common skin disorders in children

8/14/2019 Common Skin Disorders in Children

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COMMON SKINCOMMON SKIN

CONDITIONSCONDITIONS

IN CHILDRENIN CHILDREN

By

Dr.Ahmed Noureldin AhmedMBBS,DCH,DTM&H (Cairo)



Introduction

• The conditions to be described are everydayoccurrences in paediatric primary care. Yet, asapplies to so many commonly seen conditions,there are many controversies and unansweredquestions regarding aetiology and treatment.



Question 1

• This infant is 24hours old. There arered patches on thetrunk. What is therash likely to be?



• Erythema toxicum neonatorum (neonatalurticaria)

– Despite its impressive title this is a harmlessskin condition seen in most neonates at and soonafter birth. The commonest lesion is anerythematous macule with a central tiny papule,occurring anywhere on the body except the

palms and soles.

Answer 1

Continued...



Answer 1 (Contd…)

Sometimes there may small pustules at thecentre of lesions and the danger then is thatthey are regarded as signs of sepsis, which isnot the case. The lesions are packed witheosinophils, and there may be accompanyingeosinophilia in the blood count. The cause isunknown, and no treatment is required as the

rash disappears after 1-2 weeks.



Question 2

• What lesions do yousee on this infant'sface?



Answer 2

• Milia are tiny cysts of the sebaceous glands.They are seen in about half of all neonates in theearly weeks of life, as firm pearly white papulesabout 1-2 mm in size, in areas like the nose andforehead where sebaceous glands are abundant.They disappear at about 4 weeks. No treatmentis required apart from avoiding greasy

preparations.

Continued...



Answer 2 (Contd…)

• Lesions just like adolescent acne may also beseen in the first month or two of life. Papulesand pustules are seen mainly on the cheeks,presumably due to stimulation of the sebaceousglands by maternal androgen. Again, treatmentis unnecessary as the condition is almost alwaysself-limiting.



Question 3

• What is miliaria?



Answer 3

• Sweat rash, ormiliaria, results fromobstruction to thesweat gland openingswith retention ofsweat. It is seen intwo forms:

Continued...



Answer 3 (Contd…)

• In Miliaria crystallina there are numerous tinyclear vesicles, usually on the forehead. It isprobably caused, or aggravated by plugging ofthe pores with vaseline or other greasyointments.

Continued...



Answer 3 (Contd…)

• In Miliary rubra there is obstruction of thesweat ducts at a deeper level in the skin. Manyred macules with central papules, vesicles orpustules are present. These may be on thetrunk, nappy area, head or neck. The rash iscaused by heat and overdressing. Plastic pants,the overuse of vaseline and the under-use of

bathing probably play a part.



Question 4

• Describe theproblem here.



Answer 4

• Sepsis. The umbilical stump is an excellentculture medium. Any infant with a smelly stump,purulent discharge, redness, or swelling aroundthe cord should be evaluated for sepsis, and anantibiotic is indicated. The local infection canspread rapidly to any organ, including the brain,and there is the danger of portal vein

thrombosis. Remember the possibility ofneonatal tetanus also.



Question 5

• What is the cause ofthe lesion in theumbilical stump?



Answer 5

• Granuloma. When the cord drops off, a smallpink or red polyp-like lesion may form in thebase of the cord. The cause is unknown - it mayresult from a foreign body reaction to talcumpowder. It is easily dealt with by cauterising itwith silver nitrate.



Question 6

• What is the cause of a watery discharge fromthe umbilicus?



Answer 6

• Persistent discharge, if watery, may signify apatent urachus (connection with the bladder),and referral is essential.

• Types of umbilicus. There are 3 types,depending on how the skin of the abdominal wallmeets the umbilicus:

– (1) flat - the skin meets the cord at the level ofthe wall

Continued...



Answer 6 (Contd…)

– (2) indented - the abdominal skin does notreach the base of the cord, and the gap is filledin by amniotic sac. This results in an

indentation– (3) the abdominal skin extends up the cord,

resulting in a protruding umbilicus. This lasttype does not result in a hernia as there is no

defect in the abdominal wall



Question 7

• What causes an umbilical hernia?



Answer 7

• An umbilical hernia results from incomplete closureof the umbilical ring, and often a defect in theabdominal musculature. Most close spontaneously

by the age of 12 months, and even moderate andbig ones will eventually disappear by puberty. Notreatment is required as strangulation is extremelyrare. The exception is in adult female, where

there is a risk of incarceration or strangulationduring pregnancy. A persisting hernia shouldtherefore be repaired in girls during puberty.



Answer 8 (Contd…)

The rash has erythematous and a scalycomponents; scaling is particularly prominent onthe scalp, producing thick greasy crusts ('cradlecap'), the sides of the nose, glabella and ears.Red scaly patches of quite startling appearancemay be present on the trunk. The flexures ofthe neck, axillae and groins may become

reddened and weepy, and are then prone tosecondary yeast or bacterial infection. The rashcauses no discomfort or itching



Answer 9• Nappy rash or napkin dermatitis, is not a single entity

and refers to a number of different conditions whichmay affect the area covered by the napkin:

– non-specific (generic)

– minilial– nodulo-ulcerative

– seborrhoetic dermatitis

– impetigo

– folliculitis– intertrigo

Continued...



Answer 9 (Contd…)

• Some of them will be explained with an image.

Continued...



Answer 9 (Contd…)

• Non-specific - there is erythema and laterdryness and wrinkling of the exposed parts ofthe nappy area - the buttocks or thighs.Because of the depths of the folds these areusually spared. This type of rash was longattributed to production of ammonia by ureasplitting organisms ('ammoniacal dermatitis'),

but this theory has been disproved

Continued...



Answer 9 (Contd…)• Candidal - This form starts off in

the deep flexures which showdiffuse inflammation. There arealso rounded red spreading lesionswith a typical scale round the

edges. It is uncommon for therash to spread beyond themargins of the nappy as moistureand warmth are required by the

yeasts for growth. Howeverpersistent more widespreadcandidal rashes are nowincreasingly being seen in HIVinfected infants.

Continued...



Answer 9 (Contd…)

• Nodulo-ulcerative -Largish nodules withcentral erosions butno pus formation.Usually on the labia,penis, scrotum oranterior thighs.

Continued...



Answer 9 (Contd…)• Infantile seborrheic dermatitis. Here

the nappy rash is part of the picturedescribed earlier. A beefy red sharplymarginated rash without pustules orerosions appears rapidly. The rash

spreads by peripheral extension ofsatellite lesions. The skin is unbroken.The infant is virtually asymptomaticand the parents are disturbed morethan the child. There is alsoinvolvement of flexures elsewhere andusually scalp crusting is present.

Continued...



Answer 9 (Contd…)

• Impetigo - there are many superficial bullae,most of which rupture quickly

• Folliculitis - tiny inflamed follicles andsuperficial pustules - also generallystaphylococcal

• Intertrigo - involvement predominantly of the

groin flexures. Causative organism(s) uncertain.

Continued...



Answer 9 (Contd…)

• Less commonly the nappy rash may be due toatopic or contact dermatitis, with sensitivity toelastic, fabric softener, or soap powder

• It may be the first manifestation of psoriasis



Question 10

• What are the causes of nappy rash?



Answer 10NAPKIN DERMATITIS

AETIOLOGY

• Maceration

• Friction

• Irritation

• Ammonia formation (??)

• Candidiasis

• Bacterial overgrowth

• Zinc deficiency

• Cloth vs. disposable

Continued...



Answer 10 (Contd…)

• Maceration of the skin, friction, heat anddiarrhoea play a major part in the cause ofnapkin dermatitis

• Candida albicans. The role of yeasts iscontroversial. C.albicans can frequently berecovered from infants with a variety of nappyrashes and the role of candida is probably vastlyoverplayed

Continued...




• Bacterial overgrowth. The napkin area is amarvellous culture medium and the normaldensity of aerobic bacteria in cases of napkindermatitis increases three or four fold.However it is well known that bacteria willproliferate on inflamed skin and the role ofbacteria is still not well established

Continued...




• Cloth vs. disposable napkins. Undoubtedly ahigher incidence of rashes is seen in those usinghome laundered (or unlaundered!) cloth napkins.On the other hand, the use of disposable napkinsin association with lack of personal hygiene is noguarantee to an unblemished nappy area.Recently biotechnology has produced disposable

napkins which are far less liable to retainmoisture

Continued...




• Zinc deficiency. Premature infants fedintravenously on zinc deficient formulae maydevelop severe erythematous nappy rashes, withsimilar lesions in skin folds elsewhere and aroundthe mouth. Zinc deficiency may also play a partin the severe rashes seen in kwashiorkor.Persistent rashes are also due to zinc deficiency

in the rare condition of acrodermatitisenteropathica



Question 11

• What serious conditions may present with napkindermatitis?



Answer 11

• Children with protein-energy malnutrition oftenhave severe rashes.

• Persistent nappy rashes are a feature inHIV/AIDS.

• Two rare causes are:

– Langhans cell histiocytosis

– and acrodermatitis enteropathica

Continued...




• This child withLanghans cellhistiocytosis

presented first with asevere and resistantnapkin dermatitis



Question 12

• What is the Treatment?



Answer 12

• Most first episodes can be managed easily bythe following:

– Increased frequency of changing and thoroughcleansing between nappy changes. Warm tapwater and a mild neutral soap should be used(Johnson's Baby Soap). The skin should thenbe dried and simple protective cream used -

Desitin, zinc oxide ointment, Lassar's Paste orNivea

Continued...




– Impetigo and folliculitis should be treated withan appropriate antibiotic.

– Seborrheic dermatitis. This responds promptlyto 1% hydrocortisone cream together withexposure to sunlight.

– Intertrigo responds promptly to Vioform andhydrocortisone cream.

– Candida: Vioform and hydrocortisone cream isalso extremely effective. Give nystatin creamt.d.s. only if typically candidal

Continued...




• For more severe rashes the importance of goodhygiene and exposure to sunlight should beemphasised. One cream is effective for all

cases - Vioform and hydrocortisone. The formerhas mild antibacterial, and anti-fungal, and thelatter anti-inflammatory properties

• Kwashiorkor and vitamin and trace mineral

deficiencies may well be present in some cases.Neglect frequently manifests with the presenceof severe nappy rash



Question 13

• Describe theselesions.



Answer 13

• Staphylococcal and streptococcal impetigo -impetigo is a superficial infection of the skinmanifested by blisters or pustular lesions which

rapidly become crusted. It is caused bycoagulase positive Staph. aureus, or by certainstrains of Group A beta-haemolytic strep. Bothorganisms are found together in 50% of cases.

Staphylococcal infection is more likely if theintact skin is affected (especially the face), andif bullae are present.



Answer 14

• Streptococcal impetigo. Strep. impetigo tendsto complicate eruptions such as scabies andinsect bites (papular urticaria), to involve the

lower limbs more often, and to produce deeperlesions (ecthyma). If draining glands areenlarged Strep. is more likely

• TREATMENT

– All cases of impetigo should be treated with asystemic antibiotic.

Continued...




Community studies in Cape Town havedemonstrated the universal resistance ofStaph. pyogenes to penicillin. The treatment

of choice in community settings shouldtherefore be erythromycin 25mg/kilo/day 3times a day for 5 days, or cotrimoxazole, 2.5-10ml twice daily for 5 days. Local treatment

is of lesser importance. Use vioform emulsionor povidine-iodine cream, but NEVERantihistamine or antibiotic creams.

Continued...




• Other manifestations of these common skinpathogens are seen in the following slides:

Continued...




• Recurrent folliculitisand boils

Continued...



Question 15

• What conditions could you confuse withimpetigo?



Answer 15

IMPETIGO

DIFFERENTIAL DIAGNOSIS

• Impetigenisation– Scabies

– Pediculosis

– Eczema, etc

• Herpes simplex• Varicella/zoster

Continued...




• Hand foot and mouth disease

• Fungal infection

• Contact dermatitis

Continued...




• Herpes simplex - Thelips and oral mucosaare commonly

primarily affected.Again, there may besecondary infectionof these viral lesions.

Continued...




• Tinea corporis. This fungal lesion is usually asingle plaque with a well demarcated slightlyraised edge. Management will be discussed in

the next programme.



Question 15

• This 6 month old babyhas an itchy rash overthe trunk for 3

weeks. What is thelikely cause?



Answer 15

• SCABIES is a highly itchy eruption caused bysensitisation to sarcoptes scabeii mites, theireggs and excreta. The mites burrow in the

epidermis, and have a prediliction for the chestand abdomen, genitalia and extremities,particularly the wrists and hands. The maturefemale mite is shown in the next slide:




• In hot climates the mitesremain in the superficiallayers, producing only smallpapules, and linear burrows

are not present. Herd orindividual immunity is neverproduced.

• Personal skin contact is thepredominant factor ininfectivity, and theimportance of clothing andbed-linen has beenexaggerated.



Question 16

• What is the treatment?



Answer 16

• Benzyl benzoate is the most commonly used formof treatment in SA. It is not dangerous whentaken systemically. However the ointment

causes burning in full strength (25%) and mustbe diluted to 12.5% in children. There areconcerns about its safety in infancy, and itshould only be used at quarter strength in

infants under 6 months.

Continued...




• Lotions and creams containing 1% gamma-benzenehexachloride (GBHC) have been use for many years,but concerns have recently been expressed about CNS

toxicity, both as a result of oral intake, and fromabsorption through the skin when used excessively.The treatment however is effective and pleasant.

– DO’S with GBHC:

• apply to cool dry skin

• only leave on for 6 hours

Continued...




– DONT’S with GBHC:

• not in children under two

• not in malnourished

• not in sick children

• not on inflamed skin.

• Alternative therapies are crotamiton (Eurax),

sulphur cream, and Tetmosol soap. None ofthese is curative in severe cases.

Continued...




• An extremely effective, safe , and cosmeticallyacceptable treatment for both scabies and headlice is the synthetic pyrethrin Permethrin. This

is not yet available in South Africa.



Question 17

• What do you see inthis child's hair?



Answer 17

• The characteristic eggs of headlice (nits) can beseen as little white specks, glued to the scalphairs. Pediculosis capitis is a common infestation

of the scalp in children. The adult louse feeds onblood by biting into the scalp. Itchy papules resultand these often become infected from scratching,resulting in impetigo of the scalp. Posterior

cervical and occipital nodes are frequentlyenlarged. The eyelids can also be involved. Inadolescents, pubic and axillary hair may beinfested.

Continued...




• These are adultheadlice (pediculushumanis) attached to

the teeth of a comb.



Question 18

• What is the appropriate treatment?



Answer 18

• Malathion 0.4% in alcohol is a cheap, safe andeffective treatment. This kills lice as well as nits, sothat the hair need not be removed.

• Permethrin 1% lotion, is a pleasant and effectivepreparation which also kills the eggs.

• Benzyl benzoate, still widely used, is messy and lesseffective

• Gamma benzene hexachloride 1% - effective butpoisonous when swallowed!

• NB!!! Treat the whole family is the condition is highlycontagious.



Question 19

• Describe what yousee, and what is thelikely cause?



Answer 19

• There are many itchy papules on the back, someof which have become infected from scatching.The condition, papular urticaria, is common in

the hot months. Repeated bites from fleas, orsometimes bed bugs, result in hypersensitivityand marked itching at the site of both fresh andold bites. Haemolytic streptococci are a

frequent secondary invaders.



Question 20

• What treatment would you prescribe?



Answer 20

• A blitz on fleas within the house is essential -spray the bed mattress and the cracks in thefloor with a good insecticide. However, outdoor

sandfleas are often responsible.• Crotamiton cream (Eurax) is helpful - it is both

anti-pruritic and antiseptic (as well as having ananti-scabies action). Apply it three times a day.



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common skin disorders in children

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