Pruritus, commonly known as itch, is a common and often distressing symptom that can profoundly affect various aspects of an individual’s life. Pruritus is categorized into acute and chronic forms, which can significantly impact daily functioning, emotional well-being, and sleep quality.¹ Chronic pruritus, characterized by itch symptoms persisting over six weeks, affects up to 22% of people at some point in their lives and is the chief concern for approximately 1% of hospital visits in the United States annually.^2,3

When addressing itch, it is essential first to identify and treat any underlying causes, whether infectious, inflammatory, or otherwise, as this approach is ideal for achieving symptom resolution. Pruritus has many causes, ranging from skin-related conditions to systemic diseases, making it a complex symptom to manage. Although powerful new therapies have revolutionized itch management, over-the-counter (OTC) treatments and techniques remain essential for many and are often used with powerful prescription therapies. This review will focus more broadly on accessible OTC therapies to manage itch.

Topical corticosteroids (TCS) are a cornerstone treatment for inflammatory skin conditions and are often used to alleviate pruritus by reducing inflammation, vasodilation, and immune cell infiltration in the skin.⁴ TCS vary widely in potency, ranging from lower-strength OTC options to more potent formulations requiring a prescription for more severe cases. OTC hydrocortisone is available in 0.5% and 1% formulations and is commonly used to relieve itching associated with minor skin irritations, insect bites, eczema, and allergic reactions.⁵ While generally considered safe, topical use of OTC hydrocortisone has been associated with cutaneous side effects, particularly on the face and folds, and younger children may be more susceptible to these effects.^5,6 Long-term continuous use of topical corticosteroids, even low-potency ones, is not recommended. Moreover, while low-potency formulations can give itch relief for some, many patients find them only modestly effective at best and generally ineffective when used outside of underlying inflammatory conditions. Table 1 summarizes some of the most commonly available OTC topical corticosteroids.

322238 Table 1.

Histamine, a key driver of itch, is released during various skin reactions and contributes to the discomfort associated with conditions like chronic pruritus, allergies, and insect bites, making antihistamines excellent OTC options for relieving pruritus.⁷ Antihistamines are available in both topical and oral forms. Diphenhydramine, the most widely available OTC first-generation antihistamine, is the only antihistamine available topically to treat itch, with its antipruritic effects supported by controlled studies.⁸ However, topical diphenhydramine should not be used on large body areas, as it may cause skin irritation, photosensitivity, and rash.⁹ Although severe complications are very rare, topical diphenhydramine has caused severe toxicity in infants, as illustrated by a 2½-year-old who developed severe CNS effects after calamine-diphenhydramine lotion was applied during a varicella rash.¹⁰ Although extremely uncommon, fatal outcomes have been reported, including a 3-year-old who died after diphenhydramine cream was repeatedly applied, resulting in lethal systemic absorption.¹¹ Topical antihistamines are discouraged explicitly in the American Academy of Dermatology guidelines for atopic dermatitis (AD), as they are known to be frequent sensitizers.¹²

Oral antihistamines are widely used to manage chronic itch from dermatological and non-dermatological conditions.¹³ Both first and second-generation antihistamines are viable options for treating pruritus OTC by targeting the same receptor. However, first-generation antihistamines cross the blood-brain barrier, leading to sedative effects. In contrast, second-generation antihistamines offer longer-lasting relief with less sedation.¹³ First-generation antihistamines like diphenhydramine have been proven more effective for managing chronic itch.¹⁴ Despite their sedative side effects due to crossing the blood-brain barrier, they may also mimic the relief of scratching by calming the brain areas responsible for itch perception.¹⁵

However, antihistamines present unique challenges when managing pruritus. While antihistamines are used as adjunctive treatments in certain chronic skin conditions, their effectiveness for treating itch associated with some conditions remains uncertain. Despite their widespread use in atopic dermatitis, few high-quality studies have demonstrated that antihistamines, particularly expensive non-sedating agents, provide significant relief from itch.¹⁶ Even sedating antihistamines, while sometimes beneficial for temporarily improving sleep, do not directly control AD symptoms or reduce itch meaningfully.¹⁷ This highlights the need for patients with chronic skin conditions to be cautious when considering antihistamines as a primary treatment for itch. Instead, they should discuss their symptoms with a healthcare practitioner to explore therapies that may offer greater long-term relief. Some widely used OTC antihistamines for itch relief are outlined in Table 2.

322239 Table 2.

Topical anesthetics, such as lidocaine, pramoxine, and benzocaine, are practical options for temporarily managing localized itch, particularly in neuropathic, facial, or anogenital pruritus cases.¹³ Lidocaine is available OTC in concentrations ranging from 2-10% in gels, solutions, ointments, and sprays that typically act within 1-2 minutes, reach peak efficacy at 5 minutes, and last about 15 minutes.¹⁸ Pramoxine is available in 1%-2% concentrations as creams, lotions, or gels, providing rapid relief from itch within 30 minutes by interfering with sensory nerve transmission.^19,20

Benzocaine is available in 6-20% concentrations as sprays, gels, gel patches, ointments, or solutions, with 20% formulations providing anesthesia within 30 seconds and lasting approximately 5 to 15 minutes after reaching full effect in 2 to 3 minutes.¹⁸ Topical anesthetics provide effective relief for itch. However, they may carry risks such as systemic toxicity, including methemoglobinemia and central nervous system, or cardiac side effects, especially when applied to large areas, damaged skin, or used for extended periods.^21,22 Therefore, their use requires careful consideration of the anatomic location, surface area treated, and duration of application.^13,21 Some of the most popular OTC topical anesthetics can be found in Table 3.

322240 Table 3.

Menthol is a natural compound used in dermatology for its antipruritic properties, providing a cooling sensation that helps alleviate itch.²³ At OTC concentrations up to 16%, menthol works by depressing sensory receptors at lower levels and stimulating them at higher levels, effectively acting as a counter-irritant to reduce itch.²⁴ Menthol’s cooling effect is most effective in low concentrations between 1-5%, and higher levels can sometimes lead to irritation, highlighting the importance of careful dosing for optimal relief.²⁵

Camphor, long used as an antipruritic, is often combined with other topical and systemic treatments despite limited research on its efficacy.^13,26 It is theorized that camphor creates its cooling sensation by stimulating nerve endings sensitive to cold and warmth by activating involved sensory pathways, which helps to relieve pain, itch, and irritation.²⁷ OTC camphor products are currently limited to a maximum concentration of 11%.²⁸

In addition to ingredients like menthol and camphor, direct skin cooling can also relieve itch. These include tools like metal roller-ball applicators, ice packs, and certain OTC products that create immediate skin cooling upon contact. Physical cooling can reduce skin temperature and temporarily interrupt itch signaling by decreasing the excitability of cutaneous nerve fibers.²⁹ Table 4 highlights some of the most frequently used OTC cooling agents for itch relief.

322241 Table 4.

Natural remedies can provide effective relief and valuable alternatives or complementary treatments. Many patients with chronic pruritus turn to herbal and natural remedies due to the limitations of conventional treatments, particularly when the cause of the itch is unclear or when standard therapies provide only partial relief.³⁰ Certain treatments work by directly modulating nerve pathways involved in itch perception, while others help restore the skin barrier and reduce inflammation.^30–32 Among these, aloe vera and capsaicin are two of the most widely used natural remedies for itch relief due to their distinct mechanisms of action and proven benefits.

Aloe vera is known for its hydrating, anti-inflammatory, and antimicrobial properties and is an effective natural remedy for relieving pruritus and promoting skin healing.³³ The polysaccharides contained within aloe vera help soothe inflamed skin, retain moisture, and support the skin barrier.³⁴ Clinical studies have suggested the potential benefit of using aloe vera for pruritus associated with burn injuries and atopic dermatitis, though the overall quality of evidence remains limited.^35,36 Aloe vera is generally well tolerated, but rare cases of allergic contact dermatitis have been reported, underscoring the need for caution in sensitive individuals.³⁷

Topical capsaicin, derived from chili peppers, is commonly used as a pain-relieving medication and provides antipruritic effects by targeting pathways involved in the sensation of itch.³⁸ Capsaicin is available OTC in concentrations ranging from 0.025% to 0.1% in cream and patch forms.¹³ During the initial implementation of capsaicin treatment, many patients commonly experience an initial burning sensation, pain, itch, stinging, and erythema due to neurogenic inflammation, which may impact adherence.^13,39

Tea tree oil, derived from Melaleuca alternifolia, has been shown to possess antimicrobial and anti-inflammatory properties, which remain its primary therapeutic uses.⁴⁰ Despite its popularity, evidence for tea tree oil as an antipruritic is limited, with small studies and case reports suggesting potential benefit in conditions such as dandruff and minor skin irritation.⁴⁰ However, its use requires caution, as tea tree oil has been associated with allergic contact dermatitis, particularly when applied to areas with a disrupted skin barrier, highlighting the importance of dilution and appropriate formulation.⁴¹

Calendula is a botanical preparation derived from Calendula officinalis that has long been recognized for its anti-inflammatory, antimicrobial, and wound-healing properties.⁴² Although it has been incorporated into topical creams marketed for irritated or itchy skin, evidence supporting its role as an antipruritic remains limited to small trials and traditional use.^30,33 Based on current evidence, calendula’s role in itch management remains more a reflection of tradition and consumer preference than of robust clinical evidence.

Beyond these well-established options, other natural remedies have been explored for their potential itch-relieving benefits. While some work through their anti-inflammatory or antimicrobial effects, others help by forming a protective barrier that soothes and restores irritated skin.³⁰ A variety of the most commonly used OTC natural remedies for pruritus are listed in Table 5.

322242 Table 5.

Moisturizers, emollients, and skin protectants are crucial in managing itch by maintaining skin hydration, reinforcing the skin barrier, and shielding irritated areas from environmental stressors. Moisturizers primarily function by increasing water content in the skin and preventing transepidermal water loss.⁴³ Emollients work by softening and smoothing the skin, helping to restore flexibility and comfort, particularly in dry or sensitive skin types.⁴⁴ Skin protectants form a physical barrier over compromised areas, reducing irritation and shielding the skin from further damage.⁴⁵ Some commonly available OTC moisturizers, emollients, and skin protectants can be found in Table 6. It is important to know that some ingredients have multiple mechanisms of action, and the classification is somewhat arbitrary here.

322243 Table 6.

Certain OTC antipruritic treatments do not fit into established pharmacologic classes. These products often contain multiple active ingredients with potential antipruritic properties, making it difficult to attribute their effects to a single mechanism of action. In some cases, the exact way these treatments relieve itch remains unclear.

OTC formulations containing aluminum acetate and strontium, some of which also include ceramides, are widely used for itch relief, though their exact mechanisms of action remain unclear. Research suggests that aluminum acetate may help alleviate pruritus through its astringent properties, which reduce skin irritation and inflammation.^46,47 While the precise pathways remain uncertain, clinical studies have demonstrated its effectiveness in managing itch.⁴⁷ Strontium has demonstrated strong antipruritic effects in non-histaminergic models like cowhage-induced itch, suggesting that it may work through pathways beyond histamine signaling.⁴⁶ Despite these agents’ growing popularity, further research is needed to understand their specific mechanisms of action fully.

Witch hazel, another widely used ingredient in OTC itch relief formulations, is believed to exert antipruritic effects through its astringent, anti-inflammatory, and antioxidant properties.⁴⁸ However, further research is needed to determine its effectiveness in reducing pruritus and to clarify the specific pathways through which it alleviates itch. These formulations and their proposed mechanisms of action are summarized in Table 7.

322244 Table 7.

In addition to getting a firm diagnosis and treatment for what drives the itch, managing pruritus often requires proper skin care, lifestyle adjustments, and strategic OTC treatments. A proactive approach to skin care, including regular hydration and protection, is essential to minimizing itch and preventing flare-ups. Maintaining skin hydration through regular use of emollients helps restore the skin barrier and prevents moisture loss that can be associated with itch.⁴⁹ Applying fragrance-free, hypoallergenic moisturizers immediately after bathing can significantly reduce itching and improve overall skin health.⁵⁰

Identifying and avoiding potential triggers is another key component of itch management. Common triggers include harsh soaps, fragrances, allergens, dry environments, and excessive heat, all of which can exacerbate symptoms. Patients with chronic or recurrent itch should note any external factors that may worsen their condition and modify their routine accordingly.

OTC treatments can provide significant relief when used appropriately. Topical corticosteroids, such as OTC hydrocortisone, can help reduce inflammation-driven itch but should only be used for short-term symptom relief due to the risk of skin thinning and other side effects with prolonged use.⁵ Antihistamines, both oral and topical, are another common option. Due to their sedating effects, first-generation oral antihistamines like diphenhydramine can be helpful, particularly for nocturnal itch.⁷ However, they should be used cautiously, especially in older adults or those operating heavy machinery. Second-generation antihistamines offer longer-lasting relief with less sedation, making them more useful for day-to-day treatment.¹³ Cooling agents like menthol and camphor and topical anesthetics such as lidocaine or pramoxine can also help alleviate itch through their counter-irritant effects.^13,23

Natural remedies, moisturizers, emollients, and skin protectants can provide alternative relief for patients seeking non-pharmacologic options. Some treatments reduce irritation and form a physical barrier, shielding compromised skin from further stressors.^30,45 Others can increase water content in the skin, preventing transepidermal water loss and helping soften and smooth the skin, restoring flexibility and comfort, particularly in dry or sensitive skin types.^43,44

Patients should know that product formulation and delivery matter when choosing OTC itch treatments. A recent head-to-head study comparing a pramoxine hydrochloride-containing moisturizing cream with a colloidal oatmeal-based itch relief gel found that the gel provided a faster onset of relief and greater itch reduction at 8 hours.⁵¹ This study demonstrates the importance of differences in ingredients, texture, and even the application method, which can impact how quickly relief is felt and how satisfied patients are with the product. While this study showed greater efficacy for one product, patients should ultimately let their own experience guide decision-making. Individual responses can vary, and different active compounds and delivery methods may influence how quickly and effectively relief is achieved.

Despite the availability of effective OTC treatments, patients should be educated on when to seek medical attention. If itching persists beyond two weeks without improvement, worsens despite treatment, or is accompanied by additional symptoms such as skin changes, weight loss, or unexplained fever, an underlying systemic condition may be responsible. Patients with chronic dermatologic conditions should consult a healthcare professional to ensure their treatment plan aligns with long-term disease management.