Pediatric Dermatology
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Transcript of Pediatric Dermatology
Pediatric Dermatology
Board Review
Common Transient Neonatal Skin Conditions
• Erythema toxicum (neonatorum)– First 3 to 5 days of life– Central, small welt or
pustule on a broader erythematous base
– Scraping of erythema toxicum reveals eosinophils
– Resolves spontaneously
Common Transient Neonatal Skin Conditions
• Miliaria (prickly heat)– First few weeks of life
– Caused by keratin plugging of eccrine (sweat) glands in the skin
– eruption of microvesicular lesions on the face, neck, scalp, or diaper area
– Tx: dressing infant lightly & avoiding excessive humidity
Common Transient Neonatal Skin Conditions
• Milia– White or yellow
micropapules that develop when the pilosebaceous unit is obstructed by keratin/sebaceous material
– Clustered on nose, cheeks, chin, forehead
– Resolve w/o tx within several months
Eczematous Rashes
• Seborrheic dermatitis– Neonatal form
– First several months of life
– Cradle cap and then extend to other areas of skin where sebaceous glands are dense
• Forehead, eyebrows, behind the ears, sides of nose, middle of chest, umbilical, intertrigignous, and perineal areas in infant
– Lack of pruritus
– Well circumscibed plaques with a greasy, yellow-orange overlying scale
Eczematous Rashes
• Resolve by 8-12mo of age• Recur in childhood &
adolescence (hormones)• TX: antiseborrheic shampoo
– Persistant scalp seborrhea- 2% ketoconazole shampoo
– Residual scalp lesions- 1% hydrocortisone topical steroid cream
• *If rash is persistant or severe or is accompanied by anemia, adenopathy, or HSM- r/o histiocytosis
Eczematous Rashes
• Atopic Dermatitis– eczema
• erythema• microvesicles (often
confluent)• weeping and crusting• thickening (lichenification)
of the involved skin secondary to chronic scratching
– inherited predisposition of the skin
Eczematous Rashes
• Incidence– 2-3%– winter and in temperate or cold climates (air is
dry)
• Develops in conjunction with 2 other diagnoses of the atopic triad– asthma, allergic rhinitis (in the patient or family
members)
Eczematous Rashes
• Pattern– Infants- face– Toddlers- extensive surfaces of the arms and
legs– Older children and teens- antecubital and
popliteal areas, neck, and face
Eczematous Rashes
• Treatment– Interrupt the “itch-scratch” cycle
• oral antihistamine or colloidal oatmeal baths
• unscented topical moisturizers ( after tepid bath with mild soap)
• Inflamed lesions -topical steroid cream or ointment – ointments are more potent (not on face, intertriginious areas)
– Tacrolimus and pimecrolimus (topical immunomodulators)
– Secondary infection (Staph aureus)• oral antibiotics or topical mupirocin
Eczematous Rashes
• Contact dermatitis– typical pattern
• patches, linear arrays, and unusual distributions
– Poison Ivy, oak or sumac• Rhus dermatitis
– erythema develops on skin when contact with oil of plant leaves or stem…rapidly becomes microvesicular…progress to larger blisters..open and weep
– pruritic
Eczematous Rashes
• Treatment– Oral antihistamine – Topical steroids (moderate potency)– If rash is extensive or involves genitalia or the
skin around the eyes• Oral steroids 1-2mg/kg/day X1 week and then wean
during the second week to prevent rebound rash
Eczematous Rashes
• Acrodermatitis enteropathica– AR disorder
– zinc deficiency
– similar presentation to nutritional zinc deficiency
– usually presents in genetically susceptible infants that have been breast-fed and are now weaning
• ? Zinc-binding ligand in breast milk that enhances zinc absorption up to the time of weaning
Eczematous Rashes
• Presentation– rash- moist, erythematous, papular, forming plaques on
the skin around orifices and on the acral areas (hand and feet)
– foul-smelling, frothy diarrhea, alopecia, irritability or apathy, generalized failure to thrive
• Labs: low levels of zinc, alkaline phosphatase (zinc-dependent enzyme)
Eczematous Rashes
• Treatment– 5mg of zinc sulfate/kg/day– dramatic reversal of symptoms
Papulosquamous Rashes (raised and covered
with fine scales)
• Pityriasis rosea– most likely seen in
teens and older children
– cause unknown• ?viral
Papulosquamous Rashes
– initial lesion• herald patch
– 2-4cm scaly round or oval plaque w/raised border
– 5-7days later• typical exanthem follows “Xmas tree”
– 2-10mm ovoid, slightly raised plaques with central scaling in addition to smaller individual papules
– rash lasts 6-10 weeks
– TX: Resolves w/o treatment
– ***secondary syphillis mimics this..however syphillis involves palms and soles**
Papulosquamous Rashes
• Psoriasis– 1-2% adults
– 35% <20years
– 60% pediatric patients have relative w/ psoriasis
– Precipitating factors• trauma, cold, stress,
group A B-hemolytic strep infection
Papulosquamous Rashes
• Guttate psoriasis– 2-4 weeks after strep infection
– drop like lesions
• Lesions– red-based plaques w/ fine, adherent silvery scale;
– Auspitz sign- removal of scale produces pinpoints of bleeding
– knees, elbows, scrotum, scalp
• Nail pitting
Papulosquamous Rashes
• Treatment– minimal use of soap
– liberal use of thick emollients, keratolytics(w/salicylic or lactic acid)
– topical steroids
– Calcipotriene (synthetic Vit.D3 analogue) topical cream or ointment good results in teens and adults
• Consult Dermatologist
Vascular Malformations and Hemagiomas
• Vascular Malformations– hamartomas of mature endothelial cells– blood flow is normal or slower than normal– present at birth and enlarge with body growth– can affect growth of underlying bone and soft tissue…asymmetric
overgrowth• Klippel-Trenaunay syndrome
– salmon patch• MC • seen on the forehead, glabella, philtrum, or upper eyelids of about a third of
newborns• very red when infant cries• fades by 18-24 months of age• exception: nape of neck
Vascular Malformations and Hemagiomas
• Klippel-Trenaunay syndrome
Vascular Malformations and Hemagiomas
• Salmon patch
Vascular Malformations and Hemagiomas
• Port wine stains– mature, dilated dermal capillaries – persistent– if the distribution involves the opthalmic (upper eyelid to
forehead) branch of the trigeminal nerve• Sturge- Weber syndrome
– ipsilateral leptomeningeal involvement and intracranial calcifications
– MRI or CT
– seizures (60-90%), half are mentally retarded
– glaucoma
– tx: pulsed tunable dye laser
Vascular Malformations and Hemagiomas
• Portwine stain– Sturge-Weber
syndrome
Vascular Malformations and Hemangiomas
• Hemangiomas– benign neoplasms of endothelial cells
– rapid blood flow and an increased density of mast cells within the lesions
– grow rapidly during infancy, then plateau and begin to involute by 18-24 monts of age
• 50% resolve by 5years of age
• 70% by 7 years
• 90% by 9years
– Occur in 10-12% of children
– 90% resolve without treatment
Vascular Malformations and Hemangiomas
• Management– Watch– If interferes with vision or obstructs the airway
or involve lip or breast tissue• active intervention with steroids, interferon, or laser
treatment
Vascular Malformations and Hemangiomas
• Superficial hemangiomas– strawberry
hemangiomas
– well defined, raised, and light to deep red in color
Vascular Malformations and Hemangiomas
• Deeper (caveronous) hemangiomas– capillary growth into
the dermis and subcutaneous tissue
– soft blue to red
Vascular Malformations and Hemangiomas
• Kasabach-Merritt syndrome– large hemangioma
– thrombocytopenia
– consumptive coagulopathy
– not true hemangiomas
– tugted angiomas or kaposiform hemangioendothelioma
Pigmented and Hypopigmented Lesions
• Mongolian spots – dermal melanosis
– African American, Asian, Hispanic, or Mediterranean descent
– lower spine, shoulders, and arm most commonly
Pigmented and Hypopigmented Lesions
• Incontinentia pigmenti– X-linked or AD
– affecting the skin, central nervous system, eyes, and skeleton
– Skin manifestations (4 phases)• inflammatory vesicles seen in
neonates----evolve over several months to verrucous lesions----lesions develop into swirled brown to gray patches and finally become hypopigmented
Pigmented and Hypopigmented Lesions
• Nevus sebaceus of Jadassohn– sebaceous glands and
rudimentary hair follicles
– initially hairless, yellow to orange plaque that becomes darker and thicker at puberty
– scalp
– 10-15% risk for neoplastic transformation
• excision before puberty
Pigmented and Hypopigmented Lesions
• Urticaria pigmentosa– MC of the general diagnostic group of mastocytosis disorders
• pathologic accumulation of mast cells
– Majority of cases • present at 3-9 months of age
– multiple reddish brown macules, papules, or nodules…urticate when firmly rubbed• Darier sign
– trunk more than extremities– Systemic involvement( bone, liver, spleen, lymph nodes, other tissue)..if onset is
after 10yo– Prognosis: good if onset <10yo– Tx: oral antihistamines prn
• avoid food and meds that cause mast cell degranulation (codeine, aspirin, opiates, procaine, contrast agents, alcohol, cheese, spicy foods)
Pigmented and Hypopigmented Lesions
• Urticaria pigmentosa