1. Alterations of the Integument in Children Chapter 45 Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

2. 2 Acne Vulgaris  Most common skin disease  Affects 85% of people between ages 12 and 25  Acne conglobata  Highly inflammatory form of severe acne  Formation of communication cysts and abscesses beneath the skin  Sebaceous follicles sites for acne lesions

3. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 3 Acne Vulgaris  Noninflammatory acne  Blackheads  Whiteheads  Inflammatory acne  Caused by follicular wall rupture in closed comedones (whiteheads)  Cystic nodules develop when inflammation is deeper, may cause scarring

4. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 4 Acne Vulgaris  Physiologic factors  Follicular hyperkeratinization, excessive sebum production, colonization of Propionibacterium acnes, and inflammation secondary to the action of inflammatory products produced by P. acnes  Excessive production of sebum is related to androgenic hormones

5. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 5 Acne Vulgaris: Treatment  Diet not proven to cause acne  Dietary restrictions are generally not effective  Topical treatment: first line of therapy; if this fails use systemic therapies  Acne surgery, including comedo extraction, intralesional steroids, cryosurgery useful  Severe scarring treated with dermabrasion or subincision  Special consideration given to treatment for those with darker-colored skin due to greater risk for hyperpigmentation and keloidal scarring

6. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 6 Cystic Acne

7. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 7 Atopic Dermatitis  Most common form of eczema in children  Cause unknown, but 80% demonstrate a personal or family history of asthma or allergic rhinitis  Manifestations  Increased IgE levels, positive allergen skin tests, and eosinophilia

8. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 8 Atopic Dermatitis  Infants  Rash appears on the face, scalp, trunk, and extensor surfaces of the arms and legs  Children and adults  Rash tends to be on the neck, antecubital and popliteal fossae, hands and feet  Lichenification (thickening of the epidermis from constant scratching)  Common in adults with chronic eczema

9. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 9 Atopic Dermatitis

10. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 10 Diaper Dermatitis  Inflammatory disorders affecting the lower abdomen, genitalia, buttocks, and upper thigh  A nonallergic contact dermatitis  Inflammation encouraged by prolonged exposure to irritation by urine and feces, maceration by wet diapers, airtight plastic diaper covers, and possible association with intercurrent illness and early introduction of cereals

11. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 11 Diaper Dermatitis

12. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 12 Infections of the Skin  Bacterial infections  Impetigo contagiosum Superficial infection usually caused by Staphylococcus or group A streptococci Superficial infection usually caused by Staphylococcus or group A streptococci High incidence in hot, humid climates High incidence in hot, humid climates  Bullous impetigo Rarer variant of impetigo caused by Staphylococcus aureus Rarer variant of impetigo caused by Staphylococcus aureus Staphylococci produce a bacterial toxin called exfoliative toxin (ET), which causes a disruption in desmosomal adhesion molecules with blister formation Staphylococci produce a bacterial toxin called exfoliative toxin (ET), which causes a disruption in desmosomal adhesion molecules with blister formation Occurs in newborns and is highly contagious Occurs in newborns and is highly contagious Source is usually a staff member in a newborn nursery or a family member with a pustule or who is an asymptomatic carrier Source is usually a staff member in a newborn nursery or a family member with a pustule or who is an asymptomatic carrier

13. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 13 Infections of the Skin  Bacterial Infections  Vesicular impetigo Contagious, acute, superficial, vesiculopustular form of impetigo caused by group A Streptococcus pyogenes (alone or in combination with Staphylococcus aureus) Contagious, acute, superficial, vesiculopustular form of impetigo caused by group A Streptococcus pyogenes (alone or in combination with Staphylococcus aureus) Microorganisms disseminated by direct physical contact from other infected individuals or through insect bites Microorganisms disseminated by direct physical contact from other infected individuals or through insect bites

14. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 14 Impetigo

15. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 15 Infections of the Skin  Bacterial infections  Staphylococcal scalded-skin syndrome (SSSS) Serious infection caused by exfoliative toxin producing group II staphylococci Serious infection caused by exfoliative toxin producing group II staphylococci Exfoliative toxin attacks desmoglein and adhesion molecules; causes separation of the skin just below the stratum granulosum Exfoliative toxin attacks desmoglein and adhesion molecules; causes separation of the skin just below the stratum granulosum Manifestations Manifestations  Fever, malaise, rhinorrhea, and generalized erythema and skin tenderness  Seen in infants and children younger than 5 years

16. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 16 Infections of the Skin  Fungal infections  Fungi causing superficial skin lesions are called dermatophytes  Fungal disorders are called mycoses; mycoses caused by dermatophytes are termed tinea Tinea capitis (scalp) Tinea capitis (scalp) Tinea pedis (athlete’s foot) Tinea pedis (athlete’s foot) Tinea corporis (ringworm) Tinea corporis (ringworm)

17. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 17 Tinea Capitis

18. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 18 Infections of the Skin  Fungal infections  Thrush Candida present in mucous membranes of the mouths of infants, and less commonly in adults Candida present in mucous membranes of the mouths of infants, and less commonly in adults Characteristics Characteristics  White plaques or spots in the mouth that lead to shallow ulcers Thrush can spread to the groin, buttocks, and other parts of the body Thrush can spread to the groin, buttocks, and other parts of the body

19. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 19 Infections of the Skin  Viral infections  Molluscum contagiosum Highly contagious pox viridae infection of the skin Highly contagious pox viridae infection of the skin Skin-to-skin and fomite transmission Skin-to-skin and fomite transmission The virus encourages epidermal cell proliferation and blocks the immune response The virus encourages epidermal cell proliferation and blocks the immune response

20. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 20 Molluscum Contagiosum

21. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 21 Infections of the Skin  Viral infections  Rubella (German measles or 3-day measles) RNA virus RNA virus The disease is mild in most children The disease is mild in most children Manifestations Manifestations  Enlarged cervical and postauricular lymph nodes, low- grade fever, headache, sore throat, runny nose, cough  Faint pink to red maculopapular rash caused by virus dissemination to the skin Vaccination for rubella combined with mumps and rubeola (measles) (MMR) Vaccination for rubella combined with mumps and rubeola (measles) (MMR)

22. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 22 Infections of the Skin  Viral infections  Rubeola RNA paramyxovirus RNA paramyxovirus High fever, malaise, enlarged lymph nodes, runny nose, conjunctivitis, barking cough High fever, malaise, enlarged lymph nodes, runny nose, conjunctivitis, barking cough Koplik spots Koplik spots  Roseola Fever and an erythematous macular rash that lasts about 24 hours Fever and an erythematous macular rash that lasts about 24 hours

23. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 23 Infections of the Skin  Viral infections  Chickenpox (varicella) and herpes zoster (shingles) Both diseases are produced by the same virus Both diseases are produced by the same virus DNA virus DNA virus Infection occurs within keratinocytes Infection occurs within keratinocytes

24. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 24 Measles and Chickenpox

25. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 25 Insect Bites and Parasites  Scabies  Contagious disease caused by the itch mite Sarcoptes scabiei  Transmitted by personal contact and infected clothing and bedding  Female mite tunnels millimeters to 1 cm into the stratum corneum, deposits eggs, and over a 3- week period, the eggs mature into adult mites  Primary lesions are burrows, papules, and vesicular lesions with severe itching  Patient at risk for infections from scratching

26. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 26 Scabies

27. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 27 Insect Bites and Parasites  Pediculosis  Pediculus capitis (head), Pediculus corporis (body), and Phthirus pubis (crab or pubic)  Highly contagious parasite that survives by sucking blood Acquired through personal contact and shared clothing, combs, or brushes Acquired through personal contact and shared clothing, combs, or brushes  Female louse reproduces every 2 weeks and produces hundreds of nits

28. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 28 Insect Bites and Parasites  Flea bites  Cat, dog, and human fleas  Occur in clusters along the arms and legs  Characteristic lesion is an urticarial wheal with a central hemorrhagic puncture

29. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 29 Insect Bites and Parasites  Bedbugs (Cimex lectularius)  Live in the crevices and cracks of floors, walls, and furniture and in bedding or furniture stuffing  3 to 5 mm long and reddish brown  Feed in the darkness Attach to the skin, suck blood, and leave Attach to the skin, suck blood, and leave  Lesions: red macules; develop into nodules

30. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 30 Flea and Bedbug Bites

31. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 31 Hemangiomas  Benign tumors  From rapid growth of vascular endothelial cells and formation of extra blood vessels  Females affected more often than males  Superficial: strawberry hemangiomas  Deep: cavernous hemangiomas  Etiology: embolization of fetal placental endothelial cells related to placental trauma or loss of placental angiogenic inhibitor of placental and maternal origin

32. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 32 Hemangiomas  Proliferation of mast cells, thought to promote angiogenesis  Infiltration of fat cells, fibrosis, and rich vascular network; females affected more often than males  30% of hemangiomas seen at birth; most emerge during first few weeks of life  Grow rapidly during the first few years of life, then shrink or involute

33. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 33 Hemangiomas  Strawberry hemangiomas  Raised vascular lesions that usually emerge 3 to 5 weeks after birth  Lesions proliferate, become bright red, and elevate with small capillary projections  Cavernous hemangiomas  Present at birth  Involve larger and more mature vessels than strawberry hemangiomas

34. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 34 Strawberry and Cavernous Hemangiomas

35. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 35 Vascular Malformations  Port-wine stains  Congenital malformation of dermal capillaries  Flat, pink, to dark reddish-purple lesions  Salmon patches  Macular, pink lesions resulting from distended dermal capillaries; usually fade by 1 year of age  Common on the nape of the neck, forehead, upper eyelids, or nasolabial folds

36. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 36 Miliaria  Vesicular eruption after prolonged exposure to perspiration, with subsequent obstruction of eccrine ducts  Miliaria crystallina Ductal rupture within the stratum corneum Ductal rupture within the stratum corneum Clear vesicles without erythema Clear vesicles without erythema  Miliaria rubra (prickly heat) Erythematous papules and papulovesicles Erythematous papules and papulovesicles

37. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 37 Miliaria Rubra

38. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 38 Other Skin Disorders  Erythema toxicum neonatorum  Benign, erythematous macules, papules, or pustules; appear at birth or 3 to 4 days later  No treatment is required  Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome  Rare, severe drug reactions with widespread epidermal apoptosis and detachment  Mortality rates between 20% and 60%