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Pediatric DermatologyPediatric Dermatology
Dr. Jerald E. Hurdle
Kennebec Medical Consultants
Dr. Jerald E. Hurdle
Kennebec Medical Consultants
Learning ObjectivesLearning Objectives
To review common congenital & acquired skin lesions,
To recognize rashes that present in childhood, and
To manage the kids and their parents.
Vascular LesionsVascular Lesions
Commonly seen in pediatric population
Need to distinguish hemangioma from vascular malformation
Commonly seen in pediatric population
Need to distinguish hemangioma from vascular malformation
HemangiomaHemangioma
Normally not present at birth
Grows rapidly in first few months
Then involute
Rx: nothing, steroids, laser & surgery
Normally not present at birth
Grows rapidly in first few months
Then involute
Rx: nothing, steroids, laser & surgery
HemangiomaHemangioma
Gradual Involution Gradual Involution
Vascular MalformationVascular Malformation
Present at birth
Abnormal size & number of vascular structures
Salmon patch or stork bite
Present at birth
Abnormal size & number of vascular structures
Salmon patch or stork bite
Vascular MalformationVascular Malformation
Port Wine Stains
Much less common
Hypertrophy with time
If V1/V2 rule out Sturge Weber Syndrome
Rx: laser
Port Wine Stains
Much less common
Hypertrophy with time
If V1/V2 rule out Sturge Weber Syndrome
Rx: laser
Pigmented LesionsPigmented Lesions
Congenital vs. Acquired
Congenital nevomelanocytic nevus (syn. congenital hairy nevus)
Small, medium or large
50% hairy
Have verrucous surface
Small: No increased risk of melanoma
Congenital vs. Acquired
Congenital nevomelanocytic nevus (syn. congenital hairy nevus)
Small, medium or large
50% hairy
Have verrucous surface
Small: No increased risk of melanoma
Giant Congenital NeviGiant Congenital Nevi
>5% BSA in infants
8.5% MM risk in 1st 15 years
Rx: surgical excision, tissue expanders, flaps & grafts
>5% BSA in infants
8.5% MM risk in 1st 15 years
Rx: surgical excision, tissue expanders, flaps & grafts
Case 1Case 1
9/12 old baby 3/7 of fever Febrile fit Fever defervesces with
this rash
Diagnosis?
9/12 old baby 3/7 of fever Febrile fit Fever defervesces with
this rash
Diagnosis?
Case 1: RoseolaCase 1: Roseola
HHV6
2/3 of patients get erythematous papules mucosa of soft palate (Nagayama spots)
HHV6
2/3 of patients get erythematous papules mucosa of soft palate (Nagayama spots)
Case 2Case 2
3 yr old girl
Slightly irritable for a few days
Presents with this rash!
Diagnosis?
3 yr old girl
Slightly irritable for a few days
Presents with this rash!
Diagnosis?
Case 2: Fifth Disease or Erythema Infectiosum
Case 2: Fifth Disease or Erythema Infectiosum
Classical Slapped cheeks appearance
Caused by Parvovirus B19
Aplastic Anemia
Arthritis
Hydrops Fetalis
Classical Slapped cheeks appearance
Caused by Parvovirus B19
Aplastic Anemia
Arthritis
Hydrops Fetalis
Case 2: Fifth Disease or Erythema Infectiosum
Case 2: Fifth Disease or Erythema Infectiosum
Classical Slapped cheeks appearance
Caused by Parvovirus B19
Aplastic Anemia
Arthritis
Hydrops Fetalis
Classical Slapped cheeks appearance
Caused by Parvovirus B19
Aplastic Anemia
Arthritis
Hydrops Fetalis
Case 3:Case 3:
10 year old boy
Sore throat , myalgia for 3 days before presentation with this rash
Rash feels like sandpaper
10 year old boy
Sore throat , myalgia for 3 days before presentation with this rash
Rash feels like sandpaper
Case 3:Case 3:
10 year old boy
Sore throat , myalgia for 3 days before presentation with this rash
Rash feels like sandpaper
10 year old boy
Sore throat , myalgia for 3 days before presentation with this rash
Rash feels like sandpaper
Case 3: Scarlet FeverCase 3: Scarlet Fever
Group A Strep
Erythrogenic toxin
Culture potential bacterial reservoirs (throat commonest)
Rx: penicillin
Watch out for post-streptococcal glomerulonephritis
Group A Strep
Erythrogenic toxin
Culture potential bacterial reservoirs (throat commonest)
Rx: penicillin
Watch out for post-streptococcal glomerulonephritis
Case 4Case 4
7 yr old girl
Ring like lesions on the back of her hands for 3 months
PCP tried antifungals
Diagnosis?
7 yr old girl
Ring like lesions on the back of her hands for 3 months
PCP tried antifungals
Diagnosis?
Case 4Case 4
Case 4: Granuloma Annulare (GA)Case 4: Granuloma Annulare (GA)
Localized GA
Self limiting
Tends to spontaneously resolve
Can try potent topical steroids
Link with DM (controversial)
Localized GA
Self limiting
Tends to spontaneously resolve
Can try potent topical steroids
Link with DM (controversial)
Case 5Case 5
2 yr old boy presents with 2/7 of this non- itchy rash
Affects his hands & feet
Had diarrhea 1/52 ago
2 yr old boy presents with 2/7 of this non- itchy rash
Affects his hands & feet
Had diarrhea 1/52 ago
Case 5: Gianotti-Crosti SyndromeCase 5: Gianotti-Crosti Syndrome
Originally described in conjunction with Hep B in 1955
Other associations: EBV, RSV, Coxsackie, echo, Parainfluenzae, CMV etc etc.
Originally described in conjunction with Hep B in 1955
Other associations: EBV, RSV, Coxsackie, echo, Parainfluenzae, CMV etc etc.
Case 6Case 6
4/12 baby girl Febrile & irritable for
2/7 Developed rash on
face yesterday Now red all over Father noticed some
blistering
4/12 baby girl Febrile & irritable for
2/7 Developed rash on
face yesterday Now red all over Father noticed some
blistering
Case 6: Staphylococcal scalded skin syndrome (SSSS)
Case 6: Staphylococcal scalded skin syndrome (SSSS)
Occurs in kids <6 yrs
Staph producing exotoxin disrupts barrier at granular layer
Rx: admit patients with generalized disease for IVABs & minimize trauma to skin with emollients
Occurs in kids <6 yrs
Staph producing exotoxin disrupts barrier at granular layer
Rx: admit patients with generalized disease for IVABs & minimize trauma to skin with emollients
Atopic Dermatitis: CausesAtopic Dermatitis: Causes
Genetics (filaggrin gene)
Staph acting as super antigen
Extremes of climate
Food as allergen controversial
Aeroallergens & house dust mite
Genetics (filaggrin gene)
Staph acting as super antigen
Extremes of climate
Food as allergen controversial
Aeroallergens & house dust mite
Atopic dermatitisAtopic dermatitis
Itch & scratch
Sleep deprivation for the whole family
Worsening weeping eczema think Staph
Sudden painful eczema think herpes
Itch & scratch
Sleep deprivation for the whole family
Worsening weeping eczema think Staph
Sudden painful eczema think herpes
Atopic DermatitisAtopic Dermatitis
Atopic dermatitisAtopic dermatitis
Atopic dermatitisAtopic dermatitis
Secondarily Infected Eczema with Staph
Atopic dermatitisAtopic dermatitis
Secondarily Infected Eczema with Herpes: Eczema
herpeticum
TreatmentTreatment
Educate parents about what is known about AD
Encourage emollients (point to diaper area to show that moist environment helpful)
500g per week or more
Educate parents about what is known about AD
Encourage emollients (point to diaper area to show that moist environment helpful)
500g per week or more
Treatment: SteroidsTreatment: Steroids
Tackle Steroid phobia head on!
Atrophy rarely seen when appropriate steroid is used for appropriate time
No increased risk of cancer
Use potent steroid to induce quick remission & get family on your side
Tackle Steroid phobia head on!
Atrophy rarely seen when appropriate steroid is used for appropriate time
No increased risk of cancer
Use potent steroid to induce quick remission & get family on your side
Treatment: SteroidsFinger Tip Units (FTU)
Treatment: SteroidsFinger Tip Units (FTU)
Squeeze ointment DIP crease = 1 FTU
Covers 2 hands of skin
2FTUs = 1g
(http://www.patient.co.uk/showdoc/27000762/)
Squeeze ointment DIP crease = 1 FTU
Covers 2 hands of skin
2FTUs = 1g
(http://www.patient.co.uk/showdoc/27000762/)
Treatment: calcineurin inhibitorsTreatment: calcineurin inhibitors
Pimecrolimus cream limited efficacy
Tacrolimus ointment 0.1 & 0.03%
No atrophy
Pimecrolimus cream limited efficacy
Tacrolimus ointment 0.1 & 0.03%
No atrophy
Treatment: AntihistaminesTreatment: Antihistamines
No role for non-sedating
Use benadryl, atarax will make patient more drowsy
No role for non-sedating
Use benadryl, atarax will make patient more drowsy
Treatment: AntibioticsTreatment: Antibiotics
Take cultures, lesion & nares
Culture other members of family if recurrent
Treat for likely Staph
Review patient when cultures are back
Take cultures, lesion & nares
Culture other members of family if recurrent
Treat for likely Staph
Review patient when cultures are back
Treatment: Eczema herpeticumTreatment: Eczema herpeticum
Acyclovir p.o.
Analgesia
May need Staph coverage as well
Acyclovir p.o.
Analgesia
May need Staph coverage as well
Pitryriasis Alba (PA)Pitryriasis Alba (PA)
1/3 of kids in USA may have PA
Occurs in all races
♂ > ♀
More problematic in darker skin
1/3 of kids in USA may have PA
Occurs in all races
♂ > ♀
More problematic in darker skin
Pitryriasis Alba (PA)Pitryriasis Alba (PA)
Associated with Atopic Dermatitis
3 stages Papular erythematous Papular hypochromic Smooth hypochromic
Associated with Atopic Dermatitis
3 stages Papular erythematous Papular hypochromic Smooth hypochromic
Pitryriasis Alba (PA): RxPitryriasis Alba (PA): Rx
Gentle Skin care
1% Hydrocortisone Cream
Sunscreen
Reassurance
Gentle Skin care
1% Hydrocortisone Cream
Sunscreen
Reassurance
Learning ObjectivesLearning Objectives
To review common congenital & acquired skin lesions,
To recognize rashes that present in childhood, and
To manage the kids and their parents.