Negative Pressure Wound Therapy in Diabetic Foot Ulcer.pptx
Common dermatologic issues in pediatrics
1. Common Dermatologic Issues in
Pediatrics
Fall 2013 – Becky Perz
Adapted from Jennifer Kaus, MSN,
FNP-BC, APNP
2. Skin
• Bodies largest organ
• Reflects physical and emotional health
• Skin issues account for a significant
percentage of all pediatric visits
• Development is constant throughout life cycle
3. A&P
• Skin has 3 layers: epidermis, dermis, and
subcutaneous layer
• Epidermis: thin outer layer-protective barrier
between body and environment
• Dermis: thicker middle layer-contributes to
strength, support, and elasticity
• Subcutaneous: composed of adipose tissue,
insulates, cushions against trauma, providers
energy, and metabolizes hormones
4. History
• Onset, duration
• Location-where did it start, where did it go
• Characteristics: pruritic, scaling, crusting,
painful…
• Aggravate/alleviate: anything make it better or
worse
• Related symptoms: fever, URI, malaise, pain,
joint pain or swelling…
5. History Cont…
• Exposures or allergies: list is extensive
• Medications
• Recent travel
• Family history
• ROS
• PMH
6. Physical
• VS
• Location and type of lesion(s)
• Color, size and shape
• Arrangement
• Pattern
• Distribution of lesion(s)
• Borders
• Consistency
7. Terminology
• Use proper dermatology terminology
• Description should include:
– Distribution
– Configuration of lesions
– Color
– Morphology
– Shape
– Secondary Changes
9. Impetigo
• Common contagious bacterial infection of
superficial layers of skin
• Epidemiology: strep, staph, or MRSA
• Clinical Findings
– Pruritis, weakness, fever, diarrhea (possible)
– Honey colored crusts on an erythematous base
10. Impetigo
• Physical exam
– Nonbullous or classic impetigo
– 1-2 mm erythematous papules or pustules
progress to bullae that rupture leaving moist
honey colored crusts
– Bullous impetigo-large flaccid thin-wall or oval
pustules
– Common on face, hands, neck, hands, perineum
11. Impetigo
• Management
– Topical antibiotics-bactroban (if superficial)
– Oral antibiotics-augmentin, cephalexin,
dicloxicillin, clindamyicn
– If no response in 7 days, swab
– Educate on cleanliness, handwashing, spread
– Exclude from daycare/school 24 hours
– Follow up in 48-72 hours if not improved
14. Cellulitis
• Bacterial infection involving the dermis and
subcutaneous tissues
• Epidemiology: strep and staph, infections over
joints most likely H. Flu
• History: previous skin disruption, fever, pain,
malaise, irritable, anorexia, vomiting, chills
– Recent pharyngitis, or URI
16. Cellulitis
• Management
– Hospitalization for febrile child or neonate
– Antibiotic therapy
• If strep suspected, penicillin of choice
• If staph suspected, IM/IV Rocephin then dicloxacillin or
clindamycin
• If H. flu suspected, Augmentin or 3rd generation
cephalosporin
• Follow up in 24 hours, and daily visits until recovering
18. Folliculitis, furuncle
• Superficial bacterial inflammation of the hair
follicle is folliculitis
• Deeper infection with involvement of the base
of the follicle and deep dermis is furuncle
• Epidemiology: obstruction of hair follicle,
staph or pseudomonas most common cause,
E. Coli for hot-tub folliculitis
19. Folliculitis, furuncle
• Clinical Findings
– Pruritis, tenderness
– Hot-tub exposure
– Irritating surface agent
– Occasional fever, malaise, lymphadenopathy
• Physical Findings
– Discrete, erythematous papules or pustules on
inflamed base
– Furuncle-nodule with larger areas of erythema and
tenderness
– Pruritic, papules, pustules, deep red nodules
20. Folliculitis, furuncle
• Diagnostics-gram stain, cultures
• Management
– Warm compresses
– Benzoyl peroxide if chronic or recurrent
– Topical antibiotics-erythromycin, clindamycin
– Oral antibiotics-dicloxicillin, cephalexin, other
beta-lactamase antibiotics
– Review good hygiene
– Follow up in one week for folliculitis, 1 day for
furuncle or abscess
22. Candidiasis-tinea capitis, tinea corporis,
tinea cruris, tinea pedis, tinea versicolor
• Fungal infection of skin or mucosa
• Epidemiology: candida
• Clinical Findings:
– Recent antibiotics or steroid use, diabetes
– Warm, moist area
• Physical Findings:
– Mouth: friable, adherent white plaques on an
erythematous base, cracked lips, fissured corners of
mouth
– Bright erythema in flexural folds
– Diaper area: moist, beefy-red macules with sharp
borders and satellite lesions, erosions
23. Candidiasis
• Physical findings cont:
– Vulvovaginal: thick, cheesy, yellow discharge,
erythema, edema and itching
– Nail plates: transverse ridging of nail plates, loss of
cuticle, mild periungal erythema
• Diagnostics-KOH scrapings
• Management
– Thrush: nystatin swish(swallow), troches
– Skin: topical antifungals
– Vaginal: topical or PV creams or inserts, oral
antifungals
– *if inflammation severe can use hydrocortisone cream
24. Candidiasis
• Education
– Keep area cool and dry
– Frequent diaper changes, sock changes, etc…
– Mild soap and water to clean
– Discard or sterilize pacifiers
– Add oral antibiotics for secondary infection
25. Diaper Dermatitis
• Diagnostic: KOH if needed, bacterial culture of
vesicle
• Management
– Frequent diaper changes, applying barrier
– Air drying
– Topical antifungals if yeast
– Antibiotic if bacterial
– Psoriasis-steroid ointment
• Education-proper cleansing, frequent diaper
changes, proper barriers
26. Diaper dermatitis
• Inflammation of the skin in the diaper area due to
breakdown of barrier
• Clinical Findings:
– Irritant, yeast, bacterial, psoriasis
• Physical Findings:
– Confined to buttocks, perineum
– Suspected when diaper rash does not respond to
treatments
– Erythema on buttocks, raised edges with sharply
demarcated margins, possible satellite lesions
– May be bullous, or vesicles if due to impetigo
29. Herpes simplex
• Contagious infections of the skin and mucosa
membranes
• Epidemiology: transmitted through close
contact with skin, mucous membranes or
body fluids
• Clinical Findings:
– Malaise, sore throat, fever, decreased fluid intake,
painful vesicles
– Prodrome: burning, tingling, paresthesia, itching
30. Herpes Simplex
• Physical findings:
– Pharyngitis with grouped vesicles on
erythematous base
– Cluster of small, clear, tense vesicles on
erythematous base, weeping, crusting
– Deep-appearing vesicles on fingers or hands
• Diagnostics
– Tzanck smear, viral cultures, PCR
31. Herpes Simplex
• Management
– Burow’s solution compresses TID
– Antiviral may help shorten course and alleviate
symptoms in kids over 2 years
– Topical ointment-often not beneficial
– Oral anesthetics for comfort-lidocaine topical,
magic mouth wash
– Refer if needed
– Analgesics, antipyretics
33. Molluscum Contagiosum
• Benign viral skin infections with little health
risk
• Epidemiology: poxvirus replicates in host cells,
incubation 2-7 weeks, child contagious as long
as lesions are present
• Clinical Findings: itching at site, exposure to
molluscum
• Physical findings:
– Very small firm pink flesh-colored papules
– Progress to umbilicated with cheesy core
34. Molluscum Contagiosum
• Physical Findings cont:
– Surrounding dermatitis common
– Single papule to numerous
– Sexually active or abused-grouping in genital area
• Management
– Untreated lesions usually disappear in a year, can take
up to 4 years
– Mechanical removal
– Topical medications: liquid nitrogen, cantharidin,
podofilox, tretinoin
– Medications: cimetidine if topical treatment fails
35. Molluscum Contagiosum
• Education
– Contagious
– No need to exclude them from school or daycare
– Severe inflammation common after cantharidin
– Scarring is unusual
37. Warts
• Skin infection characterized by proliferation of
the epidermis
• Epidemiology: viral-induced epithelial tumors
caused by HPV
• Clinical Findings
– Common on extremities, can be anywhere
– Growth that has black dots and callous
• Physical Findings
– Elevated flesh papules with scaly, irregular
borders, black pinpoints
38. Warts
• Management
– Watchful waiting
– Typically requires more than one treatment
– Liquid nitrogen, surgical excision, cimetidine,
imiquimod cream
• Education
– Blister, hemorrhagic may form 1-2 days after
nitrogen
– Multiple or prolonged treatment is often
necessary
40. Pediculosis
• Lice infestation-affects many areas
• Epidemiology: Common in children
• Clinical Findings:
– Infestation in family or friends
– Dandruff-like substance on scalp
– Itching
– Crawling sensation
• Physical Findings:
– Nits: small white oval cases on hair shaft
– Excoriated macules or papules
– Hemorrhagic pinpoint areas
– excoriations
41. Pediculosis
• Diagnostics-microscopic examination
• Management
– Correct diagnosis imperative
– Permetherin 1% cream-treatment of choice for head
lice, may need retreatment in 7-10 days
– Lindane (neurotoxic)-only used on patients non-
responsive to adequate doses of other treatments
– Secondary step remove nits
– 3rd step-thoroughly cleanse environment
– Treatment failure not unusual
42. Pediculosis
• Education
– Daily to weekly checks for lice and nits
– Educate family members about expected course
– Treatment-avoid excess, unnecessary treatment
– Children should not be excluded from daycare or
school, parents should be notified of need for
treatment
44. Scabies
• Caused by mite that burrows into the
epidermis
• Epidemiology: highly contagious infestation
• Clinical Findings:
– Itching, worse at night
– Mild at first them progressively worse
– Fitful sleep, crankiness, rubbing of hands and feet
45. Scabies
• Physical Findings:
– Complaints greater than findings
– Curving s-shaped burrows in webs of fingers, toes
– Vesiculopustular lesions in infants and young kids
– Itchy papules, nodules from inflammation
– Crusting, excoriations, possible secondary
infections
• Diagnostics: microscopic examination, burrow
ink test
46. Scabies
• Management
– Permethrin cream
– Antihistamines
– Treatment for all family members
– Linens, clothes worn during past 48 hours
– Nonwashable items sealed for one week
• Education
– Course of disease, rash and itching persist for up to 3
weeks following treatment
– May return to school or daycare 24 hours after
treatment
48. Acne
• Epidemiology: disorder of pilosebaceous
follicles
• Clinical Findings:
– Primary lesion: open or closed comedomes
– Inflammatory acne, papules or pustules
• Physical Findings:
– Open (blackhead), closed (whitehead)
comedomes
– Papules, pustules, nodules
– Face, back, neck, chest, shoulders
49. Acne
• Management
– Depends on how severe acne is
– Benzoyl peroxide, retinoids, topical antibiotics
– May need to add oral antibiotics
– If inflammatory acne with scarring present refer to
derm for possible accutane treatment
– Follow up in 6-8 weeks to assess treatment
– Educate on proper cleansing, moisturizing, and
make-up
51. Bites
• Who or what bit them
• Assess injury
• Culture wound before treatment
• Cleanse and debridement
• Antibiotics for infected wounds
• If suturing necessary monitor closely for
infection
53. Burns
• What kinds of burn?
• Assess depth, and what percentage of body
burned
• Superficial-epidermis
• Partial thickness-epidermis and partial dermis
• Full thickness-down to subcutaneous, painless
• Management depends on degree of burn
• Electrical and chemical burns=hospital
54. Burns
• Treatment
– Superficial-cool compresses, pain control
– Partial thickness-daily cleansing, debridement,
silver sulfadiazine,
– Full thickness-managed by specialty group
• Follow up-daily if needed, and until healed in
1-2 weeks
• Education
– Prevention is key
– Scarring difficult to determine
56. Lyme Disease
• Systemic infection caused by spirochete
• Clinical Findings: flulike symptoms, malaise,
arthralgias, headache, fever
• Physical Findings:
– Red macule or papule at site of bite in 2-30 days,
expands to annular erythematous lesions with
central clearing
– Center becomes dark, vesicular, hemorrhagic, or
necrotic
• Diagnostics-ELISA, western blot
57. Lyme Disease
• Doxycycline for 14-21 days (if >8 years old) or
amoxicillin for 21 days
• Azithromycin or erythromycin as second-line
treatment
• Education:
– Proper insect repellant
– Wear long pants, long sleeves
64. Roseola
• Common illness of childhood, typically kids younger
than 2
• Human herpes 6 virus
• Clinical Findings
– fever that may exceed 40ºC (104ºF) and lasts for three to
five days
– accompanied by irritability, although most children with
roseola are otherwise well-appearing, active, and alert
– malaise, palpebral conjunctivitis, edematous eyelids,
inflammation of the tympanic membranes,
uvulopalatoglossal junctional macules or ulcers
(sometimes called Nagayama spots), upper and lower
respiratory symptoms, vomiting, diarrhea, and a bulging
fontanelle
65. Roseola
• Physical findings
– child's fever abates, a blanching macular or
maculopapular rash develops, starting on the neck
and trunk and spreading to the face and extremities
– Occasionally the rash is vesicular. It is generally
nonpruritic, rash persists for 1-2 days, occasionally
may come and go within 2-4 hours
• Management
– benign and self-limited disease. Treatment is
supportive, fever controlled with antipyretics, rash
resolves without
67. Seborrheic Dermatitis
• Inflammatory disorder characterized by
yellow-waxy scales
• Clinical Findings, Physical Findings-greasy
scales, well-demarcated borders, thick
adherent plaques
• Management
– Removal of scales with mineral oil, shampoos
head and shoulders, selsun blue
– Restart treatment at first recurrence
71. Drug Eruptions
• Drug related reactions-urticaria, morbiliform
• Epidemiology: most common allergic reaction
to a drug
• Clinical Findings
– Medications
– Itching
– Rash worsens even if drug stopped for up to 5
days
– Low grade fever, rash, arthralgia,
lymphadenopathy, edema
72. Drug eruptions
• Physical Findings
– Fairly symmetric, macular erythematous rash becomes
papular, confluent
– Rash begins on trunk, may turn brown and desquamate
over time (7-14 days)
• Diagnostics-CBC, monospot, CRP, ANA,
• Management
– Discontinue drug, label medical record
– Antihistamines, steroids if severe reaction
– Follow up visit as needed
• Education-lasts 7-14 days, communicate allergies,
wearing alert bracelet or necklace
75. Urticaria, angioedema
• Management
– Remove offending substance
– Test for dermographism
– Antihistamines
– Epi for anaphylaxis
– Follow up in 1-2 days if not improved
• Education
– Explain cause, course, and treatment
– Avoid allergen
– Carry epi if appropriate
77. Keratosis Pilaris
• Small bumps at the hair follicles, look like
chicken skin
• Can have white “heads” to them, that when
squeezed, teens feel they have pimples on
their arms – actually follicular plugs
• Typically needs moisturizers to prevent
recurrence
• Occasionally antibiotics for staph aureus
folliculitis
78. Helpful Derm Tips
• Rash before fever, or fever before
rash…helpful with diagnosis
• Where did the rash start, where did it go-
helpful for diagnosis
• Petechiae not normal in kids, rule out bad
things
• Systematic approach
• It’s ok to say, “IDK”…but then go look it up
79. References
• Burns, C. E., Dunn, A.M., Brady, M.A., Starr,
N.B., & Blosser, C. G. (2013). Pediatric Primary
Care (5th ed.) St. Louis, MO: Saunders.
• Richardson, B. (2013). Pediatric Primary Care:
Practice guidelines for nurses (2nd ed.).
• Up to date. (2013). http://www.uptodate.com
