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f. Note scratching and apply age-appropriate interventions.
3. Administer oral antipruritic medications.
a. Give medications exactly as prescribed.
b. Note the degree of sedation and presence of scratching.
Preventing Infection
1. Assess and treat secondary infection.
a. Observe the skin for signs of bacterial, viral, or fungal
infection (discharge, oozing, crusts, increased redness,
fever). Report any positive findings.
b. Administer medications, as prescribed.
c. Loosen exudate and crusts with water or wet dressings,
unless otherwise specified.
d. Note changes in the skin in response to therapy.
Family Education and Health Maintenance
1. Teach patient and family to avoid potential precipitants,
including:
Table 55-1
a. Exposure to excessive heat and cold or extremes of
humidity.
b. Contact with wool and occlusive synthetic fabrics. Soft,
lightweight cotton fabrics are preferred. Infants should
not be allowed to crawl on wool carpeting.
c. Participation in strenuous athletic activities that promote
sweating. Activities should be modified according to the
needs of the child. Swimming is recommended in chlorinated pools, although bromine in pool water may be
irritating. The child should shower afterward and apply a
lubricant or other topical medication.
NURSING ALERT Advise family that fresh water
(pond, lake, river) should be avoided if child has
breaks in skin integrity, due to risk of infection.
d. Use of irritating soaps, perfumes, detergents, and chemicals.
Common Pediatric Skin Problems
DISORDER/ORGANISM
CLINICAL MANIFESTATIONS
Impetigo
Bacterial infectious disease affecting the superficial layers of the
skin and characterized by the formation of vesicles, honey-colored
crusts, or bullae.
Etiology and incidence:
s Caused by Staphylococcus aureus and Streptococcus pyogenes.
Occurs most commonly when personal hygiene is poor.
s Common in children younger than age 10.
s Spread by close contact—easily conveyed from person to person
via hands, nasal discharge, shared towels, toys; plastic wading
pools in summer—when water is not replaced and no disinfectant is used; highly contagious.
s An abrasion of skin may serve as a portal of entry.
Diagnosis:
s Usually clinical.
s Rarely, a culture of the lesion’s exudate is indicated to confirm
the diagnosis.
s Incubation period is 1–10 days.
s Lesion first appears as pink-red macules that quickly
change to vesicles, which, in turn, rupture, develop
crusts, and leave a temporary superficial erythematous
area.
s Bullous (neonate and older child)—large, thin-roofed
blisters break to form thin, light-brown crusts. Lesions
may occur anywhere on the body but are more common on the face, axillae, and groin.
s Crusted (preschool age—seen more commonly in
summer on exposed body parts)—lesions appear
with thick, yellow crusts; skin around crusts is red and
weeping with satellite lesions.
s Regional lymphadenopathy is common with secondary infection of insect bites, eczema, poison ivy, and
scabies.
s Autoinoculation is major cause of spreading.
s Pruritus may occur.
Ringworm of the Scalp (Tinea Capitis)
(See page 1168 for ringworm of the body [Tinea corporis]) A fungal
infection of the scalp and hair follicles
Etiology and incidence:
s Most ringworm of the scalp is caused by Trichophyton tonsurans.
Microsporum canis and Microsporum audouinii are also causative
agents.
s Is seen primarily in children before puberty (usually ages 3–10).
s May be spread through child-to-child contact as well as through the
common use of towels, pillows, combs, brushes, and hats. Cats and
dogs may also be the source of the infection.
s The lesions appear on the scalp in a variety of ways:
s One or more patchy areas of dandruff like scaling with
little or extensive alopecia (hair loss).
s One or more discrete areas of alopecia with tiny
broken hairs.
s Numerous discrete pustules or excoriations with little
alopecia.
s A kerion or boggy, tender, inflammatory mass that
produces edema and pustules.
s Pruritus usually occurs in the involved area.
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2.
3.
4.
5.
e. Avoidance of stressful situations, when possible.
f. Foods that are associated with skin reactions (see “Food
Allergies,” page 1031).
g. Identified other allergens such as pets, live Christmas
trees, cigarette smoke, stuffed animals, and objects that
harbor dust.
Encourage mothers to breast-feed and follow a hypoallergenic
diet to decrease the risk of atopic dermatitis.
Advise parents and caregivers to follow the American Academy of Pediatrics guidelines of delaying the introduction of
solid foods until age 6 months and dairy products until age
12 months for infants at risk for food allergies.
Make sure that the family knows the common triggers to
avoid, how to prevent dry skin, signs of flares or secondary
infection, when to apply topical medications, and the need
for routine follow-up appointments.
Recommend consultation with dermatology specialist for
children with severe or persistent atopic dermatitis.
6. Suggest locating additional information from the following
websites:
a. American Academy of Dermatology (www.aad.org)
b. American Academy of Pediatrics (www.aap.org)
c. National Eczema Society (www.eczema.org)
7. Stress the importance of regular health maintenance examinations, immunizations, and preventive practices.
Evaluation: Expected Outcomes
s
s
s
s
Skin intact with minimal erythema and lichenification.
Names common triggers and avoidance measures.
Verbalizes less itching; less scratching observed.
No signs of secondary infection.
Other Dermatologic Disorders
See Table 55-1.
TREATMENT/PREVENTION
NURSING CONSIDERATIONS
Based on etiology and type of infection.
s Gently wash affected area with soap and water three times
per day.
s Crusts and debris can be removed from the affected area
by gentle soaking or wet compresses. Use tap water,
normal saline, or 1:20 Burrow’s solution.
*
If indicated, obtain lipid drainage or debris for culture
before antibiotics are provided.
s Apply topical antibacterial medication, such as bacitracin
or mupirocin ointment or retapamulin.
s Systemic antibiotics (cephalosporins, erythromycin, or
dicloxacillin) if widespread or recurrent.
s Methicillin-resistant S. aureus infection is common.
s Prevention—close contact with other children should be
avoided until 24 hours after treatment is initiated.
s Assess the child’s skin condition and document the location and
appearance of lesions. Note new lesions.
s Initiate and teach measures to prevent the spread of infection.
s Engage in frequent hand washing. Use separate towels.
s Daily bathing with soap and water. Regular laundering for
contaminated bed linens, towels, and clothing.
s Observe drainage and secretion precautions for 24 hours
after the start of therapy.
s Isolate the child from direct contact with other children
(school or day care) until 24 hours after treatment has
started.
s Trim fingernails and toenails. Apply small amount of bacitracin or mupirocin ointment under the fingernails to prevent
the spread of infection.
s Engage the child in diversional activities to discourage
scratching.
s Be aware that the patient with streptococcal impetigo has an
increased risk of acute glomerulonephritis.
s Micronized griseofulvin—an antifungal antibiotic that is
administered orally, 15–20 mg/kg/day (maximum 1 g) in
a single dose with a high-fat food for 4–12 weeks. Some
children may require higher doses or micronized griseofulvin 20–25 mg/kg/day or ultra-micronized griseofulvin 5–
10 mg/kg/day (maximum 750 mg).
s Topical antifungal medicines are not effective. Selenium
sulfide lotion 2.5% used twice per week decreases fungal
shedding and may curb the spread of infection.
s Treatment should be continued for 2 weeks after clinical
resolution.
s Assess the scalp for characteristic lesions.
s Administer or teach the patient and family to administer medications as prescribed.
s Be aware of adverse effects, such as headache, heartburn,
nausea, epigastric discomfort, diarrhea, urticaria, photosensitivity,
and possible granulocytopenia caused by griseofulvin.
s Griseofulvin is absorbed more efficiently with a fatty meal. Children can be given the medicine once per day with ice cream or
peanut butter.
s Liver function monitoring may be required for prolonged treatment (greater than 6 months) or for children with baseline abnormal liver functiion.
(continued)
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Table 55-1
Common Pediatric Skin Problems (continued )
DISORDER/ORGANISM
CLINICAL MANIFESTATIONS
Ringworm of the Scalp (Tinea Capitis) (continued )
Diagnosis:
s Hair or skin scrapings for microscopic evaluation or fungal culture,
obtained by rubbing a swab or toothbrush over the affected area.
Differential diagnosis:
s Tinea amiantacea, lichen planopilaris, and perifolliculitis capitis
abscendens et suffodiens must be ruled out clinically or histologically. Woods lamp inspection has limited benefit.
Pediculosis
Infestation of humans by lice.
Etiology:
s Three types of lice affect human beings:
s Pediculosis capitis (head lice)—commonly infests school-age
children.
s Pediculosis corporis (body lice)—rare in the United States.
s Pediculosis pubis (pubic or crab lice)—common in sexually active
adolescents or adults—can be found on pubic hair, chest hair,
axillary hair, eyebrows, eyelashes, and beards.
s Each type of louse generally remains in the area designated by its
name.
s Lice are transmitted by personal contact with people harboring
them or through contact with articles that temporarily harbor them
(clothing or bed linens).
s Head and pubic lice are not health hazards or signs of uncleanliness. Only body lice can transmit disease.
Diagnosis:
s Identification of lice or their eggs with the naked eye confirmed by
using a hand lens or microscope.
s In active infection of head or pubic lice, nits and eggs are found on
the hair shaft within 1 cm of the skin and are difficult to remove.
s Body lice and their eggs are found in the seams of undergarments.
s Itching in the area affected is the primary symptom
of pediculosis. Scratch marks may be evident in these
areas. However, not all affected people itch.
s Other signs of infestation are pillows or clothing that
look unusually dirty.
s Infested scalp areas may become secondarily infected
from scratching.
s Crusts, lice, nits, eggs, and dirt may combine to cause a
foul odor and matted hair.
s Body lice may produce minute red lesions.
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TREATMENT/PREVENTION
NURSING CONSIDERATIONS
s Treatment with oral itraconazole, oral terbinafine, or oral
fluconazole is effective, but only terbinafine has been
approved by the Food and Drug Administration for this
disorder.
s Teach the child and family methods to prevent further episodes.
s Teach general hygiene measures—regular shampooing and
bathing.
s Advise them to avoid sharing hats, combs, brushes, pillows.
s Routine cleaning of heavily contaminated articles, such as pillowcases, sheets, towels, hats, bike helmets, combs, brushes.
s All family members and close contacts should be screened
for tinea infections. The child’s school should be notified to
facilitate the screening of classmates.
s Hair loss is usually temporary, except in some cases with a
kerion, when the hair follicles may have been destroyed.
s Child may attend school after treatment has been initiated.
Hats are not necessary.
s Pediculosis capitis and Pediculosis pubis may be treated
with over-the-counter agents, such as permethrin or natural pyrethrin-based products. Lindane 1% (Rx) is indicated
for second-line therapy only. Natural pyrethrin-based
products and lindane may be reapplied 7–10 days later.
Lindane should be avoided in children younger than age
2, people with known seizures, and pregnant or lactating
women.
s For infestation of eyelashes by crab lice, petroleum jelly
applied twice daily to the eyelashes for 8 to 10 days is
effective.
s Pediculicides are not necessary for the treatment of
Pediculosis corporis. Washing infested clothing and linens,
where the lice harbor, in hot water and machine drying (on
hot cycle) is adequate.
s Because pediculicides kill lice shortly after application,
the detection of living lice on scalp inspection 24 hours
or more after treatment suggests incorrect use, reinfection, or resistance. Immediate retreatment with a different
pediculicide followed by a second application 7 days later
is recommended.
s A suffocation-based pediculicide (DSP) lotion applied and
then blown dry with a hair dryer weekly for up to 3 weeks
effectively treats 95% of head lice. The hair can be shampooed 8 hours after application. The lotion is not visible
and the hair can be styled.
s Studies of the efficacy of suffocation of lice by the application of occlusive agents, such as petroleum jelly, olive oil,
or mayonnaise, have not been performed. Cotrimoxazole
and ivermectin have been shown to be effective, but
neither is approved by the FDA as a pediculicide.
s “No nit” policies requiring children to be free from nits for
the return to school do not reduce transmission and are
not recommended.
s Shaving head is not necessary.
s Administer or teach administration of antiparasitic as directed.
Natural pyrethrin-based products work best on dry hair. Avoid
shampoo, cream rinses, and conditioners before application.
s Although both pyrethrins and permethrin are quite safe, limit
exposure to the skin by rinsing the hair in a sink rather than
the shower and use cool water to minimize absorption from
vasodilation.
s Removal of nits with a fine-tooth comb may be attempted
for aesthetic reasons or to decrease diagnostic confusion.
However, mechanical removal of nits after treatment does not
prevent spread.
s Inspect the scalp (or have the family inspect the scalp) 24–
48 hours after treatment to see what lice remain. The presence
of large lice may mean that the treatment was ineffective or
that the lice are resistant.
s Provide appropriate teaching for the family to prevent recurrences.
s Wash clothing, bed linens, and towels in hot water and
machine dry (on hot cycle). Temperature above 128.3° F
(53.5° C) for 5 minutes will kill lice and eggs. Dry cleaning or
simply storing contaminated articles in a well-sealed plastic
bag for 10 days is also effective.
s Teach children not to share combs, brushes, head gear or hats.
Combs and brushes can be disinfected by soaking in hot water
for 10 minutes or washing with a pediculicide shampoo.
s Environmental insecticide sprays are not helpful. Vacuuming
carpets and car seats is a safe alternative.
s Household, other close contacts, and classmates of the child
with head lice should be screened for parasites and treated
if affected. Prophylactic treatment of head lice is unnecessary
and may increase resistance. Notify the child’s school or day
care so classmates can be screened.
s Children should be allowed back to school or day care the
morning after their first treatment. “No nit” policies for the
return to school are unnecessary.
s Prophylactic treatment of all sexual contacts of adolescents
and adults with pubic lice is warranted because of the high
co-infection rate.
(continued)
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Table 55-1
Common Pediatric Skin Problems (continued )
DISORDER/ORGANISM
CLINICAL MANIFESTATIONS
Scabies
A disease of the skin produced by the burrowing action of a parasitic
mite in the epidermis, resulting in irritation and the formation of burrows, vesicles, or pustules
Etiology:
s The mite, Sarcoptes scabiei, is the cause of this disorder.
s Occurs in people of all socioeconomic levels, regardless of personal
hygiene standards.
s Is transmitted by direct skin contact with infected people or by
indirect contact through soiled bed linens, clothing.
Diagnosis:
s Identification of a mite, ova, or feces from skin scrapings.
s Often based on clinical presentation.
s Itching, particularly at night, is the primary symptom. The
onset of itching is usually insidious.
s Secondary skin infection is common and may confuse
the diagnosis.
s Systemic manifestations are absent, unless they result
from the secondary infection.
s The burrow, a gray or white, tortuous, threadlike line,
is seen most commonly in older children and adults
between the fingers, in the wrists, in the axillary and
buttock folds, along the belt-line, on the male genitalia,
on the female breasts, and on the knees, elbows, and
ankles.
s In infants and small children, the lesions may occur on
any part of the body and are usually widespread. Vesicles
on the palms and soles are characteristic.
s Incubation period in children without previous exposure
is 4–6 weeks.
Oral Candidiasis (Thrush)
Oral candidiasis is a mycotic stomatitis characterized by the appearance of white plaques on the oral mucous membranes, gums, and
tongue. (Chronic mucocutaneous candidiasis may be associated with
endocrine diseases or immunodeficiency disorders or use of systemic
antibiotic or inhaled corticosteroids.)
Etiology:
s Caused by Candida albicans.
s Maternal vulvovaginitis is the primary source of neonatal thrush.
Evaluate for endocrine diseases or immunodeficiency disorders if
thrush occurs after 6 months of life or is chronic.
s Nipples, pacifiers may be reservoirs.
s The infant develops small plaques on the oral mucous
membranes, tongue, or gums. These plaques look like
curds of milk but cannot be wiped out of the mouth.
s Most infants with thrush appear to have little pain or
discomfort, unless the case is severe and there is erosion
and ulceration of the mucosa.
s The mouth may be dry.
s Occasionally, the infant may appear to have some difficulty swallowing or may eat less vigorously.
s Enteric infection is usually associated with oral thrush.
Diaper Dermatitis
Candidal diaper dermatitis—a rash characterized by bright red,
sharply circumscribed but moist patches with pustular satellite lesions
Etiology:
s 80% of diaper rashes present for 3 or more days are caused by
Candida albicans.
s Most commonly seen in infants and toddlers who wear diapers.
s May be associated with oral candidiasis.
s Buttock rash consisting of erythematous maculopapular
eruption with perianal distribution.
s Generally causes discomfort, especially with wetting and
cleanings. Lesions last approximately 2 weeks, desquamate, and resolve without scarring.
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1789
TREATMENT/PREVENTION
NURSING CONSIDERATIONS
s Application of a scabicide to the skin:
s The drug of choice is 5% permethrin. Alternative drugs
are lindane 1% and crotamiton. Permethrin should be
removed after 8–14 hours by bathing, lindane after
8–12 hours, and crotamiton after 48 hours.
s Lindane can cause neurotoxicity from absorption
through the skin. It should be avoided in children
younger than age 2, people with known seizures, pregnant and lactating women, and people with extensive
dermatitis.
s Infected children and adults should apply the scabicidal
lotion or cream on the entire body from the neck down.
The entire head, neck, and body of infants and young
children should be treated. Bathing immediately before
treatment should be avoided.
s Oral ivermectin at 200 mcg/kg/dose is not FDAapproved, but has been shown to be effective.
s People caring for affected children should wear gloves.
s Contagion is unlikely 24 hours after treatment. Children may
return to school or day care.
s Teach the patient and family to launder all clothing, bed linens,
and towels used by the patient during the 4 days prior to therapy
with hot water and hot drying cycle to kill mites. Clothing that
cannot be laundered can be stored in a plastic bag for 1 week.
Further environmental disinfection is rarely necessary.
s Itching may continue 2–3 weeks after successful therapy due to
a hypersensitivity reaction to the mites. The use of oral antihistamines and topical corticosteroids can help relieve symptoms.
s All household and close contacts should be treated prophylactically and at the same time to prevent reinfection. Caretakers with
prolonged skin-to-skin contact with infected patients may also
benefit from prophylactic treatment. Manifestations of scabies can
occur as late as 2 months after exposure.
s Topical administration of nystatin in suspension three to
four times daily is the treatment of choice. Apply ½ doses
to each side of the mouth after feeding.
s Retain in mouth as long as possible before swallowing.
Allow the child to swallow any medication to treat any
lesions along the GI tract.
s Clotrimazole troches can be used in children older than
age 3.
s Amphotericin B, clotrimazole, ketoconazole, fluconazole,
and newer antifungal agents are used for candidiasis
resistant to nystatin. Not all of these drugs are approved
for use in infants and children.
s Recognize the appearance of thrush.
s Be aware of the infant or child who is particularly susceptible
to the development of this condition, especially normal infants
younger than age 6 months, low-birth-weight infants, immunocompromised or debilitated hosts, and people on prolonged,
broad-spectrum antibiotics.
s Teach parents to inspect the child’s mouth before every feeding
for presence of thrush and report the appearance of thrush.
s Keep the affected area clean and dry by frequent diaper
changes.
s Clean the skin with water-based, alcohol-free baby wipes
with a pH of 5.5 or with water.
s Use disposable diapers with sodium polyacrylate polymers
in the diaper core that form a gel when hydrated to keep
liquid away from the skin or a breathable diaper.
s Topical application of nystatin, clotrimazole, or miconazole
cream or ointment after gentle cleaning of the affected
area. If no improvement in 2 days, consider nonadherence, failure to relieve aggravating factors, or need for a
different drug.
s Nystatin may be given orally if rash is persistent.
s Burrow’s solution compresses for severe inflammation or
vesiculation.
s Low-potency topical corticosteroids for short-term use
may be added.
s Teach parents the general principles of prevention.
s Change diaper as soon as possible after wetting or soiling.
Prolonged contact of feces with the skin promotes the development of candidal diaper dermatitis. Check diaper frequently
(every 3–4 hours). Encourage use of disposable diapers.
s Wash entire diaper area with warm water or use water-based,
alcohol-free baby wipes.
s If using cloth diapers, use a second hot rinse when washing
diapers to neutralize ammonia produced when infant urinates;
use vinegar, Borax, or Diaparene in wash.
s Avoid powder and oil, which tend to clog pores and cake on
skin, retaining bacteria.
s Avoid occlusive plastic coverings, and tightly pinned or double
diapers, all of which tend to increase production and retention
of body heat and moisture.
s Allow the infant to go without a diaper for short periods to leave
area open to air.
s Diaper rashes present for 3 or more days should be evaluated by
a health care provider.
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