PracticalDermatology

Dr. Berger sat down with DermTube.com’s Ask an Expert Host Adam Friedman, MD to discuss management and treatment tips for elderly patients with pruritus. Watch his series of interviews at DermTube.com. Ahead are some of Dr. Berger’s recommendations about treatment considerations and safety issues for geriatric patients.

Considering the Safetly Profile of Medications

In managing itching in the geriatric population, Dr. Berger says the first thing you have to consider is the safety profile of specific medications in the elderly patient. He explains that internists and geriatricians have addressed this by using the Beers List, which lists medications that they feel have a high risk of use in the geriatric patient. Many of the medications we use for treating itch are on that list, adds Dr. Berger, explaining that, for example, hydroxyzine is on that list of medications.

“We need to pick medicines that are safe in the elderly. So we use gabapentin, we may use mirtazapine. In patients who are intolerant of gabapentin, we might use pregablin. We sometimes use thalidomide. So medications that don’t cause quite so much anticholinergic effect and aren’t quite as sedating or as likely to cause neurologic side effect,” Dr. Berger recommends.

He also cautions that when treating elderly men, it’s imperative to ask them about their prostate and how many times they have to get up at night because many antihistamines have anticholinergic effects.

Combining Multiple Medications for Best Results

Often, when treating elderly patients, Dr. Berger says it may be helpful to prescribe a mix of several anti-pruritic medications so that the toxicity for each is low but the combined effect is enough to control the itching—so low-dose but multiple agents. For example, Dr. Berger says, doxepin (Sinequan), which is used to treat itching, is believed by geriatricians to be safe at a low-dose of up to 6mg at night and is often used in combination with other medications.

Understanding the Underlying Cause

Dr. Berger says it’s also important to try to investigate and understand the underlying cause of a patient’s disease. And if that’s inflammatory, you treat with an anti-inflammatory medications. He says he uses methotrexate or mycophenolate, but adds that you can other medications, like azathioprine.

And because elderly patients with impaired barriers are at increased risk for developing allergic contact dermatitis, Dr. Berger adds that patients who may have contact dermatitis should be appropriately referred. n

DIANGOSTIC PEARLS

When diagnosing pruritus in the elderly, Dr. Berger says the key elements to get when taking a history to point you in the right direction of cause are:

• Severity
• Patient’s description of the different types of discomfort
• Where the patient localizes the itching

Watch all of Dr. Berger’s videos on DermTube.com

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