Pediatric Dermatology

Robert Hayman, MD
Clinical Assistant Professor of
Dermatology
State University of New York at
Stony Brook

3rd Year Pediatric Rotation

First day in nursery

Called to evaluate rash

You approach the newborn

What do I do next?

Erythema Toxicum Neonatorum

Common, self-limited, benign
eruption that occurs most
frequently during the first 3-4
days of life
Most lesions appear within second
24 hours of life
Rare in preterm infants


Erythema Toxicum Neonatorum
Characterized by erythematous
macules, papules, and/or pustules that
can occur anywhere on the body
There may be a background of
blotchy erythema
Face, trunk, proximal arms, and
buttocks more commonly affected
Palms and soles rarely affected



FF


Erythema Toxicum Neonatorum
Diagnosis is made clinically
Microscopic examination of pustule
reveals eosinophils
May have peripheral blood
eosinophilia
Eruption is self-limited
Reassurance


Transient Neonatal Pustular Melanosis
Benign, self-limited eruption of
unknown etiology present at birth
New lesions do not develop after birth
Superficial pustules or vesicles that
rupture easily leaving a collarette of
scale surrounding a hyperpigmented
macule
Transient Neonatal Pustular Melanosis
Lesions may be solitary or grouped
Can see pustule, ruptured pustules,
and hyperpigmented macules in the
same patient
Lesions may occur anywhere
Commonly seen on forehead, behind
the ears, under the chin, neck, back
hands and feet
May be seen on palms and soles




Transient Neonatal Pustular Melanosis
Smear of a pustule demonstrates
neutrophils (PMNs)
No organisms are seen
No treatment necessaryjust reassurance
Pustules usually resolve over a few days
Hyperpigmentation may last for a few
weeks to months
Seborrheic Dermatitis
Inflammatory condition of unknown
etiology
? Role of Pityrosporum ovale
(Malassezia furfur)
Typically starts within the first 3
months of life with a scaly dermatitis
of the scalp, often called cradle cap
Involves the face, scalp, ears,
umbilicus, and intertriginous areas
Greasy, scaly, erythematous lesions
Seborrheic Dermatitis
May rarely generalize to involve the
trunk
Tends to remit spontaneously by 8-12
months of age, with many cases
resolving earlier
Can be differentiated from atopic
dermatitis by lack of pruritus, family
history of atopy and lichenification









Seborrheic Dermatitis
Treatment of seborrheic dermatitis:
Scalp
Frequent shampooing
Thick scales can be loosened with mineral
oil or petrolatum
Gentle removal of scales
Persistent or extensive eruptions can be
treated with a low potency topical
corticosteroid

Milia

1-2 mm. epidermal inclusion cysts
Most commonly on the face
Present in 1/2 of all newborns
Solitary lesions during childhood and
adolescence


Salmon Patch (Nevus Simplex)
Capillary malformation
Angel kiss on forehead
Stork bite on nape of neck
Present in almost half of newborns
Common locations: nape, upper
eyelids, glabella, nose, nasolabial area
and upper lip, middle of forehead (V
shaped)
Sometimes seen on parietal and
occipital scalp


Salmon Patch (Nevus Simplex)
Most lesions of face tend to fade by 1
to 2 years of age
Nuchal lesions tend to be more
persistent and are present in many
adults
No treatment is necessary
Port Wine Stain (PWS)
Nevus flammeus
Capillary malformation
Present at birth
Do not undergo resolution
Grow proportionately with the child
May appear anywhere on the body
Port Wine Stain (PWS)
85% unilateral
15% bilateral
68% had more than one dermatome
affected
8% of PWS involving the V1
dermatome had ocular or CNS
involvement; 25% if involvement of
bilateral V1 or all three trigeminal
dermatomes
Port Wine Stain (PWS)
Pink or red in color during infancy
Often darker with age to purplish hue
With advancing age the PWS surface
may become irregular, thickened and
nodular, more commonly in facial
lesions
Laser can be an effective treatment
modality




Sturge-Weber Syndrome (SWS)
Encephalotrigeminal angiomatosis
Facial port-wine stain in a V1 distribution
Ipsilateral leptomeningeal vascular
malformation
Choroidal vascular malformation of the
eyecan lead to ipsilateral glaucoma and
buphthalmos
Approximately 10% of patients with a port-
wine stain in V1 have SWS


Hemangioma
Benign proliferation of endothelial
cells
Rapid growth phase
Spontaneous involution
F:M= 2:1 to 5:1
Increased incidence in prematurity

Hemangioma
Superficial type

Combined type

Deep type



Viral Exanthem
Any cutaneous eruption associated
with an acute viral syndrome
Enanthemmucosa involved
Measles
Fever
Three Cs-Cough
-Coryza
-Conjunctivitis
Maculopapular rash
Koplik spots

Measles
Blotchy erythema
Discreteconfluent macules/papules
Forehead/postauricular
trunk/extremities
Spreads head to toe
Measles
RNA Virus
Morbillivirus genus
Paramyxoviridae family


Measles
Incubation 8-14 days
Prodrome 3-5 days
Transmission via direct
contact>airborne
Measles
Complications
-otitis media
-pneumonia
-croup
-encephalitis
Measles
DiagnosisIgM antibody
Measles
Treatment:
-Vitamin A
Measles
Prevention:
-Vaccination

Rubella
Mild illness
Few or no prodrome symptoms
Up to 50% asymptomatic
Usually afebrile
Rubella
Lymphadenopathy
(Suboccipital/postauricular)
Faint pinkerythematous macular
eruption
Facetrunkproximal extremities
Palatal enanthem

Rubella
Older child/adolescent:
-fever
-arthritis
Congenital Rubella
Acquired 1
st
trimester
Thrombocytopenia
petechiae/purpura
Blueberry muffin lesions
Deafness
Heart defects
Rubella
RNA Virus
Rubivirus
Togaviridae family
Transmission via direct/droplet
contact
Rubella
Incubation 14-23 days
Rubella
Complications:
-Thrombocytopenia
-Encephalitis

Rubella
DiagnosisIgM antibody
Rubella
Treatment:
-Supportive care
Rubella
Prevention:
-Vaccination
Fifth Disease
(Erythema Infectiosum)
Mild illness
Slapped cheeks
Lacy/reticulate erythema
Extremities>trunk
No mucosal lesions
Fifth Disease
DNA Virus
Parvovirus B19
Transmission via direct contact
Fifth Disease
Incubation 4-21 days
Fifth Disease
Complications:
-Arthalgia/arthritis <10%
Fifth Disease
Precautions:
-Pregnant women
-Immunusuppressed patients
-Chronic hemolytic anemia
(ie. Sickle cell anemia)
Fifth Disease
DiagnosisIgM antibody

Fifth Disease
Self-limited
Asymptomatic
Recurrences heat,exercise,sun
Roseola
(Exanthem Subitum)
Children <2 years old
High fever (>39.5 C or >103 F)
x 2-3days
No focal signs of infection

Roseola
Defervescencethen rash
Transient eruption (hoursdays)

Roseola
DNA Virus
HHV-6 and HHV-7
Transmission via secretions

Roseola
HHV-6 incubation 9-10 days
Roseola
Complication:
-Febrile seizure
Roseola
Diagnosisclinical
Roseola
Treatmentsupportive care
Varicella(Chickenpox)
Fever
Crops of skin lesions
Erythematous
maculespapulesvesicles
Crusted lesionserosions
Mucous membranes

Varicella
DNA virus
HHV-3
Incubation 7-27 days
Transmission via direct
contact/airborne
Varicella
Complications:
-Secondary bacterial infection
-Pneumonia
-Encephalitis

Varicella
Diagnosis:
-Direct fluorescent antibody
-Viral culture
Varicella
Treatment:
-Oatmeal baths
-Antihistamines
-Oral/IV acyclovir
Varicella
Prevention:
-Vaccination
Hand-Foot-and-Mouth Disease
Coxsackie infection
Hand-Foot-and-Mouth Disease
Afebrile
Well-appearing child
Hand-Foot-and-Mouth Disease
Discrete lesions
Erythematous macules/papules
Round/oval shallow vesicles
Hands/feet/buttocks
Hand-Foot-and-Mouth Disease
RNA nonpolio enterovirus
Coxsackie A16 and enterovirus 71
Incubation 3-6 days
Transmission via direct contact
Hand-Foot-and-Mouth Disease
Diagnosisclinical
Hand-Foot-and-Mouth Disease
Treatment: supportive care