Pediatrics skin disorders

1
Objectives

At the end of this session, you will be able to:

 Mention common pediatric skin lesions
 Explain common pediatric skin problems
 Diagnose and treat common skin infections

2
Introduction
 Skin is the largest and most superficial organ of
the body.
 Integument System/skin system
contains: skin, hair, nails and glands.
 Nearly, one third(1/3rd) of the pediatric out
patient visits involve a dermatology complaints.

3
Cont…
 The skin consists of 3 layers :
1.Epidermis- is non vascular outer most layer,
continuously dividing cells.
 It provides the initial barrier to the external
environment.
 Contains melanocytes and gives color to the skin.
2. Dermis-is the middle layer of skin
 Takes the largest portion of the skin and provides
strength and structure.

4
Cont….
 It consists of glands (sebaceous, sweat), hair follicle,
blood vessels, and nerve endings.
3. Subcutaneous tissue (hypodermis)
 The inner most layer
 It composed of a type of cell known as adipocytes

specialized in accumulating and storing fats.

 Contains major vascular networks, fat, nerves, and

lymphatics.

5
Cont…

6
Function of the skin
 Protection (e.g, protect from UV rays and
infection).
 Thermoregulation
 Immunologic response
 Fluid balance (excretion)
 Secretion of wastes
 Sensory perception
 Vitamin D synthesis

7
Morphology of skin lesions

 Primary skin lesions: Initial pathologic

change.
 Secondary skin lesions: result from external
forces such as scratching, picking, infection, or
healing of primary lesions.

8
Primary skin lesions
 Macule : Flat ,non palpable discoloration < 1 cm in size
 Patch :flat ,non palpable discoloration > 1 cm in size
 Papule: solid palpable lesion < 1cm in size, flat topped or

dome-shaped
 Nodule : Dome- shaped solid palpable lesion > 1 cm
diameter
 Plaque: Raised flat, solid palpable lesion > 1 cm;
 Tumor Solid elevated lesion > 2 cm diameter;
 Vesicle :Fluid-filled (clear) < 1 cm diameter, usually < 0.5cm
 Bulla : Large fluid-filled (clear) elevation > 1 cm diameter
 Pustule : Vesicle or bulla with purulent fluid
 Cyst : Cavity lined with epithelium containing fluid, pus, or

keratin
9
Cont….
Vesicles Bullae

Figuer 3.
Figuer 2.
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Secondary skin lesions
 Exudate:Moist serum, blood or pus from either an erosion,
blister or pustule
 Scale: dry, flaky surface with normal/abnormal keratin;
present in proliferative disorders
 Lichenification: Accentuation of normal skin lines caused
by thickening, primarily of the epidermis, due to scratching
or rubbing.
 Excoriation: Localized damage to skin secondary to
scratching
 Scar:Healed dermal lesion caused by trauma, surgery,
infection.
 Fissure: Linear crack in the skin, down to the dermis eg.
warts
11
Common Disorders of the Skin

I. Inflammatory and II. Bacterial infections

allargic skin disorders
 Cellulitis
 Acne  Folliculitis
 Psoriasis  Boil(furuncle)
 Atopic dermatitis  Carbuncle
 Contact dermatitis
 Impetigo
 Sebhorric dermatitis

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Skin disorder cont…
III. fungal infections IV. Viral infections

 Tineapedis  Herpes simplex(cold

(athlet's
foot) sore)
 Herpes zoster (shingles)
 Tinea captis
V. Parasitic infestations
 Tinea corporis  Scabies
 Tinea versicolor  Pediculosis

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I. Inflammatory and allergic condition
A. Acne
 Is a very common skin condition characterised by
blackheads or white heads and pus filled spots
(pustules) .
 It usually starts at puberty but occasionally may

occur in young children.

 Cuases: hormona l(testosterone)reaction with

sebaceous gland, acne bacterium and familial

history

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Sign and Symptoms
 Oily skin
 Blackheads and white heads
 Red spots and yellow pus-filled pimples
 Scars
 Occasionally, large, tender spots or cyst may

develop

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Sign and symptom con’t…

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Diagnosis of acne
 History
 Acne is easily recognized by the appearance of spots

and by their distribution on the face, neck, chest or

back during physical exam .
 Treatment:
 Topical retinods
 Topical antibiotics
 Topical(gels, creams and lotions) eg. Benzoyl

peroxide

17
Inflammatory and allergic condition con’t…
B. Eczema, also known as dermatitis, is a syndrome
characterized by superficial inflammation of the
epidermis and itching.
 Types

A. Atopic Dermatitis (Autoimmune allergy to own

skin)
 Is a Chronic, highly inflammatory skin disease,
associated with remitting course.

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Atopic dermatitis con’t…

 Starts during infancy and early childhood

and persists into puberty and sometimes
adulthood.
 Is characterized by an immediate (type 1)
hypersensitivity reaction

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Con’t….
 Most pts has a genetic predisposition for
hypersensitivity reactions such as asthma,
allergic rhinitis, and chronic urticaria.

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Figuer 5.

Figuer 4.
Figuer 5.
Atopic dermatitis…

 The eczema comes and goes

 Triggered by dryness of the skin, infections, heat,

sweating, contact with allergens or irritants and

emotional stress
 Mostly affected sites are;
 Antecubital area, popliteal, elbow

and knee folds, wrists, ankles, face,

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Atopic dermatitis…
Cause is unknown.
 It could be a defect in the control of IgE
production by T-lymphocytes.
S/S: Dry skin and rubbing
Dx: Clinical
 Rx; bath with cold or luke warm water
 Topical corticosteroids
22
Atopic dermatitis con’t…..

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B. Seborrhic dermatitis
 Is a common chronic dermatitis cxed by redness and
greasy scaling that occurs in regions
where the sebaceous glands are most
active, such as: scalp, border of
forehead
 The eczema comes and goes

24
Treatment
 Scalp: anti seborrheic shampoo (e.g..,
 Selenium sulfide, zinc pyrithione)
 Skin: low-potency topical corticosteroid or topical

imidazol

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Seborrhic dermatitis con’t….

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C. Contact dermatitis:
 It is an acute or chronic inflammation which is caused
by contact of the skin with an irritant or an allergen.
 It is inflammatory reaction of the skin to physical,
chemical or biological agent.

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Contact dermatitis

 Common causes of contact dermatitis are on hands ,

arms and legs are excessive use of H2O, soap (if not
washed off properly) detergents, jewellery, dyes,
bleaches, perfume, nail polish/remover.

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Manifestations of dermatitis (all types)
 Sever itching (Pruritus) constant symptom
 Redness and dry skin (xerosis)
 Lichenification , excoriation, scaling skin
 Papules, blisters,
 Oozing and crusts
 Color change

29
Management of dermatitis (all types)
 Keep the site clean.
 Stop the use of irritants, allergies (contact eczema)
 Mild topical steroid such as hydrocortisone 1%

cream twice daily until lesions clear but skin

atrophy and bleaching may occur
 In severe itching use antihistamines E.g.:
promethazine or hydroxyzine at night, citrizine or
loratidine at day time/night

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Management of dermatitis (all types) con’t…

 Explain to the Patient, and Parents that is not serious

and will disappear in time.
 Shorten finger nails and covered at night/parental

education
 In photo allergies – sun protection by wide rim sun

hat, stay indoor, sunscreen, etc…

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Investigation for all types of dermatitis
 Identification of allergens (Prick Skin Test or Patch
test)
 Full blood count (Increase of Eosinophiles)
 Complication all dermatitis types

 Secondary infection (bacterial, viral, fungal, etc)

 Post inflammatory Hypo or Hyper pigmentation
 Lichenification

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D. Psoriasis
 Is a chronic recurrent, hereditary, non infectious
disease of the skin caused by abnormally fast turn
over of the epidermis
 The turn over may be up to 40 times than normal and

as a result the epidermis is not able to develop

normally,
 Skin become red, inflamed, and the scales are thicker

than normal

33
Psoriasis….
 It produces the so called candle-wax phenomenon,
when you scratch such a patch it becomes silvery
white.
 Sites can be extensor areas of extremities especially

elbow, knees, buttocks, shoulder and scalp

34
Psoriasis…
 Periods of emotional stress and anxiety aggravate the
condition.
 Sign and symptom.
 May itch severely in body folds covered
with silvery scales
DX
classical plaque type lesions with silvery
scales.
Positive family hx well help
Bilateral symmetrical appearance
35
Management of psoriasis…
 There is no cure for psoriasis but slow down the
rapid turn over of epidermis
 Salicylic acid 2-10% ointment BID to reduce scaling
 Moisturizers (Vaseline, paraffin oil, or cream)
 Treat any super infection with antibiotics if necessary

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II. Bacterial infection
A. Cellulitis
 Is infection of the skin and subcutaneous tissue
 Caused by bacteria like streptococcus/s. a
 Results from break in skin
 Infection rapidly spread through lymphatic system

37
Clinical feature
 S/S of cellulitis include:
 Tender,
 Red, hot
 Swollen area that

is well demarcated
 Possible fluctuant abscess

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B. Folliculitis
 Isinflammation of the hair follicle
 Sign & symptom

 Single or multiple papules or pustules

 Commonly seen in the hairy areas of shaving

&Women’s legs
 S.aureus, fungus & virus also cause it.
 Mgt

 Avoid shaving ( for adult child)

 Evacuate & apply GV
 If sever, topical TTC until lesion
heals
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C. Furuncles/Boils
 Is painful circumscribed, acute ,localized, deep
seated, red, hot, very tender, inflammatory
perifollicular staphylococcal abscess
 Is a deeper form of Folliculitis with a purulent core
 Common microorganism: S.aureus

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C. Furuncles/Boils con’t…

 The lesion begins in the opening of

hair follicle or sebaceous gland
 Sites can be back of the neck, face,

buttocks, thighs, perineum, breasts,

axilla, nose, genitallia, etc

41
Furuncles…
 Most common on persons who are carriers of
staphylococcus, contact with oils or grease,diabetes,
poor habits of personal hygiene, immunosuppression,
obese, malnutrited, etc..

42
Sign and symptom
 Hard nodule initially then fluctuant abscess with
centrally yellow pustule, then ruptures
 It can be isolated single lesion or multiple lesions

 Hotness and pain at the site.

 Dx: Gram stain of the pus, culture and sensitivity test

of blood/pus
 Rx: Cloxacilline 50-100mg/kg/24 hours divided in to

4 doses for 10 days

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D. Carbuncles
 Multiple furuncles
 Is an aggregation of interconnected furuncles that drain

through multiple openings in the skin.

 Exposure to grease and oil increase the risk.
 Microorganism mostly: S.aureus
 Sign & symptom
 Fever, chills, extreme pain, malaise
 Common sites are back of the neck, shoulder, buttock,

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DX
 Gram stain of the pus
 Culture of pus/blood
 Leukocytosis ( >20,000 cells/mm3)
 Mgt
 Bed rest
 Systemic antibiotics Cloxacilline 50-100mg/kg/24

hours divided in to 4 doses for 10 days

 Extraction make incision to drain pus: Should be

done by caution not to contaminate other area.

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E. Impetigo
 Is an acute, contagious, rapidly spreading infection
and is a very common bacterial infection of the
superficial skin
 Two types; based on existence of bullae;
 Non Bullous Impetigo: more common form
 Bullous impetigo: less common form
 Causative agents S. aurous or GABHS or both

46
Sign & Symptom

 Superficial pustules or blisters which becomes oozing

with yellow crusts

47
Impetigo con’t…
 Honey-colored lesions especially for non bullous
impetigo
 Blisters break easily and form crusts
 Dx: Clinical, swab for bacterial culture and sensitivity

test
 Complications
 Ulcerations - Septicemia - Staphylococcal scaled skin

syndrome (SSSS)

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Management
 Analgesia to relieve pain, soaks will help to remove
the crust, rest, avoid friction and irritation from tight
clothing
 Topical antibiotic ointment
 Systemic antibiotics like:
 Cloxacilline 50-100mg/kg/24 hours divided in to 4

doses.
 Erythromycin 25-50mg/kg/24hrs divided in to 4

doses 7-10 days

 Cut finger nails short to minimize damage to lesion

and to prevent autoinoculation from scratching.

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III. Fungal skin disorder
 Dermatophytoses (Mycoses)
 Is a fungal infection of the skin, hair ,scalp and nails
 Types

A .Tinea pedis (Athlete’s foot)

 Is itchy, whitish scaling lesions and inflammation of
the superficial skin of the feet and interdigital spaces
of the toes.

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Fungal skin disorder con’t….
 Common between the 4th and 5th toe.
 Often seen in people wearing

rubber boots/shoes

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B. Tinea corporis (Tinea circinata)
 Fungal infection of the epidermis (hairless part of the
body)
 It affects the trunk, legs, arms/neck, excluding the beard

area, feet, hands, face, and shoulders.

 S/S ; intensive itching and large patches occurs

 Spread by direct contact, fomites, occasionally from dogs

or cats.
 Dx

 Skin scraping under

microscope by using KOH

 Skin biopsy for histolegi-

cal exam
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C. Tinea capitis (ring worm)
 Is a contagious fungal disease of the scalp and hair
shaft
 Sign & symptom
 One or more round patches with scaling
 Hair loss (temporarily), alopecia
 Lymph nodes in the neck swell & the patient may

have fever and headache

 DX
 Clinical
 Microscopy of affected hairs
 Culture

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D. Tinea unguium
 Is a chronic fungal infection of the toe/finger nails
 Characterized by thickened nail, friable, lusterless.
 Accumulation of debris under the free edge of the nail
 The nail may be

destroyed
 Only treated by

Systemic antifungal

54
E. Tinea versicolor (pityriasis
versicolor)
 Isa common chronic superficial fungal infection
which is caused by the unicellular yeast pityrosporum
which is normally present on the trunk.

55
Management/all forms
 Keep the space in between the toes dry and avoid shoe
that are too tight/hot/ for tiniea pedis, keep the area
dry, avoid sharing shoes
 Treat secondary bacterial infection if present
 Imidazole cream/ Whitfield's ointment BID for a
minimum of 4 wks
 Add ketoconazole 2% shampoo BID for 2-4wks/ tenea

versicolor

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Con’t…
 Griseofulvin 10-15mg/kg once daily for 2-6wks first
line Rx for both tinea corporis and tinea capitis
 Ketaconazole 3-6mg once daily for 1-2 wks

NB: Recommend to avoid sharing combs and towels to

prevent Tinea capitis

57
IV. Parasitic skin disorder
A. Scabies
 Is an infestation of the skin caused by a parasite called mite
sarcoptes scabies, a mite which lays its eggs in burrow in the
stratum and induces an intensively itchy inflammatory
response
 It is contagious skin condition
 Sign and Symptom
 Small blisters and papules
 Sever itching, when warm particularly at night
 Common sites are between fingers, ides of the hands, sides of

the wrists, buttocks, nipple and genital region

 DX: Microscopic identification of skin scraping

to see mites, larvae or ova.

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Management
 Treat all close contacts of the patient and family.
 Benzyl benzoate 25% emulsion dilute with one part

water (1:1) for children, dilute with 3 parts water (1:3)

for infants.
 Apply for 3 consecutive nights and wash off each

morning.
 Permethrin 5 % cream, use antihistamines for itching.
 If infected use antibiotics, keep skin clean.
 Complications -Secondary skin infection,

Sepsis…

59
B. Pediculosis
 Is an infestation with a louse which may be found in
the:
 Scalp- Pediculosis capitis, body- Pediculosis corporis
 Hair bearing region- Pediculosis pubis (phthiriasis)
 Causes: Over crowding, poor personal hygiene,

prolonged wearing of the same cloth

 Sign and symptom
 Itching (excoriation), the presence of lice and nits

60
Management
Improve personal hygiene (Delousing)
Change clothing
Permethrin(1%), pyrethrums and, less

preferably, malathion and ivermectin

Treat secondary bacterial infection if

present

61
V. Viral skin disorder
 It is an acute contagious infection of the skin or
 mucus membrane caused by virus
 Types:

A. Herpes simplex: Is an infection which is caused by

herpes simplex virus that causes vesicular eruption
(cold sore or fever blister)
on lip ( herpes labialis)
and on genitalia (herpes
genitalia)

62
Sign and Symptom
 Burning sensation at the site, then a group of blisters
appear then break down to form superficial ulcer.
 Highly contagious
 Diagnose–Clinical, viral culture
 Rx – Analgesia for pain, Zink oxide to sooth the skin

 Acyclovir 20-40mg/kg 3-4 times per day for 7 days

 TTC ointment if bacterial infected

63
B. Herpes zoster (shingles)
 Is an acute unilateral and segmental inflammation of
the dorsal root of a nerve by varicella zoster infection.
 It is a highly contagious systemic disease

that normally results in lifelong immunity.

 Causes:
 Herpes zoster virus
 People with no prior immunologic exposure

to varicella virus, most commonly children

64
Sign and symptom
A localized vesicles in cluster form on one
side of the body/unilateral/
 Itching,tenderness, Prolonged fever,
skin lesion and severe pain on the site
 The thoracic, cervical and ophthalmic
nerves are frequently affected
 After1-2 weeks crusts begin to fall off with
residual scaring
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Herpes zoster cont…
 Over 10% of patients develop a persistent burning
sensation
 Common in HIV patients, old patients

and malignancy cases

 Mgt
 Analgesia with NSAIDs
 Antibiotics for secondary

infections

66
Cont….
 In immune competent children with sever
cases (disseminated or mucosal
involvement) give Acyclovir 20mg/kg a day for
5 days
 Complications :
 Bacterial super infection, extra-cutaneous
complication with neurological manifestation
 Hemorrhagic complications in immune compromised

children

67
burn

68
Introduction
 Burn is defined as a traumatic injury to the skin or
other organic tissue primarily caused by thermal or
other acute exposures.
 Burn injury is one of the common injuries
accompanied by high risk of mortality and
morbidity.
 Human skin can tolerate temperatures up to 42-440 C
 >450 C damage exceeds the capacity of the cell to
repair.
 The peak incidence of burn injury occurs in toddlers
(1 to 3 years of age).
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Etiology
The different cause of burn are:
Flame 57%
Scalding 32%
Chemical 7%
Electricity and radiation 4%

70
Classification of burn
1. First-degree:
 Burns involve only the epidermis and are

characterized by swelling, erythema, very painful

and heals without scaring (similar to mild sunburn).
 Tissue damage is usually minimal, there is no

blistering and leaving no residual scars.

 Pain resolves in 48-72 hrs.

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Classification of burn
con’t…

72
Classification of burn con’t…

2. Second-degree burn (partial thickness )

• Involves injury to the entire epidermis and a
variable portion of the dermal layer (vesicle
and blister formation are characteristic).
• It is pink to dark and has blisters , still
painful and it is blanching.
• It heals with a scar after many weeks.

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Classification of burn con’t…

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Classification of burn con’t…
3. Third degree burns (full thickness):
 Involve destruction of the entire epidermis, dermis and

hypodermis leaving no residual epidermal cells to

repopulate the damaged area.
 It is not blanching, no blister, no pain sensation.
 It has a pale or charred color, a leathery appearance

and heals by scarring.

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Classification of burn con’t…

• The wound cannot epithelialize and can

heal only by wound contraction or skin
grafting.
• The absence of painful sensation and
capillary filling demonstrates the loss of
nerve.

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Classification of burn con’t…

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Classification of burn con’t…
4. Fourth degree burns
 Fourth degree burns are deep and potentially life-
threatening injuries.
 In addition to the three layers, it extends through the

skin into underlying tissues such as fascia, muscle,

and/or bone.
 NB: Even though third and fourth degree burns are

not painful, the adjacent areas burns may be painful.

78
79
Extent of body surface area injured
Various methods are used to estimate the
TBSA affected by burns; the most common
methods are :
1. The rule of nines
2. Lund and Browder method
3. Palm method

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Rule of Nine

81
Lund and Browder method

82
Palm method
In patients with scattered burns, a method to
estimate the percentage of burn is the palm method.
 The size of the patient’s palm from crease at wrist
to tip of extended fingers is approximately 1% of
TBSA.

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Management of burn
 Disconnect the person from the source
 Remove clothing and jewelry.
 Cool burns or scalds by immediate immersion of

water with in for at least 20 min.

 Irrigation of chemical burns should be for 1 hour.
 This stops the heat as well as decreases the

progression of burn.

84
Management con’t…
 But avoid it for large area burn as it increases
hypothermia and also don’t use ice as is
causes hypothermia
 Similarly don’t use grease (e.g. butter, oil)
since it predisposes for infection and doesn’t
disperse heat
 Do NOT use ice for cooling (Water temp no
less than 8 Celsius)
 Cover with dry sheet and do not break blisters
85
Indication for Hospital Admission
 Burns affecting >10% of BSA in children
 Burns >10-20% of BSA in adolescent
 Above 3rd-Degree burns and Chemical burns
 Electrical burns caused by high-tension wires or

lightening
 Inhalation injury, regardless of the amount of BSA

burned.

86
Indication for H. Admission con’t..
 Inadequate home or social environment
 Suspected child abuse or neglect

 Burns to the face, hands, feet, perineum, genitals, or

major joints

87
Management con’t…
 Airway & Breathing:
 Mange as trauma patient, since the airway swelling

increases in the next 24 hours.

 There is a need of early advanced airway (intubation

or tracheotomy).
 Administer 100% oxygen to displace carbon
monoxide during inhalation burn.

88
Management con’t…
 Circulation/Fluid resuscitation:
 Secure urgently an IV line for burns of ≥10% of
BSA, for all inhalation and electric burns.
 If IV access couldn’t be found, use intraosseous
 Don’t put adhesive plaster circumferentially to

the body.

89
Management con’t…
 For children with severe burn (>20% BSA), give 20
mL/kg of crystalloids till assessment of the extent of
the burns and calculation of the rest of the fluid of the
24 hours is completed
 Then use the Parkland formula (i.e. 4 mL /kg/%

TBSA burned per 24 hrs), in addition to the patients

calculated maintenance fluid.

90
Management con’t…
 Lactated Ringer solution in 5% dextrose, normal saline
with 5% glucose or half-normal saline with 5% glucose
can be used.
 Half of the fluid is given over the 1st 8 hrs, calculated

from the time of onset of burn.

 The remaining is given over the next 16 hrs.

91
Prevent infection
 Most frequent pathogens in burns are Staphylococcus
aureus, Pseudomonas aeruginosa and the Klebsiella-
Enterobacter species.
 Apply topical antimicrobials, antibiotics/antiseptics
 Clean and dress the wound daily, monitor and assess
for pain
 Aseptic wound care and dressing 1-2 times/day
 A high-protein intake is also needed for wound
healing (hypermetabolic state).
 Encourage range of motion exercises to prevent
contractures.

92
Complication of burn
• Hypovolemic shock
• Fluid electrolyte and plasma loss
• Cardiac arrhythmias and Cardiac
arrest
• Infection and Sepsis
• Metabolic Acidosis and pulmonary
complications
• Decrease temperature and renal &
hepatic damage
• Extensive and disabling scarring
93
Long term complication of burn
 Hypertrophic scars  Alopecia
 Susceptibility to minor  Chronic open wounds
trauma, chemicals, or  Skin cancers
cold  Amputations
 Dry skin  Osteoporosis
 Contractures  Heat exhaustion
 Itching and neuropathic
pain

94
Thank You!

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