Approach

Most cases of PR are self-limited and require no treatment. Reassurance is offered and topical emollients may diminish the appearance of scale.[11] For patients with pruritus, treatment is symptomatic. However, there is an inadequate evidence base to support the use of the treatments currently used in clinical practice.[11]

Mild to moderate symptoms

Oral antihistamines are used to reduce symptoms of pruritus. Nonsedating antihistamines (e.g., loratadine, fexofenadine, cetirizine) can be given in the morning, while sedating antihistamines (e.g., hydroxyzine) are usually given in the evening. In patients with symptoms causing constant itching that interferes with daily activities, low-to-mid-potency topical corticosteroids such as hydrocortisone may also be used, depending on the severity of the rash and symptoms.[11][22]

Severe or refractory symptoms

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 the short-term relief of pruritus; and/or higher-potency topical corticosteroids (e.g., triamcinolone).

Narrow-band ultraviolet-B (UVB) may also be used.[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]

Refractory to all other treatments

For select patients resistant to all other therapies, the use of systemic corticosteroids may be considered, although such use remains controversial.[11][22][28][29] Reserve prednisone for patients in severe discomfort from this condition, and who are refractory to topical corticosteroids and antihistamines. It should be noted that this may help symptoms, but will not shorten the disease course or improve the appearance of the lesions.

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