Pruritus

Right Decision Service: Dermatology - Pruritus

Topical treatment of pruritus

Aqueous calamine cream is available via pharmacy first so patients should be directed there.

Crotamiton
Crotamiton 10% cream

Apply 2-3 times daily

Menthol
Menthol 1% in Aqueous cream

Apply 1-2 times a day

Prescribing Notes:

  • Pruritus may be caused by systemic disease, skin disease or as a side-effect of medication. Where possible the underlying cause should be identified and treated.
  • Anti-pruritics should be considered when an emollient on its own has been ineffective in relieving symptoms.
  • 1% menthol in aqueous cream is useful for patients with non-specific itch.
  • Menthol in aqueous cream is an appropriate choice for the elderly. A range of strengths are included as stinging may be associated with the higher strengths.
  • Topical antihistamines and local anaesthetics are not recommended as they are only marginally effective and can cause sensitisation.
  • Crotamiton is useful for pruritus persisting after treatment of scabies.
  • Emollient preparations may be useful for pruritus due to dry skin; sedating oral antihistamines may also be helpful for itch (see Allergy recommendations in the Respiratory chapter of the formulary).
  • Calamine is useful for itch associated with chickenpox.

History Notes

15/12/2021

East Region Formulary content agreed.

Oral antihistamines for the treatment of pruritis

Oral antihistamines can be used in combination with topical treatments.

Cetirizine
Cetirizine 10mg tablets

10mg daily.

Cetirizine 1mg/ml oral solution sugar free

10mg daily.

Loratadine
Loratadine 10mg tablets

10mg daily.

Loratadine 5mg/5ml oral solution sugar free

10mg daily.

Oral antihistamines can be used in combination with topical treatments. Sedating antihistamine can be helpful for troublesome nocturnal itch. Avoid in the elderly, chlorphenamine has strong anticholinergic effects – see prescribing notes

Chlorphenamine
Chlorphenamine 4mg tablets

Adult, 4mg every 4–6 hours; maximum 24mg per day.
Elderly, 4mg every 4–6 hours; maximum 12mg per day.

Chlorphenamine 2mg/5ml oral solution sugar free

Adult, 4mg every 4–6 hours; maximum 24mg per day.
Elderly, 4mg every 4–6 hours; maximum 12mg per day.

Oral antihistamines can be used in combination with topical treatments. Sedating antihistamine can be helpful for troublesome nocturnal itch. Avoid in the elderly, hydroxyzine has strong anticholinergic effects – see prescribing notes

Hydroxyzine
Hydroxyzine 25mg tablets

Adult, initially 25mg daily, dose to be taken at night; increased if necessary to 25mg 3–4 times a day.
Elderly, initially 25mg daily, dose to be taken at night; increased if necessary to 25mg twice daily.

Prescribing Notes:

  • Pruritus may be caused by systemic disease, skin disease or as a side-effect of medication. Where possible the underlying cause should be identified and treated.
  • Emollient preparations may be useful for pruritus due to dry skin.
  • Antihistamines (including non-sedative antihistamines) can cause day time somnolence, and patients should be aware of this potential side-effect, particularly in relation to driving or operating machinery.
  • If there is troublesome nocturnal itch, consider a short-term trial of a sedating oral antihistamine, such as chlorphenamine or hydroxyzine.
  • Sedating antihistamines such as chlorphenamine and hydroxyzine have strong anticholinergics effects and should be avoided in the elderly. Medicines with strong anticholinergics effects have long been linked to impaired cognition and falls risk, and more recently have also been linked to increased morbidity and mortality. Further information about anticholinergic load can be read in the Scottish Government Polypharmacy Guidance.

History Notes

15/12/2021

East Region Formulary content agreed.

Topical treatment of pruritus

Aqueous calamine cream is available via pharmacy first so patients should be directed there.


Menthol
Menthol 1% in Aqueous cream

For dose, refer to product literature.

Crotamiton is useful for pruritus persisting after treatment of scabies.

Crotamiton
Crotamiton 10% cream

For dose refer to BNF for children.

Prescribing Notes:

  • Pruritus may be caused by systemic disease, skin disease or as a side-effect of medication. Where possible the underlying cause should be identified and treated.
  • Anti-pruritics should be considered when an emollient on its own has been ineffective in relieving symptoms.
  • 1% menthol in aqueous cream is useful for patients with non-specific itch or for symptomatic treatment of hives in urticaria.
  • Topical antihistamines and local anaesthetics are not recommended as they are only marginally effective and can cause sensitisation.
  • Emollient preparations may be useful for pruritus due to dry skin; sedating oral antihistamines may also be helpful for itch (see Allergy recommendations in the Respiratory chapter of the formulary).
  • Calamine is useful for itch associated with chickenpox.

History Notes

31/05/2024

East Region Formulary content agreed.

Oral antihistamines for the treatment of pruritis

Prescribing Notes:

  • Pruritis without an underlying cause is uncommon in children. The underlying cause should be identified and treated, consider diagnosis and seek specialist advice if required. Regular oral antihistamine are rarely indicated.
  • Emollient preparations may be useful for pruritus due to dry skin.

History Notes

31/05/2024

East Region Formulary content agreed.

Pharmacy First - Allergy itch
Calamine + Zinc oxide
Aqueous calamine cream

Dose according to age and product licence.

Crotamiton
Crotamiton 10% cream

Dose according to age and product licence.

Menthol
AquaSoothe 1% cream

Dose according to age and product licence.

Topical corticosteroids.


Hydrocortisone
Hydrocortisone 1% cream

Dose according to age and product licence.

Clobetasone cream should only be used 2nd line in patients for the short term symptomatic treatment and control of patches of eczema and dermatitis.

Clobetasone
Clobetasone 0.05% cream

Dose according to age and product licence.

Oral treatment can be used in combination with topical treatments.


Cetirizine
Cetirizine 10mg tablets

Dose according to age and product licence.

Cetirizine 1mg/ml oral solution sugar free

Dose according to age and product licence.

Loratadine
Loratadine 10mg tablets

Dose according to age and product licence.

Loratadine 5mg/5ml oral solution

Dose according to age and product licence.

Chlorphenamine
Chlorphenamine 4mg tablets

Dose according to age and product licence.

Chlorphenamine 2mg/5ml oral solution

Dose according to age and product licence.

Chlorphenamine 2mg/5ml oral solution sugar free

Dose according to age and product licence.

Prescribing Notes:

  • Emollient preparations may be useful for pruritus due to dry skin.
  • Sedating oral antihistamines may also be helpful for itching in patients over 1 year of age.
  • Crotamiton is useful for pruritus persisting after treatment of scabies.
  • Acute urticaria is usually self-limiting and, if mild, treatment is often unnecessary. Sedating oral antihistamines may be particularly helpful if sleep is disturbed.
  • Topical corticosteroids are not recommended in urticaria, rosacea, acne or undiagnosed, possibly infective, disorders.
  • Topical corticosteroids should not be supplied for application to the face or on broken skin. Refer to GP instead.
  • Topical corticosteroids should be applied thinly, only to the affected area, for a maximum of 7 days. If the condition does not improve, the patient should be referred to a GP.
  • A once daily application is often sufficient but topical corticosteroids should not be used more than twice a day.
  • Hydrocortisone should not be used in those aged under 10 years, clobetasone should not be used in those aged under 12 years.
  • To minimise the risk of side effects, the smallest effective amount should be used, reducing strength and frequency of application as the condition settles. The risk of systemic side effects increases with prolonged use on thin, inflamed or raw skin surfaces, use in flexures, or use of more potent corticosteroids.
  • Topical corticosteroids should not be used on infected skin unless the infection is being treated. Palms and soles may require potent or very potent steroids.

History Notes

19/12/2024

Arjun 1% cream removed, content agreed ERFC Dec 2024

16/06/2022

Menthol formulations updated to reflect the 15th Edition (May 2022) of the NHS Pharmacy First Scotland Approved List of Products.

27/10/2020

Content migrated from ‘East Region Formulary: Pharmacy First - supporting minor ailments’ document.