Diagnostic Procedures in Pediatric Dermatology
Review Article
Diagnostic procedures in pediatric dermatology
Arini Astasari Widodo, Githa Rahmayunita, Triana Agustin, Rinadewi Astriningrum
Department of Dermatology and Venereology, Faculty of Medicine, Universitas Indonesia - dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
Email: [email protected]
Abstract
Diagnostic procedures in pediatric dermatology are different and significantly more challenging than those in adult patients, especially on how to approach the patients. We need to acknowledge that pediatric patients have unique anatomical, physiological, and psychological aspects. Compared to adults, children have smaller procedure area, are less cooperative, and more difficult to understand. For these reasons, we should perform diagnostic procedures on children cautiously. Having extensive knowledge in this field can facilitate us to carry out an ethical, efficient, targeted procedure with less risk. This article reviewed the most appropriate, most comfortable, and least invasive diagnostic procedures for children. Some of the most commonly performed pediatric dermatology procedures highlighted in this article are potassium hydroxide examination, Gram staining examination, acid fast bacilli examination, skin test for allergies, and skin biopsy for children. We also discuss the process of obtaining a written informed consent from the parents who were involved in decision making process and play a crucial role in assisting physicians to calm their children during the diagnostic procedures.
Keywords: children, dermatology, diagnostic procedures
Background instruction should be strict and given in detail to avoid complications.1 This article reviewed the In the field of dermatology and venereology, in implementation of pediatric diagnostic procedures, addition to the clinical signs and symptoms, especially the most common procedures diagnosis is also established based on results of conducted at Dermatology and Venereology Clinic. diagnostic procedures.1,2 Performing various diagnostic procedure is more difficult in children.2,3 Approach on pediatric patients This is caused by small procedure area, difficulty to cooperate, and inadequate comprehension, Physician should develop rapport with patients leading to bigger role played by the parents. The before performing the procedures, especially if the parents' psychology status, such as anxiety, will procedures will induce pain or fear on the children. greatly influence the child’s psychology and the Being friendly is an important characteristic to decision made.3 create comfort when approaching a child.
Physician should be honest and try to assure the In 2015, there were 69 biopsy procedures, 6 skin 3 tests for allergies (5 skin prick tests, 1 patch test), children. 85 slit skin smear procedures, and 766 skin scrapping procedures performed on children at Babies Dermatology and Venereology Clinic, dr. Cipto Babies will usually cry when being laid down on Mangunkusumo General Hospital.4 bed. Gentle touch on a baby’s belly will reduce the fear and give a chance to examine the baby quietly. It is wise to look for less invasive procedures, Baby can usually be quiet and relaxed after the especially for younger children. Children are more local anesthesia starts acting. This is important so prone to drug toxicity, thus post-procedure
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the baby will not move during the procedure, Informed consent for children especially skin biopsy procedure. Parents’ cooperation and trust are very important when Informed consent is a process of showing effective 3 performing a procedure. communication between physician and patient. This process bridges the idea regarding what will Children or will not be performed on the patient. This In general, school aged children are the most informed consent is a statement from patient (or difficult to be approached when performing medical their authorized guardian) containing consent on procedure. The patient’s trust is very important, the medical procedure planned by the physician, thus the trust should have been built since the first after receiving adequate explanation to be able to 3 consultation. Diagnostic procedures which will make decision whether they consent or do not induce pain should be explain first to the child, consent to this procedure.7 Principle of autonomy although the child might not understand why the is the basis of this process.7, 8 3,5 procedure should be performed. Explanation should use a proper language suitable for the All procedures that will be performed should get child’s age and the child should be able to ask consented beforehand. The consent is provided questions. In certain procedures and conditions, after the patient is provided with the necessary children can be provided with opportunity to explanation regarding why the medical procedure choose, such as which position is more needs to be performed. There are 2 types of comfortable or location for the procedure to be consent, which are written consent and verbal 5 performed. Physician should encourage and consent.9,10 High risk procedures should be praise them if they are cooperative. Toys, candies, provided with written consent.9,10 The decision to or simple joke can help to calm them. Sometimes, perform this medical procedure should be children cannot stay calm due to fear. In that case, documented in medical record.9,11 3 sedation can be used as an alternative. There are two types of informed consent, which are Adolescents general and specific informed consent. General Performing medical procedures and physical informed consent is an informed consent taken examinations in adolescents can be difficult before history taking, physical examination, and because at this age, they are usually reluctant to standard prescription (during administration, show their body. In that case, physician should before entering the clinic). Specific informed show their sympathy, listen for anxiety, ensure consent is a consent taken for certain diagnostic 3 confidentiality, and treat them like adults. procedures, especially large scale and high risk Adolescents tend to be shy to admit pain, procedures.12 especially in front of other people. On the other hand, adolescents may act like children when Some government and professional organizations’ facing pain. Adolescents can be provided with an documents, such as the World Health Organization option to choose whether they want to be attended (WHO), Good Clinical Practice, and Declaration of by their parents during procedure or not. This Helsinki, suggest that informed consent for autonomy might make them accept the conditions pediatric patient needs “consent dyad” which is 5 they are facing easier. Another thing that should parents’ permission and informed assent which is be worried about is whether this procedure can the child’s permission.11 Patient’s autonomy cause cosmetic problem which will affect their consists of accurate and complete explanation, 3 social interaction. transparency, as well as informed consent.8 Children cannot sign informed consent; thus, they Parents should be represented by their parents or Parents are usually very worried with their guardians.8,12 Currently, United Nations (UN) has children’s conditions. Their worries can induce fear provided children with the rights to make decision 3,5 and worries in their children. Parents should be for their own good, although these rights are informed regarding the importance of the limited.11 Some of these following terms should be procedure and the potential risks. Furthermore, recognized in the concept of informed consent for parents should be assured and asked to sign the pediatric patients, which are8,12 6 informed consent form. a. Proxy consent: adult who receives information and represents the child to sign the informed
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consent.11,12 focusing their attention; therefore, the physician b. Informed assent: child’s consent on medical should be patient and must be able to find the right procedure, although the child is neither legally time when the child can focus their attention. For 8 authorized nor competent in providing consent. example, the physician should not provide c. Implied consent: if parents bring their child to a information and perform informed assent when the physician to be treated or to undergo a child is hungry.11 procedure, it possibly means that the parents
give consent for medical procedures performed on their child.12 Various methods can be performed to optimize informed consent on children, such as the use of Many ethics and legal experts do not approve media, honest communication, and simpler form. proxy consent. Informed consent cannot be The availability of third party as a witness or provided for other people; therefore, currently, education by a nurse prior to the education by “informed permission” and “assent” are more physician also eases this process. Sometimes, preferred. These processes are started with written parents also have difficulty in decision making. In informed permission from parents as the child’s this case, parents have a choice to give the full 11,12 guardians.11 authority to the physician to make the decision. All of these processes should be documented in Legally, children and adolescents are not the medical record by the physician. This document considered to be able to make decision because should be ensured to be in accordance with they are not mature and have limited patient’s age.11 comprehension regarding the medical procedures.7 In Indonesia, based on the laws There is no specific standard regarding the age of (constitutional law no. 39 year 1999) about human children when they are considered to be able to rights, a child is everyone who is under the age of provide informed assent. Children are considered 13 18 years old. Children are considered as legally able to provide informed assent if they are incompetent population based on the laws in competent to understand the mechanism, risks and Indonesia, according to the Article 7 of the benefits of the procedure. The age limit is different Regulation of the Minister of Health of the Republic in several literatures.5,11,12 Some literatures state of Indonesia Number 290/MENKES/PER/III/2008, it is stated that this explanation should be provided that children age 7 years old or older are competent to the family or the guardian.9 On the other hand, enough; while others state that children under 9 children also need to be involved in decision years old are not competent enough to provide making and explained regarding the medical assent.11,12 procedure. Legally, children have the rights to receive that information.7,13 The parents’ authorities Diagnostic procedures to provide consent should be used for the best 7 interest of their children. 1. Skin tests There are various techniques for skin tests and the Physician explains protocols, facilitates discussion, choice of the test depends on the diagnosis. and provides information suitable with the age, maturity, and psychological status of the children in a. Skin prick test 5,11 a supportive environment. This relates to the law There is no age limit for children for skin prick of children’s rights, which states that every child test.14-16 This test is safe and can be performed has a right to receive information in accordance on babies and children.3,16 Standards of Care 13 with their intellectuality and age. Attention from Committee of the British Society for Allergy and the physician will form closer bond with the child, Clinical Immunology have standard operational leading to higher compliance and accurate report procedures for performing skin prick test on regarding the adverse effects of the procedure. The children.17 The child can sit on the parent’s lap decision-making process is affected mainly by how across the examiner. A pillow is placed between the physician provides information, condition and the physician and the patient so the patient can the time of information provided. Explanation be more relaxed and the arm can be more should be provided right before the procedure is stable when the skin prick test is performed. 5 performed. Location for providing the information Arm is preferred to the back because with this should be conditioned as comfortable as possible method, eye contact can be maintained and the and free of noise. Children have limited ability in child can witness the whole process.17 The
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space between two skin pricks should not be too Inform the parents about the procedure and close to prevent cross contamination. Skin test its assessment to optimize the condition of can be performed on both lower arms on the patch test. volar side if the child’s arms are too small.18 However, the choice of skin test’s location Method of the test used for adults is considered 25 should be suited with the child’s age, safe for children. The tested allergens are ® preference, and skin condition. Various placed on Finn chamber fixated by special bandage, then patched on the upper back.3 The distractions can be performed to decrease the 17 test area is smaller in children, thus in some anxiety and to increase compliance. The literatures it was advised to use Finn chamber® method of reading skin prick test result for in children; compared to other types of 15,16 pediatric patients is not different from adults. chamber, Finn chamber® is the smallest kit that can be used for patch test.22,23 Finn chamber® Physician should interpret skin prick test result has aluminum edge that provides better carefully in pediatric patients, especially in occlusion and is relatively small size, with terms of clinical relevance. Positive result does surface area of 50 mm2 for a chamber with not always mean that the child is allergic to the diameter of 8 mm.22 Currently, special unit for material. Many children with positive result pediatric patch test is available, which is IQ against certain type of food, have negative Ultimate® from Chemotechnique Diagnostics. result on provocation test. History taking and This unit has some advantages which are knowledge regarding the disease are necessary elastic, transparent, anti-leak, and water- in order to choose a rational test and how to resistant. This unit is considered ideal for active 19,20 children and can be used during bathing. interpret it. The cause of this false positive ® result should also be evaluated, including the Different from Finn chamber , this unit does not use aluminum, so it is more comfortable and presence of dermographism, deeper prick, or can reduce the risk of chemical reaction irritant reaction.18,21 Tests against various food between allergen and aluminum.22,25 Children allergens without clear history of allergy are not and parents should be instructed to keep the recommended because sensitization often material patched dry, stayed on place and away 19 happens without being clinically allergic. from sunlight.3 b. Patch test The criteria and indications for pediatric patch Patch test is a diagnostic test to determine test are the same with adults.25 Thin-layer rapid delayed type hypersensitivity in patients with use epicutaneous (TRUE) patch test is easier to allergic contact dermatitis. Most authors agree be performed on smaller children due to shorter that patch test is safe to be performed on preparation time.3,26 Generally, the standard children, but there is no guideline on how early substances tested are in accordance with the procedure can be introduced to the children. European standard series, which can be added The key problem is the technical problem due to with additional allergens depending on the smaller location for patch test, lots of motion and history taking.3,27 Study by Machovcova28 used 22, 23 parents’ reluctance. European baseline series patch test with 25 allergens on 218 children and reported that this 24 Mallory et al. suggested several things as series of patch test was safe for children and follows: adolescents. Many authors suggest that classic If the test area is too small, patch test should standard series of allergen can be used on be performed in several sessions. children, moreover other series of tests can be If the test material is detached, the parents added as necessary.22,23,25 However, several should be educated to report it and not to authors limit the types of allergen tested on attach it themselves. children.22,27 This is due to the risk of new Stronger adhesive can be used but we sensitization.3,27 On the other hand, should be careful of irritation. determination of the allergen is also important Patch test process should be performed as to prevent skin disorder in children.25 quick as possible when the child is vulnerable. Draw a map of allergen location which will be Based on the consideration that allergen tested. This process is the same with adult. exposures on children are uncommon compared to adults, and children have narrower
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area for patch test, Brasch and Geier29 allergens, such as nickel, formaldehyde, suggested a standard patch test using 16 mercury, potassium dichromate, mercapto- allergens. This series is less than the simplified benzothiazole, and thiuram mix.3,22,23,27,31 international standard series which uses 20 However, current consensus agrees to use the allergens or European standard series by same concentration as adults.27 European Society of Contact Dermatitis (ESCD) Follicular reaction and/or eczematous reaction and European Environment and Contact are often considered as positive reaction. In Dermatitis Research Group (EECDRG) that fact, this reaction is irritant reaction. This uses 28 allergens.30 Retrospective study by reaction often happens in children aged under 5 Groupe d'Etudes et de Recherches en years old.3,22 Marcussen31 reported that Dermato-Allergie (GERDA) in France observed epithelial barrier factor was varied between the patch tests on 959 children under the age of 15 age of 0-8 years old and the percentage of years old in 1995-1997. Allergens used in this irritant reaction decreased linear with the study can be seen in Table 1.29 The study children’s age and started to stop at the age of proposed to include P-phenylenediamine 7-8 years old. (PPD), cobalt, chloride, mercapto mix, mercaptobenzo-thiazole, para-tertiary Currently, there is no special standard butylphenol (PTBP) resin, and operational procedure (SOP) for children methylchloroisothiazolinon as standard regarding prick test and patch test at Pediatric allergens because there were reactions in more Dermatology Clinic in dr. Cipto Mangunkusumo than 1% tested patients. Other allergens General Hospital as SOP for adults is applied suitable with the patient’s history and for children as well. If considered necessary, environmental exposure should also be different SOP should be established in order to tested.23,29 adjust the procedure for children’s safety and comfort. There are many contradictions regarding concentration of allergen for patch test in children. Several authors recommend lower concentration in children, especially for certain
Table 1. Simplified test allergens for children*
No. Agents Dilution 1. Potassium dichromate 0.5% pet. 2. Neomycin 20% pet. 3. Thiuram mix 1% pet. 4. PPD-free base 1% pet. 5. Cobalt chloride 1% pet. 6. Formaldehyde 1% aq. 7. Colophony (colophonium) 20% pet. 8. Balsam of peru (Myroxylon Pereirae) 25% pet. 9. Alcohol lanolin 30% pet. 10. Mercapto mix 2% pet. 11. Paraben mix 16% pet. 12. PTBP-FR 1% pet. 13. Fragrances mix 8% pet. 14. Nickel sulfate 5% pet. 15. Metyhl(chloro)isothiazolinon 0.67% aq. 16. Mercaptobenzothiazol 2% pet. *Adapted from Machovcova29
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2. Specimen collection taking in various Adhesive band pediatric skin infections Specimen collection taking using adhesive Specimen collection taking for Gram staining and band can be an option.32 Adhesive band is Tzanck examination is less invasive. The method usually from vinyl and transparent material.32,35 of specimen collection taking for those Various brands of adhesive band available in examinations in children is the same as adults. Indonesia are 3M®, Daimaru®, Tulip®, Scotch®, Meanwhile, specimen collection taking for etc. The method of use is by pressing the superficial mycosis and acid-fast bacilli often adhesive band over the lesion, remove it, and causes pain and fear due to the use of scalpel, hence the method of collection and method of pain then the adhesive side is pressed on the management will be discussed further. Generally, microscope object glass. This band can be used diagnostic test for skin infection in pediatric patients later for culture if the specimen is taken with 33 is not different from adults.1 sterile technique. This method can be used for patients with both dermatophytes infection and a. Specimen collection taking for superficial candida infection.32,35 mycosis The advantages of this technique in diagnosing Scalpel superficial mycosis are: (1) painless especially Skin specimen to support diagnosis of in children (2) shorter time and easier (3) superficial mycosis can be used for both direct reliable result (4) cheaper, no need of microscopic examination and fungal culture. disposable scalpel or cover glass (5) the Skin specimen collection taking in superficial possibility of storing the specimen to be mycosis on face, neck, armpit, groin, or genital examined in the future (6) no knife is used which can harm the patients, especially pediatric usually scare the children.32,34,35 This method is patients because they seldom stay still.32 Skin considered superior for specimen collection scrapping is usually performed using scalpel no. taking in patients with tinea capitis if the scales 15, object glass, or Foman knife.1,33 Foman are few.33 Other experts suggested that use of knife is spatula-like instrument with two edges. adhesive band would make the physician try to This knife is the safest equipment to prevent take more specimen. The surface area to be trauma on skin if the baby moves during taken is generally wider than by scrapping, so scrapping.1 Specimen collection taking the specimen can be abundant and the result is technique using scalpel is considered more reliable.35 The use of adhesive is uncomfortable by some authors and takes considered to increase patient’s compliance. relatively more time than other techniques.34 To This technique is suitable to be used for daily reduce the possibility of wound, the sharp edge clinical practice.32 of the scalpel should be placed in the opposite direction of the scrapping direction. Blunt The disadvantage of this technique is that the scalpel can also be used to take nail specimen adhesive band is often insufficient to take from children suspected to be infected by fungi. specimen from wet lesion and lesions on hands The location for scrapping is not different from or feet. This technique is also less suitable for adult, however, the specimen collection taking specimen collection taking from lesions on head should be performed gently and carefully. In and nail.32 addition to the scrapping using scalpel, specimen can also be collected from nail Brush and comb clipping.27 Hubbard et al.34 studied specimen collection taking from 70 pediatric patients with tinea Another device often used for skin scrapping in capitis using brush and compared it to our hospital is object glass because children are scrapping method. Specimen collection taking often frightened when they see a scalpel. was performed by brushing in circular motion Ironically, object glasses are sometimes slowly on the area with scales and the edge of sharper than a blunt scalpel; moreover it has alopecia plaques using sterile brush. This brush sharp edges and can break easily. Therefore, was later pressed on the culture media and the object glass should be used with caution as skin brush was thrown away. This study showed that scrapper even though it is considered effective specimen collection taking using brush resulted to take adequate amount of sample. in culture with faster growth compared to the
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scrapping method. Brush was considered locations for AFB examination are three. The effective and provided shorter time to diagnosis location and number of specimen collection tinea capitis. Comb could also be used with the taking are not different from adults.38 same technique.33 On daily practice in dr. Cipto Mangunkusumo Cotton swab General Hospital, at least one lesion (which is Another study by Friedlander et al.36 proved the most suspicious lesion) is taken for biopsy that the use of cotton swab is similarly effective to make it less invasive for children. compared to brush in the case of tinea capitis. Furthermore, if a lesion most likely will require Both brush and cotton swab resulted in 100% biopsy, the child may not undergo the slit skin positive cultures.36 Specimen collection taking smear test and only undergo the biopsy instead. for candidiasis case in children, both oral candidiasis or lesion at external urethra orifice 3. Skin biopsy in children or vulvar, usually uses cotton swab technique.1 Before performing procedure, the physician should ask whether the child is allergic to topical b. Acid-fast bacilli antibiotics, antiseptic, local anesthesia, and wound Borderline tuberculoid (BT) is a type of leprosy, dressings. It should also be asked if the child commonly found in children which accounts for suffers from bleeding disorder or is on medication 55-78.8% of leprosy cases. Borderline affecting hemostasis. The determination of biopsy lepromatous (BL) type is found in approximately location is similar to adult. It should be taken into 7.8% of pediatric patients and polar account the possibility of hypertrophic scar on lepromatous (LL) type is found in 1,6-4.9% of deltoid and chest area as well as slower healing pediatric patients.37 Acid fast bacilli (AFB) and time on bony area.39 histopathology examination are advised to be performed in children suspected with leprosy. Parents or caregivers can attend their child during Histopathology examination is often advised for procedure and help distracting the child’s pediatric patients, especially in non-endemic attention.39 The child’s position should be as areas, to exclude the possibility of other comfortable as possible. Smaller children or babies diseases mimicking leprosy.37 can lie down or sleep on their parent’s lap.39
Slit skin smear with Ziehl Nielsen staining to find Baby’s skin is different from adult’s skin. Skin AFB is the standard technique used to estimate disorder, healing process, the possibility of scar the amount of Mycobacterium leprae in the skin tissue, and allergy in children can be different from lesions. However, slit skin smear has limitation adult. Many differences in baby’s skin can increase in establishing the diagnosis of leprosy. This is the risk of systemic toxicity due to use of topical because most of the leprosy in children is the medications.40 Although skin biopsy is a minor tuberculoid type.37 surgical procedure, it should be remembered that this would feel like a major procedure for children In the guideline of slit skin smear procedure by and their parents. Physician should provide leprosy national program in The United States, information and explanation in detail about there are some methods to manage pain during sampling location, the technique used, possible the procedure.37 The methods are by pinching complications, and optimal method in collecting the skin slowly or if it is not possible, compressing specimen.39 using gloves. Local anesthesia is usually not necessary, however, if the lesion is not The process of informing the patient about biopsy anesthetic or hypoesthetic, 1% xylocaine spray procedure must be comprehensive. However, in or chloride spray can be used.37 practice, biopsy in children are easier said than done and more challenging in practice. Not all The number of location for AFB examination children will have good understanding after they was different in each literature. This usually hear long explanations and sometimes they are still depends on hospital’s policy. Based on the SOP not cooperative. Depending on the circumstances, in the Dermatology and Venereology usually on non-emergency cases, biopsy may be Department of dr. Cipto Mangunkusumo delayed until the child is ready. General Hospital, the minimum number of
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a. Local anesthesia in pediatric dermatology useful to reduce pain during infiltration of local procedure anesthesia and pain caused by the superficial Before starting the procedure, local anesthesia dermatology procedure. The cream induces is usually used. In several cases, general anesthesia until maximum depth of 5 mm, so it anesthesia may be used.39 Consideration for cannot be used for excision or punch biopsy. general anesthesia technique depends on The degree, depth, and onset of anesthesia many things, such as the need for absolute correlate to the duration of use.1 The immobilization, duration of the procedure, recommended dose is different based on age, patient’s general condition, etc.41 presented in Table 2.
Topical anesthesia The use of this mixed anesthesia in babies aged Topical anesthesia can be applied on the biopsy under 6-9 months old should be careful due to location before the procedure. A study found risk of prilocaine-induced met-hemoglobinemia. that patch anesthesia was more effective than In general, the use of this mixed anesthesia is placebo in managing pain on the site of usually well tolerated.1,25 In smaller babies, it is injection. Special attention needs to be given for advised to use it in a short time and in less children with history of atopy when using this amount, which is less than two grams.1 material. Topical anesthesia or patch Comorbidities that can increase the risk of anesthesia should be cleaned, washed and methemoglobinemia are hemoglobinopathy, dried after we are assured that the child’s skin glucose 6-phosphate dehydrogenase 39 is anesthetized. deficiency (G6PD), exposure against aniline dyes, and oxidant.25 Drugs which can induce The choice of local anesthetic agent depends and increase the risk of methemoglobinemia on location, desired onset, and duration of the are sulfonamide, acetaminophen, benzocaine, anesthesia needed. Before using the topical dapsone, phenobarbital, antimalaria, and anesthesia, there are several steps to be phenytoin. The use of this anesthesia in 25 performed, which are : children aged under 3 months old is not History taking, including history of previous recommended if they are using those drugs.1 local anesthesia and the adverse effects The local side effects of this drug are transient Documenting drug dosage, drug delivery blanching, erythema, eye irritation, edema, and time and allergic reaction dermatitis. Considering the possible local side Taking informed consent from the parents effects, this drug should be used carefully Explaining to the child regarding the topical before biopsy because it can disrupt histologic anesthesia which will be used 42 interpretation for certain diagnoses. Petechial Mixed topical anesthesia or purpuric eruption had also been reported Mixed topical anesthesia which are usually after the use of this material in neonates, used are 2.5% lidocaine and 2.5% prilocaine children, and adults. The eruption did not with oil in water emulsion. These materials are correlate with the dose nor the duration of use. often used in babies and considered to be quite This eruption happened during or immediately safe if used carefully.1,25 This anesthesia is very after the drug was applied. The purpura would resolve in few days.1
Table 2. Recommended maximum dose of mixed topical anesthesia for neonates, infants, and children*
Age Maximum Dose (g) Maximum Skin Area (cm2) 0-3 months 1 10 3-12 months 2 20 1-5 years 10 100 6-11 years 20 200 *Adapted from Chang41
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Topical lidocaine in neonates is twice than adults. In neonates, Lidocaine is available in the form of topical lidocaine binding to protein is only 20% preparation, i.e. 4% liposomal lidocaine. Like compared to 60-70% in adults. The higher other topical anesthesia, this material is bioavailability of lidocaine in neonates makes recommended to be used in a short time and them more susceptible to toxicities compared to limited amount in children to avoid toxicity.1 This adults.1 anesthesia is free from risk of methemoglobinemia because it does not In general, lidocaine has lower systemic toxicity. contain prilocaine.1,5 Topical anesthesia can be Some possible toxic reactions are used before local infiltration anesthesia.24 cardiovascular symptoms, central nervous system symptoms, and even death. The central Infiltration anesthesia nervous system toxicity might start with The most common infiltration anesthesia used agitation, leading to seizure, unconsciousness, is lidocaine. In many skin surgeries, the and breathing depression.1 Lidocaine toxicity recommended anesthesia is 1% lidocaine with rarely happens if the dose is calculated epinephrine. The advantages of this correctly. The maximum recommended dose for combination are lower risk of allergy, faster 1% lidocaine without epinephrine is 4.5 mg/kg onset, and minimal bleeding. The preparation and the maximum dose for baby weighed 5 kg available on the market usually contains 1% is 2.3 mL.1 The drug dose and volume should lidocaine (10 mg/mL) and 1:100.000 be confirmed.25 In our hospital, local anesthesia epinephrine.1 is routinely used in surgery and skin biopsy. The operator preparation steps in performing Currently, there has been no adverse effect local infiltration in children are25: reported with the use of local anesthesia in History taking, including history of previous children in the dermatology outpatient clinic. local anesthesia and the adverse effects General anesthesia was used if necessary, in Measuring body weight to determine the collaboration with the Anesthesiology dose Department. Taking informed consent from the parents Explaining the infiltration technique and the b. Skin biopsy technique possible uncomfortable sensation There are various techniques of skin biopsy and Documenting the technique in detail in these depend on the lesion, location and the medical record physician’s skill. Various techniques that can be Documenting the adverse effects due to the chosen are shave biopsy, saucerization, technique being used incision, excision, or wedge biopsy. Basically, Operator should be competent in performing the least invasive procedure should be chosen, cardiopulmonary resuscitation (CPR) however, it should be suited with the 39 Subcutaneous infiltration will give stinging or diagnosis.
burning sensation. This can be reduced by Shave biopsy is a fast and easy technique mixing 1 mL NaHCO3 with 9 ml lidocaine without the need of suture. The elevated lesion (buffering) and injecting perpendicular to the on the surface or having limited pathology in skin.39,42 Furthermore, subcutaneous infiltration epidermis are suitable for shave biopsy is performed using spider-web technique and technique. Saucerization biopsy is ideal for lifting the skin fold to ensure that the vesiculobullous disease and epidermal subcutaneous injection enters the neoplasm. If all of the skin layers are needed for subcutaneous tissue.39 The smallest needle analysis, punch biopsy is the ideal procedure for should be used in children.25 In general, 0.5 diagnosis. This technique can also be used for inches 30 G needle is used for children. Several removing small lesion. This biopsy provides other methods to manage the pain caused by better result cosmetically compared to shave injection are by warming the lidocaine and biopsy. Punch biopsy can heal with secondary storing the needle at 27°C.42 intention but a section wider than 3 mm is better
to be closed with 1 or 2 sutures. Incisional and The half time of lidocaine in neonates is longer excisional biopsy can be the technique of than adults. The volume distribution of lidocaine choice if more specimens are needed, i.e. for
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culture, histopathology, immunofluorescence, operating procedures for children, physician should electron microscope, in cases of inflammatory adjust the procedures for children to give optimal disorder affecting panniculus, and larger result with the highest level of comfort for them. tumor.39 The choice of procedure technique should be the least invasive, with minimal pain, and comfortable The wound dressing should not be too sticky. for children. Baby's and child’s skin is usually Immunocompromised children should be given thinner, leading to the increased risk of toxicity topical antibiotic applied after hemostasis and caused by topical/infiltration anesthetic agents. 48 hours after the suture is removed. The Parents’ cooperation and trust are very important in performing the procedure. biopsy location should be let dry and should not
be touched for 48 hours. Written instruction References regarding wound care after biopsy should be provided and explained to the parents.39 1. Cunningham BB, Wagner AM. Diagnostic and Even though they are rare, complications can therapeutic procedures. In: Eichenfield LF, happen during skin biopsy such as bleeding, Frieden IJ, Esterly NB, editors. Neonatal . nd injection reaction, allergy, and irritation (towards dermatology 2 ed. Philadelphia: Saunders Elsevier; 2008. p. 73-84. topical antibiotic, wound dressing, and 2. Boediardja SA. Uji diagnosis di bidang bandage). Dermatologic procedures performed dermatologi. Dalam: Menaldi SL, penyunting. in premature babies can result in scar tissue. Ilmu Penyakit Kulit dan Kelamin. Edisi ke-7. Scar tissue can occur from peeled off skin due Jakarta: Balai Penerbit FKUI; 2014. p. 57-63. to adhesive. Atrophic scar tissue called Indonesian “anetoderma of prematurity” might happen in 3. Schachner L, Hansen R. The clinical history premature babies.43 and examination. In: Schachner L, Hansen R, editors. Pediatric dermatology. 4th ed. United Conclusion States: Elsevier; 2011. p.69-114. 4. Laporan kunjungan Poliklinik Ilmu Kesehatan Kulit dan Kelamin 2015 FKUI/RSCM. 2015 Diagnostic procedures in pediatric dermatology are (unpublished data). Indonesian. different and significantly more challenging than 5. Mackenzie A, Acworth J, Norden M, et al. adult patients, especially in how to approach them. Guideline statement: management of We need to acknowledge that pediatric patients procedure-related pain in children and have unique anatomical, physiological and adolescents. Pre-procedure preparation. J psychological aspects. Compared to adults, Paediatr Child Health. 2006;42 Suppl 1:S1-29. children have smaller procedure area, are less 6. Bruce L. Invasive pediatric procedures by cooperative and are more difficult to understand. physicians-in-training: recommendation on For these reasons, we should be more cautious in consent and oversight by a community performing diagnostic procedures in children. bioethics forum. Yale Community Bioethics Forum. 2015;1-12. The process of written informed consent before the 7. Siswaja TD. Informed consent. Jakarta; diagnostic procedure performed in children is 2016:1-6. (unpublished data) different from adult. Consent can be represented 8. Peraturan Mentri Kesehatan Republik by the guardians or parents, nevertheless children Indonesia. Persetujuan Tindakan Kedokteran. also need to be explained about the procedure in Nomor 290/MENKES/PER/III/ 2008. accordance with their understanding. Daily 2008;290:1-10. Indonesian. dermatology procedures performed in dermatology 9. Undang-undang Republik Indonesia. Praktik and venereology clinic are microscopic Kedokteran Nomor 29. 2004;45:1-43. examination with potassium hydroxide smear, Indonesian. Gram staining examination, slit skin smear test, 10. Simar MR, Johnson VA. Pediatric informed allergy skin test (patch test and prick test), and skin consent: challenges for investigator. Appl Clin biopsy for children. All dermatologic procedures in Trial. 2002;46-56. children are better performed under the supervision 11. Kaushik JS, Narang M, Agarwal N. Informed of pediatric dermatology division to optimize the consent in pediatric practice. Indian Pediatr. approach and documentation. Procedures in 2010;47:1039-46. children should be dynamic. Considering most of 12. Sastroasmoro S. Masalah etis dalam proses the procedures do not have specific standard pengambilan keputusan pada praktik pediatri. Sari Pediatri. 2005;7:125-31. Indonesian.
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