How should I approach the management of a patient with cutaneous mastocytosis who presents with recurrent pruritus and skin lesions?

Management of a patient with cutaneous mastocytosis presenting with recurrent pruritus and skin lesions should focus on symptom control, prevention of mast cell degranulation, and monitoring for systemic involvement.

Initial management includes the use of non-sedating H1-antihistamines to reduce pruritus and skin symptoms, as these are first-line treatments to block histamine effects released by mast cells NICE CG57. For more severe or refractory pruritus, addition of H2-antihistamines or leukotriene receptor antagonists may be considered to further control symptoms Lippert 2017.

Topical therapies such as corticosteroids can be used cautiously to reduce inflammation and skin lesions, but long-term use should be avoided due to side effects NICE CG57. Emollients are recommended to maintain skin barrier function and reduce irritation NICE CG57. Patients should be advised to avoid known triggers of mast cell degranulation, including physical stimuli (heat, friction), certain medications (NSAIDs, opioids), and stress Lippert 2017.

In cases of solitary mastocytoma or limited cutaneous disease, surgical excision may be considered, especially if lesions are symptomatic or cosmetically concerning Cohen 2016. However, this is less common in diffuse cutaneous mastocytosis.

Regular clinical follow-up is important to monitor for progression or systemic involvement, which may require further haematological evaluation and specialist referral NICE CG57. Patient education on recognising anaphylaxis and having an emergency plan, including access to adrenaline autoinjectors if indicated, is essential Lippert 2017.

Overall, management is multidisciplinary and tailored to symptom severity, with emphasis on antihistamine therapy, trigger avoidance, and supportive skin care NICE CG57; Cohen 2016Lippert 2017.