Chronic pruritus in the adult patient is both an underappreciated and a difficult to treat condition. In the vast majority of cases, itch is the result of inflammatory skin disease and therefore may be responsive to systemic anti-inflammatory therapies. Urticarial dermatitis is an under-recognized cause of chronic itch in the adult population. Patients with this disorder are characterized by prolonged, prednisone-responsive pruritus, often in the absence of substantial cutaneous findings. Skin findings, when present, can range from subtle, persistent urticarial lesions to excoriated papules, often intermixed with urticaria, eczematous change, and lichenification secondary to chronic scratching. Hereby, we describe our algorithm for evaluation and management of adult patients with refractory pruritus (urticarial dermatitis in particular), including evaluation for other etiologies of pruritus, pre-immunosuppression workup, and the use of azathioprine and other steroid-sparing agents for treatment of recalcitrant itch.