Chapter 45
Alterations of the Integument in
Children
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
Acne Vulgaris



Most common skin disease
Affects 85% of people between ages 12 and
25
Acne conglobata



Highly inflammatory form of severe acne
Formation of communication cysts and abscesses
beneath the skin
Sebaceous follicles sites for acne lesions
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
2
Acne Vulgaris

Noninflammatory acne



Blackheads
Whiteheads
Inflammatory acne

Caused by follicular wall rupture in closed
comedones (whiteheads)
 Cystic nodules develop when inflammation is
deeper, may cause scarring
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
3
Acne Vulgaris

Physiologic factors


Follicular hyperkeratinization, excessive sebum
production, colonization of Propionibacterium
acnes, and inflammation secondary to the action
of inflammatory products produced by P. acnes
Excessive production of sebum is related to
androgenic hormones
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
4
Acne Vulgaris: Treatment

Diet not proven to cause acne





Dietary restrictions are generally not effective
Topical treatment: first line of therapy; if this fails
use systemic therapies
Acne surgery, including comedo extraction,
intralesional steroids, cryosurgery useful
Severe scarring treated with dermabrasion or
subincision
Special consideration given to treatment for
those with darker-colored skin due to greater
risk for hyperpigmentation and keloidal scarring
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
5
Cystic Acne
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
6
Atopic Dermatitis



Most common form of eczema in children
Cause unknown, but 80% demonstrate a
personal or family history of asthma or
allergic rhinitis
Manifestations

Increased IgE levels, positive allergen skin tests,
and eosinophilia
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
7
Atopic Dermatitis

Infants


Children and adults


Rash appears on the face, scalp, trunk, and
extensor surfaces of the arms and legs
Rash tends to be on the neck, antecubital and
popliteal fossae, hands and feet
Lichenification (thickening of the epidermis
from constant scratching)

Common in adults with chronic eczema
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
8
Atopic Dermatitis
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
9
Diaper Dermatitis


Inflammatory disorders affecting the lower
abdomen, genitalia, buttocks, and upper thigh
A nonallergic contact dermatitis

Inflammation encouraged by prolonged exposure
to irritation by urine and feces, maceration by wet
diapers, airtight plastic diaper covers, and possible
association with intercurrent illness and early
introduction of cereals
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
10
Diaper Dermatitis
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
11
Infections of the Skin

Bacterial infections

Impetigo contagiosum
• Superficial infection usually caused by Staphylococcus or
group A streptococci
• High incidence in hot, humid climates

Bullous impetigo
• Rarer variant of impetigo caused by Staphylococcus
aureus
• Staphylococci produce a bacterial toxin called exfoliative
toxin (ET), which causes a disruption in desmosomal
adhesion molecules with blister formation
• Occurs in newborns and is highly contagious
• Source is usually a staff member in a newborn nursery or
a family member with a pustule or who is an
asymptomatic carrier
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
12
Infections of the Skin

Bacterial Infections

Vesicular impetigo
• Contagious, acute, superficial, vesiculopustular form of
impetigo caused by group A Streptococcus pyogenes
(alone or in combination with Staphylococcus aureus)
• Microorganisms disseminated by direct physical contact
from other infected individuals or through insect bites
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
13
Impetigo
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
14
Infections of the Skin

Bacterial infections

Staphylococcal scalded-skin syndrome (SSSS)
• Serious infection caused by exfoliative toxin producing group II
staphylococci
• Exfoliative toxin attacks desmoglein and adhesion molecules;
causes separation of the skin just below the stratum granulosum
• Manifestations


Fever, malaise, rhinorrhea, and generalized erythema and skin
tenderness
Seen in infants and children younger than 5 years
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
15
Infections of the Skin

Fungal infections


Fungi causing superficial skin lesions are called
dermatophytes
Fungal disorders are called mycoses; mycoses
caused by dermatophytes are termed tinea
• Tinea capitis (scalp)
• Tinea pedis (athlete’s foot)
• Tinea corporis (ringworm)
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
16
Tinea Capitis
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
17
Infections of the Skin

Fungal infections

Thrush
• Candida present in mucous membranes of the mouths of
infants, and less commonly in adults
• Characteristics

White plaques or spots in the mouth that lead to shallow
ulcers
• Thrush can spread to the groin, buttocks, and other parts
of the body
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
18
Infections of the Skin

Viral infections

Molluscum contagiosum
• Highly contagious pox viridae infection of the skin
• Skin-to-skin and fomite transmission
• The virus encourages epidermal cell proliferation and
blocks the immune response
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
19
Molluscum Contagiosum
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
20
Infections of the Skin

Viral infections

Rubella (German measles or 3-day measles)
• RNA virus
• The disease is mild in most children
• Manifestations


Enlarged cervical and postauricular lymph nodes, lowgrade fever, headache, sore throat, runny nose, cough
Faint pink to red maculopapular rash caused by virus
dissemination to the skin
• Vaccination for rubella combined with mumps and
rubeola (measles) (MMR)
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
21
Infections of the Skin

Viral infections

Rubeola
• RNA paramyxovirus
• High fever, malaise, enlarged lymph nodes, runny nose,
conjunctivitis, barking cough
• Koplik spots

Roseola
• Fever and an erythematous macular rash that lasts about
24 hours
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
22
Infections of the Skin

Viral infections

Chickenpox (varicella) and herpes zoster
(shingles)
• Both diseases are produced by the same virus
• DNA virus
• Infection occurs within keratinocytes
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
23
Measles and Chickenpox
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
24
Insect Bites and Parasites

Scabies

Contagious disease caused by the itch mite
Sarcoptes scabiei
 Transmitted by personal contact and infected
clothing and bedding
 Female mite tunnels millimeters to 1 cm into the
stratum corneum, deposits eggs, and over a 3week period, the eggs mature into adult mites
 Primary lesions are burrows, papules, and
vesicular lesions with severe itching
 Patient at risk for infections from scratching
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
25
Scabies
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
26
Insect Bites and Parasites

Pediculosis


Pediculus capitis (head), Pediculus corporis
(body), and Phthirus pubis (crab or pubic)
Highly contagious parasite that survives by
sucking blood
• Acquired through personal contact and shared clothing,
combs, or brushes

Female louse reproduces every 2 weeks and
produces hundreds of nits
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
27
Insect Bites and Parasites

Flea bites



Cat, dog, and human fleas
Occur in clusters along the arms and legs
Characteristic lesion is an urticarial wheal with a
central hemorrhagic puncture
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
28
Insect Bites and Parasites

Bedbugs (Cimex lectularius)




Live in the crevices and cracks of floors, walls,
and furniture and in bedding or furniture stuffing
3 to 5 mm long and reddish brown
Feed in the darkness
• Attach to the skin, suck blood, and leave
Lesions: red macules; develop into nodules
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
29
Flea and Bedbug Bites
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
30
Hemangiomas

Benign tumors

From rapid growth of vascular endothelial cells and
formation of extra blood vessels
 Females affected more often than males
 Superficial: strawberry hemangiomas
 Deep: cavernous hemangiomas

Etiology: embolization of fetal placental
endothelial cells related to placental trauma or
loss of placental angiogenic inhibitor of placental
and maternal origin
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
31
Hemangiomas



Proliferation of mast cells, thought to promote
angiogenesis
Infiltration of fat cells, fibrosis, and rich
vascular network; females affected more
often than males
30% of hemangiomas seen at birth; most
emerge during first few weeks of life

Grow rapidly during the first few years of life, then
shrink or involute
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
32
Hemangiomas

Strawberry hemangiomas

Raised vascular lesions that usually emerge 3 to 5
weeks after birth
 Lesions proliferate, become bright red, and
elevate with small capillary projections

Cavernous hemangiomas

Present at birth
 Involve larger and more mature vessels than
strawberry hemangiomas
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
33
Strawberry and
Cavernous Hemangiomas
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
34
Vascular Malformations

Port-wine stains



Congenital malformation of dermal capillaries
Flat, pink, to dark reddish-purple lesions
Salmon patches


Macular, pink lesions resulting from distended
dermal capillaries; usually fade by 1 year of age
Common on the nape of the neck, forehead, upper
eyelids, or nasolabial folds
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
35
Miliaria

Vesicular eruption after prolonged exposure
to perspiration, with subsequent obstruction
of eccrine ducts


Miliaria crystallina
• Ductal rupture within the stratum corneum
• Clear vesicles without erythema
Miliaria rubra (prickly heat)
• Erythematous papules and papulovesicles
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
36
Miliaria Rubra
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
37
Other Skin Disorders

Erythema toxicum neonatorum



Benign, erythematous macules, papules, or
pustules; appear at birth or 3 to 4 days later
No treatment is required
Toxic epidermal necrolysis (TEN) and
Stevens-Johnson syndrome


Rare, severe drug reactions with widespread
epidermal apoptosis and detachment
Mortality rates between 20% and 60%
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
38