgesic effects for moderate to severe pain. Causes less smooth muscle spasm and respiratory depression than morphine or meperidine. Weigh advantages against increased cost of butorphanol.

Adult

Nasal spray: 1-2 sprays qhs
IV: 0.5-2 mg IV q3-4h prn
IM: 1-4 mg IM q3-4h prn
Not to exceed 0.18 mg/kg

Pediatric

Not established

Toxicity increases with guanabenz, MAOIs, CNS depressants, phenothiazines, barbiturates, and skeletal muscle relaxants

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hepatic or renal insufficiency and in respiratory limitation (eg, bronchial asthma, obstructive respiratory conditions, cyanosis); may increase CSF pressure and cardiac overload; causes respiratory depression
Concomitant administration of an opioid analgesic and an opioid agonist/antagonist may result in withdrawal symptoms
Adverse effects include acute myocardial infarction, ventricular dysfunction, cardiac insufficiency, and hypertension

Immunosuppressant agents

These agents may prevent release of inflammatory cytokines from mast cells.


Pimecrolimus (Elidel)

First nonsteroid cream approved in United States for mild-to-moderate atopic dermatitis. Derived from ascomycin, a natural substance produced by fungus Streptomyces hygroscopicus var ascomyceticus. Selectively inhibits production and release of inflammatory cytokines from activated T cells by binding to cytosolic immunophilin receptor macrophilin-12. Resulting complex inhibits phosphatase calcineurin, thus blocking T-cell activation and cytokine release. Cutaneous atrophy not observed in clinical trials, a potential advantage over topical corticosteroids. Indicated only after other treatment options have failed. Use short-term and for intermittent use only.

Adult

Apply topically to affected areas bid

Pediatric

<2 years: Not established
>2 years: Administer as in adults

Concomitant administration of opioid analgesic and opioid agonist/antagonist may result in withdrawal symptoms

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Potential exacerbation of existing infection at site of application; may cause burning and irritation; caution with conditions that suppress immune system (eg, AIDS, cancer); possible risk of lymph node or skin cancer based on animal studies and a small number of patients; may increase risk of viral infections; other adverse effects include headache, sore throat, flulike symptoms, fever, and cough
Black box warning regarding potential for increased risk of lymphoreticular malignancy and skin cancer, although no causal relationship demonstrated

More on Pruritus and Systemic Disease

Overview: Pruritus and Systemic Disease
Differential Diagnoses & Workup: Pruritus and Systemic Disease
Treatment & Medication: Pruritus and Systemic Disease
Follow-up: Pruritus and Systemic Disease
References
[ CLOSE WINDOW ]

References

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Further Reading

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Keywords

itch, itching, itchiness, scratch, scratching, systemic pruritus, systemic disease itch, renal pruritus, cholestatic pruritus, hematologic pruritus, endocrine pruritus, polycythemia vera, PV, uremic pruritus, malignancy-related pruritus, cancer and pruritus

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Contributor Information and Disclosures

Author

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: 3M Pharmaceutical Grant/research funds Other; Graceway Pharmaceuticals Grant/research funds Other

Coauthor(s)

Jared J Lund, MD, Dermatology Resident, Department of Dermatology, Marshfield Clinic, St Joseph's Hospital
Disclosure: Nothing to disclose.

Medical Editor

Franklin Flowers, MD, Chief, Division of Dermatology, Professor, Department of Medicine and Otolaryngology, University of Florida College of Medicine
Franklin Flowers, MD is a member of the following medical societies: American College of Mohs Micrographic Surgery and Cutaneous Oncology
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Jeffrey J Miller, MD, Associate Professor of Dermatology, Penn State University College of Medicine; Staff Dermatologist, Penn State Milton S Hershey Medical Center
Jeffrey J Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Association of Professors of Dermatology, North American Hair Research Society, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

CME Editor

Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology
Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds None; Genentech Consulting fee Consulting; Centocor Consulting fee Consulting; Centocor Grant/research funds None; Covance Consulting fee Consulting; Shire  Consulting

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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