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.