How should I manage a patient with pityriasis rosea who is experiencing significant pruritus?

Management of significant pruritus in pityriasis rosea primarily involves symptomatic relief, as the condition is self-limiting and usually resolves within 2–3 months without specific treatment NICE CKS. For itch relief, start with emollients to moisturise the skin and reduce dryness and scaling, which can exacerbate itching NICE CKS. If pruritus persists, consider topical corticosteroids: a mildly potent corticosteroid such as hydrocortisone 1% or a moderately potent corticosteroid like betamethasone valerate 0.025% or clobetasone 0.05% applied once or twice daily for up to 4 weeks, with potency chosen based on itch severity NICE CKS.

Oral antihistamines may be offered off-label, particularly sedating antihistamines such as chlorphenamine at night if itching disrupts sleep; however, if no improvement occurs after 2 weeks, discontinue the antihistamine NICE CKS. It is important to note that oral corticosteroids are not recommended in primary care for pityriasis rosea and should only be considered under specialist advice if severe itch is refractory to topical treatments and antihistamines NICE CKS.

If the diagnosis is uncertain, the rash is atypical, or the itch is severe and uncontrolled by these measures, referral to dermatology is advised NICE CKS. Secondary care may consider antiviral treatments or phototherapy for severe or refractory cases, although high-quality evidence for these is limited Chuh 2016Sterling 2016Villalon-Gomez 2018.

In summary, management focuses on reassurance about the benign and self-limiting nature of pityriasis rosea, use of emollients, topical corticosteroids for itch, and short-term sedating antihistamines if sleep is affected, with specialist referral if symptoms are severe or atypical NICE CKS Chuh 2016Mashoudy et al. 2025.