Diagnosis and Management of Chronic Pruritus: An Expert Consensus Review.

The aim of this study is to formulate the best clinical practice in the diagnosis and management of chronic pruritus (CP). We searched PubMed, EMBASE, Scopus, Web of Science, and the WHO's regional databases, for studies on "Diagnosis and management of chronic pruritus" from January 1, 2014, to July 31, 2015. We included programmatic reports and hand-searched references of published reviews and articles. Two independent reviewers screened articles and extracted data. We screened 87 of 95 studies that contained qualitative data. Avoid: Dry climate, heat, alcohol compress, ice packs, frequent bathing and washing, intake of very hot and spicy food, intake of alcohol, contact with irritant substances, excitement, strain and stress, and allergens. Using: Mild nonalkaline soaps, moisturizers, bathing oils, lukewarm water while bathing, soft cotton clothing and night creams/lotions, relaxation therapy, autogenic training, psychosocial education, educating patients to cope with itching and scratching, and educational programs. Especially use of moisturizers is considered important. In addition, symptomatic treatment options include systemic H1 antihistamines and topical corticosteroids. Symptomatic therapy directed toward the cause (hepatic, renal, atopic, polycythemia, etc.). If refractory or cause is unknown, consider capsaicin, calcineurin inhibitors for localized pruritus and naltrexone, pregabalin, ultraviolet therapy, Cyclosporine for generalized itching. CP is quite frequent finding associated with skin and systemic diseases in the overall population. It is known to significantly affect quality life score of an individual and also adds burden on the health-care cost. A specific recommendation for treatment of CP is difficult as a result of varied and diverse possibility of underlying diseases associated with CP.

What was known?

The recommendations for the management presented in this paper are the result of a panel consensus meeting held in March 2014 in Mumbai. The aim of these recommendations is to improve the diagnosis and management of Indian patients with pruritus.

Introduction

Pruritus is an unpleasant sensation on the skin eliciting the desire to scratch. Chronic pruritus (CP) refers to daily/almost daily itching, lasting more than 6 weeks.[1] Clinically, pruritus has been described as the most frequent symptom in dermatological condition. It has demonstrated a significant impact on patient's quality of life (QoL) that causes various problems related to sleep, anxiety, attention, and sexual function. Moreover, CP poses a significant burden on the society in terms of health-care cost and treatment challenges.[1] In addition, many systemic diseases are also known to be associated with pruritus and further incapacitating nature of this condition.[2] Insufficient data have been reported on the prevalence of CP. It has been suggested that there is an increase in the prevalence of CP with advancing age.[3] Moderate-to-severe pruritus is known to affect 60% of the elderly individuals (≥65 years of age).[4] Recent studies have suggested a point prevalence of CP to be approximately 13.5% in the general adult population and 16.8% in those undergoing cancer screening.[56] In addition, a German population-based cross-sectional study reported a 12-month prevalence and lifetime prevalence of CP to be approximately 16.4% and 22.0%, respectively.[5]

Current Challenges in Management of Chronic Pruritus

In dermatologic practice, CP is the most troublesome symptom. It has a major impact on QoL score and also has severe psychological implications. Treatment of CP remains a challenge when it is not associated with a skin lesion or it is not of systemic origin.[7] Anti-inflammatory agents including steroids and antihistamines help in managing pruritus in case of cutaneous inflammatory disorders and allergic disorders, respectively. Systemic disorders associated with pruritus include uremic pruritus, hepatobiliary pruritus, pruritus due to hematological causes such as polycythemia vera, leukemia, lymphomas (especially Hodgkin's disease), multiple myeloma, pruritus due to endocrine disorders, and multiple sclerosis. In recent times, understanding the pathomechanism of pruritus of systemic origin has improved considerably.[7] Clinicians must offer individualized therapy in the management of pruritus. However, lack of randomized controlled trials has been reported due to the diversity and complexity of the symptom, multifactorial etiologies, and lack of well-defined outcome measures. In addition, for documenting CP, no standardized method has been reported. There is lack of guidelines suggesting apt diagnostic modalities for the management of CP. This is suggestive of the dire need for comprehensive consensus discussing diagnosis and management of CP. Therefore, the current discussion will mainly focus on expert commentaries for the diagnosis and management of CP.

Methods

We screened 87 of 95 studies that contained qualitative data. We searched PubMed, EMBASE, Scopus, Web of Science, and the WHO's regional databases, for studies on “Diagnosis and management of chronic pruritus” from January 1, 2014, to July 31, 2015. We included programmatic reports and hand-searched references of published reviews and articles. Two independent reviewers screened articles and extracted data.

Figure 1 depicts the clinical classification for the management of patients with CP.[8] Pruritus and itch are considered to be synonymous. The term “pruritus of unknown origin” or “pruritus of undetermined origin” has been commonly specified in patients with no identified underlying disease. Although Groups I and II may already suggest a category, the classification of the patient is performed in the second step based on histological, laboratory, and radiological investigations. If no category fits or several diseases are found (green arrows), the patients are classified into “mixed” or “others.”

Figure 1

Clinical classification of patients with chronic pruritus

Table 1 shows etiological classification of CP.

Table 1

Etiological classification of chronic pruritus

Dermatological origin of chronic pruritus [Table 2]

Pruritus due to dermatological diseases with/without primary skin lesions (rash)

Dermatoses induce pruritus locally or generalized and present with primary skin lesions.[10]

Systemic origin of chronic pruritus [Table 3]

Renal/uremic itch

Patients with uremia suffer from continuous itch while others experience it in episodes or exacerbations.[11]

Hepatic itch

Any liver disease with cholestasis can give rise to the development of pruritus which is generalized and without rash.[1213]

Diabetes mellitus

Generalized pruritus has been documented in diabetics; however, its frequency is unknown. Localized pruritus along with infection (around anus, genitals) is more common in DM caused due to candidiasis.[14] Neuropathic itch of the scalp has been reported in patients with DM. It must be noted that controlling diabetes mainly aid for complete relief of pruritus.[15]

Thyroid diseases

Pruritus-associated hypothyroidism and hyperthyroidism has been reported in patients.[16]

Parathyroid diseases

Pruritus is also reported in patients presenting with abnormal parathyroid gland activity. Secondary hyperparathyroidism associated with chronic renal diseases may essentially account for uremic itch. Further, in patients with primary hypoparathyroidism, pruritus is caused due to dry skin and cutaneous candidiasis.[1617]

Premenstrual or perimenstrual pruritus

CP can be due to oral contraceptive pill-induced cholestasis. Generalized pruritus can be related to intradermal estrogen administration. Hormone replacement therapy is a viable option in treatment of episodic pruritus in perimenopausal women.[1819]

Pruritus and malignancy

Generalized pruritus has been documented in cases of carcinoma of the lung, stomach, colon, prostate, breast, and pancreas. Surgical removal of the tumor and use of serotonin re-uptake inhibitors or serotonin antagonists in inoperable cases are usually the recommended treatments. Different forms of mastocytosis, i.e., solitary mastocytoma, urticaria pigmentosa, telangiectasia macularis eruptiva perstans, and systemic mastocytosis are also significantly associated with symptoms of pruritus. In addition, pruritus may be associated with flushing in patients with carcinoid syndrome. In such cases, serotonin, produced in the enterochromaffin cells of the tumor, is responsible for eliciting pruritus. The use of antiserotonin drugs is usually considered to alleviate this symptom. Frequently, brain tumors are reported to be associated with pruritus. Importantly, 50% of these cases have reported nasal pruritus. However, exact mechanism for this association has not been fully understood. It has been postulated that immunological mechanisms, toxic metabolites, iron deficiency, and dry skin may trigger pruritus in such patients. Commonly, antihistamines are not considered to be helpful for relieving itch. However, eradication of the tumor can help diminish or abolish itch. Unilateral pruritus over the scapular region has been documented in patients with multiple endocrine neoplasms syndrome and is reported to be associated with deposition of amyloid. Pruritus can also be caused due to drugs given for chemotherapy such as antimetabolites, alkaloids, alkylating agents, and irradiation.[16]

Hematologic diseases and pruritus

Several hematological diseases are linked to cause pruritus. Itching may appear following contact with water or after a hot bath in patients with polycythemia vera. Symptom of aquagenic pruritus may be reported before the development of polycythemia vera. The use of salicylates, photochemotherapy, or interferon-α can be considered for treating such cases. In addition, pruritus is often reported in patients with iron deficiency, even in absence of anemia. Iron supplementation often alleviates this symptom. Patients with hemochromatosis may also report pruritus where they demonstrate elevated levels of iron in blood and tissues. Itchiness is also reported in about 30% of patients with Hodgkin's disease. Radiation therapy or chemotherapy improves the symptoms of pruritus in Hodgkin's disease. Patients with host reactions after bone marrow transplantation may also report pruritus.[16]

Pruritus in infectious diseases

Pruritus may be reported in some generalized infections. Furthermore, pruritic papular eruption or eosinophilic folliculitis has been documented in patients infected with HIV.[1920]

Neurological and somatoform origin of chronic pruritus [Table 4]

Localized neuropathic pruritus

Neuropathic itch of the scalp has been reported in patients with herpes zoster. In addition, localized neuropathic pruritus suggesting a compression of peripheral or brachioradial pruritus is found in postzosteric pruritus, notalgia paresthetica, and brachioradial pruritus.[1521]

Systemic neurological pruritus

Such patients present with hypo/hyperesthesia with itching and have localized, dermatomal involvement.

Syringomyelia

It is characterized by chronic lichenoid rash secondary to scratching.[22]

Neurofibromatosis

Pruritus is commonly reported in patients with neurofibromatosis. Patients generally demonstrate widespread cutaneous phenomenon. Mast cells found in neurofibromas account for the release of histamine, which leads to itching. Furthermore, the presence of localized pruritus may aid for suspicion of an underlying spinal cord or central nervous tumor.[1]

Transverse myelitis

Transverse myelitis is seen mostly in the neurology or orthopedic inpatients. A case reported in 2003 stated the development of severe pruritus and hyperesthesia due to transverse myelitis. Usually, patients complain of pain in legs followed by severe pruritus and hyperesthesia. Patients with transverse myelitis may also show lichenoid plaques and excoriations over affected area. It is mostly treatable by surgical methods. Medically sedative antihistamines are helpful than nonsedative antihistamines.[23]

Cerebral lesions

Cerebrovascular accidents (CVA) may be responsible for neuropathic itch. Patients suffering from CVA have reported to develop poststroke pruritus in a few days or weeks. Patients with CVA may report excessive localized or generalized pruritus but primarily involves skin contralateral to the stroke lesion.[24]

Notalgia paresthetica

It is characterized by unilateral pruritus located medial or inferior to the scapula in the T2–T6 dermatomal region. It is commonly reported in middle-aged women and is known to last for months or years. It may also be associated with pain, paresthesias, numbness, or hypersensitivity.[25]

Drug-induced pruritus

Most of the medications including angiotensin-converting enzyme inhibitors, antibiotics, antidepressants, antidiabetics, and drugs are likely to cause generalized pruritus.[26] CP may develop due to drug-induced hepatotoxicity or cholestasis as well as drugs leading to xerosis or phototoxicity.[27] Hydroxyethyl starch used for restoration of fluids may be associated with generalized or localized pruritus.[28]

Chronic pruritus in special population

Elderly patients

Pathological mechanism of pruritus in elderly patients is still unclear. However, associated etiological factors that are known to contribute for developing pruritus may include pathophysiological changes of the aged skin, decreased function of the stratum corneum, xerosis cutis, comorbid conditions, and multiple-drug use.[29] Studies conducted in elderly patients reported pruritus as the most common symptom in 11.5% of 4099 patients.[30] Moreover, an American study and a Thailand study reported occurrence of pruritus as the common symptom among 29% and 41% elderly patients, respectively.[3132] A prevalence of about 12.8% for pruritus was observed among patients aged >85 years.[30]

Pregnant women

Estimated occurrence of pruritus in pregnancy is 18%.[33] Polymorphic eruption of pregnancy, pemphigoid gestation, intrahepatic cholestasis of pregnancy (ICP), and atopic eruption of pregnancy are specific dermatoses associated with pruritus.[343536] ICP is characterized by severe pruritus without any primary skin lesions, and it is more commonly reported in women of advanced maternal age, multiple gestations, history of cholestasis on oral contraceptives, and during winter months.[373839] Recognizing ICP is important because it is associated with increased fetal mortality. The only recognizable sign would be pruritus.

Children

A Norwegian cross-sectional questionnaire-based population study in adolescents revealed a pruritus prevalence of 8.8%. In this study, mental distress, gender, sociodemographic factors, asthma, rhinoconjunctivitis, and eczema were associated with pruritus.[40] No evident epidemiological studies have been conducted for advocating the prevalence of CP in children.[3341]

Diagnostic criteria for chronic pruritus

Figure 2 illustrates the diagnostic approach for CP.[10] Detailed history of the patient should be taken:[42] Onset (drugs, winter itch), duration of itch, quality, time course (scabies), localization (notalgia paresthetica), preceding skin changes, relieving factors (atopic atmokinesis occurs while changing clothes), exacerbating factors (scratching with brushes, combs, knitting needles), atopic diathesis, drug history, history of allergies, weight loss, fever, fatigue, emotional stress, and other symptoms indicating underlying disease have to be reviewed. Other important symptoms in diagnosing etiology of pruritus include history of infection in family members: Scabies and other parasites infection among family members. Pruritus during physical activity: Cholinergic pruritus, which is often reported to be atopic Aquagenic pruritus provoked by skin cooling/bathing, Nocturnal pruritus with chills, fatigue, sweating, weight loss reported in lymphoma, sleep disturbance are rare with psychogenic pruritus, whereas most types cause wakening, seasonal variations cause asteatotic/xerotic, atopic, solar urticarial and textile dermatitis.

Figure 2

The diagnostic approach for chronic pruritus

Clinical examination [Table 5][42]

Search for primary skin lesions: A thorough inspection of the entire skin including mucous membranes, scalp, hair, nails, and anogenital region. Look for lesions in the interscapular regions, nondominant hand site or areas not normally assessable to hand. The distribution of primary and secondary skin lesions should be recorded together with skin signs of systemic disease

General physical examination should include palpation of the liver, kidneys, spleen, and lymph nodes

A solely psychological cause of pruritus should not be diagnosed without psychiatric examination.

Screening tests

Fasting blood sugar, postprandial blood sugar, complete blood count, erythrocyte sedimentation rate, absolute eosinophil count, peripheral smear, serum IgE, urinalysis, stool routine and occult blood, thyroid-stimulating hormone (TSH) free T4, blood urea creatinine, liver function test, X-ray chest (radiologist to report), ultrasonography abdomen, Vitamin D, skin biopsy for direct immunofluorescence, serum protein electrophoresis.

Investigations[10]

Baseline screening: Creatinine, aspartate aminotransferase (AST), alanine transaminase (ALT), alkaline phosphatase, bilirubin, TSH, complete blood count, glucose, chest X-ray and in case of genitoanal pruritus calcium (Ca), gamma-glutamyl transpeptidase (γ-GT), and Stool test for parasites in genitoanal pruritus

Renal insufficiency: Creatinine (and urea for elderly), phosphate, parathyroid hormone (PTH), bicarbonate, urinalysis, urine protein concentration and sonography, computed tomography (CT) or magnetic resonance imaging (MRI) of the kidneys

Liver diseases with or without cholestasis: γ-GT, arterial pressure (AP), bilirubin, AST, ALT (and hepatitis B-, hepatitis C-antibodies, if a risk-patient), lactate dehydrogenase (LDH), antimitochondrial antibodies (AMAs), antinuclear antibody, anti-hepatitis B core antibody, hepatitis B surface antigen, anti-hepatitis C virus-antibody, anti-smooth muscle antibody, antiactin antibody, sonography of the liver, CT or MRT, magnetic resonance cholangiogram or endoscopic retrograde to rule out primary sclerosing cholangitis

Hyperparathyroidism: PTH, calcium (only, if symptoms or signs of hyperparathyroidism [“stones, bones, moans and abdominal groans and psychiatric overtones”]), phosphate, Vitamin D (1,25-Vitamin D, 25-Vitamin D) and sonography of the parathyroid glands, scintigraphy, MRI

Hyper- and hypo-thyroidism: TSH, T3, T4, Human assay for microsomal thyroid antibodies (MAKs) and Human assay for thyrotropin receptor antibodies (TRAKs), sonography of the thyroid glands and iodine-scintigraphy

Anemia: Complete blood count including mean corpuscular volume and mean corpuscular hemoglobin concentration, LDH, ferritin, transferrin saturation (TSAT) and bone marrow aspiration with iron staining

Iron deficiency: Ferritin and TSAT

Malabsorption: Serum protein, serum albumin, calcium, blood count, gliadin-antibody, Vitamin A (hyperkeratosis by Vitamin A deficiency), Vitamin B12 (neuropathy by Vitamin B deficiency) and endoscopy with biopsy

Pruritus of the elderly: Serum creatinine, ALT, AST, alkaline phosphatase, bilirubin, TSH, full blood count and blood urea nitrogen (+estimated creatinine clearance)

Infective diseases: HIV-antibodies, Western blot

Parasitoses including helminthosis, Giardia lamblia (rare): Stool culture and microscopic examination

Hematological disorders: Polycythemia vera – Blood count, thrombocytes, sedimentation rate. To rule out secondary erythrocytosis: O2 saturation, erythropoietin level (renal cell carcinoma or polycystic kidneys), bone marrow with chromosomal aberrations and sonography, CT or MRI of the spleen. Lymphoma – Blood count, blood smear, thrombocytes, sedimentation rate, bone marrow with chromosomal aberrations, sonography, CT or MRI of the abdomen, thorax and additional affected areas (positron emission tomography)

Neurological diseases: Multiple sclerosis – Cerebrospinal fluid analysis, electroencephalography (EEG), MRI and CT of the brain und functional tests. Brain tumors – Cerebrospinal fluid analysis with histopathology and EEG, MRI, CT of the brain. Notalgia paresthetica – MRI of the thoracic spine. Brachioradial pruritus – MRI of the thoracic and cervical spine

Psychiatric or psychosomatic diseases: Psychiatric and psychosomatic exploration, psychiatric short questionnaire for depressive and anxiety disorder

Pregnancy with or without cholestasis: γ-GT, AP, bilirubin, AST, ALT, bile acids, hepatitis A, B, C, Epstein–Barr and cytomegalovirus, liver autoimmune screen for chronic, active hepatitis, and primary biliary cirrhosis (anti-smooth muscle and AMAs) and liver ultrasound

Drug-induced pruritus: γ-GT, AP, bilirubin, AST, ALT, LDH, and skin biopsy in case of Hydroxy ethyl starch (HES) exposition.

Management of chronic pruritus[42]

To improve the management of CP adherence following measures to be taken:

Develop a usable document or intake sheet

Form a decision tree

Prepare a list of basic investigations

Produce guidelines for usage of drugs

Prepare a patient education pamphlet.

Grading for the management of chronic pruritus[42]

No itch (Grade 0)

Itch with no need to scratch (Grade 1)

Itch with need to scratch (Grade 2)

Itch with need to scratch requiring treatment (Grade 3).

General approach

Individualized treatment approach should be considered for patients with CP depending on their age, comorbid conditions, medications, quality, and intensity of pruritus. Medical care may extend for longer duration due to failure of previous therapies, psychological stress, and uncertainty of origin of pruritus. General measures for managing CP are shown in Table 1. Further, appropriate clinical and diagnostic evaluation may be required prior initiation of symptomatic treatment.

Stepwise approach to chronic pruritus

Overall stepwise approach for managing CP is shown in Figure 3.[10]

Figure 3

Stepwise approach for the management of chronic pruritus

Consensual Therapeutic Recommendations of Chronic Pruritus[1042]

Topical applications or treatments [Table 6]

Local anesthetics[43]

These drugs are considered effective for short treatment of mixed pain, dysesthesia, and itch over localized areas.

Capsaicin[4445]

Similar to local anesthetics, it is used for managing CP, but it is not considered suitable for facial and periorificial skin. Further, capsaicin requires frequent reapplication. Moreover, its preparations with nonsteroidal anti-inflammatory drugs (NSAIDs) have demonstrated better tolerability (personal observation).

Topical corticosteroids[4647]

Topical corticosteroids are considered very effective, only in cases of inflammatory dermatoses.

Calcineurin inhibitors[48]

These drugs are effective for medium to long-term treatment of localized pruritus of any etiology. These drugs have demonstrated good evidence mainly for all types of eczemas, Lichen sclerosus et atrophicus (LSA), Lupus erythematosus (LE). However, with its treatment, 25% patients may report initial itch and burning sensation.

Menthol, camphor, and zinc[49]

Menthol, camphor, and zinc have demonstrated rapid onset of action and short duration of relief. These drugs can be applied on widespread areas with no significant risk of systemic toxicity.

Opioid agonists[50]

Significant antipruritic activity has been demonstrated by N-palmitoylethanolamine containing product among patients with atopic dermatitis (AD). Naltrexone[5152] is considered to be effective in cholestatic pruritus. It is also observed to be effective in renal itch.

Systemic therapy [Tables 7 and 8]

Antihistamines[71727374]

H1-type antihistamines are the most clinically investigated drug for managing pruritus. Sedative first-generation antihistamines are considered to be highly effective where hydroxyzine is considered to be the most potent antihistamine in managing CP which has been demonstrated in vivo studies[10] Nonsedating second-generation antihistamines are long acting, less sedating, and have documented anti-inflammatory activity; however, they are considered to be less effective than sedative first-generation molecules for the relief from CP. Antihistamines have also been considered suitable for urticaria, mastocytosis, and allergic reactions. However, these are frequently administered and considered effective for itch of other etiologies. It is also not effective in standard doses for itch due to internal diseases. Antihistamines are the most commonly prescribed systemic antipruritic drug by the dermatologists. First-generation antihistamines such as hydroxyzine, chlorpheniramine, clemastine, cyproheptadine, diphenhydramine, and promethazine effectively bind to H1-receptors and also to muscarinic, α-receptors, dopamine, and serotonin receptors and demonstrate central sedative effect. Systemic H1-antihistamines are usually used to treat pruritus associated with AD. However, only sedative antihistamines have shown beneficial effects, mainly by improving sleep which is significantly affected leading to QoL impairments. Hydroxyzine in the dose of 75–100 mg/day and 1–2.5 mg/kg/day is recommended as an effective agent in the treatment of CP for adults and children, respectively. A controlled study reported that there was 750-fold increase in the dose of histamine that is required to elicit itch with the addition of hydroxyzine. Hydroxyzine was reported to be more efficacious in treating histamine-induced pruritus compared to neuroleptics such as thiothixene, chlorpromazine, and thioridazine. Antihistamines have demonstrated added efficacy when administered with leukotriene antagonists in physical and NSAID-aggravated urticarial.[10] However, addition of H2 antagonists has shown poor.

Gabapentin and pregabalin[75]

Gabapentin and pregabalin are effective in all types of neuropathic itch and intractable itch of other etiologies as well. It can be a good evidence for renal and hepatic itch. Serotonin-specific reuptake inhibitors (SSRIs)[64] are considered effective for neurologic, psychogenic, or paraneoplastic itch. It can be considered as the second-line treatment for intractable itch of any type.

Tricyclic antidepressants[75]

It is similar to SSRIs and has also been considered in AD other than pruritus.

Cyclosporine

Cyclosporine is reported to be effective in managing pruritus associated with AD and its variants, such as chronic urticaria.

Thalidomide[5670]

Thalidomide has reported its effectiveness in managing prurigo nodularis and pruritus associated with HIV infection.

Ultraviolet rays[5477]

Narrow-band ultraviolet (UV) B, psoralen plus UV A, and UVA1 are considered to be effective in itch of primary dermatologic conditions. In addition, they have been observed to be effective in renal, hepatic, polycythemia vera, and paraneoplastic itch. Table 9 illustrates antipruritic agents using during pregnancy.[87]

Table 9

Antipruritic drugs for pregnant women

Summary

CP is quite frequent finding associated with skin and systemic diseases in the overall population. It is known to significantly affect quality life score of an individual and also adds burden on the healthcare cost. Sedative H1 antihistamines are first-choice therapy in CP to improve night time sleep. Studies on application of higher doses are yet to be conducted. UV phototherapy is recommended for generalized pruritus, especially in the elderly pruritus patients or in case of contraindications for systemic therapy. Anticonvulsants/pain modulators are recommended in neuropathic pruritus. Antidepressants are recommended in forms of CP not responding to other therapies. Systemic glucocorticoids are not recommended for the treatment of CP except of very severe and desperate cases. Serotonin receptor antagonists and thalidomide are not recommended for treatment.

Financial support and sponsorship

Moral support and financial support provided by advisory board meeting conducted by UCB India Private Limited.

Conflicts of interest

There are no conflicts of interest.

What is new?

Chronic pruritus is quite frequent finding associated with skin and systemic diseases in the overall population. It is known to significantly affect quality life score of an individual and also adds burden on the healthcare cost. A specific recommendation for treatment of CP is difficult as a result of varied and diverse possibility of underlying diseases associated with CP. The recommendations in this guideline are offered with a view to reduce the burden on the physicians and assist in effective management of CP.

Table 2

Category 1 – Dermatological origin of chronic pruritus

Table 3

Category 2 – Systemic origin of chronic pruritus

Table 4

Category 3 and 4 – Neurological and somatoform origin of chronic pruritus

Table 5

Clinical classification of chronic pruritus as per skin changes

Table 6

General measures for managing chronic pruritus[10]

Table 7

Management of chronic pruritus due to renal causes

Table 8

Management of chronic pruritus due to hepatic cause