Treatment of Itchy Scalp Without Dandruff

Initial Assessment and Differential Diagnosis

The British Journal of Dermatology recommends starting with liberal emollient application and considering topical corticosteroids as first-line therapy, while systematically ruling out underlying causes including contact dermatitis, neuropathy, and medication effects 1, 2
Assess for medication-induced pruritus, particularly if the patient takes opioids, chloroquine, or has recently started new medications, as recommended by the British Journal of Dermatology 2, 4
Evaluate for neuropathic causes by checking for localized sensory changes or dermatomal distribution of symptoms, according to the British Journal of Dermatology 2, 4

Apply emollients liberally and frequently to the scalp, particularly after washing, to provide a surface lipid film that retards water loss, as recommended by the British Journal of Dermatology and BMJ 1, 2, 3
Consider topical clobetasone butyrate (moderate-potency corticosteroid) applied to affected areas once daily for 2-4 weeks, as recommended by the British Journal of Dermatology 1, 2
Topical menthol preparations may provide symptomatic relief through cooling effects, according to the British Journal of Dermatology 1, 2

Start with non-sedating H1 antagonists: fexofenadine 180mg daily or loratadine 10mg daily, or mildly sedating cetirizine 10mg daily, as recommended by the British Journal of Dermatology 1, 2
Consider combination H1 + H2 blockade: fexofenadine plus cimetidine may provide additive benefit, according to the British Journal of Dermatology 1, 2

Gabapentin or pregabalin may be considered for suspected neuropathic component, as recommended by the British Journal of Dermatology 1, 2
SSRIs (paroxetine, fluvoxamine) or mirtazapine may be considered for cases with psychological overlay or when neuropathic mechanisms are suspected, according to the British Journal of Dermatology 1, 2, 4

Refer if no response to optimized topical therapy after 4 weeks, as recommended by the British Journal of Dermatology 2
Refer if diagnostic uncertainty about whether subtle dermatosis is present, according to the British Journal of Dermatology 2
Refer if need for phototherapy (narrowband UVB) for refractory cases, as recommended by the British Journal of Dermatology 1, 4

Avoid prolonged use of potent topical corticosteroids on the scalp without breaks, as this can cause atrophy and rebound symptoms, as warned by the BMJ and British Journal of Dermatology 3, 6
Never use sedating antihistamines long-term due to dementia risk, as warned by the British Journal of Dermatology 2, 4