pediatric dermatology

Pediatric Dermatology

Board Review

Common Transient Neonatal Skin Conditions

• Erythema toxicum (neonatorum)– First 3 to 5 days of life– Central, small welt or

pustule on a broader erythematous base

– Scraping of erythema toxicum reveals eosinophils

– Resolves spontaneously


• Miliaria (prickly heat)– First few weeks of life

– Caused by keratin plugging of eccrine (sweat) glands in the skin

– eruption of microvesicular lesions on the face, neck, scalp, or diaper area

– Tx: dressing infant lightly & avoiding excessive humidity


• Milia– White or yellow

micropapules that develop when the pilosebaceous unit is obstructed by keratin/sebaceous material

– Clustered on nose, cheeks, chin, forehead

– Resolve w/o tx within several months

Eczematous Rashes

• Seborrheic dermatitis– Neonatal form

– First several months of life

– Cradle cap and then extend to other areas of skin where sebaceous glands are dense

• Forehead, eyebrows, behind the ears, sides of nose, middle of chest, umbilical, intertrigignous, and perineal areas in infant

– Lack of pruritus

– Well circumscibed plaques with a greasy, yellow-orange overlying scale

Eczematous Rashes

• Resolve by 8-12mo of age• Recur in childhood &

adolescence (hormones)• TX: antiseborrheic shampoo

– Persistant scalp seborrhea- 2% ketoconazole shampoo

– Residual scalp lesions- 1% hydrocortisone topical steroid cream

• *If rash is persistant or severe or is accompanied by anemia, adenopathy, or HSM- r/o histiocytosis

Eczematous Rashes

• Atopic Dermatitis– eczema

• erythema• microvesicles (often

confluent)• weeping and crusting• thickening (lichenification)

of the involved skin secondary to chronic scratching

– inherited predisposition of the skin

Eczematous Rashes

• Incidence– 2-3%– winter and in temperate or cold climates (air is

dry)

• Develops in conjunction with 2 other diagnoses of the atopic triad– asthma, allergic rhinitis (in the patient or family

members)

Eczematous Rashes

• Pattern– Infants- face– Toddlers- extensive surfaces of the arms and

legs– Older children and teens- antecubital and

popliteal areas, neck, and face

Eczematous Rashes

• Treatment– Interrupt the “itch-scratch” cycle

• oral antihistamine or colloidal oatmeal baths

• unscented topical moisturizers ( after tepid bath with mild soap)

• Inflamed lesions -topical steroid cream or ointment – ointments are more potent (not on face, intertriginious areas)

– Tacrolimus and pimecrolimus (topical immunomodulators)

– Secondary infection (Staph aureus)• oral antibiotics or topical mupirocin

Eczematous Rashes

• Contact dermatitis– typical pattern

• patches, linear arrays, and unusual distributions

– Poison Ivy, oak or sumac• Rhus dermatitis

– erythema develops on skin when contact with oil of plant leaves or stem…rapidly becomes microvesicular…progress to larger blisters..open and weep

– pruritic

Eczematous Rashes

• Treatment– Oral antihistamine – Topical steroids (moderate potency)– If rash is extensive or involves genitalia or the

skin around the eyes• Oral steroids 1-2mg/kg/day X1 week and then wean

during the second week to prevent rebound rash

Eczematous Rashes

• Acrodermatitis enteropathica– AR disorder

– zinc deficiency

– similar presentation to nutritional zinc deficiency

– usually presents in genetically susceptible infants that have been breast-fed and are now weaning

• ? Zinc-binding ligand in breast milk that enhances zinc absorption up to the time of weaning

Eczematous Rashes

• Presentation– rash- moist, erythematous, papular, forming plaques on

the skin around orifices and on the acral areas (hand and feet)

– foul-smelling, frothy diarrhea, alopecia, irritability or apathy, generalized failure to thrive

• Labs: low levels of zinc, alkaline phosphatase (zinc-dependent enzyme)

Eczematous Rashes

• Treatment– 5mg of zinc sulfate/kg/day– dramatic reversal of symptoms

Papulosquamous Rashes (raised and covered

with fine scales)

• Pityriasis rosea– most likely seen in

teens and older children

– cause unknown• ?viral

Papulosquamous Rashes

– initial lesion• herald patch

– 2-4cm scaly round or oval plaque w/raised border

– 5-7days later• typical exanthem follows “Xmas tree”

– 2-10mm ovoid, slightly raised plaques with central scaling in addition to smaller individual papules

– rash lasts 6-10 weeks

– TX: Resolves w/o treatment

– ***secondary syphillis mimics this..however syphillis involves palms and soles**


• Psoriasis– 1-2% adults

– 35% <20years

– 60% pediatric patients have relative w/ psoriasis

– Precipitating factors• trauma, cold, stress,

group A B-hemolytic strep infection


• Guttate psoriasis– 2-4 weeks after strep infection

– drop like lesions

• Lesions– red-based plaques w/ fine, adherent silvery scale;

– Auspitz sign- removal of scale produces pinpoints of bleeding

– knees, elbows, scrotum, scalp

• Nail pitting


• Treatment– minimal use of soap

– liberal use of thick emollients, keratolytics(w/salicylic or lactic acid)

– topical steroids

– Calcipotriene (synthetic Vit.D3 analogue) topical cream or ointment good results in teens and adults

• Consult Dermatologist

Vascular Malformations and Hemagiomas

• Vascular Malformations– hamartomas of mature endothelial cells– blood flow is normal or slower than normal– present at birth and enlarge with body growth– can affect growth of underlying bone and soft tissue…asymmetric

overgrowth• Klippel-Trenaunay syndrome

– salmon patch• MC • seen on the forehead, glabella, philtrum, or upper eyelids of about a third of

newborns• very red when infant cries• fades by 18-24 months of age• exception: nape of neck


• Klippel-Trenaunay syndrome


• Salmon patch


• Port wine stains– mature, dilated dermal capillaries – persistent– if the distribution involves the opthalmic (upper eyelid to

forehead) branch of the trigeminal nerve• Sturge- Weber syndrome

– ipsilateral leptomeningeal involvement and intracranial calcifications

– MRI or CT

– seizures (60-90%), half are mentally retarded

– glaucoma

– tx: pulsed tunable dye laser


• Portwine stain– Sturge-Weber

syndrome

Vascular Malformations and Hemangiomas

• Hemangiomas– benign neoplasms of endothelial cells

– rapid blood flow and an increased density of mast cells within the lesions

– grow rapidly during infancy, then plateau and begin to involute by 18-24 monts of age

• 50% resolve by 5years of age

• 70% by 7 years

• 90% by 9years

– Occur in 10-12% of children

– 90% resolve without treatment


• Management– Watch– If interferes with vision or obstructs the airway

or involve lip or breast tissue• active intervention with steroids, interferon, or laser

treatment


• Superficial hemangiomas– strawberry

hemangiomas

– well defined, raised, and light to deep red in color


• Deeper (caveronous) hemangiomas– capillary growth into

the dermis and subcutaneous tissue

– soft blue to red


• Kasabach-Merritt syndrome– large hemangioma

– thrombocytopenia

– consumptive coagulopathy

– not true hemangiomas

– tugted angiomas or kaposiform hemangioendothelioma

Pigmented and Hypopigmented Lesions

• Mongolian spots – dermal melanosis

– African American, Asian, Hispanic, or Mediterranean descent

– lower spine, shoulders, and arm most commonly


• Incontinentia pigmenti– X-linked or AD

– affecting the skin, central nervous system, eyes, and skeleton

– Skin manifestations (4 phases)• inflammatory vesicles seen in

neonates----evolve over several months to verrucous lesions----lesions develop into swirled brown to gray patches and finally become hypopigmented


• Nevus sebaceus of Jadassohn– sebaceous glands and

rudimentary hair follicles

– initially hairless, yellow to orange plaque that becomes darker and thicker at puberty

– scalp

– 10-15% risk for neoplastic transformation

• excision before puberty


• Urticaria pigmentosa– MC of the general diagnostic group of mastocytosis disorders

• pathologic accumulation of mast cells

– Majority of cases • present at 3-9 months of age

– multiple reddish brown macules, papules, or nodules…urticate when firmly rubbed• Darier sign

– trunk more than extremities– Systemic involvement( bone, liver, spleen, lymph nodes, other tissue)..if onset is

after 10yo– Prognosis: good if onset <10yo– Tx: oral antihistamines prn

• avoid food and meds that cause mast cell degranulation (codeine, aspirin, opiates, procaine, contrast agents, alcohol, cheese, spicy foods)


• Urticaria pigmentosa

pediatric dermatology

Health & Medicine

eczematous rashes incidence

areas of skin

involved skin secondary

zinc absorption

topical mupirocin

nutritional zinc deficiency

low levels of zinc

weeks tx