pediatric dermatology.ppt

18th, November 2015 Pediatric Dermatology- Amr M.

Pediatric Dermatology

BY: AMR MOHAMMED ABDULLAH

11110053

INTERNAL MEDICINE


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


Common Transient Neonatal Skin Conditions 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


Common Transient Neonatal Skin Conditions 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


Vascular Malformations and Hemagiomas Klippel-Trenaunay

syndrome


Vascular Malformations and Hemagiomas Salmon patch


Vascular Malformations and Hemagiomas

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


Vascular Malformations and Hemagiomas 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


Vascular Malformations and Hemangiomas

Management Watch

If interferes with vision or obstructs the airway or involve lip or breast tissue

active intervention with steroids, interferon, or laser treatment


Vascular Malformations and Hemangiomas Superficial

hemangiomas strawberry

hemangiomas well defined,

raised, and light to deep red in color


Vascular Malformations and Hemangiomas Deeper

(caveronous) hemangiomas capillary growth

into the dermis and subcutaneous tissue

soft blue to red


Vascular Malformations and Hemangiomas 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


Pigmented and Hypopigmented Lesions 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


Pigmented and Hypopigmented Lesions 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


Pigmented and Hypopigmented Lesions

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)


Pigmented and Hypopigmented Lesions Urticaria

pigmentosa


MCQs


1.Which treatment choice would be contraindicated in a one-year old child who presents with monomorphous, nonpruritic flat-topped papules on the face, buttocks, extremities, palms and soles? 1 Advil2 Acetaminophen3 Hydration4 Corticosteroids5 Observation


2. Most common malignancy associated with multiple lesions similar to the attached image is: 1 Acute myelogenous leukemia2 Chronic myelogenous leukemia3 Acute lymphocytic leukemia4 Chronic lymphocytic leukemia5 Melanoma


3. A newborn has a nodule over his lumbar spine. Skin biopsy reveals a lipoma. The next appropriate step is: 1 Observation2 Excision of the lesion3 Genetic testing4 Imaging study5 Malignancy work up


4. A patient presents with multiple juvenile xanthogranulomas, axillary freckling, multiple caf-au-lait macules, three neurofibromas and a family history of NF-1. What other condition is this patient at increased risk for? 1 AML2 CML3 CLL4 Medulloblastoma5 Pancreatic carcinoma


5. Schimmelpenning-Feuerstein-Mims syndrome may be associated with which of the following: 1 Osteopokilosis2 Polyostotic fibrous dysplasia3 Osteopathia striata4 Chondrodysplasia punctata5 Hypophosphatemic rickets


6. The differential diagnosis of zinc deficiency is least likely to include: 1 Granuloma gluteale infantum2 Biotin deficiency3 Multiple carboxylase deficiency4 Cystic fibrosis5 Holocarboxylase synthetase deficiency


7. All of the options result in an eczematous acrodermatitis enteropathica-like eruption except granuloma gluteale infantum. As the name suggests, the lesions of granuloma gluteale infantum are granulomatous.

Multiple cylindromas are associated with: 1 Myotonic dystrophy2 Cowden syndrome3 Carney complex4 Trichoepitheliomas5 Pilomatrichomas


8. A full term neonate is noted to have small pustules with no underlying erythema present at delivery. The pustules are easily removed with clearing of the vernix and a collarette appears. A gram stain is done showing predominately neutrophils without bacteria. What is the most likely diagnosis? 1 Miliaria2 Erythema toxicum neonatorum3 Transient neonatal pustular melanosis4 Congenital candidiasis5 Urticaria pigmentosa


9. Transient neonatal pustular melanosis typically begins with sterile pustules that leave a characteristic collarette when ruptured. The lesions heal with hyperpigmented macules.

Which of the following may be associated? 1 Paronychia2 Cleft palate3 AVM4 Seizure disorder5 Atrial septal defect


10. Nevus sebaceus can very rarely be associated with multiple anomalies. Schimmelpenning syndrome can include seizure disorder, mental retardation, coloboma, as well as skeletal, cardiac and genitourinary abnormalities.

What syndrome can accessory tragi be associated with? 1 Goldenhar syndrome2 Turner syndrome3 Neurofibromatosis4 Ichthyosis5 Birt Hogg Dube


References

Fitzpatrick's Dermatology in General Medicine, 8e: Chapter 107. Neonatal, Pediatric, and Adolescent Dermatology

CURRENT Diagnosis & Treatment: Pediatrics, 22e: Skin

pediatric dermatology.ppt

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