Pediatric Dermatology


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Pediatric Dermatology

  1. 1. Pediatric Dermatology Board Review
  2. 2. Common Transient Neonatal Skin Conditions <ul><li>Erythema toxicum (neonatorum) </li></ul><ul><ul><li>First 3 to 5 days of life </li></ul></ul><ul><ul><li>Central, small welt or pustule on a broader erythematous base </li></ul></ul><ul><ul><li>Scraping of erythema toxicum reveals eosinophils </li></ul></ul><ul><ul><li>Resolves spontaneously </li></ul></ul>
  3. 3. Common Transient Neonatal Skin Conditions <ul><li>Miliaria (prickly heat) </li></ul><ul><ul><li>First few weeks of life </li></ul></ul><ul><ul><li>Caused by keratin plugging of eccrine (sweat) glands in the skin </li></ul></ul><ul><ul><li>eruption of microvesicular lesions on the face, neck, scalp, or diaper area </li></ul></ul><ul><ul><li>Tx: dressing infant lightly & avoiding excessive humidity </li></ul></ul>
  4. 4. Common Transient Neonatal Skin Conditions <ul><li>Milia </li></ul><ul><ul><li>White or yellow micropapules that develop when the pilosebaceous unit is obstructed by keratin/sebaceous material </li></ul></ul><ul><ul><li>Clustered on nose, cheeks, chin, forehead </li></ul></ul><ul><ul><li>Resolve w/o tx within several months </li></ul></ul>
  5. 5. Eczematous Rashes <ul><li>Seborrheic dermatitis </li></ul><ul><ul><li>Neonatal form </li></ul></ul><ul><ul><li>First several months of life </li></ul></ul><ul><ul><li>Cradle cap and then extend to other areas of skin where sebaceous glands are dense </li></ul></ul><ul><ul><ul><li>Forehead, eyebrows, behind the ears, sides of nose, middle of chest, umbilical, intertrigignous, and perineal areas in infant </li></ul></ul></ul><ul><ul><li>Lack of pruritus </li></ul></ul><ul><ul><li>Well circumscibed plaques with a greasy, yellow-orange overlying scale </li></ul></ul>
  6. 6. Eczematous Rashes <ul><li>Resolve by 8-12mo of age </li></ul><ul><li>Recur in childhood & adolescence (hormones) </li></ul><ul><li>TX: antiseborrheic shampoo </li></ul><ul><ul><li>Persistant scalp seborrhea- 2% ketoconazole shampoo </li></ul></ul><ul><ul><li>Residual scalp lesions- 1% hydrocortisone topical steroid cream </li></ul></ul><ul><li>*If rash is persistant or severe or is accompanied by anemia, adenopathy, or HSM- r/o histiocytosis </li></ul>
  7. 7. Eczematous Rashes <ul><li>Atopic Dermatitis </li></ul><ul><ul><li>eczema </li></ul></ul><ul><ul><ul><li>erythema </li></ul></ul></ul><ul><ul><ul><li>microvesicles (often confluent) </li></ul></ul></ul><ul><ul><ul><li>weeping and crusting </li></ul></ul></ul><ul><ul><ul><li>thickening (lichenification) of the involved skin secondary to chronic scratching </li></ul></ul></ul><ul><ul><li>inherited predisposition of the skin </li></ul></ul>
  8. 8. Eczematous Rashes <ul><li>Incidence </li></ul><ul><ul><li>2-3% </li></ul></ul><ul><ul><li>winter and in temperate or cold climates (air is dry) </li></ul></ul><ul><li>Develops in conjunction with 2 other diagnoses of the atopic triad </li></ul><ul><ul><li>asthma, allergic rhinitis (in the patient or family members) </li></ul></ul>
  9. 9. Eczematous Rashes <ul><li>Pattern </li></ul><ul><ul><li>Infants- face </li></ul></ul><ul><ul><li>Toddlers- extensive surfaces of the arms and legs </li></ul></ul><ul><ul><li>Older children and teens- antecubital and popliteal areas, neck, and face </li></ul></ul>
  10. 10. Eczematous Rashes <ul><li>Treatment </li></ul><ul><ul><li>Interrupt the “itch-scratch” cycle </li></ul></ul><ul><ul><ul><li>oral antihistamine or colloidal oatmeal baths </li></ul></ul></ul><ul><ul><ul><li>unscented topical moisturizers ( after tepid bath with mild soap) </li></ul></ul></ul><ul><ul><ul><li>Inflamed lesions -topical steroid cream or ointment </li></ul></ul></ul><ul><ul><ul><ul><li>ointments are more potent (not on face, intertriginious areas) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Tacrolimus and pimecrolimus (topical immunomodulators) </li></ul></ul></ul></ul><ul><ul><li>Secondary infection (Staph aureus) </li></ul></ul><ul><ul><ul><li>oral antibiotics or topical mupirocin </li></ul></ul></ul>
  11. 11. Eczematous Rashes <ul><li>Contact dermatitis </li></ul><ul><ul><li>typical pattern </li></ul></ul><ul><ul><ul><li>patches, linear arrays, and unusual distributions </li></ul></ul></ul><ul><ul><li>Poison Ivy, oak or sumac </li></ul></ul><ul><ul><ul><li>Rhus dermatitis </li></ul></ul></ul><ul><ul><ul><ul><li>erythema develops on skin when contact with oil of plant leaves or stem…rapidly becomes microvesicular…progress to larger and weep </li></ul></ul></ul></ul><ul><ul><li>pruritic </li></ul></ul>
  12. 12. Eczematous Rashes <ul><li>Treatment </li></ul><ul><ul><li>Oral antihistamine </li></ul></ul><ul><ul><li>Topical steroids (moderate potency) </li></ul></ul><ul><ul><li>If rash is extensive or involves genitalia or the skin around the eyes </li></ul></ul><ul><ul><ul><li>Oral steroids 1-2mg/kg/day X1 week and then wean during the second week to prevent rebound rash </li></ul></ul></ul>
  13. 13. Eczematous Rashes <ul><li>Acrodermatitis enteropathica </li></ul><ul><ul><li>AR disorder </li></ul></ul><ul><ul><li>zinc deficiency </li></ul></ul><ul><ul><li>similar presentation to nutritional zinc deficiency </li></ul></ul><ul><ul><li>usually presents in genetically susceptible infants that have been breast-fed and are now weaning </li></ul></ul><ul><ul><ul><li>? Zinc-binding ligand in breast milk that enhances zinc absorption up to the time of weaning </li></ul></ul></ul>
  14. 14. Eczematous Rashes <ul><li>Presentation </li></ul><ul><ul><li>rash- moist, erythematous, papular, forming plaques on the skin around orifices and on the acral areas (hand and feet) </li></ul></ul><ul><ul><li>foul-smelling, frothy diarrhea, alopecia, irritability or apathy, generalized failure to thrive </li></ul></ul><ul><li>Labs: low levels of zinc, alkaline phosphatase (zinc-dependent enzyme) </li></ul>
  15. 15. Eczematous Rashes <ul><li>Treatment </li></ul><ul><ul><li>5mg of zinc sulfate/kg/day </li></ul></ul><ul><ul><li>dramatic reversal of symptoms </li></ul></ul>
  16. 16. Papulosquamous Rashes (raised and covered with fine scales) <ul><li>Pityriasis rosea </li></ul><ul><ul><li>most likely seen in teens and older children </li></ul></ul><ul><ul><li>cause unknown </li></ul></ul><ul><ul><ul><li>?viral </li></ul></ul></ul>
  17. 17. Papulosquamous Rashes <ul><ul><li>initial lesion </li></ul></ul><ul><ul><ul><li>herald patch </li></ul></ul></ul><ul><ul><ul><ul><li>2-4cm scaly round or oval plaque w/raised border </li></ul></ul></ul></ul><ul><ul><li>5-7days later </li></ul></ul><ul><ul><ul><li>typical exanthem follows “Xmas tree” </li></ul></ul></ul><ul><ul><ul><ul><li>2-10mm ovoid, slightly raised plaques with central scaling in addition to smaller individual papules </li></ul></ul></ul></ul><ul><ul><li>rash lasts 6-10 weeks </li></ul></ul><ul><ul><li>TX: Resolves w/o treatment </li></ul></ul><ul><ul><li>***secondary syphillis mimics this..however syphillis involves palms and soles** </li></ul></ul>
  18. 18. Papulosquamous Rashes <ul><li>Psoriasis </li></ul><ul><ul><li>1-2% adults </li></ul></ul><ul><ul><li>35% <20years </li></ul></ul><ul><ul><li>60% pediatric patients have relative w/ psoriasis </li></ul></ul><ul><ul><li>Precipitating factors </li></ul></ul><ul><ul><ul><li>trauma, cold, stress, group A B-hemolytic strep infection </li></ul></ul></ul>
  19. 19. Papulosquamous Rashes <ul><li>Guttate psoriasis </li></ul><ul><ul><li>2-4 weeks after strep infection </li></ul></ul><ul><ul><li>drop like lesions </li></ul></ul><ul><li>Lesions </li></ul><ul><ul><li>red-based plaques w/ fine, adherent silvery scale; </li></ul></ul><ul><ul><li>Auspitz sign- removal of scale produces pinpoints of bleeding </li></ul></ul><ul><ul><li>knees, elbows, scrotum, scalp </li></ul></ul><ul><li>Nail pitting </li></ul>
  20. 20. Papulosquamous Rashes <ul><li>Treatment </li></ul><ul><ul><li>minimal use of soap </li></ul></ul><ul><ul><li>liberal use of thick emollients, keratolytics(w/salicylic or lactic acid) </li></ul></ul><ul><ul><li>topical steroids </li></ul></ul><ul><ul><li>Calcipotriene (synthetic Vit.D3 analogue) topical cream or ointment good results in teens and adults </li></ul></ul><ul><li>Consult Dermatologist </li></ul>
  21. 21. Vascular Malformations and Hemagiomas <ul><li>Vascular Malformations </li></ul><ul><ul><li>hamartomas of mature endothelial cells </li></ul></ul><ul><ul><li>blood flow is normal or slower than normal </li></ul></ul><ul><ul><li>present at birth and enlarge with body growth </li></ul></ul><ul><ul><li>can affect growth of underlying bone and soft tissue…asymmetric overgrowth </li></ul></ul><ul><ul><ul><li>Klippel-Trenaunay syndrome </li></ul></ul></ul><ul><ul><li>salmon patch </li></ul></ul><ul><ul><ul><li>MC </li></ul></ul></ul><ul><ul><ul><li>seen on the forehead, glabella, philtrum, or upper eyelids of about a third of newborns </li></ul></ul></ul><ul><ul><ul><li>very red when infant cries </li></ul></ul></ul><ul><ul><ul><li>fades by 18-24 months of age </li></ul></ul></ul><ul><ul><ul><li>exception: nape of neck </li></ul></ul></ul>
  22. 22. Vascular Malformations and Hemagiomas <ul><li>Klippel-Trenaunay syndrome </li></ul>
  23. 23. Vascular Malformations and Hemagiomas <ul><li>Salmon patch </li></ul>
  24. 24. Vascular Malformations and Hemagiomas <ul><li>Port wine stains </li></ul><ul><ul><li>mature, dilated dermal capillaries </li></ul></ul><ul><ul><li>persistent </li></ul></ul><ul><ul><li>if the distribution involves the opthalmic (upper eyelid to forehead) branch of the trigeminal nerve </li></ul></ul><ul><ul><ul><li>Sturge- Weber syndrome </li></ul></ul></ul><ul><ul><ul><ul><li>ipsilateral leptomeningeal involvement and intracranial calcifications </li></ul></ul></ul></ul><ul><ul><ul><ul><li>MRI or CT </li></ul></ul></ul></ul><ul><ul><ul><ul><li>seizures (60-90%), half are mentally retarded </li></ul></ul></ul></ul><ul><ul><ul><ul><li>glaucoma </li></ul></ul></ul></ul><ul><ul><ul><ul><li>tx: pulsed tunable dye laser </li></ul></ul></ul></ul>
  25. 25. Vascular Malformations and Hemagiomas <ul><li>Portwine stain </li></ul><ul><ul><li>Sturge-Weber syndrome </li></ul></ul>
  26. 26. Vascular Malformations and Hemangiomas <ul><li>Hemangiomas </li></ul><ul><ul><li>benign neoplasms of endothelial cells </li></ul></ul><ul><ul><li>rapid blood flow and an increased density of mast cells within the lesions </li></ul></ul><ul><ul><li>grow rapidly during infancy, then plateau and begin to involute by 18-24 monts of age </li></ul></ul><ul><ul><ul><li>50% resolve by 5years of age </li></ul></ul></ul><ul><ul><ul><li>70% by 7 years </li></ul></ul></ul><ul><ul><ul><li>90% by 9years </li></ul></ul></ul><ul><ul><li>Occur in 10-12% of children </li></ul></ul><ul><ul><li>90% resolve without treatment </li></ul></ul>
  27. 27. Vascular Malformations and Hemangiomas <ul><li>Management </li></ul><ul><ul><li>Watch </li></ul></ul><ul><ul><li>If interferes with vision or obstructs the airway or involve lip or breast tissue </li></ul></ul><ul><ul><ul><li>active intervention with steroids, interferon, or laser treatment </li></ul></ul></ul>
  28. 28. Vascular Malformations and Hemangiomas <ul><li>Superficial hemangiomas </li></ul><ul><ul><li>strawberry hemangiomas </li></ul></ul><ul><ul><li>well defined, raised, and light to deep red in color </li></ul></ul>
  29. 29. Vascular Malformations and Hemangiomas <ul><li>Deeper (caveronous) hemangiomas </li></ul><ul><ul><li>capillary growth into the dermis and subcutaneous tissue </li></ul></ul><ul><ul><li>soft blue to red </li></ul></ul>
  30. 30. Vascular Malformations and Hemangiomas <ul><li>Kasabach-Merritt syndrome </li></ul><ul><ul><li>large hemangioma </li></ul></ul><ul><ul><li>thrombocytopenia </li></ul></ul><ul><ul><li>consumptive coagulopathy </li></ul></ul><ul><ul><li>not true hemangiomas </li></ul></ul><ul><ul><li>tugted angiomas or kaposiform hemangioendothelioma </li></ul></ul>
  31. 31. Pigmented and Hypopigmented Lesions <ul><li>Mongolian spots </li></ul><ul><ul><li>dermal melanosis </li></ul></ul><ul><ul><li>African American, Asian, Hispanic, or Mediterranean descent </li></ul></ul><ul><ul><li>lower spine, shoulders, and arm most commonly </li></ul></ul>
  32. 32. Pigmented and Hypopigmented Lesions <ul><li>Incontinentia pigmenti </li></ul><ul><ul><li>X-linked or AD </li></ul></ul><ul><ul><li>affecting the skin, central nervous system, eyes, and skeleton </li></ul></ul><ul><ul><li>Skin manifestations (4 phases) </li></ul></ul><ul><ul><ul><li>inflammatory vesicles seen in neonates----evolve over several months to verrucous lesions----lesions develop into swirled brown to gray patches and finally become hypopigmented </li></ul></ul></ul>
  33. 33. Pigmented and Hypopigmented Lesions <ul><li>Nevus sebaceus of Jadassohn </li></ul><ul><ul><li>sebaceous glands and rudimentary hair follicles </li></ul></ul><ul><ul><li>initially hairless, yellow to orange plaque that becomes darker and thicker at puberty </li></ul></ul><ul><ul><li>scalp </li></ul></ul><ul><ul><li>10-15% risk for neoplastic transformation </li></ul></ul><ul><ul><ul><li>excision before puberty </li></ul></ul></ul>
  34. 34. Pigmented and Hypopigmented Lesions <ul><li>Urticaria pigmentosa </li></ul><ul><ul><li>MC of the general diagnostic group of mastocytosis disorders </li></ul></ul><ul><ul><ul><li>pathologic accumulation of mast cells </li></ul></ul></ul><ul><ul><li>Majority of cases </li></ul></ul><ul><ul><ul><li>present at 3-9 months of age </li></ul></ul></ul><ul><ul><li>multiple reddish brown macules, papules, or nodules…urticate when firmly rubbed </li></ul></ul><ul><ul><ul><li>Darier sign </li></ul></ul></ul><ul><ul><li>trunk more than extremities </li></ul></ul><ul><ul><li>Systemic involvement( bone, liver, spleen, lymph nodes, other tissue)..if onset is after 10yo </li></ul></ul><ul><ul><li>Prognosis: good if onset <10yo </li></ul></ul><ul><ul><li>Tx: oral antihistamines prn </li></ul></ul><ul><ul><ul><li>avoid food and meds that cause mast cell degranulation (codeine, aspirin, opiates, procaine, contrast agents, alcohol, cheese, spicy foods) </li></ul></ul></ul>
  35. 35. Pigmented and Hypopigmented Lesions <ul><li>Urticaria pigmentosa </li></ul>