Treatment of Pruritic Scalp
For a pruritic scalp, begin with emollients and topical corticosteroids (moderate-to-high potency) as first-line therapy, followed by medicated shampoos containing antifungal agents or corticosteroids if initial treatment fails. 1
Initial Management Approach
First-Line Topical Therapies
Apply emollients liberally to maintain skin hydration and address any underlying xerosis that may be contributing to pruritus 1, 2
Use moderate-to-high potency topical corticosteroids such as clobetasone butyrate or mometasone furoate 0.1% ointment for localized pruritus 1
Consider topical menthol 0.5% as an antipruritic agent for mild-to-moderate symptoms 1
Topical doxepin may be prescribed but must be limited to 8 days of use, applied to no more than 10% of body surface area, with a maximum of 12g daily due to risk of allergic contact dermatitis 1, 2
Medicated Shampoo Options
Corticosteroid shampoos (clobetasol propionate 0.05% shampoo) are highly effective for scalp psoriasis and seborrheic dermatitis, applied once daily 3
Antifungal shampoos containing ketoconazole are the mainstay for seborrheic dermatitis of the scalp, which commonly presents with scaling, erythema, and itching 4
Zinc pyrithione-based shampoos with potentiated formulations demonstrate superior anti-fungal potency and clinical efficacy for dandruff-related pruritus and flaking 5
Tar shampoos can be effective for long-term maintenance of psoriasis remission 3
Second-Line Systemic Therapies
If topical treatments fail after 2 weeks, escalate to systemic options:
Antihistamines
Start with non-sedating H1 antihistamines such as fexofenadine 180 mg or loratadine 10 mg for daytime use 1, 2
Mildly sedative agents like cetirizine 10 mg can be considered as an alternative 1, 2
First-generation sedating antihistamines (diphenhydramine 25-50 mg or hydroxyzine 25-50 mg) may be used for nighttime pruritus but should be avoided long-term except in palliative care due to dementia risk 1, 2
Neuromodulatory Agents
Gabapentin (900-3600 mg daily) or pregabalin (25-150 mg daily) can be used as second-line treatment when antihistamines fail, though gabapentin should be avoided in hepatic pruritus 1, 2
These agents work peripherally by reducing calcitonin gene-related peptide release and centrally through modulation of μ-opioid receptors 1
Antidepressants
- SSRIs such as paroxetine, fluvoxamine, or mirtazapine may provide relief for refractory pruritus 1, 2
Important Caveats and Pitfalls
Avoid These Treatments
Do NOT use crotamiton cream for generalized pruritus as it lacks significant antipruritic effect 1
Do NOT use topical capsaicin or calamine lotion for generalized pruritus without underlying dermatosis 1
Avoid lindane entirely—it is no longer recommended due to central nervous system toxicity and seizure risk 1
Post-Treatment Considerations
Persistent itching after treatment is common and rarely indicates treatment failure—it reflects ongoing inflammation rather than active disease 6
Approximately 75% of patients with persistent pruritus at 2 weeks will have resolution by 4 weeks without additional intervention 6
Topical corticosteroids and oral antihistamines can help manage post-treatment inflammatory pruritus 1
When to Refer
Refer to dermatology if there is diagnostic uncertainty or if primary care management does not relieve symptoms after appropriate trials 1, 2
Consider underlying systemic causes (renal, hepatic, hematologic, malignancy) if pruritus is generalized and persistent despite treatment, particularly in older patients 2, 7, 8