Introduction

Pruritus is the medical term for itching. Although often not serious, it can cause serious discomfort, and may sometimes indicate a serious underlying medical condition.¹

It is especially prevalent among children, primarily due to various skin diseases, and can also affect their mood, quality of sleep, academic performance, and social functioning.

Medical treatment in children can differ from adults in many ways. While taking a medical history and physical examination, engaging both parents and children is vital. Clinical features and symptoms of pruritus may also differ from adults. Here, we will discuss the various causes of pruritus and the differential features associated with it.² 

Causes and differential diagnosis

Puritus in children can result from various conditions, often accompanied by a “rash and itch”, and include: scabies, atopic dermatitis, urticaria, insect bites, eczema, and urticaria.

The first step in relieving pruritus is identifying its root cause. This generally involves physical and chest examination and blood tests. The following tests and procedures may be carried out to identify the cause of itching:

Physical examination and history

Doctors will check to identify signs of potential infection, drug reaction, colour, texture, redness, dryness or inflammation.

A history of sleep patterns, eating habits, daily activities, and/or any exposure to other family members may also be taken into account.

Blood tests

Complete differential blood count analysis along with kidney or liver function tests may also be carried out, if required.^3,4,5

Symptoms (beyond itching)

• Redness
• Bumps, spots or blisters
• Dry, cracked skin
• Leathery or scaly skin¹ 

Management of Pruritus

Pharmacologic treatment

Topical treatments

Emollient

Emollients should be considered as the primary option for managing pruritus involving dry skin. They hydrate the skin, help maintain its protective function and thus provide relief from itching. These may be used as monotherapy for eczema in children or combined with other topical agents.

Topical corticosteroids

These are effective in reducing inflammation and, thereby, reducing itchiness. When treating children, it’s important that treating the inflammation should always outweigh potential side effects.

Topical Calcineurin Inhibitors

These are also used to treat inflammatory skin diseases and are preferred over steroids, due to a lack of skin atrophy even after long-term use in children. The itching improves after 48 hours of first application and further reduces with continued application. Overall, they can be used as a long-term maintenance therapy in children.

Small molecules drug

Crisaborole, a topical phosphodiesterase 4 inhibitor, is an effective treatment to reduce inflammation caused in mild to moderate atopic dermatitis in children from 2 years of age.

Systematic treatments

H1-antihistamines

These are considered the first-line treatment for pruritus induced allergic reactions, eczema, allergic skin disorders and urticarial dermatitis.

Immunomodulators

Cyclosporine and azathioprine are preferred immunomodulating agents to treat those inflammatory skin diseases that are not managed by antihistamines, such as atopic dermatitis, chronic urticaria, etc.

Ultraviolet phototherapy

Narrowband-Ultraviolet B is an effective treatment option for pediatric patients with moderate to severe eczema.²

Non-pharmacologic treatment

• Avoid tight-fitted clothes
• Keep the environment cool
• Minimise exposure to pollutants and allergic irritants
• Break the scratch-itch cycle by using distraction techniques to improve their impaired sleep
• Provide psychological support³

Dietary intervention

Food allergies including cow's milk, hen's egg, peanut, soya, nuts and fish are often responsible for eczema exacerbation in young children. In older children, adolescents and adults pollen-associated food allergy should be carefully considered.⁶ 

Prevention

Managing and preventing pruritus simply involves avoiding knowing the triggers. For example, if pruritus is caused due to allergens, then exposure to the outside environment should be avoided. Also, as discussed above, food allergies should be kept in mind in the case of young children.¹

Patient education

Very few studies have explored the educational approach, despite pruritus increasing in prevalence. It has been highlighted that educational programs should be considered for management and care. Awareness programs should be integrated into treatment regimens, and should focus on patients and their families.

The more aware the parents are, the higher the motivation to treat their children. Parents play a pivotal role in the treatment of their children and can also provide psychological support, helping to reduce the severity of the condition.

In addition to pharmacological treatment, providing knowledge about the condition is always beneficial, especially for children under 6 years of age in this case. Dermatologists, paediatricians, nurses and psychologists are obliged to train, support, and motivate parents and children in self-management.⁷

Summary

Pruritus, or itching, is a common problem in children and adolescents, often caused by various skin diseases. Misdiagnosis of the diseases can lead to difficulties in treatment. It is necessary to identify the cause of the condition to prevent or treat itchy skin. Management includes pharmacological as well as non-pharmacological approaches, with an emphasis on parental involvement and education Since this condition is related to pediatric patients, it is recommended to involve their parents and provide as much knowledge as possible.