Peds: Integumentary

eneralized eruption associated with a systemic infectious disease

Rash in oral cavity

A circumscribed area of change in normal skin

Without elevation or depression

(Ex: freckle)

A superficial, solid lesion,

< 1 cm. in diameter.

(Ex: small pimple-without fluid

A solid, round or oval lesion
May involve the epidermis, dermis, or subcutaneous tissue & is 1-2 cm.

The depth of involvement differentiates a nodule from a papule.

A circumscribed, superficial cavity of the skin
Contains a purulent exudate that may be white, yellow, greenish yellow, or hemorrhagic

(Ex: pimple)

An elevated, small superficial cavity

containing serous fluid .

(Ex: hives)

Same as a vessicle,


But larger than 0.5 cm.

Ex: blister

A plateau-like elevation above the skin surface

Occupies relatively large surface area in comparison with it’s height above the skin.

May involve a confluence of papules.
EX: eczema, psoriasis

A rounded or flat-topped, pale-red papule or plaque

Disappears within 72 hours
Ex: mark left after TB test

Scaling.

The scale may be large or tiny, adherent or loose.

Rough, thickened epidermis,

accentuated by skin markings

caused by rubbing or scratching

A pigmented (colored), congenital skin blemish that is usually benign

Has the potential to become cancerous

Many different kinds in children!

Congenital
Viral infections
Bacterial infections
Fungal infections
Insects/animal contact
Inflammatory processes
Burns

Capillary Hemangioma

Port Wine Stains

Mongolian Spots

Description:
Soft, bright-red to deep-purple, vascular nodule to plaque

Develops at birth or soon after birth
Usually disappears spontaneously by the 5th year*

Can be small or large.
A type of nevus.

Incidence: Caucasian, low birth weight.

Sites: Face, trunk, legs, oral mucous membranes

AKA: Nevus flammeus
Description:
Irregularly shaped, red or violet macular, vascular malformation of dermal blood vessels
Present at birth and never disappears spontaneously except for the “salmon patch”.

Can also be associated with congenital syndromes like Sturge Weber Syndrome

Description:
Congenital gray-blue macular lesions
Usually located on the lulmbosacral area, but can also be on scalp or on skin elsewhere.
Disappear in the first year.
Incidence: In Asian, American Indian, Hispanic, & African American children. VERY RARE in Caucasian Children.
Significant: They look just like bruises… can be mistaken for child abuse

Erythema infectiosum, aka Fifth Disease
Roseola
Shingles
Hand-Foot-Mouth Disease

Measles, Rubella & Varicella discussed in Immunization lecture…

Classic: “Slapped” cheeks, lacy rash over body which may last for weeks***

Treatment: Supportive

Characteristic Presentation:
Small blanchable macules and papules.
Pink, often with a white halo.

Usually occurs 6-18 month old group in spring & fall.

Symptoms**:
Sudden high (103-106) fever x 3-5 d*
Malaise & irritability OR child may be active & alert
*Rose-pink macules or maculopapules appearing first on trunk after fever drops
Treatment: supportive

AKA: Herpes Zoster
Etiology: Activation of latent *varicella infection in dorsal nerve root ganglion

Description:
Pain, tenderness, itching, tingling, or burning along peripheral sensory nerve of trunk, thorax or face may be present for 2 weeks before rash appears.
Unilateral vessicular lesions along sensory nerve tracts (Why? Think anatomy)

Classic finding: Vesicles on hands &
feet and ulcers in the mouth***

Treatment: Supportive

Complications: Dehydration

GABHS Scarlet Fever

Impetigo

Cellulitis

Acne Vulgaris

AKA: Scarletina, strep with rash
Etiology: Group A beta hemolytic strep pharyngitis
Symptoms:
Strep throat symptoms….

Then within 24 hours: *** Sandpapery red fine papular rash

Peeling of hands and feet

Treatment: Same as for strep throat
penicillin, erythromycin, cephalosporins

Complications:
Same as with strep throat

Description:
Most common childhood bacterial skin infection***

Superficial skin infection most commonly on face, scalp, buttocks & extremities.
Starts on broken skin, such as insect bite, scabies, or dermatitis.

Presents as “honey crust”***

Etiology: Staphlococcus aureus or Group A beta hemolytic strep
Contagious: Very contagious by direct contact***

Treatment:
*Topical antibiotics in mild cases

*Oral antibiotics if more severe… amoxicillin, cephalexin; macrolides for PCN sensitive children

Disinfect contact items

Description: *Bacterial infection of subcutaneous tissue & dermis

Incubation: Few days

Symptoms:
Arises via portal of entry through break in skin
Red, hot, swollen or indurated area

Treatment:
Warm compresses
Antibiotics:
Penicillin
Cephalosporin
Erythromycin
IV antibiotics & hospitalization if joint affected. Also a possibility if face is affected, especially around eye**

Etiology:
The result of interaction between hormones (androgens) and bacteria, causing over-activity & plugging of sebaceous glands at the base of hair follicles

Usually lasts until 20-25 years of age

Etiology: Both inflammatory and bacterial in nature

Whiteheads (closed comedones) = a build up of keratin & sebum trapped in follicle & can’t be released

Blackheads (open comedones) = follicles whose widely dilated openings are filled with thick keratin & lipid. Pigment is oxidized by tyrosine & melanin as it is open to surface of skin, causing black color… it is NOT dirt!

Papules & pustules = walls of closed comedones rupture & contents are released into dermis & epidermis


Cysts = the most severe pustules. Intense nodular inflammatory process.

Myths about Acne:
Caused by not washing face enough
Caused by chocolate, cola, etc… in diet
Caused by sexual activity

Basic care:
Wash skin twice a day & after exercise. Use a mild soap such as Dove or an acne care soap.
Shampoo hair daily
Avoid picking at pimples

Can be treated!
Graded for treatment definition:
Grade I
Grade II
Grade III
Grade IV

Medication Treatment
Topical: For grade I only. Retinoic acid, benzoyl peroxide, topical. No etoh… just sends message to brain that skin is dry and increases sebum production

Oral antibiotics for grade II –III

Accutane if cystic (grade IV)

Tinea

Candida (yeast)

Description: MANY kinds of tinea.
3 most common in pediatrics:
Tinea corporis: fungal inf. on body

Tinea pedis: fungal inf. on feet

Tinea capitis: fungal inf. on head

AKA: Fungal infection of the scalp

Description: Most common in toddlers & school age children. More prominent in blacks than in Caucasians.

Transmission: person to person, animal to person***

Description:
Dependent on type. Small circular lesion to complete coverage of scalp.
Loss of hair most common.
Scale common.

Treatment:
Oral griseofulvin
Anti-fungal shampoos

AKA: Ringworm

Description: fungal (dermatophyte) infection on trunk & extremities, excluding the feet, hands and groin

Transmission: person to person, animal to person, contaminated soil to person

Description:
Multiple, bright red, sharply marginated lesions with only minimal scaling
Often with central clearing (halo look)**
Can occur singly or as scattered multiple lesions

Treatment:
Lotrimin or miconazole topically TID & treat pets

AKA: Athlete’s feet
Description: Fungal infection of the feet
Duration: Months to years

Symptoms: erythema, chronic diffuse desquammation and/or bulla formation
Treatment: topical antifungal such as lotriman bid for 2-4 wks. Oral antifungal for non-response.

Thrush

Diaper dermatitis

AKA: Thrush
Description: Common candidal infection of infants
Etiology: C. albicans most common

Transmission: Breast yeast infection, fungal overgrowth during antibiotics, or from inadequate cleaning of bottles/pacifiers
Symptoms:
White adherent curdlike plaques
on tongue, gums & buccal mucosa

Treatment:
Nystatin oral suspension: 1 gtt. in each side of cheek tid - qid

AKA: yeast rash

Description:
Bright red
Raised rash
Present over all or part of area diaper covers
Most Common Cause:
Fungal overgrowth during antibiotics.
Diapers not changed frequently enough

Treatment: antifungal cream applied topically & frequently

Pediculosis Human Capitis
Scabies
Lyme Disease
Rocky Mountain Spotted Fever
Brown Recluse Spider Bite
Cat Scratch Disease

AKA: head lice

Description: Over 6-12 million children & adults annually. Peak incidence: 3-12 years Not a health risk, but can get secondary infection

Human parasite that lives on the scalp.
6 legged grayish white or reddish brown wingless insect, about 1/6 inch in size.
Can crawl up to 9 inches per minute.
Color depends on whether they have fed recently.
Feed on venous supply from host every 3-6 hrs.
May actually change color to match host’s hair color)
Rare in African-American children. Why????

Symptoms:
itching & scratching of head
nits resemble adherent dandruff
may see lice crawling on scalp

Transmission:
person-to-person, clothing, combs

Female Louse lays 5-10 nits (eggs)/day for 30 days close to base of hair shaft  nits hatch into nymphs in 7-10 days  sexual maturity in 8-9 days  reproduce all over again!


Nits can survive off host for 10 days
Lice can only survive off host for 48 hrs
Social stigma of having head lice
Increasing resistance to treatment
Schools often continue “no nits” policies:
Lost school time for child
Lost work time for parent
Angry parents

AAP states that total nit removal is not necessary for controlling head lice & children should be allowed to return to school the morning after treatment***

Remove nits with fine-toothed comb
OTC/prescription medication (Kwell/Lindane; Nix/Permethrin; Pyrethrum/RID)
Check close contacts for nits & lice
Launder clothing, hats, & bedding in hot water (>160’) & dry in hot dryer
Disinfect combs, brushes
Dry clean non-washable items or store in sealed plastic bag for at least 2 weeks
Education regarding transmission
Re-check for nits & lice in 7-10 days

Description: Infestation by mite with intense itching
Transmission: Close personal contact or from infested bed sheets
Symptoms: Intense itching, especially at night. May have burrows visible on skin, typically between the fingers. Linear configuration elsewhere

Complications: Impetigo is major complication

Treatment***: topical Elimite cream (permithrin) from chin down. Keep on overnight (10-14 hrs.) & wash off in shower in am. Repeat in 1 week. Safe down to 2 months of age. Benadryl for itching.
Treat contacts, wash clothing & linens hot water same as with lice

Description: Most common tick-borne disorder in US

Etiology: Caused by spirochete Borrelia burgdorferi, which enters the skin & bloodstream through the saliva & feces of ticks… especially deer ticks
Early Symptoms:
Erythema Migrans*** Circular rash surrounding tick bite appearing 3-31 days after bite

Systemic involvement of neurologic, cardiac, & musculoskeletal systems. Most serious stage of disease.

Musculoskeletal pain involving tendons, bursaie, muscles, and synovia.

Arthritis may occur, as well as deafness & encephalopathy

Treatment:
Early tmt essential!

Children > 8 yrs of age oral doxycycline

Children < 8 years of age oral amoxicillin

Treat for 14-21 days

Description: tick-born disorder. Severe disease rare in kids.


Symptoms: Gradual onset with fever, malaise, anorexia. Temperature elevation with chills, vomiting. Maculopapular or petechial rash primarily on extremities (ankles & wrists) but may spread to other areas, especially palms & soles.

Treatment: Tetracycline or chloramphenical

Can be self limiting in children.

Description: Venom injected via fangs of B. R. Spider. Venom contains neurotoxin. Spider is “shy”… bites only when surprised. Hides in piles of clothes, shoes in closet, etc.
Symptoms: Mild sting at time of bite. Transient erythema. Followed by blister. Pain in 2-8 hrs. Purple star shaped area in center. Necrotic ulceration possible in 7-14 days… not usual!

Treatment:
Antibiotics usually given… not always needed
Corticosteroids
Cool compresses

Description: Most common cause of regional lymphadenitis in children. (Shows up in lymph nodes closest to bite.)

Symptoms: Benign, self limiting. Regional lymphadenopathy occurs medially from bite or scratch.

Treatment: None needed

Atopic Dermatitits…

Seborrheic Dermatitis

Contact Dermatitis (poison ivy, etc.)

Erythema Multiforme

AKA: Eczema

Description:
Onset in first year in 60% of kids.
Chronic scratching leads to lichenification (thickening & coarsening of the skin).
Occurs most often on face, flexor surfaces. Can be head to toe. Signs and Symptoms:
Erythematous, scaling skin

Chronically dry even with moisturizer

Can be papular, pustular, or vessicular during acute flares

Can become infected with scratching

Etiology: Occurs in association with personal or family history of asthma and allergy
Has been referred to “asthma of the skin” because of close association to asthma

If at risk: breast feed, delay baby foods until 6 mo. of age, consider hypoallergenic formula if not breast feeding

Treatment:***
Mild non-perfumed soaps or “non-soap” soaps… like Cetaphil cleanser

Maintain hydration with daily moisturizing with thick emollient lotions

Topical steroids for 2 week bursts for flares

Oral antihistamines to prevent scratching

AKA: Cradle cap. Actually can occur on other parts of the body besides scalp, especially in creases & folds. A “cousin” of eczema.

Description: Most common in infancy. Appears as oily, yellow scale on scalp and as bright red macular areas in body creases.

Treatment: Selsen blue shampoo for scalp. Treatment for skin other than scalp same as for eczema.

AKA: Poison ivy/oak. Can actually occur when individual comes in contact with any sensitive trigger. Most common cause in children is exposure to poison ivy, oak & sumac.

Etiology: Inflammatory reaction of skin to direct irritant exposure. A delayed hypersensitivity response can occur, taking up to a week for symptoms to appear.

Symptoms: Well demarcated plaques or erythema and edema with closely spaced vessicles superimposed on top.

Treatment: Remove offending substance, cool compresses, 1% topical steroids, oral steroids for severe infection, antihistamines for itching