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Itch in a Child

Essentials

  • Itching in a child is usually associated with skin disorders, and treatment should focus on the disorders.
  • The diagnosis of skin disorders is usually based on typical dermatological findings and location.
  • Itching due to systemic diseases (such as haematological disorders, renal failure) or drug-induced pruritus are very rare in children. Such itching shows only as skin areas broken by scratching (excoriation, for example) or there may be no dermatological findings.
  • In children or adolescents, the possibility of clinical pictures imitating itching (such as picking, self-manipulation, habitual scratching, skin irritation) must be kept in mind. Conduct disorders or developmental disorders and psychiatric problems may also lead to conduct patterns interpreted as itching (such as compulsive symptoms, stereotypic movements, dyskinesia).

Site of itching

  • The location and extent of dermatological findings give important diagnostic clues.
  • Good clinical examination (dermatological status) and thorough history taking are key for the diagnosis.

Common paediatric skin disorders based on the site of itching

SiteCommon causes of itching
The whole bodyAtopic dermatitis, urticaria, scabies, viral exanthem, chickenpox, psoriasis
Scalp and faceAtopic dermatitis, seborrhoeic dermatitis, acne, lice, tinea capitis, psoriasis
TrunkContact dermatitis, atopic dermatitis, urticaria, pityriasis rosea, tinea corporis, impetigo
LimbsContact dermatitis (such as irritant eczema), nummular eczema, atopic dermatitis, insect bites or stings, molluscs, impetigo
Genital and/or perianal areaNappy rash, pinworms, atopic dermatitis, perianal dermatitis

Most common causes

Atopic dermatitis

Contact dermatitis

  • The patient may have either irritant dermatitis or allergic contact dermatitis.
  • Itching may be restricted to a certain exposed skin area or it may be generalized.
  • Examples of irritant dermatitis: irritant dermatitis caused by footwear or gloves, lip licker's dermatitis, irritant dermatitis of cheeks in winter or due to rhinitis/salivation
  • Causes of allergic dermatitis include detergents, skin care products (preservatives), jewellery (nickel), for example.
  • Treatment is based on reducing exposure, protection and topical treatment with glucocorticoid ointments. Emollients decrease the recurrence of irritant eczema.
  • For investigations and treatment, see also Allergic Contact Dermatitis Irritant Contact Dermatitis.

Nummular eczema

  • In children, nummular eczema is often a subtype of atopic eczema seen predominantly on limbs.
  • It may be refractory and chronically recurring. It may require longer courses of glucocorticoid ointments.
  • See also Nummular Dermatitis.

Seborrhoeic dermatitis

Urticaria

  • Acute urticaria is the most common type seen in children.
  • The symptoms usually start abruptly. In children, infections (such as common cold, ear infection, diarrhoea) are the most common cause of acute urticaria.
  • Itchy hives appear on the trunk, extremities and face.
  • An antihistamine with a dose related to the weight of the child may be used throughout the duration of urticaria.
  • See also Hives (Urticaria).

Scabies

  • The extent of the clinical signs and symptoms and amount of itching vary greatly.
  • Lesions are papular or papulovesicular. There may also be secondary rash or impetigo.
  • The eczema lesions easily break leading to incrustation.
  • Large bullous lesions suggest a secondary bacterial infection.
  • Furrows are often found by dermatoscopy especially in the palms and soles of the feet.
  • See also Scabies.

Head lice

  • Give rise to itching and reddened papules in the scalp. There is often also rash at the back of the neck.
  • Diagnosis is based on visible lice and nits in the hair.
  • See also Head Lice and Pubic Lice.

Enterobiasis (pinworms)

  • Causes perianal itching. Scratching may lead to dermatitis and ulceration.
  • The symptom is particularly cumbersome at night and may disturb the sleep so that the child wakes up every now and then.
  • See also Pinworm (Enterobiasis).

Solar dermatitis (such as polymorphous light eruption)

  • Usually occurs in the spring and summer on skin areas exposed to sunlight.
  • Often polymorphous; there may be only erythema, papules or vesicles.
  • Treatment consists of sun protection and topical glucocorticoid ointments.

Allergic itching

  • Allergy or other hypersensitivity may in its mildest form present with symptoms such as an itch. In a child with pollen allergy, the itch may be located e.g. in the outer ear canals. Known causes include citrus fruit, fresh strawberries and cocoa.

Insect stings and bites

  • Often located on the limbs, with peak incidence in the summer
  • Erythematous, strictly defined spots or plaques with possibly a sting mark at the centre (single petechia). May occur in rows.
  • See also Insect Stings and Bites.

Molluscs

  • Typically on the trunk and limbs
  • May be itchy, particularly in children with atopic dermatitis.
  • See Molluscum Contagiosum.

Ringworm

  • May cause mild itching, particularly in association with ringworm of the scalp.
  • In children, it is important to confirm the diagnosis by taking fungal samples.
  • See Dermatomycoses.

Nappy rash

  • Typically in the inguinal folds and perineal area.
  • There may also be itching on the lower abdomen, lower back or thighs.
  • Irritation caused by baby care products (such as wet wipes) should be kept in mind.
  • See also Inguinal and Genital Skin Problems.

Viral exanthem

Skin manipulation and conduct disorders

  • Picking, self-manipulation, etc. occur commonly in infants, in particular.
  • These may be related to stress or learned conduct patterns.
  • They mainly affect limbs, the same skin areas being broken by scratching over and over again.
  • In older children, conduct disorders or developmental disorders and psychiatric problems may lead to conduct patterns interpreted as itching (such as compulsive symptoms, stereotypic movements, dyskinesia).
  • This is always a diagnosis of exclusion; other causes of itching should be excluded by good clinical examination and thorough history taking.

Rarer causes

Psoriasis

  • In children, the plaques are often lighter and there is less scaling.
  • The disease may occur as acute guttate psoriasis after streptococcal throat infection.
  • In children, response to topical treatment is often good.
  • See also Psoriasis.

Pityriasis rosea

  • The course of the disease is biphasic (herald patch and subsequent exanthem).
  • Often itchy as the extensive rash erupts.
  • Itching may be aggravated by irritating factors (washing, sauna bathing, etc.).
  • See also Pityriasis Rosea.

Streptococcal perianal dermatitis

  • In addition to itching, intense reddening of the perianal skin as well as pain; Image 1
  • The most common symptom in children is constipation.
  • See also Anal Problems in Children.

Chickenpox

  • The rash is often itchy.
  • Papules and vesicles in many different stages are visible on the skin.
  • Mild fever may precede the skin eruption.
  • Itching ceases in about one week as chickenpox resolves.
  • See also Chickenpox.

Mastocytosis

  • A very rare cause of itching
  • In children, usually appears as individual mastocytomas (orange spots or plaques) on the skin.
  • Mechanical irritation of the mastocytoma provokes itching, which may also occur in more extensive areas 2.

Treatment

  • Good treatment of the skin disorder is of primary importance.
  • In children, any aggravating or irritating factors should be sought.
    • Clothes that cause sweating and woolly clothes often cause itching.
    • Washing habits: detergents drying the skin, excessive washing, insufficient washing
  • Emollients for dry skin when needed
  • It is worth trying various emollients.

Symptomatic treatment

  • Low- or mid-potency glucocorticoid ointment or solution; for children, usually in courses of 1-2 weeks
  • A light emollient (can be applied to the skin cold from the refrigerator, at night, for example)
  • Many patients find emollient sprays developed for the treatment of itching helpful (available without prescription, many kinds available).
  • Emollient or cooling gels
  • Menthol cream several times a day, as necessary
    • An extemporaneous cream, for example (consult also local instructions): 1.0-2.0 g levomenthol made up to 100.0 g with an emollient cream (or, instead of an emollient cream, levomenthol can also be mixed with a gel cream, up to 100.0 g).
  • Menthol castor oil spirit
    • Check the availability of a local dermatological solution or an extemporaneous preparation (consult also local instructions).
    • Wipe itchy areas of skin several times a day, as necessary, with the liniment; effective for chickenpox, for example. Consult product-specific instructions too.
  • Non-sedating antihistamines may be useful in the treatment of itching in some patients (particularly if there is an allergic component or urticaria). Some patients (particularly those with urticaria) get further benefit from doubling the dose (off-label use, may require special note in the prescription).
  • A sedating antihistamine can be tried in short courses; e.g., hydroxyzine syrup or tablets, 1-2 mg/kg divided into 2-3 daily doses or in the evening.

Specialist consultation

  • A dermatologist or a paediatrician should be consulted if the cause of itching remains unclear and in severe refractory cases.
  • In case of itching associated with internal diseases, a paediatrician should be consulted.
  • If a severe conduct disorder or developmental disorder is suspected, a child psychiatrist should be consulted, as necessary.

    References

    • Zeidler C, Raap U, Witte F, et al. Clinical aspects and management of chronic itch. J Allergy Clin Immunol 2023;152(1):1-10 [PubMed]
    • Kang SY, Um JY, Chung BY, et al. Differential Diagnosis and Treatment of Itching in Children and Adolescents. Biomedicines 2021;9(8): [PubMed]
    • Le Pors C, Talagas M, Abasq-Thomas C, et al. What Do We Know about Pruritus in Very Young Infants? A Literature Review. Cells 2021;10(10): [PubMed]
    • Boozalis E, Grossberg AL, Püttgen KB, et al. Itching at night: A review on reducing nocturnal pruritus in children. Pediatr Dermatol 2018;35(5):560-565 [PubMed]
    • Nowak DA, Yeung J. Diagnosis and treatment of pruritus. Can Fam Physician 2017;63(12):918-924 [PubMed]
    • Fölster-Holst R. Itch Management in Childhood. Curr Probl Dermatol 2016;50():173-91 [PubMed]
    • Metz M, Wahn U, Gieler U et al. Chronic pruritus associated with dermatologic disease in infancy and childhood: update from an interdisciplinary group of dermatologists and pediatricians. Pediatr Allergy Immunol 2013;24(6):527-39. [PubMed]