Skin (PEDS exam 3)
Introduction to Dermatology and Rashes in Pediatrics
DERV (Dermatology) has its own language, making communication challenging due to specialized terminology for describing skin lesions and conditions.
Example of difference in communication:
Simple: "There’s a red rash on his belly."
Medical: "He has a macular erythematous rash localized to the right truncal area, approximately , non-blanching to palpation."
Importance of practicing proper terminology for effective documentation and precise communication among healthcare professionals.
Diagnosing and Treating Rashes
Key to diagnosing and treating rashes is knowing their causes, which often dictate the approach to treatment:
Viral: Chickenpox (varicella), common viral exanthems (e.g., fifth disease, roseola), herpes simplex virus. These are often self-limiting or treated symptomatically.
Bacterial: Cellulitis (a deep skin infection often requiring systemic antibiotics), impetigo (superficial, highly contagious), folliculitis. These typically require antibiotic therapy.
Parasitic: Bug bites (insect reactions), scabies (mite infestation), lice (pediculosis). Treatment involves eliminating the parasite and alleviating symptoms.
Allergic/Dermatologic: Eczema (atopic dermatitis), contact dermatitis, urticaria (hives), autoimmune diseases (e.g., scleroderma, lupus). Management focuses on identifying and avoiding triggers, and using topical or systemic anti-inflammatory agents.
Anticipatory guidance should be age-appropriate and specific to developmental stages, focusing on relevant preventative measures.
Example: Preventing burns in toddlers by discussing proper outlet covers and turning pot handles inward on stoves, rather than discussing avoiding matches or lighters only.
Skin Care Basics
Appropriate skin care is essential in treating various skin conditions and promoting skin health.
This includes using gentle, pH-balanced cleansers, regular moisturizing, and protecting the skin from environmental irritants.
Acknowledge that children can develop pressure sores (also known as pressure injuries or decubitus ulcers), especially vulnerable populations like those with spina bifida, immobility, or severe nutritional deficiencies.
Pressure Sores
Refreshing terminology regarding skin injuries and lesions, not specific to pressure sores but common in pediatric dermatology:
Abrasion: A superficial injury involving the epidermis and possibly the uppermost part of the dermis, often resulting from friction against a rough surface (e.g., scraping a knee on the sidewalk).
Annular lesions: Circular or ring-shaped lesions with clear centers (e.g., tinea corporis, granuloma annulare).
Erosions: Incomplete loss of skin, specifically a loss of epidermis, often resulting from trauma or rupture of vesicles/bullae.
Café au lait spots: Uniformly hyperpigmented, coffee-colored macules or patches; the presence of spots larger than in prepubertal children or larger than in postpubertal individuals can be indicative of potential neurofibromatosis type 1 (NF1).
Contact dermatitis: A general term for skin inflammation caused by direct contact with an irritating substance (irritant contact dermatitis, ICD) or an allergen (allergic contact dermatitis, ACD).
Common Terminology
Erythema: Redness of the skin, typically caused by capillary dilation, often a sign of inflammation, infection, or irritation.
Plaque with Scales: A common presentation in conditions like psoriasis, characterized by elevated, flat-topped lesions (plaques) covered with silvery-white, flaky scales due to abnormal skin cell turnover.
Demarcation: The clarity or distinctness of the borders of a wound or lesion, which can be important for assessing the spread of an infection (e.g., cellulitis often has poorly demarcated borders, while erysipelas has sharply demarcated borders).
Maculopapular lesions: A rash that combines characteristics of both macules (flat, discolored spots less than in diameter) and papules (small, raised, solid bumps less than in diameter). Many viral exanthems present as maculopapular rashes.
Mongolian spots: Benign, bruise-like, grayish-blue or greenish-blue macular discolorations most commonly found on the sacral area, buttocks, and lower back of infants, particularly those with darker skin tones (Asian, Hispanic, African, Native American descent). They are typically present at birth and usually fade within the first few years of life.
Petechiae: Tiny, pinpoint red or purple spots on the skin, less than in diameter, caused by extravasation of blood into the skin. They do not blanch under pressure and can indicate serious underlying conditions like meningitis, sepsis, vasculitis, or leukemia, requiring urgent medical evaluation.
Triaging Rashes
Initial Assessment
Essential questions in triaging rashes help to narrow down the differential diagnosis and assess urgency:
"When did the rash start?" (Onset and duration provide clues to acute vs. chronic conditions).
"Where did it start, and how did it spread?" (The initial location and pattern of spread can be highly diagnostic, e.g., centripetal spread for chickenpox, dermatomal for shingles).
Assess characteristics: pain, itchiness, drainage, heat, and changes in texture (e.g., blistering, crusting). This helps determine the nature of the rash and potential for infection.
Determine what alleviates or aggravates the rash (e.g., medications, warmth, scratching, specific activities).
Inquire about sick contacts (exposure to contagious illnesses), recent travel (exposure to endemic diseases or unusual pathogens), new medications, and recent diet changes (potential allergic reactions).
Documentation of Rash
Documenting observed rashes in a clinical setting involves a systematic approach to ensure accuracy and completeness:
Clearly stating location (e.g., "localized to the right abdomen, extending to the flank").
Describing rash characteristics meticulously (e.g., "well-demarcated erythematous plaque with overlying silvery scales," or "vesicular rash on an erythematous base with crusted lesions").
Assessing potential diagnoses based on appearance and patient history (e.g., "consistent with contact dermatitis, consideration for impetigo especially if honey-colored crusting is noted").
Recognize pain levels as significant, particularly in conditions like shingles (herpes zoster), where neuropathic pain can be severe and precede the rash.
Common Conditions in Pediatrics
Skin Lesions and Rash Types
Shingles (Herpes Zoster): Caused by reactivation of the varicella-zoster virus (VZV), which lies dormant after a primary chickenpox infection. Characterized by a painful, unilateral rash typically presenting as grouped vesicles on an erythematous base in a dermatomal distribution. Pain can be significant and precede the eruption.
Dog Bite Management: Requires thorough documentation of characteristics (precise location, size, depth, presence of drainage, neurovascular compromise). Assess for infection risk (deep wound, puncture, hand/foot involvement, immunocompromised patient) and consider tetanus status, wound irrigation, debridement, and prophylactic antibiotics based on institutional guidelines. Wound closure is often delayed for high-risk bites.
Wound Types:
Avulsions: Flaps of skin and often underlying tissue that are forcefully torn from the body, leading to significant tissue damage and potential for necrosis. Management involves careful cleaning, possible debridement, and assessment for reattachment or grafting.
Puncture wounds: Smaller entrance wounds with potentially deep penetration into tissues, often prone to infection due to inoculation of bacteria deep within the wound and poor oxygenation. Risk of foreign bodies, tetanus, and deep structure damage (e.g., bone, joint, tendon).
Common Dermatitis Conditions
Diaper rash, impetigo (superficial bacterial infection characterized by honey-colored crusts), and contact dermatitis are prevalent in pediatrics.
Diaper rash (Diaper Dermatitis): Frequently worsened by prolonged contact with wet surfaces (urine, feces), infrequent diaper changes, and friction. Can be irritant (most common) or candidal (yeast infection, often with satellite lesions). Treatment involves barrier creams, frequent changes, and antifungals for candidal forms.
Impetigo: A highly contagious, superficial bacterial skin infection caused by Staphylococcus aureus or Streptococcus pyogenes. Presents as red sores that quickly rupture, ooze, and form characteristic honey-colored crusts. Can be bullous (fluid-filled blisters) or non-bullous. Requires good hygiene, and often topical antibiotics (mupirocin) or systemic antibiotics for widespread or non-responsive cases.
Infectious Skin Conditions in Pediatrics
Fungal Infections (Tinea): Commonly referred to as "ringworm," these are dermatophyte infections of the skin, hair, or nails. Presentations vary by location:
Tinea Capitis: Fungal infection of the scalp and hair shafts; can lead to scaly patches, alopecia (hair loss), and sometimes a painful, boggy kerion. Often requires oral antifungal agents (e.g., griseofulvin, terbinafine) for effective treatment.
Tinea Pedis: Athlete's foot; fungal infection of the feet, commonly between the toes or on the soles. Presents with scaling, itching, redness, or blistering. Treated with topical antifungals.
Jock Itch (Tinea Cruris): Fungal infection common in the groin and inner thigh areas. Characterized by an itchy, red, often ring-shaped rash. Treated with topical antifungals and general hygiene measures to keep the area dry.
Managing Skin Infections and Education
Pharmacological Suggestions
Antibacterials: Mupirocin (Bactroban) is a common topical antibiotic for localized bacterial skin infections like impetigo or for nasal decolonization of MRSA. Other topical options include bacitracin and retapamulin. Systemic antibiotics (e.g., cephalexin, clindamycin) are indicated for more extensive infections or cellulitis.
Antivirals: Acyclovir, valacyclovir, and famciclovir are used to treat herpes simplex virus (HSV) infections (e.g., cold sores, genital herpes) and varicella-zoster virus (VZV) infections (chickenpox, shingles), particularly for severe cases, immunocompromised patients, or to reduce severity/duration if started early.
Fungal Treatments: Nystatin is primarily used for candidal infections (e.g., oral thrush, candidal diaper rash). For dermatophyte infections (tinea), topical azole antifungals (e.g., clotrimazole, miconazole, ketoconazole) are commonly used. Oral antifungals are reserved for extensive or difficult-to-treat infections like tinea capitis or onychomycosis.
Antihistamines: For symptom management in cases of severe itching (pruritus) associated with allergic reactions, eczema, or urticaria. Sedating antihistamines like diphenhydramine (Benadryl) can be used at night, while non-sedating options like loratadine or cetirizine are useful for daytime relief.
Prevention Strategies
Implementing clean hygiene practices and diligently managing itching is crucial in preventing spread and secondary infections.
Keep nails trimmed short and encourage gentle patting rather than scratching to minimize skin breakdown and secondary bacterial infections.
Education programs stressing risk of infection, proper handwashing, and the importance of sanitizing shared materials (e.g., towels, athletic equipment, hairbrushes) in school and home settings.
Burn Management
Types of Burns
First-Degree (Superficial): Affects only the epidermis. Characterized by redness, mild swelling, and pain. Skin remains intact. Example: mild sunburn. Heals within a week with no scarring.
Second-Degree (Partial-Thickness): Involves the epidermis and a portion of the dermis. Presents with blistering, redness, severe pain, and often a wet, weeping appearance. Can be superficial partial-thickness (heals in 1-3 weeks with minimal scarring) or deep partial-thickness (may take 3-9 weeks, potentially with scarring, and may require grafting).
Third-Degree (Full-Thickness): Extends through all layers of the skin into subcutaneous tissues. The skin appears waxy white, leathery, charred brown, or black; often painless due to nerve destruction. May require surgical intervention (excision and grafting) for healing and to prevent severe scarring and contractures.
Fourth-Degree: Goes deeper into muscle, tendons, or bone, causing severe damage and functional loss. Requires extensive surgical intervention, often amputation, and reconstructive surgery.
Burn Treatment Approaches
Management of Fluid Loss: Crucial, especially for moderate to severe burns, to prevent hypovolemic shock. Intravenous fluid resuscitation (e.g., using Parkland formula for total body surface area burns greater than 10-15% in children) is essential for hydration and electrolyte balance.
Infection Control: Burns are highly susceptible to infection. Check tetanus immunization status and administer prophylaxis if needed. Administer topical antimicrobials (e.g., silver sulfadiazine) and systemic antibiotics if signs of infection are present. Daily wound care involving cleaning, debridement of necrotic tissue, and application of appropriate dressings.
Pain Management: Crucial during acute phase, wound care, and recovery. Involves both pharmacological agents (e.g., opioids, NSAIDs) and non-pharmacological methods (e.g., distraction, relaxation techniques).
Complications
Compartment Syndrome: A serious complication, particularly with circumferential full-thickness burns, where swelling within a confined space (fascial compartment) compromises blood flow and nerve function. Monitor for the "6 Ps": severe Pain out of proportion, Pallor, Pulselessness, Paresthesia, Paralysis, and Poikilothermia. Techniques like escharotomy (surgical incision through the burn eschar) and fasciotomy (incision into the fascia) may be necessary to relieve pressure and restore perfusion.
Education for Parents
Provide anticipatory guidance for different age groups about burn risks and prevention strategies for their developmental stage.
For infants: Ensure water heater is set below (), test bath water temperature, and keep hot liquids out of reach.
For preschoolers: Secure dangerous items like matches and lighters, turn pot handles inward on stoves, use back burners, and supervise around fireplaces/heaters.
For school-aged children: Educate on fire safety plans, safe use of microwave ovens, and dangers of fireworks.
For adolescents: Provide education related to their increased risk behaviors (e.g., tobacco use, improper use of flammable liquids, risky experiments, unattended cooking).
Nursing Considerations and Special Topics
Eczema Management
Recognize associations with environmental factors (e.g., dry climate, low humidity), specific allergens (e.g., dust mites, pet dander, certain foods), and irritants (e.g., harsh soaps, synthetic fabrics). Eczema is often part of the "atopic triad," which includes asthma and allergic rhinitis.
Use low-allergen materials for bedding (e.g., cotton), frequent washing of bedding and clothes to reduce irritants and allergens.
Keep nails short and filed smooth to prevent excoriation and secondary infections from scratching. Introduce topical steroids (e.g., hydrocortisone) as prescribed for flares, emollients (e.g., petroleum jelly, thick creams) liberally and frequently, and consider wet wrap therapy for severe cases.
Acne Considerations
Recognize that acne, especially moderate to severe forms, can lead to significant psychological effects in adolescents, including decreased self-esteem, anxiety, and depression.
Recommend a tiered approach to treatment, starting with topical agents (e.g., salicylic acid, benzoyl peroxide, topical retinoids like tretinoin or adapalene, topical antibiotics like clindamycin). Oral medications such as systemic antibiotics (e.g., doxycycline, minocycline) may be used for inflammatory acne. Hormonal therapies (e.g., oral contraceptives) can be effective for females.
Emphasize the need for routine follow-ups to monitor treatment effectiveness and side effects. For severe, recalcitrant acne, consider isotretinoin (Accutane) therapy, which is highly effective but requires strict guidelines for females regarding pregnancy prevention due to its teratogenic effects (iPLEDGE program).