L26 (Reed) - Pediatric Dermatology

describe neonatal skin (not preterm)

40-60% thinner than adult skin

less hairy

weaker attachment between epidermis and dermis —> higher risk for injury

body surface area-to-weight ratio is up to 5x larger in infants

lanugo

hair on preterm infants

not effective for thermal stability or trans epithelial water loss

describe premie skin

imature stratum corner (even at 32-34 weeks)

increased transpidermal water loss —> dehydration, electrolyte imbalances, thermal instability

increased percutaneous absorption

intact barrier function occurs by ______ weeks of life

3 weeks (can be up to 8 weeks if extremely low birthweight)

acrocyanosis

blush discoloration of hands and feet in response to vasomotor instability or cold (vasoconstriction of small arterioles)

• spares lips/mucous membranes

• perioral area may be affected

• extremities may be cool to touch

resolves within first few months —> no further evaluation, just reassurance to parents

treatment for acrocyanosis

none

acrocyanosis

cutis marmorata

reticulated bluish mottling of skin

physiological response to chilling —> dilation of capillaries and small venues

• net/lace-like appearance (“blue lines” in case presentation)

• usually disappears as infant is rewarmed

may be seen up to several months

bears no medical significance

treatment for cutis mamorata

none

cutis marmorata

harlequin color change

transient, unilateral erythema on side that is laid on

• macular

• blanchable

• sharp midline separation

unknown cause, involves cutaneous blood vessel tone

treatment for harlequin color change

none

harlequin color change

caput succedaneum

localized edema of the scalp due to mechanical forces from parturition (esp if prolonged) and venous congestion

• may see divot from where pressure was applied on sca

• often crosses midline

• halo scalp ring present

spontaneously resolves in 48 hours (days!)

treatment for caput succedaneum

none

caput succedaneum

halo scalp ring

alopecia in circular pattern around the scalp - pressure necrosis phenomenon

usually transit —> resolves in months to years (but can become permanent)

occurs with caput succedaneum or prolonged labor

treatment for halo scalp ring

none

halo scalp ring (seen in caput succedaneum or prolonged labor)

cephalohematoma

SUBPERIOSTEAL hematoma overlying calvarium - due to prolonged labor, instrument-assisted delivers, abnormal presentations

• does NOT cross midline

• limited to one cranial bone

complications:

• calcification - may persist for years

• hyperbiliruinemia - MC issue

• infection

resolution occurs spontaneously over several weeks to months

treatment for cephalohematoma

none

MC complication with cephalohematoma

hyperbilirubinemia

Cephalohematoma vs Caput succedaneum: which one crosses midline? Why?

Caput succedaneum - it is not subperiosteal, so it isn’t limited by suture lines!

cephalohematoma

miliaria

sweat-retention phenomena due to immature epidermis

• maculopapular

• maceration (thinning) and obstruction of eccrine ducts

• keratinous plugging

• occurs on neck and abdomen

two forms: rub, crystalline

prevalent in first few weeks of life

miliaria ruba

deeper level of sweat gland obstruction

• small erythematous papule, vesicles, or papulovesicles

miliaria crystallina

clear superficial pinpoint vesicles

• inflammatory surrounding

miliaria (ruba on top, crystalline on bottom)

treatment for miliaria

avoid excessive heat/humidity

cotton clothing

cool baths

air conditioning

don’t over-apply moisturizers

milia

retention cysts - due to keratin within the dermis

• tiny 1mm pearly white papules

• on cheeks, nose, chin, forehead

• epstein perals = Bilia on hard palate

• frequently clustered in groups

usually disappear spontaneously by 4 weeks

treatment for milia

none

milia

epstein pearls

milia on hard palate

sebaceous gland hyperplasia

physiologic manifestation of maternal androgen stimulation

• yellow/white pinpoint papules

• occur on nose (can also be cheeks and upper lip)

resolves spontaneously by 3 weeks

treatment for sebaceous gland hyperplasia

none

sebaceous gland hyperplasia

neonatal cephalic pustulosis

“neonatal acne” - inflammatory response to Malassezia spp.

• erythematous papules on face (cheeks, chin, eyelids)

• no comedones!!!

mean onset is 3 weeks

treatment for neonatal acne

reassurance

ketoconazole

infantile acne and it’s treatment

occurs around 9 months - due to hormonal imbalance (increased LH)

• comedones!!!

treatment: retinoids, benzyl peroxide, antibiotics

neonatal acne

infantile acne

erythema toxicum neonatorum

red splotchy area on body - idiopathic

• can be diffuse over body

• spares palms and soles

appears in first 4 days —> tends to remit and recur during first two weeks after birth

no therapy necessary —> resolves spontaneously

treatment for erythema toxicum neonatorum

erythema toxicum neonatorum

erythema toxicum neonatorum

What will a Wright or Giemsa stain show for erythema toxicum neonatorum?

predominance of eosinophils

erythema toxicum neonatorum

transient neonatal pustular melanosis

idiopathic - presents AT BIRTH

• sterile superficial pustules

• rupture easily —> leave hyper pigmented macule surrounded by fine white “collarette” of scale

  • three phases = pustules, rupture, hyper-pigmented papules

• diffuse distribution

therapy unnecessary —> disappear in 2 days (hyperpigmentation fades over three months)

treatment for transient neonatal pustular melanosis

none

what does a Giemsa stain of transient neonatal pustular melanosis show?

neutrophils and acellular debris

transient neonatal pustular melanosis

transient neonatal pustular melanosis

hemangioma

MC benign soft tissue tumor of child

• vascular

• superficial or deep (or mix)

• MC in head and neck regions

• MC in females

appear 2-3 weeks of life

etiology unknown, but maybe related GLUT-1 in placenta tissue??

superficial hemangioma

• bright red

• protuberant

• sharply demarcated

• noncompressible

deep hemangioma

• blueish

• firm

• cystic

• less likely to regress

• compressible

hemangioma phases of growth

1. proliferative phase

   • growth period

   • greatest growth by 5 months

2. Plateau phase

   • period of stability

3. Involution phase

   • spontaneous regression

   • 10% every year

treatment for hemangioma

monitoring

topical or oral beta blockers

hemangioma

hemangioma

hemangioma

nevus simplex

“salmon patch” “stork patch”

vascular lesion - due to capillary malformation

• pale pink vascular patch

• occurs in nuchal area, glabella, eyelids

• can “flare” with heat or stress

usually disappears by school age

treatment for nevus simplex

none

nevus simplex

congenital dermal melanocytosis

“slate nevus”

collections of spindle shaped melanocytes deep in dermis

• deep brown/slate grey/ blue-black patches in lumbosacral region

• black>hispanic>white

may raise abuse suspicion (looks like bruising)

congenital dermal melanocytosis

irritant diaper dermatitis

skin reaction to diaper friction - due to proteolytic enzymes in stool, soaps, excessive heat, moisture

• occurs on convex surfaces of buttocks, vulva, perineal area, lower abdomen, proximal thighs

• spares intertriginous creases

treatment of irritant diaper dermatitis

GOAL: keep dry, protected, infection-free

• frequent diaper changes (when stool is present)

• gentle cleansing with moist cloth or fragrance free wipe (do NOT over wash)

• exposure to air when possible

• lots of topical therapy (zinc oxide, petrolatum)

• educate parents

diaper candidiasis

Candida albicans is in lower intestine of infants —> feces leads to skin infection

• widespread beefy red erythema

• occurs on buttocks, lower abdomen, inner thighs

• raised edge with sharp marginization

• white scales at border

• DIAGNOSTIC HALLMARK = pinpoint satellite lesions

irritant diaper dermatitis

irritant diaper dermatitis

diaper candidiasis

diaper candidiasis

treatment for diaper candidiasis

topical nystatin (or clotrimazole or ketoconazole)

oral antifungul treatment is best when thrush is also present (or just a very severe case)

what does a potassium hydroxide smear show with diaper candidiasis?

budding yeast or pseudohyphae

seborrheic dermatitis

chronic and relapsing inflammatory disorder - due to high sebaceous gland concentration and increased hormone levels

• erythematous macule or patches with greasy scale

• seen on eyebrows, alar folds, posterior auricular region, pre-sternal region, maybe scalp

treatment for seborrheic dermatitis

vigorous scrubbing during baths —> desensitizes and reduces scaling

olive or coconut oil

low-potency topical corticosteroid or anti-fungal twice daily

anti-seborrheic shampoo with pyrithione zinc, selenium sulfide, or ketoconazole

seborrheic dermatitis

seborrheic dermatitis

seborrheic dermatitis