Stop the scratch: Current treatment recommendations and options for pruritus management

By Erica Tramuta-Drobnis, VMD, MPH, CPH

So, in 1,700 words or fewer, summarizing the management of pruritus in dogs and cats is a challenge. A lot goes into the neurobiology, immunology, and overall pathophysiology of the various etiologies of itching in dogs and cats. Various conditions trigger pruritus, ranging from primary skin conditions to immune-mediated conditions to systemic diseases. Treating the underlying condition, if feasible, is optimal, but not always realistic. Managing clinical signs, improving health outcomes (pet and pet-parent quality of life), and minimizing negative impacts on the human-animal bond (HAB) drive therapy recommendations, options, and success rates.

Pruritus in dogs and cats

Investigating and, when possible, determining the underlying cause, treating signs, and improving health remain paramount in the management of feline and canine dermatological issues that manifest as pruritus.

Many skin conditions in animals present with pruritus as a primary complaint. The scratching or licking keeps owners up all night; the constant headshaking or ear scratching brings owners to the ER at 2:00 in the morning. Pruritus can be debilitating, leading to self-trauma, behavioral abnormalities, excessive grooming, secondary infections, and more; so, managing that itch is of high priority.

We define pruritus as "an unpleasant sensation within the skin that provokes the desire to scratch."^1–5 However, it is much more than that when we consider the pathophysiology. Itchiness can be painful, unpleasant, irritating, and lead to agitation, anxiety, and distress.^2–4,6

Pathophysiology of itch

Entire articles are devoted simply to the pathophysiology of pruritus. However, itch can have a similar detrimental effect on quality of life as chronic pain. The pathway of itch is complicated; from the unpleasant sensation (regardless of the underlying etiology) to the ensuing communication among the immune system, skin, nervous system, and brain, we can see why we see such a wide array of responses from our patients.

Itch is complex and involves the thalamus, spinal cord, interleukins, other inflammatory mediators, and C-fibers (which also play a role in the pain pathway). Thus, we can see how complicated this can be and why medical management of pruritus is not as simple as a single medication that will stop the itch for all pets, regardless of etiology. It just isn't that simple.^3–5,7,8

Differentials

Causes of itchiness are varied and can manifest as a primary problem or as secondary infections in the skin (e.g., Cushing's disease, diabetes), neoplastic skin disease, or infectious causes, including ectoparasites, ringworm, or bacterial or Malassezia dermatitis. Finally, we can see pruritus secondary to a bite hypersensitivity such as flea allergy dermatitis, food allergy, atopy, or contact allergies.^1,2,9

Diagnostics

A deep dive on diagnostics is a topic for another day. However, remember to perform a minimum database, including skin scraping, impression smears, dermatophytosis testing, and/or ear cytology. Consider a food elimination trial, as we are appreciating a greater number of animals have food sensitivities than previously realized, manifesting as primary skin or GI signs, or both.^10–13 Remember, with food elimination trials, advise clients this includes: no outside foods, no treats, no people food, and ensure during the trial, no oral flea/tick/heartworm preventatives, chewable supplements, chewable NSAIDs, or even chewable anti-pruritic meds are administered. Additional diagnostics, such as a skin biopsy or culture, may be warranted later.

While a discussion of skin diagnostics is beyond the scope of this article, we should ensure we are not simply throwing medications at a clinical sign; instead, we seek to treat or cure a condition (when feasible). This, therefore, improves our ability to minimize signs, improve quality of life, and, in combination with proper client education (atopy/allergic diseases usually aren't cured but are managed), improve outcomes.

Scratch the itch: Eight therapy options

When it comes to treating pruritus, identifying the underlying condition and treating it, systemic endocrine disease, infection, be it primary or secondary (e.g., Malassezzia or bacterial), food allergy, atopic dermatitis, or immune-mediated, improves our success in managing the itch. However, in many conditions, we cannot fully cure the pet (e.g., atopy). Ensure owners understand this, as this will ultimately improve expectations and guide treatment goals for the individual client, patient, and you.

Varying evidence exists for the effectiveness of various therapies (from systematic reviews to randomized controlled trials to clinical experience alone. Utilize your knowledge, the 2023 AAHA Management of Allergic Skin Diseases in Dogs and Cats Guidelines,⁹ and additional references for evidence synthesis to stay informed about the most up-to-date treatment options and recommendations.

Treatments may include:^3,6,14–26

1. Topical shampoos and mousses (with variable ingredients); some simply act by "calming/soothing" the skin while others are medicated (e.g., anti-fungals, antibacterials) to manage secondary infections.^1,27–29However, use proper antimicrobial stewardship and think twice before reaching for antimicrobial-based shampoos without evidence of infection, as you could increase the risk of antimicrobial resistance (AMR) developing in that patient. Note: topicals should be used as first-line over oral agents when feasible, especially when considering antimicrobials, to minimize AMR and limit side effects on the microbiome.^30–36
2. Steroids (topical, oral, injectable) with varying degrees of side effects (of which owners must be properly educated and informed, and consent should be obtained before prescribing).
3. For on-label use in dogs, we have modulators of the immune system that work on cytokines and intracellular signaling pathways, e.g., ilunocitinib, oclacitinib,  and okivetmab.^{9,19–21,26,37–41}Why no anti-itch meds, like ilunocitinib, oclacitinib, or lokivetmab in cats? The expression of cytokines in feline allergic dermatitis is not as clear-cut as it is in dogs. Dogs express certain cytokines in allergic skin disease; hence, our ability to target these drugs.

   However, some research suggests cats fail to show a similar expression pattern, or in sufficient quantities, to warrant targeting these cytokines and permit a sufficient reduction in pruritus to support on-label use of these products in cats. Additional work in feline dermatological conditions and medication options is warranted.^26,42 That being said, however, oclacitinib has been used off-label with informed client consent in feline patients that fail other therapies. Research suggests efficacy and overall safety, but additional studies are needed.²¹

4. Immunosuppressive therapy, e.g., modified cyclosporine,⁴³ which is FDA-approved in dogs for atopic dermatitis and in cats for feline allergic dermatitis (aka feline atopic skin syndrome). While steroids and immune modulators can be effective within hours to days, this drug takes four to six weeks until therapeutic effects may be realized. Thus, for acute disease, it is not what we reach for; instead, it is used for long-term management and to minimize the recurrence of pruritus and other clinical signs.Numerous extra-label uses for additional skin, and many other conditions are recognized. Ensure you are using a bioavailable formulation, as several human options are not. Thus, recommendations for a modified (microemulsion) formulation are key to improving success rates.¹⁵
5. Allergen immunotherapy: The allergy shot or oral option.^9,26,44
6. Food elimination diet trials (novel protein or hydrolyzed protein diets): studies demonstrate the prevalence of adverse food reactions manifesting with cutaneous signs, e.g., pruritus (licking, scratching, overgrooming, alopecia) suggest it is warranted, if feasible with your pet and pet parent (financially, family cooperation, strict adherence is feasible, commitment).^11,12,45
7. Thinking along the lines of neuropathic pain and the close tie that pain and itch have neurologically, the use of gabapentin or its precursor, pregabalin, may have some benefit in managing pruritus,⁴⁶ though additional research is needed. Perhaps it is not working on the itch itself, but it does have anti-anxiety properties, since being itchy can increase arousal and be disturbing to anyone. Have you ever had pruritus? It can be painful. Thus, it is not unreasonable to treat the pain component of itch.³
8. Antihistamines: What about antihistamines, e.g., cetirizine? Most studies suggest antihistamines provide minimal benefit in most dogs and cats. Most specialists suggest the benefit as an anti-pruritic in animals is minimal. Thus, they are not generally recommended. That said, is it wrong for an owner, given the literature and the risks vs. benefits, to give it a try? That is a conversation for each vet with each individual pet-parent.^1,3,9

Each drug in our arsenal has pluses and minuses, variable time to onset, potential age restrictions, and contraindications based on possible concurrent or historical diseases. All have side effects and thus, ensuring you read up on each drug and understand the mechanism of action, risks, benefits, and properly educate your client, all can be beneficial in your anti-itch arsenal.⁹

Treatment considerations

When considering therapy, various factors need to be considered:^1,9

1. Primary disease: Is it treatable or just manageable?
2. Secondary disease, e.g., infection: Have we successfully managed it, or is more needed?
3. Medication selection: Varies with client and patient factors, including cost, ease of administration, frequency of administration, risk of side effects, including immunosuppression, administration concerns, and impacts to the pet's vaccination schedule (e.g., ilunocitinib, which carries a black box warning regarding vaccinations).^19,47
4. The client and family: Their wants, needs, abilities, and end goals
5. Finances
6. Underlying medical conditions: Does the cat you are about to put on steroids have a heart murmur? Is there evidence of hypertrophic cardiomyopathy? Did you warn your pet parent if underlying heart disease exists, use of a long-acting injectable steroid, for example, could increase the risk of congestive heart failure?^48,49Another consideration is a dog with severe DJD that takes NSAIDs regularly; steroids aren't going to be an option, and other choices need to be reviewed and discussed. What about that untreated canine Cushing's patient? We need to take underlying conditions into account, not just in treatment selection, but also in prognosis and in overall ability to improve health vs. provide a cure.

To scratch or not to scratch

Pruritus management is just that, general management. Ensuring clients understand most pruritus-causing conditions are manageable, not necessarily curable, with a few exceptions, is paramount. Thankfully, numerous options exist for managing our itchy pets. Selecting the right medication is sometimes a bit of a guesswork and trial-and-error process.

Ensure owners are well-informed about any side effects, benefits, restrictions (e.g., when doing a food trial), and expectations (cure vs. management). Keep up with the research and evidence-based recommendations for therapies. Ensure you utilize proper antimicrobial stewardship, try topical therapy when feasible first before reaching for orals. Discuss options with pet parents for managing pruritus; cost, frequency of administration, and other factors that may influence an owner's selection of therapy and adherence to our recommendations to ensure a successful health outcome and a much more comfortable pet.

Erica Tramuta-Drobnis, VMD, MPH, CPH, is the CEO and founder of ELTD One Health Consulting, LLC. Dr. Tramuta-Drobnis works as a public health professional, emergency veterinarian, freelance writer, consultant, and researcher. She is passionate about One Health issues and believes pet health, food safety, agricultural health, and more can address the interconnection of human, animal, and environmental health.

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