1. Pediatric dermatology

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

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

23. 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

24. 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

25. 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

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

27. 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

28. 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

29. 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

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

31. 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

32. 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

33. 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

34. 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

35. 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

36. Thank you