What are your preferred treatment options for patients with cholestatic pruritus who do not respond to light therapy?

• Initially treat with a bile acid sequestrant such as cholestyramine (total daily dose of 4 to 16 grams)
• If this does not provide adequate relief switch to rifampin (150 to 300 mg twice daily)
• If symptoms persist, then switch to naltrexone (12.5 to 50 mg/day)
• Switching to sertraline (75 to 100 mg daily) or phenobarbita...

Dupilumab is in trials and for one of my patients was an absolute game changer. Worth a shot!

Treatment of cholestatic disorders is a rapidly-changing area in gastroenterology. Use of new treatments such as maralixibat and bezafibrate to modulate bile acid transport and secretion is generally beyond the scope of what we dermatologists are going to do, but GI may be able to help there. I generally rely on rifampicin (watch LFTs--can cause liver injury in cholestatic patients) and oral naltrexone. Naltrexone is hit or miss; it either works well or not at all. Mirtazapine in low doses (7.5 ...