Pediatric Dermatology
Digital Lecture Series : Chapter 25
Dr. D. Sudha Vani
M.D., Assistant Professor
Department of DVL
Gandhi medical college,
Hyderabad
CONTENTS
 Importance
 Adolescent dermatoses
 Difference between adult and
 Child abuse
neonatal skin
 Classification
•
Physiological
•
Acquired
•
Genetic / nevoid
•
Neoplastic
 Principles of treatment
 MCQs
 Photo quiz
Importance of Pediatric Dermatology
 Approximately 30% of patients in dermatology practice are children.
 Most of the times, diagnosis is based on clinical examination alone.
 Early diagnosis and treatment is necessary to reduce disease burden
on parents.
 Good clinical examination and high index of suspicion are mandatory.
Differences in adult and neonatal skin
Adult Skin
Neonatal Skin
Surface
Dry
Vernix (gelatinous)
Full thickness
2.1 mm
1.2 mm
Epidermal thickness
More than 50µm
40-50 um
20-25 µm in premature
DEJ
Good cohesion
Less cohesion
Dermis
Normal
Less collagen &
elastic fibers
Melanosomes
Normal
Fewer
Hair
Vellus & Terminal
Lanugo & Vellus
Permeability &
Absorption
Good resistance
Increased
Classification of Pediatric Skin Diseases
 Physiological
 Acquired
Infective disorders :
•
Bacterial, Viral, Fungal
Infestations:
•
Scabies, Pediculosis, Parasitic
Inflammatory / Immunological disorders:
•
Eczemas, Psoriasis, Lichen planus, Bullous disorders
 Genetic / Nevoid disorders : Hemangiomas, Linear epidermal nevus,
Epidermolysis bullosa, Tuberous sclerosis, Neurofibromatosis, etc.
 Neoplastic disorders : Langerhans cell histiocytosis, Mastocytosis
Physiological Neonatal Dermatomes
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Vernix caseosa
Sebaceous hyperplasia
Mongolian spot
Physiological scaling
Sucking blisters
Cutis marmorata
Physiological jaundice

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Miliaria
Milia
Neonatal Acne
Cradle cap
Erythema toxicum neonatorum
Transient neonatal pustulosis
Vernix Caseosa
 White, waxy, lipophilic substance covering the newborn skin.
 Composition- protein, lipids and water.
 Provides hydrophobic layer of protection and has antimicrobial and
antioxidant properties.
 Absent in neonates born more than 42 weeks.
Vernix Caseosa
Sebaceous Hyperplasia
 Small yellow-white papules on the nose
 Thought to be as a result of hyperandrogenic state
 Resolves spontaneously
Mongolian spot
 Seen at birth - Single/multiple, slate
gray/blue macules of size 3 to 10
cms
 Sites: lumbosacral region, buttocks,
shoulders
 Fade within the first 3-4 years of life
 Delay in migration of melanocytes
from neural crest to dermo epidermal junction.
Physiological scaling
 Seen in 75% normal infants occurring in 1st week of life.
 First around the ankles, later on hands and feet and soon becomes
generalized.
 Maximum intensity by eighth day, subsides by 3-4 wks.
Sucking Blister
 One or two solitary blisters present at birth and seen over
fingertips/hands/forearm.
 Caused by vigorous sucking.
 Skin becomes fragile due to weak dermo-epidermal attachment.
 Heals rapidly without treatment within 2 weeks of life.
 DD : Herpes simplex, Bullous impetigo, Epidermolysis bullosa.
Cutis marmorata
 Benign cutaneous vascular lesions characterized by reticulated bluish
mottling of the skin.
 Accentuated by cold temperatures.
 Seen on trunk and extremities.
Physiological / Neonatal Jaundice
 Normal phenomenon seen in 1st wk of life.
 Initially starts on face around nose.
 Bronze Baby Syndrome : associated with phototherapy in children.
Miliaria
Superficial vesicles due to obstruction of sweat ducts
Miliaria crystallina :
Obstruction at level of S. Corneum
 Following fever, hot humid weather, phototherapy
 Tiny clear vesicles seen over forehead, neck, trunk
Miliaria rubra (prickly heat)
Obstruction deeper in the epidermis
 Seen in hot weather
 Non follicular papules on an erythematous base
 1 to 4 mm in diameter on trunk, face, flexures
 Usually subside in 2-3 days
Miliaria
Miliaria pustulosa :
Papulo-vesicular lesion that becomes a sterile pustule
Miliaria profunda
Obstruction at DEJ
Leakage of sweat into dermis
Advise : Cold water baths, remain in cool areas, avoid occlusive
clothing
Treatment : Calamine lotion, talcum powder
Antibiotics in secondary infection.
Milia
 Idiopathic small superficial keratin filled cysts affecting all age groups.
 Resolves spontaneously in newborns.
 Epstein Pearls : Milia on palate of newborn
Neonatal Acne
 Seen in first 3 months of life.
 Transplacental transfer of maternal hormones.
 Non-scarring type, resolves spontaneously
Cradle Cap
 Seborrhoeic dermatitis of scalp.
 Thick, greasy, adherent scales on
scalp.
 Also seen over the ears, trunk
and intertriginous areas.
 Usually begins in first 3 months
and is self limiting.
 Application of oil for few hours to
soften scales, 1% hydrocortisone
.
cream can be used.
Erythema Toxicum Neonatorum
 Benign, idiopathic self limiting
eruption
 Characterized by papules and
pustules on blotchy erythema
 Seen in 1st wk of infancy and
resolves spontaneously within 12 wks.
 Present all over the body more so
on buttocks and back
Transient Neonatal Pustular Melanosis
 Idiopathic eruption within 1st day of life.
 Sterile fragile pustules seen over forehead, chin, neck lower back and
shins.
 Treatment not required.
Diaper Dermatitis (Napkin Rash)
 Most common Irritant dermatitis in the perineal region of neonates
due to occlusion, friction, prolonged skin contact with urine, feces
and fabrics.
 Wetness leads to maceration of skin and secondary infection with
candidiasis.
 Intertriginous areas are invariably spared.
DD : Seborrheic dermatitis, candidiasis, Psoriasis, Intertrigo
Treatment :
 Cleansing
 Hydrocortisone cream twice daily
 Zinc oxide & Petrolatum are used as barrier creams
Infantile Naevi and Childhood Dermatoses
Infective, inflammatory diseases and childhood eczemas have been
discussed in respective chapters.
Certain common and genetic-naevoid conditions seen in infants and
children will be discussed.
Congenital Melanocytic Nevus
Present at birth
 1% of infants are born with CMN
•
Small - <0.5cm,
•
Moderate - <20cm
•
Large - >20cm (1 in 20,000)
 Giant CMN - >50cm, also called “Bathing trunk nevus” Verrucous,
hairy, nodular having potential to become Melanomas.
 Treatment : Serial surgical excision
Congenital Melanocytic Nevus
Linear Epidermal Nevus
 Hamartomas of embryonal ectodermal
origin.
 Seen at birth or early childhood as a
linear raised warty lesion.
 Located over head, neck, trunk &
extremities.
 Treatment: Surgical excision with
grafting, Radiotherapy, Cryotherapy, CO2
Laser.
 Retinoic acid and Calcipotriol.
Nevus of Ota
 Unilateral patch of bluish discoloration (dermal melanocytosis) in
the periocular area along ophthalmic and maxillary divisions of the
trigeminal nerve.
 Sites : periobital area, sclera, conjunctiva, temple, forehead, malar
area, nose.
 When it appears on shoulder - Nevus of Ito.
Nevus Depigmentosus
 Single, well circumscribed,
hypopigmented or depigmented
macule or patch seen at birth.
 Usually stable in size and distribution
 Sites : trunk and proximal extremities
with serrated edges.
Nevus Anemicus
 Usually congenital, single or multiple hypopigmented patches
blanchable on diascopy.
 Due to localized increased vascular response to catecholamines.
Becker’s naevus
 First appearance is in adolescence and more common in males
 Irregular hyperpigmented smooth macule, develops coarse hair later
 Sites : shoulder, anterior chest or scapular region.
 Lasers may be used for cosmetic benefit.
Haemangiomas
 Most common vascular nevi of childhood.
 Incidence more in preterm infants with female predilection beginning
at one month of age.
 Lesions undergo a proliferative phase followed by stabilization and
eventual spontaneous involution.
Complications
 Ulceration, bleeding, Secondary infection, Mutilation and scarring,
Cosmetic disfigurement.
Treatment
 Systemic Corticosteroids, propranolol, surgical excision and lasers.
Strawberry Haemangioma
Vascular malformations
 Stable dilatations of superficial or deep vasculature.
 Present at birth or any any age.
 Can be capillary, arterial, venous, lymphatic or mixed.
Clinical types
 Salmon patch
 Port-wine stain
 Sturge-Weber syndrome
 Klippel-Trenaunay syndrome
Salmon Patch (Stork Bite)
 Present in 30 to 40% of neonates.
 Superficial, red or pink flat lesions.
 Seen over forehead, upper eyelid, glabellar area, nape of neck.
 Resolution in first year of life.
Port-Wine Stain (Nevus Flammeus)
 Present at birth
 Common sites are face, neck and mucous membrane
 Flat pink-red lesion
 Sharply unilateral in distribution, may develop nodules with age
 Persists and becomes darker in adulthood
Complications :
 Glaucoma, Choroidal angiomas
Treatment :
Flash pulsed dye laser
Portwine Stain
Sturge-Weber Syndrome
 Port wine stain in distribution of ophthalmic branch of trigeminal
nerve .
 May be associated with seizures, ipsilateral glaucoma, behavioural
problems and mental retardation.
 Characteristic intracranial S-shaped calcifications.
Neurofibromatosis (NF)
 Autosomal dominant disorder.
 Benign growths of peripheral nerve sheaths.
 Riccardi classified NF into eight distinct clinical types in 1982.
 Affects skin, soft tissue, nervous system, bone and other organs.
 Classical skin lesions are Café au lait macules and neurofibromas.
Neurofibromatosis - 1
(Von Recklinghausen’s disease)
Diagnostic criteria for NF-1
Presence of two or more of the following:
 Six or more café au lait macules:
•
>0.5 cm in children
>1.5cm in adults
 Two or more neurofibromas of any type or 1 plexiform neurofibroma.
 Axillary or inguinal freckling.
 Two or more Lisch nodules (brown coloured small nodules on iris
surface).
 Optic glioma.
 A distinctive osseous lesion.
 A first-degree relative with NF-1.
Neurofibromatosis
Neurofibromatosis - 2
 Bilateral acoustic neuromas
 Multiple CNS tumors
 Few café au lait macules
 Few neurofibromas
 No axillary freckling
 No Lisch nodules
 Juvenile posterior subcapsular cataracts
Treatment :
 Multi- disciplinary management
 surgical excision
 lasers
Tuberous sclerosis (Bourneville’s disease)
Syn. EPILOIA (Epilepsy, Low IQ, Adenoma sebaceum)
 AD inheritance
 Skin Lesions:
Ash leaf macules / hypopigmented macules.
Angiofibroma (adenoma sebaceum) begins at 2-5 years of age as small
pink papules on mid-face.
Shagreen’s patch (yellowish brown plaque on lumbo - sacral area).
Koenen’s tumors (periungual fibroma)
 Mental retardation, Seizures
Treatment : angiofibromas with lasers and electrodessication.
Tuberous sclerosis (Bourneville’s disease)
Angiofibromas
Ash leaf macule
Ichthyosis
 Inherited disorder of keratinization.
 Characterized by the accumulation of scales on the skin surface, dry
skin.
 Fish like scales most prominent over the trunk, abdomen, buttocks
and legs.
 May be associated with ectropion, eclabion, nail dystrophy, internal
organ involvement in few cases.
Types :
 Ichthyosis vulgaris: most common
 X-linked ichthyosis
 Lamellar ichthyosis
 Collodion baby / Harlequin fetus
Lamellar Ichthyosis
Xeroderma pigmentosum
 Photosensitivity, oculocutaneous pigmentation and early neoplasia
resulting from abnormal DNA repair.
 Autosomal Recessive.
 Multiple freckles, atrophic hypo-pigmented macules over photoexposed skin.
 Prone to malignancies BCC, SCC, malignant melanoma & systemic
malignancies.
 Treatment : strict photo-protection, eye protection.
Epidermolysis Bullosa
 Inherited bullous disorders characterized by non-inflammatory blister
formation at sites of trauma.
 Variable severity depending on genetic defect.
 Types : Simple, Junctional, Dystrophic.
 Some subtypes, especially the milder EB forms, improve with age.
 Autosomal recessive types have bad prognosis with severe mucosal,
esophageal involvement and atrophic scarring of skin.
 Treatment : Prevention of trauma, wound care.
Epidermolysis Bullosa
Ectodermal dysplasia
 Autosomal X linked recessive is most
common.
 Characterised by defects in hair, teeth,
nail and sweat glands.
Hypohidrotic ectodermal dysplasia:
 Sparse hair, decreased sweat and
absent dentition.
 Risk of hyperthermia in warm weather
Adolescent Dermatoses
 Acne
 Dandruff
 Striae
 Pseudo-acanthosis nigricans
 Contact dermatitis to cosmetics, perfumes, artificial jewellery /
accessories (metals)
 Hyperhidrosis
Dandruff (Pityriasis capitis)
 Most common condition affecting the scalp.
 Causative organism: Malassezia species.
 Seen as mild, moderate or severe scaling of scalp.
 May or may not be associated with itching.
 Simple dandruff does not cause hair loss.
Striae (Stretch Marks)
 Seen as pinkish white lines around knees, axillae, outer aspect of
thighs, lumbosacral region.
 Sudden increase in height or weight causes rupture of connective
tissue beneath an intact epidermis.
Striae
Pseudoacanthosis nigricans
 Velvety hyperpigmented skin in flexures
 Asymptomatic
 Mostly seen in obese children
Child abuse
 Includes physical abuse, neglect, sexual exploitation.
Cutaneous manifestations
 Bruises.
 Traumatic alopecia.
 Thermal burns.
 Sexual abuse : Vaginal tears, anal tears, hematomas.
 Sexually transmitted infections.
General principles of skin care in neonates children
Bathing, soaps and cleansers :
 Gentle cleansers are advised.
 Excessive cleansing, scrubbing & incomplete rinsing lead to irritation.
Shampoos :
 Should be isotonic to tears and less irritating to eyes.
 Shampooing twice a week controls normal flaking.
Care of the diaper area :
 Gentle cleansing & limiting use of disposable diapers.
 Intertriginous areas should be kept dry and ventilated.
Differences in treatment of Pediatric and Adult Patients
 Conservative management is best.
 Surface area is more in children as compared with adults.
 Percentage of absorption of topical drugs is more.
 Try to use lowest effective dose of medications.
 Do not use treatments which may retard growth or mental
development.
 Avoid off-label uses of medications.
MCQ’s
Q.1) One of the criteria to diagnose neurofibromatosis-I is cafe-au-lait
macule. The size of the macule in children should be
A. > 1cm
B. > 0.5cm
C. > 1.5cm
D. > 0.05cm
Q.2) In erythema toxicum neonatorum, Wright stain of a pustule reveals
majority of the cells are of
A. Neutrophils
B. Eosinophils
C. Lymphocytes
D. Mast cells
MCQ’s
Q.3)
A.
B.
C.
D.
In Miliaria crystallina, obstruction of sweat duct is at the level of
Stratum corneum
Stratum granulosum
Stratum spinosum
Dermoepidermal junction
Q.4)
A.
B.
C.
D.
Koenen’s tumor is associated with
Neurofibromatosis
Icthyosis
Tuberous sclerosis
Epidermolysis bullosa
MCQ’s
Q.5) Neonatal perineal dermatitis, intertriginous areas are invariably
spared in
A. Allergic contact dermatitis
B. Diaper dermatitis
C. Seborrheic dermatitis
D. Candidiasis
Photo Quiz
Q. Identify the condition.
Photo Quiz
Q. What is the most probable diagnosis
Thank You!