Chapter 47: Alterations of the Integument in Children
Overview
This chapter provides comprehensive insights into various skin conditions in children, including explanations of common skin diseases, their pathophysiology, clinical manifestations, diagnosis, and treatment options.
Chapter Objectives (1 of 2)
Compare acne vulgaris and acne conglobata.
Identify pathophysiologic factors contributing to acne.
Compare inflammatory and non-inflammatory acne.
Describe atopic dermatitis concerning children.
Characterize diaper dermatitis's pathophysiology and manifestations.
Discuss common bacterial infections of the skin in children, including:
Impetigo
Bullous impetigo
Vesicular impetigo
Staphylococcal scalded-skin syndrome (SSSS).
Chapter Objectives (2 of 2)
Describe common fungal infections of the skin in children:
Tinea capitis
Tinea pedis
Tinea corporis
Thrush
Compare and contrast common viral infections of the skin in children, including:
Molluscum contagiosum
Rubella
Rubeola
Roseola
Varicella
Herpes zoster
Variola
Characterize common insect bites and parasites in children:
Scabies
Lice
Fleas
Bedbugs
Discuss the development and treatment for:
Hemangiomas
Port-wine stains
Salmon patches
Miliaria
Erythema toxicum neonatorum
Toxic epidermal necrolysis
Acne Vulgaris
Overview
The most common skin disease affecting 85% of children and young adults aged 12 to 25 years.
Acne Conglobata
A highly inflammatory form of severe acne characterized by:
Communication cysts and abscesses forming beneath the skin.
Treatments include systemic and combination therapies.
Sebaceous Follicles
Sites where acne lesions form, facilitating the development of acne.
Types of Acne
Non-inflammatory acne:
Blackheads (open comedones)
Whiteheads (closed comedones)
Inflammatory acne:
Caused by rupture of the follicular wall in closed comedones.
Pustules: Surface inflammation.
Papules and cystic nodules: Deeper inflammation that may cause scarring.
Pathophysiology
Key factors include:
Follicular proliferation of Propionibacterium acnes.
Hyperkeratinization of the follicular epithelium.
Excessive sebum production.
Inflammation and rupture of the follicle, exacerbated by androgenic hormones increasing sebaceous gland size and productivity.
Treatment
Preferred treatments include:
Topical retinoids, benzoyl peroxide, and antimicrobial agents.
Acne surgery (comedo extraction, intralesional steroids, cryosurgery).
For severe scarring: Options include dermabrasion or lasers.
Special considerations for individuals with darker skin: Increased risk for hyperpigmentation and keloidal scarring.
Examination Questions
Definition of acne vulgaris as associated with:
Follicular hypokeratinization.
Deep inflammation that leads to pustules.
Linked with excessive sebum production.
Atopic Dermatitis
Overview
The cause is primarily unknown, though genetics play an essential role.
Pathophysiology
Two theories:
“Inside-out”: Immunologic dysregulation leading to epidermal barrier abnormalities.
“Outside-in”: Benzyl dysfunction as the root cause.
Alterations in filaggrin protein, indicating a defect in the epidermal barrier.
Clinical Manifestations
Frequent exacerbations and severe pruritus (itching is the hallmark sign).
Eczematoid appearance characterized by:
Redness.
Edema.
Scaling.
In infants:
Rash (red, scaly lesions) primarily on the face, scalp, trunk, and extensors.
In children and adults:
Rash typically appears on the neck, antecubital and popliteal fossae, hands, and feet.
Lichenification: Thickening of the epidermis resulting from chronic scratching, common in adults.
Treatment
Regular use of emollients and maintaining skin hydration.
Non-soap cleansers and bleach baths are recommended.
Identification of specific and non-specific trigger factors should be emphasized.
Mainstay topical agents include cortisol and calcineurin inhibitors.
For severe cases: Options include immunomodulator therapy, wet wrap therapy, antihistamines, and antibiotics.
Notably, children with atopic dermatitis may also be prone to asthma.
Irritant Contact Dermatitis
Overview
Also known as diaper dermatitis.
Results from prolonged exposure to irritants such as urine, feces, and friction from wet diapers.
Clinical Manifestations
Erythematous rash with pustulovesicular satellite lesions.
Potential for developing candidal infections.
Treatment
Emphasizes frequent diaper changes.
Air exposure to the perineal area is encouraged.
Use of super absorbent diapers recommended.
Applying topical barriers with products containing petrolatum or zinc oxide or both.
If candidal infection arises, topical antifungal medication should be applied.
Bacterial Infections
Impetigo
Impetigo contagiosum is prevalent in children, with notable transmission via both direct and indirect contacts.
Superficial infections typically caused by Staphylococcus aureus or Streptococcus pyogenes, with incidence peaking in hot, humid climates.
Types of Impetigo
Nonbullous impetigo:
Small vesicles with honey-colored crust, usually around the face and mouth.
Important to differentiate from herpes simplex lesions.
Bullous impetigo:
Rare variant caused by Staphylococcus aureus, wherein exfoliative toxins disrupt desmosomal adhesion molecules and lead to blister formation.
Treatment for Impetigo
Combination of topical mupirocin, topical fusidic acid, or oral antibiotics.
Good handwashing practices and isolation methods to avoid spread.
Staphylococcal Scalded-Skin Syndrome (SSSS)
Observed more frequently in infants and children under 5 years of age with low antistaphylococcal antibody titers.
Serious infections arise due to staphylococcal exfoliative toxins causing epidermal separation below the granular level.
Clinical Manifestations of SSSS
Generalized erythema and skin tenderness, often accompanied by fever and malaise.
Blisters and bullae formation can lead to severe pain and the appearance of scalded skin.
Evaluation and Treatment for SSSS
Important to obtain a culture for accurate diagnosis.
Treat with oral or intravenous antibiotics; topical antibiotics are ineffective.
Skin should be treated akin to severe burns, utilizing aseptic techniques and possibly skin substitutes.
Fungal Infections
Overview
Fungal disorders, or mycoses, occur prominently in children, especially from fungi thriving on keratin known as dermatophytes.
Types of Mycoses
Tinea conditions classified by location:
Tinea capitis: Scalp infection.
Tinea pedis: Athlete’s foot; seldom observed in children.
Tinea corporis: Known as ringworm, affecting the body.
Tinea Capitis
Most prevalent fungal infection among children, characterized by circular lesions displaying broken hairs.
Evaluation is via KOH examination or fungal culture.
Treatment typically includes oral griseofulvin, and possibly terbinafine, itraconazole, or fluconazole.
Tinea Corporis
Commonly resulting from contact with animals, particularly kittens and puppies.
Lesions appear as erythematous, round, or oval scaling patches that spread with central clearing.
Diagnosis confirmed through KOH examination of scaled samples.
Topical antifungal medications provide effective treatment.
Candidiasis (Thrush)
Common in infants; presents as white plaques in the mouth leading to ulceration.
Treatment includes antifungal washes and sterilizing feeding equipment.
Viral Infections
Overview
Various viral infections can affect children's skin and often require distinct treatment protocols.
Molluscum Contagiosum
A poxvirus characterized by skin-to-skin transmission, causing epidermal cell proliferation and immune response blockage.
Manifests as discrete, dome-shaped, waxy or pearl-like papules.
Treatment options include immunomodulatory, antiviral therapy, and destructive procedures, noting that children may poorly tolerate such procedures.
Rubella (German measles)
Caused by an RNA virus; predominantly mild in children, symptoms include lymphadenopathy, fever, and a rash that spreads from the face to extremities.
Rubeola (Measles)
Caused by RNA paramyxovirus; presents with high fever, cough, conjunctivitis, and a distinctive rash. Vaccination helps prevent rubeola.
Roseola
Related to human herpesviruses, typically features a fever followed by a non-pruritic rash.
Chickenpox and Herpes Zoster
Caused by Varicella-zoster virus; chickenpox is highly contagious presenting with itchy vesicular lesions.
Treatment includes symptomatic relief and potential antiviral intervention if required.
Treatment for Viral Infections
Supportive care, rest, fluids, and sometimes vaccinations (e.g., MMR) serve to control incidents of viral infections rather than direct treatment of the viral cause.
Insect Bites and Parasites
Scabies
An infestation caused by Sarcoptes scabiei, transmitted through personal contact.
Symptoms include burrows, papules, and severe itching.
Treatment involves scabicides and thorough cleanliness protocols.
Fleas
Lead to urticarial wheals; treatments include insecticide applications and maintaining clean environments.
Bedbugs
Nocturnal blood-sucking insects causing pruritic papules, treatable with antihistamines or insecticides.
Pediculosis (Lice infestation)
Highly contagious; clinical manifestations may include itching and the presence of nits.
Treatment requires topical pediculicides and thorough cleaning of personal items.
Infantile Hemangiomas
Overview
Classified as benign tumors resulting from rapid endothelial cell growth; more common in females.
Types
Superficial (strawberry hemangiomas): Appear bright red and typically emerge weeks post-birth.
Deep (cavernous hemangiomas): Present at birth, involve larger vessels, may regress over time.
Treatment Modalities
Use of propranolol, steroids, cryosurgery, and laser therapy for hemangiomas.
Miliaria
Overview
A common dermatosis in infants due to perspiration and duct obstruction.
Types
Miliaria crystallina: Clear vesicles without erythema.