Management of Chronic Pruritus in the Elderly Includes Compounded Topical Treatments and Medications
People often think that getting older means they will develop unavoidable health problems like dry, itchy skin. As long as it doesn’t become inflamed or infected, they tend to not worry when itchy skin becomes chronic—they simply continue to use their favorite OTC lotion. But pruritus deserves more attention, as it often signals a more serious skin condition or an underlying disease. When it’s not properly treated, it can develop into a persistent itch that can interfere with their sleep and normal daily routine. Compounding pharmacists can intervene to talk with their elderly patients about chronic pruritus and to improve the management of the condition.
What Pharmacists Need to Know About Chronic Pruritus in the Elderly
Pruritus is the most common skin problem in people aged 65 and older. With the projected growth of the elderly population—one in five Americans will be 65 or older by 2030—compounding pharmacists can expect to see more patients with itchy skin.1 As you encounter these patients, keep the term chronic pruritus on the tip of your tongue rather than the more colloquial “itchy skin,” because it does a better job of communicating the serious nature of this condition in the elderly pruritus.
Multiple aging-related changes contribute to pruritus. As skin ages, the integumentary and vascular systems atrophy, which leads to significant moisture loss and dry skin, or xerosis. Loss of barrier lipids and proteins, along with sluggish barrier repair contribute to the problem, while decline in immune function increases the risk of autoimmune skin disorders that lead to pruritus. Chronic systemic diseases that develop with advancing age and that may cause this condition include endocrine disorders, kidney disease and liver disease. The list of potential underlying health conditions wraps up with several neurologic and psychiatric disorders, as well as more than 30 dermatologic disorders.2 Some of the most common causes of chronic pruritus in the elderly include:
- Nummular dermatitis
- Seborrheic dermatitis, especially in patients with dementia and Parkinson’s disease
- Scabies and lice, possibly more common in institutionalized care settings
- Malignancy, such as low-grade lymphoma, multiple myeloma and myelodysplastic syndromes
Pharmacists should be aware that polypharmacy—a common concern in this age group—increases the risk. The following drugs, often prescribed for the elderly, also boost the chance of chronic pruritus:
- Angiotensin-converting enzyme inhibitors
Recommended Topical Treatments
Considering the diverse causes of pruritus and the potential for multiple comorbid conditions in the elderly, chronic pruritus is a classic example of a condition that demands an individualized approach to treatment. It begins by identifying and treating underlying health conditions. Physicians may also consider systemic treatments, such as antihistamines, antidepressants—SNRIs, SSRIs and tricyclic antidepressants—and opioid agonists or antagonists, since itch is induced by mu-opioid receptor agonists and kappa-opioid receptor antagonists. Gabapentin and pregabalin have emerged as promising alternatives when topical therapies fail.3
A universally-accepted treatment hasn’t been defined, but topical treatments are key components of any pruritus therapeutic regimen:4
- Moisturizers, emollients, barrier creams – Barrier repair creams are the mainstay of chronic pruritus, especially when associated with xerosis. Topical treatments with a low pH support the skin barrier by maintaining the normal pH of the skin surface. Low-pH creams may also reduce serine proteases that trigger itch. Encourage patients to use skin creams at least two to three times daily and to apply them right after bathing.
- Topical corticosteroids – Steroids won’t relieve the itch, but their anti-inflammatory action is effective for pruritus associated with inflammatory skin diseases such as psoriasis. Short-term treatment to avoid adverse effects, especially skin thinning, is vital in the elderly. Watch for patients purchasing OTC steroids and talk with them about safer compounded options.
- Menthol – The cooling sensation of topical menthol at concentrations of 1 to 3 percent effectively relieves itching in elderly patients.
- Capsaicin – Chronic pruritus of neuropathic origin, such as postherpetic neuralgia, notalgia paresthetica and brachioradial pruritus, may respond to topical capsaicin, but elderly patients may not adhere to treatment due to its transient burning sensation.
- Immunomodulators – The topical calcineurin inhibitors tacrolimus and pimecrolimus relieve pruritus associated with dermatitis, lichen sclerosis and prurigo nodularis. Like capsaicin, burning and stinging side effects may limit their use in the elderly.
- Local anesthetics – Lidocaine gel 0.5 to 5 percent may be used on small areas, but any gel made from an alcohol-based delivery vehicle may be too drying. Pramoxine blocks sensory impulses that cause itching and reduces pruritus in hemodialysis patients. A combination of urea 5 percent and polidocanol 3 percent is effective when pruritus is caused by contact dermatitis, psoriasis and atopic dermatitis.
- Salicylic acid – About 12 percent of older patients with pruritus have lichen simplex chronicus.5 These patients may benefit from topical salicylic acid.
Lifestyle recommendations: It may help to remind patients that scratching worsens pruritus and boosts inflammation. Keeping fingernails short, warm rather than hot water during bathing, and staying cool with light clothing can all help relieve itching.
Reach Out to Elderly Patients to Guide Treatment
Most of the elderly patients visiting your pharmacy for skin-care products to treat pruritus—certainly all those who aren’t aware of any underlying health problems—tend to grab their favorite product off the shelf. As long as they’re getting temporary relief and the itch isn’t getting worse, many elderly individuals may believe that’s the best they can achieve. Compounding pharmacists who proactively reach out to customers can raise awareness of the complexity of pruritus, encourage a medical assessment and recommend tailored compounded products that achieve better results.
Pharmaceutica North America provides high-quality bulk APIs, compounding kits and delivery bases suitable for elderly patients with chronic pruritus. Call us today to talk about how we can help you meet the needs of this expanding population.
- “Projections of the Size and Composition of the U.S. Population: 2014 to 2060,” March 2015, http://www.census.gov/content/dam/Census/library/publications/2015/demo/p25-1143.pdf ↩
- “Pruritus,” April 2010, http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/dermatology/pruritus-itch/ ↩
- “Gabapentin and Pregabalin for the Treatment of Chronic Pruritus,” May 2016, http://www.ncbi.nlm.nih.gov/pubmed/27206757 ↩
- “The Management of Chronic Pruritus in the Elderly,” December 2015, http://www.skintherapyletter.com/2010/15.8/2.html ↩
- “Lichen Simplex Chronicus,” March 2016, http://emedicine.medscape.com/article/1123423-overview#a6 ↩