1. Paediatric Dermatology
By Janakan Natkunarajah
Kingston Hospital

2. Newborn

4. Milia Epidermal inclusion cysts 50% of infants have milia
Micropapules over face
Usually resolve in the 1st month

7. Toxic erythema neonatorum
Affects 50% of newborn term babies
Arises in first few days (1-5 days)
Well child
Blotchy erythema with papules & pustules
Spares palms and soles
Resolves spontaneously over days

9. Miliaria Obstruction of sweat glands
Multiple tiny blister like lesions +/- erythema
Face, neck, arms, groin
Avoid occlusive clothing /looser clothing
Cool baths

12. Sucking Blisters Sucking in womb
Solitary Blisters /erosions over forearm, wrists and hands
Benign –resolve spontaneously

14. Benign cephalic pustulosis
Pustular eruption over the face and scalp in newborns
Often during the 3rd week
Related to Malassezia colonisation
Resolves with no treatment
topical antifungals if needed

16. Seborrhoeic dermatitis
Last several months, mostly resolve by 1 year
Erythematous patches with waxy scale over the scalp +/- axillae and groin
Oils
Emollient +/- Daktocort

17. Infantile

19. Haemangioma Benign Tumour of Infancy - Proliferating endothelial cells
Apparent days to weeks
Superficial or Deep or mixed

20. Predisposing factors Females Prematurity Low birth weight babies
Multiple births

21. 80% - Head and Neck
80% of maximum size in first 3 months
80% Involute or regress with age without treatment

22. Most cases Majority - No treatment required Reassurance Involution
Approx 30% by 3 yrs, 50% by 5yrs, 70% by 7 yrs, 90% by 9 yrs

23. Significant morbidity
Ulcerating haemangioma
Obstruct – eyes, mouth, airway, ear canal, nasal tip
Large lesion on the face

24. Oral Propranolol Effective in the proliferative phase of growth
Beta blocker
block the beta adrenergic receptors
-> blood vessels narrower and reducing amount of blood flowing through them
-> reducing colour and making them softer

25. Side effects Bradycardia Bronchospasm Hypotension Hypoglycaemia
Restless sleep

26. Prescreening Clinical Exam – cardio and resp exam
FBC, U&E, Glucose, TSH
ECG
Echo
Medical Photo

27. 1mg/kg/day in 3 divided doses in 1st week
2mg/kg/day by 2nd week if tolerated
5mg/5ml to avoid confusion
Propranolol given with feeds to avoid hypoglycaemia

28. 4 weeks
Ulster Med J 2013;82(1):16-20

29. Dramatic response of propranolol in hemangioma: Report of two cases Vikrant M Jadhav, Sunil N Tolat

31. Atopic Eczema Eczema – “Boil over”
Chronic Inflammatory itchy skin disease
15-20% children
Relapsing-remitting
Breakdown of skin barrier

32. Natural History
50% develop Atopic dermatitis within the first year of life; most cases symptoms disappear by 2 yrs
By 5 yrs, 80% will have developed their condition
The condition improves with age. 50% resolve by age of 13

33. Child with itchy skin + 3 or more
History - flexural dermatitis (cheeks and extensor surfaces in children <18 months)
History – dry skin in the last 12 months
Personal history – asthma & allergic rhinitis or history of atopic dermatitis in a first degree relative
Visible- flexural dermatitis (cheeks and extensor surfaces in children <18 months)
Onset of signs and symptoms under the age of 2 yrs

34. Trigger Factors Irritants Skin Infection Contact allergens
Food allergens
Inhalant allergens

35. Morphology

36. Infantile
Cheeks is often the first site affected

37. Toddlers and Preschool
Localised & thickened
Extensor involvement – wrist, elbow, knees, ankles

39. School age
Flexural pattern- lichenification

40. Discoid Eczema

42. Papular Eczema

44. Pityriasis Alba

45. Lip Licker

46. Food Allergy Reacted to food with immediate symptoms
Moderate/severe eczema not controlled with optimum treatment
Associated gut dysmotility (vomiting, colic, altered bowel habit) or failure to thrive

47. Inhalant allergy Seasonal flares of eczema
Children with eczema and asthma or hayfever
Children >3yr with eczema over face, particularly eyes

48. Management
Time
Emollients
Steroids
Enpowerment

49. Management: Expectation
Most – Atopic eczema improves with time
Not all grow out of it
Develop asthma and/or allergic rhinitis

50. Written Instructions Keep it simple

51. Emollient Use all the time even when eczema is clear Large quantities
Moisturiser
Bath

52. Steroids Steroid Phobia: Benefits outweigh the risks Steroid strengths
Mild eczema – mild potency
Moderate eczema – moderate potency
Severe eczema - potent

53. Axillae and Groin – limit moderate/potent steroids for up to 7-14 days
2 consecutive days steroids- to prevent flares

54. Steroid Sparing Topical Tacrolimus & Pimecrolimus
Not first line & Not for mild eczema
Second line- moderate/severe eczema in children ages 2 yr or more – not controlled on steroids

55. Tailor treatment to severity
Emollients
Mild disease – emollients + mild steroid creams 1% hydrocortisone
Moderate disease – emollients + moderate steroid creams. Topical calcineurin inhibitors, bandages.
Severe disease – potent steroid creams (short periods only) topical calcineurin inhibitors, bandages, phototherapy, systemic therapy

57. Eczema Herpeticum Areas of rapidly worsening painful eczema
Punched out erosions (1-3mm)
Clustered vesicles
Fever, lethargy & distress

58. Aciclovir- oral/iv
Systemic antibiotics for secondary infection
Ophthalmology – eye or eyelid involvement

60. Eczema Coxsackium
Vesiculobullous eruption in areas of eczema caused by Coxsackie virus A6
Lesions are painless and children are well
Not monomorphous, not punched out
Vesicular fluid PCR
Reassured – self limiting

63. Impetigo Highly Contagious Bacterial skin infection
Staphylococcus aureus and streptococcus pyogenes
Topical antibiotics – localised infection
Systemic antibiotics – extensive infection
Flucloxacillin -1st line choice; erythromycin if penicillin allergic
Recurrent infections- nasal carriage clearance

66. Staphylococcal scalded skin syndrome
Staphylococcal exofoliative toxin
Admission for iv flucloxacillin
Children < 5 yrs or immunosuppressed adults

67. Staphylococcal Scalded Skin Syndrome
Prodrome – fever, malaise, irritability
Erythema (localised to head-> spread- > 24-48hrs fragile bullae /superficial slough-> rupture like a burn
Flexural areas first to exfoliate
Skin swabs always negative; blood cultures almost always negatve
Perioral crusting & fissuring
3-5 days scaling and desquamation
Re-epithelisation over days

69. Molluscum Contagiosum
Pox - Viral infection
Umbilicated papules – esp flexural sites
Spread by direct contact
Clears months
Molluscum frequently induces dermatitis

71. Treatment Crystacide – 1% hydrogen peroxide
twice a day for 4-6 weeks
Molludab- 5% potassium hydroxide
twice a day – for 2 weeks
Cryotherapy

72. Viral warts

74. Salicylic Acid

77. Filiform wart
Cryotherapy
Curettage and cautery

79. Tinea Capitis

80. Ectothrix
Endothrix
e.g. M. Canis
e.g. T. tonsurans

81. 3-10 yrs olds

100. Tinea capitis needs oral treatment

101. Treatment for tinea capitis in UK
Acts on fungal cell wall synthesis
20mg/kg for 8-12 weeks
Take with food to increase absorption

102. Acts on fungal cell membrane
<20kg mg
20-40kg 125mg
>40kg mg
Treat for 4 weeks

103. TOPICAL TREATMENT ALONE IS NOT RECOMMENDED IN TINEA CAPITIS

104. Carriers Culture positive with no clinical disease
Treat oral antifungals
Antifungal shampoo twice a week for 4 weeks

106. Repeat mycology at end of treatment period
Mycology cure
Repeat mycology at end of treatment period

107. Treatment failure Compliance Suboptimal absorption
Insensitivity of organism
Reinfection