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PEDIATRICS 2
7)

Bulla- a circumscribed, elevated lesion greater than

1cm in diameter and containing clear serous fluid

8)

Wheal

DERMATOLOGY
Structure of the Skin:
Epidermis
Dermis
Subcutaneous tissue
Functions of the Skin:
Physical protection
Metabolic
Sensory
Immunologic
Approach to Diagnosis:
History
History of Present Illness
Family History
Review of System
Physical Exam:
Inspection and palpation morphology (color, texture, shape,
distribution, arrangement), primary vs secondary lesions
Distribution of Lesions:
Sun Exposed Sites
Flexural Rashes
Dermatomal
Truncal e.g. Ptyriasis rosea
Lines pf Blaschko
Primary Lesions:
1)

Macule any circumscribed color change in the skin

that is flat less than 1cm

2)

Papule a solid elevated area less than 1cm in

diameter whose top may be pointed, rounded or flat

3)

Nodule a deep-seated mass that elevates the

overlying epidermis, measures greater than or equal to
1cm

4)

Plaque a palpable lesions covering an area greater

than 1cm in diameter usually flat topped

5)

Patch a circumscribed color change that is flat and

greater than or equal to 1cm diameter

6)

Vesicle a circumscribed, elevated lesion less than

1cm in diameter and containing clear, serous fluid

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Secondary Lesions:
1)
2)

Scales dry, thin plates of keratinized epidermal cells

Lichenification dry, leathery, thickening of skin with
deep and exaggerated skin lines and shiny surface
resulting from chronic rubbing of the skin

3)

Erosion and oozing a moist circumscribed slightly

depressed area representing a blister base with roof of
the blister removed

4)

Crust dried exudate of plasma on skin surface

5)

Excoriation

Common Disorders in Children:

Eczemas atopic dermatitis
Diaper dermatitis
Infections and infestations
Acne
Birthmarks pigmented vascular (hemangiomas,
stains, malformations)
Atopic dermatitis
Recurrent, chronic disease
Very itchy
Often those with a family history of asthma or allergic
rhinitis
Eczematous red lesions due to a hyper response to
certain trigger factors
Early: extensor involvement
Late: flexural involvement
Treated with anti-inflammatory agents and emolients,
antibiotics for infections and comprehensive care plan
Common Eczema Triggers:
Irritants detergents, chemicals, rough fabrics
Allergens molds, pollens, dust mites, pet dander, food
allergies
Infections viral, fungal, bacterial
Environment stress, perspiration, temperature
extremes
Diaper dermatitis
Most common cause: prolonged contact with urine and
stools
Differentiate from psoriasis and candida intertrigo
Bacterial Infections
Impetigo

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Impetigo
-

Folliculitis
Cellulitis
Erosions covered by honey-colored crusts
Group A strep/staph
Common with secondarily-infected dermatitis
Local (mupirocin)
Or systemic reaction Cephalexin, Amox/Clav 1st line
MRSA possible
Gram stain and culture helpful

Folliculitis
Pustule At Follicle Opening sometimes with intense
Erythema
Staph and Strep
Treatment: cool compresses
Anti-staph solution/foam eg. clindamycin
Severe systemic antibiotics
Furuncles, Carbuncles
Isolated or scattered
Staph
When resistant: often with family history of abscesses
and recurrent folliculitis
Treatment: drainage, warm compresses
Dicloxacillin, cephalexin but consider MRSA
Cellulitis
-

Erythematous, hot tender plaques, lymphadenopathy

Strep and staph
Rare H. influenza, or opportunistic infection
Treatment: Dicloxacillin

Fungal infections
Dermatophytes
Candida albicans
Malassezia

Fungal culture
Gold standard
Saborauds glucose agar
Hair brush
Skin scale
Nail nail plate
Candida albicans
Diaper dermatitis: very red appearance
May see weeping, vesicles, pustules and papules
Characteristics satellite lesions
Thrush thick white plaque on oral mucosa
Treatment: Nystatin
Azoles
Malassezia (Tinea versicolor)
Scaling hypo or hyperpigmented plaques (thus
versatile color)
Usually chest neck location
Usually asymptomatic, or mild pruritus
KOH: spaghetti and meatballs
Treatment: Ketoconazole shampoo/solution
Alternative treatment: Oral Fluconazole
Viral infections
Herpes simplex
Varicellaa (Chicken Pox)
Herpes zoster
Virus-induced tumors
Herpes simplex
Grouped vesicles or grouped erosions
HSV I acute gingivostomatitis
Periorbitally or on thumb
HSV II genitalia and mouth via close sexual contact
Treatment: Acyclovir
Oral anesthetics

Tinea capitis
Hair infection
Scaling, erythema, broken hairs, pustules
Human to human or animal to human
Treatment: Griseofulvin PO
Alternative treatment: Terbinafine, Azoles

Varicella (Chicken Pox)

Clinical manifestation:
o Vesicles, papules, pustules on an
erythematous base (dewdrop on aa rose
petal)
o Incubation period: 10 to 23 days
o Contagious 2 days before onset of rash to 6
days after onset
Natural course
Complications

Tinea corporis (ring worm)

Body infection
Annular marginated scaling plaque with clearing center
+/- pustules
Advancing border
Treat topically

Herpes zoster
Reactivation of HZV
Grouped vesicles in dermatomal distribution
Natural course
Treatment: Acyclovir/valacyclovir
Pain medications

Laboratory Diagnosis:

Diagnostic work up (viral):

Dermatophytes
Tinea capitis and Tinea corporis

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Tzanck smear giemsa: multinucleated giant cells

Direct fluorescent antibody technique (DFA technique)
Biopsy
Viral culture

Virus-induced Tumors
Molluscum Contagiosum umbilicated, white papules
in groups on genitalia or trunk
Treatment: Wait; Cantharadin; Extraction; others
Warts skin colored papules with irregular surfaces
Treatment: electrocautery; liquid nitrogen; salicylic
acid; others
Condyloma acuminatum perineal warts
Podophyllin, imiquimod
Viral Exanthems
Measles
Paramyxovirus
Incubation period: 9-14 days
Contagious from onset of respiratory symptoms to 3-4
days after rash
Pink, maculopapular rash, confluent on face, discrete
on extremities
Prodrome: high fever, conjunctivitis, hacking bark-like
cough
o 3 Cs: cough, coryza, conjunctivitis
Rubeola (Measles)
Kopliks spots pathognomonic enanthem; blue
specks on buccal mucosa opposite 2nd molar
Lymphadenopathy generalized
Rash lasts 5-6 days
Complications:
o Encephalitis (most dreaded
o Thrombocytopenia
o Otitis media
o Pneumonia
o Aggravation of TB
Treatment:
o Symptomatic
o Prevention vaccination (MMR)
Scabies
Linear burrows around wrist, ankles, finger webs,
areolas, genitalia and face
Intensely pruritic especially at night
Excoriations, honey-colored crusts, papules
Diagnosis: microscopic exam definitive diagnosis
Treatment: Permethrin 5%
Educate
Pediculosis (louse infestations)
Head lice
o Infect scalp
o Transmitted by close contact and sharing
personal items
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Acne
-

o Nits oval cases attached to hair shaft

Pubic lice
o Pubic hair, eye lashes
Transmission by close contact with infected individual
or sharing personal items
Treatment: Permethrin 1% shampoo or lotion
resistance not uncommon
Causes: increased sebum production, abnormal
keratinization of epithelium, inflammation, bacteria
Manifestations: noninflammatory, inflammatory, combo
Treatment: antibiotics, retinoids, benzoyl peroxide,
keratolytics

Birthmarks
Pigmented
o Caf au lait spots
Vascular birthmarks
o Stains: nevus simplex, port-wine stain
o Hemangiomas
Salmon patch/stork bite/angel kiss
Seen in 22% of asians
Flat pink birthmarks (also called capillary
hemangiomas)
Lightens as the child gets older
May occur on the forehead, nose, eyelids, back of neck
Common Lesions in the Newborn:
What you may see on the first day
Vernix caseosa cheesy material

Caput succedaneum cone head

Swelling of soft tissue on the head as it passed
through the narrow birth canal

Lanugo carpet of hair

Fine hair in utero
The younger the baby the more hair it is

Acrocyanosis blue hands and feet

Bluish hands and feet as the blood circulation is
maturing

Cutis marmorata red mottling

Net like pattern on arms and legs due to immature
blood vessels
Disappears upon rewarming

Desquamation peeling
Physiologic peeling of skin
More pronounced when born later than due date

At home
Acne neonatorum

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-

May appear during 2nd 3rd week of life

Due to maternal hormone stimulation
Does not signal acne when the child gets oldr
Resolves in a few weeks to months
No treatment needed
May persists up to 1y/o

Miliaria
Due to sweat retention
Immature sweat glands
Common in the Philippines
2 kinds in the newborn: shallow (miliaria rubra);
deep (miliaria pustulosa)
Prevention: dress baby in light cotton
Use fan for gentle breeze
Avoid use of powders

Erythema Toxicum Neonatorum (ETN)

Benign/non toxic
Cause: unknown
Seen in fullterm infants
Occurs in 2 to 3 days
Red blotches with white or yellow papules in the
center
Spares palms and soles
Numerous and recurring
Resolves in a few days

Sebaceous Gland Hyperplasia

Enlarged oil glands
Maternal hormone stimulation
Shiny yellow papules usually on the nose and
cheeks
Resolves in a few weeks

Milia
Tiny cysts caused by the retention of old skin
cells and oily material (keratin) within hair follicles
Scattered or grouped
May be found on cheeks, forehead, nose, chin,
trunk, limbs, genitalia
May occur until 2nd to 3rd month

Transient Neonatal Pustular Melanosis

Benign self resolving eruption of tiny clear or pusfilled pustules
Superficial and easily ruptures (fragile)
Leaves a ring of scale and light brown
discoloration
Fades in weeks to months
No treatment needed

Mongolian Spots
Bluish gray flat birthmark
Common in asians (84-86%)
Collection of pigment producing cells within the
skin

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Usually on the back and buttocks

Most fades at 4y/o

Seborrheic dermatitis
Greasy, waxy, yellow scaling with a red base
May be seen on the forehead, eyebrows, sides of
the nose, ears and diaper area
First few months of life
Cause: unknown
Treatment: mild shampoo, mineral oil
Can last up to 12 months old