Pediatric dermatology

1. Pediatric dermatology

2. Differences in adult and neonatal skin

3. Classification of pediatric skin diseases • Infective disorders: Bacterial, Viral, Fungal • Infestations: • Scabies, Pediculosis, Parasitic • Inflammatory/ Immunological disorders: Eczemas, Psoriasis, Lichen planus • Genetic/Nevoid disorders : Hemangiomas, Linear epidermal nevus, Epidermolysisbullosa, Tuberous sclerosis, Neurofibromatosis, etc. • Neoplastic disorders: Langerhans cell histiocytosis, Mastocytosis

4. Neonatal Dermatoses • Physiological • Vernixcaseosa • Mongolian spot • Physiological scaling • Sebaceous hyperplasia • Sucking blisters • Physiological jaundice • Miliaria • Milia • Erythematoxicumneonatorum • Transient neonatal pustulosis • Neonatal Acne

5. Mongolian spot • Single or multiple slate gray or blue macules of size 3 to 10 cms • Seen at birth • Seen over lumbosacral region, buttocks, shoulders • Fade within the first 3-4 years of life

6. Physiological scaling • Seen in 75% normal infants • Occurs within first week of life • First around the ankles, later on hands and feet and soon becomes generalized • Maximum intensity by eighth day, subsides by 3-4 weeks • No treatment required

7. Sucking blister • One or two solitary blisters • Present at birth • Seen over fingertips / hands / forearm • Caused by vigorous sucking • Heals rapidly without treatment within 2 weeks of life • Differential diagnosis: Herpes simplex, Bullous impetigo, Epidermolysisbullosa

8. Miliaria Superficial vesicles resulting from sweat retention in stratum corneum A. Miliariacrystallina: • Following fever, phototherapy • Tiny clear vesicles seen over forehead, neck • Erythema absent • Peels off within 24 hrs

9. Miliaria B. Miliariarubra (prickly heat) • Seen in hot weather • Non follicular papules on erythematous base • 1 to 4 mm in diameter • Trunk, face • Subside in 2 to 3 days • Itching, secondary infection is common

10. Infantile and Childhood dermatoses Infective and inflammatory diseases have been discussed in respective chapters. Certain common and genetic-naevoid conditions seen in infants and children will be discussed including: • Cradle cap, Diaper dermatitis • Nevus depigmentosus, Linear epidermal nevus • Haemangiomas, Vascular malformations • Sturge Weber syndrome • Neurofibromatosis, Tuberous sclerosis • Epidermolysisbullosa • Ichthyosis

11. Cradle cap • Seborrhoeic dermatitis of scalp • Thick, greasy, adherent scales on scalp • Commonly begins in the first 3 months • Self limiting • Apply oil for few hours to soften scales, rinse, 1% hydrocortisone cream can be used

12. Diaper dermatitis (Napkin rash) • Irritant dermatitis in the perineal region • Due to occlusion, fricton and prolonged skin contact with urine, faeces and fabrics • Wetness leads to maceration of skin • Secondary infection by C.albicans is common

13. Nevus Depigmentosus • Single, well circumscribed, hypopigmented or depigmentedmacule or patch • Seen at birth • Stable in size and distribution • Seen over trunk and proximal extremities

14. Linear epidermal nevus • Congenital hamartomas of embryonalectodermal origin • Seen in early childhood as a linear raised warty lesion • Located over neck, trunk and extremities

15. Hemangiomas • Incidence more in preterm infants • Female predilection • Begin at one month of age • Undergo a proliferative phase followed by stabilization and eventual spontaneous involution Complications • Ulceration, bleeding • Secondary infection • Mutilation and scarring • Cosmetic disfigurement

16. Vascular malformations • Stable dilatations of superficial or deep vasculature • Can be capillary, arterial, venous, lymphatic or mixed Clinical types: • Salmon patch • Portwine stain • Sturge-Weber syndrome • Klippel-Trenaunay syndrome

17. Salmon Patch • Present in 30 to 40% of neonates • Superficial, red or pink flat lesions • Seen over forehead, upper eyelid, glabellar area, nape of neck • Resolution in first year of life

18. Portwine Stain (Nevus flammeus) • Present at birth • Common sites are face, neck and mucous membrane • Flat pink-red lesion • Sharply unilateral in distribution • Persist in childhood and darker in adulthood Complications • Glaucoma, Choroidalangiomas

19. Sturge-Weber Syndrome • Portwine stain in distribution of first branch of trigeminal nerve • May be associated with seizures, ipsilateral glaucoma, behavioral problems, mental retardation • Characteristic intracranial S-shaped calcifications

20. Neurofibromatosis (NF) • Riccardi classified NF into eight distinct clinical types in 1982 • Autosomal dominant disorder • Affects skin, soft tissue, nervous system, bone, other organs • Classical skin lesions are café au laitmacules, neurofibromas

21. Neurofibromatosis - 1 (Von Recklinghausen’s disease) Diagnostic criteria for NF-1 Presence of two or more of the following: • Six or more café au laitmacules larger than 5 mm • Two or more neurofibromas of any type or 1 plexiformneurofibroma • Axillary or inguinal freckling • Two or more Lisch nodules (brown coloured small nodules on iris surface) • Optic glioma • A distinctive osseous lesion • A first-degree relative with NF-1

22. Neurofibromatosis - 2 • Bilateral acoustic neuromas • Multiple CNS tumors • Few café au laitmacules • Few neurofibromas • No axillary freckling • No Lisch nodules

23. Tuberous sclerosis (Bourneville’s disease) • Syn. EPILOIA (Epilepsy, Low IQ, Adenoma sebaceum) • Ash leaf macules/ hypopigmentedmacules • Adenoma sebaceum (angiofibroma) begins at • 2-5 years of age as small pink papules on mid-face • Shagreen’s patch (yellowish brown plaque on lumbo - sacral area) • Koenen’s tumors (periungualfibroma) • Mental retardation • Seizures

24. Epidermolysisbullosa • Inherited bullous disorders characterized by blister formation in response to mechanical trauma • Onset at birth or shortly after • Seen on sites of trauma and friction • Types: Simple, Junctional, Dystrophic • Some subtypes, especially the milder EB forms, improve with age • Autosomal recessive types have bad prognosis with severe mucosal, esophageal involvement and atrophic scarring of skin

25. Ichthyosis • Inherited disorder of keratinization • Characterized by the accumulation of scales on the skin surface, dry skin • Fish like scales most prominent over the trunk, abdomen, buttocks and legs • May be associated with ectropion, eclabion, nail dystrophy, internal organ involvement • Types: • Ichthyosisvulgaris • X-linked ichthyosis • Lamellar ichthyosis • Collodion baby / Harlequin fetus

26. Adolescent Dermatoses • Acne • Dandruff • Striae • Pseudo-acanthosisnigricans • Contact dermatitis to cosmetics, perfumes, artificial jewellery / accessories (metals) • Hyperhidrosis

27. Acne vulgaris • Characterized by comedones, papules, pustules and nodules • Common in males • Seen around puberty • Sites: face, upper part of the chest, back, shoulders Complications • Psychological impact • Hyperpigmentation • Scarring

28. Dandruff (Pityriasissicca/capitis) • Most common condition affecting the scalp • Causative organism: Malassezia species • Seen as mild, moderate or severe scaling of scalp • May or may not associated with itching • Simple dandruff does not cause hair loss

29. Striae (stretch marks) • Seen as pinkish white lines around knees, axillae, outer aspect of thighs, lumbosacral region • Sudden increase in height or weight causes rupture of connective tissue beneath an intact epidermis

30. Pseudo-acanthosisnigricans • Weight gain in puberty produces dark, thick, velvety skin in neck, axillae, groins • Asymptomatic

31. Side effects of cosmetic products • Cosmetic products like eye liner, ‘fairness’ creams, lipstick, nail polish, henna can produce contact reactions • Reactions may be immediate or delayed Types of reactions • Folliculitis • Acneiform eruptions • Contact dermatitis • Pigmentary changes

32. Child abuse • Includes physical abuse, neglect, sexual exploitation Cutaneousmanifestations • Bruises • Traumatic alopecia • Thermal burns • Sexual abuse: Vaginal tears, anal tears, hematomas • Sexually transmitted infections

33. Care of newborn • Gentle handling • Avoid frictional trauma • Use gentle soaps, cleansers • Too frequent bathing may lead to dryness • Maintain hygiene after feeds, diaper changes • Keep body folds dry and ventilated Skin care in pre-terms • Gentle handling • Use adhesive tape sparingly • Avoid frictional trauma

34. General principles of skin care in children Bathing, soaps and cleansers • There is no need to use special cleansing products • Excessive cleansing, scrubbing and incomplete rinsing lead to irritation Shampoos • Should be isotonic to tears and less irritating to eyes • Shampooing twice a week controls normal flaking Care of the diaper area • Frequent diaper changes with gentle cleansing and limiting use of plastic or rubber diaper cover

35. Differences in treatment of Paediatric and Adult Patients • Conservative management is best • Surface area is more in children as compared with adults • Percentage of absorption of topical drugs is more • Try to use lowest effective dose of medications • Do not use treatments which may retard growth or mental development • Avoid off-label uses of medications

36. Thank you