Pediatric dermatology

Differences in adult and neonatal skin Adult Skin Neonatal Skin Surface Dry Vernix (gelatinous) Full thickness 2.1 mm 1.2 mm Epidermal thickness > 50um 40-50 um 20-25 um in premature Dermo-epidermal Junction Ridged Flat Dermis Normal Less collagen & elastic fibers Melanosomes Fewer Hair Less

Classification of pediatric skin diseases Infective disorders: Bacterial, Viral, Fungal Infestations: Scabies, Pediculosis, Parasitic Inflammatory/ Immunological disorders: Eczemas, Psoriasis, Lichen planus Genetic/Nevoid disorders : Hemangiomas, Linear epidermal nevus, Epidermolysis bullosa, Tuberous sclerosis, Neurofibromatosis, etc. Neoplastic disorders: Langerhans cell histiocytosis, Mastocytosis

Neonatal Dermatoses Physiological Vernix caseosa Mongolian spot Physiological scaling Sebaceous hyperplasia Sucking blisters Physiological jaundice Miliaria Milia Erythema toxicum neonatorum Transient neonatal pustulosis Neonatal Acne

Mongolian spot Single or multiple slate gray or blue macules of size 3 to 10 cms Seen at birth Seen over lumbosacral region, buttocks, shoulders Fade within the first 3-4 years of life

Physiological scaling Seen in 75% normal infants Occurs within first week of life First around the ankles, later on hands and feet and soon becomes generalized Maximum intensity by eighth day, subsides by 3-4 weeks No treatment required

Sucking blister One or two solitary blisters Present at birth Seen over fingertips / hands / forearm Caused by vigorous sucking Heals rapidly without treatment within 2 weeks of life Differential diagnosis: Herpes simplex, Bullous impetigo, Epidermolysis bullosa

Miliaria Superficial vesicles resulting from sweat retention in stratum corneum A. Miliaria crystallina: Following fever, phototherapy Tiny clear vesicles seen over forehead, neck Erythema absent Peels off within 24 hrs

Miliaria B. Miliaria rubra (prickly heat) Seen in hot weather Non follicular papules on erythematous base 1 to 4 mm in diameter Trunk, face Subside in 2 to 3 days Itching, secondary infection is common

Infantile and Childhood dermatoses Infective and inflammatory diseases have been discussed in respective chapters. Certain common and genetic-naevoid conditions seen in infants and children will be discussed including: Cradle cap, Diaper dermatitis Nevus depigmentosus, Linear epidermal nevus Haemangiomas, Vascular malformations Sturge Weber syndrome Neurofibromatosis, Tuberous sclerosis Epidermolysis bullosa Ichthyosis

Cradle cap Seborrhoeic dermatitis of scalp Thick, greasy, adherent scales on scalp Commonly begins in the first 3 months Self limiting Apply oil for few hours to soften scales, rinse, 1% hydrocortisone cream can be used

Diaper dermatitis (Napkin rash) Irritant dermatitis in the perineal region Due to occlusion, fricton and prolonged skin contact with urine, faeces and fabrics Wetness leads to maceration of skin Secondary infection by C.albicans is common

Nevus Depigmentosus Single, well circumscribed, hypopigmented or depigmented macule or patch Seen at birth Stable in size and distribution Seen over trunk and proximal extremities

Linear epidermal nevus Congenital hamartomas of embryonal ectodermal origin Seen in early childhood as a linear raised warty lesion Located over neck, trunk and extremities

Hemangiomas Incidence more in preterm infants Female predilection Begin at one month of age Undergo a proliferative phase followed by stabilization and eventual spontaneous involution Complications Ulceration, bleeding Secondary infection Mutilation and scarring Cosmetic disfigurement

Vascular malformations Stable dilatations of superficial or deep vasculature Can be capillary, arterial, venous, lymphatic or mixed Clinical types: Salmon patch Portwine stain Sturge-Weber syndrome Klippel-Trenaunay syndrome

Salmon Patch Present in 30 to 40% of neonates Superficial, red or pink flat lesions Seen over forehead, upper eyelid, glabellar area, nape of neck Resolution in first year of life

Portwine Stain (Nevus flammeus) Present at birth Common sites are face, neck and mucous membrane Flat pink-red lesion Sharply unilateral in distribution Persist in childhood and darker in adulthood Complications Glaucoma, Choroidal angiomas

Sturge-Weber Syndrome Portwine stain in distribution of first branch of trigeminal nerve May be associated with seizures, ipsilateral glaucoma, behavioral problems, mental retardation Characteristic intracranial S-shaped calcifications

Neurofibromatosis (NF) Riccardi classified NF into eight distinct clinical types in 1982 Autosomal dominant disorder Affects skin, soft tissue, nervous system, bone, other organs Classical skin lesions are café au lait macules, neurofibromas

Neurofibromatosis - 1 (Von Recklinghausen’s disease) Diagnostic criteria for NF-1 Presence of two or more of the following: Six or more café au lait macules larger than 5 mm Two or more neurofibromas of any type or 1 plexiform neurofibroma Axillary or inguinal freckling Two or more Lisch nodules (brown coloured small nodules on iris surface) Optic glioma A distinctive osseous lesion A first-degree relative with NF-1

Neurofibromatosis - 2 Bilateral acoustic neuromas Multiple CNS tumors Few café au lait macules Few neurofibromas No axillary freckling No Lisch nodules

Tuberous sclerosis (Bourneville’s disease) Syn. EPILOIA (Epilepsy, Low IQ, Adenoma sebaceum) Ash leaf macules/ hypopigmented macules Adenoma sebaceum (angiofibroma) begins at 2-5 years of age as small pink papules on mid- face Shagreen’s patch (yellowish brown plaque on lumbo - sacral area) Koenen’s tumors (periungual fibroma) Mental retardation Seizures

Epidermolysis bullosa Inherited bullous disorders characterized by blister formation in response to mechanical trauma Onset at birth or shortly after Seen on sites of trauma and friction Types: Simple, Junctional, Dystrophic Some subtypes, especially the milder EB forms, improve with age Autosomal recessive types have bad prognosis with severe mucosal, esophageal involvement and atrophic scarring of skin

Ichthyosis Inherited disorder of keratinization Characterized by the accumulation of scales on the skin surface, dry skin Fish like scales most prominent over the trunk, abdomen, buttocks and legs May be associated with ectropion, eclabion, nail dystrophy, internal organ involvement Types: Ichthyosis vulgaris X-linked ichthyosis Lamellar ichthyosis Collodion baby / Harlequin fetus

Adolescent Dermatoses Acne Dandruff Striae Pseudo-acanthosis nigricans Contact dermatitis to cosmetics, perfumes, artificial jewellery / accessories (metals) Hyperhidrosis

Acne vulgaris Characterized by comedones, papules, pustules and nodules Common in males Seen around puberty Sites: face, upper part of the chest, back, shoulders Complications Psychological impact Hyperpigmentation Scarring

Dandruff (Pityriasis sicca/capitis) Most common condition affecting the scalp Causative organism: Malassezia species Seen as mild, moderate or severe scaling of scalp May or may not associated with itching Simple dandruff does not cause hair loss

Striae (stretch marks) Seen as pinkish white lines around knees, axillae, outer aspect of thighs, lumbosacral region Sudden increase in height or weight causes rupture of connective tissue beneath an intact epidermis

Pseudo-acanthosis nigricans Weight gain in puberty produces dark, thick, velvety skin in neck, axillae, groins Asymptomatic

Side effects of cosmetic products Cosmetic products like eye liner, ‘fairness’ creams, lipstick, nail polish, henna can produce contact reactions Reactions may be immediate or delayed Types of reactions Folliculitis Acneiform eruptions Contact dermatitis Pigmentary changes

Child abuse Includes physical abuse, neglect, sexual exploitation Cutaneous manifestations Bruises Traumatic alopecia Thermal burns Sexual abuse: Vaginal tears, anal tears, hematomas Sexually transmitted infections

Care of newborn Gentle handling Avoid frictional trauma Use gentle soaps, cleansers Too frequent bathing may lead to dryness Maintain hygiene after feeds, diaper changes Keep body folds dry and ventilated Skin care in pre-terms Use adhesive tape sparingly

General principles of skin care in children Bathing, soaps and cleansers There is no need to use special cleansing products Excessive cleansing, scrubbing and incomplete rinsing lead to irritation Shampoos Should be isotonic to tears and less irritating to eyes Shampooing twice a week controls normal flaking Care of the diaper area Frequent diaper changes with gentle cleansing and limiting use of plastic or rubber diaper cover

Differences in treatment of Paediatric and Adult Patients Conservative management is best Surface area is more in children as compared with adults Percentage of absorption of topical drugs is more Try to use lowest effective dose of medications Do not use treatments which may retard growth or mental development Avoid off-label uses of medications

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