Paediatric dermatology

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Paediatric dermatology

• By Emily

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Objectives

• By the end of this session we should be able to
• Recognise common rashes in infants and children
  and know how to treat them
• Manage common paediatric infestations (scabies,
  head lice)
• Treat eczema and know when to refer

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• Quiz
• 2 teams
• Shout when you know the rash
• Extra bonus points available
• Prize for winners!

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What's that rash?
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Milia

• Epidermal inclusion cysts
• Pearly, yellow, 1-3mm diameter papules
• Face, chin, forehead
• 50 newborns
• Usually resolve in first month without treatment,
  but may persist for several months

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What's this?
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Hemangioma

• Most common benign tumours of infancy
• Begin as barely visible telangiectasia or red
  macules and grow into 0.5-4cm bright red
  partially compressible tumours
• 60 occur on head and neck area
• Virtually all gone by age 5yrs

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What's this?
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Capillary malformations

• 2 common types
• Salmon patch (naevus simplex)
• Common (40 newborns)
• Small flat patches pink or red, poorly defined
  borders
• Nape of neck (stork mark), forehead (angel kiss),
  eyelids and sacrum
• Worse with crying
• Not associated with extracutaneous findings

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Capillary malformations

• Port wine stain
• Less common
• Large flat patch of purple or dark red skin with
  well defined borders
• Persist in childhood then darkens and thickens
• Extracutaneous defects

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What's that rash?
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Nappy rash

• Caused by combination of factors, irritation to
  the skin by urine and faeces, occlusion and
  candida
• Intertriginous areas usually spared
• Secondary staph inf thin-walled pustules on
  erythematous base
• If persistent and creases involved think
  seborrheic dematitis, psoriasis, and candidiasis
• Resolves when stop wearing nappies

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Nappy Rash - prevention and treatment

• Nappy off!
• Change nappy frequently
• Wash bottom at each change, can use aqueous cream
• Use emollient (aqueous cream) and barrier (zinc
  oxide)
• Low potency topical steroid (hydrocortisone)
• Candida - antifungal eg nystatin, can add low
  potency steroid for few days
• Sebhorrhoeic dermatitis - Emollients and steroid
  help, can add ketoconazole

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What's that rash?
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Cradle cap

• Greasy, yellow scaly patches over the scalp
• Seborrheic dermatitis of newborn
• possibly due to overactive sebaceous glands in
  the skin of newborn babies
• Possible relationship with skin yeasts
  (malassezia)
• Not itchy
• Treatment with mild baby shampoos. Wash regularly
  and brush softly to remove scales
• Baby oil can help soften scales (not olive oil!)
• Resolves by 6-12mths
• If fails to improve can try medicated shampoo
  with ketoconazole or low potency steroids

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What's that rash?
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Chicken pox

• Begins as an itchy red papules progressing to
  vesicles on bright red base (dew drops on a rose
  petal) on the stomach, back and face, and then
  spreading to other parts of the body
• Central umbilication of blisters follows rapidly,
  crusting and desquamation within 10 days
• Fever, sore throat, anorexia, malaise may precede
  rash by several days
• Incubation 7-21 days
• symptomatic treatment only in immunocompetent
• Cool compress, calamine lotion, antihistamines
• ?Vaccinate

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What's that rash?
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Meningococcus

• What every parent worries about
• Rash is seldom early sign
• Classically non-blanching haemorrhagic rash
• In early stages rash may be blanching and macular
  or maculopapular (sometimes confused with flea
  bites)
• Important to search whole body for small
  petechiae
• Give IM Ben Pen and refer

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What that rash?
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Impetigo

• Superficial bacterial skin infection
• Strep pyogenes or staph aureus
• Round/oval lesions, begin as small pustular areas
  and rapidly extend
• Lesions rupture, oozy surface with honey-covered
  crust
• Advice about avoiding spread
• Localised lesion- topical antibiotic eg Fucidin
  cream
• Widespread infection - oral flucloxacillin or
  erythromycin

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What's that rash?
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Molluscum

• Viral skin infection Pox virus
• aka dimple wart
• Clusters of small round flesh-coloured
  umbilicated papules
• Often on face, trunk, axillae (warm moist places)
• Harmless but can persist for months, occasionally
  a couple of years
• No treatment necessary
• Can refer for cryotherapy/curratage

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What's that rash?
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Measles

• Prodrome fever, malasie, dry cough, coryza,
  conjunctivitis, photophobia
• Koplik spots on buccal mucosa
• Rash 3-4th day of illness
• Starts on face as blanching red macules and
  papules, non itchy
• Spreads down trunk and extremities
• Rash coincides with high fever
• Lesions become confluent, older lesions develop
  rusty hue
• Contagious 4 days before rash and 4 days after

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What's that rash?
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Hand, Foot and Mouth

• Common, mild, viral infection caused by Coxsackie
  A16
• Occurs in young children in summer/autumn
• 1-2 day fever, anorexia, sore throat followed by
  development of 3-6mm elongated, gray, thin-walled
  vesicles
• May be asymptomatic or severe pruritus and
  burning
• Symptomatic treatment
• Lasts lt 1 week

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What's that rash?
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Eyrthema infectiosum

• Fifth disease, slapped cheek, Parvovirus B19
• First sign is firm red cheeks, which feel burning
  hot
• Rash follows 1-4 days later with a lace pattern
  on the limbs and then the trunk
• Fades over 2-3wks
• Usually well, may have slight fever or headache
• Rare complications
• Arthritis in teenagers/adults, aplastic crisis,
  miscarriage

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What's that rash?
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Herpes simplex

• Gingivostomatitis commonest manifestation of
  primary herpes infection in kids
• Clusters of red papules, evolve into vesicles and
  often pustules in 24-48hrs. Vesicles rupture and
  crust over. Heal in 10-14days
• Cool compress, analgesia, consider aciclovir
• Monitor hydration when oral lesions
• Can be recurrent

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Head Lice

• Infest clean and dirty hair
• Adult lice are size of sesame seed, brownish
  grey, and wiggle their legs
• Only adult lice contagious
• Spread by head to head contact
• They dont jump/fly
• Normally asymptomatic
• Can present with itchy scalp

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Head Lice- Treatment

• Insecticides - malathion, phenothrin, permethrin,
  carbaryl
• Local policy?
• 2 applications 7 days apart
• Shampoos not effective
• Wet-comb conditioned hair with fine tooth comb
  until lice removed and rpt at 3-4 day intervals
  for 2/52
• Electric combs, tea tree - no evidence

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What that rash?
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Scabies

• Sarcoptes scabiei mite
• Pruritic burrows pathognomic (irregular,
  tortuous, and slightly scaly)
• In infants, burrows are widespread with
  involvement of trunk, scalp, extremities, palms
  and soles
• Consider in infants with widespread dermamtosis
  that involves the palms and soles

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Scabies - treatment

• Permethrin (malathion)
• Ivermectin in combination for norwegian scabies
• Not after hot bath
• All family members at same time
• Whole body treatment inc, scalp, neck, face, ears
  and under nails
• Rpt week later

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Infantile eczema
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Eczema

• Infants
• Infants less than one year old often have widely
  distributed eczema.
• The skin is often dry, scaly and red with small
  scratch marks made by sharp baby nails
• The cheeks of infants are often the first place
  to be affected by eczema.
• The napkin area is frequently spared due to the
  moisture retention of nappies (but they can still
  get nappy rash)

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Childhood eczema
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Eczema

• Toddlers and pre-school
• As children begin to move around, the eczema
  becomes more localised and thickened.
• Toddlers scratch vigorously and the eczema may
  look very raw and uncomfortable
• Often affects the extensor aspects of joints,
  particularly the wrists, elbows, ankles and
  knees. It may also affect the genitals
• As the child becomes older the pattern frequently
  changes to involve the flexor surfaces of the
  same joints
• The affected skin often becomes lichenified

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Eczema

• School children
• Older children tend to have the flexural pattern
  of eczema and it most often affects the elbow and
  knee creases. Other susceptible areas include the
  eyelids, earlobes, neck and scalp.
• Many children develop a 'nummular' pattern of
  atopic dermatitis. This refers to small coin-like
  areas of eczema scattered over the body. These
  round patches of eczema are dry, red and itchy
  and may be mistaken for ringworm
• Mostly improves during the school years

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Treatment of eczema

• Advice - loose cotton clothes, avoid wool, keep
  cool, nails short, gloves in bed
• Emollients
• Antihistamines
• Topical steroids
• Topical immunosuppressant
• Bandages (zinc/ ichthammol/ Tar)
• Wet wrapping - weeping eczema
• ?Oral steroids
• Immunosuppressant
• Phototherapy