What are the treatments for scalp itching?

Treatment of Scalp Itching

For scalp itching without an underlying rash, start with topical moisturizers and emollients to address dry skin, followed by topical corticosteroids (hydrocortisone 1-2.5% or clobetasol propionate 0.05% solution for more severe cases), with oral antihistamines added for persistent symptoms. 1, 2

Initial Assessment and First-Line Topical Therapy

The cornerstone of managing scalp pruritus begins with addressing skin dryness, as this is a common underlying trigger. 1

• Apply adequate moisturizers and emollients to prevent or treat xerosis (dry skin), as this alone may resolve mild itching 1
• Avoid dehydrating practices such as hot showers, excessive soap use, and alcohol-containing lotions 1
• Use oil-in-water creams or ointments rather than drying formulations 1

For mild-to-moderate scalp itching that persists despite moisturization:

• Topical corticosteroids are the primary treatment: Apply hydrocortisone 1-2.5% to affected areas 3-4 times daily 1, 2
• Clobetasol propionate 0.05% solution is the preferred high-potency option for scalp application due to its effectiveness and cosmetic acceptability in solution form 3
• Alternative topical agents include menthol 0.5% preparations or lotions containing urea or polidocanol for soothing relief 1
• Mometasone furoate 0.1% ointment or betamethasone valerate 0.1% ointment are additional moderate-to-high potency options 1

Systemic Antihistamine Therapy

When topical treatments provide insufficient relief, oral antihistamines should be added:

• Non-sedating second-generation antihistamines (loratadine 10 mg daily, fexofenadine 180 mg daily, or cetirizine 10 mg daily) are recommended as first-line systemic therapy for daytime pruritus 1
• First-generation sedating antihistamines (diphenhydramine 25-50 mg daily or hydroxyzine 25-50 mg daily) may be considered specifically for nighttime itching due to their sedative properties 1

Second-Line Treatments for Refractory Cases

For patients who fail to respond to topical corticosteroids and antihistamines:

• Gabapentin (900-3600 mg daily) or pregabalin (25-150 mg daily) are antiepileptic agents that can provide relief through peripheral and central mechanisms 1
• These should only be used as second-line treatment after failure of antihistamines and topical therapies 1
• Topical doxepin (limited to 8 days, 10% body surface area, maximum 12 g daily) is a potent histamine antagonist option, though use should be restricted due to potential systemic absorption 1

Additional Considerations and Alternative Agents

For severe or widespread pruritus:

• Aprepitant (neurokinin-1 receptor antagonist, 80 mg daily) has shown benefit in refractory cases 1
• Systemic corticosteroids (0.5-2 mg/kg daily) may provide temporary relief for particularly severe pruritus but should be reserved for short-term use 1
• Antidepressants such as paroxetine, fluvoxamine, or mirtazapine may be considered in refractory cases 1

Special Considerations for Specific Scalp Conditions

If seborrheic dermatitis is suspected as the underlying cause:

• Ketoconazole 2% cream applied once or twice daily can be effective, with comparable efficacy to hydrocortisone for seborrheic dermatitis 4, 5
• Treatment duration is typically 2-4 weeks 4, 5

For scalp psoriasis presenting with itching:

• Clobetasol propionate 0.05% solution is particularly effective due to its high potency and scalp-appropriate vehicle 6, 3
• Coal tar preparations have potent anti-pruritic effects and can be used as adjunctive therapy 6, 7

Common Pitfalls to Avoid

• Do not retreat immediately for persistent itching after treatment initiation: Mild burning or itching from topical agents can persist for days after application and is not an indication for re-treatment 1, 8
• Topical corticosteroids and oral antihistamines can help manage this post-treatment inflammation 1, 8
• Avoid crotamiton cream and topical capsaicin as they lack evidence for efficacy in generalized pruritus 1
• Limit high-potency topical corticosteroid use to avoid potential adverse effects with prolonged application, though specific duration limits are not well-established 6, 7