Paediatric Dermatology

Dermatology Terminology
Macule: a flat area of altered colour covering a

small area

Patch: Macule over a larger area

Papule: raised area less than 5mm in size.
- Acne papular or nodular (nodular associated
with worse scarring)
- Eczema
- Naevi (localised malformation of tissue
structures)
- Cancers
Nodule: a raised area more than 5mm
Erythema: redness which blanches on
pressure
Petechiae:
small red
non-blanching dots (love bites
are petichiae)
Purpura: reddish
discolouration of the skin in
larger patches non-blanching due to bleeding into the
mucous membranes (ecchymoses = larger patches)
Vesicle: fluid filled space less than 5 mm in diameter (below left)

filled space more than 5 mm

right)
Plaque: raised area with a

Bullae: clear fluid

in diameter (above
central plateau

Erosion: a superficial erosion of the skin which does not

infiltrate the dermis.

Ulcer: a deeper erosion of the skin which infiltrates

into the dermis (can see muscle or fat)
Pustule: A pus filled cavity in the skin can be infectious or noninfectious
- Infectious:
o Bacterial: 1) Staph aureus, 2)
Streptococcus 3) gram ve folliculitis
(Pseudomonas common outbreaks from
hot-tubs ect)
o Viral: varicella zoster (shingles)
o Fungal: Candida very common in elderly.
- Non-infectious: Acne, drugs (steroids), Trauma
(irritation of hair follicles from rubbing)
Comedone: a plug in a sebaceous follicle containing altered sebum, bacteria
and cellular debris. (open = black heads, closed = white heads)

Flexural: in the body folds groin, neck, behind ears, popliteal and antecubital
fossas
Koebner phenomenon: a linear eruption along a line of
a site of trauma
Annular: a ring or a

Discoid: a disc shaped lesion

circle

coin shaped

Lichenification: well defined roughening of

skin with accentuation of skin markings

the

Birthmarks
Strawberry Nevus aka Infantile
Haemangioma
They are either present at birth or develop over
the first few weeks of life.
They tend to gradually enlarge over 6-12 months,
and then regress most are gone by 5 years old,
or 10 at the latest.
If you want to get rid of them sooner, or they dont go away by themselves you
can give steroids, laser therapy or surgery.
You do need to rule out serious complications:
Ulceration
Eye complications
Airway obstruction (skin ones mean there might be ones on the epiglottis)
Cardiac failure (very big ones can take a lot of blood)
Interference with feeding

Port Wine Stain aka Nevus Flameus

They are capilliary malformations in the skin.
45% are restricted to one branch of the
trigeminal nerve. They cause deep pink or red
patches which present at birth and get darker
with age, they are permanent.

It can be associated with glaucoma, and with

Sturge-Webber syndrome (port wine stain,
blindness, learning difficulties). Rule these out by giving all of them an MRI head
and sending to opthal.
Manage with pulsed dye laser therapy can only do this from 1 year old as they
need a GA.

Salmon Patch

Aka stork bite (on back of neck) or angel kiss (on

face). They are very common pale pink patches
caused by dilated superficial dermal capilliaries.
They usually fade by a few months old (unless on
the neck), and have no complications or
associated conditions. No treatment needed.

Mongolian Blue Spot aka Congenital Dermal

Melanocytosis
It is a benign flat irregular birthmark. They are very prevalent
in Asian and Afro-Carribbean babies. They are harmless, with
no associated conditions or complications, and they generally
disappear by 3-5 years.
They can, however, be mistaken for bruises, so you need to
document them carefully to avoid NAI allegations.

Caf au Lait Patch

They are irregular coffee coloured macules/patches.
They are harmless on their own, but they can be
associated with neurofibromatosis type 1 especially
if there are lots of them or a family history.
More tend to come up, so you need to document their
number and location. If there are more than 5 by the
age of 6 then you need to screen for NF1.

Nappy Rash
There are a number of potential causes of nappy rash most are benign.

Ammonical Dermatitis
It is caused by prolonged contact with urine/faeces in an
unchanged nappy, as bacteria convert the urea to irritant
ammonia.
It causes an erythematous scaly eruption which usually
spares the skin creases.
Manage with regular nappy changes and zinc oxide ointment
to act as a barrier to the ammonia.

In severe cases you should think neglect, as its a sign the nappy isnt being
changed enough.

Thrush
It is an infection with Candida Albicans. It causes a
bright red raised rash with well-defined edges.
There are often satellite spots away from the rash,
or superficial pustules. The skin creases are
affected.
Treat with topical imidazole, barrier cream and
topical steroid, or combination therapy (Daktacort
which is miconazole and hydrocortisone).

Cradle Cap
AKA seborrhoeic dermatitis. It is caused by overactive
sebaceous glands, which causes a scaly yellow rash. It isnt
itchy, and it doesnt bother the child. It presents at about 6
weeks old, and goes away after a few weeks (6 months at the
latest).
You MUST NOT pick at it, as it scars if you do that.
It is cradle cap if confined to the scalp, but it can also be in
the neck, groin and axilla.
Manage it by softening it with baby oil, and washing it
once per day with baby oil and gently brushing it with a
soft brush, then putting on a moisturiser. Dont pick it!

Spotty Babies
Erythema Toxicum Neonatarum
It is neonatal acne. It is a benign condition which
affects 50% of newborns at day 3-14.
There is an eruption of red pustules and papules
with surrounding erythema. The individual lesions
are transient, with individual spots disappearing
as others form. It can affect the whole body
except palms and soles. There are no systemic
symptoms, and it goes away fairly quickly (lasts 2
days-2 weeks) as it is caused by maternal
hormones which rapidly get out of the babys circulation.

Milia
They are pearly white papules caused by epidermal
keratin-filled cysts. They are most frequently around
the cheeks, nose, ears and eyelids. 50% of neonates
have them, and they are harmless.
No management is needed; they go away by
themselves. DO NOT SQUEEZE them, as they scar if
you do that.

Miliaria (Heat Rash)

It is caused by blocked sweat ducts. They are
common in neonates, as their immature sweat glands
re very prone to blocking. Causes vesicles, with or
without surrounding erythema.
Manage by taking them into a cooler
environment, and giving E45 cream/calamine
lotion.

Eczema
Atopic eczema this is the most common type of
eczema, and is characterised by papules and
vesicles on an erythematous base. Presents
with itchy dry scaly patches on the face and
flexor aspects of limbs (extensor in neonates). It
can -> lichenification in chronic eczema. There
may be nail pitting and ridging.
It usually develops by early childhood (affects 20% of under 12s) and resolves
during teenage years, but it can reoccur.
There is often a history of
allergy/atopy/hayfever, and a family history of
eczema.
Exclusively breastfeeding until 6 months old
reduces the risk.
Can be exacerbated by: infections, allergens,
sweat, heat and severe stress. It can become
infected, as there is defective skin barrier
function.
In chronic eczema may see Lichenification exaggerated surface markings from
scratching and rubbing.
Management:

Avoid allergens
Use cotton clothes, avoid bio washing
powders, stop scratching by keeping nails
short and putting cotton mittens on babies
at night
Give emollients, and use emollients as a
soap substitute
Antihistamines (symptomatic relief from
itching)
Topical steroids: in young children mild
steroids are mainstay treatment / older children and adults require more
potent steroids. NOT ON FACE.
Topical tacrolimus for resistant eczema
Light therapy and immunosuppression for severe refractory cases

Psoriasis
It is an autoimmune condition characterised by rapid epidermal proliferation ->
plaques of red, dry, thickened skin. It affects about 2% of adults, but 10% of
children (mostly over 7s).
We need to know about 2 types: plaque and gutate.
Plaque: silvery scaled red plaques on the face, scalp and
extensors. Scalp lesions mean it is probably psoriasis. Trauma
-> psoriasis around the wound (Koebner phenomenon). Nail
changes are often present pitting, onycholysis, subungual
hyperkeratosis. There may be arthropathy (see rheum notes).
Gutate: many scattered small plaques on the trunk,
often precipitated by recent strep throat infection.
Recovers on its own over a few weeks/months,
emollients can soothe symptoms in the meantime and
UV light can speed up the process
Management:
Refer babies with psoriasis to dermatology
Topical steroids
Coal tar shampoos (anti-dandruff shampoo)
Vitamin D analogues
Dithranol
UV light

Kawasaki Disease
NB: common in exams

It is a systemic vasculitis that has a broad range of symptoms. It is particularly

common in Asian people. Affects children 6 months 4 years
old.
Clinical Features:
Fever lasting more than 5 days (need to exclude Kawasaki
disease in any fever lasting more than a week)
Conjunctivitis
Strawberry tongue
Truncal rash
Erythema and swelling -> later on peeling of the
extremeties
Cervical lymphadenopathy
Coronary artery aneurisms (1/3 children)
Raised CRP and ESR and white cells
It is a clinical diagnosis, there is no diagnostic test.
You need to rule out coronary artery aneurisms with an echo. 1-2% of children
with Kawasaki disease will die from this.
Management:
Asprin 300mg until fever subsides reduces thrombosis risk, then 75mg
until 6 week echo
IV immunoglobulins reduce the risk of developing coronary artery
aneurisms, but they must be given before 10 days after symptom onset.
If fever recurs give a second dose
Close followup and warfarin for any children with big aneurisms

Cutaneous Reactions
Urticaria AKA Hives
It is an itchy, blotchy rash of raised wheals
surrounded by erythema caused by swelling of the
superficial skin. There may also be angioedema if
the subcut tissues are involved. It is an acute
condition that lasts a few hours and then subsides.
It is usually an allergic reaction. Watch out for
signs of anyphylaxis.
Manage with antihistamines (chlorphenamine or cetirizine), if severe give a few
days of PO prednisolone.

Contact Dermatitis

It is skin inflammation caused by exposure to an

allergen. Causes an erythematous vesicular
eruption in the area where the allergen
exposure took place.
It is common in children often due to exposure
to nickel in cheap jewellery, to plasters or
suncream.
It can take days-weeks to heal, so manage with antihistamines (cetirizine,
chlorphenamine) and topical hydrocortisone.
If it recurs and you cant find a cause then think about allergen testing, but the
cause if often obvious.

Pityriasis Rosea
It is a reaction to viral infection often preceded by URTI.
It is benign and self-limiting.
The symptoms evolve over several days/weeks.
You first get a herald patch a single annular scaly
macule
This is followed 1-2 weeks later by a generalised rash of small scaly
itchy patches. On the back it tends to follow the ribs
-> Christmas tree rash
The rash lasts 2-6 weeks then goes away by itself
Although its self limiting it is unpleasant, so give
emollients and topical hydrocortisone.

Erythema Nodosum

They are painful, shiny, hot red nodules that usually appear on the shins. They
then turn purple, and gradually fade over 2-4 weeks. There are often systemic
symptoms (fever, malaise, arthralgia, hilar lymphadenopathy).
They are more common in girls over 6.
They are caused by immune activation in infection, IBD and autoimmune
disease (SLE and sarcoidosis). They may also be cause by the combined oral
contraceptive pill.
Manage them with bed rest and NSAIDs, and by treating the cause.

Erythema Multiforme

It is a reaction to HSV infection, some drugs, and after some infections, in which
autoimmune activation kills keratocytes.

It causes characteristic target lesions with an

erythematous border around a dusky centre with a paler
ring separating the two. The lesions can present
anywhere on the body, but classically start on the feet.
There may be some mucosal involvement too.
It is harmless, and resolves spontaneously in 2-3 weeks
with no treatment, although if itchy you can give oral
antihistamines and topical corticosteroids.

Stevens Johnson Syndrome and Toxic Epidermal Necrolysis

They are now believed to be variants of the same condition. They were once
believed to be a severe form of erythema multiforme, but are now seen as being
distinct.
It is a very rare condition (1-2 people/million/year)
caused by a reaction to practically any medication. It
usually starts between a few days to a month after
starting a new drug.
There is a prodrome of malaise, fever over 39 degrees,
conjunctivitis and URTI symptoms. A painful red rash
then forms, starting on the trunk and spreading rapidly
to the face and limbs. The rash may be erythematous, macular, target-like or
blistering. Gently rubbing the skin -> blisters (Nikolsky
sign). Blisters may fuse -> large areas of skin
desquamation. There is severe mucosal involvement, with
at least 2 mucous membranes involved.
Stevens-Johnson Syndrome: desquamation of less than 10%
body surface area
Toxic Epidermal Necrolysis: Desquamation of more than
30% BSA
Overlap = between the two
It is really painful, and 10-30% fatal.

Skin Signs of Systemic Disease

Acute Lymphocytic Leukaemia

It causes easy bruising and a non-blanching rash due to pancytopenia. As well

as the rash the patient has vague symptoms:
Pale
Tired
Bruises easily
Lymphadenopathy
Hepatosplenomegaly

FBC shows a pancytopenia, and bone marrow aspirate shows lots of

lymphoblasts.
It tends to present in children ages 2-5 years old (and also in old people).
Treat it with chemo, average 5 year survival is 80%.

Henoch-Schoenlein Purpura
It is an autoimmune vasculitis. It most often affects children aged 3-10, and is
often preceded by an infection (usually URTI). Caused by
immune complex deposition.
Clinical Features
A palpable purpuric rash on the legs and buttocks
Leg joint pains (can be severe)
Colicky abdominal pain (with nausea, vomiting,
constipation or diarrhoea)
Sometimes GI bleeds
Frank or microscopic haematuria
Nephrotic syndrome may develop
It is a clinical diagnosis, and there is no specific test. There may be raised IgA,
ESR and CRP, and Us and Es go up in renal involvement.
Management
Analgesia
Usually wait for it to get better by itself (takes a few weeks)
If kidney disease is getting worse then biopsy it. If its bad then give
methylprednisolone, cyclosporine and dipyridamole
Prognosis is generally good, although it can rarely cause end stage renal failure.

Crohns Disease

As well as the classical GI symptoms, Crohns can cause a number of systemic

symptoms:
Anterior uveitis (eye pain, conjunctival injection, blurred vision)
Erythema nodosum
Pyoderma gangrenosum (a progressive ulcer that rapidly breaks down)
Arthralgia
Perianal fistulae

Coeliac Disease

Coeliac disease can cause dermatitis

herpetiformis, which occurs when excess IgA
produced vs gluten is deposited in the dermis.
There is an intensely itchy vesicular rash on
the extensor surfaces of the limbs and neck.
Diagnose it via skin biopsy. Treat with a glutenfree diet, and with topical Dapsone (topical
antibiotic which reduces the itch).

Down Syndrome
Aside from the obvious facial characterstics
(LMFAO Low set ears, Moon face, Flattening of
nose and occiput, Almond speckled eyes, Open
mouth) and the visceral malformation, people
with Down Syndrome have 2 characteristic skin
changes:
Single palmar crease
Palmaoplantar keratoderma (abnormally
thick skin on palms and plantar surfaces of
feet)

Type 1 Diabetes
There are 2 characteristic skin signs associated with T1DM: necrobiosis lipoidica
and granuloma annulare.
Necrobiosis lipoidica is a rare lesion that presents on the
shins of type 1 diabetics as a shiny, tender, yellow/brown
patch covered with telangiectasia which slowly grows. Minor
injuries tend to ulcerate. You dont necessarily need to treat
it, but it can persist for years and topical steroids help.
Granuloma annulare is a common lesion found in a number of
autoimmune conditions, often T1DM and autoimmune
thyroiditis. There are rings of small erythematous bumps,
usually on the backs of the forearms, hands and feet. They
are harmless and usually cause no discomfort, but can be
tender if bashed.