Common Skin Disorders In Children

COMMON SKIN CONDITIONS IN CHILDREN By

Dr.Ahmed Noureldin Ahmed MBBS,DCH,DTM&H (Cairo)

Introduction • The conditions to be described are everyday occurrences in paediatric primary care. Yet, as applies to so many commonly seen conditions, there are many controversies and unanswered questions regarding aetiology and treatment.

Question 1 • This infant is 24 hours old. There are red patches on the trunk. What is the rash likely to be?

Answer 1 • Erythema toxicum neonatorum (neonatal urticaria) – Despite its impressive title this is a harmless skin condition seen in most neonates at and soon after birth. The commonest lesion is an erythematous macule with a central tiny papule, occurring anywhere on the body except the palms and soles.

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Answer 1 (Contd…) Sometimes there may small pustules at the centre of lesions and the danger then is that they are regarded as signs of sepsis, which is not the case. The lesions are packed with eosinophils, and there may be accompanying eosinophilia in the blood count. The cause is unknown, and no treatment is required as the rash disappears after 1-2 weeks.

Question 2 • What lesions do you see on this infant's face?

Answer 2 • Milia are tiny cysts of the sebaceous glands. They are seen in about half of all neonates in the early weeks of life, as firm pearly white papules about 1-2 mm in size, in areas like the nose and forehead where sebaceous glands are abundant. They disappear at about 4 weeks. No treatment is required apart from avoiding greasy preparations.

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Answer 2 (Contd…) • Lesions just like adolescent acne may also be seen in the first month or two of life. Papules and pustules are seen mainly on the cheeks, presumably due to stimulation of the sebaceous glands by maternal androgen. Again, treatment is unnecessary as the condition is almost always self-limiting.

Question 3 • What is miliaria?

Answer 3 • Sweat rash, or miliaria, results from obstruction to the sweat gland openings with retention of sweat. It is seen in two forms:

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Answer 3 (Contd…) • In Miliaria crystallina there are numerous tiny clear vesicles, usually on the forehead. It is probably caused, or aggravated by plugging of the pores with vaseline or other greasy ointments.

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Answer 3 (Contd…) • In Miliary rubra there is obstruction of the sweat ducts at a deeper level in the skin. Many red macules with central papules, vesicles or pustules are present. These may be on the trunk, nappy area, head or neck. The rash is caused by heat and overdressing. Plastic pants, the overuse of vaseline and the under-use of bathing probably play a part.

Question 4 • Describe the problem here.

Answer 4 • Sepsis. The umbilical stump is an excellent culture medium. Any infant with a smelly stump, purulent discharge, redness, or swelling around the cord should be evaluated for sepsis, and an antibiotic is indicated. The local infection can spread rapidly to any organ, including the brain, and there is the danger of portal vein thrombosis. Remember the possibility of neonatal tetanus also.

Question 5 • What is the cause of the lesion in the umbilical stump?

Answer 5 • Granuloma. When the cord drops off, a small pink or red polyp-like lesion may form in the base of the cord. The cause is unknown - it may result from a foreign body reaction to talcum powder. It is easily dealt with by cauterising it with silver nitrate.

Question 6 • What is the cause of a watery discharge from the umbilicus?

Answer 6 • Persistent discharge, if watery, may signify a patent urachus (connection with the bladder), and referral is essential. • Types of umbilicus. There are 3 types, depending on how the skin of the abdominal wall meets the umbilicus: – (1) flat - the skin meets the cord at the level of the wall

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Answer 6 (Contd…) – (2) indented - the abdominal skin does not reach the base of the cord, and the gap is filled in by amniotic sac. This results in an indentation – (3) the abdominal skin extends up the cord, resulting in a protruding umbilicus. This last type does not result in a hernia as there is no defect in the abdominal wall

Question 7 • What causes an umbilical hernia?

Answer 7 • An umbilical hernia results from incomplete closure of the umbilical ring, and often a defect in the abdominal musculature. Most close spontaneously by the age of 12 months, and even moderate and big ones will eventually disappear by puberty. No treatment is required as strangulation is extremely rare. The exception is in adult female, where there is a risk of incarceration or strangulation during pregnancy. A persisting hernia should therefore be repaired in girls during puberty.

Question 8 • This infant is thriving, but has a widespread, non-itchy rash. What is it?

Answer 8 • Seborrhoeic dermatitis - This is a common, generally self-limiting condition in infants affecting the scalp, trunk and flexures. Its cause remains ill-understood. There is undoubtedly a genetic basis to 'seborrhoea' and in affected families it occurs also in older children and adults. Seborrhoeic dermatitis is most frequent between the ages of 1 to 6 months. Continued...

Answer 8 (Contd…) The rash has erythematous and a scaly components; scaling is particularly prominent on the scalp, producing thick greasy crusts ('cradle cap'), the sides of the nose, glabella and ears. Red scaly patches of quite startling appearance may be present on the trunk. The flexures of the neck, axillae and groins may become reddened and weepy, and are then prone to secondary yeast or bacterial infection. The rash causes no discomfort or itching

Question 9 • What types of 'nappy rash' do you know?

Answer 9 • Nappy rash or napkin dermatitis, is not a single entity and refers to a number of different conditions which may affect the area covered by the napkin: – non-specific (generic) – minilial – nodulo-ulcerative – seborrhoetic dermatitis – impetigo – folliculitis – intertrigo

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Answer 9 (Contd…) • Some of them will be explained with an image.

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Answer 9 (Contd…) • Non-specific - there is erythema and later dryness and wrinkling of the exposed parts of the nappy area - the buttocks or thighs. Because of the depths of the folds these are usually spared. This type of rash was long attributed to production of ammonia by urea splitting organisms ('ammoniacal dermatitis'), but this theory has been disproved

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Answer 9 (Contd…) • Candidal - This form starts off in the deep flexures which show diffuse inflammation. There are also rounded red spreading lesions with a typical scale round the edges. It is uncommon for the rash to spread beyond the margins of the nappy as moisture and warmth are required by the yeasts for growth. However persistent more widespread candidal rashes are now increasingly being seen in HIV infected infants.

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Answer 9 (Contd…) • Nodulo-ulcerative Largish nodules with central erosions but no pus formation. Usually on the labia, penis, scrotum or anterior thighs.

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Answer 9 (Contd…) • Infantile seborrheic dermatitis. Here the nappy rash is part of the picture described earlier. A beefy red sharply marginated rash without pustules or erosions appears rapidly. The rash spreads by peripheral extension of satellite lesions. The skin is unbroken. The infant is virtually asymptomatic and the parents are disturbed more than the child. There is also involvement of flexures elsewhere and usually scalp crusting is present.

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Answer 9 (Contd…) • Impetigo - there are many superficial bullae, most of which rupture quickly • Folliculitis - tiny inflamed follicles and superficial pustules - also generally staphylococcal • Intertrigo - involvement predominantly of the groin flexures. Causative organism(s) uncertain.

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Answer 9 (Contd…) • Less commonly the nappy rash may be due to atopic or contact dermatitis, with sensitivity to elastic, fabric softener, or soap powder • It may be the first manifestation of psoriasis

Question 10 • What are the causes of nappy rash?

Answer 10 NAPKIN DERMATITIS AETIOLOGY • • • • • • • •

Maceration Friction Irritation Ammonia formation (??) Candidiasis Bacterial overgrowth Zinc deficiency Cloth vs. disposable

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Answer 10 (Contd…) • Maceration of the skin, friction, heat and diarrhoea play a major part in the cause of napkin dermatitis • Candida albicans. The role of yeasts is controversial. C.albicans can frequently be recovered from infants with a variety of nappy rashes and the role of candida is probably vastly overplayed

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Answer 10 (Contd…) • Bacterial overgrowth. The napkin area is a marvellous culture medium and the normal density of aerobic bacteria in cases of napkin dermatitis increases three or four fold. However it is well known that bacteria will proliferate on inflamed skin and the role of bacteria is still not well established

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Answer 10 (Contd…) • Cloth vs. disposable napkins. Undoubtedly a higher incidence of rashes is seen in those using home laundered (or unlaundered!) cloth napkins. On the other hand, the use of disposable napkins in association with lack of personal hygiene is no guarantee to an unblemished nappy area. Recently biotechnology has produced disposable napkins which are far less liable to retain moisture

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Answer 10 (Contd…) • Zinc deficiency. Premature infants fed intravenously on zinc deficient formulae may develop severe erythematous nappy rashes, with similar lesions in skin folds elsewhere and around the mouth. Zinc deficiency may also play a part in the severe rashes seen in kwashiorkor. Persistent rashes are also due to zinc deficiency in the rare condition of acrodermatitis enteropathica

Question 11 • What serious conditions may present with napkin dermatitis?

Answer 11 • Children with protein-energy malnutrition often have severe rashes. • Persistent nappy rashes are a feature in HIV/AIDS. • Two rare causes are: – Langhans cell histiocytosis – and acrodermatitis enteropathica

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Answer 11 (Contd…) • This child with Langhans cell histiocytosis presented first with a severe and resistant napkin dermatitis

Question 12 • What is the Treatment?

Answer 12 • Most first episodes can be managed easily by the following: – Increased frequency of changing and thorough cleansing between nappy changes. Warm tap water and a mild neutral soap should be used (Johnson's Baby Soap). The skin should then be dried and simple protective cream used Desitin, zinc oxide ointment, Lassar's Paste or Nivea

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Answer 12 (Contd…) – Impetigo and folliculitis should be treated with an appropriate antibiotic. – Seborrheic dermatitis. This responds promptly to 1% hydrocortisone cream together with exposure to sunlight. – Intertrigo responds promptly to Vioform and hydrocortisone cream. – Candida: Vioform and hydrocortisone cream is also extremely effective. Give nystatin cream t.d.s. only if typically candidal

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Answer 12 (Contd…) • For more severe rashes the importance of good hygiene and exposure to sunlight should be emphasised. One cream is effective for all cases - Vioform and hydrocortisone. The former has mild antibacterial, and anti-fungal, and the latter anti-inflammatory properties • Kwashiorkor and vitamin and trace mineral deficiencies may well be present in some cases. Neglect frequently manifests with the presence of severe nappy rash

Question 13 • Describe these lesions.

Answer 13 • Staphylococcal and streptococcal impetigo impetigo is a superficial infection of the skin manifested by blisters or pustular lesions which rapidly become crusted. It is caused by coagulase positive Staph. aureus, or by certain strains of Group A beta-haemolytic strep. Both organisms are found together in 50% of cases. Staphylococcal infection is more likely if the intact skin is affected (especially the face), and if bullae are present.

Question 14 • What are these lesions on the legs?

Answer 14 • Streptococcal impetigo. Strep. impetigo tends to complicate eruptions such as scabies and insect bites (papular urticaria), to involve the lower limbs more often, and to produce deeper lesions (ecthyma). If draining glands are enlarged Strep. is more likely • TREATMENT – All cases of impetigo should be treated with a systemic antibiotic. Continued...

Answer 14 (Contd…) Community studies in Cape Town have demonstrated the universal resistance of Staph. pyogenes to penicillin. The treatment of choice in community settings should therefore be erythromycin 25mg/kilo/day 3 times a day for 5 days, or cotrimoxazole, 2.510ml twice daily for 5 days. Local treatment is of lesser importance. Use vioform emulsion or povidine-iodine cream, but NEVER antihistamine or antibiotic creams. Continued...

Answer 14 (Contd…) • Other manifestations of these common skin pathogens are seen in the following slides:

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Answer 14 (Contd…) • Recurrent folliculitis and boils

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Answer 14 (Contd…) • Streptococcal perianal cellulitis. This results in an angry red eruption around the anus. – NB Scalded skin syndrome is caused by certain strains of staphylococci. The surface layer of the skin rapidly separates over large areas.

Question 15 • What conditions could you confuse with impetigo?

Answer 15 IMPETIGO DIFFERENTIAL DIAGNOSIS • Impetigenisation – Scabies – Pediculosis – Eczema, etc • Herpes simplex • Varicella/zoster Continued...

Answer 15 (Contd…) • Hand foot and mouth disease • Fungal infection • Contact dermatitis

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Answer 15 (Contd…) • Varicella. Blisters are uniform in size, come out in crops, and are widespread. The may become secondarily infected, i.e. there is superimposed impetigo.

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Answer 15 (Contd…) • Herpes simplex - The lips and oral mucosa are commonly primarily affected. Again, there may be secondary infection of these viral lesions.

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Answer 15 (Contd…) • Herpes zoster. The blisters are in a characteristic pattern over the distribution of a nerve or ‘dermatome’. • Hand foot and mouth syndrome. This viral infection (usually Coxsackie A) causes a crop of blisters symmetrically situated over the hands, feet, knees or elbows, with a few in the oral cavity.

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Answer 15 (Contd…) • Tinea corporis. This fungal lesion is usually a single plaque with a well demarcated slightly raised edge. Management will be discussed in the next programme.

Question 15 • This 6 month old baby has an itchy rash over the trunk for 3 weeks. What is the likely cause?

Answer 15 • SCABIES is a highly itchy eruption caused by sensitisation to sarcoptes scabeii mites, their eggs and excreta. The mites burrow in the epidermis, and have a prediliction for the chest and abdomen, genitalia and extremities, particularly the wrists and hands. The mature female mite is shown in the next slide:

Answer 15 (Contd…) • In hot climates the mites remain in the superficial layers, producing only small papules, and linear burrows are not present. Herd or individual immunity is never produced. • Personal skin contact is the predominant factor in infectivity, and the importance of clothing and bed-linen has been exaggerated.

Question 16 • What is the treatment?

Answer 16 • Benzyl benzoate is the most commonly used form of treatment in SA. It is not dangerous when taken systemically. However the ointment causes burning in full strength (25%) and must be diluted to 12.5% in children. There are concerns about its safety in infancy, and it should only be used at quarter strength in infants under 6 months.

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Answer 16 (Contd…) • Lotions and creams containing 1% gamma-benzene hexachloride (GBHC) have been use for many years, but concerns have recently been expressed about CNS toxicity, both as a result of oral intake, and from absorption through the skin when used excessively. The treatment however is effective and pleasant. – DO’S with GBHC: • apply to cool dry skin • only leave on for 6 hours

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Answer 16 (Contd…) – DONT’S with GBHC: • not in children under two • not in malnourished • not in sick children • not on inflamed skin. • Alternative therapies are crotamiton (Eurax), sulphur cream, and Tetmosol soap. None of these is curative in severe cases.

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Answer 16 (Contd…) • An extremely effective, safe , and cosmetically acceptable treatment for both scabies and head lice is the synthetic pyrethrin Permethrin. This is not yet available in South Africa.

Question 17 • What do you see in this child's hair?

Answer 17 • The characteristic eggs of headlice (nits) can be seen as little white specks, glued to the scalp hairs. Pediculosis capitis is a common infestation of the scalp in children. The adult louse feeds on blood by biting into the scalp. Itchy papules result and these often become infected from scratching, resulting in impetigo of the scalp. Posterior cervical and occipital nodes are frequently enlarged. The eyelids can also be involved. In adolescents, pubic and axillary hair may be infested.

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Answer 17 (Contd…) • These are adult headlice (pediculus humanis) attached to the teeth of a comb.

Question 18 • What is the appropriate treatment?

Answer 18 • Malathion 0.4% in alcohol is a cheap, safe and effective treatment. This kills lice as well as nits, so that the hair need not be removed. • Permethrin 1% lotion, is a pleasant and effective preparation which also kills the eggs. • Benzyl benzoate, still widely used, is messy and less effective • Gamma benzene hexachloride 1% - effective but poisonous when swallowed! • NB!!! Treat the whole family is the condition is highly contagious.

Question 19 • Describe what you see, and what is the likely cause?

Answer 19 • There are many itchy papules on the back, some of which have become infected from scatching. The condition, papular urticaria, is common in the hot months. Repeated bites from fleas, or sometimes bed bugs, result in hypersensitivity and marked itching at the site of both fresh and old bites. Haemolytic streptococci are a frequent secondary invaders.

Question 20 • What treatment would you prescribe?

Answer 20 • A blitz on fleas within the house is essential spray the bed mattress and the cracks in the floor with a good insecticide. However, outdoor sandfleas are often responsible. • Crotamiton cream (Eurax) is helpful - it is both anti-pruritic and antiseptic (as well as having an anti-scabies action). Apply it three times a day.

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