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Kidney disease and urology Skin and nail

Itch - widespread

Last revised in June 2026

Itch (also known as pruritus) can be defined as a sensation that elicits a desire to scratch.

Itch - widespread: Summary

  • Itch is a subjective symptom which can be defined as a poorly localized, usually unpleasant sensation of the skin which elicits a desire to scratch.
    • Itch is defined as acute when symptoms last for less than 6 weeks, and chronic when symptoms last for more than 6 weeks.
    • The pathophysiology of itch is complex, multifactorial, and not fully understood, although an interplay between histamine and other mediators may be involved.
  • Widespread itch which is not associated with a skin disorder or rash may be idiopathic, or may be associated with one or more underlying conditions which may co-exist, including:
    • Infection and infestation (such as scabies).
    • End-stage renal disease.
    • Cholestasis.
    • Haematological malignancy (such as lymphoma) and lymphoproliferative disease (such as polycythaemia vera).
    • Endocrine disease (such as diabetes mellitus).
    • Neurological (such as multiple sclerosis).
    • Drugs (such as opiates, statins, angiotensin-converting enzyme inhibitors, or calcium-channel blockers).
    • Psychogenic (including functional itch disorder and rarely delusional infestation).
    • Solid malignant tumours (rare).
  • Itch is a common symptom in the general population, and its prevalence increases with age.
  • Assessment of a person with widespread itch should include:
    • Asking about the characteristics of itch, associated sensory symptoms, impact on quality of life and associated psychological conditions, associated systemic symptoms, comorbidities, treatments tried, drugs, family history, household contacts, and travel history.
    • Examining the skin for secondary scratch lesions, signs of infestation, lymphadenopathy, hepatosplenomegaly, or other clinical features of underlying disease.
    • Arranging investigations such as initial blood tests to assess for an underlying cause, depending on the clinical presentation.
  • Management of a person with widespread itch should include:
    • Advising on sources of information and support.
    • Treating the underlying cause if appropriate.
    • Offering support for any emotional distress, stress, anxiety, or depression.
    • Managing secondary scratch lesions if needed.
    • Advising on self-care strategies, including the use of emollients as a soap substitute and moisturizer.
    • Considering a short-term trial of a non-sedating oral antihistamine (off-label) for symptom relief.
    • Considering a short-term trial of a sedating oral antihistamine if there is troublesome nocturnal itch.
    • Arranging referral or seeking advice from a dermatologist if symptoms remain unexplained and/or persist.

Have I got the right topic?

From age 12 years onwards.

This CKS topic covers the diagnosis and management of chronic widespread itch that is not associated with an underlying skin disorder or rash, as well as chronic widespread itch of unknown cause.

This CKS topic does not cover localized itch or itch in pregnancy.

There are separate CKS topics on Candida - female genital, Chickenpox, Chilblains, Dermatitis - contact, Eczema - atopic, Fungal skin infection - body and groin, Fungal skin infection - foot, Fungal skin infection - scalp, Head lice, Insect bites and stings, Itch in pregnancy, Psoriasis, Pruritus ani, Pruritus vulvae, Pubic lice, Scabies, Seborrhoeic dermatitis, and Urticaria.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

June 2026 — minor update. Wording has been changed to note that myeloma is rarely associated with generalised pruritus.

Previous changes

November 2025 — reviewed. A literature search was conducted in November 2025 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The recommendations have been updated in line with current evidence in the literature. 

January 2024 — minor update. Cetirizine doses for people with renal impairment updated in line with manufacturer's SPC.

June 2023 — minor update. Cetirizine doses for people with renal impairment updated in line with BNF.

August 2021 — minor update. Recommendations on use of cetirizine in people with renal impairment have been updated in line with the updated manufacturer's Summary of Product Characteristics.

February 2021 — reviewed. A literature search was conducted in December 2020 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. In the Scenario on Management, the sections on management of itch of known and unknown cause have been merged to avoid repetition of text. The recommendations have been updated in line with current evidence in the literature. The recommendations on prescribing oral antihistamines have been amended to consider the use of non-sedating oral antihistamines first line unless there is a history of troublesome nocturnal itch. New sections on Cetirizine, Loratadine, and Fexofenadine have been added to the section on Prescribing information.

December 2016 — minor update. The adverse effects of hydroxyzine have been updated in line with the manufacturer's Summary of Product Characteristics (2016).

October to November 2015 — reviewed. A literature search was conducted in September 2015 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. There are no major changes to the recommendations.

October 2009 to February 2010 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 November 2025.

HTAs (Health Technology Assessments)

No new HTAs since 1 November 2025.

Economic appraisals

No new economic appraisals relevant to England since 1 November 2025.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 November 2025.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 November 2025.

New policies

No new national policies or guidelines since 1 November 2025.

New safety alerts

No new safety alerts since 1 November 2025.

Changes in product availability

No changes in product availability since 1 November 2025.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Identify the underlying cause of itch, if possible.
  • Provide advice on self-care measures to help symptom relief.
  • Provide appropriate management in primary care.
  • Arrange referral to a hospital specialist if clinically indicated, depending on the suspected underlying cause.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

  • Itch (synonymous with the term 'pruritus') is a subjective symptom, which can be defined as a poorly localized, usually unpleasant sensation of the skin that elicits a desire to scratch [Pereira, 2019; Kremer, 2020; Hashimoto, 2025; Weisshaar, 2025]. It may also be described as 'the sensation that is relieved by scratching the skin' [Millington, 2018].
  • The International Forum for the Study of Itch (IFSI) classifies the spectrum of cutaneous pruritus patients into three groups based on their skin condition: Patients with pruritus on primarily diseased/inflamed skin are classified into 'Group I'; patients with primarily normal skin into 'Group II'; and patients with characteristic, chronic secondary scratch lesions into 'Group III' [Weisshaar, 2025].
    • From the IFSI classification, the aetiology of cutaneous pruritus is labelled in categories such as 'dermatological' (including pregnancy-related dermatoses), 'systemic' (including drug-induced pruritus), 'neurological', 'somatoform', 'mixed origin' and 'others' [Weisshaar, 2025].
  • Itch is defined as acute when symptoms last for less than 6 weeks, and chronic when symptoms last for more than 6 weeks [Elmariah, 2018; Millington, 2018; Hashimoto, 2025].
  • The pathophysiology of itch is complex, multifactorial, and not fully understood, although an interplay between histamine and other mediators (including neuropeptides; proteases released with skin barrier disruption, infection, or inflammation; interleukins from immune cells; cytokines released by keratinocytes; or peptides present in the skin in systemic diseases or drug-mediated itch) may be involved [Criado, 2025; Weisshaar, 2025].

What causes it?

Widespread itch that is not associated with a skin disorder or rash may be idiopathic, or may be associated with one or more underlying conditions, which may co-exist [Criado, 2025; Hashimoto, 2025; Weisshaar, 2025]:

  • Dry skin (xerosis).
    • This often contributes to widespread itch and is most common in the elderly, due to atrophy of the skin barrier and reduced hydration of the skin [Chung, 2020; Rupert, 2022].
  • Infection and infestation.
    • Scabies, for example, can cause severe itch and minimal skin signs, particularly in people with HIV [Millington, 2018]. See the CKS topic on Scabies for more information.
    • Parasitic helminthic infection, hepatitis B, and hepatitis C can cause itch in some people. See the CKS topics on Hepatitis B and Hepatitis C for more information.
  • Systemic disease (seen in 20–30% of cases) [Millington, 2018; Kremer, 2020; Hashimoto, 2025; Weisshaar, 2025].
    • Renal disease — predominantly affects people with end-stage renal disease (ESRD), particularly those on long-term renal replacement therapy (such as haemodialysis), due to uraemia. See the CKS topic on Chronic kidney disease for more information.
    • Liver disease — itch is usually secondary to cholestasis, due to conditions such as primary biliary cholangitis, primary sclerosing cholangitis, or cirrhosis. Typically, the itch affects the palms and soles, but it may also be generalized. See the CKS topics on Jaundice in adults and Gallstones for more information.
    • Haematological/lymphoproliferative — including disorders of iron metabolism, polycythaemia vera, Waldenstrom's macroglobulinaemia, essential thrombocytosis, and haemochromatosis (rare). See the CKS topic on Anaemia - iron deficiency for more information.
    • Endocrine disorders — such as diabetes mellitus, thyroid disorders, and primary hyperparathyroidism (rare). See the CKS topics on Diabetes - type 1, Diabetes - type 2, Hyperthyroidism, Hypothyroidism, and Hypercalcaemia for more information.
    • Malignancy — for example, Hodgkin's lymphoma, cutaneous T-cell lymphoma, leukaemia, and multiple myeloma. See the CKS topic on Haematological cancers - recognition and referral for more information. Very rarely, generalized itch may be a paraneoplastic symptom associated with solid malignant tumours, such as breast, colorectal, lung, testicular, gastric, insulinoma, and carcinoid syndrome.
    • Neurological — for example, due to spinal cord tumours or multiple sclerosis. See the CKS topic on Multiple sclerosis for more information. There have also been reports of neurosensory skin issues in some people with COVID-19 infections. 
    • Note: be aware that itch may precede other clinical features of the underlying disease [Kremer, 2020; Weisshaar, 2025].
  • Menopause — See the CKS topic on Menopause for more information.
  • Iatrogenic [Millington, 2018; Rupert, 2022].
    • Drugs such as opioids, statins, angiotensin-converting enzyme (ACE) inhibitors, digoxin, thiazide diuretics, calcium-channel blockers, topiramate, chloroquine, and sulphonamides.
    • Cancer treatments such as radiotherapy and biological treatments.
  • Psychogenic.
    • 'Functional itch disorder' describes an intense urge to scratch or pick at the skin, without an associated skin disease or other underlying cause. It may be triggered or worsened by stress, psychological trauma, substance misuse, anxiety (including obsessive-compulsive disorder), and depression [Hashimoto, 2025; Weisshaar, 2025]. See the CKS topics on Depression, Generalized anxiety disorder, and Post-traumatic stress disorder for more information.
    • Delusional infestation/delusions of parasitosis is a rare psychotic disorder in which the person falsely believes their skin is infested with parasites, and reports sensory symptoms such as itching, biting, or crawling under the skin. The person may damage their own skin in an attempt to remove the parasites [Millington, 2018].
  • Idiopathic.
    • Widepread itch of unknown origin represents approximately 6-8% of all cases of itch [Millington, 2018; Criado, 2025], with higher prevalence noted among the elderly.

How common is it?

  • Itch is a common symptom in the general population, and its prevalence increases with age [Criado, 2025; Hashimoto, 2025; Weisshaar, 2025].
    • Chronic Pruritus (pruritus that lasts more than 6 weeks) has an estimated prevalence ranging from 8–25% and can be localized or generalized. In older people (older than 65 years), the prevalence is estimated at 25% [Roh, 2022; Criado, 2025].
    • A population-based cohort follow-up study (n = 1190) found the 12-month cumulative incidence of self-reported chronic itch was 7%, and the lifetime prevalence of chronic itch was 25.5%, with incidence increasing with age [Matterne, 2013].
    • A larger German cross-sectional observational study (n = 11,730 adults) found the point prevalence of chronic itch was 16.8%, and the prevalence increased with age from 12.3% (16–30 years) to 20.3% (61–70 years) [Ständer, 2010].
    • A 2022 systematic review involving 28,666 participants found the overall pooled prevalence of senile pruritus was 21.04% (95% CI 11.37% to 32.72%)[Chen, 2022].

What are the complications?

Widespread itch can significantly impact a person's quality of life, and complications may include:

  • Disturbed sleep. See the CKS topic on Insomnia for more information.
  • Anxiety and depression — may affect up to one-third of people with chronic itch. See the CKS topics on Generalized anxiety disorder and Depression for more information.
  • Social isolation, embarrassment, stigmatization, and negative body image due to uncontrolled scratching and visible skin lesions.
  • Impaired memory and concentration.
  • Secondary scratch lesions, such as excoriations, lichenification, skin nodules (chronic prurigo/prurigo nodularis), lichen simplex chronicus (localized skin thickening typically in 'reachable' areas of the extremities, upper back, and buttocks), atrophic scarring, and hypo- or hyperpigmentation due to persistent scratching.
  • Secondary bacterial infection of excoriations such as impetigo. See the CKS topic on Impetigo for more information.

[Millington, 2018; Kremer, 2020; Ferreira, 2023; Criado, 2025; Hashimoto, 2025; Weisshaar, 2025]

Diagnosis of widespread itch

How should I assess a person with widespread itch?

If a person presents with widespread itch with no obvious associated skin disease or rash, assess clinical features to determine the underlying cause, if possible.

  • Ask about:
    • The location, onset, timing, severity, and duration of itch.
      • Nocturnal itch may suggest uraemia, cholestasis, or psychogenic itch.
      • Keeping a patient diary of itch characteristics may be helpful to monitor the course of symptoms over time.
    • The appearance of the skin when the itch started.
      • The presence of secondary scratch lesions may obscure primary skin lesions and make the diagnosis of an underlying skin condition challenging.
    • Any associated sensory symptoms.
      • Prickling — itch provoked by skin cooling after a hot shower or bath ('aquagenic pruritus') may be associated with lymphoproliferative disorders.
      • Crawling — itch described as 'like insects crawling over the skin' may be psychogenic in origin and indicative of delusions of parasitosis.
      • Burning — may be a feature of a neuropathic cause or lymphoma.
    • The impact on quality of life and associated emotional distress, stress, anxiety, or depression — itch exacerbated by stress may indicate a psychogenic cause. Stress may also worsen the severity of pre-existing itch.
      • There are several well-validated tools that evaluate itch severity, including the itch numerical rating scale, pruritus grading system, peak pruritus rating scale, worst itch numerical rating scale, and verbal itch rating scale, which are convenient to use in daily practice. Impact on quality of life can also be assessed through the 5D itch scale, and is one of the most comprehensive tools to capture multiple domains of itch-related quality of life disruptions.
    • Any associated systemic symptoms such as fatigue, fever, night sweats, or weight loss (may suggest haematological malignancy).
    • Any pre-existing comorbidities that may cause itch.
    • Any relieving factors and treatments tried — itch that is relieved with emollients or topical preparations is rarely associated with a serious underlying cause.
    • Any drugs including over-the-counter and herbal remedies.
    • Any family history, particularly of systemic conditions that may cause itch.
    • Household or other contacts — may indicate scabies infection. See the CKS topic on Scabies for more information.
    • Alcohol intake — heavy alcohol intake may indicate liver disease.
    • Travel history — may increase the risk of parasitic helminthic infection, for example.
  • Consider performing a full physical examination if there are no localizing clues from the history, including:
  • Arrange blood tests if there is no sign of active skin disease to account for widespread itch:
    • Full blood count and blood film.
    • Liver function tests.
    • Lactate dehydrogenase (LDH) - rising levels are a marker for lymphoma.
    • Renal function tests.
    • Serum iron and ferritin levels.
    • Inflammatory markers such as ESR (erythrocyte sedimentation rate) and/or CRP (C-reactive protein).
  • Consider arranging additional tests depending on the clinical presentation, suspected underlying cause, and risk factors, such as:
    • Thyroid function tests and parathyroid hormone levels.
    • HbA1c.
    • Bone chemistry.
    • Antimichondrial antibody (to rule out primary biliary cirrhosis)
    • HIV and hepatitis B and C serology.
    • Chest X-ray.
  • For older patients, depending on clinical or biochemical features (or high suspicion) of multiple myeloma, consider the following tests noting that myeloma is rarely associated with generalised itch:
    • Paraproteins (using serum protein electrophoresis), and serum free light chains, or Bence-Jones protein urine assessment (if serum free light chain assessment is not available).

Basis for recommendation

The recommendations on assessment are based on the British Association of Dermatologists' (BAD) publication Guidelines for the investigation and management of generalized pruritus in adults without an underlying dermatosis, 2018 [Millington, 2018], the European consensus publication European S2k guideline on chronic pruritus [Weisshaar, 2025], and expert opinion in review articles on itch in systemic disease [Hashimoto, 2019], on chronic itch [Pereira, 2016; Elmariah, 2018; Fleurant, 2018; Kremer, 2020], on itch in the elderly [Chung, 2020], and on itch measurement tools [Pereira, 2019].

Clinical features on history and examination

  • The recommendations on history taking and examination are largely based on the British Association of Dermatology guidelines [Millington, 2018], the European guideline [Weisshaar, 2025], and expert opinion in review articles [Roh, 2022; Rupert, 2022; PCDS, 2023; Kremer, 2020; Hashimoto, 2025].
    • The information about the potential significance of nocturnal itch is based on the BAD guidelines and expert opinion in review articles [Pereira, 2019; Kremer, 2020].
      • Itch may be felt more intensely in the evenings and at night when the person is less distracted by daily activities [Pereira, 2019].
    • The recommendation to keep a patient itch diary is based on expert opinion in a review article [Pereira, 2019].
    • The information that secondary scratch lesions may make diagnosis of an underlying cause challenging is based on expert opinion in review articles [Fleurant, 2018; Pereira, 2019].
    • The information about the potential significance of aquagenic pruritus is based on the BAD guidelines and expert opinion in review articles [Hashimoto, 2019; Criado, 2025].
    • The information that stress may worsen the severity of itch is based on the European guideline [Weisshaar, 2025] and expert opinion in review articles [Pereira, 2016; Elmariah, 2018].
      • Psychosocial factors can affect the 'itch threshold' and can trigger or enhance chronic itch [Weisshaar, 2025].
    • The recommendation on taking a travel history is based on expert opinion in review articles [Elmariah, 2018; Fleurant, 2018].
  • The recommendation to use an objective tool to measure the severity of the itch, or the impact of the itch on quality of life (5D Itch scale [Elman, 2010]) was taken from various guidelines and review articles [Roh, 2022; Hashimoto, 2025; Weisshaar, 2025].

Arranging investigations

Management

Scenario: Management of widespread itch

From age 12 years onwards.

How should I manage itch in primary care?

If a person has widespread itch, offer management using a stepwise approach, depending on the person's age, itch characteristics, impact on quality of life, comorbidities, and drug treatments.

  • If the underlying cause is:
    • Known or suspected, manage the person in primary care where possible, or arrange referral to an appropriate specialist, depending on clinical judgement.
    • Unknown, consider arranging referral to an appropriate specialist, the urgency depending on clinical judgement.
  • Offer support for any emotional distress, stress, anxiety, or depression.
  • Offer management of any skin lesions due to chronic scratching, including secondary infection.
    • See the CKS topic on Impetigo for more information.
  • Offer advice on self-care strategies.
  • Discuss options of treatment to provide symptom relief.
    • Offer an emollient to use as a soap substitute to wash and moisturize the skin. See the CKS topic on Eczema - atopic for more detailed information on the use of emollients for dry skin.
    • If an emollient alone does not provide adequate symptom relief, consider a trial of an emollient with an active ingredient (such as menthol 0.5% or 1% in aqueous cream). 
    • Before considering further treatments, check adherence to the topical regimen.
    • If symptoms persist despite regular emollients and self-care advice, consider a short-term trial of a non-sedating oral antihistamine (off-label indication), such as cetirizine 10 mg, loratadine 10 mg, or fexofenadine 180 mg for 2–3 weeks. See the sections on Cetirizine, Loratadine, and Fexofenadine in Prescribing information for more information.
    • If there is troublesome nocturnal itch, consider a short-term trial of a sedating oral antihistamine, such as hydroxyzine 25 mg at night (adults) or chlorphenamine 4 mg at night (off-label indication, adults and children) for 2–3 weeks. See the sections on Hydroxyzine and Chlorphenamine in Prescribing information for more information.
    • Note: be aware that treatment with topical anaesthetics, antihistamines, crotamiton, calamine, capsaicin, corticosteroids, calcineurin inhibitors, and doxepin, and treatment with oral corticosteroids are not routinely recommended in primary care.
  • If symptoms persist, arrange referral or seek specialist advice from a dermatologist.
    • Additional investigations, such as a skin biopsy, may be needed in some cases.
    • Additional treatment options may include selective serotonin reuptake inhibitors (SSRIs), mirtazapine, tricyclic antidepressants, gabapentin, pregabalin, immunosuppressant drugs, or phototherapy, depending on the suspected underlying cause.

Basis for recommendation

The recommendations on management of itch are based on the British Association of Dermatologists' publication Guidelines for the investigation and management of generalized pruritus in adults without an underlying dermatosis, 2018 [Millington, 2018], the European S2k guideline on chronic pruritus [Weisshaar, 2025], a Cochrane systematic review Interventions for chronic pruritus of unknown origin [Andrade, 2020], and expert opinion in review articles on chronic itch [Fleurant, 2018; Kremer, 2020; Rupert, 2022; Criado, 2025; Hashimoto, 2025], on treatments for itch [Bonchak, 2020], and on itch in the elderly [Pereira, 2018; Chung, 2020].

Managing the underlying cause  
  • The recommendation to manage the underlying cause of itch is based on the BAD guidelines [Millington, 2018], the European guideline publication [Weisshaar, 2025]. Expert opinion in review article agrees with this but notes that there are exceptions, such as short-term pruritus associated with Hodgkin’s disease and early chemotherapy, where the itch may not fully resolve even with treatment of the underlying condition [Criado, 2025].
  • The recommendation to arrange referral to an appropriate specialist is extrapolated from expert opinion in a review article [Elmariah, 2018].
Managing emotional distress and psychological conditions
  • This recommendation is based on the European guideline [Weisshaar, 2025] and expert opinion in review articles [Pereira, 2017; Bonchak, 2020].
    • The European consensus publication recommends psychosocial education on how to avoid the scratch-itch cycle, and the use of behavioural techniques and relaxation therapy to help symptom relief.
    • Limited evidence extrapolated mainly from studies on atopic eczema has found that psychological therapies may alter the perception of itch or behaviours associated with it, and may reduce associated anxiety and sleep disturbance [Bonchak, 2020].
Offering treatment with topical emollients
  • The recommendation to use emollients to wash and moisturize the skin is based on limited indirect evidence largely extrapolated from studies on dry skin and eczema [Millington, 2018; Kremer, 2020].
    • Controlled studies on damaged skin (eczema or dry skin in haemodialysis patients) have shown reduction of itch after treatment with emollients as monotherapy, probably through improvement of the skin barrier [Magnolo, 2023; Nevols, 2023]. However, the evidence from controlled studies on the efficacy of emollients on normal-appearing skin is lacking [Andrade, 2020]. The question is whether tactile stimulation of the skin by pressure while applying emollients sooths itch.
  • Symptomatic measures may be appropriate where no cause of itch can be identified or treated [Elmariah, 2018; Millington, 2018].
  • A 2–3 week trial of emollients can be used if the underlying cause of itch is unknown [Fleurant, 2018].
  • The recommendation to check adherence to topical therapy before considering systemic treatment is based on the European guideline publication [Weisshaar, 2025].
  • The recommendation to consider a trial of emollient with active ingredient such as menthol is based on the BAD guidelines [Millington, 2018], the European guideline [Weisshaar, 2025], and expert opinion in review articles [Hashimoto, 2025].
    • The BAD guidelines found limited evidence for the anti-irritant (rather than anti-itch) effect of menthol for widespread itch.
    • The European consensus publication notes that menthol has a cooling effect and acts as a counter-irritant, and also states emollients with other active ingredients such as urea, glycerol, camphor, and zinc may help symptoms to a lesser extent.
Offering treatment with oral antihistamines
  • The recommendation to consider a short-term trial of a non-sedating antihistamine first line is based on the BAD guidelines [Millington, 2018] and the European guideline publication [Weisshaar, 2025]. This approach is supported by expert opinion in a review articles [Pereira, 2018; PCDS, 2023], and the British National Formulary (BNF) [BNF, 2025].
    • The BAD guidelines recommend a trial of non-sedating antihistamines first line for itch of unknown cause, due to the better adverse effect profile compared with sedating antihistamines.
    • The European consensus publication notes that non-sedating antihistamines may be helpful for itch of unknown origin, however there is limited evidence of effectiveness for itch caused by non-histaminergic pathways.
    • Expert opinion in a review article recommends that treatment with non-sedating antihistamines should be discontinued if there is no benefit after four weeks. In addition, it notes that sedating antihistamines are not recommended due to a lack of evidence of benefit, and risk of adverse effects [PCDS, 2023].
    • The suggested drug doses are based on the BAD guidelines and extrapolated from the BNF.
  • The recommendation to consider a short-term trial of a sedating antihistamine for nocturnal itch is based on the BAD guidelines [Millington, 2018] and the European consensus publication, which states this may be helpful if there is an associated sleep disorder [Weisshaar, 2025]. This approach is supported by expert opinion in a review article [Criado, 2025] and the British National Formulary (BNF) [BNF, 2025].
    • The BAD guidelines suggest a short-term trial of sedating antihistamines such as hydroxyzine for itch of unknown cause, based on very limited evidence.
    • The European consensus publication notes that hydroxyzine is the most commonly used sedating antihistamine with anxiolytic and anti-itch activity, but also has multiple potential adverse effects including impaired sleep and drowsiness. It also highlights that antihistamines are widely used as first-line drugs in the treatment of itch due to underlying systemic causes, but conventional doses may not be effective.
    • The suggested drug doses are extrapolated from the BNF.
Treatments not recommended
  • These recommendations are based on the BAD guidelines [Millington, 2018], the European consensus publication [Weisshaar, 2025], and a Cochrane systematic review [Andrade, 2020].
    • The BAD guidelines found no good-quality evidence for the use of crotamiton, calamine (zinc oxide), capsaicin (except may be used in uraemic itch), or topical doxepin due to the risk of allergic contact dermatitis.
    • The European consensus publication found topical anaesthetics had limited effect in studies with a very short duration of action of 10 minutes, but noted they may be used for selected cases of itch due to specific underlying causes. It found limited evidence that capsaicin may be used in itch of unknown cause or itch refractory to antihistamines, but noted any benefit is short lived as itch tends to recur weeks after treatment has stopped. It recommends topical corticosteroids and topical doxepin are not routinely used for itch unless associated with skin disease or inflammation. Topical corticosteroids may be used for cases of itch of unknown cause or itch refractory to antihistamines. Similarly, it does not recommend the use of topical calcineurin inhibitors for widespread generalized itch. It cites limited evidence that oral corticosteroids may be used short term in exceptional circumstances to treat severe refractory chronic itch associated with systemic disease such as paraneoplastic itch, and in palliative care settings, due to the risk of severe adverse effects.
    • A Cochrane systematic review of interventions for chronic itch of unknown origin found an absence of good-quality evidence for emollient creams, cooling lotions, topical corticosteroids, topical antidepressants, systemic antihistamines, systemic antidepressants, systemic anticonvulsants, and phototherapy.
Arranging dermatology referral
  • The recommendation to arrange dermatology referral is based on the BAD guidelines [Millington, 2018], the European guideline publication [Weisshaar, 2025], and expert opinion in review articles  [Rupert, 2022; Criado, 2025; Hashimoto, 2025].
    • The BAD guidelines note that dermatology referral may be needed if there is diagnostic doubt, or there are troublesome ongoing symptoms despite optimal management in primary care.
    • The information that skin biopsy may be needed in some cases of persistent unexplained itch is based on the BAD guidelines, which note that very rarely conditions such as cutaneous T-cell lymphoma may present with itch on normal-looking skin. This approach is supported by the European consensus publication and expert opinion in review articles [Rupert, 2022; Criado, 2025].
    • The BAD guidelines note that various specialist treatments may help symptom relief, depending on the underlying cause. Small case series and case reports suggest that cimetidine, gabapentin, carbamazepine, and mirtazapine may help symptomatic people with lymphoma, for example. Selective serotonin reuptake inhibitors (SSRIs) can help itch associated with some solid tumours, and phototherapy may be used for people with uraemic itch or lymphoma. Oral corticosteroids may be used for itch in palliative care settings, for example for people with lymphoma.
    • The European consensus publication cites limited evidence for specialist treatments of itch due to an underlying cause, such as gabapentin and pregabalin for neuropathic or renal itch, itch refractory to antihistamines, and itch of unknown cause. Selected antidepressants such as mirtazapine, SSRIs such as paroxetine, or tricyclic antidepressants such as doxepin or amitriptyline may be used for psychogenic itch, and refractory chronic itch due to malignant, cholestatic, or renal causes. Phototherapy and immunosuppressant drugs such as ciclosporin may be used for itch of unknown cause or itch refractory to antihistamines. There is emerging evidence that mu-opioid receptor antagonists and kappa-opioid receptor agonists may help chronic itch in selected cases.
    • Expert opinion in review articles notes that phototherapy may help uraemic or cholestatic itch [PCDS, 2023; Criado, 2025].

What self-care advice should I offer?

If a person has widespread itch of known or unknown cause:

  • Offer advice on self-care strategies to help with symptom relief.
    • Advise to avoid excessive showering or bathing, as this may dry the skin and exacerbate symptoms.
      • Advise to spend less than 20 minutes bathing, where possible.
      • Wash the axillae, genital area, and under the breasts daily, but other skin areas can be washed 2–3 times weekly.
      • Use cool or lukewarm water, where possible.
      • Avoid bubble baths, high pH soaps, and perfumed products. Use mild, alcohol-free cleansers, or use an emollient as a soap substitute. See the CKS topic on Eczema - atopic for more prescribing information on emollients.
      • Advise to pat the skin dry and avoid vigorous rubbing.
    • Keep nails short to minimize skin damage. Try to rub or pat rather than scratch the skin if the urge to relieve the itch is unavoidable.
    • Keep the indoor environment cool and consider humidifying the air, particularly during cold winter months.
    • Wear loose clothing that does not irritate the skin (for example, cotton or silk). Avoid wool or synthetic fabrics.
    • Avoid spicy foods, alcohol, and caffeine as they may worsen symptoms.
  • Offer advice on sources of information and support from the British Association of Dermatologists website (available at www.bad.org.uk), which has a patient information leaflet Pruritus (itching).

Basis for recommendation

The recommendations on self-care advice are based on the British Association of Dermatologists' publication Guidelines for the investigation and management of generalized pruritus in adults without an underlying dermatosis, 2018 [Millington, 2018], the European consensus European S2k guideline on chronic pruritus [Weisshaar, 2025], and expert opinion in review articles on chronic itch [Rupert, 2022; Criado, 2025; Hashimoto, 2025] and on itch in the elderly [Pereira, 2018; Chung, 2020].

  • The BAD guidelines note that self-care advice to break the 'scratch-itch cycle' is based on limited indirect evidence extrapolated from studies on the management of dry skin and eczema [Millington, 2018].
  • The recommendations on bathing are largely based on the European consensus document, which notes that there is no good-quality evidence to support the use of cold showers to reduce itch, but states that brief hot showers may relieve itch, as may lukewarm water baths of 20 minutes maximum. It recommends avoiding frequent washing and bathing, as this may dry the skin and worsen itch [Weisshaar, 2025].

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC), or the British National Formulary (BNF).

Cetirizine

Contraindications and cautions

  • Do not prescribe cetirizine to people with:
    • End-stage renal disease — estimated glomerular filtration rate (eGFR) less than 15 mL/min/1.73 m2.
  • Prescribe cetirizine with caution to people with:
    • Epilepsy.
    • Renal impairment
      • If the eGFR is 30-59 mL/min/1.73 m2, use half the normal dose.
      • If the eGFR is 15–29 mL/min/1.73 m2, use 5 mg once every 2 days. 

[EMC, 2024a; BNF, 2025]

Adverse effects

Possible adverse effects of cetirizine include:

  • Blurred vision, dry mouth, headache, diarrhoea, psychomotor impairment, and urinary retention.
  • Drowsiness (frequency not known) — cetirizine and loratadine cause less sedation and psychomotor impairment than first-generation antihistamines, because they penetrate the blood–brain barrier to a lesser extent.
    • Advise people taking non-sedating antihistamines that some people may experience sedation, which may affect their ability to drive, and that the sedative effects are enhanced when combined with alcohol.
  • Angio-oedema, tachycardia, thrombocytopenia, confusion, seizure, depression, dizziness, extrapyramidal effects, hypersensitivity reactions, liver dysfunction, rashes, sleep disturbance, and tremor.

[BNF, 2025]

Drug interactions

Possible drug interactions with cetirizine include:

  • Betahistine — cetirizine is predicted to decrease the effects of betahistine.

[BNF, 2025; Preston, 2025]

Loratadine

Contraindications and cautions

Prescribe loratadine with caution to people with: 

  • Severe hepatic impairment — reduce the dose frequency to alternate days (risk of increased exposure).

[EMC, 2024b; BNF, 2025]

Adverse effects

Possible adverse effects of loratadine include:

  • Drowsiness — cetirizine and loratadine cause less sedation and psychomotor impairment than first-generation antihistamines, because they penetrate the blood–brain barrier to a lesser extent.
    • Advise people taking non-sedating antihistamines that some people may experience sedation, which may affect their ability to drive, and that the sedative effects are enhanced when combined with alcohol.
  • Increased appetite, headache, and insomnia.
  • Alopecia, angio-oedema, dizziness, dry mouth, fatigue, gastritis, liver dysfunction, nausea, palpitations, rash, seizure, and tachycardia (all rare).

[BNF, 2025]

Drug interactions

Possible drug interactions with loratadine include:

  • Betahistine — loratadine is predicted to decrease the effects of betahistine.

[BNF, 2025; Preston, 2025]

Fexofenadine

Contraindications and cautions

There are no absolute contraindications or cautions when prescribing fexofenadine.

[EMC, 2023a; BNF, 2025]

Adverse effects

Possible adverse effects of fexofenadine include:

  • Dizziness, nausea, headache, and fatigue.
  • Drowsiness — fexofenadine causes less sedation and psychomotor impairment than first-generation antihistamines, because it penetrates the blood–brain barrier to a lesser extent.
    • Advise people taking non-sedating antihistamines that some people may experience sedation, which may affect their ability to drive, and that the sedative effects are enhanced when combined with alcohol.
  • Diarrhoea, anxiety, palpitations, skin reactions, sleep disorders, and tachycardia.

[BNF, 2025]

Drug interactions

Possible drug interactions with fexofenadine include:

  • Antacids — absorption of fexofenadine is reduced by antacids. The manufacturer advises separation of administration by 2 hours.
  • Betahistine — fexofenadine is predicted to decrease the effects of betahistine.
  • Leflunomide — leflunomide is predicted to increase the concentration of fexofenadine.
  • Mirabegron — mirabegron is predicted to increase the exposure to fexofenadine.
  • Phenelzine — phenelzine is predicted to increase the risk of antimuscarinic adverse effects when given with fexofenadine.
  • Rifampicin — effects of fexofenadine possibly reduced by rifampicin.

[BNF, 2025; Preston, 2025]

Hydroxyzine

Contraindications and cautions

  • Do not prescribe hydroxyzine in people with:
    • A prolonged QT interval, or risk factors for QT interval prolongation, which may lead to torsade de pointes, including [MHRA, 2015]:
      • Use of drugs which prolong the QT interval.
      • Cardiovascular disease.
      • Family history of sudden cardiac death.
      • Low plasma potassium or magnesium levels.
      • Significant bradycardia.
    • A previous history of hypersensitivity to hydroxyzine.
    • Asthma with a previous serious antihistamine-induced adverse bronchopulmonary effect.
    • Severe liver disease.
  • Hydroxyzine should be used with caution in people with:
    • Mild or moderate hepatic impairment — reduce the dose by 33%.
    • Moderate to severe renal impairment — reduce the dose by 50%.
    • Prostatic hypertrophy.
    • Urinary retention, bladder outflow obstruction.                
    • Severe hypertension.
    • Hyperthyroidism.
    • Raised intraocular pressure or glaucoma.
    • Pyloroduodenal obstruction, stenosing peptic ulcer.
    • Epilepsy — may reduce the seizure threshold.
    • Myasthenia gravis.
    • Asthma, bronchitis, or bronchiectasis.
    • Increasing age — increased susceptibility to adverse effects in the elderly.

 [BNF, 2025; EMC, 2025]

Adverse effects

Possible adverse effects of hydroxyzine include:

  • Headache, psychomotor impairment, and antimuscarinic effects (such as urinary retention, dry mouth, blurred vision, and gastrointestinal disturbances).
  • Hypotension, palpitations, arrhythmias (QT interval prolongation and Torsade de Pointes), dizziness, confusion, tremor, Stephens-Johnson syndrome, and erythema multiforme.
  • Toxic epidermal necrolysis (frequency unknown).

[MHRA, 2015; BNF, 2025]

Drug interactions

  • Avoid prescribing hydroxyzine with:
    • Drugs that prolong the QT interval, such as amiodarone, amisulpride, apomorphine, chlorpromazine, clarithromycin, clomipramine, domperidone, droperidol, erythromycin, escitalopram, flecainide, fluconazole, haloperidol, levomepromazine, lithium, mefloquine, mizolastine, moxifloxacin, ondansetron, pimozide, quinine, ranolazine, risperidone, sildenafil, sotalol, sulpiride, tolterodine, venlafaxine.
    • Monoamine oxidase inhibitors (MAOIs).
  • Possible drug interactions with hydroxyzine include:
    • Hypnotics and anxiolytics — may cause an increase in sedative effects.
    • Drugs with antimuscarinic properties — dosage adjustment may be required.
    • Cimetidine — increases the plasma concentration of hydroxyzine.
    • Aminophylline and theophylline — aminophylline and theophylline are predicted to cause hypokalaemia (potentially increasing the risk of torsade de pointes) when given with hydroxyzine.
    • Beclometasone and betamethasone — beclometasone and betamethasone are predicted to cause hypokalaemia (potentially increasing the risk of torsade de pointes) when given with hydroxyzine.
    • Bendroflumethiazide — bendroflumethiazide is predicted to cause hypokalaemia (potentially increasing the risk of torsade de pointes) when given with hydroxyzine.
    • Betahistine — hydroxyzine is predicted to decrease the effects of betahistine.
    • Bumetanide — bumetanide is predicted to cause hypokalaemia (potentially increasing the risk of torsade de pointes) when given with hydroxyzine.
    • Citalopram — citalopram is predicted to cause hypokalaemia (potentially increasing the risk of torsade de pointes) when given with hydroxyzine.
    • Dexamethasone — dexamethasone is predicted to cause hypokalaemia (potentially increasing the risk of torsade de pointes) when given with hydroxyzine.
    • Furosemide — furosemide is predicted to cause hypokalaemia (potentially increasing the risk of torsade de pointes) when given with hydroxyzine.
    • Indapamide — indapamide is predicted to cause hypokalaemia (potentially increasing the risk of torsade de pointes) when given with hydroxyzine.
    • Levodopa — hydroxyzine decreases the absorption of levodopa.
    • Metolazone — metolazone is predicted to cause hypokalaemia (potentially increasing the risk of torsade de pointes) when given with hydroxyzine.
    • Prednisolone — prednisolone is predicted to cause hypokalaemia (potentially increasing the risk of torsade de pointes) when given with hydroxyzine.
    • Salbutamol and salmeterol — salbutamol and salmeterol are predicted to cause hypokalaemia (potentially increasing the risk of torsade de pointes) when given with hydroxyzine.
    • Terbutaline — terbutaline is predicted to cause hypokalaemia (potentially increasing the risk of torsade de pointes) when given with hydroxyzine.
    • Torsemide — torasemide is predicted to cause hypokalaemia (potentially increasing the risk of torsade de pointes) when given with hydroxyzine.

[MHRA, 2015; BNF, 2025; Preston, 2025]

Chlorphenamine

Contraindications and cautions

  • Chlorphenamine should be used with caution in people with:
    • Hepatic impairment.
    • Prostatic hypertrophy.
    • Urinary retention.
    • Raised intraocular pressure or glaucoma.
    • Pyloroduodenal obstruction.
    • Epilepsy — may reduce the seizure threshold.

[EMC, 2023b; BNF, 2025]

Adverse effects

  • Adverse effects of chlorphenamine include:
    • Neurological — dizziness, restlessness, psychomotor impairment, reduced concentration, headache, and sedation.
    • Anticholinergic effects — blurred vision, dry mouth, and urinary retention.
    • Skin — urticaria, rash, exfoliative dermatitis, and photosensitivity.
    • Gastrointestinal — nausea, vomiting, abdominal pain, diarrhoea, dyspepsia, and decreased appetite.
    • Cardiovascular — palpitations, tachycardia, arrhythmias, and hypotension.
    • Neuropsychiatric — depressed mood, excitation, irritability, nightmares, and confusion.

[BNF, 2025]

Drug interactions

  • Possible drug interactions with chlorphenamine include:
    • Drugs with antimuscarinic properties, such as amantadine, amitriptyline, chlorpromazine, clomipramine, clozapine, dicycloverine, dosulepin, haloperidol, hyoscine, imipramine, ipratropium, levomepromazine, lofepramine, nefopam, nortriptyline, oxybutynin, phenelzine (manufacturer advises avoid), pimozide, prochlorperazine, procyclidine, solifenacin, tiotropium, and tolterodine — may increase antimuscarinic effects.
    • Drugs which can have central nervous system depressant effects, such as alcohol, amisulpride, amitriptyline, aripiprazole, baclofen, buprenorphine, chlorpromazine, clobazam, clomipramine, clonazepam, clonidine, clozapine, codeine, diazepam, dihydrocodeine, dosulepin, droperidol, fentanyl, gabapentin, haloperidol, imipramine, lamotrigine, levetiracetam, levomepromazine, lofepramine, lorazepam, melatonin, midazolam, mirtazapine, morphine, moxonidine, nortriptyline, olanzapine, oxycodone, phenobarbital, pimozide, pregabalin, primidone, prochlorperazine, promazine, quetiapine, risperidone, sulpiride, temazepam, tramadol, trazodone, venlafaxine, zolpidem, and zopiclone — may increase sedative effects.
    • Betahistine — chlorphenamine is predicted to decrease the effects of betahistine.
    • Levodopa — chlorphenamine decreases the absorption of levodopa.

[BNF, 2025; Preston, 2025]

Supporting evidence

This CKS topic is largely based on the British Association of Dermatologists' publication Guidelines for the investigation and management of generalized pruritus in adults without an underlying dermatosis, 2018 [Millington, 2018], the European consensus publication European S2k guideline on chronic pruritus [Weisshaar, 2025] , a Cochrane systematic review Interventions for chronic pruritus of unknown origin [Andrade, 2020], and expert opinion in review articles [Rupert, 2022; Criado, 2025; Hashimoto, 2025]. The rationale for recommendations is summarized in the relevant basis for recommendation sections.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of widespread itch.

Search dates

December 2020 - November 2025

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

  • exp Pruritus/, therapy*
  • prurit$.tw, itch$.tw
  • antipuritic$ or itch occurence$ or itch intensity or itch chronicity.ti,ab.
  • Emollients/,therapeutic use*

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • Andrade, A., Kuah, C.Y., Martin-Lopez, J.E., et al. (2020) Interventions for chronic pruritus of unknown origin (Cochrane Review/Cochrane Intervention Protocol). Issue 1. John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
  • BNF (2025) British National Formulary. National Institute for Health and Care Excellence. https://bnf.nice.org.uk
  • Bonchak, J. and Lio, P.A. (2020) Non-pharmacologic interventions for chronic pruritus. Itch 5(1). [Free Full-text]
  • Chen, S., Zhou, F. and Xiong, Y. (2022) Prevalence and risk factors of senile pruritus: a systematic review and meta-analysis. BMJ (British Medical Journal) Open 12(2). [Abstract] [Free Full-text]
  • Chung, B.Y., Um, J.Y., Kim, J.C., et al. (2020) Pathophysiology and treatment of pruritus in elderly. International Journal of Molecular Sciences 22(1), 174. [Abstract] [Free Full-text]
  • Criado, P.R., Criado, R.F.J., Ianhez, M. and Miot, H.A. (2025) Chronic pruritus: a narrative review. Anais Brasileiros de Dermatologia 100(3), 487-519. [Abstract] [Free Full-text]
  • Elman, S., Hynan, L.S., Gabriel, V. and Mayo, M.J. (2010) The 5-D itch scale: a new measure of pruritus. British Journal of Dermatology 162(3), 587-593. [Abstract] [Free Full-text]
  • Elmariah, S.B. (2018) Diagnostic work-up of the itchy patient. Dermatologic clinics 36(3), 179-188. [Abstract]
  • EMC (2023a) SPC for fexofenadine hydrochloride 120 mg film-coated tablets. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • EMC (2023b) SPC for piriton allergy tablets (chlorphenamine maleate 4 mg). Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • EMC (2024a) SPC for cetirizine hydrochloride 10 mg film-coated tablets. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk [Free Full-text]
  • EMC (2024b) SPC for loratadine 10 mg Tablets. Electronic Medicines Compendium. Datapharm Pharmaceuticals Ltd. https://www.medicines.org.uk [Free Full-text]
  • EMC (2025) SPC for hydroxyzine 10 mg film-coated tablets. Electronic Medicines Compendium. Datapharm Pharmaceuticals Ltd. https://www.medicines.org.uk [Free Full-text]
  • Ferreira, B.R. and Misery, L. (2023) Psychopathology associated with chronic Pruritus: a systematic review. Acta Dermato Venereologica 103. [Abstract] [Free Full-text]
  • Fleurant, A. and Elmariah, S.B. (2018) Evaluation of the itchy patient. Current Dermatology Reports 7(16), 16-23. [Free Full-text]
  • Hashimoto, T. and Yosipovitch, G. (2019) Itching as a systemic disease. Journal of Allergy and Clinical Immunology 144(2), 375-380. [Abstract] [Free Full-text]
  • Hashimoto, T. and Okuno, S. (2025) Practical guide for the diagnosis and treatment of localized and generalized cutaneous pruritus (chronic itch with no underlying pruritic dermatosis). Journal of Dermatology 52(2), 204-220. [Abstract] [Free Full-text]
  • Kremer, A.E., Mettang, T. and Weisshaar, E. (2020) Non-dermatological challenges of chronic itch. Acta Dermato-Venereologica 100(2). [Abstract] [Free Full-text]
  • Magnolo, N., Jaenicke, T., Tsianakas, A., et al. (2023) Comparison of different skin care regimens in patients with moderate to severe atopic dermatitis receiving systemic treatment: A randomized controlled trial. Journal of the European Academy of Dermatology and Venereology 37(5), 18-26. [Abstract] [Free Full-text]
  • Matterne, U., Apfelbacher, C.J., Vogelgsang, L., et al. (2013) Incidence and determinants of chronic pruritus: a population-based cohort study. Acta Dermato-Venereologica 93(5), 532-537. [Abstract] [Free Full-text]
  • MHRA (2015) Hydroxyzine (Atarax, Ucerax): risk of QT interval prolongation and Torsade de Pointes. Medicines and Healthcare Products Regulatory Agency. https://www.gov.uk [Free Full-text]
  • Millington, G.W.M., Collins, A., Lovell, C.R., Leslie, T.A. et al. (2018) British Association of Dermatologists' guidelines for the investigation and management of generalized pruritus in adults without an underlying dermatosis, 2018. British Journal of Dermatology 178(1), 34-60. [Abstract] [Free Full-text]
  • Nevols, J., Watkins, L. and Lewis, R. (2023) A phase IV, randomised, double-blind, controlled, parallel group trial to evaluate the effectiveness and safety of Balneum Plus versus emollient in the treatment of chronic kidney disease-associated pruritus in haemodialysis patients. Clinical Kidney Journal 16(8https://pmc.ncbi.nlm.nih.gov/articles/PMC10387385/), 1307-1315. [Abstract] [Free Full-text]
  • NICE (2025) Suspected cancer: recognition and referral. National Institute for Health and Care Excellence. https://www.nice.org.uk [Free Full-text]
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