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Common Skin Problems in Children Rashes Other Than Atopic Dermatitis GAYLE FISCHER OAM, MB BS, FACD, MD

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Common Skin Problems in Children Rashes Other Than Atopic Dermatitis GAYLE FISCHER OAM, MB BS, FACD, MD PEER REVIEWED FEATURE Common skin problems in children Rashes other than atopic dermatitis GAYLE FISCHER OAM, MB BS, FACD, MD In addition to atopic dermatitis, numerous other he earliest dermatoses seen in infants other than atopic endogenous and exogenous dermatoses are seen dermatitis are nappy rash, seborrhoeic dermatitis and in prepubertal children including nappy rash, neonatal acne. In preschool-aged children, florid insect psoriasis, neonatal acne and allergic rashes. Many bite reactions may be a problem. Skin conditions that Tare often confused with atopic dermatitis are childhood-onset of these childhood dermatoses will clear over time with environmental modification or no intervention, psoriasis and the keratinisation disorders, ichthyosis vulgaris but some may require treatment. and keratosis pilaris. The most common allergic skin conditions in children, other than insect bite reactions, are virally induced urticaria and contact allergy to plants. Early dermatoses Nappy rash Nappy rash is the term used to describe any rash occurring in the area under the nappy. It has become less common, probably due to the use of highly absorbent disposable nappies. KEY POINTS A simple irritant dermatitis is the most common cause of nappy rash, but there are many other causes, including Candida • Most cases of nappy rash are due to irritation and maceration, but Candida albicans infection, seborrhoeic albicans infection (Figure 1), seborrhoeic dermatitis and pso- dermatitis and psoriasis are other common causes. riasis (Figure 2). There are also some very rare causes, such as • Not all babies with seborrhoeic dermatitis recover; zinc deficiency and Langerhans cell histiocytosis, and thus any one-third will develop psoriasis and another third, atopic infants with a severe, nonresponsive rash, particularly with dermatitis. lesions in areas other than under the nappy, should be referred • The early signs of psoriasis in children include cradle cap, to a dermatologist. Nappy rash can be mild or it can become nappy rash, and post- and infra-auricular scaling and so inflammatory that ulceration occurs. Rarely, it may become fissuring. papular or nodular and result in lesions that can appear alarm- • Childhood-onset psoriasis, ichthyosis vulgaris and ing. This condition is called pseudoverrucous papules and keratosis pilaris are often confused with atopic dermatitis. nodules (PPN).1 • Urticaria is the only childhood skin condition that is effectively treated with antihistamines. • Hypersensitivity to insect bites and plant contact dermatitis are common in children and preventative MedicineToday 2021; 22(3): 33-43 measures are often the best treatment. Professor Fischer is Professor of Dermatology at Sydney Medical School – © LEUGCHOPAN/STOCK.ADOBE.COM© MODEL USED FOR ILLUSTRATIVE PURPOSES ONLY Northern, The University of Sydney, Royal North Shore Hospital, Sydney, NSW. MedicineToday ❙ MARCH 2021, VOLUME 22, NUMBER 3 33 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2021. https://medicinetoday.com.au/mt/march-2021 RASHES OTHER THAN atopic dermatitis continued Figure 1. Nappy rash caused by Candida albicans infection. Figure 2. Nappy rash caused by psoriasis. Figure 3. Generalised seborrhoeic dermatitis. Generally, a simple irritant rash does hydrocortisone cream used in conjunc- Seborrhoeic dermatitis not involve the flexures, whereas endo- tion with a topical antifungal such as Seborrhoeic dermatitis is the term used genous dermatoses and infections do. nystatin or an imidazole (clotrimazole to describe a clinical presentation that may Irritant nappy rash results from loss of or miconazole). There are several com- occur in three common infantile derma- barrier function of the epidermis due to bined products, such as clotrimazole plus toses: idiopathic seborrhoeic dermatitis, maceration from urine and irritation from hydrocortisone, which are convenient atopic dermatitis and psoriasis. The erup- faecal enzymes. Sometimes topical prod- and not much more expensive. The treat- tion is seen most often before 2 months ucts, including soap and over-the-counter ment should be used three times daily of age. Initially, the face, scalp, neck, axillae treatments, aggravate the rash. In many until the rash has resolved. Generally, and nappy areas are involved, but the rash cases of nappy rash, the affected area is hydrocortisone 1% is the only cortico- may generalise (Figure 3). The lesions are colonised with C. albicans. steroid that should be used in the nappy well defined and have a greasy scale. area. Characteristically, babies with seborrhoeic Management Inadequate response to treatment may dermatitis are well and not itchy. Generally, management for all forms of be due to: The rash in classic, idiopathic sebor- nappy rash is the same, even when the • noncompliance with treatment rhoeic dermatitis is self-limiting, clearing rash is very severe. Treatment involves • irritancy or allergy from topical spontaneously in a few weeks or sooner environmental modification and spe- therapy if treated. However, both atopic dermatitis cific medical management. Highly • bacterial or viral infection and infantile psoriasis may also present absorbent disposable nappies are pref- • psoriasis in this way, and in these cases, the rash erable to cloth nappies. If cloth nappies • an underlying rare condition. recurs. In about one-third of cases, seb- are used, parents should be advised to Pustules, erosions, vesicles, ulcers or orrhoeic dermatitis will remit completely change them every two hours and avoid areas of weeping may indicate a bacterial and the babies will have no further prob- using plastic overpants and nappy liners. or viral infection, particularly in infants lems with their skin; in the other two- As with any sort of dermatitis, a soap in whom there has been an inadequate thirds, psoriasis or atopic dermatitis will substitute should be used instead of response to therapy. A bacterial, and pos- develop. Infection with either C. albicans soap and a dispersible bath oil used in sibly a viral, swab should be taken and or Staphylococcus aureus is common; it every bath. At each nappy change, a damp treatment started according to culture and should be suspected if crusting, weeping cloth and bland emollient should be used sensitivity results. C. albicans will grow or pustulation are present and actively instead of commercial wipes, and further from a bacterial swab. treated. emollient applied. Zinc and castor oil In the very rare instance of a herpetic Very rarely, Langerhans cell histiocy- preparations are popular as a nappy rash infection, no specific treatment is needed, tosis (an increase in Langerhans cells in treatment, but any greasy emollient is as the lesions will heal spontaneously the skin) may simulate seborrhoeic der- effective. within two weeks. If the infection is severe matitis. The cause for this is unknown. In many cases, environmental modi- with ulceration or urinary retention, the In small children it may cause death as fication alone is inadequate and the infant may need to be admitted to hospital the infiltrate may also involve internal medical treatment of choice is 1% for intravenous aciclovir. organs. The condition is differentiated 34 MedicineToday ❙ MARCH 2021, VOLUME 22, NUMBER 3 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2021. https://medicinetoday.com.au/mt/march-2021 from seborrhoeic dermatitis by the pres- Management DIFFERENTIATING CHILDHOOD ence of purpura and erosions as well as Neonatal acne is self-limiting and usually PSORIASIS FROM ECZEMA treatment resistance. remits by 12 months of age, but it may persist to 24 months. If treatment is A diagnosis of classic paediatric Management needed, topical therapy usually used for psoriasis requires any of the following: Management of seborrhoeic dermatitis is mild teenage acne is appropriate. This • palmoplantar disease essentially the same as that for atopic includes topical tretinoin 0.025% cream • guttate disease 2 dermatitis. Scalp scaling responds to once daily and erythromycin 2% gel once • pustular psoriasis treatment with liquor picis carbonis (LPC, daily. Rarely, neonatal acne may be nod- • nail pits or coal tar solution) 2% and salicylic acid ulocystic and can be treated with oral • napkin psoriasis 2% in a moisturising base, and the nappy isotretinoin to prevent permanent scar- • well-demarcated psoriatic plaques area is treated with a combination of 1% ring. In this case referral to a paediatric on elbows, knees or lower back hydrocortisone and an anticandidal dermatologist is required.3 For prepu- cream, such as nystatin or an imidazole. bertal children with acne, topical therapy A diagnosis of atopic eczema can be made in children with itchy skin and It is a good idea to follow up the infant to is also often adequate. Oral antibiotic three or more of the following: ensure that this is not the first presentation therapy is usually not required, but in • visible flexural dermatitis in the skin of a chronic dermatosis such as atopic severe cases, oral erythromycin may be creases (such as the bends of the dermatitis or infantile psoriasis. used (tetracycline is contraindicated in elbows or behind the knees) this age group because it may stain teeth). OR visible dermatitis on the cheeks Childhood acne and/or extensor areas in children Acne is usually thought of as a condition Other childhood rashes aged ≤18 months seen in teenagers, but it may also occur in Psoriasis
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