Pruritus in Children: Clinical Diagnosis & Management Learning Tool
Clinical History Assessment
Systematic approach to history taking for a child presenting with pruritus (itching)
Physical Examination Guide
Systematic approach to examining a child with pruritus
Diagnostic Approach
Initial Assessment
For a child presenting with pruritus, the initial assessment should include:
- Detailed history focusing on onset, duration, timing, and exacerbating/relieving factors
- Complete skin examination to identify primary or secondary skin lesions
- Assessment of distribution pattern of skin changes or scratching
- Evaluation of impact on sleep, activities, and quality of life
Classification of Pruritus
Pruritus in children can be classified as follows:
| Category | Definition | Examples |
|---|---|---|
| Dermatological (Pruritoceptive) | Originates from skin inflammation or damage | Atopic dermatitis, scabies, urticaria, insect bites |
| Systemic (Pruritogenic) | Secondary to systemic disease | Cholestasis, chronic kidney disease, lymphoma, iron deficiency |
| Neurological (Neuropathic) | Due to lesions in the afferent neural pathway | Post-herpetic neuralgia, nerve compression, multiple sclerosis |
| Psychogenic | Related to psychological disorders | Anxiety, obsessive-compulsive disorder, parasitophobia |
| Mixed | Multiple mechanisms involved | Atopic dermatitis with anxiety, urticaria with thyroid disease |
Differential Diagnosis
| Category | Conditions | Key Features |
|---|---|---|
| Inflammatory Dermatoses |
- Atopic dermatitis - Contact dermatitis - Seborrheic dermatitis - Psoriasis - Pityriasis rosea |
- Characteristic distribution - Chronicity and recurrence - Family history of atopy - Visible inflammation - Typical morphology |
| Infectious Causes |
- Scabies - Pediculosis - Tinea infections - Varicella - Molluscum contagiosum with eczema |
- Household contacts affected - Night-predominant itching (scabies) - Visible parasites or burrows - Scalp involvement (tinea, lice) - Secondary bacterial infection |
| Systemic Diseases |
- Cholestatic liver disease - Chronic kidney disease - Iron deficiency - Thyroid disorders - Malignancy (lymphoma) |
- Generalized pruritus without rash - Associated systemic symptoms - Abnormal laboratory findings - Poor response to topical treatments - Night sweats, weight loss (malignancy) |
| Allergic Conditions |
- Urticaria - Angioedema - Drug reactions - Food allergies - Insect bite reactions |
- Acute onset - Wheals/hives - Temporal relation to exposures - Associated with facial swelling - Often transient |
| Other Dermatological |
- Xerosis (dry skin) - Keratosis pilaris - Miliaria (heat rash) - Mastocytosis - Aquagenic pruritus |
- Seasonal variation - Environmental triggers - Response to moisturization - Associated with bathing - Darier's sign in mastocytosis |
Laboratory Studies
Consider these studies based on clinical presentation:
| Investigation | Clinical Utility | When to Consider |
|---|---|---|
| Complete Blood Count | Assess for infection, anemia, polycythemia, eosinophilia, lymphoma | Generalized pruritus without primary skin lesions, systemic symptoms |
| Liver Function Tests | Evaluate for cholestasis or hepatobiliary disease | Generalized pruritus, jaundice, right upper quadrant pain |
| Renal Function Tests | Assess for chronic kidney disease | Generalized pruritus without rash, history of renal disease |
| Thyroid Function Tests | Evaluate for hypo/hyperthyroidism | Generalized pruritus, other signs of thyroid dysfunction |
| Skin Scraping for KOH Preparation | Identify fungal infections | Scaling skin lesions, typical distribution |
| Scabies Preparation | Identify Sarcoptes scabiei mites or eggs | Nocturnal pruritus, characteristic distribution, household contacts affected |
| Serum IgE Levels | Assess for atopic diathesis | Suspected atopic dermatitis, personal or family history of atopy |
| Iron Studies | Evaluate for iron deficiency | Generalized pruritus, pallor, fatigue |
Advanced Studies
Reserve for selected cases:
| Investigation | Clinical Utility | When to Consider |
|---|---|---|
| Skin Biopsy | Histopathological diagnosis | Unclear diagnosis, suspected cutaneous T-cell lymphoma, mastocytosis |
| Allergen-Specific IgE Testing | Identify specific allergens | Suspected specific allergic triggers, resistant atopic dermatitis |
| Patch Testing | Identify contact allergens | Suspected allergic contact dermatitis, localized persistent dermatitis |
| Chest X-ray/CT Scan | Evaluate for lymphoma, pulmonary disease | Persistent unexplained pruritus with systemic symptoms, lymphadenopathy |
| HIV Testing | Screen for HIV infection | Risk factors present, persistent generalized pruritus, opportunistic infections |
| Serum Tryptase | Evaluate for mastocytosis | Urticaria pigmentosa, positive Darier's sign, flushing episodes |
Diagnostic Algorithm
A stepwise approach to diagnosing pruritus in children:
- Determine presence of primary skin lesions
- Present: Focus on dermatological diagnoses
- Absent: Consider systemic causes
- Evaluate distribution pattern
- Localized: Consider contact dermatitis, insect bites, scabies, tinea
- Generalized: Consider atopic dermatitis, drug reaction, systemic disease
- Specific patterns: Check for diagnostic distributions (e.g., flexural - atopic dermatitis)
- Assess timing and triggers
- Nocturnal predominance: Consider scabies, atopic dermatitis
- Seasonal: Consider xerosis, environmental allergies
- Related to specific exposures: Consider contact dermatitis, urticaria
- Consider basic laboratory tests based on clinical suspicion
- Trial of empiric therapy for common conditions when diagnosis is clear
- Refer for specialist assessment if diagnosis remains unclear or management is challenging
Management Strategies
General Approach to Management
Key principles in managing pruritus in children:
- Identify and treat underlying cause: Address specific etiology when identified
- Break the itch-scratch cycle: Implement strategies to reduce scratching
- Restore skin barrier function: Moisturize and protect damaged skin
- Educate families: Provide information on triggers, prevention, and treatment
- Address impact on quality of life: Consider sleep, school performance, and psychological effects
General Measures for All Types of Pruritus
| Intervention | Description | Evidence Level |
|---|---|---|
| Skin Hydration |
- Regular application of emollients - Lukewarm (not hot) baths - Pat dry, don't rub - Apply moisturizer immediately after bathing |
High; multiple studies show benefit for most causes of pruritus |
| Avoidance of Triggers |
- Fragrance-free products - Cotton clothing rather than wool or synthetic fabrics - Avoiding excessive heat and sweating - Allergen avoidance when identified |
Moderate; based on clinical experience and observational studies |
| Environmental Modifications |
- Humidification in dry environments - Temperature control (cool environment) - Dust mite reduction measures - Gentle detergents for laundry |
Moderate; particularly important in atopic dermatitis |
| Prevention of Scratching |
- Keeping fingernails short and clean - Cotton gloves at night - Distraction techniques for younger children - Cool compresses for immediate relief |
Moderate; reduces secondary skin damage and infection |
| Psychological Support |
- Stress reduction techniques - Age-appropriate education - Addressing sleep disruption - Behavioral approaches to reduce scratching |
Moderate; especially important in chronic pruritus |
Topical Pharmacological Therapies
| Medication Class | Examples and Dosing | Indications and Considerations |
|---|---|---|
| Corticosteroids |
- Low potency: Hydrocortisone 1-2.5% - Mid potency: Triamcinolone 0.1% - High potency: Betamethasone - Frequency: Usually twice daily for 1-2 weeks |
- First-line for inflammatory dermatoses - Match potency to body site (lower potency for face/intertriginous areas) - Monitor for skin atrophy with prolonged use - Consider weekend therapy for chronic conditions - Not for use in infectious causes |
| Calcineurin Inhibitors |
- Tacrolimus ointment 0.03% for children 2-15 years - Pimecrolimus cream 1% for children ≥2 years - Apply twice daily |
- Steroid-sparing agents for atopic dermatitis - Particularly useful for face, neck, and intertriginous areas - May cause transient burning/stinging - No skin atrophy risk - Second-line therapy or for steroid-resistant cases |
| Topical Antihistamines |
- Doxepin cream 5% - Pramoxine (OTC) - Apply 3-4 times daily |
- Limited use in children - Risk of systemic absorption - Potential contact sensitization - Generally avoid due to limited efficacy and potential side effects - Short-term use only if considered |
| Local Anesthetics |
- Lidocaine 2-5% - Pramoxine - Apply as needed, not to exceed recommended maximum doses |
- Short-term relief - Useful for localized pruritus - Risk of sensitization with prolonged use - Monitor for systemic absorption when used on large areas - Can be combined with cooling effects (menthol) |
| Crotamiton |
- 10% cream or lotion - Apply once or twice daily |
- Antipruritic and scabicidal properties - Used primarily for scabies but has antipruritic effects - Variable efficacy - Generally well-tolerated |
| Menthol/Camphor |
- Concentrations of 1-3% menthol - Various OTC preparations - Apply as needed |
- Cooling sensation provides counter-irritant effect - Safe for most ages - Short-duration of action - Useful for mild, generalized pruritus - Good option for pruritus of systemic origin |
Systemic Therapies
| Medication Class | Examples and Dosing | Indications and Considerations |
|---|---|---|
| Antihistamines (H1) |
- First generation: Diphenhydramine, hydroxyzine - Second generation: Cetirizine, loratadine, fexofenadine - Age-appropriate dosing per package or formulary |
- First-line for urticaria - Limited efficacy in non-histamine mediated pruritus - First generation useful at bedtime for sleep (sedating effect) - Second generation preferred for daytime use - Limited evidence in atopic dermatitis |
| Systemic Corticosteroids |
- Prednisolone 1-2 mg/kg/day (short course) - Maximum 60mg/day - Typically for 5-7 days with/without taper |
- Reserved for severe, acute flares - Not for chronic management - Consider for severe contact dermatitis, drug eruptions - Monitor for short and long-term side effects - Use lowest effective dose for shortest duration |
| Antimicrobials |
- Antiscabetics: Permethrin 5% cream, ivermectin - Antifungals: Fluconazole, terbinafine - Antibiotics for secondary infection |
- Targeted therapy for infectious causes - Treat all household contacts when indicated (scabies) - Consider decontamination of fomites - Full course of treatment important to prevent recurrence - Antibiotics only when clear signs of secondary infection |
| Immunomodulators |
- Cyclosporine - Methotrexate - Azathioprine - Dupilumab (age-dependent approval) |
- Reserved for severe, recalcitrant cases - Specialist consultation required - Regular monitoring for adverse effects - Not first-line therapy - Consider for severe atopic dermatitis unresponsive to conventional therapy |
| Phototherapy |
- Narrowband UVB - UVA1 - Treatment protocols vary |
- Considered for chronic, widespread dermatoses - Limited availability for pediatric patients - Usually reserved for older children - Requires multiple sessions - Specialist referral needed |
Management of Specific Conditions
| Condition | Management Approach | Follow-up Recommendations |
|---|---|---|
| Atopic Dermatitis |
- Aggressive skin hydration with emollients - Topical anti-inflammatory therapy (corticosteroids, calcineurin inhibitors) - Trigger identification and avoidance - Bath additives (colloidal oatmeal, dilute bleach baths for recurrent infections) - Step-up therapy for flares |
- Regular follow-up every 1-3 months depending on severity - Educate on maintenance therapy - Written action plan for flares - Consider allergy testing for persistent cases - Monitor growth if using potent topical steroids extensively |
| Scabies |
- Permethrin 5% cream applied head-to-toe (except face in infants) - Leave on for 8-14 hours, then wash off - Repeat in 7 days - Treat all household contacts simultaneously - Wash all bedding/clothing in hot water |
- Follow-up in 1-2 weeks - Persistent pruritus for 2-3 weeks after treatment is normal - Symptomatic treatment with antihistamines and topical corticosteroids - Re-treat if new lesions appear after 2 weeks - Ensure all contacts treated to prevent reinfestation |
| Urticaria |
- Second-generation antihistamines as first line - May increase dose (up to 4x standard) for refractory cases - Add H2 antagonist or leukotriene receptor antagonist for resistant cases - Identify and remove triggers if possible - Short course of oral corticosteroids for severe acute flares |
- Follow-up in 2-4 weeks initially - Consider food/drug diary for chronic urticaria - Allergy testing only if history suggests specific trigger - Consider further investigation for chronic urticaria (>6 weeks) - Emergency action plan if history of angioedema |
| Contact Dermatitis |
- Identify and remove offending agent - Topical corticosteroids appropriate for affected area - Cool compresses for acute relief - Oral antihistamines for sleep/comfort - Short course of oral steroids for severe/widespread cases |
- Follow-up in 1-2 weeks - Consider patch testing for recurrent cases - Education on common contactants - Preventive measures - Occupational considerations for adolescents |
| Pruritus of Systemic Disease |
- Treat underlying condition - Topical therapies for symptomatic relief (menthol, camphor) - Oral antihistamines for comfort/sleep - Gabapentin/pregabalin for neuropathic component (specialist consultation) - UVB phototherapy for refractory cases (e.g., renal pruritus) |
- Coordinate care with appropriate specialist - Regular monitoring of underlying condition - Adjust symptomatic therapy based on response - Consider psychiatric support for chronic cases affecting quality of life - More frequent follow-up initially (every 2-4 weeks) |
Patient and Family Education
- Nature of condition: Age-appropriate explanation of cause and expected course
- Trigger identification: Guidance on identifying and avoiding triggers
- Proper bathing and moisturizing techniques: Demonstration of application methods
- Medication use: Clear instructions on application, frequency, quantity (fingertip unit)
- Breaking the itch-scratch cycle: Strategies to minimize scratching behavior
- Warning signs: When to seek medical attention for worsening or new symptoms
- Psychological impact: Addressing stigma, school issues, sleep disturbance
When to Refer
- Dermatology: Uncertain diagnosis, severe or recalcitrant disease, need for advanced therapies
- Allergy/Immunology: Suspected significant allergic component, need for specialized testing
- Gastroenterology: Suspected or confirmed hepatobiliary disease causing pruritus
- Nephrology: Pruritus associated with renal dysfunction
- Hematology/Oncology: Pruritus with suspicious systemic symptoms (weight loss, night sweats)
- Psychiatry/Psychology: Significant psychogenic component, substantial quality of life impact
