Thursday, December 24, 2020

An Infant With Uncontrolled Itching

 The patient is a 6-month-old infant who presents with a history of “eczema” since age 3 months. 

The parents’ main concern is uncontrolled rubbing and scratching.  He lives with his parents.  They have a dog (a Yorkie) and 2 cats.  His mother had eczema as a baby in Brazil and her sister has atopic dermatitis.  His aunt's eczema is still quite active although the mother is doing better.  She does, however, have respiratory allergies and is on immunotherapy per allergist. 

 

They are using hydrocortisone 2.5% cream as necessary, avoiding bathing as much as possible, and have found that Vaseline seems to work the best.  The real problem is that Vinny rubs and scratches his skin daily. 

 

On one occasion, when the dog licked him, he developed contact urticaria, which lasted a few minutes and disappeared, but the dog licks him all the time and mostly there have not been problems. 

 

EXAMINATION:  The examination shows a pleasant, well-cared for infant.  He has a suggestion of Dennie-Morgan folds.  His skin is generally xerotic but there is no acute crusting. There are some mildly erythematous patches.  Otherwise, the exam was unremarkable. Photographs were taken.      

 

IMPRESSION:  Generalized pruritus in an infant.  He has little in the way of skin findings.  Relatively strong family history of eczema.  Animals at home.  The child was bottle-fed.  The parents have tried many different types of formula and present he is on Similac. He is eating solids, but problem began before that.

 

The main problem is how to control his itching since this leads to rubbing and scratching. 

 

Questions:

1. Should one consider alternative diagnoses?

            Is there a role for lab tests?  CBC, CMP, IgE, others

2. What is the role of allergy testing at age six months?

            RAST tests to foods, environmental and animals

3.  Should antihistamines be prescribed, and it so what is your choice for an infant?

 

References:

1. Martin Metz  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 Sep;24(6):527-39. Abstract.

 

2. U Blume-Peytavi, M Metz. Atopic dermatitis in children: management of pruritus. J Eur Acad Dermatol Venereol. 2012 Nov;26 Suppl 6:2-8. Abstract.


6 comments:

  1. I find a common cause of itch <2 are common irritants in baby products; I.e. cocamidopropyl betaine in soaps (Dove Baby, Cetaphil Baby, Babyganics, Honest Baby, Aquaphor baby) and fragrance in baby laundry detergents (Dreft). I typically recommend vanicream cleanser or Cetaphil Gentle Skin Cleanser (not Cetaphil baby), and tide free and gentle laundry soap. (All free and clear has MC/MI) in it last time I checked. I typically do a thorough review of personal products before starting antihistamines or doing an itch workup.

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  2. Dr. Cheng-Leng Ong. Malaysia
    He has many reasons for the diagnosis of atopic dermatitis:-

    1). A very strong family history of atopy;
    2). A typical age of onset at three months old.
    3). Bottle feeding all along;
    4). A severe itch with lots of scratching. However, he scratches everywhere and not much of dermatitis has so far appeared. But these may be explained by :-

    A). Topical steroid is used as main treatment. Research findings showed topical 1% and 2% hydrocortisone share the same efficacy, except for the fact that 2% contains more steroid. Since his pruritus is widespread, we must be careful to be calculative to prevent too much steroid absorption.
    B). He does not use liquid soap to bathe, thus avoiding irritants which cause dermatitis.
    C). His pruritus may be more due to xerosis and also possible contact urticaria due to saliva or other animal allergens. May be the pets can be lodged with admiring friends or even the vets?
    D). His skin thankfully reacts more by type 1 reaction rather than type 4 ( dermatitis). But it may eventually break down into dermatitis if correct measures are not taken up.

    I highly recommended a medical device like Atopiclair lotion or cream to be the mainstay to deal with the itch, inflammation and restore barrier function besides. If not irritating to this baby, it can be used many times a day to control itch and spare steroid usage. Parents must be instructed to try it as a better moisturiser than the Vaseline they have been using. If they want to continue applying Vaseline, there should be a time gap between atopiclair and Vaseline, otherwise the Vaseline can mop it up . There are alternative medical devices available should the baby find atopiclair smarting.

    Syrup desloratadine ( third generation antihistamine) can be used to counter the urticaria element and may offer control of itch and resulting scratching. Ceririzine may control itch better by virtue of the fact that it is of second generation which can be dopey.
    Since atopic dermatitis is multi factorial, all factors have to be controlled, even passive smoking, otherwise full-fledged atopic dermatitis may break through.

    Blood allergen test is not able to cover every allergens under heaven. The test is also not lacking in false positives and false positive. Dermatologists often do not have to resort to it for management of dermatitis. Food allergies are rarely the cause and the parents would have noticed which food is the cause of trouble, avoidance of which spells cure which cancels appointment with dermatologists.

    Investigations like serum IgE may support diagnosis of atopic dermatitis, but not essential.

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  3. Brian Maurer, Connecticut: B. Maurer: Richard Antaya (from Yale) spoke to the pediatric community on treatment of infantile eczema at one of the weekly Zoom meetings last summer. As I recall, he emphasized copious moisturization of the skin (Vaseline works great, if the patient can tolerate the greasiness) with liberal use of topical steroid preparations to "quench the fire," as it were. He advocates hitting exacerbations hard with slow tapering over 2 or 3 weeks, followed by a 1 to 2 week steroid holiday. He also uses long acting antihistamines to help control itching (e.g. Zyrtec, 2.5 mL to 5 mL QD). The big offending foods in atopic patients include milk protein, egg, peanut, wheat, soy, fish, and shellfish. We used to give our atopic kids a trial of one of the elemental formulas, e.g. Alimentum or Nutramigen, although these can be pricey for families. Bleach baths 2 to 3 times a week can be beneficial to prevent secondary skin infection. If crusting does occur, sometimes a trial of cephalexin helps (30 mg/kg/d PO divided BID X 7 to 10 days). For recalcitrant cases, Antaya has prescribed dupilumab in young children; although not in infancy.

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  4. Probably highly allergic to dust mites, dog and cat. Most likely Atopic dermatitis. Should be isolated from the pets. Rast test if you don't believe. If you can get a sample of Dupixent it would be a hugh relief and diagnostic trial for this kid.
    Much safer than methylprednisolone or e CysA but those would be acceptable in a severe patient. 300mg or 200mg would be an acceptable starting dose if under 39Kg
    Doug Johnson

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  5. Prof. Bhushan KumarDecember 26, 2020

    Diagnosis of atopic dermatitis is obvious. Sometimes mastocytosis can present with extreme pruritus.
    Liberal amount of emollients is a must.
    If possible the pets have to be removed.
    In India- where sunshine is plenty- early morning sun exposure (UVR) is known to help.
    Even though diet restriction does not work in all- avoidance of eggs, cow’s milk, peanuts may help.
    We do not hold back the evening dose of antihistaminics

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  6. From Luke Johnson,SLC: . Based on the description, I would make sure to exclude scabies, but otherwise treat empirically for atopic dermatitis. I usually use triamcinolone 0.1% ointment bid until the skin is smooth and clear. I wouldn't go to labs or further investigation unless this doesn't work--but strange things, like bullous pemphigoid, have been reported in children, so if this condition proves refractory and doesn't declare itself as atopic dermatitis, labs and/or biopsy could be helpful.

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