PAEDIATRICSKIN DISORDERS

Richie Chacko

Paediatric & Nonatal Nursing

ATOPIC ECZEMA/DERMATITIS

Definition

Atopic Eczema/ dermatitis is a chronic,

relapsing, inflammatory skin condition

characterised by an itchy red rash that

favours the skin creases such as the foldsof the elbows or behind the knees.

ETIOLOGY

• Unknown

• combination of genes and environmentaltriggers

• families with a history of atopic dermatitis,asthma, or hay fever (known as the atopictriad) are more likely to develop AD.

• Immune response.

What’s the difference between eczema and AD?

• Atopic dermatitis is one of the most common

types of eczema. Both AD and other forms of

eczema are conditions that infants, toddlers

and older children can develop. Symptoms

include skin redness and itch. Atopic

dermatitis is considered a chronic condition

and may last into the child’s teenage years and

beyond.

Some of the most common eczema triggers, include:

• Dry skin

• Irritants

• Stress

• Heat and sweating

• Infection

• Allergens

• Abrasive fabrics

• Food allergy

• Inhaled allergens

• Hormonal changes in women

Symptoms• A tendency to dry skin• Acute flare-ups vary in appearance from vesicles• areas of poorly demarcated redness• Repeated scratching often leads to thickening of

chronic lesions.• localised to the flexure of the limbs.• Bacterial infection is suggested by:Crusting,

weeping, pustulation and/orsurrounding cellulitis with erythema of otherwisenormal-looking skin.

• Clustered blisters• Punched-out erosions usually 1-3 mm that are

uniform in appearance• Possible fever, lethargy or distress.

Diagnostic criteria

• Must have an itchy skin condition plus History of itchiness in skin creases such as folds of the elbows, behind the knees, fronts of ankles, or around the neck.

• Estimation of immunoglobulin E (IgE) and specific radioallergosorbant tests (RASTs) only confirm the atopic nature of the individual.

• Swabs for bacteriology test

Management

• Emollients: emollients should be every 4 hours or at least 3-4 times per day. 250 g/week for a child.

• Topical steroids: once or twice daily.

• Bacterial infection: 14-day course should be given. Oral flucloxacillin

• Exudative eczema: Potassium permanganate solution (1 in 10,000) can be used in exudativeeczema, for its antiseptic and astringent effect.

• Diet: hydrolysed formulas for the treatment atopic eczema

• Managing flare-ups: Settle inflammation with topical corticosteroids.

• Other Rx includes:

• Bandaging (eg, use of wet wraps).

• Phototherapy.

• Initiation and monitoring of a systemic immunosuppressant.

Complications

• Infection• Psychosocial impact• Disturbed sleep patterns.• Reduced self-esteem because of chronic visible

disease.• Isolation from other children - eg, when they are

unable to swim.• Adverse effects on a child's behaviour and

development: poor sleep, reduced self-esteem and social isolation.

Prognosis

• Atopic eczema can be expected to clear in 60-70% of children by their early teens, although relapses may occur.

SEBORRHOEIC DERMATITIS

DEFINITION

• Dermatitis means inflammation of the skin, and seborrhoeic means it affects the areas where there are sebaceous glands. These are the glands that make the oil (sebum) for the skin.

ETIOLOGY• The exact cause of seborrhoeic dermatitis is not

known.• It is thought that yeast germs from

the Malassezia species may be involved.• it is not contagious• immune system problems• emotional stress• a lack of cleanliness does not cause seborrhoeic

dermatitis.• Endocrine disease that leads to obesity, such as

diabetes• Some medications

PATHOPHYSIOLOGY

• The germs live in the sebum of human skin

• most people they do no harm.

• some people may react to these yeast germs, making the skin become inflamed.

SYMPTOMS• The areas of the body that tend to be affected are

those where there are the most skin glands which make the oil (sebum).

• Dandruff is scaling of the scalp• Mild patches of flaky skin may also develop on

the face.• a rash also develops.• round or oval patches of red, scaly, greasy skin.• Yellow-brown crusts may form• rash may be itchy and feel slightly raised• inflammation of the outer ear canal and/or of the

eyelids.

INVESTIGATIONS

• In most cases, no investigations are needed and seborrhoeic dermatitis is diagnosed by the typical symptoms and rash.

MANAGEMENT

• An anti-yeast (antifungal) shampoo such as Ketoconazole

• An antifungal cream: clotrimazole,econazole

• A scale softener

• A mild steroid cream and/or steroid scalp lotion: hydrocortisone, betamethasone

• Light treatment (phototherapy) with ultraviolet B is sometimes used in severe cases.

PREVENTION

• antifungal shampoo

• daily washing with soap and water helps to remove the greasy sebum from the body. This helps to keep the number of fungal germs to a minimum.

• antifungal cream 1-2 times a week.

• discuss with your doctor the best preventative treatment for you.

PSORIASIS• Psoriasis is a disease which affects the skin

and joints.• It commonly causes red scaly patches to

appear on the skin.• The scaly patches caused by psoriasis, called

psoriatic plaques, are areas of inflammationand excessive skin production.

• Skin rapidly accumulates at these sites andtakes a silvery-white appearance.

• Plaques frequently occur on the skin of theelbows and knees, but can affect any areaincluding the scalp and genitals.

ETIOLOGY

• The exact cause of psoriasis is not known.

• believed to have a genetic component.

• Several factors are thought to aggravatepsoriasis. These include stress, excessivealcohol consumption, and smoking.

• Certain medicines, including lithium salt andbeta blockers, have been reported to triggeror aggravate the disease.

There are two main hypotheses about the process that occurs in the development of the disease.

• The first considers psoriasis as primarily a disorder of excessive growth and reproduction of skin cells.

• The second hypothesis sees the disease that being an immune-mediated disorder in which the excessive reproduction of skin cells takes place.

Types of Psoriasis

• Plaque psoriasis: It affects 80 to 90% of people with psoriasis. Plaque psoriasis typically appears as raised areas of inflamed skin covered with silvery white scaly skin. These areas are called plaques.

• Flexural psoriasis: It occurs in skin folds, particularly around the genitals (between the thigh and groin), the armpits, under an overweight stomach (pannus), and under the breasts (inframammary fold). It is aggravated by friction and sweat, and is vulnerable to fungal infections.

• Guttate psoriasis is characterized by numerous small oval (teardrop-shaped) spots. These numerous spots of psoriasis appear over large areas of the body, such as the trunk, limbs, and scalp. Guttate psoriasis is associated with streptococcal throat infection

• Pustular psoriasis appears as raised bumps that are filled with non-infectious pus (pustules). The skin under and surrounding pustules is red and tender. Pustular psoriasis can be localised, commonly to the hands and feet , or generalised with widespread patches occurring randomly on any part of the body.

• Nail psoriasis produces a variety of changes in the appearance of finger and toe nails. These changes include discolouring under the nail plate, pitting of the nails, lines going across the nails, thickening of the skin under the nail, and the loosening and crumbling of the nail.

• Erythrodermic psoriasis involves the widespread inflammation and exfoliation of the skin over most of the body surface.

• Scalp psoriasis (thick scales found on areas of the scalp)

SYMPTOMS

• raised red patches of skin that can have silveryscales on them.

• dry, cracked skin that may bleed at times.

• itching, soreness, or a burning sensation in theaffected area.

• thick, pitted fingernails.

DIAGNOSIS

• A diagnosis of psoriasis is usually based on theappearance of the skin. There are no specialblood tests or diagnostic procedures forpsoriasis. Sometimes a skin biopsy, orscraping, may be needed to rule out otherdisorders and to confirm the diagnosis.

• Another sign of psoriasis is that when theplaques are scraped, one can see pinpointbleeding from the skin below (Auspitz's sign).

MANAGEMENT

• Topical therapy: Vitamin D analogues such as Calcipotriol , Topical corticosteroids

• Coal Tar

- Prefered for limited or scalp psoriasis

- Can be effective in widespread psoriasis

- Antimitotic, anti-pruritic

- No quick onset but longer remission

- Often combined with SA, UV light therapy

- 2 types: Crude coal tar and Liquor picis carbonis

• Phototherapy: Narrowband UV phototherapy

• Methotrexate

• Immunomodulators:

- Cyclosporin, methotrexate commonly used

• Antibiotics in case of secondary bacterial infections

MILIA

• Milia are benign, keratinous cysts thatcommonly manifest as tiny white bumps onthe face of the newborn (see the imagebelow). When present on the gum margin andmidline palate they are referred to as Bohnnodules and Epstein pearls, respectively.

• primary milia is congenital milia in newborns.

• Secondary milia may be associated with an underlying skin disease, medications, or trauma.

ETIOLOGY

• Milia occur when dead skin becomes trapped in tiny pockets near the surface of your baby's skin. When the surface of the bump wears away, the dead skin is sloughed off and the bump disappears

• triggered by hormones from the mother.

RISK FACTORS

• Milia are so common in newborn babies (occurring in up to 50% of them) that they are considered normal.

• Secondary milia may appear in affected skin of people with the following:

1. Blistering injury (trauma) to skin, such as poison ivy

2. Burns

3. Blistering skin disorders, such as epidermolysisbullosa or porphyria

4. Following long-term use of topical steroids

TYPES OF MILIA• Neonatal Milia (develops in newborns)

• Juvenile Milia (genetic disorders)

• Primary Milia in Children (keratin trapped beneath the skin surface)

• Milia en Plaque (autoimmune skin disorders)

• Multiple Eruptive Milia(itchy areas on the face, upper arms, and torso)

• Traumatic Milia(occur where injury to the skin has occurred)

• Milia Associated with Drugs(steroid creams can lead to milia)

SIGNS AND SYMPTOMS

The most common locations for primary milia include:• Around the eye (periorbital area) in children and

adults• Around the nose, especially in infantsThe most common locations for secondary milia

include:• Anywhere on the body, where another skin condition

exists• On the faces of people who have had a lot of damage

from sun exposure• A single lesion (milium) appears as a small (1–2 mm),

white-to-yellow, dome-shaped bump on the outersurface of the skin.

DIAGNOSIS

• Physical examination of skin and candetermine if you have the conditionbased on the appearance of thecysts.

MANAGEMENT• deroofing, or using a sterile needle to pick out

the contents of the cyst

• medications, such as topical retinoids

• laser ablation

• diathermy, which involves using extreme heat to destroy the cysts

• destruction curettage, which involves surgical scraping and cauterization to destroy the cysts

• cryotherapy, which involves freezing and is the most frequently used method to destroy the cysts

PROGNOSIS

• Milia are benign cysts with a tendencyfor spontaneous resolution withoutscarring.

• Patient Education: Educate the familyabout the benign course of milia andtendency towards spontaneousresolution without scarring.

ERYTHEMA TOXICUM

• Erythema toxicum neonatorum (also knownas erythema toxicum, urticarianeonatorum and toxic erythema of thenewborn) is a common rash in neonates. Itappears in up to half of newborns carried toterm, usually between day 2–5 after birth; itdoes not occur outside the neonatal period.

ETIOLOGY

• Idiopathic

• activation of the immune system.

• hypersensitivity to detergents in bedsheetsand clothing is sometimes suspected.

• It is thought to be a benign condition thatcauses no discomfort to the infant. The rashwill generally disappear spontaneously inabout 2 weeks.

• The etiology remains uncertain; however,more recent hypotheses explaining theappearance of this eruption include thefollowing:

1. Self-limited, acute, cutaneous reactioncaused by maternal lymphocytes in therelatively immuno suppressed neonate.

2. An innate immunologic response to stopmicrobes within hair follicle.

3. An inflammatory response.

INCIDENCE/RISK FACTORS

• Erythema toxicum may appear in 50 percent or more of all normal newborn infants.

• The condition may be present in the first few hours of life, generally appears after the first day, and may last for several days. Although the condition is harmless, it can be of great concern to the new parent.

SYMPTOMS

• few or several rash of small, yellow-to-white-coloured papules surrounded by red skin.

• appear on the face and middle of the body, also be seen on the upper arms and thighs.

• The rash can change rapidly, appearing and disappearing in different areas over hours to days.

DIAGNOSIS

• Physical Examination is usuallysufficient to make the diagnosis. Notesting is usually needed.

MANAGEMENT

• The large red rashes typicallydisappear without any treatment orchanges in skin care.

PATIENT EDUCATION

• Parents with older children often are notconcerned by the appearance of erythematoxicum neonatorum, but first-time parentsshould be informed in the perinatal periodthat an rash is likely to appear within the first2 weeks of life. They should be reassuredregarding the benign, self-limited,asymptomatic nature of this and othereruptions.