Pediatric Dermatology
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  • 1. Pediatric Dermatology Board Review
  • 2. 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
  • 3. 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
  • 4. 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
  • 5. 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
  • 6. 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
  • 7. 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
  • 8. 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)
  • 9. Eczematous Rashes
    • Pattern
      • Infants- face
      • Toddlers- extensive surfaces of the arms and legs
      • Older children and teens- antecubital and popliteal areas, neck, and face
  • 10. 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
  • 11. 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
  • 12. 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
  • 13. 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
  • 14. 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)
  • 15. Eczematous Rashes
    • Treatment
      • 5mg of zinc sulfate/kg/day
      • dramatic reversal of symptoms
  • 16. Papulosquamous Rashes (raised and covered with fine scales)
    • Pityriasis rosea
      • most likely seen in teens and older children
      • cause unknown
        • ?viral
  • 17. 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**
  • 18. Papulosquamous Rashes
    • Psoriasis
      • 1-2% adults
      • 35% <20years
      • 60% pediatric patients have relative w/ psoriasis
      • Precipitating factors
        • trauma, cold, stress, group A B-hemolytic strep infection
  • 19. Papulosquamous Rashes
    • 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
  • 20. Papulosquamous Rashes
    • 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
  • 21. 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
  • 22. Vascular Malformations and Hemagiomas
    • Klippel-Trenaunay syndrome
  • 23. Vascular Malformations and Hemagiomas
    • Salmon patch
  • 24. 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
  • 25. Vascular Malformations and Hemagiomas
    • Portwine stain
      • Sturge-Weber syndrome
  • 26. 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
  • 27. 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
  • 28. Vascular Malformations and Hemangiomas
    • Superficial hemangiomas
      • strawberry hemangiomas
      • well defined, raised, and light to deep red in color
  • 29. Vascular Malformations and Hemangiomas
    • Deeper (caveronous) hemangiomas
      • capillary growth into the dermis and subcutaneous tissue
      • soft blue to red
  • 30. Vascular Malformations and Hemangiomas
    • Kasabach-Merritt syndrome
      • large hemangioma
      • thrombocytopenia
      • consumptive coagulopathy
      • not true hemangiomas
      • tugted angiomas or kaposiform hemangioendothelioma
  • 31. Pigmented and Hypopigmented Lesions
    • Mongolian spots
      • dermal melanosis
      • African American, Asian, Hispanic, or Mediterranean descent
      • lower spine, shoulders, and arm most commonly
  • 32. 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
  • 33. 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
  • 34. 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)
  • 35. Pigmented and Hypopigmented Lesions
    • Urticaria pigmentosa