Pediatric Skin Disorders

Keloid

A benign excess of scar tissue beyond sites of original injury: surgery, acne, ear piercing, tattoos, infections, burns.16 Looks smooth, rubbery, shiny and "clawlike"; feels smooth and firm. Found in ear lobes, back of neck, scalp, chest, and back; may occur months to years after initial trauma. Most common ages are 10-30 years; higher incidence in Blacks, Hispanics, and Asians.

Ecchymosis

A purplish patch resulting from extravasation of blood into the skin, >3 mm in diameter.

Scar

After a skin lesion is repaired, normal tissue is lost and replaced with connective tissue (collagen). This is a permanent fibrotic change. Examples: healed area of surgery or injury, acne.

Purpura

Confluent and extensive patch of petechiae and ecchymoses; >3 mm, flat, red to purple, macular hemorrhage. Seen in generalized disorders such as thrombocytopenia and scurvy. Also occurs in old age as blood leaks from capillaries in response to minor trauma and diffuses through dermis.(Jarvis 236)

Types of skin infections

bacterial infections (impetigo contagiosa, cellulitis, scalded skin syndrome, folliculitis). Viral infections (communicable viral diseases of childhood, warts, HSV, varicella, molluscum contagiosum). Fungal infections (tinea - corporis, pedis, capitis; candidiasis) - infections that live on skin, person to person transmission.

Molloscum contagiosum

benign superficial disease. Caused by poxvirus. Self-limited, if left alone. Small pearly, flesh colored papules, 2-5 mm. Central depression and cheesy core, umbilicated. Transmitted by contact, autoinoculable. Tx may be unnecessary, but includes cryotherapy, laser therapy, curettage, topical creams or ointments, cimetidine (found to have immunomodulatory properties). Cantharidin (topical blistering agent) and podophyllotoxin (antimitotic agent).

Pediculosis capitis

commonly called head lice, very common, especially in school age children, but not particular to age. Adult louse lives only 48 hours without human host, females lay eggs (nits) at base of hair shaft. Nits hatch in 7-10 days.

Scale

compact, dessidcated flakes of skin, dry or greasy, silvery of white

Contact dermatitis - plants

contact with poisonous plants (ivy, oak, sumac). Offending substance - urushiol oil. Localized, red, itchy lesion. Advances to streaks and blisters. Sensitivity to oil developed after 1-2 exposures. Full reaction seen in 2 days with redness, swelling, itching where contact and after 10-14 days, heals.

Ulcer

deeper depression extending into dermis, irregular shape, may bleed, leaves scar when heals

Assessment of skin lesions

distribution and size, color, location, arrangemen.

Arthropod bites and stings

include insects and arachnoids such as mites, ticks, spiders, scorpions. Most relatively harmless, mild to mod discomfort. Manage with symptomatic measures (compresses, calamine lotion, prevention of secondary infection). Only scorpions and brown recluse and black widow spider inject deadly venom with bite.

Fungal skin infections

live on skin, not in. Multiply at rate of keratin in order to maintain itself. Person to person, animal to human. Dx with scraping examination.

Patch

macules larger than 1 cm

Macule

solely a color change, flat and circumscribed, less than 1 cm

Nodule

solid, elevated, hard or soft, larger than 1 cm, may extend deeper into dermis than papule

Foreign bodies

splinters of wood, cactus spines. Tx - removal of object. Can cover with glue and gause. When dried, peel off gauze. Can also apply hair removal wax or body sugar. Place cellophane tape and remove.

Bees

stingers need to be removed asap. Can be deadly in hypersensitive kids.

Wheal

superficial, raised, transient, erythematous, slightly irregular shape from edema

Eczema tx

hydrate skin (lotions), relieve itch, reduce flareups or inflammation (reduce irritants), prevent and control secondary infection. May have remissions and exacerbations. May use antihistamines to help sleep. Little evidence that it improves itching though. Mild soaps, detergents. Avoid abrasive clothing, excessive heat, low humidity.

Tick removal

grasp tick as close as possible to point of attachment and pull straight up with steady even pressure.

Cellulitis

Inflammation of skin and subcutaneous tissues with intense redness, swelling, and firm infiltration. Fever and malaise if systemic. Organism(s): Streptococcus, Staphylococcus, Haemophilis influenza. Tx - Oral or intravenous antibiotics, warm, moist compress to area. I&D if abscesses. Lymphangitis = streaking often. Facial ___may be associated with otitis media.

Pediculosis tx

Pediculicide and manual removal of nits. Permethrin 1% cream rinse (Nix). Second treatment 7-10 days after first. Lice do not jump or fly, they are transmitted person to person. Children do not need to be excluded from school. Hospitals require contact isolation, bunny suit, hair net, shoe coverings.

Lichenification

Prolonged, intense scratching eventually thickens skin and produces tightly packed sets of papules; looks like surface of moss (or lichen).(Jarvis 226)

Impetigo contagiosa

Staphylococcus infection. Can start as a simple skin irritation. Progresses to vesicular lesions with exudate. Classic sign: Honey colored crusts. Very contagious and autoinoculable. Usually itchy. Lesions typically found around mouth and nose. Common in preschoolers, toddlers. Tx: Topical antibiotic ointment, oral antibiotics if severe

Petechiae

Tiny punctate hemorrhages, 1 to 3 mm, round and discrete; dark red, purple, or brown in color. Caused by bleeding from superficial capillaries; will not blanch. May indicate abnormal clotting factors. In dark-skinned people petechiae are best visualized in the areas of lighter melanization (e.g., the abdomen, buttocks, and volar surface of the forearm). When the skin is black or very dark brown, petechiae cannot be seen in the skin. Most of the diseases that cause bleeding and microembolism formation such as thrombocytopenia, subacute bacterial endocarditis, and other septicemias are characterized by petechiae in the mucous membranes and on the skin. Thus you should inspect for petechiae in the mouth, particularly the buccal mucosa, and in the conjunctivae.

Tinea pedis

aka athlete's foot. Between toes or on plantar surfaces of feet, itchy. Variable lesions - between toes (maceration and fissuring). Plantar surfaces - patches with vesicles. Tx - Griseofulvin and/or topical antifungal powder (1st line tx) . Avoid head, moisture, occlusive shoes.

Herpes simplex virus

aka cold sore, fever blister (type 1), genital (type 2). Grouped vesicular lesions, typically near mucocutaneous junctions. Vesicles progress to crusts over 2-8 days. Complete spontaneous resolution in about 8-10 days. Oral and topical abx may shorten duration/severity of lesions. Prevent secondary infection and usually heal without scar.

Atopic dermatitis

aka eczema. Refers to descriptive category of dermatologic disease and not specific etiology. Inflammatory dermatosis, itching. Defective epidermal barrier. Commonly associated with asthma, allergic rhinitis, food allergies, family history. Common sites - antecubital, popliteral, scalp, face, cheeks, extensor surfaces.

Tinea corporis

aka ringworm. Round, scaly patch of rough erythema. Annular plaque with central clearing. Tx - Griseofulvin and/or topical antifungal

Fungal diaper dermatitis

candida common cause. Dermarcated confluent beefy red plaques, papules, pustules, white scale. Characteristic satellite papules and pustules. Involves thighs, genital creases, abd, genitalia. Check mouth for oral infection. Tx - nystatin cream or topical antifungal.

Scabies

caused by scabies mite as female burrows into stratus corneum of epidermis to deposit eggs and feces. Inflammation occurs 30-60 days later, sooner with previous sensitization. Minute grayish brown, threadlike. Pruritic.

Seborrheic dermatitis

chronic recurrent inflammatory reaction of the skin, cause unknown. Common on scalp (cradle cap). Also on eyelids, nasolabial folds, ears. Cause unknown, seen more when sebum production increased. Lesions that are thick, adherent, yellowish, scaly, oily patches, itchy. No relation to family hx. Tx - hygiene, soak remove crusts, antiseborrheic shampic. (sulfur and salicylic acid).

Contact dermatitis - plants tx

cleanse skin ASAP w/ isopropyl alcohol, shower. Soothing agents such as calamine lotion, topical steroids, diphenhydramine.

Vesicle

elevated cavity containing free fluid, up to 1 cm, blister

Papule

elevated, palpable, firm and circumscribed, less than 1 cm

Cyst

encapsulated fluid filled cavity in dermis or subq layer, tensely elevating skin

Acne tx

general measures/overall health, mild cleanser 1-2 times a day, shampooing hair. Treatment success dependent upon teen, topical creams, etc, oral antibiotics, oral contraceptive pills, isotretinoin (Accutane) - last line treatment.

Age related skin lesions

infants - birth marks, diaper dermatitis, early childhood - atopic dermatitis (eczema), viral illness, school age children - ringworm, adolescents - acne, contact dermatitis.

Folliculitis

infection of hair follicle. Organism - staph aureus. Furuncles and carbuncles. Tx - local warm compresses, IV antibiotics if severe, incision and drainage prn. If extensive, can cause malaise.

Contact dermatitis

inflammatory reaction of skin to chemical agent. Allergic and irritant. Perfumes, jewelry, plants, animals, more. Irritated areas are erythematous, edematous. Can be vesicles, papules, and denudation of the skin. Characteristic sharp delineation between inflamed and normal skin. Only in areas of direct contact.

Scabies distribution

intertriginous areas = interdigital, axillary-cubital, popliteal, inguinal. Children> 2 years = primarily hands and wrists. Children < 2 years = primarily feet and ankles.

Furuncle

larger lesion (than folliculitis) with more redness and swelling at a single follicle.

Bulla

larger than 1 cm, usually single chamber, superficial in epidermis, ruptures easily

Tinea capitis

lesion on scalp, may extend to hairline and neck. Characteristic scaly patches of alopecia with itching. Patches of alopecia with black dots. Widespread scaling with subtle hair loss. Boggy edematous painful plaque called a kerion. Hairloss rarely permanent. May have some cervical lymphadenopathy. Tx - Griseofulvin (oral antifungal) - better absorbed with fatty foods, selenium sulfide shampoo, topical antifungal.

Fissure

linear crack with abrupt edges, extends into dermis, dry or moist

Drug reactions

most common on skin. Rash most common drug reaction. May be immediate or delayed. D/C drug, antihistamines, corticosteroids, anaphylactic rxns = medical emergency. Common offenders = PCN, sulfonamides. IV drugs more likely to cause reaction.

Lyme disease

most common tick borne, red donut shaped or bull's eye rash - annular erythema. Transmitted by ticks, usually in wooded areas. Need to be attached 1-2 hours to cause disease. Most common from deer ticks, spirochete Borrelia burdorferi. Three stages to disease. 8 yrs or older = doxycycline. If younger, oral amoxicillin.

Animal bites

most pts are boys 5-9yrs to upper extremities. Small children likely to be bit or scratched on head, face, neck. Tx - irrigate wound, prophylactic antibiotics. Review tetanus status and evaluate need for rabies protocol.

Carbuncle

multiple. More extensive, widespread inflammation, involving several follicles.

Pediculosis capitis diagnosis

observation of nits on hair shafts. Adults hard to locate. Differentiate nits from lint, etc. Typically found occipital, behind ears, nape of neck. Itching typically only symptom.

Herpes simplex virus prodromal symptoms

pain, burning, tingling, itching.

Plaque

papules coalesce to form surface elevation wider than 1 cm

Acne

predominantly in adolescents. Peak in girls 16-17, boys 17-18. More common in boys. Myths and truths of causes - stress (not supported by research), dietary intake - myth, exposure to oils in cooking grease - truth, certain cosmetic ingredients - some can increase comedone production. Minimize scarring and prevent.

Pustule

pus in cavity

Rocky mountain spotted fever

red spotty rash, maculopapular or petechial. Rickettsia ricketsii. Gradual onset - fever, malaise, anorexia, myalgia. Abrupt - rapid fever elevation, chills, vomiting, myalgia, severe HA. Tx - tetracycline or chloramphenicol, usually self limiting in kids. Tick borne.

Accutane

reserved for severe case of cystic acne nonresponsive to other treatments. Prescribed and monitored by derm doctor. Monitor for depression and suicide ideation. Monitor cholesterol and triglyceride levels. Teratogenic. Dry skin and mucous membranes, nasal irritation, mood changes, depression, photosensitivity, dry eyes, headaches, decreased night vision, arthralgia.

Skin lesions

result from contact with injurious agent, hereditary factors, external factors (allergens), systemic diseases (measles, varicella, nutritional deficiency diseases), age related.

Scar (atrophic)

resulting skin level is depressed with loss of tissue; thinning of the epidermis

Erosion

scooped out but shallow depression; superficial; heals without scar because erosion does not extend into dermis

Excoriation

self inflicted abrasion, superficial, sometimes crusted, scratches from intense itching

Acne patho

testosterone stimulates sebaceous glands to enlarge, produce oil, and plug pores. Comedogenesis - formation of comedones, non-inflammatory lesions. Open - black heads. Closed - white heads. Inflammatory - papules, pustules, nodules, cysts.

Crust

thickened, dried out exudate left when vesicles/pustules burst/dry up.

Contact dermatitis tx

topical corticosteroids, oral for more severe. Cold compresses, calamine lotion, lotion, ointment, avoid irritating agent.

Scabies tx

topical scabicides, permethrin 5% cream = less toxicity than Lindane so safe for kids, infants. Permethrin applied to skin, left on for 8-14 hours and washed off. Repeat in two weeks. Takes 2-3 weeks for tracks to disappear. Treat people in contact with pt (family, etc). Hot water laundry, dry clean, bag for 72 hrs. Generally don't survive past 2-3 days off the skin.

Diaper dermatitis

very common in infancy, uncomfortable, painful, most commonly irritant dermatitis, can also be allergic, fungal, bacterial, viral. Repetitive contact with irritant aka urine, feces. Erythema, maceration, erosions, ulceration. Mostly involves convex surfaces, buttocks, genitalia, lower abd, upper thighs. Tx - prevent, maintain dry skin, barrier creams, avoid irritants. Wipe with damp rag instead of baby wipes.

Warts

well circumscribed, gray or brown, elevated firm papules with a roughened, finely papillomatous texture. Caused by human papillomavirus. Can appear anywhere but generally found on exposed areas like fingers, hands, face, soles of feet. Asymptomatic usually. Tx - difficult and local destructive therapy. Common in kids, tends to disappear spontaneously. Autoinoculable.