1. By Dr Inas Alassar

2. Skin over viewTypes of skin lesions Hypersensitivity reactions and the skinEczema over viewApproach to a Skin RashAtopic dermatitisMCQ Questions 3. A 2-month-old infant is brought to your office byhis mother. He developed an erythematous , dry skin rash on bothcheeks approximately 1 week ago. Although the rash is always present, themother states that it seems to be worse after she feeds him.The mother breast-fed for the first 4 weeks of life, but she returned towork 4 weeks ago and switched the baby from breast-feeding to bottle-feeding.The mother has a history of asthma, and the father has seasonalallergies.On examination, the child appears healthy. He has an erythematousmaculopapular eruption that covers his cheeks, and he appears to bedeveloping an erythematous rash on his neck, both wrists, and bothhands The rest of the physical examination is within normal limits. 4. 1. What is the most likely cause of this infants skinrash?2. What is (are) the recommended initial treatment(s) ofthe skin rash in the infant presented? 5. Overview of the SkinThe skin is the body's largest organ.It serves many important functions, includingRegulating body temperature,Maintaining water and electrolyte balance,Sensing painful and pleasant stimuli.The skin keeps vital chemicals and nutrients in thebody while providing a barrier against dangeroussubstances from entering the body and provides a shieldfrom the harmful effects of ultraviolet radiation emittedby the sun. In addition, skin color, texture, and folds help markpeople as individuals. Anything that interferes with skin function or causeschanges in appearance can have important consequencesfor physical and mental health. 6. Skin Structure 7. Types of skin lesions 8. Types of skin lesions 9. Types of skin lesions 10. Types of skin lesions 11. EczemaEczema is an inflammatory condition of the skin characterisedby groups of vesicular lesions with a variable degree of exudateand scaling. In some cases dryness and scaling predominate,with little inflammation.In more acute cases there may be considerable inflammation and vesicleformation, in keeping with the Greek for to boil out, from which the wordeczema is derived. Sometimes the main feature may be blisters thatbecome very large.Eczema commonly itches and the clinical appearance maybe modified by scratching, which with time may producelichenification (thickening of the skin with increased skinmarkings). Also as a result of scratching the skin surfacemay bebroken and have excoriations, exudate, and secondaryinfection 12. Pathology of EczemaThe characteristic change is oedema between thecells of the epidermis, known as spongiosus, leadingto formation of vesicles.The whole epidermis becomes thickened with anincreased keratin layer.A variable degree of vasodilatation in the dermisand an inflammatory infiltrate may be present. 13. Types of EczemaIn acute eczema epidermal oedema(spongiosis) , with separation of keratinocytesleads to the formation of epidermal vesicles ,dermal vessels are dilated and inflammatorycells invade the epidermis and dermisIn chronic eczema there s thickening ofthe prickle cell layer ( acanthosis)And stratum corneum ( heyperkeratosis)with retention of nucleiby some corneocytes ( parakeratosis )The rete ridges are lengthened ,dermal vessels dilated and inflammatorymononuclear infiltrate in the skin 14. Eczema 15. Types of Eczema 16. Types of Eczema 17. Approach TO A Skin Rash 18. History 19. History of presenting illnessWhen was the problem first noticed? How have things changed since? Has it been a continuous orintermittent problem? Where did it start? Has it spreadis it still spreading? If spreading, is it spreading from the edge or appearing in crops? What is the distribution of the problem? Is there any discharge, bleeding, or scale? Is there pain, itch, or altered sensation? Has it started to resolve? Are there any obvious factors that either trigger or relieve theproblem? Ask especially about the following: UV light (sunlight) Foods Temperature Contact with any other substances What has it been treated withwas the treatment effective? Are there any systemic symptoms such as fever, headache, fatigue,anorexia, weight loss, or sore throat? 20. History 21. History 22. History 23. HistoryWhich drugs is the patient takingand for how long? Did the start of any therapycoincide with the start of the skincomplaint? (Remember, there canbe a delay of months before a rashbecomes apparent.) Remember to ask about topicaland over-the-counter drugs andalternative treatments and herbalproducts. 24. Examination 25. ExaminationGeneral inspection of the skinBegin by scanning the whole surface of the skin for any abnormal lesions.This can be done in any order, but it will help you to build a pattern thatyou can consistently remember that does not miss any areas!Remember to inspect those areas that are usually hidden: Inner thighs Undersurfaces of female breasts External genitalia Axilla Gluteal cleft (between the buttocks)0 Remember also to inspect the mucosal surfaces of the mouth, nails,hair, and scalp. 26. ExaminationSkin colorSkin color varies widely between individuals but should always be even indistribution, with normal variation for sun-exposed surfaces.Inspecting a lesionInspect each lesion carefully and note the following: Grouped or solitary? Pattern if grouped Distribution and location Symmetrical or asymmetrical? Peripheral? In only light-exposed areas? Dermatomal? Color Shape Size Surface Edge Nature of the surrounding skin 27. ExaminationPalpationEach lesion should be felt (remember to ask for, and be granted, permissionfirst). It is rare to catch an infection from touching a rash or lesion,and its even rarer to see a dermatologist wearing gloves. Each situationshould be judged at the timeobviously, gloves should be worn if there isbleeding or exudate present or if you are examining the genitalia.For each lesion, note the following: Tenderness (watch the patients face) Consistency Temperature Use the back of your hand (inflamed lesions are usually hot) Depth and height Mobility What skin layer is the lesion in? Is it attached to any underlying ornearby structures? Can it be moved in all directions or only in one or two? Does it move with movement of underlying muscle or tendons? 28. ExaminationBeyond the lesionThe skin condition must be seen in the context of the whole patient, andother organ systems should be examined as necessary. Remember topalpateregional lymph nodes if appropriateSome common skin color abnormalities Jaundice: a yellow tinge to the skin; best appreciated at sclera Carotenemia: a yelloworange tinge to the skin that is similar to thatof jaundice but the sclera are spared Hemochromatosis: slate-gray skin coloration Addisons disease: darkened scars and skin creases on the palms andsolesalso darkening of mucosa Albinism: a lack of pigmentation with white skin and pink irises Vitilgo: autoimmune phenomenon resulting in patchy loss of skincolo 29. Kobner sphenomenonThis is thetendency forcertain rashes orlesions to form atthe site ofskin trauma,including surgicalscars. 30. 1. What is the most likely cause of this infants skinrash? 31. Atopic dermatitis 32. How could you think about thedifferential diagnosis ?! 33. DDCondition Similar rashes (distinguishing features)Atopic dermatitis Contact dermatitis (not associated with dry skin)Keratosis pilaris (nonpruritic, involvesposterolateral upper arms)Mycosis fungoides (lesion borders sharper, fixedsize and shape)Psoriasis (well-defined plaques, silvery whitescale, involves extensor surfaces)Scabies (involves genitalia, axillae, finger webs)Seborrheic dermatitis (nonpruritic, greasy scale,characteristic distribution) 34. fine red follicular papulesand erythema on thecheeks and earsNonprureticKeratosis pilaris 35. lesion borderssharper, fixed sizeand shapeMycosis fungoides 36. well-definedplaques, silvery whitescale, involvesextensor surfacesPsoraiasis 37. involves genitalia,axillae, finger webspruritic pustuleswith surroundingerythemaSacbies 38. Typically the lesions are discrete anderythematous and theymay develop a yellow crust. The lesions tendto develop from the hair follicles. It is apersistent condition that varies in severity.Clinically and pathologically the conditionhas features of both psoriasis and eczema.There is thickening of the epidermis withsome of the inflammatory changes ofpsoriasis and the intercellular oedema ofeczema.Seborrheicdermatistis 39. TreatmentTopical steroids produce a rapid improvement, but not permanent clearing. Topicalpreparations containing salicylic acid, sulphur, or ichthammol may help in longterm control. Triazole antifungal drugs by mouth have been reported to produceclearing and can be used topically. These drugs clear yeasts and fungi from the skin,including P. ovale, which is urther evidence for the role of this organism. 40. discrete symmetricerythematouspatches and plaquesnot associated withdry skinContact dermatitis 41. Types of Contact dermatitisIrritant contact dermatitisAn irritant substance is one that would cause inflammation in almostevery individual if it was applied in sufficiently high concentration forlong enough.An irritant reaction is caused by the direct contact of an irritantsubstance with the skin and does not involve the immune system.Allergic contact dermatitisAn allergic reaction is specific to the individual and to a substance (or agroup of related substances) called an allergen.Allergy is a hypersensitivity (oversensitivity) to a particular substance,and always involves the immune system.All areas of skin that are in contact with the allergen develop the rash.The rash will disappear if you avoid contact with the substance.Patch testing can help to differentiate between the two. 42. Patch testingPatch testing is used to determine the substances causing contactdermatitis. The concentration used is critical. If it is too low there may beno reaction, giving a false negative result, and if it is too high it mayproduce an irritant reaction,which is interpreted as showing an allergy (false positive). Anotherpossible danger is the induction of an allergy by the test substance.The test patches are left in place for 48 hours then removed, the sitesmarked, and any positive reactions noted.A further examination is carried out at 96 hours to detect anyfurther reactionseseInterpretation of results+? = doubtful reaction: mild redness only.+ = weak, positive reaction: red and slightly thickened skin.++ = strong positive reaction: red, swollen skin with individual smallwater blisters.+++ = extreme positive reaction: intense redness and swelling withcoalesced large blisters or spreading reaction. 43. Treatment of contact dermatitisProtectionMost irritant contact dermatitis involves the hands.Gloves are therefore the mainstay of protection. Forgeneral purposes and household tasks, rubber orpolyvinyl chloride household gloves, possibly with acotton liner or worn over cotton gloves, should suffice.It is important to take off the gloves on a regular basisas sweating may aggravate existing dermatitis. 44. Treatment of contact dermatitisDetection and avoidance of the allergenIt may be possible to substitute nonirritating agents. The mostcommon example of this is the use of a soap substitute.Topical corticosteroidsTopical corticosteroids, soap substitutes and emollients arewidely accepted as the treatment of established contactdermatitis.Second-line treatmentsSecond-line treatments such as psoralen plus UVA,azathioprine and ciclosporin are used for steroid-resistantchronic hand dermatitis. 45. Slapped cheekappearance withsparing of periorbitalareas and nasal bridge;unique fishnet pattern;erythema onextremities, trunk, andbuttocks; keys todiagnosis in childrenare slapped cheekappearance and net-likerash, and in adults arearthralgias and historyof exposure to affectedchildFifth disease 46. Violaceous flat-toppedpapules and plaques;commonly on ankles andwrists; 5 P's (pruritic,planar, polygonal, purpleplaques); Wickham striae(reticular pattern of whitelines on surface of lesions);lacy white buccal mucosallesions; Koebnerphenomenon (developmentof typical lesions at the siteof trauma); keys todiagnosis are purple colorand distribution of lesionsLichen planus 47. TreatmentThere is usually a gradual response to topical steroids, but invery extensive and inflamed lesions systemic steroids may beneeded. Localised hypertrophic lesions can be treated withintralesional injections. 48. Flat, red, scaly lesionsprogressing to annularlesions with centralclearing or browndiscoloration; keys todiagnosis are annularlesions with centralclearing and positiveKOH preparationTinea corporis 49. Treatment of tinea corporisKeep the skin clean and dry.Wash and dry the area first.Apply the cream, beginning just outside the area of the rash by 2 cm andmoving toward the center.Be sure to wash and dry your hands afterward.Use the cream twice a day for 7 to 10 days.Do not use a bandage over ringworm.Creams that contain miconazole, clotrimazole, ketoconazole, terbenifine, oroxiconazole are often effective in controlling ringworm.Once treatment has started, a child can return to school.To prevent the infection from spreading:Wash all towels in warm, soapy water and then dry them.Use a new towel and washcloth every time.Clean sinks, bathtubs, and bathroom floors well after using.Wear clean clothes every day and do not share clothes 50. Another Causes of epidermal rashes 51. symmetric round to oval pink scaly papulesand plaquesThenumerous pale pink oval or round patchescan be confusedwith psoriasis or discoid eczema. The historyhelps because thiscondition develops as an acute eruption andthe patient canoften point to a simple initial lesiontheherald patch. There may be prodromalsymptomswith malaise, fever, orlymphadenopathy. Numerous causeshavebeen suggested, from allergy to fungi;the current favourite is avirus infection.Pityriasis rosea 52. Treatment : The most common symptom is itching, which can be treatedwith topical steroid creams (like hydrocortisone cream) and oralantihistamines (like diphenhydramine [Benadryl], loratidine (Claritin)Thesewill not shorten the duration of the rash but will decrease the itching.Another treatment for itching is UVB light or sunlight. However, exposure tosunlight increases the risk of skin cancer. Generally, the best treatment is toavoid being overheated by reducing exercise and avoiding hot showers andbaths. 53. The lesions are: (a) flat;(b) only partially depigmentedareasof vitiligo are totallywhite; and (c) do not showinflammation or vesiclesdevelops aftersun exposure with white macules onthe tanned skin but palebrown patches on the covered areasPityriasis versicolor 54. Pityriasis versicolor treatmentTreatment is simple: selenium sulphide shampooapplied regularly with ample water whileshowering or bathing will clear the infection. -The colour change may take some time to clear -Ketoconazole shampoo is an effectivealternative.Oral terbinafine, which is very effective in otherfungal infections, has no effect 55. Malar erythemawith markedphotosensitivityand a butterflypatternLupus erythematosus 56. Treatment is with systemic steroids,with immunosuppressiveagents if necessary. Antimalarialdrugs, such ashydroxychloroquine, are moreeffective in the subacute type.Treatment is with moderate to verypotent topical steroidsand hydroxychloroquine by mouth,together with suitable sunscreens. 57. Atopic DermatitisAtopic dermatitis is an inflammatory skin diseasecharacterized by erythema, edema, pruritus, exudation,crusting, and scaling.It is often referred to as the itch that rashes.Pruritus may lead to intensescratching and secondary infection.Atopic dermatitis may be exacerbatedby food allergies (in approximately 40% of cases), asfrom eggs, wheat, peanuts, or cows milk; environmentalstimuli such as dust mites or animal dander; oremotional stress. 58. Atopic DermatitisAtopic dermatitis is often associated with a family history ofallergies, asthma, hay fever, or atopic dermatitis. Individualsare more sensitive to certain fibers, particularly wool.Keratosis pilaris, which is characterized by asymptomatichorny follicular papules on the upper arms, buttocks, andthighs, is another manifestation of atopic dermatitis.Immunodeficiency should be considered in an infant with arash that does not resolve, but it is not typical of atopicdermatitis in general. 59. How does patient age affectdisease presentation?There are three distinct stages of the disease:Infantile: patients < 1 year have exudative, crusted patches ontheir extensor and flexural surfaces, cheeks, and scalp, whilethe diaper area is spared.Childhood: patches have less exudate and are found in the flexural areas, especially the antecubital and popliteal fossae.Adulthood: ~40% of patients clear the disease by adulthood;distribution is similar to childhood, but patches are morelocalized and lichenified 60. Atopic DermatitisUK diagnostic criteria: must have an itchy skincondition and any three of:-Personal or family history of atopyVisible flexural involvement (or cheeks if under 10)Dry skin in last yearHistory of flexural involvement (or cheeks if under 10)Onset under 2 (not used if child under 4)Exclude scabies 61. Atopic dermatitisTrigger factors: heating, washing, pets, smoking, house dustmite, tree and grass pollens, infections (bacterial and herpessimplex), family interactions, stress.Investigations: Height and weight monitoring in children.Swabs for bacterial and viral culture as appropriate.-NB. Prolonged obesity in early childhood is a risk factor foratopic dermatitis. Weight loss might be an important approachfor the prevention and treatment of atopic dermatitis inchildren.-Cross sectional studies have reported impaired growth inchildren with atopic dermatitis ,Children treated with topicalcorticosteroids need careful growth monitoring 62. Treatment of atopic dermatitis- Outlines for treatmentThe treatment of atopic dermatitis beginswith the avoidance of any environmental factors thatprecipitate the condition-Maintenance of the skin barrier In addition, emollients (e.g., petroleumproducts) to restore skin hydration should be applied within 3 minutes ofbathing.-Excessive drying of the skin should be avoided.-Atopic dermatitis is best managed with local therapy.-Flare-ups of the condition are treated with topical corticosteroid creamsor lotions.-To further prevent scratching, the fingernails should be cut short.-Percutaneous absorption of corticosteroid does occur,and atrophy of the skin should be watched for. This canbe avoided by using only low or moderate potency topical corticosteroids. 63. Treatment of atopic dermatitis-Topical calcineurin inhibitors (Topical immunomodulatorsare agents that regulate the local immune response of the skin)such as pimecrolimus (Elidel) are not approved for infantsyounger than 2 years of age, especially since the addition of theFood and Drug Administration black box warning forlymphomas and skin cancer, but they are used for second-linetherapy in older children and are still used by some physiciansin place of high-potency .Unlike topical steroids, TCIs selectively target inflammatorycytokine production without affecting collagen synthesis,thereby avoiding any risk for cutaneous atrophy.- 64. Treatment of atopic dermatitisSteroids in younger children with severe atopicdermatitis.-Systemic antihistamines and nonsedatingantihistamines have to be used to control pruritus,but not in infants. These can improve sleep andprevent more excoriations and secondary infections.Secondarily infected atopic dermatitis may often bemanaged by topical mupirocin, but occasionally it mayrequire systemic treatment 65. Topical steroids: a two-stage therapeutic approach isrecommended.Use a mild/moderate potency corticosteroid for long-termmaintenance, but a potent topical corticosteroid for short-term use(5-7 days)In infants and young children, use milder preparations (e.g. l%hydrocortisone ointment and Eumovate ointment respectively).-Facial eczema can be safely treated with regular l% hydrocortisoneointment.- Palms and soles may require superpotent corticosteroid formaintenance treatment.-Elocon and Cutivate are newer generation steriods applied oncedaily.- -Ointments are preferable to creams for non-weepy dry skin.Dermatology Guidelines Book 66. Topical steroids dose in skin lesionsSuggested finger tip dosages for affected areas 67. The following chart lists the topical corticosteroids that have beenapproved by the FDA for use with children.FDA approval is awarded based on studies with children ina specific range of ages.These medications are commonly used in younger children. 68. Itching with skin manifestationsEczema is associated with itching due to the accumulation of fluidbetween the epidermal cells that are thought to producestretching of the nerve fibres.As a result of persistent scratching there is often lichenificationwhich conceals the original underlying areas with eczema.Exposure to irritants and persistent allergic reactions can produceintense itching and should always be considered.-Allergic reactions due to external agents often cause intenseitching.- Systemic allergic reactions such as a fixed drug eruption,erythema multiforme, and vasculitis are less likely to causepruritus. 69. Psoriasis, which characteristically has hyperkeratotic plaques,usually does not itch but sometimes there can be considerableitching. Occasionally this is due to secondary infection of breaksin the skin surface.Lichen planus presents with groups of flat-topped papuleswhich often cause an intense itch. Blistering disorders of theskin may itch.In herpes simplex there is usually burning and itching in theearly stages.Eczema and dermatitisIn herpes zoster there may be a variable degree of itching, butthis is overshadowed by the pain and discomfort of the fullydeveloped lesions.By contrast, bullous impetigo causes few symptoms,although there may be extensive blisters. Itching is usuallynot present 70. Dermatitis herpetiformis is characterised by intense persistent andsevere itching that patients often describe as being unendurable. Usualmeasures such as topical steroids and antihistamines have little if anyeffect.By contrast, the blisters of pemphigoid do not itch although the earlierinflamed lesions can be irritating.Parasites Fleas and mites cause pruritic papules in groups.The patient may not realise that they may have been acquired after awalk in the country or encountering a dog or cat.Nodular prurigo may develop after insect bites and ischaracterised by persistent itching, lichenified papules, and nodulesover the trunk and limbs. The patient attacks them vigorously andpromotes a persisting itchscratchitch cycle which is very difficult tobreak. 71. Infestations with lice cause irritation and a scabies mitecan cause widespread persistent pruritus, even thoughonly a dozen or so active scabies burrows are present. It isalways acquired by close human contact and thediagnosis may be missed unless an adequate history ofpersonal contacts and a thorough clinical examination iscarried out. However, a speculative diagnosis of scabiesshould be avoidedParasitophobia is characterised by the patient reporting the presence ofsmall insects burrowing into the skin which persists despite all forms oftreatment. The patient will produce small flakes of skin, fibres of clothing,and pieces of dust, usually in carefully folded pieces of paper, forexamination. These should always be examined and the patient gentlyinformed that no insect could be found but this will not be believed. 72. Itching with no skin lesionsIf no dermatological lesions are present generalised pruritus or itchyskin may indicate an underlying internal cause.In elderly patients, however, the skin may itch simply because it is dry.Hodgkins disease may present with pruritus as a sign of the internalmalignancy long before any other manifestations.A 35 year old ambulance driver attended the dermatology clinic withintense itching but a normal skin and no history of skin disease. Hisgeneral health was good and both physical examination and all bloodtests were normal. However, a chest x ray examination showed amediastinal shadow that was found to be due to Hodgkins lymphoma.Other forms of carcinoma rarely cause pruritus. 73. Metabolic and endocrine diseaseBiliary obstruction and chronic renal disease causeintense pruritus.Thyroid disease can be associated with an itching skin. Inhyperthyroidism the skin seems normal but inhypothyroidism there is dryness of the skin causingpruritus.Blood diseases Polycythaemia and iron deficiency aresometimes associated with itching skin. 74. Treatment guidelines for Eczema ( PatientEducation ) Treat the patient, not just the rash Complete cure may not be possible Be realistic about the problems of applying treatmentsat home Make sure the patient understands how to carry out thetreatment Advise using emollients and minimal soap Provide detailed guidance on using steroids 75. Dry skin tends to be itchy, so advise minimal use of soap.Emollients are used to soften the skin, and the simpler thebetter. Emulsifying ointment BP is cheap and effective butrather thick. By mixing two tablespoons in a kitchen blenderwith a pint of water, the result is a creamy mixture that caneasily be used in the bath.A useful preparation is equal parts of white soft paraffin andliquid paraffin.-Various proprietary bath oils are available and can be applieddirectly to wet skin.Wet weeping lesions should generally be treated with creamsrather than ointments (which remain on the surface) 76. Steroid ointments are effective in relieving inflammation anditching but are not always used effectively.Advise patients to use a strong steroid (such as betamethasone orfluocinolone acetonide) frequently for a few days to bring the conditionunder control; then change to a weaker steroid (dilutebetamethasone, fluocinolone, clobetasone, hydrocortisone) lessfrequently.-Strong steroids should not be continued for long periods, and, as a rule,do not prescribe any steroid stronger than hydrocortisone for the face.-Strong steroids can cause atrophy of the skin if used for long periods,particularly when applied under occlusive dressings. On the face they maylead to florid telangiectasia and acne-like pustules.-Avoid using steroids on ulcerated areas.-Prolonged use of topical steroids may mask an underlying bacterial orfungal infection. 77. Immunosuppressants are a valuable adjunct in severe casesnot responding to topical treatment and antibiotics.Ciclosporin is usually given on an intermittent basis, withcareful monitoring for side effects.Azathioprine is also used, provided the thiopurine methyltransferase (TPMT) level is normal.Tacrolimus is an immunosuppressant that has recentlybecome available in two strengths as an ointment. It promisesto be a successful treatment but is relatively expensive. 78. Wet, inflamed, exuding lesions(1) Use wet soaks with plain water, normal saline, oraluminium acetate (06%). Potassium permanganate(01%) solution should be used if there is any sign ofinfection.(2) Use wet compresses rather than dry dressings(wet wraps).(3) Steroid creams should be used as outlined above.Greasy ointment bases tend to float off on the exudate.(4) A combined steroidantibiotic cream is often neededas infection readily develops.(5) Systemic antibiotics may be required in severe cases.Take swabs for bacteriological examination first. 79. Dry, scaling, lichenified lesions(1) Use emollients.(2) Use steroid ointments, with antibiotics if infection is present.(3) A weak coal tar preparation or ichthammol can be used ontop of the ointments. This is particularly useful at night toprevent itching. 12% coal tar can be prescribed in anointment. For hard, lichenified skin salicylic acid can beincorporated and the following formulation has beenfound useful in our department:(a) Coal tar solution BP 10%, salicylic acid 2%, and unguentum drench to100%.(b) 1% ichthammol and 15% zinc oxide in white softparaffin is less likely to irritate than tar and is suitable for children.(4) In treating psoriasis start with a weaker tar preparation andprogress to a stronger one.(5) For thick, hyperkeratotic lesions, particularly in the scalp,salicylic acid is useful. It can be prescribed as 25% inaqueous cream, 12% in arachis oil, or 6% gel. 80. A 3-Week-Old Infant with a Crusty HeadA grandmother brings in a 3-week-old infant withthe complaint that she has crusting on her hair.Since it has been quite cold, the grandmother (whocares for the child) has been careful not to bathethe child too often, and she does not use shampoo.The child is bottle-feeding and has otherwise hadno health problems. On examination, the infantappears healthy and interactive. Her scalp is coveredwith a crusty, yellowish rash with some erythemaand crusting at the base of the ears and scalpThe most likely diagnosis of this rash isa. atopic dermatitisb. allergic contact dermatitisc. seborrheic dermatitisd. infectious eczematoid dermatitise. none of the above 81. c. Pityriasis capita, or cradle capa diffuseor focal scaling and crusting of the scalpis a commonform of seborrheic dermatitis seen in infancy.Seborrheic dermatitis is most common in children duringthe first 3 months of life. Typically, it is a dry, scaly,erythematous, papular dermatitis that is usually nonpruritic.It may involve the face, neck, retroauricularareas, axillae, and diaper area. The dermatitis may bepatchy or focal, or it may spread to involve the entirebody. Although common, the etiology of seborrheicdermatitis is unclear, but it is possibly related to theproliferation of the Mallassezia species. Hormonal andgenetic factors as well as alteration of essential fattyacid patterns are also thought to play a major role. 82. Treatment of Pityriasis capita, or cradlecapGenerally, gentle cleaning with a soft washcloth,occasionally using baby or mineral oil to remove scales,is curative for cradle cap.-If the seborrheic dermatitis extends onto the face orpersists, a low-dose hydrocortisone cream may be usedfor a short time or selenium shampoo may be used onthe scalp. Often, caretakers are afraid to shampoo thehair, causing buildup of the crust. 83. A 2-Week-Old Infant Who LooksToo Ugly for PhotosA 2-week-old infant, a product of a normalbirth and delivery, is brought to your officebecause the mother says she cannot takebaby photos since hisskin wont clear up. According to the mother, ever sincebirth the child has had small pimple-like lesions onhis face and scattered over his body that come and go (Sometimes, they get slightly erythematous, but they are notcrusty.The baby is not bothered by them, but his face looks sougly his mother doesnt want to get his photo taken. Shewants medicine to get rid of it.8. What is the most likely diagnosis in this infant?a. atopic dermatitisb. Miliac. seborrheic dermatitisd. miliariae. infantile acne 84. e. This infant has infantile acne, a benign conditionthat generally only presents problems of appearancesand for photographs. It spontaneously resolves anddoes not require treatment. It should be distinguishedfrom atopic dermatitis, seborrheic dermatitis, erythematoxicum neonatorum, and neonatal pustular melanosis.Erythema toxicum neonatorum usually appears soonafter birth and lasts up to 2 weeks. It is characterizedby vesicles, pustules, and papules on an erythematoushalo base. Transient pustular neonatal melanosis, morecommon in dark-skinned infants, also has vesicles andpustules, but no erythematous base, and may have acollarette of scale. Milia are epidermal inclusion cystsand miliaria is essentially a heat rash. 85. Treatment of infantile acneReassurance that it will clear, and an understandingthat no treatment is necessary, is important.None of the other treatments listed are necessary. 86. An 8-Month-Old Infant witha Long-Term Persistent Diaper RashAn 8-month-old infant is brought to your office by hismother for assessment of a diaper rash. His motherhas tried cornstarch powder, vitamin E cream, zincoxide, and a prescribed corticosteroid cream froma different physician.On examination, the infant has an intenselyerythematous diaper dermatitis that has a scallopedborder and a sharply demarcated edge. There arenumerous satellite lesions present on the lowerabdomen and thighs (Fig. 103-4).10. What is the most likely diagnosis in this infant?a. atopic dermatitisb. allergic contact dermatitisc. seborrheic dermatitisd. infectious eczematoid dermatitise. candidal diaper dermatitis 87. e. This infant has candidal diaper dermatitis, whichpresents as an erythematous confluent plaque formed bypapules and vesiculopustules, with a scalloped border and asharply demarcated edge. Candidal diaper dermatitis canusually be distinguished from other childhood diaperdermatoses by the presence of satellite lesionsproduced at some distance from the primary eruption.Although this childs rash is not primarily perianal,streptococcal dermatitis should be considered in the case of achronic perianal rash.Diagnosis can be made by culture, and it responds totreatment with amoxicillin.Intertrigo, common in infants with overlapping skin and fatfolds, usually responds to treatment to decrease the moisture. 88. Candidal diaper dermatitisThe Treatment of choice in candidal diaper Dermatitis is atopical antifungal agent. Topical miconazole,clotrimazole, or ketoconazole are commonly used. In aninfant with a severe inflammatory reaction, a topicalcorticosteroid may be mixed 50/50 with a topical antifungalagent and applied on a regular basis for a few daysto 1 week. Rather than using a high-potencysteroid/antifungal combination, however, use of a low-Potency steroid such as hydrocortisone with the antifungalagent is preferred because the infant is at risk for striae andlocal complications of steroid therapy. 89. A 4-Month-Old Infant with a DiaperRash Caused by Dirty DiapersA 4-month-old infant is brought to your officeby her mother. Her mother complains that thechild has a diaper rash that is probably relatedto her not changing the diapers often.The mother has five other children and was tryingto save money by using fewer diapers. She admitsthat she waits until the diaper is soaked beforechanging it.On examination, the infant has erythematous,scaly, papulovesicular diaper dermatitis withnumerous bullous lesions, fissures, anderosions.12. What is the most likely diagnosis in this infant?a. atopic dermatitisb. primary irritant contact dermatitisc. seborrheic dermatitisd. fungal dermatitise. allergic contact dermatitis 90. b. This child has a primary irritant contact dermatitis.Irritant contact dermatitis is a reaction tofriction, maceration, and prolonged contact with urineand feces. It usually presents as an erythematous, scalydermatitis with papulovesicular or bullous lesions, fissures,and erosions. The eruption can be either patchyor confluent. The genitocrural folds are often spared.Secondary infection with either bacteria or yeast canoccur. The infant can be in considerable discomfortbecause of the marked inflammation that is sometimesassociated with this type of diaper rash. Primary irritantdiaper dermatitis should be managed by frequentchanging of diapers and thorough washing of the genitaliawith warm water and a mild soap. Occlusive plasticpants that promote maceration should be avoided.If cloth diapers are used, they should be changed frequently,as should disposable diapers. Drying out theskin by allowing the infant to go without diapers canbe helpful but can be logistically challenging. 91. Treatment of irritant contact dermatitisAn occlusive topical agent such as zinc oxideor A&D ointment can be applied until healing occurs.Topical 1% hydrocortisone ointment is also very usefulin the management of diaper dermatitis in its more severeform. Systemic antibiotics are not indicated in the treatmentof primary irritant diaper dermatitis. Again, the primarytreatment is frequent diaper changing or leaving the childwithout a diaper as much as possible untilthe skin heals. 92. A useful diagnostic pearl for differentiatingCandidal diaper rash from irritant diaperdermatitis is that candidal diaper rash tendsto involve the warm, moistfolds of the skin, whereas irritant diaper dermatitistendsto spare the folds, occurring mainly in the areas ofgreatestskin contact with urine and feces. Candidal diaperrash also tends to present with satellite lesions and willworsen with prolonged topical corticosteroid therapy. 93. After several months of persistentdiaper dermatitis, red scaly papulesand plaques erupted on the trunkand extremities of a healthy toddler.His grandfather had psoriasis.Plaques on the trunk and diaperarea healed with medium potencytopical steroids within 3 weeks.Descriptionbright red papules and plaques withoverlying silvery scale in exposedareasInfantile psoriasis 94. A red or reddish-brown rash that canappear anywhere skin rubs together ortraps wetness. The most common areasinclude between toes, in the armpits, inthe groin area, on the underside of thebelly or breasts, and in the crease of theneck. Intertrigo can also affect the skinbetween the buttocks.The affected skin will often be very rawand may itch or ooze. In severe cases,intertrigo may cause a foul odor, and theskin may crack and bleedInterigo 95. A cement plant worker presents to your office with therecurrent acute skin eruption on his legsshown in. It extends proximally from the dorsum of the feetto just below the knees.This is the third eruption in 2 years.This patient most likely hasA) tinea with a secondary id reactionB) rhus dermatitisC) methicillin-resistant Staphylococcus aureus (MRSA)cellulitisD) contact dermatitis related to his occupation 96. ANSWER: DBecause this dermatitis is recurrent and symmetric, contact dermatitis should besuspected.Rhus dermatitisis a contact dermatitis, but it is more acute and presents with bullae and vesicles thatare more linear than those seen in this patient.MRSA usually presents as a unilateral cellulitis, or more commonly asinflammatory nodules or pustules.This dermatitis is not scaling and does not have a distinct border thatwould suggest tinea. 97. The answer is A. (Rhus dermatitis) Poison ivy or poison oakis also referred to as Rhus dermatitis. The condition isassociated with intensely pruritic linear streaks of vesicles,papules, and blisters. The plants contain a resinous oil thatgives rise to an allergic response approximately 2 days afterexposure. Contrary to common belief, the fluid in the blisterscan neither transfer the rash to others nor cause it to spread.Treatment involves topical steroid creams, Burow's solution,calamine lotion, antihistamines, cool baths with colloidaloatmeal, and oral steroids (for 2 to 3 weeks to preventrebound dermatitis) for more widespread cases. 98. SourcesDermatology guidelinesIllustrated dermatologyABC dermatologyBlue PrintSwansonhttp://www.dermnetnz.info/http://dermatlas.med.jhmi.edu/derm/index.cfmhttp://www.dermnetnz.org/