Curr Geri Rep (2016) 5:266274
DOI 10.1007/s13670-016-0189-2
DERMATOLOGY AND WOUND CARE (A CHANG, SECTION EDITOR)
Pruritus and Dermatitis in the Elderly
Sarah L. Sheu 1 & Kevin C. Wang 1,2
Published online: 15 October 2016
# Springer Science+Business Media New York (outside the USA) 2016
Abstract Pruritus is common in all age groups but is especial-
ly prevalent in the elderly due to senescence of the integumen-
tary, immune, and nervous systems. In developing a treatment
regimen, clinicians must consider the many potential therapeu-
tic options for pruritus and how these interplay with common
comorbidities and functional limitations of elderly patients.
While the causes of pruritus are numerous, effective topical
and systemic treatments are limited, especially in the elderly,
due to the unique pharmacokinetics and pharmacodynamics of
aging bodies. The major etiologies and treatment options for
dermatitis and pruritus are reviewed, taking into account the
challenges of local and systemic treatment in elderly patients.
Keywords Aging . Antidepressants . Antihistamines .
Elderly . Eruption of senescence . Geriatric . Immune
senescence . Itch . Phototherapy . Polypharmacy . Pruritus .
Quality of life . SSRIs . Xerosis
Introduction
Pruritus, the unpleasant sensation that evokes the desire to
scratch, is the most common dermatologic complaint in the
elderly [1]. Chronic pruritus leads to poor sleep, depressed
This article is part of the Topical Collection on Dermatology and Wound
Care
* Kevin C. Wang
kevwang@stanford.edu
1
Department of Dermatology, Stanford Medicine Outpatient Center,
Stanford University School of Medicine, 450 Broadway Street,
Redwood City, CA 94063, USA
2
Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA, USA
mood, and impaired quality of life [2, 3]. Kini et al. found a
comparable reduction in the quality of life of adults with chron-
ic pruritus and chronic pain and reported that the average patient
with chronic pruritus would be willing to forfeit 13 % of life
expectancy to live without pruritus [2]. This burden of disease
is comparable to that of patients with mycosis fungoides and
higher than that of patients with breast cancer [4, 5].
The reported prevalence of pruritus in the elderly ranges
from 12 to 41 % [1, 6, 7]. Among patients with the complaint
of chronic pruritus at a single institution, itch severity was
greater among patients over the age of 65 [8]. The population
of elderly adults (i.e., age 65 and older) in the USA will dis-
proportionately increase relative to the general population and
is expected to double by the year 2050 [9]. As the population
ages, the task of treating pruritus in the elderly will continue to
challenge patients and healthcare providers alike.
The high prevalence of pruritus in the elderly is a natural
consequence of age-related changes in the integumentary, im-
mune, and nervous systems. Aging skin is characterized by
impaired sebum production, attenuated water content, and
compromised barrier function [1012]. Given these changes,
it is unsurprising that 38 % of elderly patients with generalized
pruritus have associated xerosis [6]. Decades of exposure to
ultraviolet radiation, which results in further impairment of the
skins water binding capacity, leads to accentuated xerosis in
photo-exposed areas of the skin [13]. Furthermore, the inter-
cellular lipid content is diminished in aged skin, contributing
to compromised barrier function even in the absence of exter-
nal perturbation [14]. The barrier function of the skin can be
demonstrated in vivo by soaking the skin in acetone, which
dissolves the intercellular lipids that contribute to keratinocyte
cohesion. While 30 to 60 min of acetone treatment is neces-
sary to perturb the skin barrier in subjects under the age of 30,
the skin barrier can be disrupted in subjects over the age of 80
in as little as 3 min [12]. At 24 h after acetone treatment,
Curr Geri Rep (2016) 5:266274
barrier function recovers in 50 % of young subjects but in only
15 % of elderly subjects. Thus, the barrier function of aged
skin is doubly impacted by an accelerated rate of barrier dis-
ruption and a delayed rate of barrier recovery.
The high prevalence of pruritus in the elderly is also a result
of immunosenescence or age-related changes in systemic im-
munity. Progressive alterations in the function of T lympho-
cytes, B lymphocytes, and the innate immune system contrib-
ute to the development of a chronic low grade, pro-
i n f l a m m a t or y s t a t e t ha t h a s b e e n r ef e r r e d t o a s
Binflammaging^ [14, 15]. Owing to a lifetime of antigen ex-
posure, aging immune systems demonstrate a loss of nave T
cells and the accumulation of differentiated memory T cells
[16]. In addition to the development of this generalized pro-
inflammatory state, the previously described impairment in
cutaneous barrier function permits the penetration of potential
antigens through the epidermis, promoting the release of in-
flammatory cytokines on a local level [17]. These local and
systemic pro-inflammatory processes are thought to underlie
the increased incidence of inflammatory diseases in the elder-
ly, including of the skin [18].
Finally, changes in the central and peripheral nervous sys-
tems contribute to patterns of pruritus that are more commonly
seen in the elderly. Degenerative changes of the spine narrow
the vertebral foramina, which may impinge on sensory nerves
as they exit the spinal cord. This is the proposed etiology for
two well-described pruritic entities that disproportionately af-
fect the elderly, brachioradial pruritus, and notalgia
paresthetica [19]. Brachioradial pruritus has been consistently
linked with cervical disk herniation, particularly between the
C5 and C6 vertebrae [20, 21]. Patients with notalgia
paresthetica similarly demonstrate degenerative changes of
the cervical and thoracocervical vertebrae [22]. Successful
treatments for brachioradial pruritus and nostalgia paresthetica
modify the disordered neurotransmission that is triggered by
these degenerative spinal changes [23].
Understanding this myriad of changes associated with se-
nescence is critical to approaching the unique challenges of
treating pruritus in the elderly. In this review, we provide
evidence-based recommendations for current topical and sys-
temic therapies for pruritus in the elderly and introduce emerg-
ing therapies for the management of pruritus.
General Management Principles
There are two general therapeutic approaches to the manage-
ment of patients with dermatitis and pruritusskin-directed
topical therapies and systemic approaches. Prior to starting an
elderly patient on a regimen for pruritus, the clinician should
take into account the patients cognitive, functional, and social
resources.
267
The appropriate application of topical medications can be
challenging for patients of all age groups. Among new pa-
tients to a dermatology clinic who received a prescription for
a topical medication, patients applied approximately 35 % of
the expected amount when assessed at follow-up [24].
Healthy subjects who were asked to treat their entire skin
surface with a topical cream neglected to treat up to 31 % of
the skin surface, and all subjects had at least one neglected
area, most commonly, the upper back [25]. Given that the task
of evenly applying topical medications is challenging even for
young volunteers without cognitive or functional limitations,
it may be especially difficult for elderly patients who have a
higher rate of cognitive, visual, and musculoskeletal comor-
bidities [26].
Age-related changes in pharmacokinetics and pharmaco-
dynamics alter the response of elderly patients to systemic
medications. Prior to initiating any systemic treatment for pru-
ritus, clinicians should consider the changes in drug metabo-
lism and clearance that occur with aging and comorbidities
that are more prevalent among the elderly. The reduction in
hepatic mass and blood flow that occur with aging can affect
the response of elderly patients to antipruritic medications that
are metabolized by the liver, such as loratidine [27]. The age-
related decline in renal function results in elevated plasma
concentrations of renally cleared medications, including
cetirizine and gabapentin, two commonly used antipruritic
agents [27, 28]. Furthermore, the risk of drug-drug interac-
tions is high in the elderly due to the frequency of
polypharmacy in this patient population: 39 % of elderly
Medicare beneficiaries take five or more prescription medica-
tions per month [29].
The effective management of pruritus and dermatitis in the
elderly is further complicated by the prevalence of medication
nonadherence in this patient population, which has been re-
ported to be as high as 54 % [30]. The factors contributing to
nonadherence among the elderly are numerous and include
the prevalence of comorbidities, relative social isolation, fixed
incomes, and decreased mobility [31]. The numerous intrinsic
and extrinsic barriers to treating pruritus, including the diffi-
culty of adhering to treatment plans, the effects of declining
drug metabolism and renal clearance, and the risks of
polypharmacy, all contribute to the difficulty of treating an
already challenging problem in the general population.
Management of Dermatitis in the Elderly
Dermatitis is a broad, nonspecific term that encompasses all
inflammatory disorders of the skin. The elderly are prone to
the development of dermatitis due to the aforementioned im-
pairment in barrier function and the pro-inflammatory state
that characterize senescent integumentary and immune
268
systems. Successful management of dermatitis in the elderly
focuses on the amelioration of these age-associated changes.
Preserving the skins integrity through gentle skin care
practices is a starting point in the management of all elderly
patients with dermatitis and pruritus [32]. These recommen-
dations include limiting time in the shower or bath, the use of
warm rather than hot water, and the avoidance of harsh and
scented products [33]. Patients should be instructed to liberal-
ly apply a thick, unscented moisturizer within minutes of dry-
ing the skin.
Topical corticosteroids (topical steroids) can be used to
reduce the cutaneous inflammation that characterizes derma-
titis, and are the first line treatment for many pruritic disorders.
Topical steroids vary in potency, ranging from the ultra-potent
class 1 steroids to the weakest class 7 steroids. Side effects of
prolonged use include epidermal atrophy, steroid acne, de-
layed wound healing, and cataracts [34].
Guidelines regarding the use of topical steroids in the el-
derly are generally extrapolated from studies of the wider
adult population. However, the use of ultra-potent topical ste-
roids has been specifically studied in patients with bullous
pemphigoid (BP), an autoimmune blistering condition that
primarily affects the elderly [35]. Topical ultra-potent steroids
have been used as an alternative to systemic steroids in the
management of BP and are well tolerated in this elderly pa-
tient population [36]. However, it is important to note that
senescent skin is especially susceptible to developing
steroid-induced cutaneous changes; among BP patients who
received 4 months of topical clobetasol (a class 1 steroid) up to
once daily, 23 % of subjects experienced adverse effects [37].
Atrophy was the most frequently reported adverse effect (re-
ported in 18 % of patients), followed by the development of
purpura (5 %) and striae (3 %). The prescribing clinician
should monitor all patients, especially elderly patients, for
signs of steroid-induced cutaneous changes.
As mentioned previously, the application of topical medi-
cations is challenging even for healthy young patients without
cognitive or functional limitations, a useful consideration prior
to starting any elderly patient on a management regimen that
emphasizes the use of topical medications.
Management of Pruritus in the Elderly
The causes of pruritus without dermatitis are numerous and
include systemic diseases, medication-induced pruritus, and
neurologic diseases. As mentioned above, optimizing skin
care practices and skin hydration is essential in the manage-
ment of all elderly patients with dermatitis or pruritus.
Addressing skin hydration has a beneficial effect on a wide
range of pruritogenic etiologies, including systemic diseases,
which are responsible for up to one third of generalized pru-
ritus cases [38]. In an analysis of Medicare claims data
Curr Geri Rep (2016) 5:266274
between 2007 and 2012, common comorbidities in the elderly
included diabetes mellitus (11 %), renal disease (15 %), and
malignancy (15 %), all of which may be associated with pru-
ritus [29, 39]. The elderly represent the fastest growing popu-
lation of patients with chronic kidney disease, and 50 % of
patients with chronic kidney disease on hemodialysis report
having generalized pruritus [40, 41]. Patients with mild ure-
mic pruritus who applied an emollient twice daily for 2 weeks
experienced an improvement in their pruritus by the second
week [42]. This effect was not sustained after the emollient
was discontinued, highlighting the importance of ongoing
skin hydration to maintaining symptomatic improvement.
Identifying exogenous causes of pruritus is also critical in
the management of elderly patients, who are more likely to
have chronic diseases for which they require medications.
Calcium channel blockers, thiazide diuretics, angiotensin-
converting-enzyme inhibitors, and angiotension II receptor
blockers are commonly implicated triggers for chronic derma-
titis and pruritus in the elderly [4345]. Among patients
whose pruritus was thought to be triggered by a calcium chan-
nel blocker, 83 % of patients experienced symptomatic relief
after a mean withdrawal period of approximately 3 months
[43].
Though topical steroids may provide relief of pruritus as-
sociated with an underlying dermatitis, they may not be as
effective in patients without underlying cutaneous inflamma-
tion. There are a variety of over-the-counter topical remedies
that can provide temporary relief of mild pruritus with or
without associated cutaneous inflammation. These products
often contain pramoxine, menthol, capsaicin, or camphor.
The beneficial effect of pramoxine in reducing pruritus was
first described in the 1950s, and its effective use has been
corroborated in subsequent case series [4649]. Pramoxine
has been used alone or in combination with hydrocortisone
and lactic acid in the treatment of uremic pruritus [4749]. Its
mechanism of action remains unclear but may involve inter-
fering with the transmission of impulses along sensory nerve
fibers [50].
Ambient temperature can alter the perception of pruritus, as
demonstrated by the exacerbation of pruritus experienced by
patients with atopic dermatitis or uremic pruritus during ex-
posure to heat [51, 52]. The transient receptor potential (TRP)
family of cation channels plays an integral role in
somatosensation, including the detection and transduction of
thermal stimuli [53]. Menthol, camphor, and capsaicin can
modulate the experience of pruritus, in part, through their
effects on members of the TRP channel family. Menthol pro-
duces a cooling sensation by activating the TRP melastatin 8
(TRPM8) channel, the primary transducer for cold
somatosensation [54, 55]. Through its activation and subse-
quent desensitization of the heat-sensitive, nociceptive TRP
vanilloid 1 (TRPV1) receptor, camphor is thought to calm
nociceptive nerves [56].
Curr Geri Rep (2016) 5:266274
Like camphor, capsaicin is also an agonist of the heat-
sensitive nociceptor TRPV1 [57]. Capsaicin has also been
found to deplete peripheral neurons of substance P, a peptide
involved in the neurotransmission of pain and pruritus [58,
59]. Topical capsaicin has been readily available for decades
in the form of ointments, lotions, and creams. Though topical
agents containing pramoxine, menthol, capsaicin, and cam-
phor have a relative paucity of data supporting their use, they
may be attractive options for elderly patients with multiple
comorbidities or concurrent medications in whom the risks
of adverse effects and drug-drug interactions are high.
Antihistamines are commonly used in the treatment of pru-
ritus, but there is little evidence to support their use in the
management of non-histamine-mediated pruritus [59, 60].
First-generation antihistamines including diphenhydramine
and hydroxyzine act nonselectively on histamine H1 receptors
of the central and peripheral nervous systems. According to
the Beers Criteria, a list of potentially inappropriate medica-
tions (PIMs) maintained by the American Geriatric Society,
the use of first-generation antihistamines should be avoided in
the elderly [61]. Rationale for the inclusion of the first-
generation antihistamines as PIMs included the reduced clear-
ance of these medications with advanced age. In addition to
age-related changes in the pharmacokinetics of the anticholin-
ergic medications, the pharmacodynamics of these medica-
tions is affected by the already attenuated cholinergic trans-
mission that occurs with senescence [62]. These changes lead
to the first-generation antihistamines having prominent anti-
cholinergic side effects in the elderly, including sedation, con-
fusion, dry mouth, urinary retention, and constipation. Elderly
men are an especially high risk of developing drug-induced
urinary retention due to the prevalence of benign prostatic
hyperplasia in this patient population [63].
In analyzing over 60,000 women between the ages of 65
and 79 who were enrolled in the Womens Health Initiative
studies, Marcum et al. found that 11 % were using a medica-
tion with anticholinergic activity, of which antihistamines rep-
resented the largest category [64]. In the same study, the use of
anticholinergic medications was associated with an increased
risk of falls, a finding that has also been reported in elderly
men [65]. Medications with anticholinergic activity may in-
crease the risk of functional decline, delirium, and institution-
alization in older adults [66]. Given the preceding rationale,
first-generation antihistamines are generally not recommend-
ed for use in the elderly except in the acute treatment of severe
allergic reactions [61].
Second-generation antihistamines including fexofenadine,
cetirizine, and loratidine are more selective for peripheral ner-
vous system H1 receptors. Though they are referred to as
Bnon-sedating^ antihistamines, sedation can occur with their
use, though the risk is lower than with first-generation antihis-
tamines [67]. A common practice in patients with urticaria is
to prescribe a second-generation antihistamine in the morning
269
and a first-generation antihistamine at night. However, a re-
cent study suggests that sedating nighttime antihistamines in-
crease daytime somnolence without providing additional ben-
efit in sleep quality or quality of life [68]. Thus, antihistamine
therapy in older adults should be limited to patients in whom a
histamine-mediated etiology is suspected (such as urticaria)
and limited to the newer generation antihistamines.
Tricyclic antidepressants (TCAs) including doxepin and
amitriptyline inhibit the reuptake of serotonin and norepineph-
rine and act as antagonists of histamine and acetylcholine
receptors [69]. In a randomized, placebo-controlled cross-over
trial of 24 patients with uremic pruritus, 58 % of subjects
reported a complete resolution of their pruritus while taking
doxepin [70]. Doxepin was superior to diphenhydramine at
improving pruritus and hive count in patients with chronic
idiopathic urticaria [71]. Like the first-generation antihista-
mines, TCAs are considered to have high anticholinergic ac-
tivity [72]. TCAs can also cause lengthening of the cardiac
ventricular repolarization phase, which is associated with a
prolongation of the QT interval on electrocardiography. QT
interval prolongation is associated with an increased risk of
sudden cardiac death and the arrhythmia torsades de pointes,
especially in patients with a history of heart disease [73]. The
QT-prolonging effects of TCAs can be potentiated by other
QT-prolonging medications, including the antiarrhythmic
agent amiodarone. Given the prevalence of heart disease and
polypharmacy in the elderly, the elderly are at an increased
risk of developing potentially fatal cardiac complications
resulting from the use of TCAs [74]. Thus, while doxepin
has support from small-scale randomized controlled trials in
the management of uremic pruritus and chronic idiopathic
urticaria, it should not be used as a first-line agent in the
elderly due to the heightened risk of anticholinergic and car-
diac adverse effects in this patient population, some of which
are potentially fatal.
Mirtazapine is a tetracyclic antidepressant described in case
reports and case series as a useful treatment option for patients
with a wide range of pruritogenic etiologies including lym-
phoma, cholestasis, and renal failure [75, 76]. Mirtazapine
inhibits the H1 receptor in addition to the serotonergic 5HT2
and 5HT3 receptors, all of which have been implicated in the
neurotransmission of pruritus [75]. Mirtazapine was found to
cause weight gain in approximately 10 % of patients taking
this medication to treat major depressive disorder [77, 78].
While weight gain may be undesired in most segments of
the population, the elderly are at risk of unintentional weight
loss resulting from physiologic changes in metabolism and
functional limitations that lead to poor nutritional intake
[79]. Furthermore, medications that are commonly taken by
the elderly can cause unintentional weight loss [80]. For ex-
ample, laxatives and proton pump inhibitors can reduce calo-
rie absorption. The appetite stimulating effects and the rela-
tively low anticholinergic activity of mirtazapine may make it
270
an attractive option for the treatment of pruritus in the elderly,
though data from large scale, randomized controlled trials are
currently lacking to support their use [72].
The antipruritic effects of selective serotonin reuptake in-
hibitors (SSRIs), including paroxetine, fluoxetine, and sertra-
line, have also been reported in patients with a wide range of
pruritogenic etiologies. In a trial that included patients with
drug-induced, paraneoplastic, and cholestatic pruritus, 92 %
of subjects reported lower pruritus intensity scores while tak-
ing paroxetine [81]. In a subsequent open-label study of 72
patients with chronic pruritus treated with paroxetine and
fluvoxamine, 68 % of subjects reported an improvement in
their pruritus [82]. Similar benefits were seen in patients with
uremic pruritus and polycythemia vera [83, 84]. Of note, 71 %
of patients experienced an adverse drug effect while taking
fluvoxamine or paroxetine, most frequently reporting drows-
iness, vertigo, fatigue, and gastrointestinal pain [82]. SSRIs
are generally considered to have low anticholinergic activity;
though due to the previously mentioned pharmacokinetics and
pharmacodynamics changes in the elderly, these patients may
exhibit anticholinergic effects that are seldom seen in other
age groups [85, 86].
Gabapentin is an antiepileptic agent that has been effective-
ly used in the treatment of brachioradial pruritus, notalgia
paresthetica, and post-herpetic neuralgia [23, 8790].
Aforementioned neurodegenerative changes make the elderly
particularly susceptible to the development of brachioradial
pruritus and nostalgia paresthetica [2022]. The incidence of
herpes zoster also increases with age and up to 20 % of pa-
tients with shingles develop post-herpetic neuralgia [91, 92].
Gabapentin, an analog of the inhibitory neurotransmitter gaba-
aminobutyric acid, has pleomorphic effects on the central and
peripheral nervous systems, including the inhibition of excit-
atory neurotransmitter release in the spinal cord [93]. Side
effects of gabapentin are most commonly observed during
dose titration and include somnolence, dizziness, and gait dis-
turbance [91]. Gabapentin is exclusively eliminated by renal
excretion, an important consideration in the elderly due to
changes in renal excretion with senescence and the high prev-
alence of kidney disease in this patient population [94].
Azathioprine, methotrexate, and mycophenolate mofetil
have been reported to be effective in the management of gen-
eralized pruritus, but data supporting their use is sparse, par-
ticularly in the elderly population [95, 96]. Taken into account
with the need for frequent lab monitoring and side effect pro-
files of these medications leads to the recommendation that
these systemic immunosuppressants be reserved for recalci-
trant cases of pruritus.
Phototherapy, or the therapeutic use of ultraviolet light, has
been used for over 90 years in the treatment of pruritus sec-
ondary to dermatitis, renal impairment, chronic liver disease,
malignancy, and pruritus of unspecified origin [97100].
Phototherapy is well tolerated and effective if used judiciously
Curr Geri Rep (2016) 5:266274
in elderly patients [101]. Senescent skin responds differently
to phototherapy owing to a reduction in melanocyte density,
epidermal turnover, and an attenuated hyperplastic response to
ultraviolet radiation [102]. Radiation-induced erythema takes
longer to peak and resolve in the elderly, warranting a cautious
selection of starting dose and dose increases [103]. Numerous
medications can potentiate the effects of ultraviolet radiation
on the skin, again evoking the importance and prevalence of
polypharmacy in the elderly. Photosensitizing medications
that are commonly taken by the elderly include the nonsteroi-
dal anti-inflammatory drugs, diuretics, statins, diltiazem, and
amiodarone [104].
Senescence of the integumentary system and the preva-
lence of polypharmacy are two of many factors that must be
considered prior to referring an elderly patient for photother-
apy. Suitable candidates for phototherapy must reside within
traveling distance to a phototherapy center and present for
treatments up to three times weekly. They must also have
the physical and cognitive ability to stand in a phototherapy
booth for the duration of each treatment session [101]. Age-
related changes in muscle strength, which decreases by 12
15 % per decade after the age of 40, and the prevalence of
osteoarthritis can impair mobility and balance of elderly pa-
tients and limit their ability to safely undertake the time and
travel requirements of phototherapy [105].
In review, maximizing the barrier function of the elderly
skin through gentle skin care and skin hydration is fundamen-
tal to the management of all elderly patients with dermatitis
and pruritus. Evidence of an active dermatitis on examination
should prompt the clinician to consider the initiation of topical
steroids. Newer generation histamines can be beneficial in the
management of urticaria, but first-generation antihistamines
should generally be avoided due to the high risk of anticho-
linergic side effects. Reuptake inhibitors, such as SSRIs and
TCAs, can also be considered in patients with generalized
pruritus, though TCAs carry the risk of serious cardiac adverse
effects. Pruritus that is primarily neurogenic in origin can be
effectively managed with neuromodulating agents, such as
gabapentin. Systemic immunosuppressant agents can be con-
sidered in recalcitrant cases of pruritus, though data
supporting their use is scarce. Phototherapy can also be used
effectively in elderly patients with dermatitis and pruritus if
age and photosensitizing medications are considered in the
selection of starting dose and dose increments.
Emerging and Investigational Therapies
Many of the aforementioned treatments for pruritus have been
available for decades. Novel therapies have been introduced
targeting both old and new pathways in the pathogenesis of
pruritus, including aprepitant, which inhibits the binding of
substance P with the neurokinin-1 receptor [106]. Initially
Curr Geri Rep (2016) 5:266274
used in the management of chemotherapy-induced emesis,
aprepitant was later reported to improve chronic, treatment-
refractory pruritus in 16 of 20 patients [16]. This cohort in-
cluded patients with uremic pruritus, multifactorial pruritus,
and pruritus of unknown origin following extensive laborato-
ry and radiologic evaluation. Aprepitant was also reported to
be an effective antipruritic in patients receiving anti-epidermal
growth factor receptor antibodies and tyrosine kinase inhibi-
tors, which are commonly associated with pruritus [107].
Interestingly, only 6 of the 41 patients reported a recurrence
of their pruritus after completing a 5-day course of aprepitant
despite continuing the inciting therapies.
Another emerging therapy in the treatment of pruritus is
the monoclonal antibody omalizumab, which was origi-
nally studied in the management of moderate to severe
allergic asthma and subsequently used in the management
of patients with chronic idiopathic urticaria and atopic
dermatitis [108, 109]. Omalizumab reduces the levels of
free immunoglobulin E (IgE) and the high-affinity recep-
tor for the Fc region of IgE, which are involved in mast
cell activation. Activated mast cells release histamine, se-
rotonin, and neuropeptides, all of which act as mediators
of pruritus [110]. By acting on histaminergic and non-
histaminergic itch pathways, omalizumab may be a thera-
peutic option in patients with pruritus that is recalcitrant to
antihistamine therapy [111]. Though the use of
omalizumab has not been specifically examined in elderly
patients, given that the intradermal mast cell population
increases with age, targeting mast cell activation may
prove to be especially effective in this population [112].
Interleukin-31 (IL-31) is a pro-inflammatory cytokine that
is produced by T helper type 2 lymphocytes that stimulates the
secretion of pro-inflammatory cytokines and has been linked
to the development of pruritus and pruritic dermatoses [113].
Though the changes in IL-31 levels with aging have not been
fully characterized, one study of postmenopausal women
demonstrated higher levels of IL-31 levels in women over
the age of 65 [114]. Transgenic mice overexpressing IL-31
were found to develop a severely pruritic dermatitis that re-
sembles atopic dermatitis in humans [115]. IL-31 mRNA was
found to be expressed at higher levels in the skin of patients
with atopic dermatitis, allergic contact dermatitis, and prurigo
nodularis [116, 117]. Serum levels of IL-31 were also corre-
lated with disease severity in patients with atopic dermatitis
and were elevated in patients on hemodialysis with uremic
pruritus when compared to patients on hemodialysis without
pruritus [118, 119]. In a mouse model of atopic dermatitis,
mice treated with monoclonal IL-31 antibody exhibited a de-
crease in scratching behavior [120]. While evaluation of anti-
IL-31 antibody for the treatment of pruritic dermatoses in
humans is ongoing, the potentially increased levels of IL-31
in the elderly may make this treatment strategy especially
applicable to elderly patients.
271
Conclusions
The high prevalence of dermatitis and pruritus in the elderly is
a natural consequence of the aging integumentary, immune,
and neurologic systems. Understanding the prevalence and
consequences of comorbidities and polypharmacy in this age
group, as well as expected age-related changes in pharmaco-
kinetics, pharmacodynamics, cutaneous permeability, and re-
sponse to ultraviolet radiation are essential to the safe and
effective treatment of dermatitis and pruritus in the elderly.
Though finding an effective treatment for patients suffering
from chronic pruritus can be a time-consuming process in-
volving multiple steps of trial and error, the clinician has the
potential to dramatically improve quality of life through the
effective management of pruritus.
Though the armamentarium of treatments for pruritus was
relatively static for decades, the recent introduction of targeted
agents has been a promising development. Elderly patients
represent a heterogeneous group of patients with respect to
age, comorbidities, and functional status, and the etiologies
for dermatitis and pruritus within this age group are also nu-
merous. With a continued emphasis on elucidating these dif-
ferences, clinicians will develop a clearer understanding of the
disparate but overlapping causes of pruritus and lay the
groundwork for developing targeted treatments for pruritus
in the elderly.
Compliance with Ethical Standards
Conflict of Interest Kevin Wang and Sarah Sheu declare no conflict of
interest.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.
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