The range and clinical picture of skin problems in children differ from those in adults.
The diagnosis is often based on the patient history and clinical picture. It is worthwhile examining the skin status thoroughly (skin, scalp, nails, palms and soles of the feet, oral mucosa).
Remember to look for any external factors aggravating or maintaining the skin problem (e.g. maceration, hobbies, and various habits, such as licking).
If a skin infection is suspected, any skin problems in the patient's contacts (family, day care, school, etc.) should be investigated.
Diagnosis
Is the problem acute or chronic?
Does the patient have systemic symptoms in association with the skin problem, such as fever or malaise?
Does the patient have any history of skin disorders, such as atopic eczema?
Are there any external aggravating factors (hobbies, day care, school, animal contacts)?
Do the patient's contacts have skin problems (scabies, impetigo, ringworm, pox diseases)?
Travel history
Are the lesions itchy (atopic eczema, scabies)?
Examine the skin status thoroughly, including other important areas (scalp, palms, soles of the feet, oral mucosa, nails).
Usually single patches at first, but may later spread
Clearly defined erosive surfaces, rim-like ("collarette") scaling, covered by yellow crust
Usually few symptoms
Eczemas as well as skin lesions caused by itch mites or lice (Pediculus capitis) may be secondarily infected, causing a clinical picture resembling impetigo.
Miliaria
Common particularly in babies and small children
Asymptomatic red papules, trunk-focused
Heat, heating, too warm clothes causing maceration, and a hot climate cause erythematous papules on the trunk and the limbs.
Usually benign, in which case follow-up is sufficient
Malignant tumours are possible but extremely rare in children.
Workup
Bacterial culture, as necessary, if the response to empirical antimicrobial treatment of impetigo or folliculitis is poor or resistance is suspected.
Contact allergies are rare in small children. If contact allergy is strongly suspected, perform limited epicutaneous tests (paediatric epicutaneous patch test batteries).
Samples for microscopy and fungal culture are required if ringworm is suspected.
In seborrhoeic eczema, Malassezia yeast may be seen in samples sent for microscopy but fungal culture may still be negative. The diagnosis should be based on clinical features.
If a skin tumour is suspected of being malignant, perform a histological examination (PAD, by punch biopsy, for example).
Treatment
Irritating factors (moisture, dirt, dust, abrasion, scratching) should be avoided.
For small children (below 2 years of age) with eczematous disease, use primarily a treatment such as mild, and for older (than 2-year-old) children mild or mid-potency, topical glucocorticoids intermittently for 1 to 2 weeks. Regular use of non-medicated ointments may prevent recurrence and exacerbations.
In children, facial eczema should be treated with mild topical corticosteroids, only, such as 1% hydrocortisone ointment.
Topical comedolytic ointments should be used for the treatment of acne, with short courses of topical antimicrobial products, as necessary. In severe cases, systemic antimicrobial treatment can be added to topical treatment, as necessary. Tetracyclines are not recommended for children below the age of 8 years because they may damage the dental enamel.
For children with psoriasis, use mild or mid-potency topical corticosteroids intermittently for 1 to 2 weeks, for example.
Nappy dermatitis should be treated by regular washing and by keeping the baby dry; zinc paste or talcum powder, for example, can be applied every morning and evening. In addition, intermittent treatment with an antimycotic ointment, miconazole powder or mild corticosteroid as such or combined with an antimycotic ointment can be used twice daily for 1 to 2 weeks.
Impetigo Impetigo and other Pyoderma: for impetigo confined to a limited area, topical treatment with an antimicrobial ointment may be sufficient but for more extensive disease systemic antimicrobial treatment is necessary Interventions for Impetigo.
For folliculitis, a topical antimicrobial solution (e.g. clindamycin) or ointment (e.g. fusidic acid) and washing with antiseptic agents (e.g. benzoyl peroxide); for extensive and severe forms of the disease systemic antimicrobial treatment with cephalexin, for example, may be needed.
For urticaria, symptomatic treatment with a long-acting antihistamine, such as desloratadine.
For miliaria, symptomatic treatment with air baths and showering, intermittent treatment with a mild corticosteroid ointment or a combination ointment with mild corticosteroid and an antiseptic agent applied once or twice daily for 1 to 2 weeks at a time.
Topical antifungal products, such as an azole ointment in courses of 1 to 3 weeks with application once or twice daily, or a ketoconazole shampoo (washing the affected areas once daily for 5 days, for example) are effective for pityriasis versicolor.
The first-line treatment of scabies is a permethrin ointment Treatments for Scabies and for head lice a permethrin shampoo. Also oral ivermectin may in special cases be used in children weighing over 15 kg.
Early forms of cutaneous borreliosis can be diagnosed on a clinical basis. The first-line treatment in children is amoxicillin.
Specialist consultation
Consult a dermatologist if there is a persistent skin problem that is refractory to treatment.
If a child with systemic symptoms is suspected of having skin lesions due to a systemic disease, a paediatrician should be consulted.
If the patient's general state is getting worse or a severe infection is suspected, emergency referral to hospital is indicated.