1. CHILDHOOD DERMATOLOGY
Dr. SATAM ALSHAMMARI
ASSISTANT PROFESSOR OF PEDIATRIC MEDICINE
CONSULTANT OF PEDIATRIC PULMONOLOGY
MOH.KSA

2. Introduction
-There are more than 3000 dermatologic diagnoses -Approximately 5% of ED visits are for a dermatologic complaint

3. The structure and function of the skin
Epidermis
Dermis
Subcutaneous tissue
Functions
Thermal control : regulates body temperature
Excretion : by regulating the volume and chemical content of sweat.
Makes vitamin D
Immunity (Defenses)
sensation: the widespread of the millions of different somatic sensory receptors that detect stimuli.

4. History
Age
Onset
Is the rash raised (papular) or flat (macular)?
Is the rash red?
Is the rash scaly?
Is the rash itchy?
When did the rash start?
Where did the rash start, and how did it spread?
Duration
Body location
Any change of individual lesions
Did the patient present with other symptoms
(Fever ,Pruritus ,Conjunctivitis, Swollen extremities, Sore throat, Abdominal pain)
Involvement of palms and soles, mucous membranes, conjunctiva
Was the lesion caused by trauma/insect bite?
Is there any associated discharge or odour?
What makes the skin condition better or worse?

5. History (cont) Past Medical History (asthma, eczema)
Family Medical History: Has the patient had close contact with someone else with the same symptoms?
Social History : Has the patient travelled recently?, animals contact
Immunizations History
Allergies History
Medications History: Has the patient been exposed to new topical applications

6. Physical Exam nails hair mucous membranes
General Appearance: (well, uncomfortable, toxic)
Vital signs: (pulse, respiration, temperature, etc)
Skin exam: (entire skin should be inspected, including mucous membranes, genital/anal regions).
Remember SCALDA to describe a lesion4
S Site/Size/Shape/texture (centripetal,centrifugal)(morbilliform,varicelliform)
C Colour (Erythematous,Hypopigmented,Hyperpigmented,Depigmented)
A Arrangement (Solitary, Grouped, Linear)
L Lesion type (primary, secondary)
D Distribution(eg.Symmetrical, dermatomal,extensor surfaces,intertriginous
(between body folds), dependent areas, sun-exposed skin)
A Always check involvement of:
nails
hair
mucous membranes
feel the lesion raised or flat? wet or dry ,what dose it feel like? blanchable

7. Terminology Macules, Papules, Nodules Patches and Plaques
Vesicles, Pustules, Bullae
Erosions
Ulcerations and excoriations

8. Primary &Secondary Lesions
Primary Lesions:
Those lesions that are the direct result of a pathologic process
Secondary Lesions:
Lesions that are the result of alteration of a primary lesion (e.g. rubbing, scratching, infection)

9. Common Primary Lesions
>1 cm
<1 cm
Profile
Patch
Macule
Flat
Plaque
Papule
Elevated
Tumor
Nodule
Palpable, deep
Bulla
Vesicle
Fluid filled

10. Common Primary Lesions

11. Common Primary Lesions
hemorrhages into the skin.
Not blanch on pressure
petechiae (< 1-2 mm )
Purpura spots (3-10 mm in diameter)
palpable: vasculitic
HSP
meningococcaemia
non-palpable: ITP
ecchymoses (>1 cm bruises).
Telangiectasia
is the name given to prominent cutaneous blood vessels.

12. Common Primary Lesions

13. Secondary skin lesions
Scale:
Flakes of keratin that can be fine or coarse; loose or adherent.
Example: Dandruff
Lichenification:
thickened and rough epidermis with accentuation of skin markings.
Excoriation:
Traumatized or abraded skin, usually due to scratching or rubbing.

14. Secondary skin lesions
Fissure A fissure is a thin crack within epidermis or epithelium, and is due to excessive dryness
Ulcer Deep open wound extending into the dermis or subcutaneous tissue. May lead to scar formation.
Erosion Superficial open wound involving only epidermis or mucosa. Does not extend into the underlying dermis, so healing occurs without scar formation

15. Secondary skin lesions

16. Causes of maculopapular rash
Remember blanch on pressure
Measles
Rubella (macular)
Erythema infectiosum (fifth’s disease)
Roseola HHV6/7
Enrerovirus (coxsackie,echo,polio viruses)
-more 90% aysymptomatic
-faecal oral route
-effective vaccine for polio
Scarlet fever
Kawasaki disease
Durgs

17. Measles

18. Measles Incubation period 8-14 days
Prodromal illness 3-4 days Fever, conjunctivitis, runny nose & cough
Koplik spots
-white spot on buccal mucosa
hours before rash
- pathognomonic
-difficult to see
Rash:
begins on face & behind ears
usually with onset high fever
spreads to body
Usually spares palms/soles

19. Measles Complications Otitis media Febrile convulsion Bronchopneumonia
Encephalitis (1/5000)
Myocarditis/pericarditis(ECG abnormalities)
SSPE (rare) after years
Other hepatitis corneal ulceration

20. Measles
Diagnosis
IgG and IgM serologies, acute and convalescent titers
Treatment Symptomatic.
Antipyretics.
In severe disease, vitamin A
in immunocompromised ribavirin
Prevention - immunization at 1year
-10% failure of vaccine
-at school age

22. Rubella Mild disease IP:14-21 days Spread by respiratory route s/s
Fever low grade or none at all
Maculopapular rash first sign on face (Fade in 3-5 days)
LAP especially suboccipital and postauricular
Complication are rare
Arthritis,
Encephalitis,
Myocarditis,
Thrombocytopenia
Diagnosis by serology
No effective anti viral

25. Erythema Infectiosum Fifth Disease
known as ‘slapped cheek disease’ or 5th disease
Features
Parvovirus B19
Incubation period 4-14 days
Mostly preschool age
Fever in 15-30% for 1-2 days
Slapped cheek appearance
Generalised maculopapular rash for 7-10 days
transmission is via respiratory secretion
Management
Supportive

27. Roseola Roseola Infantum Human herpesvirus 6
Most Children are infected by 2 years
Abrupt onset of high fever for 3 days
Followed by generalized macular Rash which appears as the fever wane
Is common cause of Febrile seizures
Rarely associated aseptic meningitis, hepatitis.

29. Scarlet fever Cause Group A beta-haemolytic Streptococcus Features
Incubation 2-4 days
Bright red blanching rash (sandpaper)
First in axilae/groins, then widespread
Red face with circumoral pallor
Strawberry tongue (white then red)
Treatment
Symptomatic relief
Penicillin V 7-10 days

33. Kawasaki Disease Affect children 6 months-4 years Cause unknown
Clinical diagnosis
Vasculitis affecting small and medium size vessels
Affect coronary arteries about one third
Mortality 1%

34. Kawasaki Disease Diagnostic Criteria
Fever for 5 or more days
Presence of 4 of the following:
Bilateral conjunctival injection
Changes in the oropharyngeal mucous membranes
Changes of the peripheral extremities
Rash
Cervical adenopathy
Illness can’t be explained by other disease
Fever for 5 or more days
Presence of 4 of the following:
Bilateral conjunctival injection
Changes in the oropharyngeal mucous membranes injected pharynx, injected lips, dry or cracked lips, strawberry tongue
Changes of the peripheral extremities – peripheral edema or erythema, desquamation, periungual dequamation
Rash - mostly truncal, polymorphic but not vesicular
Cervical lymph node

35. Kawasaki Disease Lab Features
 WBC
 ESR, positive CRP
Mild  transaminases
 albumin
Sterile pyuria, aseptic meningitis
 platelets by day 10-14

36. Kawasaki Disease Treatment
IV Ig 2 g/kg as single dose
Expect rapid resolution of fever
Decrease coronary artery aneurysms from 20% to < 5%
ASA - reduce risk of thrombosis
- Repeat echocardiogram at 6 weeks

37. Causes of vesicular rash
Chickenpox
Shingles
Herpes simplex
Hand foot mouth disese

40. Chickenpox Causes Varicella zoster virus Features Very common
Incubation period days
Prodrome mild fever & malaise
Vesicles on erythematous base
Change to macule→papule→vesicle→crust
Last 3-4 days
Mainly on trunk
Can appear in mouth/genital region
Usually no scarring
Infectious for 1-2 days before rash & 5 days afterwards

41. Chickenpox Complications
Always look carefully at child if fever persists > 5 days after appearance rash
?secondary bacterial infection staphlococcal,strptococcal
toxic shock syndrome
necrotising fascitis
Pneumonitis
Encephalitis
Cerebellar ataxia(cerebelitis)
Eczema herpeticum
Management
Supportive – fluids/paracetamol/calamine lotion
Admit if complications suspected

44. Herpes Simplex Gingivostomatitis most common 1º infection in children
10 months – 3 years
There are Vesicular lesion on lips, gums , ant surface of tonge and hard palate
progress to painful ulceration and bleeding
High Fever, irritability, miserable child
Eating and drinking are painful lead to dehydration
Treatment: supportive
severe (IVF,aciclovir)

46. Herpetic Whitlow Lesions on thumb usually 2° to autoinoculation
Group, thick-walled vesicles on erythematous base
Painful
Tend to coalesce, ulcerate and then crust
May require topical or oral acyclovir

49. Coxsackie Virus Hand-Foot-and-Mouth
Painful, shallow, yellow ulcers
Found on buccal mucosa, tongue, soft palate, uvula and anterior tonsillar pillars
Exanthem involves palmar, plantar and interdigital surfaces of the hands and feet +/- buttocks
Cause
Coxsackie viral infection
Can be complicated by aseptic meningitis
Management
Supportive

50. peticheal &purpuric rash
hemorrhages into the skin.
Not blanch on pressure
petechiae (< 1-2 mm )
Purpura spots (3-10 mm in diameter)
palpable: vasculitic
non-palpable: ITP
ecchymoses (>1 cm bruises).

51. Causes of purpuric & peticheal rash
Meningococcal infection
Idiopathic thrombocytopenia purpura
Henoch-Schonlein Purpura (HSP)
Viruses - particularly enterovirus infection
Leukemia
Excessive vomiting
Extreme crying
Violent coughing
Trauma or injury
Defect in blood clotting factor
Durgs

53. Meningococcemia Caused by Neisseria meningitides
Although there are vaccines against groups A,C
No vaccine against group B
Meningococcal septicemia can kill children in hours
Any febrile child with purpuric rash should given
treatment immediately
Petechial rash develops in 75% of cases
Fever, rash, hypotension, shock, DIC

56. Henoch-Schonlein Purpura
Usually occurs 3-10 years
More common in boys
Often Preceded by URTI

57. Clinical features Skin rash: Palpable purpura of extremities
cornerstone of the diagnosis
Arthralgia or non-migratory arthritis
No permanent deformities
Mostly ankles and knees
Periarticular oedema
Abdominal pain
May develop intussusception
Renal involvement
Hematuria, hypertension, renal failure,NS

58. MACULOPAPULAR RASH

59. MACULOPAPULAR RASH
Viral Exanthem - Measles, Rubella, Fifths, etc, self-limiting, supportive care
Lyme Disease - Tick bite, erythema migrans, arthralgias, headache, doxycycline
Pityriasis - scaly lesions, herald patch, Christmas tree pattern, treatment includes: UV light, moisturizing lotion, oatmeal bathes, antihistamines
Stevens-Johnson Syndrome - mucosal involvement, remove drug/treat illness, supportive therapy, hospital admission
EM = Erythema Multiforme - treat illness/stop drug, supportive care, topical steroids and outpatient follow-up for minor cases
Meningiococcemia - ill appearing, mental status change, lumbar puncture,
ceftriaxone, isolation, treat close contacts, hospital admission
RMSF = Rocky Mountain Spotted Fever - tick bite, endemic area, headache, arthralgias, doxycycline
Scabies - excoriated burrows, itches worse at night, permethrin

60. PETECHIAL/PURPURIC RASH

61. PETECHIAL/PURPURIC RASH
Meningiococcemia - ill appearing, mental status change, lumbar puncture,
ceftriaxone, isolation, treat close contacts, admission
Disseminated GC= Gonococcemia - purple vesicles, sparse, peripheral, associated urethritis/cervicitis/septic arthritis, ceftriaxone
Endocarditis – new murmur, vegetations on valves, positive blood cultures
RMSF = Rocky Mountain Spotted Fever - tick bite, endemic area, headache, arthralgias, doxycycline
HSP = Henoch Schonlein Purpura – children, associated arthralgias, hematuria andGI symptoms, supportive therapy
TTP= Thrombotic Thrombocytopenic Purpura - low platelet count, fever, neuro sx, hemolytic anemia, renal failure, ICU admission, treat underlying cause,
plasmapheresis, splenectomy, selective transfusion, NO platelets
Vasculitis – treat the underlying process if possible, may require steroids
ITP – Idiopathic Thrombocytopenic Purpura - transfuse platelets if bleeding or less than 5000/mm3 – 10000/mm3, emergent Hematology consultation

62. VESICULO-BULLOUS RASH

63. VESICULO-BULLOUS RASH
Varicella/Chicken Pox – excoriated lesions in multiple stages, starts centrally,isolate, rare hospitalization, symptomatic treatment, antipyretics (not Aspirin)
Small Pox – all lesions in one stage, more peripheral distribution, isolate, notify office of public health and CDC
Disseminated GC= Gonococcemia - purple vesicles, sparce, peripheral, associated urethritis/cervicitis/septic arthritis, ceftriaxone
Purpura Fulminans/DIC = Disseminated Intervascular Coagulation - treat the underlying cause, fresh frozen plasma, platelet transfusions, ICU admission
Necrotizing Fasciitis – surgical emergency, debridement, IV anti- streptococcal broad spectrum antibiotic, hyperbaric oxygen therapy
Hand, Foot and Mouth Disease – children, vesicles on palms, soles and in mouth,self-limited, symptomatic treatment
Bullous Pemphigus -chronic autoimmune blistering, elderly, usually benign, steroids
Pemphigus Vulgaris – mucous membrane involvement, much higher mortality than Bullous Pemphigus, steroids, admission
Zoster – acyclovir, analgesia, steroids
Contact Dermatits - symptomatic treatment, long taper of steroids for severe cases

64. Causes of napkin rash Irritant(contact dermatitis) flexure are spared
Seborrhoeic dermatitis
Candida infection

66. Napkin dermatitis Features
Usually due to irritant contact dermatitis which spares groins
Treat with barrier cream, frequent nappy changes

68. Napkin rash
Satellite lesions and skin-fold involvement may indicate candida
Look for mouth lesions as well
Treat with anti-fungal cream

74. Atopic Dermatitis
superficial inflammation of the skin characterized by redness edema oozing crusting scaling (vesicles)

75. Atopic Dermatitis 12-26% of children Onset usually in first year
Uncommon in first 2 months
Diaper area spared
Sites of Predilection
Face in the young
Extensor surfaces of the arms and legs 8-10 mo.
Antecubital and popliteal fossa , neck, face in older

76. Atopic Dermatitis The diagnosis is made clinically
The patient must have each of the following
1-pruritis
2-Typical morphology and distribution
Facial and extensor involvement in infant and children
Flexural in adult
3-Tendency toward chronic and relapsing

77. complications Flare-up are common Infection (strep,staph,herpes)
lymphadenopathy

78. Treatment Avoidance or elimination of predisposing factors
(nylon,long nail. Cow milk)
Hydration and lubrication of dry skin
Anti-pruritic agents
Topical steroids
Antibiotic or antiviral
Dietary elimination (egg , cow milk)
occurs in 6% of infant with eczyma
4-6 weeks required to detect response

81. Seborrheic Dermatitis
Its cause remains unknown
Most frequent present in first 2 months of life.
erythamatous scaling eruption
The scales form thick yellow adherent layer (cradle cap)
The rash causes no discomfort or itching like eczema
Treatment -mild case resolve with emollient
-scales treated with ointment contain sulphur and salicylic acid
-Topical steroids

84. Urticaria Transient, well-demarcated wheels Pruritic
Due to increase premeablity of capillaries and venules
May involve deep tissue to produce angioedema
Etiology are
- idiopathic common
- drugs penicillin's, cephalosporin's
- food egg ,cheese, strawberries, fish, peanut
- physical agent heat,cold pressure

88. Impetigo Localized ,highly contagious Common in infant
It is common where underlying skin disease eczema
Strep or Staph
Honey-coloured crust
Mostly face, extremities, hands and neck
Treatment: topical (mild)
systemic antibiotics flucloxacillin,erythromycin.(severe)
Nasal carriage is important source of infection chlorhexidine,neomycin,mupirocine (cream)

89. Thank you