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Pediatric Dermatology Overview -‐ From Head to Toe
Joanna Guenther, PhD, RN, FNP-‐BC, CNE
September 2014
ObjecMves
• Discuss a systemaMc approach to common dermatologic condiMons of children encountered in primary care.
• Describe the clinical manifestaMons of common dermatologic condiMons of children.
• Review therapeuMc and pharmacologic treatments for each dermatologic condiMon.
History Taking
• Age, race, and sex • Onset/duraMon • LocaMon on body • EvoluMon of lesions • Treatment aUempted • Associated symptoms – Pruritus, fever, headache, GI, etc – Think infecMon with rash + fever
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AddiMonal Aspects of History
• Family history • Known personal contacts • Trauma • Travel & play • Environmental exposure – Insects, plants, toxins, sun, etc
• Season
Primary Skin Lesions
Atopic DermaMMs
Eczema Treatment: • Inherited predisposiMon -‐
oZen hx. Asthma, allergic rhiniMs, food allergies
• Usually affects cheeks, face, trunk, extremiMes
• Erythematous papules to scaly plaques
• Intense pruritus >> scratching >> risk of impeMgo
• RehydraMon of skin, anMhistamines, topical low potency steroid creams, Elidel or Protopic cream bid
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Seborrheic DermaMMs
Cradle Cap • Common during first several
months of life • OZen on face & scalp, but
can extend to other areas • Well circumscribed plaques
with scaling • Resolves by 6-‐12 months
Treatment: • Emollient – baby oil • Baby shampoo + soZ brush
ImpeMgo
Characteris4cs: Treatment: • InfecMon usually caused by
staph aureus; contagious • Red papules >>> fragile
vesicles >>> honey-‐colored crusted papules
• Bactroban (mupirocin) oint Md X 7 days; Altabax oint bid X 5 days + warm compresses and gentle washing
• Oral anMbx -‐ dicloxacillin, cephalexin, clindamycin X 7 days
• Recurrence: check for nasal carrier of MRSA with C&S swab (Bactroban intranasally)
MRSA • Methicillin-‐resistant staphylococcus aureus • Only responds to certain anMbioMcs – local anMbioMc suscepMbility (clindamycin 40 mg/kg in 3-‐4 daily doses or, bactrim 8-‐12 mg trimethoprim/kg in 2 daily doses)
• Enters through cuts and wounds • OZen starts as small bumps that resemble pimples and quickly turn to painful, deep abscesses
• Risk factors: contact sports, sharing towels, weakened immune system
• PrevenMon: Good handwashing
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CelluliMs
Characteris4cs: Treatment: • Erythema, edema, warmth, taut shiny
skin, tender • Erisypelas – superficial erythematous
patch >>> fiery red, indurated, tense • CelluliMs – deep infecMon, usually caused
by beta-‐hemolyMc Strep or Staph aureus, or complicaMon of wound or trauma (dog/cat bite)
• Cause staph or strep, complicaMon of wound or trauma (dog/cat bite)
• The borders are well defined and change rapidly
• Immediate aUenMon – C&S if draining; CBC; IV anMbioMcs followed by oral
• Facial celluliMs can cause visual damage if spreads to eyes
• Elevate & heat
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Trauma
• Animal Bite vs. Scratch – Cat & Dog Bite: Pasteurella species most common – also staph and strep
– Txment: Wound care, AnMbioMcs • Amoxicillin-‐clavulanate, doxycycline > 8 yrs old • Oral vs. parenteral depends on wound depth & severity • Tetanus/Rabies prophylaxis
– Cat Scratch: Bartonella pathogen most common • Azithromycin or clarithromycin most effecMve
Candidal Diaper DermaMMs
Characteris4cs: • Confluent bright red papules and
plaques with scaUered pustulo-‐vesicular satellite lesions
• Caused by moist environment, urine/stool increase the pH, fricMon from diaper
• Candida albicans invade
Treatment: • Frequent diaper changes;
expose skin to air • Topical pastes and ointments
to serve as a barrier – zinc oxide (DesiMn, A&D Ointment)
• AnMfungal creams (nystaMn, clotrimazole, miconazole)
• Severely inflamed – 1% hydrocorMsone sparingly bid for 5-‐7 days
• Mupirocin ointment only if infecMon present
Hand-‐Foot-‐and -‐Mouth
Characteris4cs: • Caused by Coxsackie virus
A16 • Abrupt onset of scaUered
papular & 3-‐6 mm elongated vesicular lesions on palms, soles & mouth
• Sxs: fever, malaise, joint aches, sore throat
Treatment: • SupporMve; oral ulcers
tender – Anbesol, Orajel • Lasts < 1 week
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Erythema InfecMosum
Fi6h Disease • Caused by parvovirus B19;
common in late winter & early spring; spread by resp. droplets
• Fever, malaise, h/a, sore throat, coryza >>> slapped cheek rash appears aZer 48 hrs >>> diffuse, lacy pink rash on body X 1-‐2 wks
• Contagious before rash
Treatment: • SupporMve (fever,
hydraMon); Good handwashing
Pityriasis Rosea
Characteris4cs: • Prodrome sxs: malaise, headache,
sore throat • Diffuse raised red patches with
central scales in Christmas tree paUern; first lesion is herald patch (large oval plaque) with more lesions 5-‐10 days later
• ? Viral eMology
Treatment: • Control pruritus: calamine,
topical steroids, oral anMhistamines
• Rash will subside without treatment – may last 6 weeks
Roseola
Characteris4cs: • Caused by Human
herpesvirus 6 (HHV-‐6) • Common age 7-‐13 months • High fever (oZen >104⁰ F)
and irritability for 3-‐5 days • Blanching maculopapular
rash develops as fever decreases
Treatment: • SupporMve: Control fever
and increased hydraMon
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Measles
Characteris4cs: • Rubeola – Paramyxovirus • Prodrome: fever, malaise, dry
cough, conjuncMviMs, photophobia >> 3-‐4 days rash develops
• NonpuriMc maculopapular, blanching rash starts on face and spreads to trunk & extremiMes
• Koplik spots on buccal mucosa • IncubaMon period 8-‐12 days
Treatment: • Highly contagious 4 days
before and aZer rash • SupporMve care: control
fever; increase fluids
Varicella
Chicken Pox • Fever, sore throat, malaise
X 2 D >>> rash starts on face or trunk and spreads downward
• Rash progresses from red macules >> papules >> vesicles >> umbilicated pustules >>> crusMng
• Less common since varicella vaccine
• IncubaMon 7-‐21 days
Treatment • SymptomaMc: Cool compresses,
oatmeal baths; RX. diphenhydramine, hydroxyzine, fexofenadrine, loratadine
• Watch for secondary impeMgo due to scratching
Verruca
Warts • Caused by HPV -‐ > 150
subtypes • Lesions raised, pink, rough
growths
Treatment • No rouMnely effecMve treatment
– may spontaneously resolve – Cryotherapy q wk X3 – Podofilox (Condylox) topical
0.5% soln bid for 3 consecuMve days/wk up to 4 weeks
– Aldara topical thin layer 3 X per week – alternaMng days
– Laser ablaMon
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Molluscum Contagiosum
Molluscum • Caused by pox virus – more
common in pedi; considered contagious
• Clusters of 3-‐5 mm flesh colored papules with umbilicated center; usually < 30 lesions
• Resolve spontaneously over months to yrs
Treatment • May treat to prevent spread to
others: – Cryotherapy – Laser ablaMon
Herpes Simplex Virus
Fever blister; genital herpes Treatment: • Either Type I or II • Clear papules with superficial
ulceraMons/erosions • OZen preceded by burning pain
• Acyclovir topical q 3 h X 7 D • > 2 yrs – acyclovir susp
20mg/kg qid X 5 D • Genital herpes – child abuse • Contagious
GuUate Psoriasis
Characteris4cs: Treatment: • Inflammatory changes occur
within the epidermis & dermis; increased turnover rate of dermal cells
• Numerous salmon-‐pink, scaling, small plaques on trunk and extremiMes (usually 2-‐4 weeks aZer strep pharyngiMs or URI)
• Rash usually resolves on own (weeks to months)
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Adolescent Acne
Characteris4cs: Treatment: • ObstrucMon of oil glands • Open comedones or closed
comedones; pustules, nodules, cysts
• Avoid oil based cosmeMcs • Mild: topical clindamycin and
erythromycin in AM & benzoyl peroxide 2.5-‐5% @ hs or topical reMnoids (Differin, ReMn-‐A) .025-‐.05% @ hs
• Moderate: above regimen + minocycline or doxycycline 50-‐100 mg bid, tapering to 50 mg/d as acne improves; OCP (progesMn & estrogen)
• Severe: Accutane – refer to dermatologist (labs & pregnancy test, contracepMon, informed consent)
Tinea CapiMs/Tinea Corporis
Characteris4cs: Treatment: • Well defined circular patches with
scaly borders • Occurs aZer contact with person/
animal that has fungus
• Topical anMfungals – Terbinafine (lamisil),
Miconazole, ketoconazole, not nystaMn (for candida)
• Use oral anMfungals if creams fail
Tinea Pedis
Athlete’s Foot Treatment: • Lesions are pruriMc and
scaly with raised border; may become fissured
• KOH examinaMon of scales – clusters of hyphae
• Keep feet dry • Contagious • Extensive – oral terbinafine, itraconazole • AnMfungal cream/powders (1-‐4 wks)
– OTC -‐Miconazole, clotrimazole
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Keratosis Pilaris
Characteris4cs: • Excess keraMn forms plugs in the
hair follicles • Symmetric sandpaper like
follicular papules • Considered a normal skin variant
Treatment • Emollients and mild
exfoliaMon
ParasiMc -‐ Pediculosis
Lice Treatment: • Nit (egg) adheres to hair >>>
develops into louse in 3-‐4 D >>> able to reproduce in 12 D >>> single ferMlizaMon needed to lay 10 eggs/day for 30 day life span
• Louse pierce the skin and secrete saliva which causes intense itching
• Spread by shared hats, clothing, towels, combs, etc.
• OTC pyrethrin (RID) and permethrin (Nix) – usually 2 txments 7-‐10 days apart; RX malathion loMon; benzyl alcohol; ivermecMn
• Fine tooth comb • Wash clothing/bedding in very
hot water; place nonwashable items in a sealed plasMc bag for 2 weeks
ParasiMc -‐ Scabies
Scabies Treatment
• Papular linear rash primarily on hands, feet, & body folds; pruritus; spreading rash
• Female mites burrow under skin and lay eggs
• Can survive off human host up to 4 days
• Skin scrapings – microscope
• Wash clothing/bedding in very hot water
• 5% Permethrin (Elimite) cream applied from neck to feet – wash off aZer 8-‐14 hrs; may retreat aZer 10 days
• AnMhistamine for pruritus
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Henoch-‐Schonlein Purpura
Characteris4cs: • IgA vasculiMs, oZen occurs
post viral • 2-‐10 years of age • Palpable purpura over the
buUocks and legs • Transient migratory arthriMs • Renal disease and
abdominal pain
Treatment: • SupporMve care: Adequate
hydraMon, rest, symptomaMc relief of pain
• HospitalizaMon in presence of renal insufficiency or worsening symptoms
Kawasaki Syndrome
Characteris4cs: • Systemic inflammaMon • Peak incidence 19-‐24 months • Clinical findings:
– Fever at least 5 days – ConjuncMviMs – Polymorphous rash – Strawberry tongue; cracked red
lips – Cervical adenopathy – Edema hands and feet
• Increased risk coronary thrombosis
Treatment: • HospitalizaMon for treatment and
close monitoring; high risk for cardiac complicaMons
A few closing thoughts… • Dermatology has its own
language – learn to speak it
• Obtaining a thorough history, along with the physical exam, will help idenMfy the rash/lesion
• Have a pictorial dermatology reference available
• Refer to a dermatologist as needed
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