CHILDHOOD DERMATOLOGY CHILDHOOD DERMATOLOGY Dr. SATAM ALSHAMMARI Dr. SATAM ALSHAMMARI ASSISTANT PROFESSOR OF PEDIATRIC MEDICINE ASSISTANT PROFESSOR OF PEDIATRIC MEDICINE CONSULTANT OF PEDIATRIC PULMONOLOGY CONSULTANT OF PEDIATRIC PULMONOLOGY MOH.KSA MOH.KSA
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CHILDHOOD DERMATOLOGY Dr. SATAM ALSHAMMARI ASSISTANT PROFESSOR OF PEDIATRIC MEDICINE CONSULTANT OF PEDIATRIC PULMONOLOGY MOH.KSA.
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CHILDHOOD DERMATOLOGYCHILDHOOD DERMATOLOGY
Dr. SATAM ALSHAMMARIDr. SATAM ALSHAMMARI
ASSISTANT PROFESSOR OF PEDIATRIC MEDICINE ASSISTANT PROFESSOR OF PEDIATRIC MEDICINE CONSULTANT OF PEDIATRIC PULMONOLOGY CONSULTANT OF PEDIATRIC PULMONOLOGY
MOH.KSAMOH.KSA
IntroductionIntroduction
-There are more than 3000 dermatologic -There are more than 3000 dermatologic diagnosesdiagnoses
-Approximately 5% of ED visits are for a -Approximately 5% of ED visits are for a dermatologic complaintdermatologic complaint
The The structurestructure and and functionfunction of the of the skinskin
FunctionsFunctions Thermal control : regulates body temperature Thermal control : regulates body temperature Excretion : by regulating the volume and chemical content of Excretion : by regulating the volume and chemical content of
sweat.sweat. Makes vitamin D Makes vitamin D Immunity (Immunity (Defenses)Defenses) sensationsensation:: the widespread of the millions of different somatic the widespread of the millions of different somatic
sensory receptors that detect stimuli.sensory receptors that detect stimuli.
HistoryHistory AgeAge OnsetOnset Is the rash raised (papular) or flat (macular)?Is the rash raised (papular) or flat (macular)? Is the rash red?Is the rash red? Is the rash scaly?Is the rash scaly? Is the rash itchy?Is the rash itchy? When did the rash start?When did the rash start? Where did the rash start, and how did it spread?Where did the rash start, and how did it spread? DurationDuration Body locationBody location Any change of individual lesionsAny change of individual lesions Did the patient present with other symptoms Did the patient present with other symptoms
(Fever (Fever ,Pruritus ,Conjunctivitis, Swollen extremities, Sore throat, Abdominal pain),Pruritus ,Conjunctivitis, Swollen extremities, Sore throat, Abdominal pain) Involvement of palms and soles, mucous membranes, conjunctivaInvolvement of palms and soles, mucous membranes, conjunctiva Was the lesion caused by trauma/insect bite?Was the lesion caused by trauma/insect bite? Is there any associated discharge or odour?Is there any associated discharge or odour? What makes the skin condition better or worse?What makes the skin condition better or worse?
History (cont)History (cont)
Past Medical History 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 MedicationsMedications History: Has the patient been exposed to new
topical applications
Physical ExamPhysical Exam General Appearance: (well, uncomfortable, toxic)General Appearance: (well, uncomfortable, toxic) Vital signs: (pulse, respiration, temperature, etc)Vital signs: (pulse, respiration, temperature, etc) Skin exam: (entire skin should be inspected, including mucous membranes, Skin exam: (entire skin should be inspected, including mucous membranes,
genital/anal regions).genital/anal regions). Remember SCALDA to describe a lesionRemember SCALDA to describe a lesion44
S Site/Size/Shape/texture (centripetal,centrifugal)(morbilliform,varicelliform)S Site/Size/Shape/texture (centripetal,centrifugal)(morbilliform,varicelliform) C Colour (Erythematous,Hypopigmented,Hyperpigmented,Depigmented)C Colour (Erythematous,Hypopigmented,Hyperpigmented,Depigmented) A Arrangement (Solitary, Grouped, Linear)A Arrangement (Solitary, Grouped, Linear) L Lesion type (primary, secondary)L Lesion type (primary, secondary) D Distribution(eg.Symmetrical, dermatomal,extensor surfaces,intertriginous D Distribution(eg.Symmetrical, dermatomal,extensor surfaces,intertriginous (between body folds), dependent areas, sun-exposed skin)(between body folds), dependent areas, sun-exposed skin) A Always check involvement of:A Always check involvement of:
feel the lesion raised or flat? wet or dry ,what dose it feel like? blanchable feel the lesion raised or flat? wet or dry ,what dose it feel like? blanchable
TerminologyTerminology
Macules, Papules, NodulesMacules, Papules, Nodules Patches and PlaquesPatches and Plaques Vesicles, Pustules, BullaeVesicles, Pustules, Bullae Erosions Erosions Ulcerations and excoriationsUlcerations and excoriations
Primary LesionsPrimary Lesions: : Those lesions that are the direct result of a pathologic Those lesions that are the direct result of a pathologic
processprocess
Secondary LesionsSecondary Lesions: : Lesions that are the result of alteration of a primary lesion Lesions that are the result of alteration of a primary lesion
hemorrhages into the skin. hemorrhages into the skin. Not blanch on pressureNot blanch on pressure
petechiae (< 1-2 mm )petechiae (< 1-2 mm )Purpura spots (3-10 mm in diameter)Purpura spots (3-10 mm in diameter) palpable: vasculiticpalpable: vasculitic HSPHSP meningococcaemiameningococcaemia non-palpable: ITPnon-palpable: ITPecchymoses (>1 cm bruises). ecchymoses (>1 cm bruises).
Telangiectasia Telangiectasia is the name given to prominent cutaneous blood vessels. is the name given to prominent cutaneous blood vessels.
CommonCommon Primary LesionsPrimary Lesions
Secondary skin lesionsSecondary skin lesions• Scale:Scale: Flakes of keratin that can be fine or coarse; loose or Flakes of keratin that can be fine or coarse; loose or
• Lichenification: Lichenification: thickened and rough epidermis with accentuation of skin thickened and rough epidermis with accentuation of skin
markings.markings.
• Excoriation:Excoriation: Traumatized or abraded skin, usually due to scratching or Traumatized or abraded skin, usually due to scratching or
rubbing.rubbing.
Secondary skin lesionsSecondary skin lesions
FissureFissure A fissure is a thin crack within epidermis or epithelium, A fissure is a thin crack within epidermis or epithelium, and is due to excessive drynessand is due to excessive dryness
Ulcer Ulcer Deep open wound extending into the dermis or Deep open wound extending into the dermis or subcutaneous tissue. May lead to scar formation. subcutaneous tissue. May lead to scar formation.
ErosionErosion Superficial open wound involving only epidermis or Superficial open wound involving only epidermis or mucosa. Does not extend into the underlying dermis, so mucosa. Does not extend into the underlying dermis, so healing occurs without scar formationhealing occurs without scar formation
SecondarySecondary skin lesionsskin lesions
Causes of maculopapular rashCauses of maculopapular rash
• Incubation period 8-14 daysIncubation period 8-14 days• Prodromal illness 3-4 days Fever, conjunctivitis, Prodromal illness 3-4 days Fever, conjunctivitis,
runny nose & coughrunny nose & cough• Koplik spots Koplik spots -white spot on buccal mucosa -white spot on buccal mucosa - 24-48 hours before rash- 24-48 hours before rash - pathognomonic- pathognomonic -difficult to see -difficult to see
Rash:Rash:◦ begins on face & behind ears begins on face & behind ears ◦ usually with onset high feverusually with onset high fever◦ spreads to bodyspreads to body◦ Usually spares palms/solesUsually spares palms/soles
MeaslesMeasles
ComplicationsComplications◦ Otitis mediaOtitis media◦ Febrile convulsionFebrile convulsion◦ BronchopneumoniaBronchopneumonia◦ Encephalitis (1/5000)Encephalitis (1/5000)◦ Myocarditis/pericarditis(ECG abnormalities)Myocarditis/pericarditis(ECG abnormalities)◦ SSPE (rare) after years SSPE (rare) after years ◦ Other hepatitis corneal ulcerationOther hepatitis corneal ulceration
MeaslesMeasles
Diagnosis Diagnosis IgG and IgM serologies, acute and convalescent titersIgG and IgM serologies, acute and convalescent titers
Treatment Symptomatic. Treatment Symptomatic. Antipyretics.Antipyretics. In severe disease, vitamin AIn severe disease, vitamin A in immunocompromised ribavirin in immunocompromised ribavirin Prevention - immunization at 1yearPrevention - immunization at 1year -10% failure of vaccine-10% failure of vaccine -at school age -at school age
RubellaRubella Mild disease Mild disease IP:14-21 daysIP:14-21 days Spread by respiratory routeSpread by respiratory route s/ss/s Fever low grade or none at allFever low grade or none at all Maculopapular rash first sign on face (Fade in 3-5 days)Maculopapular rash first sign on face (Fade in 3-5 days) LAP especially suboccipital and postauricularLAP especially suboccipital and postauricular Complication are rare Complication are rare Arthritis,Arthritis, Encephalitis,Encephalitis, Myocarditis,Myocarditis, ThrombocytopeniaThrombocytopenia Diagnosis by serologyDiagnosis by serology No effective anti viral No effective anti viral
known as ‘slapped cheek disease’ or 5known as ‘slapped cheek disease’ or 5thth disease diseaseFeaturesFeatures
◦ Parvovirus B19Parvovirus B19◦ Incubation period 4-14 daysIncubation period 4-14 days◦ Mostly preschool ageMostly preschool age◦ Fever in 15-30% for 1-2 daysFever in 15-30% for 1-2 days◦ Slapped cheek appearanceSlapped cheek appearance◦ Generalised maculopapular rash for 7-10 daysGeneralised maculopapular rash for 7-10 days◦ transmission is via respiratory secretiontransmission is via respiratory secretion
Management Management ◦ SupportiveSupportive
RoseolaRoseola
Roseola InfantumRoseola InfantumHuman herpesvirus 6Human herpesvirus 6Most Children are infected by 2 yearsMost Children are infected by 2 yearsAbrupt onset of high fever for 3 daysAbrupt onset of high fever for 3 daysFollowed by generalized macular Rash Followed by generalized macular Rash
which appears as the fever wanewhich appears as the fever wane Is common cause of Febrile seizuresIs common cause of Febrile seizuresRarely associated aseptic meningitis, Rarely associated aseptic meningitis,
hepatitis. hepatitis.
Scarlet feverScarlet feverCauseCause
◦Group A beta-haemolytic StreptococcusGroup A beta-haemolytic StreptococcusFeaturesFeatures
◦ Incubation 2-4 daysIncubation 2-4 days◦Bright red blanching rash (sandpaper)Bright red blanching rash (sandpaper)
First in axilae/groins, then widespreadFirst in axilae/groins, then widespread◦Red face with circumoral pallor Red face with circumoral pallor ◦Strawberry tongue (white then red)Strawberry tongue (white then red)
TreatmentTreatment◦Symptomatic relief Symptomatic relief ◦Penicillin V 7-10 daysPenicillin V 7-10 days
Kawasaki DiseaseKawasaki Disease
Affect children 6 months-4 yearsAffect children 6 months-4 yearsCause unknownCause unknownClinical diagnosisClinical diagnosisVasculitis affecting small and medium size Vasculitis affecting small and medium size
vesselsvesselsAffect coronary arteries about one thirdAffect coronary arteries about one thirdMortality 1%Mortality 1%
Fever for 5 or more daysFever for 5 or more daysPresence of 4 of the following:Presence of 4 of the following:
1.1. Bilateral conjunctival injectionBilateral conjunctival injection2.2. Changes in the oropharyngeal mucous membranesChanges in the oropharyngeal mucous membranes3.3. Changes of the peripheral extremities Changes of the peripheral extremities 4.4. Rash Rash 5.5. Cervical adenopathyCervical adenopathy
Illness can’t be explained by other diseaseIllness can’t be explained by other disease
Kawasaki DiseaseKawasaki DiseaseLab FeaturesLab Features
WBCWBC ESR, positive CRPESR, positive CRP Mild Mild transaminases transaminases albuminalbumin Sterile pyuria, aseptic meningitisSterile pyuria, aseptic meningitis platelets by day 10-14platelets by day 10-14
IV Ig 2 g/kg as single doseIV Ig 2 g/kg as single dose◦ Expect rapid resolution of feverExpect rapid resolution of fever◦ Decrease coronary artery aneurysms from 20% to < 5%Decrease coronary artery aneurysms from 20% to < 5%
ASA - reduce risk of thrombosis ASA - reduce risk of thrombosis - Repeat echocardiogram at 6 weeks- Repeat echocardiogram at 6 weeks
◦Very commonVery common◦ Incubation period 14-21 daysIncubation period 14-21 days◦Prodrome mild fever & malaiseProdrome mild fever & malaise◦Vesicles on erythematous baseVesicles on erythematous base
Change to maculeChange to macule→papule→vesicle→crust→papule→vesicle→crust Last 3-4 daysLast 3-4 days Mainly on trunkMainly on trunk Can appear in mouth/genital regionCan appear in mouth/genital region Usually no scarringUsually no scarring
◦ Infectious for 1-2 days before rash & 5 Infectious for 1-2 days before rash & 5 days afterwardsdays afterwards
ChickenpoxChickenpox ComplicationsComplications
◦ Always look carefully at child if fever persists Always look carefully at child if fever persists > 5 days after appearance rash> 5 days after appearance rash ?secondary bacterial infection ?secondary bacterial infection
ManagementManagement◦ Supportive – fluids/paracetamol/calamine lotionSupportive – fluids/paracetamol/calamine lotion◦ Admit if complications suspectedAdmit if complications suspected
Herpes SimplexHerpes Simplex
Gingivostomatitis most common 1º Gingivostomatitis most common 1º infection in childreninfection in children
10 months – 3 years10 months – 3 yearsThere are Vesicular lesion on lips, gums , There are Vesicular lesion on lips, gums ,
ant surface of tonge and hard palate ant surface of tonge and hard palate progress to painful ulceration and bleedingprogress to painful ulceration and bleedingHigh Fever, irritability, miserable childHigh Fever, irritability, miserable childEating and drinking are painful lead to Eating and drinking are painful lead to
dehydrationdehydrationTreatment: supportiveTreatment: supportive severe (IVF,aciclovir)severe (IVF,aciclovir)
Herpetic WhitlowHerpetic Whitlow
Lesions on thumb usually 2Lesions on thumb usually 2° to ° to autoinoculationautoinoculation
Group, thick-walled vesicles on Group, thick-walled vesicles on erythematous baseerythematous base
PainfulPainfulTend to coalesce, ulcerate and then crustTend to coalesce, ulcerate and then crustMay require topical or oral acyclovirMay require topical or oral acyclovir
Painful, shallow, yellow ulcers Painful, shallow, yellow ulcers Found on buccal mucosa, tongue, soft Found on buccal mucosa, tongue, soft
palate, uvula and anterior tonsillar pillarspalate, uvula and anterior tonsillar pillarsExanthem involves palmar, plantar and Exanthem involves palmar, plantar and
interdigital surfaces of the hands and feet interdigital surfaces of the hands and feet +/- buttocks+/- buttocks
CauseCause◦Coxsackie viral infectionCoxsackie viral infection◦Can be complicated by aseptic meningitisCan be complicated by aseptic meningitis
ManagementManagement◦SupportiveSupportive
peticheal &purpuric rashpeticheal &purpuric rash
hemorrhages into the skin. hemorrhages into the skin. Not blanch on pressureNot blanch on pressure
petechiae (< 1-2 mm )petechiae (< 1-2 mm )Purpura spots (3-10 mm in diameter)Purpura spots (3-10 mm in diameter) palpable: vasculiticpalpable: vasculitic non-palpable: ITPnon-palpable: ITPecchymoses (>1 cm bruises). ecchymoses (>1 cm bruises).
Causes of purpuric & peticheal Causes of purpuric & peticheal rashrash
Caused by Neisseria meningitidesCaused by Neisseria meningitidesAlthough there are vaccines against groups Although there are vaccines against groups
A,C A,C No vaccine against group BNo vaccine against group BMeningococcal septicemia can kill children Meningococcal septicemia can kill children
in hoursin hoursAny febrile child with purpuric rash should Any febrile child with purpuric rash should
given given treatment immediatelytreatment immediatelyPetechial rash develops in 75% of casesPetechial rash develops in 75% of casesFever, rash, hypotension, shock, DICFever, rash, hypotension, shock, DIC
Henoch-Schonlein PurpuraHenoch-Schonlein Purpura
Usually occurs 3-10 years Usually occurs 3-10 years More common in boysMore common in boysOften Preceded by URTIOften Preceded by URTI
Clinical featuresClinical features Skin rash:Skin rash: Palpable purpura of extremitiesPalpable purpura of extremities cornerstone of the diagnosiscornerstone of the diagnosis Arthralgia or non-migratory arthritisArthralgia or non-migratory arthritis
◦ No permanent deformitiesNo permanent deformities◦ Mostly ankles and kneesMostly ankles and knees◦ Periarticular oedemaPeriarticular oedema
Abdominal painAbdominal pain◦ May develop intussusceptionMay develop intussusception
EM = Erythema Multiforme - treat illness/stop drug, EM = Erythema Multiforme - treat illness/stop drug, supportive care, topical steroids and outpatient follow-up for supportive care, topical steroids and outpatient follow-up for minor casesminor cases
Meningiococcemia - ill appearing, mental status change, Meningiococcemia - ill appearing, mental status change, lumbar puncture,lumbar puncture,
plasmapheresis, splenectomy, selective transfusion, NO plasmapheresis, splenectomy, selective transfusion, NO plateletsplatelets
Vasculitis – treat the underlying process if possible, may Vasculitis – treat the underlying process if possible, may require steroidsrequire steroids
ITP – Idiopathic Thrombocytopenic Purpura - transfuse ITP – Idiopathic Thrombocytopenic Purpura - transfuse platelets if bleeding or less than 5000/mm3 – 10000/mm3, platelets if bleeding or less than 5000/mm3 – 10000/mm3, emergent Hematology consultationemergent Hematology consultation
VESICULO-BULLOUS RASHVESICULO-BULLOUS RASH
VESICULO-BULLOUS RASHVESICULO-BULLOUS RASH Varicella/Chicken Pox – excoriated lesions in multiple stages, Varicella/Chicken Pox – excoriated lesions in multiple stages,
Small Pox – all lesions in one stage, more peripheral distribution, Small Pox – all lesions in one stage, more peripheral distribution, isolate, notify office of public health and CDCisolate, notify office of public health and CDC
Hand, Foot and Mouth Disease – children, vesicles on palms, soles Hand, Foot and Mouth Disease – children, vesicles on palms, soles and in mouth,self-limited, symptomatic treatmentand in mouth,self-limited, symptomatic treatment
Pemphigus Vulgaris – mucous membrane involvement, much Pemphigus Vulgaris – mucous membrane involvement, much higher mortality than Bullous Pemphigus, steroids, admissionhigher mortality than Bullous Pemphigus, steroids, admission
Zoster – acyclovir, analgesia, steroidsZoster – acyclovir, analgesia, steroids Contact Dermatits - symptomatic treatment, long taper of steroids Contact Dermatits - symptomatic treatment, long taper of steroids
for severe casesfor severe cases
Causes of napkin rashCauses of napkin rash
Irritant(contact dermatitis) Irritant(contact dermatitis) flexure are sparedflexure are spared
Seborrhoeic dermatitisSeborrhoeic dermatitis
Candida infectionCandida infection
Napkin dermatitisNapkin dermatitis
FeaturesFeatures◦ Usually due to irritant contact dermatitis which Usually due to irritant contact dermatitis which spares spares
groinsgroins◦ Treat with barrier cream, frequent nappy changesTreat with barrier cream, frequent nappy changes
Napkin rashNapkin rash
Satellite lesions and skin-fold Satellite lesions and skin-fold involvement may indicate candidainvolvement may indicate candida
Look for mouth lesions as wellLook for mouth lesions as well Treat with anti-fungal creamTreat with anti-fungal cream
Atopic DermatitisAtopic Dermatitis
superficial inflammation of the skin superficial inflammation of the skin
characterized bycharacterized by rednessrednessedemaedemaoozingoozingcrustingcrustingscalingscaling(vesicles)(vesicles)
Atopic DermatitisAtopic Dermatitis
12-26% of children 12-26% of children Onset usually in first yearOnset usually in first year Uncommon in first 2 monthsUncommon in first 2 months Diaper area sparedDiaper area spared Sites of PredilectionSites of Predilection
◦ Face in the youngFace in the young◦ Extensor surfaces of the arms and legs 8-10 mo.Extensor surfaces of the arms and legs 8-10 mo.◦ Antecubital and popliteal fossa , neck, face in olderAntecubital and popliteal fossa , neck, face in older
Atopic DermatitisAtopic Dermatitis
The The diagnosis is made clinicallydiagnosis is made clinicallyThe patient must have each of the followingThe patient must have each of the following1-pruritis1-pruritis2-Typical morphology and distribution 2-Typical morphology and distribution Facial and extensor involvement in infant and childrenFacial and extensor involvement in infant and children Flexural in adultFlexural in adult3-Tendency toward chronic and relapsing3-Tendency toward chronic and relapsing
complicationscomplications
Flare-up are commonFlare-up are common Infection (strep,staph,herpes)Infection (strep,staph,herpes) lymphadenopathylymphadenopathy
TreatmentTreatment
Avoidance or elimination of predisposing Avoidance or elimination of predisposing factorsfactors
(nylon,long nail. Cow milk)(nylon,long nail. Cow milk) Hydration and lubrication of dry skinHydration and lubrication of dry skin Anti-pruritic agentsAnti-pruritic agents Topical steroidsTopical steroids Antibiotic or antiviralAntibiotic or antiviral Dietary elimination (egg , cow milk)Dietary elimination (egg , cow milk) occurs in 6% of infant occurs in 6% of infant
with eczymawith eczyma 4-6 weeks required to 4-6 weeks required to
detect responsedetect response
Seborrheic DermatitisSeborrheic Dermatitis Its cause remains unknown Its cause remains unknown Most frequent present in first 2 months of Most frequent present in first 2 months of
life.life.erythamatous scaling eruption erythamatous scaling eruption The scales form thick yellow adherent layer The scales form thick yellow adherent layer
(cradle cap) (cradle cap) The rash causes no discomfort or itching The rash causes no discomfort or itching
like eczemalike eczema• Treatment -mild case resolve with Treatment -mild case resolve with
emollientemollient -scales treated with ointment -scales treated with ointment
contain sulphur and salicylic acid contain sulphur and salicylic acid -Topical steroids-Topical steroids
UrticariaUrticaria
Transient, well-demarcated wheelsTransient, well-demarcated wheels PruriticPruritic Due to increase premeablity of capillaries and Due to increase premeablity of capillaries and
venulesvenules May involve deep tissue to produce angioedemaMay involve deep tissue to produce angioedema Etiology are Etiology are - idiopathic common- idiopathic common - drugs penicillin's, cephalosporin's- drugs penicillin's, cephalosporin's - food egg ,cheese, strawberries, fish, - food egg ,cheese, strawberries, fish,
ImpetigoImpetigo Localized ,highly contagious Localized ,highly contagious Common in infant Common in infant It is common where underlying skin disease It is common where underlying skin disease
eczemaeczema Strep or StaphStrep or Staph Honey-coloured crustHoney-coloured crust Mostly face, extremities, hands and neckMostly face, extremities, hands and neck Treatment: topical (mild) Treatment: topical (mild) systemic antibiotics systemic antibiotics
flucloxacillin,erythromycin.(severe)flucloxacillin,erythromycin.(severe) Nasal carriage is important source of infection Nasal carriage is important source of infection