Pruritus that is refractory to moisturizers and conservative measures can be treated with antihistamines or tricyclic antidepressants. Compared with the newer, nonsedating histamines, the older, sedating agents such as hydroxyzine (Atarax) and diphenhydramine (Benadryl) are more effective in controlling pruritus. 20 However, these agents can affect a child's ability to learn or an adult's ability to drive and work. 21 If drowsiness is a problem, a nonsedating antihistamine can be tried to see if it is effective. Tricyclic antidepressants such as doxepin (Sinequan) and amitriptyline (Elavil) also have an antihistaminic effect, induce sleep and reduce pruritus. 22
Occlusive therapy is highly effective. Apply the topical steroids mentioned above under subacute eczema and cover with a plastic wrap such as Saran wrap. The plastic dressing does not have to be airtight. Secure the dressing with tape on either end. A sock will hold the plastic dressing against a foot. The dressing may stay on for 2 hours or overnight. Remove the dressing and apply an emollient or more medication. It is not necessary to wash the skin each time a plastic dressing is applied. The appearance of pustules indicates a secondary infection. Stop treatment and prescribe topical or oral antibiotics for this side effect of occlusive therapy.