Itch is an integral part of the clinical spectrum of superficial dermatophytosis, a common and rising problem in India¹.

While superficial fungal infections may not be life-threatening, these diseases have a significant effect on the patient’s quality of life. Along with painful or itching conditions that patients suffer from during the course of the disease, they also suffer from depression or anxiety conditions that may also develop². A few studies have also indicated that some patients also feel socially stigmatized due to their skin issues³.

A study conducted to assess the prevalence, intensity and clinical features of itch in superficial dermatophytosis showed that itch is not only an important symptom in superficial fungal infection of skin and nails, but it also has a negative impact on sleep and is linked to a significant psychosocial burden. 34.3% of participants reported difficulty in falling asleep while 54.6% complained of sleep awakenings¹. Another study reported young patients with atopic dermatitis suffering from poor sleep health and attention dysregulation³. It has also been reported that female patients were more influenced by dermal fungal infections compared to their male counterparts².

The itch can be defined as a “subjective unpleasant sensation leading to scratching.” The inflammatory response of the host to superficial dermatophytoses makes ‘itch’ an important, and persistent feature of the clinical manifestation of the condition. Itch is usually associated with a burning sensation and the most severe itch usually occurs during the evening. Itch is primarily responsible for sleep disturbances.  It is therefore important to address the factors exacerbating itch and find solutions to relieve itch. The best approach to managing itch effectively is¹;

1. Alleviate itch
2. Reduce scratching behavior
3. Prevent secondary bacterial infections.

Oral H1 antihistamines are frequently the first line of treatment for generalized itch. ⁵. Hydroxyzine is a competitive antagonist of histamine H1-receptors. Hydroxyzine is often the first line of treatment⁵. It is the earliest prescribed first-generation antihistamine drug for the mitigation of pruritic skin disease⁶. It is used in the management of itchy skin occurring secondary to allergic conditions such as chronic urticaria or atopic or contact dermatoses, and in histamine-mediated pruritus. It is the most efficacious and longest-acting antihistamine in suppressing the wheal and flare response to histamine⁷. Considering the sleep issues associated with dermatophytosis, hydroxyzine with its sedative effect can be beneficial in improving the quality of life of the patients. Hydroxyzine benefits patients suffering from nocturnal itch even if the itch is not mediated by histamine⁵.

In a study, it was shown that hydroxyzine has a significant effect on decreasing all the scores of pruritus including pruritus intensity, consequences, and the verbal descriptor. It was demonstrated to be an effective pharmaceutical therapy in decreasing pruritus⁸.

An important advantage of hydroxyzine is that it is rapidly absorbed from the gastrointestinal tract following oral administration, with its action occurring within 15-30 minutes after administration. The typical side effects seen with hydroxyzine are those that are common to the anticholinergic histamine H1 antagonist class of drugs. These include dry mouth, constipation, and drowsiness⁷.

Clinical tips

1. Itch is one of the most common and persistent clinical manifestations of superficial fungal infections.
2. Hydroxyzine is an antihistaminic H1 antagonist that is used in the treatment of itch, wheal, and flare triggered by histamine.
3. The onset of action of hydroxyzine is 15 minutes, which helps in providing immediate relief to the patients.
4. Owing to its sedative effect, hydroxyzine is also beneficial in patients with nocturnal itch.

References

1. Verma S, Vasani R, Reszke R, Matusiak L, et al. Prevalence and clinical characteristics of itch in epidemic like scenario of dermatophytoses in India: a cross-sectional study. JEADV. 2020; 34: 180-183.
2. Nguyen SH, Nguyen LH, Vu GT, Nguyen CT, et al. Health-related quality of life impairment among patients with different skin diseases in Vietnam: A cross-sectional study. Int J environ Res Public Health. 2019; 16: 305.
3. Otasevic SA, Golubovic M, Dordevic M, Binic I, et al. The risk factors and quality of life of patients with superficial fungal infections. Presented at 8^th trends in medical mycology, organised under the auspices of EORTC-IDG and ECMM. 2019, Belgrade, Serbia.
4. Nina Y, Zhou B, Amanda N, Blackwell CK, et al. Parent report of sleep health and attention regulation in a cross-sectional study of infants and preschool-aged children with atopic dermatitis. Pediatric Dermatology. 2022; 39: 61-68.
5. Nowak D, Yeung J. Diagnosis and treatment of pruritus. Can Fam Physician. 2017; 63: 918-924.
6. Gober HJ, Ki KH, Yan K, Bailey AJ, et al. Hydroxyzine use in preschool children and its effect on neurodevelopment: A population-based longitudinal study. Front. Psychiatry. 2022; DOI: https://doi.org/10.3389/fpsyt.2021.721875
7. Kiningham KK. Hydroxyzine. xPharm: the comprehensive pharmacology reference. 2007. 1-5.
8. Nakhaee S, Nasiri A, Waghei Y, Morshedi J. Comparison of Avena sativa, vinegar, and hydroxyzine for uremic pruritus of hemodialysis patients: a crossover randomized clinical trial. Iran J Kidney Dis. 2015; 9:316-322.