Paediatric Skin Problems

Essentials

• 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).

The most common causes

• Atopic eczema Atopic Dermatitis in Children: Clinical Picture, Diagnosis and Treatment; pictures
  • The clinical picture varies depending on the patient's age
  • In children often on the face, neck or wrists, and in elbow and knee creases
• Acne Acne; picture
  • Typical age, can also occur in young children
  • On the face and upper trunk
  • Comedones and pustules are diagnostic.
  • There is often a family history of the disease.
• Seborrhoeic eczema Seborrhoeic Dermatitis in the Adult
  • Common in infants
  • On the scalp, in creases and in the ear area
  • Clearly defined diffuse erythema, scaling
• Irritant eczema, irritant contact dermatitis Irritant Contact Dermatitis; picture
  • Mechanical irritation, maceration, lip licking
  • Hand eczema, nappy dermatitis, etc.
• Impetigo Impetigo and other Pyoderma; picture
  • 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.
• Scabies Scabies; pictures
  • Rather acute onset nocturnal itching
  • In small children often with blisters
  • Children have papules and blisters typically on the palms and soles of the feet
  • In older children burrows between the fingers and on wrists, skin lesions on the flanks, wrists, ankles, nipples and genital area
• Lice (Pediculus capitis) Head Lice and Pubic Lice
  • The main symptom is often itching on the back of the head and the neck.
  • The scalp and skin on the neck are often inflamed and the skin broken from scratching.
  • Lymph nodes of the neck and ears may swell.
• Allergic reactions Food Allergy and Hypersensitivity in Children
  • Food hypersensitivity, for example
  • Usually appears as rapidly flushing erythema on the face and trunk and, more rarely, as urticaria.
  • Clear temporal association with the triggering factor
  • Some children may show delayed aggravation of atopic eczema.
• Exanthems and pox diseases in children Exanthem (Eruptive Skin Rash)
  • Unspecific viral exanthems are the most common.
  • Remember to assess the patient's vaccination status and contacts.

Rarer skin problems

• Pityriasis versicolor Pityriasis Versicolor
  • In older children
  • Asymptomatic, orange-red hypo- or hyperpigmented, slightly scaly patches on the upper back, shoulders and décolletage
• Pityriasis alba
  • Hypopigmented patches on the face, trunk and limbs
  • A sequel of eczema, often associated with atopic eczema
• Folliculitis Skin Abscess and Folliculitis
  • Inflammation of single hair follicles
  • Often due to maceration, mechanical irritation or greasy topical treatment
• Ringworm Dermatomycoses
  • Annular, clearly defined erythema, scaly at the margins
  • Usually scaling and loss of hair on the scalp
  • Secondary bacterial infection is possible (folliculitis, abscesses)
• Urticaria Hives (Urticaria)
  • Usually acute urticaria due to an infection, drug or allergic reaction (e.g. otitis media, common cold)
• Alopecia areata Hair Loss and Balding
  • Asymptomatic, patchy loss of hair on the scalp, with no scaling or erythema
• Psoriasis Psoriasis; picture
  • May also occur in children
  • Faint patches resembling eczema
  • Often less scaling than in adults
  • Guttate psoriasis triggered by a streptococcus infection causes an eruptive clinical picture.
• Allergic contact dermatitis Allergic Contact Dermatitis
  • Usually acute, itchy, clinically eczematous dermatitis
  • Children, too, also have contact allergies.
• Borrelia infection Lyme Borreliosis (LB)
  • Erythema migrans on the trunk or the limbs (picture )
  • Multiple lesions may occur (multiple erythema migrans).
  • More rarely borrelial lymphocytoma, which is usually seen on the ear lobes or in the genital area (picture )

Single skin lesions

• Warts Warts (Verruca Vulgaris)
  • Usually on the fingers or feet
  • Extensive flat warts may be seen on the hands or the face.
• Molluscs Molluscum Contagiosum; picture
  • May occur extensively
  • Often in atopic people
• Naevi (congenital pigmented naevi, haemangiomas, etc.)
• Skin tumours
  • 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 calcineurin inhibitors are also effective in the treatment of atopic eczema (0.03% tacrolimus ointment or pimecrolimus ointment; both can be used long-term as intermittent treatment; see Atopic Dermatitis in Children: Clinical Picture, Diagnosis and Treatment).
• 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.
• Topical mild to mid-potency corticosteroid solutions applied to the scalp and ointments applied to the skin are effective in the treatment of seborrhoeic eczema Topical Anti-Inflammatory Agents for Seborrhoeic Dermatitis of the Face or Scalp. Skin oil, for example, can be used to detach the crust on the scalp in the evening before washing. Topical azole antifungals (clotrimazole, miconazole, tioconazole, ketoconazole; shampoo, solution or ointment) are also effective.
• 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.

Pictures