Itch - Management in Clinical Practice

J. Szepietowski, E. Weisshaar

• Publisher: S. Karger
• Year: 2016
• ISBN:
  9783318058895
• Topic: Medizin
• Subtopic: Nephrologie

Albeit a very common symptom in dermatology, internal medicine, psychosomatics, neurology, and even oncology, itching was under-researched up until 15 years ago. Since then, the clinical aspects of acute and chronic itch have been examined extensively. As a result, some books on the topic have become available. Whereas most publications focus on experimental aspects and diagnostics, this volume of the series 'Current Problems in Dermatology' provides a comprehensive overview regarding the management of chronic itch. Select authors consider interdisciplinary aspects as well as age, body region, and specific diseases as they present a great variety of available treatments. All physicians with patients suffering from itch – especially dermatologists, general practitioners, gerontologists, nephrologists, hepatologists, neurologists, and palliative care doctors – will find this publication to be an essential source of information.

Szepietowski JC, Weisshaar E (eds): Itch - Management in Clinical Practice.
Curr Probl Dermatol. Basel, Karger, 2016, vol 50, pp 173-191 (DOI: 10.1159/000446090)

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Itch Management in Childhood

Regina Fölster-Holst

Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany

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Abstract

Itch in children is a very common symptom and is mainly related to a skin disease rather than an underlying systemic disorder. The most common dermatoses include atopic dermatitis, contact dermatitis, insect bites, scabies, and pediculosis capitis. There are specific diagnostic patterns which require the evaluation of a careful history and dermatological examination. For dermatological treatment, we have to consider that children, especially infants, show differences in physiology and pathophysiology, and also in pharmacokinetics and pharmacodynamics compared with adults.

© 2016 S. Karger AG, Basel

Itch (pruritus) is a common symptom in children and therefore it is surprising that there are no data on the prevalence of itch in childhood regarding the general population. After searching for ‘itch and children’ and ‘pruritus and children’ in PubMed (up to March 9, 2016) there were 2,629 and 2,136 publications, respectively, but in the majority they were related to specific diseases and usually included case reports. Pruritus in childhood is mainly associated with dermatoses. Systemic diseases and drug reactions are rare compared with adults. Itchy dermatoses in childhood include eczematous diseases (especially atopic dermatitis), exanthemas, infestations/infections, urticaria/mastocytosis, autoimmune diseases, as well as genodermatoses. For dermatologic treatment (topical and systemic), we have to consider special features in childhood regarding physiology and pathophysiology, and also pharmacokinetics and pharmacodynamics, which differ from those of adults.

Special Features of Skin Physiology, Pathophysiology, and Skin Care of Early Childhood That Should Be Considered in Treatment

We have to consider special features regarding skin physiology and pathophysiology in childhood, mainly in young infants. The high ratio of body surface to body weight [1] determines the absorption of topically applied drugs and emollients. In addition, the skin of infancy is characterized by a thinner epidermis and stratum corneum, and also by smaller corneocytes [1, 2]. Physical measurements of the epidermal barrier function show that natural moisturizing factors and surface lipid concentrations of infant skin are reduced compared with adults. In addition there are high pH, high desquamation, high proliferation rates, and higher transepidermal water loss [3]. These findings lead to impaired epidermal structure and function, resulting in high absorption of topically applied drugs and high penetration of environmental factors such as irritants, allergens, and infectious agents [4]. We should consider these facts in the treatment of infants in general, and especially in those infants who suffer from diseases with a known barrier defect as atopic dermatitis [5]. However, besides the properties of the skin barrier, the percutaneous absorption of drugs and topical agents of the emollients is related to the physical and chemical characteristics of the drug [6]. Emollients in early childhood should be free of perfumes, dyes, and preservatives, which are known for their risk of irritation and allergenicity. Although emollients do not have antipruritic properties in general, they lubricate and moisturize the skin, protect the integrity of the stratum corneum and of the skin barrier, and treat dry skin [7]. There are studies that have shown relief of itching using emollients [8, 9].

Special Features of History, Dermatological Examination, and Diagnoses in Childhood

Medical care in childhood is in many ways different from that in adulthood. To get reasonable statements during the anamnesis, adequate contact to both child and parents is necessary. When the children are of preschool/school age, the questions should be addressed to both the parents and the children, including regarding itch. The dialogue between the patient and the doctor is the basis of a good bond of trust [4]. This also determines the adherence to treatment [4].

Anamnesis regarding questions for itch in children do not differ so much from those in adults. However, there are special issues to consider in this phase of life, including contact with other children, clothing, and vaccinations within the regular pediatric control examinations, everyday activities, and eating habits. When taking the history for itch in childhood, the following questions and examinations are helpful:

• Is the itch localized (regional infection, localized dermatosis) or generalized (symmetrical distribution in relation to generalized dermatosis or systemic disease)?

• Do other family members also suffer from itch?

• Is there a history of known diseases and/or allergies of the child and/or other family members (e.g. atopic diseases)?

• When did the sensation of itch begin and how is the quality of itch?

• Does the family have pets at home? In which environment does the child live?

• Is the child in a good general condition?

• Are there foods which are related to pruritus?

• Is there an infection related to pruritus?

• Is there emotional stress or a history of psychiatric disease?

• What products do the child/parents use for skin care? What are the child’s bathing habits (frequency per week, temperature, duration, etc.)?

• Does the child take drugs? If yes, which drugs, for which indication, how long already?

• Which clothes does the child wear (cotton, silk, wool, others)?

• Are there infections around (kindergarten, school, etc.)?

The clinical examination of the child differs from that of adults. This includes not only being able communicate on the child’s level, which requires inter alia a different language, but also the assessment of itch by the child. In the literature there are some itch assessment scales, which may be used in childhood, for example the itch assessment scale for the Pediatric Burn Survivor [10]. This ‘itch man scale’ correlates with other scales, for example the 5D itch scale and the visual analogue scale.

Table 1. Itchy eczematous diseases (selection)

Diseases	Clinical pattern	Age of onset
Dermatitis
Atopic dermatitis	eczema of the extremity folds, associated with asthma, allergic rhinitis, and food allergy	mainly in the first year of life
Contact dermatitis	eczema at the sites of contact	anytime
Seborrheic dermatitis in infancy	eczema of axillary, groins, and diaper area	in the first weeks of life
Infestations Scabies (infantile)	burrows, disseminated eczema (including face and head), pustules plantar	anytime
Pediculosis capitis	papules, pustules, eczema of head and neck	mainly in school age
Genodermatose...