What is the treatment for a patient with a pruritic (itchy) rash of one week's duration?

Treatment of Pruritic Rash (One Week Duration)

Start with regular emollients applied at least once daily to the entire body, followed by topical corticosteroids (hydrocortisone 1-2.5% for face, medium-to-high potency steroids for body), and if symptoms persist beyond 2 weeks or worsen, add a non-sedating antihistamine. 1, 2

Initial Management Approach

First-Line: Emollients and Moisturizers

• Apply emollients at least once daily to prevent xerosis, which commonly triggers pruritus 2
• Use oil-in-water creams or ointments; avoid alcohol-containing lotions 2
• For elderly patients (>65 years), select moisturizers with high lipid content 1, 2
• Continue emollient use throughout treatment regardless of other interventions 1

Second-Line: Topical Corticosteroids

• For facial involvement: Apply hydrocortisone 1-2.5% cream 3-4 times daily 1, 3, 4
• For body involvement: Use medium-to-high potency topical steroids (mometasone furoate 0.1%, betamethasone valerate 0.1%, or triamcinolone) 1, 2
• Apply topical steroids for 2-3 weeks, then reassess 1
• Evidence shows 1% hydrocortisone produces 68% reduction in itch compared to placebo 4

Critical caveat: Avoid prolonged steroid use on the face to prevent skin atrophy; low-potency hydrocortisone only for facial application 1, 5

When to Escalate Treatment

Add Oral Antihistamines (If No Response After 2 Weeks)

• First choice: Fexofenadine 180 mg daily or loratadine 10 mg daily (non-sedating) 2, 5
• Alternative: Cetirizine 10 mg daily (mildly sedating) 2
• Short trial of non-sedating antihistamine is appropriate for generalized pruritus without obvious cause 1

Important warning: Avoid long-term sedating antihistamines except in palliative care due to dementia risk 1, 5

Alternative Topical Options

Topical Calcineurin Inhibitors (For Atopic Dermatitis)

If the rash appears consistent with atopic dermatitis:

• Tacrolimus 0.03% or 0.1% ointment twice daily 1
• Pimecrolimus 1% cream for mild-to-moderate disease 1
• These agents show 53% improvement in 7 days versus 20% with placebo 1
• Superior to hydrocortisone in pediatric studies with 56% EASI score reduction versus 27% 6

Adjunctive Topical Agents

• Menthol 0.5% preparations for symptomatic relief 2, 5
• Urea or polidocanol-containing lotions 2

Red Flags Requiring Further Investigation

Refer to specialist or investigate further if:

• No response to emollients plus topical steroids after 2 weeks 1
• Patient is distressed despite primary care management 1
• Diagnostic uncertainty exists 1
• Elderly patients with persistent pruritus after 2-week trial should be reassessed for asteatotic eczema or underlying conditions 1, 5

Specific Clinical Scenarios

If Rash Appears Eczematous in Elderly

• Trial emollients plus topical steroids for at least 2 weeks to exclude asteatotic eczema 1, 5
• High lipid content moisturizers preferred 1
• Consider gabapentin if no response 1

If Superadded Infection Suspected

• Add topical antibiotics in alcohol-free formulations for at least 14 days 1
• Consider oral antibiotics (tetracycline ≥2 weeks) if extensive 1

Treatment Algorithm Summary

1. Week 1: Emollients daily + topical corticosteroids (hydrocortisone 1-2.5% face, medium-high potency body) 3-4 times daily 1, 2, 3
2. Week 2-3: Continue above; if no improvement, add non-sedating antihistamine 1, 2
3. Week 4+: If refractory, consider tacrolimus/pimecrolimus or refer to dermatology 1

The evidence strongly supports this stepwise approach, with high-quality guidelines from the American Academy of Dermatology and British Association of Dermatologists consistently recommending emollients plus topical steroids as first-line therapy. 1, 2