Alterations of the Integument in Children Chapter 45 Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc

Alterations of the Integument in Alterations of the Integument in Children Children

Chapter 45Chapter 45

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

22Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Acne VulgarisAcne Vulgaris Most common skin diseaseMost common skin disease Affects 85% of people between ages 12 and Affects 85% of people between ages 12 and

2525 Acne conglobataAcne conglobata

Highly inflammatory form of severe acneHighly inflammatory form of severe acne Formation of communication cysts and abscesses Formation of communication cysts and abscesses

beneath the skinbeneath the skin Sebaceous follicles sites for acne lesionsSebaceous follicles sites for acne lesions


Acne VulgarisAcne Vulgaris Noninflammatory acneNoninflammatory acne

BlackheadsBlackheads WhiteheadsWhiteheads

Inflammatory acneInflammatory acne Caused by follicular wall rupture in closed Caused by follicular wall rupture in closed

comedones (whiteheads)comedones (whiteheads) Cystic nodules develop when inflammation is Cystic nodules develop when inflammation is

deeper, may cause scarringdeeper, may cause scarring


Acne VulgarisAcne Vulgaris Physiologic factors Physiologic factors

Follicular hyperkeratinization, excessive sebum Follicular hyperkeratinization, excessive sebum production, colonization of production, colonization of Propionibacterium Propionibacterium acnes,acnes, and inflammation secondary to the action and inflammation secondary to the action of inflammatory products produced by of inflammatory products produced by P. acnesP. acnes

Excessive production of sebum is related to Excessive production of sebum is related to androgenic hormonesandrogenic hormones


Acne Vulgaris: TreatmentAcne Vulgaris: Treatment Diet not proven to cause acneDiet not proven to cause acne

Dietary restrictions are generally not effectiveDietary restrictions are generally not effective Topical treatment: first line of therapy; if this fails Topical treatment: first line of therapy; if this fails

use systemic therapiesuse systemic therapies Acne surgery, including comedo extraction, Acne surgery, including comedo extraction,

intralesional steroids, cryosurgery usefulintralesional steroids, cryosurgery useful Severe scarring treated with dermabrasion or Severe scarring treated with dermabrasion or

subincisionsubincision Special consideration given to treatment for Special consideration given to treatment for

those with darker-colored skin due to greater those with darker-colored skin due to greater risk for hyperpigmentation and keloidal scarring risk for hyperpigmentation and keloidal scarring


Cystic AcneCystic Acne


Atopic DermatitisAtopic Dermatitis Most common form of eczema in childrenMost common form of eczema in children Cause unknown, but 80% demonstrate a Cause unknown, but 80% demonstrate a

personal or family history of asthma or personal or family history of asthma or allergic rhinitisallergic rhinitis

ManifestationsManifestations Increased IgE levels, positive allergen skin tests, Increased IgE levels, positive allergen skin tests,

and eosinophiliaand eosinophilia


Atopic DermatitisAtopic Dermatitis InfantsInfants

Rash appears on the face, scalp, trunk, and Rash appears on the face, scalp, trunk, and extensor surfaces of the arms and legsextensor surfaces of the arms and legs

Children and adultsChildren and adults Rash tends to be on the neck, antecubital and Rash tends to be on the neck, antecubital and

popliteal fossae, hands and feetpopliteal fossae, hands and feet Lichenification (thickening of the epidermis Lichenification (thickening of the epidermis

from constant scratching) from constant scratching) Common in adults with chronic eczemaCommon in adults with chronic eczema


Atopic DermatitisAtopic Dermatitis


Diaper DermatitisDiaper Dermatitis Inflammatory disorders affecting the lower Inflammatory disorders affecting the lower

abdomen, genitalia, buttocks, and upper thighabdomen, genitalia, buttocks, and upper thigh A nonallergic contact dermatitisA nonallergic contact dermatitis

Inflammation encouraged by prolonged exposure Inflammation encouraged by prolonged exposure to irritation by urine and feces, maceration by wet to irritation by urine and feces, maceration by wet diapers, airtight plastic diaper covers, and possible diapers, airtight plastic diaper covers, and possible association with intercurrent illness and early association with intercurrent illness and early introduction of cerealsintroduction of cereals


Diaper DermatitisDiaper Dermatitis


Infections of the SkinInfections of the Skin

Bacterial infectionsBacterial infections Impetigo contagiosumImpetigo contagiosum

• Superficial infection usually caused by Superficial infection usually caused by StaphylococcusStaphylococcus or or group A streptococcigroup A streptococci

• High incidence in hot, humid climatesHigh incidence in hot, humid climates Bullous impetigoBullous impetigo

• Rarer variant of impetigo caused by Rarer variant of impetigo caused by Staphylococcus aureusStaphylococcus aureus• Staphylococci produce a bacterial toxin called Staphylococci produce a bacterial toxin called exfoliative exfoliative

toxin (ET),toxin (ET), which causes a disruption in desmosomal which causes a disruption in desmosomal adhesion molecules with blister formation adhesion molecules with blister formation

• Occurs in newborns and is highly contagiousOccurs in newborns and is highly contagious• Source is usually a staff member in a newborn nursery or a Source is usually a staff member in a newborn nursery or a

family member with a pustule or who is an asymptomatic family member with a pustule or who is an asymptomatic carrier carrier


Infections of the SkinInfections of the Skin Bacterial InfectionsBacterial Infections

Vesicular impetigoVesicular impetigo• Contagious, acute, superficial, vesiculopustular form of Contagious, acute, superficial, vesiculopustular form of

impetigo caused by group A impetigo caused by group A Streptococcus pyogenesStreptococcus pyogenes (alone or in combination with (alone or in combination with Staphylococcus aureusStaphylococcus aureus))

• Microorganisms disseminated by direct physical contact Microorganisms disseminated by direct physical contact from other infected individuals or through insect bites from other infected individuals or through insect bites


ImpetigoImpetigo


Infections of the SkinInfections of the Skin

Bacterial infectionsBacterial infections Staphylococcal scalded-skin syndrome (SSSS)Staphylococcal scalded-skin syndrome (SSSS)

• Serious infection caused by exfoliative toxin producing group II Serious infection caused by exfoliative toxin producing group II staphylococcistaphylococci

• Exfoliative toxin attacks desmoglein and adhesion molecules; Exfoliative toxin attacks desmoglein and adhesion molecules; causes separation of the skin just below the stratum granulosum causes separation of the skin just below the stratum granulosum

• ManifestationsManifestations Fever, malaise, rhinorrhea, and generalized erythema and skin Fever, malaise, rhinorrhea, and generalized erythema and skin

tendernesstenderness Seen in infants and children younger than 5 yearsSeen in infants and children younger than 5 years


Infections of the SkinInfections of the Skin Fungal infectionsFungal infections

Fungi causing superficial skin lesions are called Fungi causing superficial skin lesions are called dermatophytesdermatophytes

Fungal disorders are called mycoses; mycoses Fungal disorders are called mycoses; mycoses caused by dermatophytes are termed caused by dermatophytes are termed tineatinea• Tinea capitis (scalp)Tinea capitis (scalp)

• Tinea pedis (athlete’s foot)Tinea pedis (athlete’s foot)

• Tinea corporis (ringworm)Tinea corporis (ringworm)


Tinea CapitisTinea Capitis


Infections of the SkinInfections of the Skin Fungal infectionsFungal infections

ThrushThrush• CandidaCandida present in mucous membranes of the mouths of present in mucous membranes of the mouths of

infants, and less commonly in adultsinfants, and less commonly in adults

• CharacteristicsCharacteristics White plaques or spots in the mouth that lead to shallow White plaques or spots in the mouth that lead to shallow

ulcersulcers

• Thrush can spread to the groin, buttocks, and other parts Thrush can spread to the groin, buttocks, and other parts of the bodyof the body


Infections of the SkinInfections of the Skin Viral infectionsViral infections

Molluscum contagiosumMolluscum contagiosum• Highly contagious pox viridae infection of the skinHighly contagious pox viridae infection of the skin

• Skin-to-skin and fomite transmissionSkin-to-skin and fomite transmission

• The virus encourages epidermal cell proliferation and The virus encourages epidermal cell proliferation and blocks the immune responseblocks the immune response


Molluscum ContagiosumMolluscum Contagiosum



Rubella (German measles or 3-day measles)Rubella (German measles or 3-day measles)• RNA virusRNA virus• The disease is mild in most childrenThe disease is mild in most children• ManifestationsManifestations

Enlarged cervical and postauricular lymph nodes, low-Enlarged cervical and postauricular lymph nodes, low-grade fever, headache, sore throat, runny nose, coughgrade fever, headache, sore throat, runny nose, cough

Faint pink to red maculopapular rash caused by virus Faint pink to red maculopapular rash caused by virus dissemination to the skindissemination to the skin

• Vaccination for rubella combined with mumps and Vaccination for rubella combined with mumps and rubeola (measles) (MMR)rubeola (measles) (MMR)



RubeolaRubeola• RNA paramyxovirusRNA paramyxovirus

• High fever, malaise, enlarged lymph nodes, runny nose, High fever, malaise, enlarged lymph nodes, runny nose, conjunctivitis, barking coughconjunctivitis, barking cough

• Koplik spotsKoplik spots

RoseolaRoseola• Fever and an erythematous macular rash that lasts Fever and an erythematous macular rash that lasts

about 24 hoursabout 24 hours



Chickenpox (varicella) and herpes zoster Chickenpox (varicella) and herpes zoster (shingles) (shingles) • Both diseases are produced by the same virusBoth diseases are produced by the same virus

• DNA virusDNA virus

• Infection occurs within keratinocytesInfection occurs within keratinocytes


Measles and ChickenpoxMeasles and Chickenpox


Insect Bites and ParasitesInsect Bites and Parasites ScabiesScabies

Contagious disease caused by the itch mite Contagious disease caused by the itch mite Sarcoptes scabieiSarcoptes scabiei

Transmitted by personal contact and infected Transmitted by personal contact and infected clothing and beddingclothing and bedding

Female mite tunnels millimeters to 1 cm into the Female mite tunnels millimeters to 1 cm into the stratum corneum, deposits eggs, and over a 3-stratum corneum, deposits eggs, and over a 3-week period, the eggs mature into adult mitesweek period, the eggs mature into adult mites

Primary lesions are burrows, papules, and Primary lesions are burrows, papules, and vesicular lesions with severe itchingvesicular lesions with severe itching

Patient at risk for infections from scratchingPatient at risk for infections from scratching


ScabiesScabies


Insect Bites and ParasitesInsect Bites and Parasites PediculosisPediculosis

Pediculus capitisPediculus capitis (head), (head), Pediculus corporisPediculus corporis (body), and (body), and Phthirus pubisPhthirus pubis (crab or pubic) (crab or pubic)

Highly contagious parasite that survives by Highly contagious parasite that survives by sucking bloodsucking blood• Acquired through personal contact and shared clothing, Acquired through personal contact and shared clothing,

combs, or brushescombs, or brushes

Female louse reproduces every 2 weeks and Female louse reproduces every 2 weeks and produces hundreds of nitsproduces hundreds of nits


Insect Bites and ParasitesInsect Bites and Parasites Flea bitesFlea bites

Cat, dog, and human fleasCat, dog, and human fleas Occur in clusters along the arms and legsOccur in clusters along the arms and legs Characteristic lesion is an urticarial wheal with a Characteristic lesion is an urticarial wheal with a

central hemorrhagic puncturecentral hemorrhagic puncture


Insect Bites and ParasitesInsect Bites and Parasites Bedbugs Bedbugs (Cimex lectularius)(Cimex lectularius)

Live in the crevices and cracks of floors, walls, and Live in the crevices and cracks of floors, walls, and furniture and in bedding or furniture stuffingfurniture and in bedding or furniture stuffing

3 to 5 mm long and reddish brown3 to 5 mm long and reddish brown Feed in the darknessFeed in the darkness

• Attach to the skin, suck blood, and leaveAttach to the skin, suck blood, and leave

Lesions: red macules; develop into nodulesLesions: red macules; develop into nodules


Flea and Bedbug BitesFlea and Bedbug Bites


HemangiomasHemangiomas

Benign tumors Benign tumors From rapid growth of vascular endothelial cells and From rapid growth of vascular endothelial cells and

formation of extra blood vesselsformation of extra blood vessels Females affected more often than malesFemales affected more often than males Superficial: strawberry hemangiomasSuperficial: strawberry hemangiomas Deep: cavernous hemangiomasDeep: cavernous hemangiomas

Etiology: embolization of fetal placental Etiology: embolization of fetal placental endothelial cellsendothelial cells related to placental trauma or related to placental trauma or loss of placental angiogenic inhibitor of placental loss of placental angiogenic inhibitor of placental and maternal originand maternal origin


HemangiomasHemangiomas Proliferation of mast cells, thought to promote Proliferation of mast cells, thought to promote

angiogenesisangiogenesis Infiltration of fat cells, fibrosis, and rich Infiltration of fat cells, fibrosis, and rich

vascular network; females affected more vascular network; females affected more often than malesoften than males

30% of hemangiomas seen at birth; most 30% of hemangiomas seen at birth; most emerge during first few weeks of lifeemerge during first few weeks of life Grow rapidly during the first few years of life, then Grow rapidly during the first few years of life, then

shrink or involuteshrink or involute


HemangiomasHemangiomas Strawberry hemangiomasStrawberry hemangiomas

Raised vascular lesions that usually emerge 3 to 5 Raised vascular lesions that usually emerge 3 to 5 weeks after birthweeks after birth

Lesions proliferate, become bright red, and Lesions proliferate, become bright red, and elevate with small capillary projectionselevate with small capillary projections

Cavernous hemangiomasCavernous hemangiomas Present at birthPresent at birth Involve larger and more mature vessels than Involve larger and more mature vessels than

strawberry hemangiomasstrawberry hemangiomas


Strawberry and Strawberry and Cavernous HemangiomasCavernous Hemangiomas


Vascular MalformationsVascular Malformations Port-wine stainsPort-wine stains

Congenital malformation of dermal capillariesCongenital malformation of dermal capillaries Flat, pink, to dark reddish-purple lesionsFlat, pink, to dark reddish-purple lesions

Salmon patchesSalmon patches Macular, pink lesions resulting from distended Macular, pink lesions resulting from distended

dermal capillaries; usually fade by 1 year of agedermal capillaries; usually fade by 1 year of age Common on the nape of the neck, forehead, upper Common on the nape of the neck, forehead, upper

eyelids, or nasolabial foldseyelids, or nasolabial folds


MiliariaMiliaria Vesicular eruption after prolonged exposure Vesicular eruption after prolonged exposure

to perspiration, with subsequent obstruction to perspiration, with subsequent obstruction of eccrine ductsof eccrine ducts Miliaria crystallinaMiliaria crystallina

• Ductal rupture within the stratum corneumDuctal rupture within the stratum corneum

• Clear vesicles without erythemaClear vesicles without erythema

Miliaria rubra (prickly heat)Miliaria rubra (prickly heat)• Erythematous papules and papulovesiclesErythematous papules and papulovesicles


Miliaria RubraMiliaria Rubra


Other Skin DisordersOther Skin Disorders Erythema toxicum neonatorum Erythema toxicum neonatorum

Benign, erythematous macules, papules, or Benign, erythematous macules, papules, or pustules; appear at birth or 3 to 4 days later pustules; appear at birth or 3 to 4 days later

No treatment is requiredNo treatment is required Toxic epidermal necrolysis (TEN) and Toxic epidermal necrolysis (TEN) and

Stevens-Johnson syndromeStevens-Johnson syndrome Rare, severe drug reactions with widespread Rare, severe drug reactions with widespread

epidermal apoptosis and detachmentepidermal apoptosis and detachment Mortality rates between 20% and 60% Mortality rates between 20% and 60%

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Alterations of the Integument in Children Chapter 45 Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc