If results from the national ambulatory Medical Care Survey conducted by the CDC are correct, pruritus as a presenting complaint in ambulatory care may merit more of our attention. In a retrospective review of data from 1999-2009, there were approximately 7 million office visits per year in which pruritus (or itching) was indicated as a presenting symptom. In comparison, there were almost 18 million visits per year for low back pain. Since itch may or may not have been specifically indicated when syndromes such as a drug allergic reaction occur, the authors suggest that these numbers likely underestimate the true prevalence of pruritus.
The consequences of pruritus may range from minor nuisance to intolerable. Indeed, patients taking opioid analgesia frequently mention pruritus as a treatment-limiting adverse effect. Fortunately, clinicians have a diversity of agents to treat pruritus, including multiple generations of antihistamines as well as steroids (topical and systemic). Finally, it has been recognized for more than 2 decades that doxepin — traditionally used as an antidepressant — has antihistaminic potency as much as 50 times greater than the most potent “traditional” antihistamines such as hydroxyzine. Because of this antihistaminic potency, doxepin is often used in refractory urticaria, when other antihistamines have failed, even though sedation is common at typical therapeutic doses.