Transcript Lect.13 - Cellular and Integumentary Alterations

Nursing Care Of Children With
Cellular and Integumentary
Problems
Dr. Nataliya Haliyash
Nursing Care of Children
Cellular Alterations
Childhood Cancers
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Five-year-old Alec
Zhloba, suffering from
leukemia, looks on in a
children cancer unit at a
hospital in Gomel,
Belarus, in this March
19, 1996 file photo.
The deadly explosion in
reactor No.4 in the
Chernobyl nuclear power
plant on April 26, 1986,
sent radioactive clouds
through Ukraine, Belarus
and most of Europe,
causing the world's worst
nuclear accident. (AP
Photo/Efrem Lukstaky)
Lecture objectives
Upon completion of this chapter, the reader will be able to:
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Identify the different treatment modalities used to treat
cancer in children.
Explain how the different treatment modalities affect
malignant cells.
Discuss the nursing management of common side
effects of treatment modalities.
Describe the clinical manifestations, treatment, and
nursing management of common malignancies in
children.
Identify the emotional and educational needs of families
who have children with cancer.
Discuss the long-term, late effects of childhood cancer
therapy.
Treatment Modalities
• Goal: to rid the body of all malignant cells
 Surgery
 Chemotherapy
 Radiation Therapy
 Bone Marrow Transplants
 Biological Response Modifiers
 Or a combination of all of the above
Surgery removal of all visible and
microscopic cancer cells
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• Biopsy
• Tumor staging
• Assess response to surgery
• Palliative
Types of biopsy
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Fine needle aspiration biopsy. This test
uses a thin, hollow needle in a syringe to
collect a small amount of fluid and cells from
the suspicious area.
Core needle biopsy. A core biopsy uses a
slightly larger needle to obtain a cylinder of
tissue. It is often done instead of a fine needle
aspiration biopsy because it provides more
tissue for the pathologist to review.
Surgical biopsy.
In a surgical biopsy, a surgeon makes an incision in the skin and
removes some or all of the suspicious tissue. It is often used
after a needle biopsy shows cancer cells, or it can be used as
the first method to obtain tissue for diagnosis. There are two
types of surgical biopsies:
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An incisional biopsy removes a piece of the suspicious area for
examination. An incisional biopsy may be used for soft tissue
tumors, such as those from muscle or fat tissue, to distinguish
between benign (noncancerous) lumps and cancerous tumors
called sarcomas.
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An excisional biopsy removes the entire lump. An excisional
biopsy, which was more common before the development of fine
needle aspiration, may be used for enlarged lymph nodes or
breast lumps, or in situations where the lump is small enough to
be completely removed in one procedure.
Bone marrow aspiration and biopsy.
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A bone marrow aspiration and biopsy is a diagnostic
examination of the bone marrow, the spongy tissue
inside of bone that has both fluid and solid parts. The
sample is usually collected from the back of the hip
bone. For this test, the patient’s skin is numbed with
a local anesthetic, and a needle is inserted into a
bone in the hip until it reaches the bone marrow. A
small amount of bone marrow fluid is removed and
examined under a microscope. This is called an
aspirate. The doctor may also use a hollow needle in
the same location to withdraw a solid core of bone
marrow. This is called a biopsy. This test is used to
determine if a person has a blood disorder or a blood
cancer, such as leukemia or multiple myeloma. It can
also be used to find out if a cancer that started in
another part of the body has spread to the bone
marrow.
Tumor staging
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Staging is a way of describing a cancer, such
as where it is located, if or where it has
spread, and if it is affecting the functions of
other organs in the body.
The staging system used by doctors is the
TNM system of the American Joint Committee
on Cancer (AJCC).
TNM is an abbreviation for tumor (T), node
(N), and metastasis (M), or cancer that has
spread to other areas of the body.
Tumor staging
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T: The letter "T" (local tumor growth) describes the extent of the cancer
in its original location. Each cancer is described using a term T0, T1,
T2, T3, or T4. The larger or more extensive the tumor, the larger the
number assigned. The T number reflects a combination of the size and
the extent to which the tumor invades nearby structures.
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N: The letter "N" (regional lymph node) describes whether the is cancer
present in the lymph nodes near the tumor, and, in some types of
cancer, how many of these lymph nodes contain cancer cells. The
lymph nodes are tiny, bean-shaped organs that are located throughout
the body that help fight infections as part of the immune system. Each
cancer may be assigned one of these terms: N0 (meaning no cancer is
found in the nodes), N1, N2, or N3. In many instances, the more lymph
nodes with cancer, the larger the number assigned. For other tumors,
the location of the nodes that have cancer may determine the N rating.
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M: The letter "M" (distant metastasis) describes if the cancer has
metastasized from its original (primary) location to other distant areas
of the body. Each cancer is assigned either M0 (no metastasis), or M1
(metastasis has occurred).
Tumor staging
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Central nervous system tumors (brain
cancers). Because malignant (cancerous)
brain tumors do not normally spread outside
of the central nervous system (CNS, brain
and spinal cord), only the "T" description of
the TNM system applies. Currently, there is
no universal staging system for central
nervous system tumors.
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Childhood cancers. AJCC does not include
childhood cancers in its staging manual. Most
childhood cancers are staged separately,
according to other staging systems.
Chemotherapy
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• Effective against systemic cancers
• Classified into
– Alkylating agents
– Antimetabolites
– Antitumor antibiotics
– Plant alkaloids
– Corticosteroids
– Miscellaneous agents
Side Effects
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Systems with rapidly reproducing cells
– GI, hematopoietic, hepatic, renal,
integumentary and reproductive systems
– Myelosuppression
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Anemia – Pallor fatigue and HA
Thrombocytopenia <20,000/mm3
Neutropenia ANC< 500/mm3
Immunosuppression
Side Effects
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Gastrointestinal Effects
– • Mucositis
– • Nausea and vomiting
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Hepatic Effects
– • Elevated liver enzymes
– • Liver fibrosis
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Renal Effects
– • BUN and Creatinine
Mucositis
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The pathobiology
of mucositis
Nursing Tip:
Nausea and vomiting
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Giving chemotherapy at bedtime may
alleviate nausea and vomiting in children. It
may allow them to sleep through the emetic
effects.
Playing soft music, such as lullabies, or
recording a caregiver singing soft songs is
soothing and distracting and may alleviate
symptoms of nausea and vomiting.
Side Effects
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Integumentary
– • Alopecia
– • Vesicants
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Reproductive Effects
Fertility may be affected
Oligomenorrhea
Excessive bleeding
Sterility in males may be permanent
Alopecia, bruising
Nursing Tip:
Coping with alopecia
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Role-play with the child as to what to say when
someone asks,"What happened to your hair?“
Children returning to school have many anxieties
regarding their acceptance back into their peer group
because of the many changes in their
appearance.This activity helps to develop coping
strategies to deal with alopecia.A school visit from the
oncology team nurse to speak with the child's teacher
and classmates can help the transition back to
school.
Radiation Therapy
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• Deliver therapeutic doses of ionizing
radiation
• Lymphomas solid tumors and brain
tumors
• Palliative
Side Effects of Radiation
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• Hematopoietic
• Mucositis
• Esophagitis
• Skin damage
• Radiation pneumonitis
• Somnolence syndrome
Bone marrow transplant (BMT)
• Replacement of hematopoietic cells
 • Leukemia Lymphoma and certain solid
tumors
3 phases of BMT
 • Pre-transplant
 • Transplant
 • Post transplant
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Bone marrow transplant (BMT)
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Transplant stage
– • Cytoreduction
– • Bone marrow infusion
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Post transplant
– • Period of pancytopenia
– • Graft vs host disease (GVHD)
LEUKEMIA
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Board term used to describe a group of
malignant diseases in which normal bone
marrow elements are replaced by abnormal
immature lymphocytes. (Blast cells)
Most common childhood malignancy
– • Acute lymphocytic leukemia ALL
– • Acute myelogenous leukemia AML
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Peak incidence between 2 and 5 years of age
Immature lymphocytes. (Blast cells)
LEUKEMIA
Clinical Manifestations
 • Fever
 • Bone pain
 • Pallor
 • Bruising
LEUKEMIA
Diagnosis
 • Bone marrow aspiration
– > 25% of abnormal lymphoblasts is
diagnostic
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White blood count for prognosis
Lumber puncture to assess for CNS
disease
Chest xray
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bone marrow test
Bone marrow smear of a patient with
chronic myelogenous leukemia.
LEUKEMIA
Treatment
 Systemic medication done in 3 phases
– Induction phase: reduce tumor burden to
undetectable levels or remission
– Can be done outpatient basis
– Drugs used to induce remission
• Vincristine (Oncovin)
• L-asparaginase (Elspar)
• Prednisone
LEUKEMIA
Tumor lysis syndrome- complication of
treatment IV hydration containing Sodium
bicarbonate
– Allopurinol (Zyloprim)
Remission is defined
 • No evidence of leukemia on physical exam
 • Bone marrow evaluation
 • Peripheral blood counts
 • CNS fluid
 • Or extramedullary site
LEUKEMIA
The second phase of treatment is consolidation
 • Goal to eradicate any residual leukemic
cells and starts once remission is attained
 • Hospitalization required
 • CNS prophylaxis with chemotherapy
administered intrathecally
 • Radiation to brain and spinal cord
 • Radiation to testes in males with testicular
involvement
 • Intense and lasts about six months
LEUKEMIA
The maintenance phase
 • Follows consolidation phase
 • Maintains control of the leukemia
 • Chemotherapy administer oral, IV or
IM
 • May need IV vincristine and IT therapy
 • Therapy continues for 2 ½ to 3 years
LEUKEMIA
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Bone marrow transplant – a treatment
option for children with ALL who attain a
second remission after a relapse and
have a compatible donor.
LEUKEMIA
Nursing care
 • Monitor VS every 4 hours and prn
 • Proper hand washing
 • Inspect skin daily
 • Inspect mouth for ulcers
 • Do not use vaporizers
 • Place on neutopenic diet
 • Do no give live virus vaccines
LEUKEMIA
Nursing care
 • Isolate the child from children who are sick
 • Give VZIG within 96 hours of exposure
 • Give acetominophen for fever
 • Monitor activity in sever thrombocytopenic
pt
 • Administer anti emetic before therapy
 • Offer small frequent meals
 • Daily weights
Acute Myelogenous Leukemia
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A condition in which malignant myeloid blasts
in the bone marrow
Clinical presentation
 • Benign flu like symptoms
 • Bleeding
 • Gingival hypertrophy
 • Chloromas
– Chloromas usually present as reddish-blue, not
green, thickenings in the skin, but pressing the
blood out of the nodule unmasks a green color for
a few seconds.
Acute Myelogenous Leukemia
Diagnosis
 • Bone marrow aspiration of > 25%
malignant myeloid blast
 • Treat underlying anemias, bleeding,
infections and hyperuricemia
 • Treatment phases: remission induction
and contiuation
Acute Myelogenous Leukemia
Chemotherapy agents use in remission
induction
 • Cytarabine (Ara-C)
 • Daunorubicin (Daunomycin)
Chemotherapy agents use in continuation
therapy
 • Cytarabine (Ara-C)
 • Cyclophosphamide (Cytoxin)
 • Daunorubicin (Daunomycin)
 • Etoposide (VePesid)
Acute Myelogenous Leukemia
Treatment of possible CNS involvement
 • Cytarabine (Ara-C)
 • Methotrexate (MTX)
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• Radiation of the head
• Bone marrow transplant
• Treatment intense requires hospitalization
Brain Tumors
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• Most common solid tumor of childhood
• Most occur in children under the age
of ten
Medial view of the brain of a child
in cross-section.
Brain Tumors
Diagnosis
 • MRI’s
 • CT scan
Treatment
 • Surgery
 • Radiation therapy (not recommended <3)
 • Chemotherapy:
Brain Tumor MRI
Nursing Tip:
Sedation for neurodiagnostic testing
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Adequate sedation is necessary in obtaining the
needed neurodiagnostic information to confirm the
diagnosis of a brain tumor.
Sedation protocols vary from institution to institution,
but sleep deprivation can enhance the effects of
sedation.
Advising caregivers to put the child to sleep an hour
or two later the night before a procedure and then
waking her or him a few hours earlier will enhance
the effects of the medication.
All children who are sedated must be monitored
carefully with pulse oximetry and telemetry to prevent
complications of oversedation.
Brain Tumors
Nursing Management
Preoperative neurological assessment
 • VS
 • LOC
 • Strength and equality of grips
 • Head circumference
 • Assess of anterior fontanel in infants
Brain Tumors
Nursing Management
 • Providing support for parents or
caregivers
 • Frequent monitoring for post op
increased intracranial pressure
 • Monitor fluid and electrolytes
 • Administer medications such as
steroids
Wilm’s tumor
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Nephroblastoma– arising from the
kidney
• Rapidly growing tumor
• Seen in children ages 2 to 6
Wilm’s tumor is a cancerous tumor
of the kidney that occurs in children.
Wilm’s tumor
Clinical manifestations
 • Mobile abdominal mass
 • Microscopic or gross hematuria
 • Hypertension
 • Abdominal pain
 • Malaise
 • Fever
 • Primary site for metastasis is the lungs
Treatment
 • Nephrectomy and lymph node sampling
 • Chemotherapy and radiation may be done
 postoperatively
Wilm’s tumor
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Nursing Assessments
• Parents may notice abnormal swelling in
child’s abdomen
• Essentially normal examine except for
palpable abdominal mass which does not
cross the midline
The mass must not be palpated beyond
the initial assessment because
excessive manipulation can lead to
tumor seeding
Neuroblastoma
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• Solid tumor found only in children
• Most children diagnosis by age two
• Diagnosis: X-rays, CT Scan, Bone
marrow
• Treatment depends on presence and
extent of metastasis
Osteosacroma
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• Most common bone malignancy in children
• Aggressive tumor
• Symptoms can be attributed an injury or
“growing pains”
• Most common site is the distal femur
• Site of metastasis is the lungs
• Associated with teen age years- a period of
rapid bone growth
Osteosacroma
Clinical Manifestations
 • Progressive, insidious, intermittent
pain at the tumor site
 • Palpable mass
 • Limping
 • Progressive limited range of motion
 • Eventually a pathological fx at the
tumor site
Ewing’s scarcoma
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• Common bone tumor
• Has no defining characteristics–
therefore may be difficult to diagnosis
• Found in mid shaft of long bones, such
as femur, vertebrae, ribs and pelvis
• Gross metastasis uncommon
Ewing’s scarcoma
Clinical manifestations
 • Pain
 • Soft tissue swelling around the bone
 • With metastasis anorexia, fever, malaise,
 fatigue and weight loss
 • With a vertebral tumor may be
 neurological symptoms
 • With rib tumor may be respiratory
 symptoms
Retinoblastoma
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• Rare malignant tumor of the eye found
only in children
• May be assess by parents who see a
white reflection in the eye instead of red
• Most often occurs as multiple
independent tumors on the retina
• Average eye of diagnosis is 11 to 23
months of age
Retinoblastoma
Clinical manifestations
 • Leukokoria – cat’s eye reflex
 • Vision loss
 • Pain
 • Redness and inflammation of the eye
 • Strabismus
 • Squinitng
Only treatment known is enucleation of the eye
← cat’s eye
reflex
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Child's right eye →
completely covered
with a tumor
associated with
retinoblastoma.
(Custom Medical
Stock Photo Inc.)
Integumentary Alterations
Childhood Skin Diseases
The Skin
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Epidermis– Epithelial cells
– Melanocytes- provides difference in skin color
– Keratinocytes-fibrous, water-repellent protein that
gives the epidermis its tough, protective quality
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Dermis– Second, deeper layer
– Blood cells, nerve fibers, and lymphatic vesicles
– Hair follicles, sebaceous glands, and sweat glands
The Skin
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Subcutaneous tissue
– Below the dermis & not part of the skin
– Attaches skin to muscle & bone
– Stores fat
– Regulates temperature
– Provides shock absorption
The Skin
– Sebaceous glands
• Contain sebum to soften and lubricate the skin
and hair
• Secretion stimulated by sex hormones
– Sweat glands
• Eccrine glands-forehead, palms, and soles
• Apocrine sweat glands- axillary, anal, and
genital
• Ceruminous glands-external ear canal for
cerumen
The Skin
– Nails• Nail bed
• Color ranges from pink to yellow or brown
depending on skin color
• Pigmented bands in nail bed normal for dark
skinned people
• Protects ends of fingers and toes
The Skin
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Hair
– Grows over most of body except lips,
palms & soles
– Color is inherited & depends on amount of
melanin
– Protects and warms the head
Common Assessment
Abnormalities
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Alopecia- absence of hair
Comedo – blackheads & whiteheads
Cyst – fluid filled sac d/t obstructed duct
or gland
Ecchymosis – bruise
Erythema – redness occurring in
patches
Hematoma – extravasion of blood
causing swelling d/t trauma
Common Assessment
Abnormalities
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Hirsutism – male distribution of hair in
women
Keloid – hypertrophied scar beyond
margin of trauma
Mole – benign overgrowth of
melanocytes
Petechiae – pinpoint deposits of blood
under the skin
Telangiectasia – dilated, superficial
small blood vessels found on face &
thighs
Primary Skin Lesions
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Macule – flat, nonpalpable, less than 1 cm
Papule – elevated, solid, palapable, less than 0.5 cm
Vesicle – circular, superficial collection of serous fluid,
less than 1 cm.
Plaque – elevated, solid, palpable, more than 0.5 cm.
Wheal – firm, edematous
Pustule – elevated, superficial, filled with purulent
fluid
Nodule – elevated , solid, extends into dermis,
circumscribed border, 0.5 – 2 cm
Tumor – elevated, solid, extends into dermis,
irregular border, greater than 2 cm
Secondary Skin Lesions
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Fissure – linear cracks
Scale - excess shedding of dead keratinized
tissue
Scar – abnormal formation of connective
tissue
Ulcer – irregular, crater-like loss of epidermis
& dermis
Atrophy – depression in skin from thinning of
the epidermis or dermis
Excoriation – area where epidermis is
missing, exposing dermis
Mongolian spots
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Mongolian spots are areas of bluish-black
hyperpigmentation that most frequently occur over
the lumbosacral area of dark-skinned infants.These
areas are normal skin variations and tend to fade as
the child gets older.
The presence of Mongolian spots should be included
as a part of the child's documentation. Mongolian
spots can be misdiagnosed as bruises, commonly
found in child abuse.
Are found in 80-90 % of African-American and Asian
and Hispanic American babies
Mongolian spots
Nursing Diagnoses
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Impaired skin integrity
Situational low self esteem
Ineffective health maintenance
Altered body image
Social interaction, impaired
Common Benign Conditions
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Pruritis
Psoriasis
Acne
Pruritis
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Itching
If a chronic problem…
– C/S of scrapings
– Fungal studies
– Cutaneous patch testing
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Pharmacology
– Antihistamines, Tranquilizers, and
Antibiotics
Pruritis
– Nursing Intervention
• Therapeutic baths
– Aveno, colloid , alpha-keri
• Administer creams, pastes, or ointments
• Comfortable, cool room temperature
• Monitor skin for infection
Psoriasis
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Chronic, noninfectious skin condition
characterized by raised, reddened,
round circumscribed plaques covered
by silvery white scales. Size varies.
Cause unknown; some evidence
supports autoimmune.
Stress, sunlight, hormonal fluctuations,
and some medications can induce.
Psoriasis
Psoriasis
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Pharmacology
– Corticosteriods
– Tar preparations-suppress miotic activity
Amevive (alefacept) injection- suppress rapid
turnover of epidermal cells
Antimetabolites (Methotrexate)
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Treatments
– Sunlight
– Ultraviolet Light Therapy-decreases the growth
rate of epidermal cells
ACNE
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Acne vulgaris effects 85% of the population. The
peak incidence is age 17 to 18 years of age. Family
history, premenstrual flares, and sometimes stress
can cause a flare up.
Cosmetics containing lanolin, petrolatum, vegetable
oils, lauryl alcohol, butylsterate, and oleic acid can
increase comedome production. Exposure to oils in
cooking grease can be a precursor in adolescents.
Acne
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Acne is a disease that involves the sebacceous glands
& hair follicles of the face, neck, chest, and upper
back..
Characterized by comedones & inflammatory lesions
Adequate rest, moderate exercise, a well-balanced
diet, reduction of emotional stress, and elimination of
any foci of infections are all part of general health
promotion.
Acne
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three-year-old child with
large acne
Acne
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Retin-A is the only drug that disrupts the abnormal follicular
keratinization that produces microcomedones. It is available in
cream, gel, or liquid. A pea-sized dot of medication is used. It
should not be applied until 30 minutes after washing face to
prevent burning.
Topical benzyl peroxide is antibacterial and can be
used to treat mild cases. The medication can have a
bleaching effect on sheets and clothes.
Other antibacterials used topically are Clindamycin,
Erythromycin and Metronidazole. When combined
with benzyl peroxide, glycolic acid or Retin-A
penetration improves
Acne
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Accutane is a potent and effective oral agent. It
decreases sebum production. This medication needs
to be managed by a dermatologist. Adolescents with
multiple, active, deep dermal or subcutaneous cyctic
and nodular acne lesions are treated for 20 weeks.
Side effects include dry skin, dry mucous
membranes, nasal irritation, dry eyes decreased night
vision, photosensitivity, arthralgia, headaches, mood
changes, depression, and suicidal ideation. The most
significant is tetragenic effects. It is contraindicated
in pregnancy. If the young women are sexually
active, they must be on some kind of contraceptive.
Tetracycline longterm
Acne
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Gentle cleansing with a mild cleanser once or twice
daily is needed. Antibacterial soaps are not effective
and may cause drying.
Nursing care is focused on supportive and educating
the child and parent. Teenagers need to understand
that it takes 4 to 6 weeks to see improvement.
Infections of the Skin
Bacterial, Viral & Fungal
Bacterial Infections
Impetigo- Staphylococcus. Reddish macule, vesicle,
then erupts.
Dries to a honey-colored crusts.
Topical, oral, or IV antibiotics.Contagious. Seen in
toddler and preschool.
FolliculitisStaph aurous. Pimple- infection of hair follicle. On
legs of women or bearded faces of men. Contagious.
Never pop or squeeze.
Bacterial Infections
FurnucleBoil. Larger lesion with more redness and edema . Painful.
Moist compress
Systemic antibiotics. Contagious. Never pop or squeeze
CarbuncleMultiple boils. Wide spread inflammation. Moist compress.
Systemic antibiotics. Never pop or squeeze.
Treatment: good hand washing, antibiotics, good hygiene, warm
compresses
Bacterial Infections
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Cellulitis – inflammation of
subcutaneous tissue following break in
skin -Caused by staph of strep. Treat
with anitbiotics
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Erysipelas – involved the dermis –
Caused by strep. Treatment is IV
antibiotics (PCN usually) to prevent
septicemia
Cellulitis of face
Viral Infections
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Warts (Verrucae) – caused by HPV
(human papilloma virus).
– Common wart – fingers
– Planter warts – soles of feet
– Flat wart – forehead
– Condylomata acuminata – venereal warts
– Treatment
• Salicylic acid, Cyrotherapy, Liquid Nitrogen
Viral – Herpes Simplex
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Vesicle type lesion
Type 1 – above the waist – cold sores
Type 11 – below the waist – STD,
Genital herpes
Signs/Symptoms – burning, tingling
Diagnosed with Tzanck smear –
identifies herpes but doesn’t
differentiate between simplex & zoster
Treatment – Zovirax (Acyclovir), moist
compresses & white petrolatum
Herpes Simplex – Clinical Manifestations
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In newborn infants, HSV infection can manifest as the
following:
(1) disseminated disease involving multiple organs, most
prominently liver and lungs;
(2) localized central nervous system (CNS) disease;
(3) disease localized to the skin, eyes, and mouth.
Neonatal herpetic infections often are severe, with
attendant high mortality and morbidity rates, even when
antiviral therapy is administered. Recurrent skin lesions
are common in surviving infants and can be associated
with CNS sequelae if skin lesions occur frequently during
the first 6 months of life.
Herpes Simplex – Clinical Manifestations



CHILDREN BEYOND THE NEONATAL
PERIOD AND ADOLESCENTS.
Most primary HSV infections are
asymptomatic.
Gingivostomatitis, which is the most common
clinical manifestation in this age group, usually
is caused by HSV type 1 (HSV-1).
– fever, irritability, tender submandibular adenopathy,
and an ulcerative enanthem involving the gingiva
and mucous membranes of the mouth, often with
perioral vesicular lesions.
Herpes Simplex. This is a close-up of a herpes simplex lesion of the lower lip on the 2nd day after
onset. Also known as a cold sore, this lesion is caused by the contagious herpes simplex virus
Type-1 (HSV-1), and should not be confused with a canker sore, which is not contagious. The
HSV-1 virus remains in the body throughout an exposed person’s entire life.
Red Book Online Visual Library, 2006. Image 060_57. Available at:
http://aapredbook.aappublications.org/visual. Accessed November 29, 2007
Copyright ©2006 American Academy of Pediatrics
Herpes Simplex. Herpes simplex stomatitis, primary infection of the anterior oral mucous
membranes. Tongue lesions also are common with primary herpes simplex virus infections.
Red Book Online Visual Library, 2006. Image 060_07. Available at:
http://aapredbook.aappublications.org/visual. Accessed November 29, 2007
Copyright ©2006 American Academy of Pediatrics
Herpes Simplex. This 7yr. old child with a history of recurrent herpes labialis presented with
a periocular herpes simplex vesicular outbreak.
Red Book Online Visual Library, 2006. Image 060_53. Available at:
http://aapredbook.aappublications.org/visual. Accessed November 29, 2007
Copyright ©2006 American Academy of Pediatrics
Herpes Simplex. The patient shown in images 060_22, 060_23, and 060_24 with extensive
eczema herpeticum and primary herpetic gingivostomatitis.
Red Book Online Visual Library, 2006. Image 060_23. Available at:
http://aapredbook.aappublications.org/visual. Accessed November 29, 2007
Copyright ©2006 American Academy of Pediatrics
Herpes Simplex. Herpes
Simplex. Neonatal herpes simplex skin lesions.
Red Book Online Visual Library, 2006. Image 060_32. Available at:
http://aapredbook.aappublications.org/visual. Accessed November 29, 2007
Copyright ©2006 American Academy of Pediatrics
Viral – Herpes Zoster


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
AKA Shingles
Caused by varicella zoster which also
causes chickenpox
Painful
Treatment – Acyclovir & Narcotics
Isolate from people who have not had
chickenpox
Fungal Infections

Candidiasis – caused by Candida
albicans
– Occurs with immunosuppression & following
antibiotics, T-lymphocytes dysfunction, other
immunologic disorders, and endocrinologic
diseases
– Candida albicans is ubiquitous. Like other
Candida species, C albicans is present on
skin and in the mouth, intestinal tract, and
vagina of immunocompetent people.
– Clinical Manifestations: Mucocutaneous
infection results in oral-pharyngeal (thrush)
or vaginal candidiasis.
Candidiasis (Moniliasis, Thrush)


Candida (thrush) infection in a 1-week-old neonate.
Candida albicans (thrush) infection of the tonsils and uvula of
an otherwise healthy 6-month-old infant. The white exudate may
resemble curds of milk.
Severe Candida diaper dermatitis
with satellite lesions ↓

Candida (monilia)
rash with typical
satellite lesions in
an infant boy.
Fungal Infections – the “tineas”

Etiology : dermatophytes, a group of closely related
fungi that invade the outer keratin layer of the skin
and its appendages, the hair and nails

Tinea pedis – athlete’s foot
Tinea capitis – scalp ringworm
Tinea corporis – body ringworm
Tinea cruris – groin – jock itch
Treatment – antifungal cream or solution,
Griseofulvin, Diflucan
Contagious





Tinea Capitis (Ringworm of the Scalp). Three-year-old male with a Tinea lesion on the occiput
for 1 month. The mother had been applying a topical antifungal agent but the lesion became
progressively larger. The patient was treated successfully with griseofulvin.
Red Book Online Visual Library, 2006. Image 132_08. Available at:
http://aapredbook.aappublications.org/visual. Accessed August 31, 2007
Copyright ©2006 American Academy of Pediatrics
Tinea Capitis (Ringworm of the Scalp). An 8-year-old boy with a bald spot, hair loss, and
enlarging posterior cervical lymph node for 2 weeks. The node was described as tender, not
fluctuant, and without erythema of the overlying scalp. The area of hair loss was boggy and
fluctuant. The patient responded well to treatment with griseofulvin.
Red Book Online Visual Library, 2006. Image 132_09. Available at:
http://aapredbook.aappublications.org/visual. Accessed October 19, 2007
Copyright ©2006 American Academy of Pediatrics
Tinea Capitis (Ringworm of the Scalp). Photograph of an individual with ringworm, or tinea
capitis of the scalp caused by Microsporum gypseum. Although it is rare, M gypseum, a natural
soil habitant, can cause tinea on humans and animals. This fungus usually produces a single
inflammatory skin lesion which has scaly patches and hair loss, or broken hair shafts.
Red Book Online Visual Library, 2006. Image 132_17. Available at:
http://aapredbook.aappublications.org/visual. Accessed October 19, 2007
Copyright ©2006 American Academy of Pediatrics
Treatment



Griseofulvin, the agent most commonly used
to treat tinea capitis is better absorbed in the
presence of fatty foods.
Caregivers should be taught to administer the
medication with foods high in fat such as
peanut butter or ice cream to enhance the
drug's effectiveness.
Children receiving griseofulvin for longer than
three months should receive laboratory
testing for leukopenia, anemia, and elevated
liver enzymes.
INFESTATIONS

Infestations from pediculosis and
scabies are among the most prevalent
communicable diseases that affect
children.
Pediculosis
CLINICAL MANIFESTATIONS:
 Itching is the most common symptom, but many children are
asymptomatic.
 Adult lice or eggs (nits) are found in the hair, usually behind the
ears and near the nape of the neck.
 Excoriations and crusting
 regional lymphadenopathy.
 In temperate climates, head lice deposit their eggs on a hair
shaft 3 to 4 mm from the scalp. Because hair grows at a rate of
approximately 1 cm per month, the duration of infestation can be
estimated by the distance of the nit from the scalp.

ETIOLOGY: Pediculus humanus capitis is the head louse. Both
nymphs and adult lice feed on human blood.
Pediculosis Capitis. Head lice (nits on hair shaft).
Red Book Online Visual Library, 2006. Image 095_04. Available at:
http://aapredbook.aappublications.org/visual. Accessed December 9, 2007
Copyright ©2006 American Academy of Pediatrics
Pediculosis Capitis. Head louse, baby louse, and hair.
Red Book Online Visual Library, 2006. Image 095_05. Available at:
http://aapredbook.aappublications.org/visual. Accessed December 9, 2007
Copyright ©2006 American Academy of Pediatrics
Pediculosis Capitis. Nits on the hair shaft.
Red Book Online Visual Library, 2006. Image 095_01. Available at:
http://aapredbook.aappublications.org/visual. Accessed December 9, 2007
Copyright ©2006 American Academy of Pediatrics
Pediculosis: treatment

Permethrin (1%): over-the-counter 1% cream
rinse that is applied to the scalp and hair for 10
minutes after washing and towel drying the hair.
– repeated application 7 to 10 days later is necessary.
– advantages : a low potential for toxic effects and a
high cure rate.
– Do not rewash the hair for I to 2 days following
treatment.

Lindane (1%). An organochloride available only
by prescription. It should be used as secondline treatment on the basis of safety concerns. It
must be rinsed out no longer than 4 minutes
after application and should not be used more
than once to treat a lice infestation
Pediculosis: treatment



the hair should be thoroughly combed to
remove all nits and lice.
A fine-toothed comb, often included in the
pediculocide package, should be used.
An application of 50% distilled white vinegar
and 50% water or formic acid solution prior to
combing may aid in loosening the nits from
the hair shaft.
Pediculosis




Isolation Of The Hospitalized Patient: In addition to
standard precautions, contact precautions are
recommended until the patient has been treated with
an appropriate pediculicide.
Household and other close contacts should be
examined and treated if infested.
Bedmates and immediate members of the household
of infested individuals should be treated
prophylactically.
Children should not be excluded or sent home early
from school because of head lice. "No-nit" policies
requiring that children be free of nits before they
return to child care or school have not been effective
in controlling head lice transmission and are not
recommended
Common Allergic Conditions



Contact dermatitis - Hypersensitivity
response/ chemical irritation, i.e Latex
glove allergy
Urticaria – allergic phenomena causing
hives
Treatment – remove the irritant & give
antihistamines
Atopic Dermatitis



A chronic, relapsing inflammation of the
dermis and epidermis resulting in itching,
edema, papules, erythema, excoriation,
serous discharge, and crusting.
Although atopic dermatitis is commonly
known as "eczema," it actually is one disease
in a group of eczematous conditions.
Is associated with allergy with a hereditary
tendency
Atopic Dermatitis






Cause unknown, thought to be related to IgE, T
lymphocytes, monocytes, and other inflammatory
cells.
The prime cause is food allergy. A child who is born
with a tendency towards allergy can become
sensitized to any number of food through breast milk.
For the infant who is not breast-fed, the situation is
very complicated if he or she becomes allergic to
cow's milk at an early stage.
About 10% of the population has been affected by
atopic dermatitis at some point in their lives
compared with 2-5% in 1960
Most common in infants and young children (75%).
Increased risk for associated asthma or hayfever
Familial history: foods, cold weather, stress can be
the cause
Atopic Dermatitis
Clinical signs:
 pruritus and scratching.
 lack of adequate sleep
 dryness and roughness on the young infant's
skin
 erythema, and papules develop after the skin
has been irritated.
 excoriation, and subsequent serous
discharge and crusting.
 African-Americans are more likely to have
follicular and papular lesions.
Atopic Dermatitis
Lesions present in three stages:

Acute lesions
– extremely pruritic erythematous papules, which
may occur with excoriation, erosion, serous
exudate, and crusting.

Subacute stage:
– the papules are excoriated with fine scaling. Mild
lichenification, or thickening of the skin with
exaggeration of its normal markings

Chronic phase:
– marked lichenification, fibrotic papules and hyperor hypopigmentation
Atopic infant. The infant with atopic dermatitis is often quite
unhappy, the skin is very itchy, and sleeping is difficult.
Hyperlinear palms and lichenification. Atopic patients often
develop accentuation of the palmar creases.
Factors associated with exacerbation
of atopic dermatitis



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
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• Dust mites
• Pets/animal dander
• Pollens
• Soaps/detergents
• Food allergies
• Changes in climate and temperature
• Sweating
• Infections
• Textiles
• Emotional stressors
Treatment
Food allergy test
 Correct the diet
 Strengthen the immune system
 Inhibit inflammatory chemicals
 Deal with the itch, to prevent secondary infection from
scratching
Diet
Avoid food which cause any allergy. Avoid all processed, refined
food in cans and packages. Reduce intake of meat, eggs and
dairy products. Drink organic honey or other organic health
products.
Care
Avoid cosmetics, harsh soap and shampoo. Get more rest and
exercise. There are organic skin care at livelifeorganic too.

The End
Q&A?