Itching Treatment in Ankara, Turkey

Itching treatment is a multifaceted approach aimed at determining the underlying cause and relieving symptoms. Skin irritation, allergic reactions, or systemic diseases are among the main causes of pruritus. The treatment plan is arranged individually in accordance with the etiology.

Topical treatments are the first step in the local control of itching. Creams containing menthol, calamine, pramoxine, or low-potency corticosteroids provide symptomatic relief. The use of moisturizers helps restore the skin barrier, especially in itching associated with xerosis.

In systemic treatments, antihistamines are effective, especially in histamine-mediated itching. In chronic cases, sedative antihistamines may relieve nighttime symptoms. Antidepressants or gabapentinoids may be considered as alternative treatment options in neuropathic itching.

In resistant or unexplained itching cases, advanced investigations may be required. Laboratory evaluations such as liver, kidney, and thyroid function tests are performed. Along with the treatment of the underlying disease, hygiene, stress control, and avoiding irritating substances support symptom control.

What Is Itching and When Is It Called “Chronic Itching”?

Itching (pruritus, by its Latin name) is an uncomfortable sensation we all know, which creates the urge to scratch or rub the skin. In fact, it is a defense mechanism of the skin. However, when this sensation lasts for six weeks or longer, it is no longer a temporary symptom and turns into a medical condition in itself called “chronic itching.” Chronic itching is a health problem that affects a significant part of society and can seriously reduce quality of life. It may lead to insomnia, anxiety, and impaired concentration in daily life.

Why Should Chronic Itching Not Be Seen Only as a Skin Problem?

Many people think of itching only as a problem that is “on the skin.” However, the roots of chronic itching are often much deeper. Although it may sometimes result from a visible skin problem such as eczema, psoriasis, or dry skin, it can often also occur without any underlying visible skin findings.

In these cases, that is, when the skin appears normal, itching may be the sign of a completely different health problem. Underlying causes may include internal organ diseases such as kidney, liver, or thyroid disorders, diabetes, some blood diseases, nervous system disorders (neuropathic), and even some types of cancer (especially lymphoma). Therefore, chronic itching requires a broad perspective involving dermatology, internal medicine, neurology, and sometimes psychiatry.

How Does Your Doctor Classify Your Itching Complaint?

For an effective treatment plan, it is essential to determine the type of itching correctly. Doctors use a classification based on clinical appearance established by the International Forum for the Study of Itch (IFSI). This classification consists of three main groups:

• Group I: Itching on diseased skin (such as eczema, psoriasis, urticaria)
• Group II: Itching on normal-appearing skin (an underlying systemic cause is investigated)
• Group III: Itching accompanied by severe scratching marks (such as Prurigo Nodularis)

In this classification, especially Group II, that is, “itching on normal-appearing skin,” requires a comprehensive investigation to exclude situations such as an underlying internal organ disease, a neurological problem, or a drug reaction.

How Does the Constant Sensation of Itching Affect Our Nervous System?

One of the most important characteristics of chronic itching is that over time it causes permanent changes in both the skin’s (peripheral) and the brain and spinal cord’s (central) nervous system. This situation can be explained as “the nervous system learning itching” or “pruriplasticity.”

Constant itch signals make nerve fibers excessively sensitive. The nerve pathways in the brain and spinal cord “get used to” this continuous itch signal. This is called “central sensitization.” Over time, the natural braking mechanisms of the nervous system that inhibit itching weaken. The brain may begin to produce itch signals even when there is actually no external stimulus. This explains why chronic itching has mechanisms similar to chronic pain and why medications that act on the nervous system (neuromodulators) are sometimes used in its treatment.

What Information Should You Give Your Doctor for the Correct Diagnosis of Itching?

The basis of diagnosis is the detailed medical history taken from the patient. Some key questions asked during this interview are:

• The time the itching started
• The hours during the day when it increases (especially at night)
• The areas of the body where it is concentrated
• Accompanying fever, sweating, or weight loss
• Whether there is a seasonal change
• Medications used and known triggers
• Whether there are similar complaints in the family

For example, itching that increases at night and is also seen in family members suggests the possibility of scabies, while itching accompanied by weight loss and night sweats may be a warning sign for more serious underlying systemic diseases.

How Are the Causes of Itching Investigated in Physical Examination?

A comprehensive dermatological examination is essential. In this examination, “primary lesions” that existed before the itching (such as an eczema rash) and “secondary lesions” that develop due to scratching (scratches, crusting, thickening of the skin) are carefully distinguished.

There are some specific anatomical areas that should be paid particular attention to during the examination:

• Between the fingers
• Wrists and ankles
• The anogenital (anal and genital) area
• Nails
• Scalp

For example, seeing tunnel-like structures between the fingers is very typical for the diagnosis of scabies. In addition, a general systemic examination (e.g. abdominal and lymph node examination) may also be performed to determine whether there is enlargement in the liver, spleen, or lymph glands.

If There Is No Cause on the Skin, Which Blood Tests Are Requested for the Underlying Cause of Itching?

Especially in Group II itching (where there is no visible cause on the skin), comprehensive laboratory tests are requested to investigate an underlying systemic cause. The standard initial screening panel usually includes the following:

• Complete Blood Count (Hemogram)
• Liver Function Tests (ALT, AST, ALP, Bilirubin)
• Kidney Function Tests (Creatinine, BUN)
• Thyroid Function Tests (TSH)
• Fasting Blood Glucose / HbA1c
• Iron Panel and Ferritin
• Erythrocyte Sedimentation Rate (ESR) and CRP

These tests help screen for common causes of itching such as anemia, blood diseases, liver or bile duct problems (cholestasis), chronic kidney disease, thyroid disorders, or diabetes. If the initial tests are normal, more advanced tests (hepatitis panel, HIV, protein electrophoresis, etc.) may be requested according to suspicion.

When Is Skin Biopsy (Taking a Sample) Necessary for Itching?

In itching with no visible finding on the skin (Group II), biopsy is generally not necessary because the results usually show non-specific changes related to scratching. However, biopsy is critically important in certain situations.

For example, when the clinical features suggest more than one disease, when a difficult diagnosis needs to be confirmed (e.g. autoimmune bullous diseases), or when conditions such as an “invisible” cutaneous lymphoma are suspected, biopsy becomes guiding. Biopsy is a strategic tool for the pathologist to interpret the tissue sample and for the dermatologist to combine this information with the patient’s examination findings in order to reach the correct diagnosis.

What Is the First and Fundamental Step in Itching Treatment?

The basis of chronic itching management is to stabilize the skin barrier and avoid known triggers before moving to systemic medications. This “basic care” process includes:

• Avoiding wool clothing
• Not taking showers with excessively hot water
• Stopping harsh soaps and chemical irritants
• Using fragrance-free, hypoallergenic cleansers
• Taking lukewarm and short showers
• If there is a parasite such as scabies or lice, treating it first

Do Moisturizers Really Work in Itching Treatment?

Absolutely yes. Moisturizers (emollients) are the first and most important non-pharmacological step in the treatment of chronic itching. They play a critical role especially in itching related to dry skin (xerosis) or chronic kidney disease.

Moisturizers do more than just hydrate the skin; they also repair the skin’s natural protective lipid layer, improve the skin barrier function, and directly reduce itching. Special formulations containing urea, ceramides, or lactic acid increase the skin’s ability to retain water in the upper layer and strengthen the skin’s defense against external factors. Applying them immediately after a shower, while the skin is still moist, increases their effectiveness.

Which Creams Are Used for Inflammatory Itching Such as Eczema?

If itching is caused by an inflammatory skin disease (Group I) such as eczema or psoriasis, anti-inflammatory creams are used to suppress this inflammation.

• Topical Corticosteroids (Cortisone Creams): They are very effective in reducing inflammation in the skin and the itching related to it. They are available in different strengths (potencies), and it is important that they are used in the strength and duration recommended by the dermatologist.
• Topical Calcineurin Inhibitors (TCI): These creams (Tacrolimus, Pimecrolimus) do not contain cortisone. They are especially ideal for areas where the skin is thin and sensitive, such as the face, neck, eyelids, or genital area. These agents do not cause side effects such as skin thinning that cortisone may cause with long-term use.

Are There Special Creams for Nervous (Neuropathic) Itching?

Yes, when the cause of the itching is nerve damage or hypersensitivity of the nerves (neuropathic itching), standard anti-inflammatory creams generally do not work. In these cases, special topical agents that target nerve endings are used:

• Capsaicin: It is a substance found in hot peppers. It works by depleting “substance P,” which carries the itch signal in the nerve endings. It may cause a strong burning sensation when first used, but with regular use this effect decreases and relief in itching is achieved.
• Local Anesthetics and Menthol: Creams containing menthol or pramoxine provide immediate relief by temporarily “numbing” or cooling the skin.
• Topical Gabapentin: Compounded formulations of gabapentin, which is normally an oral neuromodulatory medication, may be used in some types of localized neuropathic itching when prepared as a cream.

Why Are Allergy Medications (Antihistamines) Usually Ineffective for Chronic Itching?

This is one of the issues patients ask about most frequently and find the most confusing. Acute (suddenly developing) allergic itching or hives (urticaria) result from the release of a chemical called “histamine.” Standard antihistamines work by blocking this histamine and are very effective in these situations.

However, chronic itching (eczema, kidney disease, neuropathic itching, etc.) is generally not caused by histamine. Its pathophysiology is much more complex; it involves different pathways and molecules in the nervous system (opioid receptors, interleukins, nerve growth factors, etc.). Therefore, antihistamines do not stop itching in most chronic itching cases. Only first-generation (sedating, sleep-inducing) antihistamines may indirectly relieve nighttime itching by calming the patient and helping them sleep, but they generally do not have a marked effect on daytime itching.

Why Are ‘Neuromodulator’ Medications (Nervous System Medications) Used in Itching Treatment?

Since it has been understood that chronic itching is caused by the hypersensitization of the nervous system (central sensitization), the focus of treatment has shifted to medications that “calm” this sensitivity. These medications are called “neuromodulators.”

The main groups of drugs used for this purpose are:

• Gabapentinoids (Gabapentin and Pregabalin)
• SSRI Group Antidepressants (Paroxetine, Sertraline)
• Tricyclic Antidepressants (Doxepin)
• Neurokinin-1 Receptor Antagonists (Aprepitant)

In particular, Gabapentin and Pregabalin are actually drugs developed for epilepsy or neuropathic pain. However, over time it has been realized that they also have an excellent effect on chronic itching by slowing itch signals in the spinal cord and changing the way the brain perceives itching. They are frequently preferred as first-line systemic treatment in itching related to chronic kidney disease, neuropathic itching, and chronic itching of unknown cause.

How Is Itching Related to Kidney Disease (CKD-aP) Managed?

Itching seen in patients with chronic kidney disease, especially those on dialysis, can be very severe and resistant. Management is multifaceted and includes:

• Optimizing dialysis adequacy
• Phosphorus and parathyroid hormone control
• Continuously moisturizing the skin as basic treatment
• Gabapentinoids as the first pharmacological option
• Kappa-Opioid Receptor (KOR) Agonists in resistant cases

Especially KOR agonists (such as Difelikefalin) are new-generation treatments developed for these patients. They target the imbalance of the opioid system thought to play a role in chronic itching and can provide very effective results.

How Is Itching Related to Liver and Bile Duct Disease (Cholestatic Itching) Treated?

Impaired bile flow (cholestasis) due to liver disease or gallstones causes bile acids to accumulate in the blood and leads to very severe, persistent itching. Treatment requires a special stepwise approach:

• Step: Cholestyramine (binds bile acids in the intestine)
• Step: Rifampin (accelerates the metabolism of bile acids)
• Step: Naltrexone (reduces the perception of itching by blocking the opioid system)
• Step: Sertraline (an SSRI antidepressant)

These treatments must be managed in close cooperation with the relevant specialist (gastroenterologist), because medications such as Rifampin and Naltrexone may cause side effects on the liver.

What Role Does Phototherapy (Light Therapy) Play in Itching Treatment?

Phototherapy, especially Narrowband UVB (NB-UVB), is a very effective and safe option in the treatment of generalized itching, atopic dermatitis, and prurigo nodularis. Patients enter a special cabin 2-3 times a week and receive controlled ultraviolet light under the supervision of a dermatologist for short periods measured in seconds.

Although the mechanism by which phototherapy reduces itching has not been fully clarified, it is thought to work not only by suppressing inflammatory cells in the skin but also, like systemic medications, by modulating (affecting) the nervous system and nerve endings in the skin. This makes it a valuable treatment option in systemic itching such as kidney or liver failure as well.

Which Treatments Are Applied in Very Severe and Resistant Itching Conditions Such as Prurigo Nodularis?

Some patients, especially in cases where firm, raised, wound-like nodules called “Prurigo Nodularis” (PN) develop as a result of intense scratching of the skin, may not respond to any of the above treatments. In these “resistant” cases, stronger treatments targeting the immune system and the specific inflammatory pathways that cause itching are used.

In the past, medications that generally suppress the immune system (immunosuppressants) such as Cyclosporine and Methotrexate were used in these cases. Cyclosporine may still be used as a short-term “bridge treatment” to provide rapid relief in severe cases. However, their long-term use is not preferred because of their potential for serious side effects.

How Have Biological Agents (Injections) Created a Revolution in Itching Treatment?

Targeted biological treatments developed in recent years have created a real revolution in the management of chronic itching. Instead of generally suppressing the immune system, these drugs block only the specific molecules (cytokines) responsible for itching and inflammation. The main ones are:

• IL-4 and IL-13 Inhibition (Dupilumab)
• IL-31 Inhibition (Nemolizumab)
• OSM Receptor Inhibition (Vixarelimab)

For example, Dupilumab blocks two important signaling molecules that play a key role in atopic dermatitis and prurigo nodularis. Nemolizumab, on the other hand, targets IL-31, known as the “itch cytokine,” which directly carries the itch signal between nerves and immune cells. These targeted agents provide much stronger and more specific itch control with fewer side effects.

How Do JAK Inhibitors (Small Molecule Pills) Accelerate Itching Treatment?

JAK Inhibitors (e.g. Abrocitinib, Upadacitinib, Baricitinib) are “small molecule” drugs. Like biological agents, they do not interrupt signals outside the cell but rather the inflammatory signaling pathways inside the cell (JAK enzymes).

The greatest advantage of these drugs is that they are taken orally and act very quickly. Especially in severe atopic dermatitis or prurigo nodularis, JAK inhibitors may provide a dramatic reduction in itching within a few days after treatment is started. This rapid effect makes them an excellent option for urgently stabilizing severe symptoms.

Why Is the “Stepwise Approach” So Important in Chronic Itching Treatment?

Chronic itching is not a single disease but a complex symptom that may have dozens of different causes. The “step by step” (stepwise) model ensures that treatment is planned in a patient-specific, safe, and effective way. No patient starts treatment directly with the strongest immunosuppressive drug. Treatment is like a pyramid:

This pyramid works as follows:

• Basic Stage (0 and 1): Barrier repair, moisturizers, avoiding triggers, local creams.
• Second Stage (2): If basic care is not enough, systemic neuromodulators (such as Gabapentin) or phototherapy.
• Third Stage (3): Treatment is customized with more targeted drugs (such as KOR agonists) directed at the specific underlying cause (e.g. kidney failure).
• Top Stage (4): In severe and inflammatory conditions resistant to all other steps (such as Prurigo Nodularis), biological agents and JAK inhibitors come into play.

The success of treatment is measured not only by the stopping of itching but also by improvement in the patient’s sleep quality and the objective reduction of scratching-related skin lesions (scratches, crusting) on examination.