Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

mild-to-moderate symptoms

1st line – reassurance + emollients

Back
ACUTE
|
mild-to-moderate symptoms
1st line – 

reassurance + emollients

Most cases of PR are self-limiting and require no treatment; however, provide reassurance.

Topical emollients may diminish the appearance of scale.[11]

Plus – antihistamines

Back
ACUTE
|
mild-to-moderate symptoms
Plus – 

antihistamines

Treatment recommended for ALL patients in selected patient group

Oral antihistamines are used to reduce symptoms of pruritus.

Non-sedating antihistamines (e.g., loratadine, fexofenadine, cetirizine) can be given in the morning, while sedating antihistamines (e.g., hydroxyzine) are usually given in the evening.

Primary options

loratadine: 10 mg orally once daily

OR

fexofenadine: 180 mg orally once daily

OR

cetirizine: 10 mg orally once daily

OR

hydroxyzine: 10-25 mg orally once daily at night

Consider – low-to-mid-potency topical corticosteroids

Back
ACUTE
|
mild-to-moderate symptoms
Consider – 

low-to-mid-potency topical corticosteroids

Additional treatment recommended for SOME patients in selected patient group

In patient with symptoms causing constant itching that interferes with daily activities, low-to-mid-potency topical corticosteroids may be used, depending on the severity of the rash and symptoms.[11][22]

Primary options

hydrocortisone topical: (2.5%) apply sparingly to the affected area(s) twice daily for 2 weeks

severe or refractory disease

1st line – doxepin and/or higher-potency topical corticosteroid

Back
ACUTE
|
severe or refractory disease
1st line – 

doxepin and/or higher-potency topical corticosteroid

For patients with more severe symptoms, or those unresponsive to lower-potency therapies, more potent antipruritic agents may be beneficial. These include: doxepin, a tricyclic antidepressant with limited evidence to support its use for short-term relief of pruritus; and/or high-potency topical corticosteroids (e.g., triamcinolone).

Primary options

doxepin: 10 mg orally once daily at night; (5% cream) apply to the affected area(s) up to four times daily

and/or

triamcinolone topical: (0.1%) apply sparingly to the affected area(s) twice daily for 2 weeks

Consider – narrow-band ultraviolet-B (UVB)

Back
ACUTE
|
severe or refractory disease
Consider – 

narrow-band ultraviolet-B (UVB)

Additional treatment recommended for SOME patients in selected patient group

Narrow-band UVB may be used in severe or refractory disease.[22]

This requires a significant commitment by the patient to attend all sessions. However, there is no good evidence that UVB results in shortening of duration or improvement of symptoms.[11]

The mechanism of action of light therapy is cross-linking DNA to prevent DNA synthesis, and inhibiting activity and action of inflammatory cells in the skin.

Most common adverse effects are phototoxicity and small theoretical increased risk of skin cancer if therapy is prolonged.

refractory to all other treatments

1st line – systemic corticosteroids

Back
ACUTE
|
refractory to all other treatments
1st line – 

systemic corticosteroids

Reserve prednisolone for patients in severe discomfort, and those who are refractory to topical corticosteroids and antihistamines, although such use remains controversial.[11][22][27][28]

It should be noted that prednisolone may help symptoms, but will not shorten the disease course or improve the clinical appearance of the lesions.

Despite this, it should be noted that some physicians do not advocate the use of prednisolone in PR.

Primary options

prednisolone: 1 mg/kg/day orally for 4 days, followed by gradual taper over 2 weeks, maximum 60 mg/day

back arrow

Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer