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Pediatric  Dermatology  Overview    -­‐  From  Head  to  Toe  

Joanna  Guenther,  PhD,  RN,  FNP-­‐BC,  CNE  

September  2014  

ObjecMves  

•  Discuss  a  systemaMc  approach  to  common  dermatologic  condiMons  of  children  encountered  in  primary  care.  

•  Describe  the  clinical  manifestaMons  of  common  dermatologic  condiMons  of  children.  

•  Review  therapeuMc  and  pharmacologic  treatments  for  each  dermatologic  condiMon.  

History  Taking  

•  Age,  race,  and  sex  •  Onset/duraMon    •  LocaMon  on  body  •  EvoluMon  of  lesions  •  Treatment  aUempted  •  Associated  symptoms  – Pruritus,  fever,  headache,  GI,  etc  – Think  infecMon  with  rash  +  fever    

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AddiMonal  Aspects  of  History  

•  Family  history    •  Known  personal  contacts  •  Trauma  •  Travel  &  play    •  Environmental  exposure  –  Insects,  plants,  toxins,  sun,  etc  

•  Season  

Primary  Skin  Lesions  

Atopic  DermaMMs  

Eczema   Treatment:  •  Inherited  predisposiMon  -­‐

oZen  hx.  Asthma,  allergic  rhiniMs,  food  allergies    

•  Usually  affects  cheeks,  face,  trunk,  extremiMes  

•  Erythematous  papules  to  scaly  plaques  

•  Intense  pruritus  >>  scratching  >>  risk  of  impeMgo  

•  RehydraMon  of  skin,  anMhistamines,  topical  low  potency  steroid  creams,  Elidel  or  Protopic  cream  bid  

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Seborrheic  DermaMMs    

Cradle  Cap  •  Common  during  first  several  

months  of  life  •  OZen  on  face  &  scalp,  but  

can  extend  to  other  areas  •  Well  circumscribed  plaques  

with  scaling  •  Resolves  by  6-­‐12  months  

Treatment:  •  Emollient  –  baby  oil  •  Baby  shampoo  +  soZ  brush  

ImpeMgo  

Characteris4cs:   Treatment:  •  InfecMon  usually  caused  by  

staph  aureus;  contagious  •  Red  papules  >>>  fragile  

vesicles  >>>  honey-­‐colored  crusted  papules  

•  Bactroban  (mupirocin)  oint  Md  X  7  days;  Altabax  oint  bid  X  5  days  +  warm  compresses  and  gentle  washing  

•  Oral  anMbx    -­‐  dicloxacillin,  cephalexin,  clindamycin  X  7  days  

•  Recurrence:  check  for  nasal  carrier  of  MRSA  with  C&S  swab  (Bactroban  intranasally)  

MRSA  •  Methicillin-­‐resistant  staphylococcus  aureus  •  Only  responds  to  certain  anMbioMcs  –  local  anMbioMc  suscepMbility  (clindamycin  40  mg/kg  in  3-­‐4  daily  doses  or,  bactrim  8-­‐12  mg  trimethoprim/kg  in  2  daily  doses)  

•  Enters  through  cuts  and  wounds  •  OZen  starts  as  small  bumps  that  resemble  pimples  and  quickly  turn  to  painful,  deep  abscesses    

•  Risk  factors:  contact  sports,  sharing  towels,  weakened  immune  system  

•  PrevenMon:  Good  handwashing  

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CelluliMs  

Characteris4cs:   Treatment:  •  Erythema,  edema,  warmth,  taut  shiny  

skin,  tender  •  Erisypelas  –  superficial  erythematous  

patch  >>>  fiery  red,  indurated,  tense  •  CelluliMs  –  deep  infecMon,  usually  caused  

by  beta-­‐hemolyMc  Strep  or  Staph  aureus,  or  complicaMon  of  wound  or  trauma  (dog/cat  bite)  

•  Cause  staph  or  strep,  complicaMon  of  wound  or  trauma  (dog/cat  bite)  

•  The  borders  are  well  defined  and  change  rapidly  

•  Immediate  aUenMon  –  C&S  if  draining;  CBC;  IV  anMbioMcs  followed  by  oral  

•  Facial  celluliMs  can  cause  visual  damage  if  spreads  to  eyes  

•  Elevate  &  heat  

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Trauma  

•  Animal  Bite  vs.  Scratch  – Cat  &  Dog  Bite:  Pasteurella  species  most  common  –  also  staph  and  strep    

– Txment:  Wound  care,  AnMbioMcs  •  Amoxicillin-­‐clavulanate,  doxycycline  >  8  yrs  old  •  Oral  vs.  parenteral  depends  on  wound  depth  &  severity    •  Tetanus/Rabies  prophylaxis  

– Cat  Scratch:  Bartonella  pathogen  most  common  •  Azithromycin  or  clarithromycin  most  effecMve  

 

Candidal  Diaper  DermaMMs  

Characteris4cs:  •  Confluent  bright  red  papules  and  

plaques  with  scaUered  pustulo-­‐vesicular  satellite  lesions  

•  Caused  by  moist  environment,  urine/stool  increase  the  pH,  fricMon  from  diaper  

•  Candida  albicans  invade  

Treatment:  •  Frequent  diaper  changes;  

expose  skin  to  air  •  Topical  pastes  and  ointments  

to  serve  as  a  barrier  –  zinc  oxide  (DesiMn,  A&D  Ointment)  

•  AnMfungal  creams  (nystaMn,  clotrimazole,  miconazole)  

•  Severely  inflamed  –  1%  hydrocorMsone  sparingly    bid  for  5-­‐7  days  

•  Mupirocin  ointment  only  if  infecMon  present  

Hand-­‐Foot-­‐and  -­‐Mouth    

Characteris4cs:  •  Caused  by  Coxsackie  virus  

A16    •  Abrupt  onset  of  scaUered  

papular  &  3-­‐6  mm  elongated  vesicular  lesions  on  palms,  soles  &  mouth  

•  Sxs:  fever,  malaise,  joint  aches,  sore  throat  

Treatment:  •  SupporMve;  oral  ulcers  

tender  –  Anbesol,  Orajel    •  Lasts  <  1  week  

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Erythema  InfecMosum    

Fi6h  Disease  •  Caused  by  parvovirus  B19;  

common  in  late  winter  &  early  spring;  spread  by  resp.  droplets  

•  Fever,  malaise,  h/a,  sore  throat,  coryza  >>>  slapped  cheek  rash  appears  aZer  48  hrs  >>>  diffuse,  lacy  pink  rash  on  body  X  1-­‐2  wks  

•  Contagious  before  rash  

Treatment:  •  SupporMve  (fever,  

hydraMon);  Good  handwashing  

Pityriasis  Rosea    

Characteris4cs:  •  Prodrome  sxs:  malaise,  headache,  

sore  throat  •  Diffuse  raised  red  patches  with  

central  scales  in  Christmas  tree  paUern;  first  lesion  is  herald  patch  (large  oval  plaque)  with  more  lesions  5-­‐10  days  later  

•  ?  Viral  eMology  

Treatment:  •  Control  pruritus:  calamine,  

topical  steroids,  oral  anMhistamines  

•  Rash  will  subside  without  treatment  –  may  last  6  weeks  

Roseola  

Characteris4cs:  •  Caused  by  Human  

herpesvirus  6  (HHV-­‐6)  •  Common  age  7-­‐13  months  •  High  fever  (oZen  >104⁰  F)  

and  irritability  for  3-­‐5  days    •  Blanching  maculopapular  

rash  develops  as  fever  decreases  

Treatment:  •  SupporMve:  Control  fever  

and  increased  hydraMon  

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Measles  

Characteris4cs:  •  Rubeola  –  Paramyxovirus  •  Prodrome:  fever,  malaise,  dry  

cough,  conjuncMviMs,  photophobia  >>  3-­‐4  days  rash  develops  

•  NonpuriMc  maculopapular,  blanching  rash  starts  on  face  and  spreads  to  trunk  &  extremiMes  

•  Koplik  spots  on  buccal  mucosa  •  IncubaMon  period  8-­‐12  days  

Treatment:  •  Highly  contagious  4  days  

before  and  aZer  rash    •  SupporMve  care:  control  

fever;  increase  fluids  

Varicella    

Chicken  Pox  •  Fever,  sore  throat,  malaise  

X  2  D  >>>  rash  starts  on  face  or  trunk  and  spreads  downward    

•  Rash  progresses  from  red  macules  >>  papules  >>  vesicles  >>  umbilicated  pustules  >>>  crusMng  

•  Less  common  since  varicella  vaccine  

•  IncubaMon  7-­‐21  days  

Treatment  •  SymptomaMc:  Cool  compresses,  

oatmeal  baths;  RX.  diphenhydramine,  hydroxyzine,  fexofenadrine,  loratadine  

•  Watch  for  secondary  impeMgo  due  to  scratching  

Verruca  

Warts  •  Caused  by  HPV  -­‐  >  150  

subtypes  •  Lesions  raised,  pink,  rough  

growths  

Treatment  •  No  rouMnely  effecMve  treatment  

–  may  spontaneously  resolve  –  Cryotherapy  q  wk  X3  –  Podofilox  (Condylox)  topical  

0.5%  soln  bid  for  3  consecuMve  days/wk  up  to  4  weeks  

–  Aldara  topical  thin  layer  3  X  per  week  –  alternaMng  days  

–  Laser  ablaMon  

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Molluscum  Contagiosum    

Molluscum  •  Caused  by  pox  virus  –  more  

common  in  pedi;  considered  contagious  

•  Clusters  of  3-­‐5  mm  flesh  colored  papules  with  umbilicated  center;  usually  <  30  lesions    

•  Resolve  spontaneously  over  months  to  yrs  

Treatment  •  May  treat  to  prevent  spread  to  

others:  –  Cryotherapy  –  Laser  ablaMon  

 

Herpes  Simplex  Virus  

Fever  blister;  genital  herpes   Treatment:  •  Either  Type  I  or  II  •  Clear  papules  with  superficial  

ulceraMons/erosions  •  OZen  preceded  by  burning  pain  

•  Acyclovir  topical  q  3  h  X  7  D  •  >  2  yrs  –  acyclovir  susp  

20mg/kg  qid  X  5  D  •  Genital  herpes  –  child  abuse  •  Contagious    

GuUate  Psoriasis  

Characteris4cs:   Treatment:  •  Inflammatory  changes  occur  

within  the  epidermis  &  dermis;  increased  turnover  rate  of  dermal  cells  

•  Numerous  salmon-­‐pink,  scaling,  small  plaques  on  trunk  and  extremiMes  (usually  2-­‐4  weeks  aZer  strep  pharyngiMs  or  URI)  

•  Rash  usually  resolves  on  own  (weeks  to  months)  

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Adolescent  Acne  

Characteris4cs:   Treatment:  •  ObstrucMon  of  oil  glands  •  Open  comedones  or  closed  

comedones;  pustules,  nodules,  cysts  

•  Avoid  oil  based  cosmeMcs  •  Mild:  topical  clindamycin  and  

erythromycin  in  AM  &  benzoyl  peroxide  2.5-­‐5%  @  hs  or  topical  reMnoids  (Differin,  ReMn-­‐A)  .025-­‐.05%  @  hs  

•  Moderate:  above  regimen  +  minocycline  or  doxycycline  50-­‐100  mg  bid,  tapering  to  50  mg/d  as  acne  improves;  OCP  (progesMn  &  estrogen)  

•  Severe:  Accutane  –  refer  to  dermatologist  (labs  &  pregnancy  test,  contracepMon,  informed  consent)  

Tinea  CapiMs/Tinea  Corporis  

Characteris4cs:   Treatment:  •  Well  defined  circular  patches  with  

scaly  borders  •  Occurs  aZer  contact  with  person/

animal  that  has  fungus  

•  Topical  anMfungals  –  Terbinafine  (lamisil),  

Miconazole,  ketoconazole,  not  nystaMn  (for  candida)  

•  Use  oral  anMfungals  if  creams  fail  

Tinea  Pedis    

Athlete’s  Foot   Treatment:  •  Lesions  are  pruriMc  and  

scaly  with  raised  border;  may  become  fissured  

•  KOH  examinaMon  of  scales  –  clusters  of  hyphae  

•  Keep  feet  dry  •  Contagious  •  Extensive  –  oral  terbinafine,  itraconazole  •  AnMfungal  cream/powders  (1-­‐4  wks)  

–  OTC  -­‐Miconazole,  clotrimazole    

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Keratosis  Pilaris  

Characteris4cs:  •  Excess  keraMn  forms  plugs  in  the  

hair  follicles  •  Symmetric  sandpaper  like  

follicular  papules  •  Considered  a  normal  skin  variant  

Treatment  •  Emollients  and  mild  

exfoliaMon  

ParasiMc  -­‐  Pediculosis  

Lice   Treatment:  •  Nit  (egg)  adheres  to  hair  >>>  

develops  into  louse  in  3-­‐4  D  >>>  able  to  reproduce  in  12  D  >>>  single  ferMlizaMon  needed  to  lay  10  eggs/day  for  30  day  life  span  

•  Louse  pierce  the  skin  and  secrete  saliva  which  causes  intense  itching  

•  Spread  by  shared  hats,  clothing,  towels,  combs,  etc.  

•  OTC    pyrethrin  (RID)  and  permethrin  (Nix)  –  usually  2  txments  7-­‐10  days  apart;  RX  malathion  loMon;  benzyl  alcohol;  ivermecMn    

•  Fine  tooth  comb  •  Wash  clothing/bedding  in  very  

hot  water;  place  nonwashable  items  in  a  sealed  plasMc  bag  for  2  weeks  

ParasiMc  -­‐  Scabies  

Scabies   Treatment  

•  Papular  linear  rash  primarily  on  hands,  feet,  &  body  folds;  pruritus;  spreading  rash  

•  Female  mites  burrow  under  skin  and  lay  eggs  

•  Can  survive  off  human  host  up  to  4  days  

•  Skin  scrapings  –  microscope  

•  Wash  clothing/bedding  in  very  hot  water    

•  5%  Permethrin  (Elimite)    cream  applied  from  neck  to  feet  –  wash  off  aZer  8-­‐14  hrs;  may  retreat  aZer  10  days  

•  AnMhistamine  for  pruritus  

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Henoch-­‐Schonlein  Purpura  

Characteris4cs:  •  IgA  vasculiMs,  oZen  occurs  

post  viral  •  2-­‐10  years  of  age  •  Palpable  purpura  over  the  

buUocks  and  legs  •  Transient  migratory  arthriMs  •  Renal  disease  and  

abdominal  pain  

Treatment:  •  SupporMve  care:  Adequate  

hydraMon,  rest,  symptomaMc  relief  of  pain  

•  HospitalizaMon  in  presence  of  renal  insufficiency  or  worsening  symptoms  

Kawasaki  Syndrome  

Characteris4cs:  •  Systemic  inflammaMon  •  Peak  incidence  19-­‐24  months  •  Clinical  findings:  

–  Fever  at  least  5  days  –  ConjuncMviMs  –  Polymorphous  rash  –  Strawberry  tongue;  cracked  red  

lips  –  Cervical  adenopathy  –  Edema  hands  and  feet  

•  Increased  risk  coronary  thrombosis  

Treatment:  •  HospitalizaMon  for  treatment  and  

close  monitoring;  high  risk  for  cardiac  complicaMons  

A  few  closing  thoughts…  •  Dermatology  has  its  own  

language  –  learn  to  speak  it  

•  Obtaining  a  thorough  history,  along  with  the  physical  exam,  will  help  idenMfy  the  rash/lesion  

•  Have  a  pictorial  dermatology  reference  available  

•  Refer  to  a  dermatologist  as  needed  

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