As discussed previously, pruritus in the elderly can be caused by a multitude of factors and physiological changes that occur with aging, including impaired skin barrier function, immunosenescence, neuropathies, and polypharmacy [2]. Therefore, the identification of one potential cause for pruritus does not eliminate the need to complete a full evaluation. Unfortunately, little evidence supports pruritus treatment, limiting therapeutic possibilities and resulting in challenging management problems. Thus, it is essential to recognize the profound effect pruritus can have on a patient’s function and quality of life, as part of the approach to treatment. As with other symptoms in the geriatric population, pruritus evaluation requires integration and consideration of all of the patient’s medical conditions [21]. Furthermore, management of pruritus in the elderly can be challenging because of additional physical and/or cognitive limitations. Elderly patients are frequently unable to apply topical treatments effectively on their own, and medication compliance becomes a major issue. In addition, comorbid conditions and polypharmacy increase the risk of adverse drug reactions, especially with systemic therapy. Any treatment plan must take into consideration the patient’s general health, living situation, severity of symptoms, and the adverse effects of available treatment(s) [21, 30]. Because the immunosenescence that drives the pruritus is not reversible, long-term treatment with a combination of modalities is often required. Table 1 summarizes the most commonly employed therapeutic options in these patients.

Topical immunomodulators, including medium to ultrapotent strength topical corticosteroids and calcineurin inhibitors, are reasonable first-line agents for elderly patients with moderate-to-severe pruritus that is secondary to localized inflammatory skin processes. The topical therapies should always be instituted with concurrent aggressive emollient use and gentle skin care to improve skin barrier function. Because of the increased fragility of senescent skin, prolonged topical corticosteroid use should be avoided to prevent development of atrophy.

Antihistamines are a popular adjunct medication often used as antipruritic agents, because of the presumed benefit of sedation; yet there is limited evidence with respect to their efficacy in treating chronic pruritus in elderly patients—in fact, there is only one small randomized trial from the early 1980s with oxatomide, a first-generation antihistamine, where it was shown to improve both the duration and severity of itching [31]. In fact, antihistamine use in the older population is generally not recommended due to the anticholinergic effects (confusion, constipation, and dry mouth) [32]. Furthermore, there is little evidence that standard second-generation nonsedating antihistamines are effective in the management of pruritus in elderly patients [16]. Neuromodulatory agents such as gabapentin may be tried instead, dosed according to the underlying state and response of each patient [21].

UV-based therapy (phototherapy and photochemotherapy) is an alternative treatment modality that can be effective for certain pruritic conditions—for example, dermatoses with an atopic dermatitis-like component, pruritus associated with renal failure, and even pruritus of unclear etiology [21]. Phototherapy, including narrowband or broadband UVB, or less often UVA, is widely used in patients of all ages with chronic pruritus [33], and has been shown to be effective in treating a variety of pruritic conditions that afflict elderly patients, including pruritus due to atopic dermatitis, renal failure, polycythemia vera, chronic liver disease, and Hodgkin’s lymphoma [34]. It has wide cutaneous anti-inflammatory activities, and can offer relief without many of the adverse effects and risks of systemic immunosuppressive medications. Its efficacy has also been demonstrated in some randomized controlled trials [34–36]. Areas of long-term sun exposure (head and neck, dorsal hands) can be protected to avoid increasing skin cancer risk in these regions.

For patients with primary lesions, medications, contactants, and photosensitivity must be considered as causal or coexistent factors that are contributing to the pruritus. For the majority of these patients, barrier failure is often present, and a “soak and smear” approach to initiate treatment is often very effective. Soaking in a warm tub for 15 min and applying a high-potency topical steroid diluted in a heavy moisturizer such as petrolatum, onto the wet skin followed by an occlusion (with a suit or wet wraps) can be quite effective [2]. Antihistamines can be used with caution to complement the topical steroids, and phototherapy can be considered in refractory cases. If the dermatitis and pruritus remain chronic and treatment-resistant, low-dose immunosuppressive agents may be useful. Methotrexate, azathioprine, or mycophenolate mofetil can all be effective systemic medications, with the agent used dependent upon the patient’s risk profile, comorbidities, and at times, medication availability [2, 33]. Occasionally, after barrier repair has been accomplished via aggressive topical regimens, and the inflammatory reaction calms, the systemic immunosuppressive(s) can then be removed gradually and the patient maintained with topical treatment or phototherapy.

In the patient with generalized pruritus and secondary skin morphologies only, a primarily neuropathic process of the peripheral or central nervous system should be sought. Neurally acting antipruritic agents such as gabapentin, duloxetine, and mirtazepine alone or in combination can be effective [2, 21, 33]. Neurologists and physical medicine physicians are often useful in aiding the evaluation of such patients.

In recent years, pruritus has garnered more attention and is now appreciated as an important symptom that can dramatically reduce quality of life in patients [9]. Unfortunately, the pathophysiology of pruritus is only partially understood. The optimal evaluation strategy with respect to yield and cost-effectiveness has not been determined, and data from randomized, controlled trials of various pharmacologic and nonpharmacologic treatments for chronic pruritus are scarce. It is clear that more high-quality research is needed in order to be able to assess the burden of pruritus in specific diseases and patient populations. The empirical basis for an assessment in the general population is growing but replications of the available findings in specific patient groups would be desirable. Nevertheless, the recent population-based studies have revealed various new insights regarding the epidemiological underpinnings of chronic pruritus (e.g., prevalence, incidence, and determinants).

In daily clinical practice, consideration of coexisting disease and overlapping symptoms across diseases may help in the attribution of the cause of pruritus. The role of mixed etiologies has rarely been studied. This is of growing importance, especially in elderly individuals who are more likely to suffer from several diseases (multi-morbidity) and regularly require medication(s). Taking this multi-morbidity into account will, however, make the design of epidemiological research attempting to quantify the frequency of pruritus in patient populations much more complex.

Pruritus, like pain, is a stimulus that cannot be measured directly. Currently, most ongoing clinical studies are concentrated on methods of pruritus assessment. Despite many issues that have already been answered, there are still a number of problems remain—for example, development of a new, widely accepted itch questionnaire is essential to provide a valid instrument for multiple studies, to enable better comparisons of various pruritus subtypes and different treatment strategies. Chronic pruritus poses a significant threat to overall quality of life (QoL). A recent survey of patients with chronic pruritus and those with chronic pain (mean age of participants was 55 years), which utilized directly elicited health utility scores, demonstrated that chronic pruritus has an impact comparable to that of chronic pain on QoL [17], underscoring the significant burden of disease with which chronic itch patients suffer. In fact, studies in patients with uremic pruritus have suggested that itch, via its impact on sleep, not only affects morbidity, but increases mortality [37].

The next steps in chronic pruritus research must revolve around understanding the factors that mediate the impact of chronic pruritus on QoL, with more frequent use of ItchyQoL, an itch-specific quality of life instrument [38]. A better appreciation of the complex relationship between chronic itch and quality of life can only improve the clinical evaluation and treatment of chronic pruritus [39]. Future directions along this line of research include investigating how race influences the impact of chronic pruritus on QoL, and exploring whether support groups or personality-specific interventions may help mitigate the QoL impact of chronic pruritus [39

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