Pruritus in pregnancy and childhood – do we really consider all relevant differential diagnoses?

ARTICLE

Auteur(s) : Elke Weisshaar¹, Thomas L Diepgen¹, Thomas A Luger², Stephan Seeliger³, Ralf Witteler⁴, Sonja Ständer²

¹Department of Social Medicine, Occupational and Environmental Dermatology, University Hospital of Heidelberg, GermanyFax: (+ 49) 6221/56-5584.
²Department of Dermatology and Venereology, University Hospital of Münster, Germany
³Department of Paediatrics, University Hospital of Münster, Germany
⁴Department of Gynecology and Obstetrics, University Hospital of Münster, Germany

accepté le 5 Mai 2005

General aspects

Pruritus during pregnancy

Scabies frequently presents with urticarial-like lesions and must be distinguished from urticaria and PEP (polymorphic eruption of pregnancy, ( figure 1 )). In scabies, itching papules are often localized in the genital area. A close inspection often shows similar efflorescences in other sites of the body such as perimamillary region, interdigital spaces or even generalized, as well.

Besides pre-existing pruritogenic dermatoses (table 1) and coincidentally acquired pruritogenic dermatoses, the specific pregnancy dermatoses must be considered (table 3( Table 3 )). Some authors additionally distinguish papular dermatitis in pregnancy; it is more likely that this is not an entity but is a form of prurigo gestationis [9, 10]. Precise medical history and diagnostics are of great importance when dealing with the specific dermatoses of pregnancy. Among those, polymorphic eruption of pregnancy is the most common one. Pemphigoid (herpes) gestationis (( figure 1 )) and pruritus gravidarum are associated with intrahepatic cholestasis and can imply an increased risk to the fetus such as impaired development of the child, intrauterine death or premature birth. Furthermore, the possibility of recurrence during a subsequent pregnancy must be pointed out for pemphigoid (herpes) gestationis, pruritus gravidarum with cholestasis and prurigo gestationis.

Drug-induced pruritus during pregnancy is not one of the more probable differential diagnoses but in tropical regions chloroquine-induced pruritus in malaria therapy during pregnancy is a frequent cause with a prevalence rate of 64.5%. According to a study, it occurred in 75% of those affected within 24 hours after consumption and was described as severe by over 60% [11].
Table 1 Pruritic diseases during pregnancy

Pruritus in children

Differential diagnoses of pruritus in children have a great range and resemble those of adults with different frequencies (table 4( Table 4 )). Most commonly, it is due to eczemas, especially AD (( figure 2 )), irritant contact dermatitis is very rare in children. Seborrheic eczema can occur in newborns and thereafter mostly recurs during adolescence. 38% of AD starts before the age of 3 months, 85% during the first year and 95% prior to the 5^th year [12]. The prevalence differs worldwide, varying in industrial countries between 9.3% (Japan), 17.2% (USA) and 20.1% (Hong Kong), whereas AD occurs in only 7% of third world countries like Tansania [13]. The main symptom of AD is severe pruritus affecting mostly face, hairy scalp and lateral extremities in infants and young children. In older children, the typical clinical picture of AD develops with eczemas in the flexural parts of arms and legs. Interestingly, pruritus can also occur, especially on the neck, in allergic asthma. It was described in 40% of affected children 30 minutes prior to the onset of an asthma attack [14]. The Wiskott-Aldrich syndrome, a rare X-chromosomal recessive hereditary disease, manifests with thrombocytopenia, cutaneous petechiae, recurring infections and eczematous lesions that strongly resemble AD. The Konigsmark-Hollander-Berlin syndrome is an autosomal recessive hereditary disease between the age of 9 and 11, which is associated with amblyacousia and AD. When AD occurs in newborns, Abt-Letterer-Siwe disease (histiocytosis X) must be considered as a differential diagnosis but in general, pruritus in histiocytosis is rather uncommon. Chronic lichen simplex is very rare in children, however occurs with increasing age, mostly during adolescence.

Scabies is among the most common epizoonosis in children, also occurring in newborns. In the latter, it can be accompanied by sleeplessness, refusal to eat, and failure to thrive, which is possibly also due to the limited scratching capability. Excoriations are prevalent only in older children. Pediculosis mainly occurs in children aged 3 to 13, mostly leading to severe itching of the hairy scalp. Insect bites are also frequent in children and can lead to prurigo strophulus, a highly itching dermatosis associated with wheals, papules, erythema, excoriations and superinfection especially between the ages of 2 and 8.

The most frequent pruritic viral infection in childhood is varicella. Parovirus B 19 infections are accompanied by pruritus in 70% of cases [15]. Mollusca contagiosa, as well, can be associated with itching and eczema-like lesions in the surrounding skin. Unspecific exanthemas may occur in connection with viral infections leading to strong pruritus. The Gianotti-Crosti syndrome is an occasionally itching disease, mainly occurring in children between the ages of 2 and 6 which is associated with viral infections, such as hepatitis B, Coxsackie or Epstein-Barr viruses. Laterothoracic exanthema is a recently described itching skin disease in children between 1 and 4 years of life, which is probably elicited by a viral infection [15].

Prurigo nodularis is an extremely pruritic dermatosis with keratotic excoriated nodules and papules. In children, it is triggered by insect bites (mostly in tropical regions), but it frequently occurs in connection with severely pruritic AD or nummular eczemas. It can also be induced by psychological disorders or systemic diseases, such as kidney insufficiency, hepatobiliary liver diseases, thyroid dysfunction, diabetes mellitus or haematologic diseases/malignoma (mostly Hodgkin’s disease) [13]. According to recent studies, it must be assumed that the typical skin changes in prurigo nodularis are caused by chronic severe scratching. It is suspected that a hyperproliferation of sensitive nerve fibers and neuropeptides contribute to the development of prurigo nodularis [4].

Mastocytosis is a relatively rare disease but in more than 90%, it is diagnosed in the first 6 months of life (( figure 2 )). Solitary mastocytoma almost exclusively occurs in children. Disseminated cutaneous mastocytosis (Urticaria pigmentosa) is the most common form of mastocytosis during childhood and in most cases, newborns develop it during their first months of life. The tendency to develop blisters (urticaria bullosa) diminishes after the first year of life and is the commonest variant of urticaria pigmentosa during the first 3 years of life. In 5-10% of cases, mast cell infiltration of internal organs (systemic mastocytosis) is observed and pruritus occurs in 41% of patients [16]. Altogether, 20% of those affected experience pruritus but it is less pronounced in children compared with adults.

Urticaria is characterized by highly pruritic wheals. The incidence rate in Western countries is about 3.4% in children, and about 15% in adolescents [15]. Some forms of urticaria also affect other family members (e.g. urticaria factitia, cold urticaria, heat-induced urticaria). In children, acute urticaria is often triggered by viral infections (mainly of the upper respiratory tract), food, bacterial infections, rarely by drugs and systemic diseases. Chronic urticaria during childhood can frequently be attributed to food intolerances and systemic diseases, especially autoimmune diseases [15, 16].

Approximately 2% of psoriasis starts before the age of 2 [12]. It usually manifests in the diaper and head area, however, it may already occur all over the body. Type I psoriasis mostly begins in the 2^nd decade of life. A recent study showed that 31% of affected patients developed psoriasis during childhood [17]. Head and genital areas are frequently characterized by pruritus and scratching.

5% of Lichen planus cases affect children who are almost always affected by persistent itching. The most common form at this age is the typical clinical variant with chronic polygonal papules on the flexural sides of the wrist, forearms, lower legs and, very rare at this age, involvement of the mucous membrane [15].

Blistering autoimmune dermatoses often present with severe pruritus (( figure 2 )). Linear IgA dermatosis is the most common one in children in Europe and North America [15]. Dermatitis herpetiformis Duhring is characterized by urticarial plaques, vesicles and excoriated papules including severe pruritus and burning. 80% of children with bullous pemphigoid are under 8 years of age but this disease is rare during childhood [13, 15]. Juvenile idiopathic arthritis frequently manifests with pruritic urticarial exanthems.

Pruritus vulvae, a frequent problem well investigated in adolescent girls and women, is less investigated in children (table 5( Table 5 )). Various triggers of pruritus vulvae may be explained by the anatomical and biological specifics of this age group, such as the anatomical proximity of the anus and introitus vaginae, so that contamination with faeces is more common. The child’s vulva is thinner, more vulnerable and due to the lack of pubic hair, more exposed to irritation [18]. The vaginal flora is pH neutral, thin and thus more susceptible to possible bacterial growth. In a recent study, in most cases the triggers were unspecific, hence, the problem was essentially caused by poor hygiene and application of irritating topicals. Interestingly, half of those affected were at the same time experiencing vaginal discharge [18]. In another study (not focused on pruritus), the majority had atopic or irritative dermatitis, followed by lichen sclerosus, psoriasis vulgaris and streptogenic vulvovaginitis [19]. In both studies, candidiasis was rarely found or absent because candida species do not thrive in a child’s vagina. When occurring prior to adolescence, immune deficiency, diabetes mellitus, antibiotic therapy or preexisting dermatoses must be taken into account. In case of anal pruritus, oxyuriasis must be considered as well, which is characterized by night time anal pruritus.

Genodermatoses such as neurofibromatosis, an autosomal dominant disease, is the second most common hereditary disease in children. At 90%, type 1 neurofibromatosis is the most frequent one during childhood. Frequently, pruritus occurs during fibroma growth which is attributed to increased mast cell numbers and explains relief by antihistamines [15, 20]. Unilateral pruritus in the face was reported in children suffering from neurofibromatosis resulting from a glioma of the brainstem [21]. Interestingly, pruritus occurred as an early symptom which finally led to the diagnosis. Darier (-White) disease is a frequently itching genodermatoses that usually does not manifest before adolescence and young adulthood, and therefore does not play a role during childhood pruritus.
Table 4 Differential diagnoses of pruritus in childhood

Systemic diseases associated with pruritus in childhood

Even though the number of HIV-positive children and children suffering from AIDS in Western countries is relatively low, children in third world countries are much more affected. Besides varicella and mollusca contagiosa, mycoses, bacterial skin infections, AD, seborrheic dermatitis, drug-induced exanthemas and pruritus without specific efflorescences are among the most common pruritic dermatoses in HIV infected children [15].

Adverse cutaneous drug reactions occur in 2% of treated children. The most common ones are maculo-papular exanthemas that are frequently accompanied by considerable pruritus. Each medication including herbal drugs should be considered as a possible trigger of pruritus including antibiotics (e.g. ampicillin, amoxicillin, cotrimoxazol), barbiturates, phenytoin and aspirin in children. Drug-induced pruritus can occur without any specific skin symptoms and has been observed in children treated for pain with morphine [23, 24]. It could be shown that almost 25% of patients older than 12 years of age experienced pruritus during tumor pain therapy with morphine. Of those younger, almost every 10^th child was affected [24]. Typical medications associated with pruritus in adults [2] play only a minor role in children, due to limited use at that age. Thrombocyte transfusions have also been observed as a cause for pruritus in children.

Diagnosing pruritus in pregnancy and children

General therapy measures and recommendations

During recent years, education programmes for parents and AD-children older than 7 years have been developed as one cornerstone of therapy to improve health status and the quality of life of children, adolescents and parents. The first results of a randomized multicenter study show statistically significant advantages of the group attending the education programme compared with the control group in all physical and psychological parameters [27].

Particularly in AD therapy, parents of affected children often prefer so-called natural medicine including topical medications. It has been reported that preparations used in herbal medicine can contain glucocorticosteroids and it has just recently been verified in a topical with extracts from the Dead Sea that contained triamcinolone and halcinonide [28].

Topical therapy in pregnancy and childhood

Parents are often unsure of how much topical therapy they should apply, especially when using glucocorticosteroids. According to a practical guide, it is recommended to use an adult fingertip unit as a measure for the amount that should be applied [29]. The number of finger tips required depends on the age of the child and the body location. When treating children, special attention must be paid to the fact that the body surface to bodyweight ratio in infants and small children is clearly greater than in adults. Therefore, it is more likely that systemic (side) effects will occur in children than in adults, especially when active substances are applied on a large area of the affected skin. Application to skin under diapers leads to a greater penetration of the topical substance due to occlusion effects.

• – Cooling lotions, menthol, camphor are widely used and self-administered by patients [30] as a symptomatical therapy but do not represent a causal treatment. They can relieve itching, however if applied long-term, they can dry out the skin and thus reactivate the itch-scratch cycle. When applied to eroded or scratched up skin areas, they can often cause burning.
• – Tannin preparations are well-suited for the treatment of itching dermatoses during pregnancy and childhood. They are available for local application on the skin (lotion, cream, gel, ointment, fatty ointment) and as additives to baths (powder, granulate, liquid).
• – Topical local anesthetics especially polidocanol is a widely used substance applied for symptomatic itch relief e.g. in lotions, creams and oily bath, also available in combination with urea [2, 15].
• – Topical antihistamines are more and more widely used as additives to creams and ointments for itch relief. Dimetinden maleate can reduce the itch intensity, however, is not effective in case of AD [2]. Promethazine, as well, has an antihistaminic effect, however, it may lead to intoxication. Diphenhydramine is one of the most commonly recommended antipruritic medication by physicians in the USA [30]. Doxepine is a tricyclic antidepressant with antihistaminergic, antimuscarinergic and antiserotoninergic effect. It is recommended for topical application in a 5% concentration in the treatment of itching dermatoses, such as AD, lichen simplex, nummular eczema and in particular for the symptomatic treatment of pruritus, but due to its increased risk for allergic contact dermatitis it should not be used to treat pruritus in pregnant women and children.
• – Antiseptics and antimicrobial topicals are used for the treatment of secondary bacterial or mycotic infections of the skin. Antiseptics available are e.g. clioquinol, chinolin sulfate, triclosane and chlorohexidine. Polyvidone iodine should not be applied on a large area or repeatedly on eroded skin and mucous membranes of children, especially in those under 6 months of age. Fusidic acid, bacitracin and polymycin B are approved for topical application in children. Metronidazol should be applied only short-term and not on large skin areas in children under 8 years, due to its possible systemic resorption and accretion into the teeth [15]. Even though neomycin is a weak allergen itself, allergic contact dermatitis is quite frequent due to its worldwide distribution and use. Type IV allergies to neomycin are therefore five times more common than to chinosol and 10 times more common than to fusidic acid [31]. The high prevalence rate in the US, especially among women, is best explained by the widespread use of neomycin in the topical therapy of gynaecological diseases [32]. A short-term and/or intermittent topical application in e.g. wound treatment, does not pose a risk for becoming sensitised. Metronidazol must not be used during the first trimester of pregnancy. In summary, neomycin and gentamycin should, if possible, not be used topically. According to our experience, fusidic acid is the topical antibiotic of choice for children and pregnant women.Nystatin and clotrimazol are the topical antimycotics of choice during pregnancy [25]. The modern broad-spectrum antimycotics (azole, imidazole) such as e.g. miconazol and ciclopirox are considered safe for topical therapy during pregnancy, should not, however, be applied intravaginally during the first trimenon [25]. In children, well-established antimycotics such as clotrimazol, ketoconazol, miconazol and ciclopirox, can be used topically.
• – Tars such as hard coal tar should not be used in infants and in small children longer than 4 weeks due to their possible toxic side effects. Liquor carbonis detergens is well tolerated by children in a 3% concentration, however, does not have the same antipruritic effect as hard coal tar. Plant tars are not used to treat infants or young children. Bituminolsulfonates and tumenol, however, can be used to treat young children [15]. In pregnant women, tar preparation should not be used.
• – Antiparasitics/antihelmintics such as lindane (hexachlorocyclohexane) should be applied only under close medical supervision, possibly in-patient in small children, due to its toxicological significance. Systemic resorption of the agent through skin lesions pose a risk of neurotoxic side effects. Benzylbenzoate is contra-indicated in newborns, and there is a relative contra-indication for use in small children. Pyrethroids, such as allethrin are derivates of chrysanthemums which can be applied to treat lice and mite diseases even in premature babies in form of a 2.5% or 5% permethrin cream [12, 15]. Crotamiton must be applied for at least 5 consecutive days, no controlled studies in small children have been carried out. In the case of severe or therapy-resistent scabies or larva migrans, an oral therapy with ivermectin 200 μg/kg body weight (one-time dose) can be attempted. Lindane, pyrethroids and crotamiton are also effective against pediculosis. Strophulus infantum and insect bite reactions are treated topically with cooling creams, topical antiseptics or topical glucocorticosteroids. There are no studies on benzylbenzoate and crotamiton either with animals or with humans (FDA group C). Benzylbenzoate and pyrethroids as well as permethrin (FDA group B) can be applied. Allethrin and lindane (hexachlorocyclohexane) should not be administered during the first trimenon. Lindane should not be administered in pregnancy because of its neurotoxic side effects, even though an absolute contra-indication does, so far, only exist during lactation (FDA group B) [12, 23]. Larva migrans can be treated topically with 5-20% thiabendazol in pregnancy and children. In therapy-resistant cases a systemic therapy with albendazol 400 mg for a duration of at least 3 days can be carried out, whereby it should not be applied in children under 6 years of age, because of insufficient therapeutic experience [12, 15].
• – Bufexamac is an antiphlogistic topical with a low to moderate anti-inflammatory potency for therapy of dermatitis and eczema. Due to pharmacological (being non-steroid) and economical reasons, it is quite popular in various countries. It has a high allergic potency leading to contact dermatitis, erythema-multiforme-like exanthemas, shows an increased penetration in diseased skin, and can therefore not be recommended for topical therapy [34]. There is not sufficient experience for its use during pregnancy; during the last 6 weeks prior to delivery bufexamac is contraindicated.
• – Topical glucocorticosteroids are available in different strengths ranging from class 1 (high-strength) to class seven (low-strength). They are often the therapy of first choice, when treating moderate and severe forms of eczema. In children and pregnant women, low- to medium-strength (class 3) glucocorticosteroids are to be preferred. High-strength glucocorticosteroids should not be used during pregnancy and childhood [33]. When treating children, systemic side effects are more likely to occur through transdermal resorption, showing symptoms similar to the side effects that occur after systemic application. Thus, growth retardation and adrenal cortex suppression have been described, especially in children under 5 years.
• – Topical immunomodulators are approved for the treatment of slight to moderate AD (pimecrolimus), and moderate to severe AD (tacrolimus) in children older than 2 years. Just recently, their successful and safe application in children younger than 2 years has been reported [35, 36] and pimecrolimus is now licensed for use in children older than 3 months in several countries. In AD, but also in other pruritic dermatoses, topical immunomodulators suppress pruritus, which, besides their anti-inflammatory effects, may also be attributed to a direct effect on the nerve fibers [37]. This theory is supported by the observation of itching, burning and other skin irritations within the first few days of topical treatment in some patients. Relapses and tachyphylaxia occur more rarely and the amount of glucocorticosteroids needed can be reduced by the application of topical immunomodulators [38]. The use of topical immunomodulators is not approved during pregnancy. In the USA, tacrolimus is also considered safe during pregnancy, because there was no evidence for systemic side effects [8]. Because of lack of clinical experience and due to the fact that they are immuno-suppressive agents, whose effects during pregnancy cannot yet be anticipated, they are so far not used in Germany.
• – Capsaicin is an alkaloid extracted from the chilli pepper, which can efficiently suppress pruritus of various etiologies [2, 39]. The practical use in young children is limited due to the necessity of frequent and repeated application (3 to 6 times daily) and the initial associated burning on treated skin sites. In some cases with therapy resistant pruritus we have successfully applied capsaicin topically in children younger than 10 years of age (( figure 3 )). Topical capsaicin therapy is not to be performed during pregnancy due to absence of experience and reported neurotoxic effects in animal studies.

Systemic therapy in pregnancy and childhood

• – Antihistamines such as H1-antihistamines are widely used as systemic antipruritics but are only sufficiently effective in histamine-mediated diseases such as urticaria and anaphylactic reactions. According to clinical studies, the efficacy of H1-antihistaminics in the treatment of AD is controversial and not yet proven [40]. Antihistamines of the 1^st generation show a certain effect, which may be largely attributed to their sedative effects e.g. hydroxyzine or clemastine hydrogen fumarate, which should therefore be administered in the evening. They are suitable for use in children who have difficulty going to sleep or who scratch themselves during the night. The antihistamines of the 2^nd (e.g. cetirizine) and 3^rd generation (e.g. levocetirizine, desloratadine) are not approved for all ages and must be administered in an age-adjusted dose (table 6( Table 6 )). According to the ETAC study in over 800 children with AD, cetirizine is well tolerated by children aged 1 year and older and has now already been approved for this age group. Besides, the amount of topical glucocorticosteroids used was smaller when using this antihistamine [41]. For many antihistamines, no safe clinical data are available concerning their use during pregnancy. The older sedating ones such as chloropheniramine, dimetinden, diphenhydramine, and hydroxycine are considered relatively safe during pregnancy based on long-time experience and single studies and have not shown any teratogenic effects [25]. Astemizol, terfenadine and cetirizine did not show any conspicuity during pregnancy [25] but terfenadin as well as fexofenadine led to decreased fetal weight gain in animal studies. In antihistamines of the younger generation e.g. levocetirizine, animal studies have not demonstrated so far any impairment of pregnancy, embryonal and fetal development [25]. In summary, antihistamines of the 2^nd and 3^rd generation should not be administered during the first trimenon of pregnancy. If antihistamines are necessary during this period of pregnancy, the older sedating ones are to be preferred. Fexofenadine, terfendine, astemizol are not suitable for therapy during pregnancy.There is no causal therapy available for mastocytosis but symptomatic therapy e.g. of associated pruritus is achieved either with the combined application of H1 and H2 antihistaminics or with mast cell degranulation blockers, such as cromoglycine acid (table 6). Derivates of cromoglycine should be taken with causion during the 1^st trimenon of pregnancy [25].
• – Systemic glucocorticosteroids are highly anti-inflammatory and are used for the treatment of severe forms of e.g. acute contact dermatitis, phototoxic/photoallergic contact dermatitis, severe and exacerbated AD and certain pregnancy dermatoses, such as pemphigoid gestations and severe forms of PEP [1, 9, 10, 42, 43]. Non-methylated glucocorticosteroids are to be preferred because they pose a very small risk to the fetus [42, 43]. Prednisolone (alternatively prednisone) is the glucocorticosteroid of choice if systemic therapy is required in pregnant women and children, mostly as a short-term therapy (< 4 weeks). Parenteral depot medication and crystalline suspensions are contra-indicated in children under 6 years and in children between 6 and 12 years used only if vitally indicated. The dose required depends on the severity of the disease and the child’s body weight (table 6). Glucocorticosteroids are usually administered orally once a day, in severe cases they can be portioned in two to four doses. The required daily dose rate during pregnancy depends on the severity of the dermatoses and the body weight, usually starting with a daily dose of 0.5-2 mg/kg body weight and a maintenance dose of 0.1-0.5 mg/kg body weight of prednisolone [25]. Intravenous application is usually not required except for very severe cases.
• – Antibiotics/antimycotics/antivirals: penicillin, ampicillin, erythromycin and cephalosporins are the systemic antibiotics of choice during pregnancy [25, 43]. Newer macrolides such as azithromycin, clarithromycin, josamycin and roxythromycin as well as sulfonamides, trimethoprim and cotrimoxazol are second line systemic antibiotics in pregnancy [25]. Various ones must not be applied during pregnancy such as tetracyline (not after the 16^th gestational week), metronidazol, clindamycin, aminoglycosides, chloramphenicol [25]. In children, penicillin, amoxicillin, ampicillin, cephalosporins of the 1^st and 2^nd generation, erythromycin, azithromycin and clindamycin can be administered as systemic antibiotics. Tetracyclines, such as metronidazol, minocyclin are contra-indicated in children under the age of 8 years because they can cause irreversible discoloration of the teeth, enamel hypoplasia, and a reversible bone growth retardation. Nystatin can be administered systemically during pregnancy but griseofulvin and terbinafin are contra-indicated [25, 43]. Itraconazole, ketoconazole, and fluconazole (FDA category C) should not be taken during pregnancy because there is no long-term experience with these drugs or data on teratogenic effects have been confliciting [33, 43]. In children, griseofulvin (10 mg/kg body weight) is the systemic antimycotic of choice. Itraconazole, ketoconazole, fluconazole and terbinafine have been approved only for patients of 18 years and older, however, in severe cases, off-label use may be considered. Whereas topical application of acyclovir is safe in pregnancy, systemic aciclovir is limited to severe forms of herpes or varicella only [25, 43]. Famciclovir, ganciclovir and valaciclovir are contraindicated in pregnancy [25, 43]. In children, aciclovir may be administered depending on the child’s age, in severe forms of herpes infections it may be needed in a dose rate of 5 mg up to 10 mg/kg body weight three times daily [15]. Famciclovir, ganciclovir and valaciclovir are not indicated in patients younger than 18 years old but the latter one may be used off-label in severe forms of e.g. herpes zoster [15].
• – Cyclosporine is not teratogenic and can therefore be administered in a maximum dose of 3 mg/kg body weight during pregnancy. This should be limited to severe cases of AD and psoriasis, where the therapeutic benefit outweighs the risk of side effects [8]. In children and adolescents under 18 years, cyclosporine is not approved for treatment of dermatological diseases. It was shown that it is well tolerated in children aged 2 to 16 suffering from AD in a daily dosage of 5 mg/kg body weight without causing any severe side effects [44].
• – Ultraviolet (UV) light therapy ranks high in the treatment of pruritic dermatoses. Different therapeutic regimens have been successfully reported when treating e.g. AD, psoriasis vulgaris, nummular eczema. Phototherapy is successful when carried out in suitable patients and under the rofessional guidance of a dermatologist. Therapeutic success depends on the appropriate choice of therapy for the respective indication. Data regarding safety and efficacy of UV-phototherapy in children are minimal. It should not be carried out in children younger than 10 years of age and should be limited to severe forms of dermatoses, such as AD or psoriasis. Even though the administration of UV therapy during pregnancy is not generally contraindicated, it should, however, be well thought about, due to its immunosuppressive effects. It should be limited to advanced pregnancy and be performed only after thorough information and education of the patient. PUVA therapy with oral psoralen administration is contra-indicated in pregnancy and children. Consideration of long-term side effects such as premature skin aging and increased risk of skin cancer is especially important in children, also depending on the patient’s skin type, the type, dose and duration of UV light therapy performed.
• – Aspirin showed significant antipruritic efficacy in a systematic review, when it was administered in a dose of 600 mg four times daily and was compared with chloropheniramine 4 mg three times daily applied during late pregnancy. A higher efficacy of aspirin was observed when pruritus occurred without skin lesions, whereas in pruritus with skin lesions, antihistamine was more effective [45]. Aspirin may not be given during the last trimenon because it can lead to an early occlusion of the ductus arteriosus [1, 42]. There is no data about aspirin therapy for pruritus in children.

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