What You Need to Know First about Pediatric Dermatology

What You Need to Know First about Pediatric Dermatology
Marsha J. Rhodes, MD, FAAP Department of Pediatrics Levine Children’s Hospital Carolinas Medical Center July 2, 2007

Quick Overview “Children are not little adults” History taking
Descriptions Briefly, the most common rashes Handy hints Debunking steroid myths “Fun” rashes

Children’s Skin is Different
Stratum corneum Body surface area Transitioning to life outside the womb Development Behaviors Exploration Hygiene Scratching

Most Common Rashes Eczema (Atopic dermatitis) Newborn rashes
Diaper rashes Viral exanthems Insect bites Tinea capitis Tinea corporis Impetigo Pityriasis rosea Hand-foot-and-mouth disease Scabies Burns RMSF Acne

History Taking Age, race, and sex Onset / duration Location on body
Evolution of lesions Treatment attempted “Dermatitis incognito” Associated symptoms Pruritus, fever, headache, GI, etc Think infection with rash + fever

Other Aspects of History
Family history Known personal contacts Trauma Travel & play Environmental exposure Insects, plants, toxins, sun, etc Season

Seasonal Rashes Summer Spring Fall Winter RMSF Poison Ivy Bug bites
Erythema infectiosum Scarlet fever

Describing the Rash Appearance Age Sex Race
Primary vs secondary changes Age Tinea capitis generally pre-pubertal Tinea pedis generally post-pubertal Sex Wiskott-Aldrich occurs only in males Race Psoriasis more common in Caucasians

Infectious Rashes Usually present w/ fever or headache
or other signs of systemic illness

Describing the Rash Number of lesions Distribution Size Color
Morphology: shape and texture Flat, bumpy, scaley, fluid or pus filled, etc Secondary changes (from scratching, superinfection, reaction to meds, etc)

Distribution (ex: eczema)

Primary Lesions “Morphology Made Simpler?”

Macule = flat ex: café au lait lesions, nevus simplex

Papule = small bump ex: insect bites, erythema toxicum

Nodule = bigger bump ex: juvenile xanthogranuloma, mastocytosis

Patch = large flat lesion ex:

Plaque = raised patch ex: psoriasis, Nevus of Jadassohn

Vesicle = small blister ex: chickenpox, contact dermatitis, acropustulosis

Bulla = large blister ex: burns, bullous impetigo, epidermylosis bullosa

Pustule = superficial pus-filled lesion ex: acne, transient neonatal pustular melanosis

Abcess = deeper pus-filled lesion ex: boils, furuncles Think MRSA

Wheal = hive (urticaria) ex: erythema multiforme, insect bites

Morbilliform Rashes

Secondary Changes Medical Terms Scaly Scabbed Excoriated Lichenified
Fissured Eroded Layman’s Terms Flakey Crusted Scratched Leathery Cracked Open or abraded

Lichenification = Leathery ex: eczema

Describing What You See
Number of lesions Distribution on body Location Discrete, grouped, coalesced Color Flesh, erythematous*, white, black, brown, yellow, green, blue Think ink Morphology Linear, circinate, serpetiginous, fluid filled

Describing What You See
Texture Superficial vs palpable (deep) Macular, papular, plaque-ish, scaly, rough, lichenified Borders Sharp, indistinct, raised, surrounding erythema, satellite lesions Secondary changes Eczematized or lichenified, excoriations, scabbing, crusting, draining, inflammation Other physical findings Uninvolved skin, observed scratching, nails, adenopathy, fever

Narrowing the Diagnostic Possibilities
The most common truly pruritic rashes Eczema, insect bites, chickenpox, contact dermatitis, scabies, dyshidrosis The most common causes of scaly scalps Seborrhea, tinea capitis, psoriasis, eczema The most common vesicular rashes Insect bites, chickenpox, contact dermatitis, herpes

The Most Common The most common rash under the nares
Impetigo Scattered papular lesions Flying insect bites The most common cause of odd drip looking patterns on the chin and chest Phytophotodermatitis The most common cause of eczema flares Bacterial superinfection

Tinea “Confusiatum” (lesions frequently mistaken for tinea corporis and vice versa)
Well-circumscribed, +1 lesion, scaly with central clearing, papular rim, not pruritic, enlarges rapidly, generally erythematous Eczema >1 lesion, extremely pruritic, uniform lesions with “epithelial disruption,” entire skin generally dry, personal or FH + for atopies, easily infected, typical locations (extensor in young children then flexural) Pityriasis rosea Hundreds to thousands of ovoid lesions, preceded by herald patch, light scaling with suggestion of central clearing, fir or Christmas tree pattern, may have mild prodromal symptoms and pruritus

Tinea “Confusiatum” (lesions frequently mistaken for tinea corporis and vice versa)
Psoriasis Raised erythematous base (plaque), sheets of thick silvery mica-like scale, Auspitz sign, Koebner phenomenon, + FH, more common in Caucasians Contact dermatitis Acute, very pruritic, unusual patterns or distributions, typically more vesicular than scaly, may become eczematized Granuloma annulare Lack of scale, central clearing, usually at wrists and ankles, 1-2 lesions Secondary syphilis Check palms and soles

Insert photos of look alikes

Topical Medications Two considerations The active medication
The vehicle

Topical Medications Two considerations Creams Ointments Gels Lotions
The active medication The vehicle Creams Suspension of oil in water Water washable Hygroschopic May be drying, occasionally sensitizing Ointments Occlusive: allow for high transcutaneous of the active drug Stable for long time Require few preservatives and bacteriostatic additives Most lubricating Least likely to cause contact allergy or irritation Gels Aqueous preparations that liquefy on contact with skin Leave a uniform film on drying Well tolerated in hair-bearing areas Lotions Powder suspended in water Cool the skin when drying Provide uniform covering of the suspended agent Open wet dressings Powders Promote drying Useful in intertriginous areas Aerosols Pastes Emollients

Topical Medications Creams Suspension of oil in water Water washable
Hygroschopic May be drying, occasionally sensitizing

Topical Medications Ointments
Occlusive: allow for high transcutaneous of the active drug Stable for long time Require few preservatives and bacteriostatic additives Most lubricating Least likely to cause contact allergy or irritation

Topical Medications Gels
Aqueous preparations that liquefy on contact with skin Leave a uniform film on drying Well tolerated in hair-bearing areas

Powders and Lotions Powders Lotions Promote drying
Useful in intertriginous areas Lotions Powder suspended in water Cool the skin when drying Provide uniform covering of the suspended agent

Topical Medications Open wet dressings Aerosols & sprays Pastes
Similar to lotions and gels Active ingredients in aqueous phase Convenient delivery Easy dispersion over skin Good for scalp Pastes Emollients

Topical Medications Open wet dressings Pastes
Use tap water or normal saline Symptomatic relief by cooling and drying acute inflammatory lesions Cleanse skin Loosen exudates and crusts Astringents and antiseptics Vinegar, 5% aluminum acetate (Burrow solution) can be added (1:20-40) Pastes Powder in ointment Messy Can be difficult to remove (use mineral oil) Used to protect areas prone to irritation (diaper area)

Topical Medications Two considerations Creams Ointments Gels Lotions
The active medication The vehicle Creams Suspension of oil in water Water washable Hygroschopic May be drying, occasionally sensitizing Ointments Occlusive: allow for high transcutaneous of the active drug Stable for long time Require few preservatives and bacteriostatic additives Most lubricating Least likely to cause contact allergy or irritation Gels Aqueous preparations that liquefy on contact with skin Leave a uniform film on drying Well tolerated in hair-bearing areas Lotions Powder suspended in water Cool the skin when drying Provide uniform covering of the suspended agent Open wet dressings Powders Promote drying Useful in intertriginous areas Aerosols Pastes Emollients

Topical Steroids Classes of Strength vs frequency of use
The ones we use Triamcinolone 1% hydrocortisone in acid mantle cream Useful in younger children 5 g hydrocortisone powder in 1 lb. of AMC Best to get at MP Pharmacy Sig: Apply QID Avoid fluorinated steroids on face Hydrocortisone 0.5%, 1%, and 2.5% Desonide Certain genital rashes may require fluorinated steroids

Handy Hints Inflammation purplish-black in darker skin persons
Id reactions Non-fluorinated steroids can be used on the face Fever with rash is always more worrisiome Not all hair loss is tinea capitis Nail pitting occurs in psoriasis and eczema Any diaper rash more than 3 days old has a candidal component Neosporin Antifungal + steroids OTC products vs rx

Handy Hints Diaper areas – occlusive dressings
Psoriasis may start as diaper rash Not all alopecia is tinea capitis Neonatal acne is overdiagnosed Intertrigo can be superinfected with GAS Check the perianal region in child in fever without a source: GAS perianal cellulitis Seborrhea only occurs in 2 age groups Infants and adolescents/adults Not all scaly scalp is seborrhea Nor is all scaly scalp tinea capitis Seborrheic form of tinea capitis Neomycin sensitivity occurs in 3-5% Not all molluscum are umbilicated Rethink the diagnosis if the rash is not following “the rules”

Diaper Rashes General term with many Most common rash
Peak incidence 9-12 months Most common Chafing Irritant contact Candidal (yeast) The 3 day rule Check for thrush Treat breastfeeding mothers Always consider Intertrigo (can become superinfected with bacteria and/or yeast) Seborrhea Dermatophytic infection Psoriasis Acrodermatits enteropathica Histiocytosis X And others

ABCDE’s of Melanoma A = appearance (asymmetric halves)
B = border (notched, scalloped, irregular) C = color changes (esp blue, red, black, white) D = diameter greater than 0.6 cm (pencil eraser) Doesn’t apply to congenital nevi E = enlargement (evolutionary change in the lesion)

A New Rash Papular dermatitis of the newborn?????

Racial Variations in Skin
Physiologic variations Increased pigmentation of gums and tongue Pigmented streaks in nails Pigmentary demarcation b/w posterolateral & anteromedial skin on extremities (Voight-Futcher lines) Increased pigmentation in top of pinnae and nail cuticles Inflammation (erythema) can be difficult to appreciate Purplish-black tinge Some common rashes may be more follicular than scaly Pityriasis rosea, eczema, syphilis Postinflammatory hyper- and hypo-pigmentation Common Noticeable Cosmetically worrisome Darker skin can burn but sun-related disorders are less common Congenital melanocytic nevi less likely to undergo malignant transformation Café-au-lait lesions more common in AA (worry about >6) Mongolian spots more common

Hair Hair quality Pediculosis capitis more common in Caucasians
AA hair tends to tangle when dry and become matted when wet Naturally curly or spiral contributes to increased incidence of pseudofolliculitis barbae Increased incidence of tinea capitis (prepubertal) Trichophyton tonsurans can grow in Vaseline Jelly Pediculosis capitis more common in Caucasians Traction alopecia due to prolonged traction Certain hair grooming techniques can contribute to permanent alopecia AA descent Pomade acne, keloids, transient neonatal pustular melanosis, infantile acropustulosis, impetigo, papular urticaria, sickle cell ulcers, sarcoidosis, dissecting cellulitis of scalp Asian descent: eczema and Kawasaki disease

Fundamentals of Eczema Management
Description Variable presentations Tidbits Whole skin generally dry Personal and/or family histories usually + for atopies Very pruritic rash Management Avoid irritants Hot water and climate Wash new clothing, etc Use fragrance free detergents No bleach or fabric softner Manage inflammation Topical steroids are still first line choice Topical immune modulators if under good control Avoid systemic steroids in all but most extreme cases Manage hydration 3 minute rule Choices: Vaseline, Lubriderm, Kerilotion, Nivea, Eucerin*, etc Mild soap (unscented white Dove, Aveeno, etc) Deorderant soaps and Ivory are drying Treat infection Systemic Keflex Avoid topical antibiotics (risk of sensitization) Your chance to be a “cheerleader”

Fundamentals of Diaper Rash Management
Air exposure Keep clean Change often Water-proofing Ointments preferred over creams Avoid combination products 1% hydrocortisone for 3 days if inflammed enough Consider Candidal superinfection Check the mouth! Breastfeeding moms

Fundamentals of Seborrhea Management
Description Fine papular rash on forehead, eyebrows, around ears + erythema May involve diaper area, neck, then entire corpus Management Wash face with baby shampoo; mild soap for rest of body Wash behind ears May use 1% hydrocortisone BID for 3 days if seriously inflammed Check scalp for cradle cap Oil may be used only to soften scale before shampooing, not after Scrub scalp with soft brush Protect eyes if dandruff shampoo used New rash …..

Fundamentals of Tinea Capitis Management
Description One or more lesions in scalp Classic triad: skin changes, alopecia, adenopathy Most common in African-American population Considered to be a prepubertal phenomenon Can occur in young infants Management Culture not needed if classic triad First line treatment: Griseofulvin 20-25 mg/kg once a day with fatty meal for 6-8 wks LFTs not needed Wash hair with Selsun Blue shampoo 2-3 times a week Avoid sharing hats, combs, brushes, etc Keep hair utensils clean Role of hair palmades RTC if not responding in 2-3 wks Kerion & scarring alopecia & systemic steroids Id reaction Tinea corporis Treat topically OTC Lotrimin or Rx ketoconzole BID for 2 wks after cleared Carefully consider diagnosis if more than 1 lesion

Newborn Rashes Erythema toxicum Transient neonatal pustular melanosis
Mongolian spots Nevus simplex (blanch) Nevus flammeus (non-blanching) Congenital nevus Café-au-lait lesions Hemangiomas Cutaneous candidiasis Livedo reticularis = cutis mamorata (HSV)

The Lowdown on Amoxicillin Rashes
ALLERGIC NONALLERGIC Mechanism IgE mediated Unknown mechanism Reaction Urticaria Maculopapular Associated symptoms Angineurotic edema Arthralgia Fever Mild pruritus Predisposing factors Prior allergic reaction to penicillin Viral illess (EBV, CMV), CLL Sex Male = female Female > male Onset Minutes to days 5-9 days into course Duration Hours to weeks Average 3 days Response to continued therapy Usually persists, may worsen Not influenced

The Numbered Rashes First = Measles (Rubeola) Second = Scarlet Fever
Third = Rubella Fourth = Duke’s Disease ??? Fifth = Erythema infectiosum Sixth = Roseola

Steroids Use the least potent that is effective
Avoid use of fluorinated steroids on face, axillae, groin Use only for steroid responsive disorders Choose appropriate vehicle Ointment for lichenified areas Creams in moist places Consider size and ease of application Use ancillary therapies Avoid occlusion Monitor growth and BP if used for long periods Prescribe enough to use but monitor

Adult Amounts Amount required for one application
Face, hands, head or groin 2 g One arm, ant or post chest g each One leg g Entire body g One gram of cream will cover a 10x10 area Ointment spreads 30% further From: presentation by W.W.Tunnessen, MD

Steroids in Children Lotrisone (Lotrimin + high potency steroid) should not be used in children! Nearly 1700 X potency of HC n

Steroids Abused by some but feared by many Side effects feared
Anabolic steroids confused with glucocorticoids Fear causes needless suffering Confusion from number of preparations and varying potencies

Steroid Classes Rankings based on vasoconstrictor assays (predicts efficacy): STRONGEST Temovate, Diprolene, Ultravate Cyclocort, Diprosone, Halog, Lidex, Topicort Aristicort ointment, Diprosone cream, Cyclocort cream, Cutivate cream Kenalog cream, Synalar ointment, Westcort ointment, Elocon ointment Cultivate cream, Synalar cream, Valisone cream, Westcort cream Tridesilone cream, Acylovate Hydrocortisone 0.5% and 1% (OTC) or 2.5% (Rx) MILDEST Used since 1951 Basic compound is hydrocortisone, modified to enhance glucocorticoid activity & dec mineralocorticoid effects; halogenation at different positions on HC nucleus changes potency

Relative Potencies Potency affected by formulation and vehicle, not concentration
Preparation Rel Pot Clobetasol (Temovate) 1869 Betamethasone dipropionate (Diprolene) 1660 Betamethasone valerate (Valisone) 360 Fluocinolone acetonide (Synalar) 100 Triamcinolone acetate (Kenalog, Aristocort) 75 Hydrocortisone <1

HC Absorption by Body Site
Forearm (ventral) 1x (dorsal 1.1x) Plantar arch 0.14x Lateral ankle 0.42x Palm 0.83x Back 1.7x Scalp 3.5x Axilla 3.6x Forehead 6x Jaw angle 13x Scotum 42x

Side Effects of Topical Steroids
Local Atrophy, striae, pigmentary changes, easy bruising, hypertrichosis, rosacea, acne, milia, tinea incognito (scabies, impetigo), delayed wound healing, Candidiasis Systemic Sypothalamic-pituitary-adrenal axis suppression Cushing Syndrome Growth retardation Increased intracranial pressure Hypertension Glaucoma and cataracts

Choosing the Best Product
What is being treated? How long will it be used? 1%HC can be used over entire body for years without SE What part of body being treated? What vehicle will be used? Ointment have optimal absorption; use for lichenified or thickened areas; not in hairy or moist areas; heat retention. Creams best for hairy areas; can be sensitizing and/or drying. Lotions & gels best for scalp; may burn or sting.

Bad Rashes Petechiae Purpura > 6 café au lait lesions
> 3 ash leaf spots Port wine stain in trigeminal area Livedo reticularis in older children

Fun Rashes Geographic tongue Liplicker’s dermatitis
Tennis shoe dermatitis Picker’s nodule Gloves and socks syndrome Dirty socks syndrom

Best References Introduction to Pediatric Dermatology, Chapter 1, Pediatric Dermatology, BA Cohen, 2nd edition, Mosby, 1999.

What You Need to Know First about Pediatric Dermatology

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