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Pediatric Dermatology Overview - From Head to Toe Joanna Guenther, PhD, RN, FNP-BC, CNE September 2014
Objec ves
• Discuss a systema c approach to common dermatologic condi ons of children encountered in primary care. • Describe the clinical manifesta ons of common dermatologic condi ons of children. • Review therapeu c and pharmacologic treatments for each dermatologic condi on.
History Taking
• Age, race, and sex • Onset/dura on • Loca on on body • Evolu on of lesions • Treatment a empted • Associated symptoms – Pruritus, fever, headache, GI, etc – Think infec on with rash + fever
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Addi onal Aspects of History
• Family history • Known personal contacts • Trauma • Travel & play • Environmental exposure – Insects, plants, toxins, sun, etc • Season
Primary Skin Lesions
Atopic Derma s
Eczema Treatment: • Inherited predisposi on - • Rehydra on of skin, o en hx. Asthma, allergic an histamines, topical low rhini s, food allergies potency steroid creams, • Usually affects cheeks, face, Elidel or Protopic cream bid trunk, extremi es • Erythematous papules to scaly plaques • Intense pruritus >> scratching >> risk of impe go
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Seborrheic Derma s
Cradle Cap Treatment: • Common during first several • Emollient – baby oil months of life • Baby shampoo + so brush • O en on face & scalp, but can extend to other areas • Well circumscribed plaques with scaling • Resolves by 6-12 months
Impe go
Characteris cs: Treatment: • Infec on usually caused by • Bactroban (mupirocin) oint d X 7 days; Altabax oint bid X 5 days + staph aureus; contagious warm compresses and gentle • Red papules >>> fragile washing vesicles >>> honey-colored • Oral an bx - dicloxacillin, cephalexin, clindamycin X 7 days crusted papules • Recurrence: check for nasal carrier of MRSA with C&S swab (Bactroban intranasally)
MRSA
• Methicillin-resistant staphylococcus aureus • Only responds to certain an bio cs – local an bio c suscep bility (clindamycin 40 mg/kg in 3-4 daily doses or, bactrim 8-12 mg trimethoprim/kg in 2 daily doses) • Enters through cuts and wounds • O en starts as small bumps that resemble pimples and quickly turn to painful, deep abscesses • Risk factors: contact sports, sharing towels, weakened immune system • Preven on: Good handwashing
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Celluli s
Characteris cs: Treatment: • Erythema, edema, warmth, taut shiny skin, tender • Cause staph or strep, • Erisypelas – superficial erythematous complica on of wound or trauma patch >>> fiery red, indurated, tense (dog/cat bite) • Celluli s – deep infec on, usually caused by beta-hemoly c Strep or Staph aureus, • The borders are well defined and or complica on of wound or trauma (dog/ change rapidly cat bite) • Immediate a en on – C&S if draining; CBC; IV an bio cs followed by oral • Facial celluli s can cause visual damage if spreads to eyes • Elevate & heat
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Trauma
• Animal Bite vs. Scratch – Cat & Dog Bite: Pasteurella species most common – also staph and strep – Txment: Wound care, An bio cs • Amoxicillin-clavulanate, doxycycline > 8 yrs old • Oral vs. parenteral depends on wound depth & severity • Tetanus/Rabies prophylaxis – Cat Scratch: Bartonella pathogen most common • Azithromycin or clarithromycin most effec ve
Candidal Diaper Derma s
Characteris cs: Treatment: • Confluent bright red papules and • Frequent diaper changes; plaques with sca ered pustulo- expose skin to air vesicular satellite lesions • Topical pastes and ointments • Caused by moist environment, urine/ to serve as a barrier – zinc stool increase the pH, fric on from oxide (Desi n, A&D Ointment) diaper • An fungal creams (nysta n, • Candida albicans invade clotrimazole, miconazole) • Severely inflamed – 1% hydrocor sone sparingly bid for 5-7 days • Mupirocin ointment only if infec on present
Hand-Foot-and -Mouth
Characteris cs: Treatment: • Caused by Coxsackie virus • Suppor ve; oral ulcers A16 tender – Anbesol, Orajel • Abrupt onset of sca ered • Lasts < 1 week papular & 3-6 mm elongated vesicular lesions on palms, soles & mouth • Sxs: fever, malaise, joint aches, sore throat
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Erythema Infec osum
Fi h Disease Treatment: • Caused by parvovirus B19; • Suppor ve (fever, common in late winter & hydra on); Good early spring; spread by resp. handwashing droplets • Fever, malaise, h/a, sore throat, coryza >>> slapped cheek rash appears a er 48 hrs >>> diffuse, lacy pink rash on body X 1-2 wks • Contagious before rash
Pityriasis Rosea
Characteris cs: Treatment: • Prodrome sxs: malaise, headache, • Control pruritus: calamine, sore throat topical steroids, oral • Diffuse raised red patches with an histamines central scales in Christmas tree • Rash will subside without pa ern; first lesion is herald treatment – may last 6 weeks patch (large oval plaque) with more lesions 5-10 days later • ? Viral e ology
Roseola
Characteris cs: Treatment: • Caused by Human • Suppor ve: Control fever herpesvirus 6 (HHV-6) and increased hydra on • Common age 7-13 months • High fever (o en >104⁰ F) and irritability for 3-5 days • Blanching maculopapular rash develops as fever decreases
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Measles
Characteris cs: Treatment: • Rubeola – Paramyxovirus • Highly contagious 4 days • Prodrome: fever, malaise, dry before and a er rash cough, conjunc vi s, photophobia >> 3-4 days rash • Suppor ve care: control develops fever; increase fluids • Nonpuri c maculopapular, blanching rash starts on face and spreads to trunk & extremi es • Koplik spots on buccal mucosa • Incuba on period 8-12 days
Varicella
Chicken Pox Treatment • Fever, sore throat, malaise • Symptoma c: Cool compresses, X 2 D >>> rash starts on face oatmeal baths; RX. or trunk and spreads diphenhydramine, hydroxyzine, downward fexofenadrine, loratadine • Rash progresses from red • Watch for secondary impe go macules >> papules >> due to scratching vesicles >> umbilicated pustules >>> crus ng • Less common since varicella vaccine • Incuba on 7-21 days
Verruca
Warts Treatment • Caused by HPV - > 150 • No rou nely effec ve treatment subtypes – may spontaneously resolve – Cryotherapy q wk X3 • Lesions raised, pink, rough – Podofilox (Condylox) topical growths 0.5% soln bid for 3 consecu ve days/wk up to 4 weeks – Aldara topical thin layer 3 X per week – alterna ng days – Laser abla on
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Molluscum Contagiosum
Molluscum Treatment • Caused by pox virus – more • May treat to prevent spread to common in pedi; others: – Cryotherapy considered contagious – Laser abla on • Clusters of 3-5 mm flesh colored papules with umbilicated center; usually < 30 lesions • Resolve spontaneously over months to yrs
Herpes Simplex Virus
Fever blister; genital herpes Treatment: • Either Type I or II • Acyclovir topical q 3 h X 7 D • Clear papules with superficial • > 2 yrs – acyclovir susp ulcera ons/erosions 20mg/kg qid X 5 D • O en preceded by burning pain • Genital herpes – child abuse • Contagious
Gu ate Psoriasis
Characteris cs: Treatment: • Inflammatory changes occur • Rash usually resolves on own within the epidermis & (weeks to months) dermis; increased turnover rate of dermal cells • Numerous salmon-pink, scaling, small plaques on trunk and extremi es (usually 2-4 weeks a er strep pharyngi s or URI)
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Adolescent Acne
Characteris cs: Treatment: • Obstruc on of oil glands • Avoid oil based cosme cs • Mild: topical clindamycin and • Open comedones or closed erythromycin in AM & benzoyl peroxide 2.5-5% @ hs or topical comedones; pustules, re noids (Differin, Re n-A) .025-. nodules, cysts 05% @ hs • Moderate: above regimen + minocycline or doxycycline 50-100 mg bid, tapering to 50 mg/d as acne improves; OCP (proges n & estrogen) • Severe: Accutane – refer to dermatologist (labs & pregnancy test, contracep on, informed consent)
Tinea Capi s/Tinea Corporis
Characteris cs: Treatment: • Well defined circular patches with • Topical an fungals scaly borders – Terbinafine (lamisil), • Occurs a er contact with person/ Miconazole, ketoconazole, animal that has fungus not nysta n (for candida) • Use oral an fungals if creams fail
Tinea Pedis
Athlete’s Foot Treatment: • Lesions are pruri c and • KOH examina on of scales – clusters of scaly with raised border; hyphae may become fissured • Keep feet dry • Contagious • Extensive – oral terbinafine, itraconazole • An fungal cream/powders (1-4 wks) – OTC -Miconazole, clotrimazole
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Keratosis Pilaris
Characteris cs: Treatment • Excess kera n forms plugs in the • Emollients and mild hair follicles exfolia on • Symmetric sandpaper like follicular papules • Considered a normal skin variant
Parasi c - Pediculosis
Lice Treatment: • Nit (egg) adheres to hair >>> • Spread by shared hats, clothing, develops into louse in 3-4 D >>> able towels, combs, etc. to reproduce in 12 D >>> single • fer liza on needed to lay 10 eggs/ OTC pyrethrin (RID) and day for 30 day life span permethrin (Nix) – usually 2 • Louse pierce the skin and secrete txments 7-10 days apart; RX saliva which causes intense itching malathion lo on; benzyl alcohol; ivermec n • Fine tooth comb • Wash clothing/bedding in very hot water; place nonwashable items in a sealed plas c bag for 2 weeks
Parasi c - Scabies
Scabies Treatment • Wash clothing/bedding in very hot • Papular linear rash primarily on water hands, feet, & body folds; pruritus; • 5% Permethrin (Elimite) cream spreading rash applied from neck to feet – wash off • Female mites burrow under skin and a er 8-14 hrs; may retreat a er 10 lay eggs days • Can survive off human host up to 4 • An histamine for pruritus days • Skin scrapings – microscope
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Henoch-Schonlein Purpura
Characteris cs: Treatment: • IgA vasculi s, o en occurs • Suppor ve care: Adequate post viral hydra on, rest, symptoma c relief of pain • 2-10 years of age • Hospitaliza on in presence of • Palpable purpura over the renal insufficiency or worsening bu ocks and legs symptoms • Transient migratory arthri s • Renal disease and abdominal pain
Kawasaki Syndrome
Characteris cs: Treatment: • Systemic inflamma on • Hospitaliza on for treatment and • Peak incidence 19-24 months close monitoring; high risk for cardiac • Clinical findings: complica ons – Fever at least 5 days – Conjunc vi s – Polymorphous rash – Strawberry tongue; cracked red lips – Cervical adenopathy – Edema hands and feet • Increased risk coronary thrombosis
A few closing thoughts…
• Dermatology has its own language – learn to speak it • Obtaining a thorough history, along with the physical exam, will help iden fy the rash/lesion • Have a pictorial dermatology reference available • Refer to a dermatologist as needed
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