Clinical Impression

1. Chronic Kidney Disease-Associated Pruritus (CKD-aP) - the primary driver
2. Acquired Perforating Dermatosis (APD) - the reddish-brown keratotic papules with central cores seen on scratching/picking

Causes / Pathogenesis of CKD-Associated Pruritus

Why the Reddish-Brown Papules?

Management

Step 1 - Optimize Dialysis & Address Mineral Metabolism

• Ensure adequate dialysis (high-permeability membranes preferred)
• Control serum phosphate, calcium, PTH
• Correct anemia, albumin, and inflammatory markers

Step 2 - Skin Care (essential baseline)

• Gentle skin care with fragrance-free emollients (petroleum jelly, urea-based creams) applied after each dialysis session to treat xerosis
• Avoid hot water bathing, harsh soaps

Step 3 - Pharmacological Treatment

• Narrowband UVB phototherapy (3x/week) - well established, can be combined with other treatments

• Activated charcoal 6g orally daily
• Montelukast 10 mg daily
• Ondansetron (limited evidence)
• Antidepressants (mirtazapine for nighttime itch)

Step 4 - For Acquired Perforating Dermatosis (the reddish-brown papules)

• Controlling the underlying itch is the most important step (stops the scratch-perforate cycle)
• Topical corticosteroids (moderate potency) on active lesions
• Cryotherapy for individual keratotic nodules
• Narrowband UVB (also treats both CKD-aP and APD simultaneously)
• Allopurinol has been reported helpful in some APD cases
• Lesions may resolve spontaneously if itching is controlled

Summary Prescription Approach

For a 26-year-old HD patient:

1. Gabapentin 100 mg PO after each dialysis session (titrate to 300 mg if tolerated)
   OR Difelikefalin 0.5 mcg/kg IV at end of each HD session

2. Emollient moisturizer (urea 10% or petroleum-based) twice daily

3. Moderate-potency topical corticosteroid (e.g., triamcinolone 0.1% cream)
   to active APD lesions twice daily x 2 weeks

4. Narrowband UVB phototherapy if above insufficient after 4-6 weeks

5. Address metabolic triggers: optimize phosphate/PTH control

Prescription - India Brand Names

STEP 1 - FIRST LINE (Antipruritic - Neuropathic)

Start with 25 mg at night in dialysis patients and titrate slowly. Prefer pregabalin over gabapentin - Indian data shows equal efficacy with less somnolence at low doses.

STEP 2 - SKIN CARE (Mandatory Baseline)

STEP 3 - TOPICAL FOR PERFORATING DERMATOSIS LESIONS (Reddish-Brown Papules)

STEP 4 - TOPICAL CAPSAICIN (For localized persistent itch)

STEP 5 - IF INADEQUATE RESPONSE (Second-line Systemic)

SAMPLE PRESCRIPTION FORMAT

Rx

1. Tab. Pregabalin (Lyrica/Pregalin) 25 mg
   - 1 tab at bedtime
   - Increase to 75 mg after 2 weeks if tolerated

2. Lacticare Lotion / Moisturex Soft Cream
   - Apply twice daily all over body after bathing

3. Elocon (Mometasone 0.1%) Cream
   - Apply to brown papular lesions twice daily x 2 weeks

4. Tab. Nodict (Naltrexone) 25 mg
   - 1/2 tab once daily (if itch not controlled in 4 weeks)

5. Refer for Narrowband UVB phototherapy
   - 3 sessions/week x 6-8 weeks
   (Available at dermatology centers - treats both CKD-aP and perforating dermatosis)

Important Notes for This Patient

• Difelikefalin (Korsuva - the most effective kappa-opioid agonist for HD pruritus) is not yet available in India as of 2025-26. It is FDA-approved (US) but not yet approved by CDSCO.
• Avoid antihistamines (Avil, Allegra, Cetrizine) as monotherapy - they are ineffective for CKD-aP and only cause sedation.
• Hydroxyzine (Atarax) can be used at night for its sedative + mild antipruritic effect in resistant cases.
• Monitor for dizziness and sedation with gabapentin/pregabalin, especially post-dialysis - fall risk is real.
• Optimize dialysis adequacy and control phosphate (use Renvela/Phosvisc sevelamer if phosphate high).