Transcript EO_018.08 Treat Paediatric Skin Conditions

PAEDIATRIC
DERMATOLOGY
OBJECTIVES
Common paediatric dermatologic
conditions
 Dermatologic presentation of systemic
disease
 Conditions which may require
urgent/emergent management

ASSESSMENT OF SKIN
PROBLEMS
History
DESCRIBE WHAT YOU SEE!
ASSESSMENT OF SKIN
PROBLEMS
History
 Onset,
progression, change
 blister,
bleed, drain
 Distribution
 Duration
 Aggravating/relieving
 Itch,
factors
pain, triggers
 Treatment
 Associated S & S e.g. fever
ASSESSMENT OF SKIN
PROBLEMS
Past Medical History
 Asthma,
atopy
 Illnesses
Allergies
 Food,
drugs, seasonal, environmental
ASSESSMENT OF SKIN
PROBLEMS
Family History
 Skin
disease
 Systemic
Social
 Others
affected at home, school or daycare
 Crowding, poverty
5 ITCHES
1.
2.
3.
4.
5.
Dermatitis
Varicella
Urticaria
Scabies
Insect bites
DERMATITIS
Itching, redness, swelling, oozing, scabbing,
scaling, lichenification, +blisters
DERMATITIS
Atopic (eczema)
 Diaper dermatitis
 Seborrheic dermatitis (cradle cap)

ATOPIC DERMATITIS
(ECZEMA)

Site:
 Infant
- face, scalp, extensor surfaces
 Child - flexor surfaces
FH atopy (asthma, hayfever, anaphylaxis,
allergies)
 Inheritance:

1 parent >60%
2 parents >80%
ATOPIC DERMATITIS
(ECZEMA)
ATOPIC DERMATITIS
(ECZEMA)

Complications:
 Secondary
bacterial infections
 Eczema herpeticum (herpes infecting the
lesions)

Prognosis:
 50%
clear by age 13
MANAGEMENT OF
DERMATOLOGICAL
PROBLEMS
If it’s dry – wet it
If it’s wet – dry it
And if you don’t know what to do give
steroids!!
ATOPIC DERMATITIS
(ECZEMA)
Management
 Bathing
 Bath
oil (e.g. Aveeno, Keri)
 Pat dry
 Ointments when wet
ATOPIC DERMATITIS
(ECZEMA)
Management
 Topical
corticosteroids
 Vaseline
 Antihistamines
 Warn about course!
TOPICAL STEROIDS
Weak = 1% hydrocortisone
 Moderate = 0.05% betamethasone


3 times a day and reduce…
BEST ANTI-ITCH

Hydroxyzine 0.5 mg/kg QID
 (max
400 mg/day)
DESCRIBE WHAT YOU SEE!
DIAPER DERMATITIS
DIAPER DERMATITIS

Contact iirritation
DIAPER DERMATITIS
Management
 Keep
area dry – expose to air
 Protect
DESCRIBE WHAT YOU SEE!
CANDIDIASIS
CANDIDIASIS
Folds
 Management:

 Nystatin
– 4 times a day/every diaper change
 Consider oral too
 Nystatin
 7-10
days
– 1 mL PO 4-6 times a day after food
DESCRIBE WHAT YOU SEE!
SCALP SEBORRHEIC
DERMATITIS (CRADLE CAP)
SEBORRHEIC DERMATITIS
(CRADLE CAP)
Occurs in any baby
 Sebaceous glands pump out greasy
substance that keeps the old skin cells
attached as it dries
 Greasy
 Yellow

SEBORRHEIC DERMATITIS
(CRADLE CAP)
Onset most commonly in first 3 months
 gone by 8 to 12 months
 Teens often have a similar scalp condition
= dandruff!!

SEBORRHEIC DERMATITIS
(CRADLE CAP)

Management:
 Oil
to soften/loosen scales
 Soft brush or dry terry cloth to brush away
 Consider mild topical steroid, if red/inflamed

Rarer now because cleaner
SCABIES
Management:
 Permethrin 5% dermal cream – single
application
 Neck
down for 12 hours adults
 Include head and scalp in prepubertal
 Hot
launder clothes from last 3 days or
 Seal for 48 hours
 Safety under 3 months not established
 Hydroxyzine
 IVERMECTIN
HEAD LICE
Nix (shampoo) cream rinse
 Nits = dead
 School after treatment


http://www.cps.ca/ENGLISH/statements/I
D/id08-06.htm
BIRTH MARKS
 Mongolian
Spots
 Café-au-lait spots
-
Transient macular stains (Salmon patches)
Port wine stains
MONGOLIAN SPOTS
Blue/grey macula
 Appear at or shortly after birth
 Base of spine, buttocks and back
 Not associated with any conditions or
illnesses
 Gradually disappear

MONGOLIAN SPOTS
CAFÉ-AU-LAIT SPOTS
CAFÉ-AU-LAIT SPOTS
Well-circumscribed, homogenously
pigmented, light brown macules
 1.5 - 15 cm in diameter
 Frequently present at birth, are almost
always present by 1 year of age
 May increase in number during early
childhood

CAFÉ-AU-LAIT SPOTS
Approximately 2% of all newborn infants
 Up to 25% of the normal adults
 More common in darker-pigmented races
 ≥6 with diameter > 0.5 cm before
puberty, and 1.5 cm after puberty
suggests neurofibromatosis

SALMON PATCH
SALMON PATCH
Transient, macular
 Present in up to 70% of newborns
 Eyelids, nape of neck, glabella
 Most fade by 1 year of age
 Those in nape of neck persist in 25% of
adults

PORT WINE STAIN
PORT-WINE STAIN
Malformation of superficial capillaries of
skin
 Pinkish/red macules
 Well defined edges in infancy
 Facial most common

PORT-WINE STAIN
Present at birth
 Permanent
 Variable size
 Do not proliferate but enlarge as child
grows
 Lesions darken to purple and may develop
a pebbly or slightly thickened surface with
time

MANAGEMENT
Most are uncomplicated
 Laser therapy may help fade the lesion,
best done in infancy
 Around eye innervated by branch 1 of
trigeminal nerve – need ophthalmology
assessment /neuroimaging

VASCULAR MALFORMATIONS
 Hemangiomas
 Capillary (strawberry)
 Cavernous
HEMANGIOMAS
CAPILLARY (STRAWBERRY)
HEMANGIOMAS
Begin as flat, pale white spots & later
become larger & elevated, bright red, non
compressible
 mm - several cm
 Usually solitary
 Females 3:1
 55% present at birth, rest develop later

CAVERNOUS HEMANGIOMAS
CAVERNOUS HEMANGIOMAS
HEMANGIOMAS
CAPILLARY (CAVERNOUS)
Lie deeper in in skin with a slightly bluish
discoloration
 Growth until 1 year of life
 Involute over 3-10 years

COMPLICATIONS

Peri-orbital
 risk

to vision ( amblyopia)
Ear
 decreased
delay
auditory conduction, speech
Multiple cutaneous/large facial may be
associated with visceral hemagiomas
 Subglottic

 hoarseness,

Cosmetic
stridor, respiratory failure
CASE
5 week old with croup
 6 day history of cough-initially harsh,loose
 now high pitched seal-like cough
 no distress, O2 sat 99%, HR 130, RR 30
 erythema of left anterior tongue, left
posterior palate with ? thrush

…reassessment...
1 hour post epi
 moderate-severe respiratory distress
 classic “croupy” cough, RR40
 severe intercostal indrawing, abd
breathing, tracheal tug
 improved with 2nd dose epi

“let’s bring her in…”
admission
 NPO/IV/epi/steroids/ O2
 unable to discontinue steroids
 breast feeding well limited to 10 mins
 no better by day 10

SIDE EFFECTS STEROIDS
Cushingoid
 hypernatremia/hypertension/wt gain
 hyperglycemia
 adrenal suppression/immunity
 bone density
 cataracts

MANAGEMENT
Natural history of haemangiomata
 Oral systemic steroids were the mainstay
of Rx if complications arise
 Propranolol 2 mg/kg/day

INFECTIONS
Fungal
 Bacterial

TINEA CAPITIS
TINEA CAPITIS
Non-scarring alopecia with scales
 Round, scaly patches of alopecia, +/broken hairs
 + Boggy, elevated, discharging


May be secondarily infected +/scarring
TINEA CAPITIS
Etiology: Fungal
 Investigations:

 Wood’s
light: green fluorescence only for
microsporum infections
 Culture of scales/hair shaft
 Microscopic exam of KOH preparation
showing hyphae
TINEA CAPITIS

Management:
 Terbinafine
(Lamisil) for 1 month
 10-20 kg 62.5 mg daily
 20-40 kg 125 mg daily
TINEA CORPORIS
(RINGWORM)
TINEA CORPORIS
(RINGWORM)
Etiology: fungal
 Pruritic (not severe), scaly, round/oval
plaque(s) with erythematous margin(s)
and central clearing
 Peripheral enlargement of lesions
 Mostly trunk, limbs, face
 Contact with infected animals/pets

TINEA CORPORIS
(RINGWORM)

Management
 Clotrimazole
(Canesten) cream
BACTERIAL INFECTIONS
Impetigo
 Staphylococcal scalded skin syndrome
(SSSS)
 Cellulitis
 Furuncle/boil

IMPETIGO
IMPETIGO
Purulent, vesicular lesion  golden
yellow crust
 Pre-school & young adults
 Crowded conditions, poor hygiene,
minor trauma
 DDx: infected eczema, HSV, varicella
 Organisms: Staph. Aureus, GAS, both
 Potential complication: poststreptococcal glomerulonephritis

IMPETIGO
Organisms: Staph. aureus, GAS, both
 Potential complication: poststreptococcal glomerulonephritis

TREATMENT

Topical
 e.g.

2% mupirocin or fucidin tid
Systemic 7-10 days
 e.g.
cephalexin 50 mg/kg divided tid/qid
BULLOUS IMPETIGO
Scattered, thin-walled bullae containing
yellow/turbid fluid
 Staph. aureus
 Complications:

 Generalized
skin peeling
 Staphylococcal Scalded Skin Syndrome
STAPHYLOCOCCAL
SCALDED SKIN SYNDROME
(SSSS)
STAPHYLOCOCCAL
SCALDED SKIN SYNDROME
(SSSS)
CELLULITIS
CELLULITIS
Erythematous, flat, poorly-demarcated
lesions, not uniformly raised
 Tender
 Warm
 Group A Strep, Staph. aureus
 Differential diagnosis:

 necrotizing
fasciitis
CELLULITIS
TREATMENT
 Cephalexin
q6h PO
 Second
 Cefazolin
severe
50 – 100 mg/kg/d divided
line = cloxacillin or clindamycin
IV +/- clindamycin for
FURUNCLES (BOILS)
Red, hot, tender, inflammatory nodules
 Tense for 2-4 days, then fluctuant
 Yellowish point ruptures with discharge
of pus
 Commonly around hair follicles at areas
of friction & sweat

 nose,
neck, face, axillae, buttocks
MANAGEMENT

Incision and Drainage
 Relieves
pressure & pain
 Hot packs

Antibiotic PO:
 e.g.

cloxacillin
Consider:
 Culture
blood/pus
SYSTEMIC ILLNESS
Erythema multiforme
 Bullous erythema multiforme
 Toxic epidermal necrolysis (Stevens
Johnson)
 Henoch Schonlein purpura
 Kawasaki disease

ERYTHEMA MULTIFORME
Target lesions (3 rings)
 HERPES SIMPLEX VIRUS
 Fixed (not transient e.g. giant urticaria)

 No
pain
 No pruritus
 No scale/crust
May include palms/soles
 May include mucosa

ERYTHEMA MULTIFORME
Management:
 Herpes isolation
 Oral acyclovir
 Topical steroids
BULLOUS ERYTHEMA
MULTIFORME

Atypical targets
 Central
vesicle
Vesicles without targets
 Discrete lesions
 Erosions & crusts
 Mucous membranes involved
 MYCOPLASMA

BULLOUS ERYTHEMA
MULTIFORME
Management:
 Admit
 Mycoplasma isolation
 Antibiotics for mycoplasma
 Ophthalmology, dermatology/wound oral
care
 Systemic steroids often needed
STEVENS JOHNSON
SYNDROME
TOXIC EPIDERMAL NECROLYSIS
(STEVENS JOHNSON)







Vesicles & bullae
May begin as dusky papule
Rapid progression
Develops confluence
Mucous membrane involvement
Systemic involvement
DRUG CAUSE USUALLY



Antiepileptics
Sulphurs
Penicillins
TOXIC EPIDERMAL NECROLYSIS
(STEVENS JOHNSON)
Management:
 Life threatening  ICU/burns unit
 Supportive treatment
 History for all infections/medicines
 IVIG (0.75-1 g/kg/d x 3 days)
 Cyclosporin
 Steroids are controversial
COURSE
<
5% mortality overall
 Regrowth of epidermis by 3 weeks
COMPLICATIONS
•corneal scarring/blindness,
•phimosis, vaginal synechiae (stenosis)
• renal tubular necrosis
•renal failure
•esophageal strictures
•respiratory failure
•scarring/cosmetic deformity
HENOCH-SCHONLEIN PURPURA
“Anaphylactoid purpura”
 Autioimmune vasculitis
 Skin – petichiae, palpable, purpura
 Joints – arthralgia/arthritis
 Renal – hematuria, ↑BP,
(glomerulonephritis)
 GI – pain secondary to edema,
intussusception

KAWASAKI DISEASE
>80% less than age 4
 Seen in all races
 Asian>Black>White
 Most common cause of acquired heart
disease in children
 Typical vs atypical

DIAGNOSTIC CRITERIA
FEVER > 38.5C > 5 days PLUS 4 of:
1.
EYES
 Bilateral non-purulent conjunctivitis
2.
‘CENTRAL’
 Oral mucosal changes – fissured red lips, strawberry
tongue
3.
NECK
 Asymmetric cervical lymphadenopathy >1.5 cm
4.
PERIPHERAL
 Desquamation (edema, erythema)
5.
RASH
 Polymorphic

Illness not explained by other (e.g. Strep/measles)
ASSOCIATED FEATURES
Irritability ***
 Arthritis
 Aseptic meningitis
 Hydrops of the gallbladder
 Hepatic dysfunction
 Diarrhea
 Pneumonitis
 Uveitis

COMPLICATIONS

Coronary artery ectasia/dilatation
 20%
if untreated
 2% treated
Myocarditis/pericarditis
 Arrhythmias

TREATMENT
IVIG infusion
 High dose then low dose aspirin
 Supportive

SUMMARY






Assessment of skin problems
Itchy (2/5)
Birth Marks
Vascular malformations
Infections
Systemic illnesses
REFERENCES
E.O. 021.08, 021:09 and 021:11
 Nelson’s Essentials of Pediatrics
 Color Atlas/Synopsis of Clinical
Dermatology
 Class Handout
 Canadian Paediatric Society Policy
Statements
 http://www.aboutkidshealth.ca
