Successful Treatment of Intractable Palmoplantar Pruritus With Ondansetron

A 61-year-old woman presented with a 2-year history of intense itching of her palms and soles. The irritation was relieved only by plunging her hands and feet into cold water. She would awaken at least 4 times per night to rub her hands and feet for 15 minutes before falling asleep again. Her symptoms were more marked in the summer compared with the winter. Her medical history included chronic obstructive pulmonary disease, hiatal hernia, nasal polyps, and 3 previous deep vein thrombi. She took sulfalene tablets and ipratropium bromide, albuterol, and beclomethasone dipropionate aerosol inhalers during the winter for her bronchitis. On examination, her hands and feet appeared healthy. There were no color changes, dryness, or abnormal neurologic symptoms. Investigation showed that the results of a complete blood cell count, electrolyte levels, liver function tests, immunoglobulin profile, total IgE level, and autoantibody profile all were within normal limits. A biopsy of the palm showed a mild chronic inflammatory infiltrate of the upper dermis, mild acanthosis, and no spongiosis. These changes were nonspecific and consistent with rubbing of the skin. A psychological assessment by a clinical psychologist showed no evidence for a psychosomatic cause of her pruritus. The following treatments were tried for several months per treatment, one after another: 0.5% to 2% menthol in aqueous cream (BP cream, Hillcross Pharmaceuticals, Briercliff, England), 30% emulsifying ointment in purified water, various emollients, oral antihistamines, 10% crotamiton cream twice per day (Emla cream, Astra, Westboro, Mass), 2.5% lignocaine hydrochloride and 2.5% prilocaine hydrochloride cream twice per day, 0.05% clobetasol propionate cream under occlusion twice per day, oral doxepin hydrochloride, 75 mg/d, carbamazepine, 200 mg twice per day, and topical 0.07% capsaicin cream twice per day, all without beneficial effect. She also underwent a twice-weekly course of local UV-B phototherapy for 6 weeks and a twice-weekly course of UV-A phototherapy with topical psoralen paint for 10 weeks, but both of these treatments were ineffective. THERAPEUTIC CHALLENGE