Pediatric dermatology

Differences in adult and neonatal skin

Adult Skin Neonatal Skin

Surface Dry Vernix (gelatinous)

Full thickness 2.1 mm 1.2 mm

Epidermalthickness

> 50um40-50 um

20-25 um in premature

Dermo-epidermal Junction

Ridged Flat

Dermis NormalLess collagen &

elastic fibers

Melanosomes Normal Fewer

Hair Normal Less

Classification of pediatric skin diseasesInfective disorders:

Bacterial, Viral, FungalInfestations: Scabies, Pediculosis, ParasiticInflammatory/ Immunological disorders:

Eczemas, Psoriasis, Lichen planusGenetic/Nevoid disorders :

Hemangiomas, Linear epidermal nevus, Epidermolysis bullosa, Tuberous sclerosis, Neurofibromatosis, etc.

Neoplastic disorders:

Langerhans cell histiocytosis, Mastocytosis

Neonatal Dermatoses

Physiological• Vernix caseosa

• Mongolian spot

• Physiological scaling

• Sebaceous hyperplasia

• Sucking blisters

• Physiological jaundice

• Miliaria

• Milia

• Erythema toxicum neonatorum

• Transient neonatal pustulosis

• Neonatal Acne

Mongolian spotSingle or multiple slate gray or blue macules of

size 3 to 10 cmsSeen at birth Seen over lumbosacral region, buttocks,

shouldersFade within the first 3-4 years of life

Physiological scalingSeen in 75% normal infantsOccurs within first week of lifeFirst around the ankles, later on hands and feet

and soon becomes generalizedMaximum intensity by eighth day, subsides by

3-4 weeksNo treatment required

Sucking blisterOne or two solitary blistersPresent at birthSeen over fingertips / hands / forearmCaused by vigorous suckingHeals rapidly without treatment within 2 weeks

of lifeDifferential diagnosis: Herpes simplex, Bullous

impetigo, Epidermolysis bullosa

Miliaria

Superficial vesicles resulting from sweat retention in stratum corneum

A. Miliaria crystallina:Following fever, phototherapyTiny clear vesicles seen over forehead, neckErythema absentPeels off within 24 hrs

Miliaria

B. Miliaria rubra (prickly heat)Seen in hot weatherNon follicular papules on erythematous base1 to 4 mm in diameterTrunk, faceSubside in 2 to 3 daysItching, secondary infection is common

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 Epidermolysis bullosa Ichthyosis

Cradle cap Seborrhoeic dermatitis of scalp Thick, greasy, adherent scales on scalp Commonly begins in the first 3 months Self limitingApply oil for few hours to soften scales, rinse, 1%

hydrocortisone cream can be used

Diaper dermatitis (Napkin rash) Irritant dermatitis in the perineal regionDue 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

Nevus Depigmentosus Single, well circumscribed, hypopigmented or

depigmented macule or patch Seen at birth Stable in size and distribution Seen over trunk and proximal extremities

Linear epidermal nevus Congenital hamartomas of embryonal ectodermal

origin Seen in early childhood as a linear raised warty

lesion Located over neck, trunk and extremities

HemangiomasIncidence more in preterm infantsFemale predilection Begin at one month of ageUndergo a proliferative phase followed by

stabilization and eventual spontaneous involution

ComplicationsUlceration, bleedingSecondary infectionMutilation and scarringCosmetic disfigurement

Vascular malformationsStable dilatations of superficial or deep

vasculatureCan be capillary, arterial, venous, lymphatic or

mixed

Clinical types: Salmon patchPortwine stainSturge-Weber syndromeKlippel-Trenaunay syndrome

Salmon Patch Present in 30 to 40% of neonatesSuperficial, red or pink flat lesionsSeen over forehead, upper eyelid, glabellar area,

nape of neckResolution in first year of life

Portwine Stain (Nevus flammeus) Present at birthCommon sites are face, neck and mucous

membraneFlat pink-red lesion Sharply unilateral in distributionPersist in childhood and darker in adulthood

Complications Glaucoma, Choroidal angiomas

Sturge-Weber SyndromePortwine 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

Neurofibromatosis (NF)Riccardi classified NF into eight distinct clinical

types in 1982 Autosomal dominant disorder Affects skin, soft tissue, nervous system, bone,

other organsClassical skin lesions are café au lait macules,

neurofibromas

Neurofibromatosis - 1 (Von Recklinghausen’s disease)

Diagnostic criteria for NF-1

Presence of two or more of the following:Six or more café au lait macules larger than 5 mmTwo or more neurofibromas of any type or 1

plexiform neurofibroma Axillary or inguinal frecklingTwo or more Lisch nodules (brown coloured small

nodules on iris surface)Optic gliomaA distinctive osseous lesionA first-degree relative with NF-1

Neurofibromatosis - 2Bilateral acoustic neuromasMultiple CNS tumorsFew café au lait maculesFew neurofibromasNo axillary frecklingNo Lisch nodules

Tuberous sclerosis (Bourneville’s disease)

Syn. EPILOIA (Epilepsy, Low IQ, Adenoma sebaceum)

Ash leaf macules/ hypopigmented maculesAdenoma sebaceum (angiofibroma) begins at 2-5 years of age as small pink papules on mid-

faceShagreen’s patch (yellowish brown plaque on

lumbo - sacral area)Koenen’s tumors (periungual fibroma)Mental retardationSeizures

Epidermolysis bullosaInherited bullous disorders characterized by

blister formation in response to mechanical trauma

Onset at birth or shortly after Seen on sites of trauma and frictionTypes: Simple, Junctional, DystrophicSome subtypes, especially the milder EB forms,

improve with ageAutosomal recessive types have bad prognosis

with severe mucosal, esophageal involvement and atrophic scarring of skin

IchthyosisInherited disorder of keratinization Characterized by the accumulation of scales on the

skin surface, dry skinFish like scales most prominent over the trunk,

abdomen, buttocks and legs May be associated with ectropion, eclabion, nail

dystrophy, internal organ involvement

Types: Ichthyosis vulgaris X-linked ichthyosis Lamellar ichthyosis Collodion baby / Harlequin fetus

Adolescent DermatosesAcneDandruffStriaePseudo-acanthosis nigricansContact dermatitis to cosmetics, perfumes,

artificial jewellery / accessories (metals)Hyperhidrosis

Acne vulgarisCharacterized by comedones, papules, pustules

and nodules Common in malesSeen around puberty Sites: face, upper part of the chest, back,

shoulders

Complications Psychological impact Hyperpigmentation Scarring

Dandruff (Pityriasis sicca/capitis)

Most common condition affecting the scalpCausative organism: Malassezia speciesSeen as mild, moderate or severe scaling of scalpMay or may not associated with itchingSimple dandruff does not cause hair loss

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

Pseudo-acanthosis nigricans

Weight gain in puberty produces dark, thick, velvety skin in neck, axillae, groins

Asymptomatic

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

Child abuse

Includes physical abuse, neglect, sexual exploitation

Cutaneous manifestations Bruises Traumatic alopecia Thermal burnsSexual abuse: Vaginal tears, anal tears,

hematomasSexually transmitted infections

Care of newborn

Gentle handlingAvoid frictional traumaUse gentle soaps, cleansers Too frequent bathing may lead to drynessMaintain hygiene after feeds, diaper changesKeep body folds dry and ventilated

Skin care in pre-termsGentle handlingUse adhesive tape sparinglyAvoid frictional trauma

General principles of skin care in children

Bathing, soaps and cleansersThere is no need to use special cleansing

productsExcessive cleansing, scrubbing and incomplete

rinsing lead to irritation

ShampoosShould be isotonic to tears and less irritating to

eyesShampooing twice a week controls normal flaking

Care of the diaper areaFrequent diaper changes with gentle cleansing

and limiting use of plastic or rubber diaper cover

Differences in treatment of Paediatric and Adult Patients

Conservative management is bestSurface area is more in children as compared

with adultsPercentage of absorption of topical drugs is

moreTry to use lowest effective dose of medicationsDo not use treatments which may retard growth

or mental developmentAvoid off-label uses of medications

Thank you