Itchy Skin (Pruritus) and the Elderly

Elderly patients are often bothered by itchy skin. Itch (pruritus) is one of the most common reasons that older patients see an allergist or a dermatologist. Itch can be caused by allergic skin conditions, such as eczema, hives (urticaria) and contact allergy. It can also be caused by systemic diseases, such as those that affect the kidney, liver and thyroid. Diabetes is another example. 

Age-related skin changes, medications (both oral and topical), psychological and neurological conditions may also contribute to itch. In elderly patients with itch, a complete medical work-up is important. Skin diseases will have an identifiable cause and body locations. Itch that is due to a systemic disease, neurologic condition or psychogenic issue will frequently present without a rash. In 11% of the general population, no identifiable cause will be found.

The most common cause of itching is dry skin (xerosis). Dry skin is due to age-related changes in the barrier protection and loss of ability to produce sebum and ceramide generating enzymes. In females, dry skin can happen with the onset of menopause. Scratching leads to further irritation of the skin’s protective barrier. A continued scratch-itch cycle causes more itching.

Degenerative diseases of the spine may cause nerve damage (neuropathy) and neuropathic itching. Frequently, neuropathic itch does not respond to treatment with antihistamines but does respond to cold compresses. Neuropathic itch often happens with decreased quality of life and sleep issues.

The following dermatologic conditions that can cause itch in the elderly include:
• Seborrheic dermatitis
• Stasis dermatitis: due to poor circulation and commonly affecting the legs above the ankle
• Irritant or allergic contact dermatitis 
• Psoriasis: an autoimmune disease that usually appears on the elbows and knees
• Bullous pemphigoid: in the early stages of the disease, the only skin symptoms may be blisters, occurring years after itch first appears
• Scabies: the most common among those living in long-term care facilities; the mite that causes this type of itch has a liking to the armpits, between fingers and the groin
• Post-herpetic: this type of itch happens most often after shingles
• Radiculopathy: due to nerve compression because of trauma or osteoarthritis, such as brachial radial itch of both arms 
• Notalgia paresthetica: itch and burning pain of the upper back leads to a darkened area of skin where the itch has been steady

The treatment approach begins first with a non-medication process aimed at improving the skin barrier and consists of:
• Using mild low pH cleanser
• Lukewarm bath water
• Moisturizing damp skin with creams or ointments within 3-5 minutes of patting dry after a bath or shower

Inflammatory components of the skin, such as eczema (atopic dermatitis), psoriasis, seborrheic dermatitis or contact dermatitis, respond well to topical corticosteroids when used at times. Non-steroidal alternative topical treatments include drugs known as calcineurin inhibitors and phosphodiesterase inhibitors, which unlike corticosteroids do not cause thinning of the skin. 

Oral medications to treat itch are available. However, care must be taken because of the risk of drug interactions. Non-drowsy antihistamines are preferred as first generation antihistamines cause drowsiness and should be avoided. Short courses of oral corticosteroids may be helpful. However, long-term use is not recommended due to multiple adverse effects. 

Antiepileptics, such as gabapentinoids, can help neurogenic itch. However, doses should be adjusted and taken at night as needed due to their sedative properties.

Biologic drugs (such as dupilumab) or interleukin-31 inhibitors (such as nemolizumab) are helpful in reducing itch in patients with eczema.

Chronic itch is a common symptom in the elderly and may be due to age-related changes in the skin, dermatologic conditions, systemic disease, neuropathic disease or drugs.

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11/14/2025