Pediatric Dermatology

Pediatric Dermatology
BY: AMR MOHAMMED ABDULLAH

11110053
INTERNAL MEDICINE
18th, November 2015
Pediatric Dermatology- Amr M.
Common Transient Neonatal

Skin Conditions
Erythema toxicum
(neonatorum)
First 3 to 5 days of life
Central, small welt or

pustule on a broader
erythematous base
Scraping of erythema
toxicum reveals
eosinophils
Resolves
spontaneously
18th, November 2015

Skin Conditions
Miliaria (prickly heat)
First few weeks of life
Caused by keratin
plugging of eccrine
(sweat) glands in the
skin
eruption of
microvesicular lesions
on the face, neck,
scalp, or diaper area
Tx: dressing infant

lightly & avoiding
excessive humidity
18th, November 2015

Skin Conditions
Milia
White or yellow
micropapules that
develop when the
pilosebaceous unit is
obstructed by
keratin/sebaceous
material
Clustered on nose,
cheeks, chin, forehead
Resolve w/o tx within

several months
18th, November 2015
Eczematous Rashes
Seborrheic dermatitis
Neonatal form
First several months of life
Cradle cap and then extend to other
areas of skin where sebaceous glands
are dense
Forehead,
eyebrows, behind the ears, sides

of nose, middle of chest, umbilical,
intertrigignous, and perineal areas in infant
Lack of pruritus
Well circumscibed plaques with a greasy,
yellow-orange overlying scale
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Eczematous Rashes
Resolve by 8-12mo of age
Recur in childhood &

adolescence (hormones)
TX: antiseborrheic shampoo
Persistant scalp seborrhea2% ketoconazole shampoo
Residual scalp lesions- 1%

hydrocortisone topical
steroid cream
*If rash is persistant or

severe or is accompanied
by anemia, adenopathy, or
HSM- r/o histiocytosis
18th, November 2015
Eczematous Rashes
Atopic Dermatitis
eczema
erythema
microvesicles (often
confluent)
weeping and crusting
thickening
(lichenification) of the
involved skin secondary
to chronic scratching
inherited predisposition
of the skin
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Eczematous Rashes
Incidence
2-3%
winter and in temperate or cold climates (air is

dry)
Develops in conjunction with 2 other diagnoses

of the atopic triad
asthma, allergic rhinitis (in the patient or family

members)
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Eczematous Rashes
Pattern
Infants- face
Toddlers- extensive surfaces of the arms and legs
Older children and teens- antecubital and

popliteal areas, neck, and face
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Eczematous Rashes
Treatment
Interrupt the itch-scratch cycle

oral
antihistamine or colloidal oatmeal baths

unscented topical moisturizers ( after tepid
bath with mild soap)
Inflamed lesions -topical steroid cream or
ointment
ointments are more potent (not on face,

intertriginious areas)
Tacrolimus and pimecrolimus (topical

immunomodulators)
Secondary infection (Staph aureus)

oral
18th, November 2015
antibiotics or topical mupirocin

Eczematous Rashes
Contact dermatitis
typical pattern
patches, linear arrays,

and unusual distributions
Poison Ivy, oak or sumac
Rhus dermatitis
erythema develops on
skin when contact
with oil of plant leaves
or stemrapidly
becomes
microvesicular
progress to larger
blisters..open and
weep
pruritic
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Eczematous Rashes
Treatment
Oral antihistamine
Topical steroids (moderate potency)
If rash is extensive or involves genitalia or the

skin around the eyes
18th, November 2015
Oral steroids 1-2mg/kg/day X1 week and then wean

during the second week to prevent rebound rash
Eczematous Rashes
Acrodermatitis
enteropathica
AR disorder
zinc deficiency
similar presentation to
nutritional zinc deficiency
usually presents in
genetically susceptible
infants that have been
breast-fed and are now
weaning
18th, November 2015
? Zinc-binding ligand in
breast milk that
enhances zinc absorption
up to the time of weaning
Eczematous Rashes
Presentation
rash- moist, erythematous, papular,

forming plaques on the skin around orifices
and on the acral areas (hand and feet)
foul-smelling, frothy diarrhea, alopecia,

irritability or apathy, generalized failure to
thrive
Labs: low levels of zinc, alkaline

phosphatase (zinc-dependent enzyme)
18th, November 2015
Eczematous Rashes
Treatment
5mg of zinc sulfate/kg/day
dramatic reversal of symptoms
18th, November 2015
Papulosquamous Rashes
(raised
and covered with fine scales)
Pityriasis
rosea
most
likely seen in
teens and older
children
cause
unknown
?viral
18th, November 2015
initial lesion
herald patch
2-4cm scaly round or oval plaque w/raised border
5-7days later
typical exanthem follows Xmas tree
2-10mm ovoid, slightly raised plaques with central

scaling in addition to smaller individual papules
rash lasts 6-10 weeks
TX: Resolves w/o treatment
***secondary syphillis mimics this..however

syphillis involves palms and soles**
18th, November 2015
Psoriasis
1-2% adults
35% <20years
60% pediatric
patients have
relative w/ psoriasis
Precipitating factors
trauma,
cold, stress,
group A B-hemolytic
strep infection
18th, November 2015
Guttate psoriasis
2-4 weeks after strep infection
drop like lesions
Lesions
red-based plaques w/ fine, adherent

silvery scale;
Auspitz sign- removal of scale produces

pinpoints of bleeding
knees, elbows, scrotum, scalp
Nail pitting
18th, November 2015
Treatment
minimal
use of soap
liberal
use of thick emollients,

keratolytics(w/salicylic or lactic acid)
topical
steroids
Calcipotriene
(synthetic Vit.D3
analogue) topical cream or ointment
good results in teens and adults
Consult
18th, November 2015
Dermatologist
Vascular Malformations
and Hemagiomas
hamartomas of mature endothelial cells
blood flow is normal or slower than normal
present at birth and enlarge with body growth
can affect growth of underlying bone and soft tissue

asymmetric overgrowth
Klippel-Trenaunay syndrome
salmon patch
MC
seen on the forehead, glabella, philtrum, or upper eyelids of

about a third of newborns
very red when infant cries
fades by 18-24 months of age
exception: nape of neck
18th, November 2015
Vascular Malformations and

Hemagiomas
Klippel-Trenaunay
syndrome
18th, November 2015

Hemagiomas
Salmon
18th, November 2015
patch
and Hemagiomas
Port wine stains
mature, dilated dermal capillaries

persistent
if the distribution involves the opthalmic
(upper eyelid to forehead) branch of the
trigeminal nerve
18th, November 2015
Sturge- Weber syndrome
ipsilateral leptomeningeal involvement and

intracranial calcifications
MRI or CT
seizures (60-90%), half are mentally retarded
glaucoma
tx: pulsed tunable dye laser

Hemagiomas
Portwine
stain
Sturge-Weber
syndrome
18th, November 2015
and Hemangiomas
Hemangiomas
benign neoplasms of endothelial cells
rapid blood flow and an increased density of

mast cells within the lesions
grow rapidly during infancy, then plateau

and begin to involute by 18-24 monts of age
50% resolve by 5years of age
70% by 7 years
90% by 9years
Occur in 10-12% of children
90% resolve without treatment
18th, November 2015
and Hemangiomas
Management
Watch
If interferes with vision or obstructs the airway or

involve lip or breast tissue
18th, November 2015
active intervention with steroids, interferon, or laser

treatment

Hemangiomas
Superficial
hemangiomas
strawberry
hemangiomas
well
defined,
raised, and light to
deep red in color
18th, November 2015

Hemangiomas
Deeper
(caveronous)
hemangiomas
capillary
growth
into the dermis
and subcutaneous
tissue
soft
18th, November 2015
blue to red

Hemangiomas
Kasabach-Merritt
syndrome
large hemangioma
thrombocytopenia
consumptive
coagulopathy
not true
hemangiomas
tugted angiomas or
kaposiform
hemangioendothelio
ma
18th, November 2015
Pigmented and
Hypopigmented Lesions
Mongolian
dermal
spots
melanosis
African
American,
Asian, Hispanic, or
Mediterranean
descent
lower
spine,
shoulders, and arm
most commonly
18th, November 2015
Pigmented and
Incontinentia pigmenti
X-linked or AD
affecting the skin, central

nervous system, eyes,
and skeleton
Skin manifestations (4
phases)
18th, November 2015
inflammatory vesicles
seen in neonates---evolve over several
months to verrucous
lesions----lesions develop
into swirled brown to
gray patches and finally
become hypopigmented
Pigmented and
Nevus sebaceus of
Jadassohn
sebaceous glands and

rudimentary hair follicles
initially hairless, yellow to

orange plaque that
becomes darker and
thicker at puberty
scalp
10-15% risk for

neoplastic transformation
excision before puberty
18th, November 2015
Pigmented and
Urticaria pigmentosa
MC of the general diagnostic group of mastocytosis disorders
Majority of cases
pathologic accumulation of mast cells
present at 3-9 months of age
multiple reddish brown macules, papules, or nodulesurticate

when firmly rubbed
Darier sign
trunk more than extremities
Systemic involvement( bone, liver, spleen, lymph nodes, other

tissue)..if onset is after 10yo
Prognosis: good if onset <10yo
Tx: oral antihistamines prn
18th, November 2015
avoid food and meds that cause mast cell degranulation (codeine,
aspirin, opiates, procaine, contrast agents, alcohol, cheese, spicy
foods)
Pigmented and
Urticaria
pigmentosa
18th, November 2015
MCQs
18th, November 2015
1.Which treatment choice would be contraindicated in a oneyear old child who presents with monomorphous, nonpruritic
flat-topped papules on the face, buttocks, extremities, palms
and soles?
1
Advil
2
Acetaminophen
3
Hydration
4
Corticosteroids
5
Observation
18th, November 2015
2. Most common malignancy associated with multiple

lesions similar to the attached image is:
1
Acute myelogenous leukemia
2
Chronic myelogenous leukemia
3
Acute lymphocytic leukemia
4
Chronic lymphocytic leukemia
5
Melanoma
18th, November 2015
3. A newborn has a nodule over his lumbar spine. Skin

biopsy reveals a lipoma. The next appropriate step is:
1
Observation
2
Excision of the lesion
3
Genetic testing
4
Imaging study
5
Malignancy work up
18th, November 2015
4. A patient presents with multiple juvenile xanthogranulomas, axillary

freckling, multiple caf-au-lait macules, three neurofibromas and a family
history of NF-1. What other condition is this patient at increased risk
for?
1
AML
2
CML
3
CLL
4
Medulloblastoma
5
Pancreatic carcinoma
18th, November 2015
5. Schimmelpenning-Feuerstein-Mims syndrome may be associated with

which of the following:
1
Osteopokilosis
2
Polyostotic fibrous dysplasia
3
Osteopathia striata
4
Chondrodysplasia punctata
5
Hypophosphatemic rickets
18th, November 2015
6. The differential diagnosis of zinc deficiency is least likely to include:

1
Granuloma gluteale infantum
2
Biotin deficiency
3
Multiple carboxylase deficiency
4
Cystic fibrosis
5
Holocarboxylase synthetase deficiency
18th, November 2015
7. All of the options result in an eczematous acrodermatitis

enteropathica-like eruption except granuloma gluteale infantum. As the
name suggests, the lesions of granuloma gluteale infantum are
granulomatous.
Multiple cylindromas are associated with:
1
Myotonic dystrophy
2
Cowden syndrome
3
Carney complex
4
Trichoepitheliomas
5
Pilomatrichomas
18th, November 2015
8. A full term neonate is noted to have small pustules with no underlying

erythema present at delivery. The pustules are easily removed with
clearing of the vernix and a collarette appears. A gram stain is done
showing predominately neutrophils without bacteria. What is the most
likely diagnosis?
1
Miliaria
2
Erythema toxicum neonatorum
3
Transient neonatal pustular melanosis
4
Congenital candidiasis
5
Urticaria pigmentosa
18th, November 2015
9. Transient neonatal pustular melanosis typically begins with sterile

pustules that leave a characteristic collarette when ruptured. The lesions
heal with hyperpigmented macules.
Which of the following may be associated?
1
Paronychia
2
Cleft palate
3
AVM
4
Seizure disorder
5
Atrial septal defect
18th, November 2015
10. Nevus sebaceus can very rarely be associated with multiple

anomalies. Schimmelpenning syndrome can include seizure disorder,
mental retardation, coloboma, as well as skeletal, cardiac and
genitourinary abnormalities.
What syndrome can accessory tragi be associated with?
1
Goldenhar syndrome
2
Turner syndrome
3
Neurofibromatosis
4
Ichthyosis
5
Birt Hogg Dube
18th, November 2015
References
Fitzpatrick's Dermatology in General Medicine, 8e:

Chapter 107. Neonatal, Pediatric, and Adolescen
t Dermatology
CURRENT Diagnosis & Treatment: Pediatrics, 22e: Skin
18th, November 2015

Pediatric Dermatology

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Pediatric Dermatology

BY: AMR MOHAMMED ABDULLAH

18th, November 2015