What is your approach to treating dermatomyositis patients with pruritus recalcitrant to oral and topical steroids?

I find this issue of pruritus is best handled by getting better control of the cutaneous inflammatory disease. In this regard, typical DMARD agents (e.g. MTX, mycophenolate, etc) can be helpful in addition to IVIG or even JAK inhibitors. Obviously, all a risk/benefit assessment depends on how debilitating the itch is.

You can try to address the itch, per se, but it is often not very helpful. Using moisturizers (if not scalp itch) may provide some benefit. Immediate relief can be obtained with cool compresses (sometimes I have patients put clobetasol solution on their scalp at night and then go to bed with the head wrapped in a damp towel), topical menthol, or pramoxine containing lotions. Sometimes gabapentin can be helpful, especially at n...

I would also add that I have had some success adding compounded or off-label topical jak inhibitors (ruxolitinib or tofacitinib) as well as oral jak inhibitors (tofacitinib or Upadacitinib but sure that others could work as well). I have also had success adding dupilumab off-label as well. This is all in addition to traditional dermato therapies in my experience since these patients are often recalcitrant (like Dr. @Dr. First Last said, if they are well controlled they probably aren’t itchy).