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  2. INTRODUCTION Skin is the largest and most superficial organ of the body. Nearly one third (1/3rd) of the pediatric outpatient visits involve dermatology complaints. Skin disorders are associated manifestations of many systemic and hereditary diseases. 2
  4. DEFINITION 4 The skin is an organ of the integumentary system made up of multiple layers of ectodermal tissue, and guards the underlying muscles, bones, ligaments and internal organs.
  6. Epidermis 6
  7. 7 Dermis
  9. 9
  11. Primary-Macule Well defined but flat lesions with a change in colour. A macule may be hyperpigmented (e.g. cafe au lait macule), hypopigmented (e.g. leprosy), depigmented (e.g. vitiligo) or erythematous (e.g. drug rash). 11
  12. Primary-Patch A macule that is larger than 1cm in size. 12
  13. Primary-Papule A raised and palpable solid lesion, smaller than 5mm. 13
  14. Primary-Nodule A large papule, usually 5 – 10 mm in diameter. 14
  15. Primary-Plaque A raised flat-topped lesion on skin or mucous membrane, usually over 1cm in size. 15
  16. Primary-Blister A small bubble on the skin filled with serum and caused by friction, burning or other damage. 16
  17. Primary-Vesicles Raised fluid-filled lesion. 17
  18. Primary-Pustule Pus-containing well- circumscribed lesion. 18
  19. Primary-Abscess A thick-walled pus-filled cavity developed from necrosis of tissue. 19
  20. Primary-Wheal A whitish, firm and elevated lesions surrounded by red flare as a result of dermal edema. 20
  21. Primary-Petechiae A circumscribed deposit of extravasated blood, less than 5mm in diameter. 21 Primary-Purpura Primary-Ecchymosis A circumscribed deposit of extravasated blood, more than 5mm in diameter. A blend of several petechiae and purpuric spots, occupying a large area of skin.
  22. Primary-Telangiectasia A visible dilatation of superficial blood vessels. 22
  23. Primary-Poikiloderma A triad of atrophy of skin, reticular pigmentation and telangiectasia. 23
  24. Primary-Cyst A circumscribed lesion having a wall and a lumen containing fluid or solid matter. 24
  25. Primary-Comedone An inspitated plug of sebaceous and keratinous material lodged in dilated orifice; closed white and open black types are known. 25
  26. Primary-Milia A small subepidermal keratin cyst that is normal finding in neonates. 26
  27. Primary-Burrow A thread-like elevated tortuous channel in the skin typically seen in scabies 27
  28. Secondary lesions Scale A visible flake comprising shed stratum corneum (horny layer) of he skin. Crust A collection of dried serum and cellular debris. 28
  29. Secondary lesions Erosion A focal breech in the continuity of epidermis with preservation of dermis, leaving no scarring after healing. Ulcer A focal breech in the continuity of epidermis as well as upper dermis. 29 Fissure A linear slit-like breech in the epidermis as well as dermis (full layer, not just the upper dermis).
  30. 30 Fissure, erosion, ulcer - difference Fissure Erosion Ulcer
  31. Secondary lesions Excoriation A linear erosion or ulcer caused by scratching. Atrophy A formation of connective tissue that replaces the original skin. Normal skin markings are absent in scar. 31 Scar A thinning of epidermis, dermis or subcutaneous tissue.
  32. Secondary lesions Sclerosis A circumscribed or diffuse area of induration and binding down of skin. Lichenification An area of skin that is thickened along with hyperpigmentation and enhanced skin markings due to repeated scratching. 32
  33. ARRANGEMENT OF LESIONS 33 Linear Eg: Verrucous epidermal nevus Grouped Eg: Herpes Simplex Dermatomal Eg: Herpes Zoster Arcuate Eg: Granuloma Annulare
  34. 34 SITES OF PREDILECTION OF LESIONS The sites of predilection of lesions indicates the sites of preference of occurrence of lesions.
  35. 35 COMMON DIAGNOSTIC TESTING FOR SKIN DISEASES Diagnostic Test Material to obtain Indications Findings Potassium hydroxide preparation and microscopic examination Skin scraping from scale or pustules Presence of scales or pustules Hyphae or pseudo hyphae indicating dermatophyte or yeast infection 1
  36. 36 COMMON DIAGNOSTIC TESTING FOR SKIN DISEASES Diagnostic Test Material to obtain Indications Findings Gram stain and microscopic examination Skin scraping from pustules or bullae Presence of pustules or bullae Gram-positive or Gram negative bacteria. 2
  37. 37 COMMON DIAGNOSTIC TESTING FOR SKIN DISEASES Diagnostic Test Material to obtain Indications Findings Tzank stain and microscopic examination Skin scraping from the base of a vesicle Presence of vesicles Rounded, multinucleated keratinocytes indicating a herpes virus infection. 3
  38. 38 COMMON DIAGNOSTIC TESTING FOR SKIN DISEASES Diagnostic Test Material to obtain Indications Findings Oil mount and microscopic examination Skin scraping from the base of a burrow or non- excoriated papule Presence of burrows or pruritic papules Mites or eggs indicating scabies infection 4
  39. 39 COMMON DIAGNOSTIC TESTING FOR SKIN DISEASES Diagnostic Test Material to obtain Indications Findings Punch biopsy Core of anaesthetized skin using a punch biopsy instrument. Lesions suspected to be malignant (such as basal cell carcinoma or squamous cell carcinoma) or an undiagnosed inflammatory skin lesion. Microscopic alterations in the epidermis, dermis and subcutaneous tissue. 5
  40. 40 COMMON DIAGNOSTIC TESTING FOR SKIN DISEASES Diagnostic Test Material to obtain Indications Findings Shave or snip biopsy All parts of an anaesthetized skin lesion that protrudes from the surface of the skin. Raised lesions suspected to be malignant (such as basal cell carcinoma or squamous cell carcinoma) or bothersome raised lesions. Microscopic alterations in the epidermis and upper dermis. 6
  41. 41 COMMON DIAGNOSTIC TESTING FOR SKIN DISEASES Diagnostic Test Material to obtain Indications Findings Excisional biopsy An entire anaesthetized skin lesion Lesions suspected to be malignant (such as melanoma) or bothersome flat skin lesion. Microscopic alterations in the epidermis, dermis and subcutaneous tissue with the entire architecture of the lesion in the specimen. 7
  42. 42 TYPES/CLASSIFICATION OF SKIN DISORDERS IN CHILDHOOD Infections Infestations (Parasitic skin infections) Bacterial Viral Fungal Scabies Pediculosis Disorders of skin appendages Acne Vulgaris Miliaria/Prickly heat
  43. 43 TYPES/CLASSIFICATION OF SKIN DISORDERS IN CHILDHOOD Papulosquamous disorders Others Lichen Planus (LP) Psoriasis Eczematous dermatitis
  44. INFECTIONS 44 A. BACTERIAL B. VIRAL C. FUNGAL The invasion and multiplication of microorganisms such as bacteria, viruses, and parasites that are not normally present within the body. An infection may cause no symptoms and be subclinical, or it may cause symptoms and be clinically apparent. Infection may be local or generalized and spread throughout the body.
  46. 46 Classification Based on predisposing factors Based on morphology Primary Secondary Non- follicular Follicular Localized Spreading Folliculitis Boils Carbuncles Cellulitis Ecthyma Impetigo
  47. IMPETIGO DEFINITION: Impetigo is a highly-contagious bacterial infection of the surface layers of the skin, usually exhibited as painful and itchy blisters and sores around the mouth and nose (in very young children it can also occur in the nappy area). It is not serious, but it is sore and itchy in nature 47
  48. TYPES: 48 (1) Bullous impetigo: It causes large, painless, fluid-filled blisters that stay longer. (2) Impetigo Contagiosa (Non- bullous impetigo): It is more contagious and causes sores that quickly burst to leave a yellow- brown crust.
  49. Etiology 49  Staphylococcus aureus  Streptococcus pyogenes Common bacteria, some of which are found normally on the skin, causes impetigo. When the bacterium enters an open area in the skin, infection can occur.
  50. Incidence ∆Common in children below 10 years of age with poor personal hygiene. ∆Toddlers and preschool children are the most commonly affected, often when recovering from upper respiratory tract infection 50 Risk Factors ∆Local skin trauma such as insect bites, wounds ∆Skin lesions from other disorders such as eczema, scabies, pediculosis ∆Age: more common in toddlers and pre-schoolers (2- 5yrs) ∆Crowded living condition ∆Poor hygiene ∆Warm, moist climate
  52. CLINICAL FEATURES AND SITES OF PREDILECTION: BULLOUS IMPETIGO Clinical features ► Thin-walled blisters on erythematous base (Crusted blisters, that pop and leave wet patches of red skin, initially with vesicles or pustules on reddened skin) ► The vesicles or pustules eventually rupture to leave the characteristic honey-colored (yellow-brown) crust. ► Lesions spread without central clearing. ► Lymphadenopathy frequent 52 Face, especially around the mouth and nose Sites of Predilection Bullous impetigo
  53. 53 Clinical features ► Thick-walled, persistent blisters on bland skin. ► Rupture only after a few days to leave thin golden yellow crusts. ► Lesions heal in center to form annular plaques. ► Lymphadenopathy rare Occurs on the face and extremities Sites of Predilection Non - Bullous impetigo CLINICAL FEATURES AND SITES OF PREDILECTION: BULLOUS IMPETIGO
  54. 54 DIAGNOSTIC EVALUATION COMPLICATIONS TREATMENT  Complete medical history and physical examination of the child.  The lesions of impetigo are unique and usually allow for a diagnosis which is based simply on physical examination.  A culture and sensitivity of lesions may be done to confirm the diagnosis and the type of bacteria that is present. Impetigo contagiosa  Post streptococcal glomerulonephritis (PSGN)  Eczematization Bullous impetigo  Staphylococcal scalded skin syndrome ∆ The affected area must be cleaned several times per day with either water or an antibacterial wash ∆ Warm saline compresses to be applied qid for 15 minutes to soften and soak away the crusts ∆ Topical antibiotics should be applied after every soakage ─ Mupirocin ointment ─ Fusidic acid ointment or cream ∆ Oral antibiotics in case of systemic symptoms ─ Cephalexin ─ Cloxacillin
  55. ECTHYMA (ULCERATIVE IMPETIGO) 55 Ecthyma is a pyogenic infection of the skin characterized by the formation of adherent crusts beneath which ulceration occurs ETIOLOGY Streptococcus pyogenes Staphylococcus aureus DEFINITION
  56. 56 Predisposing Factors
  57. 57 Vesicle or veiscopustule on erythematous base Enlarge and becomes indurated, tender plaque and thickly crusted Removal of crust Saucer-shaped ulcer with raw irregular base and elevated edges Healing and scar formation (rarely: gangrene) Ecthyma is similarly to superficial impetigo. The difference is that in impetigo the erosion is at the stratum corneum and in ecthyma the ulcer is full thickness (includes both epidermis and dermis) and thus heals with scarring
  58. 58 Clinical features ◙ Adherent crusts, beneath which purulent irregular ulcers occur. ◙ Healing occurs after few wks, with scarring More on distal extremities (thighs & legs) Sites of Predilection Ecthyma (Ulcerative Impetigo) CLINICAL FEATURES AND SITES OF PREDILECTION: ECTHYMA (ULCERATIVE IMPETIGO)
  59. 59 Treatment Cleansing with soap and water Application of Mupirocin or Bacitracin ointment twice a day Oral Dicloxacillin or first-generation Cephalosporin Proper hygiene and nutrition
  60. 60 CELLULITIS DEFINITION Cellulitis is an acute spreading bacterial infection below the surface of the skin characterized by redness (erythema), warmth, swelling, and pain. Cellulitis occurs when an entry point through normal skin barriers allows bacteria to enter and release their toxins in the subcutaneous tissues.
  61. 61 Etiology Bacteremic spread of infection - bacteria arriving from a distant source via the bloodstream.  Staphylococcus aureus  streptococci pyogenes Break in the skin from an abrasion, a cut, or a skin ulcer. Local trauma, such as an animal bite
  62. Pathophysiology 62 Break in the skin, such as a fissure, cut, laceration, insect bite, or puncture wound causes entry of bacteria into the subcutaneous tissue. This results in deep inflammation of subcutaneous tissue from enzymes produced by bacteria. Break in the skin Entry of bacteria into the subcutaneous tissue Enzymes produced by bacteria Deep inflammation of subcutaneous tissue
  63. 63 Signs & Symptoms Swelling of the skin Tenderness Pain Warm skin Bruising Blisters Fever Headache Chills Feeling weak Red streaks from the original site of cellulitis
  64. 64 Some cases of cellulitis are considered an emergency if any of the following symptoms are present: A very large area of red, inflamed skin Fever If the area is affected, causing the child to complain of numbness, tingling or other changes in a hand, arm, leg, or foot If the skin appears black If the area that is red and swollen is around the child's eye(s) or behind his/her ear(s) If the child has diabetes or has a weakened immune system and develops cellulitis
  65. 65 Fig: Cellulitis Fig: Cellulitis Fig: Cellulitis
  66. 66  History collection  Physical examination  Complete Blood Count (CBC)  Culture and sensitivity DIAGNOSIS COMPLICATIONS  Blood infection (septicaemia)  Bone infection (osteomyelitis)  Inflammation of the lymph vessels (lymphangitis)  Inflammation of the heart (endocarditis)  Meningitis  Shock  Tissue death (gangrene)  General  Immobilize the part and elevate the extremity above the level of heart  Provide moist heat to promote wound healing  Mild cases:  An outpatient basis with oral antibiotic therapy  Dicloxacillin  Amoxicillin  Cephalexin  Severe cellulitis  The patient is hospitalized and treated with intravenous antibiotics for at least 7 to 14 days MANAGEMENT
  67. FOLLICULITIS, BOILS AND CARBUNCLES DEFINITIONS Folliculitis Folliculitis is the inflammation of hair follicles due to an infection, injury or irritation. It is characterized by tender, swollen areas that form around hair follicles, often on the neck, breasts, buttocks and face. 67 Fig: Folliculitis
  68. FOLLICULITIS, BOILS AND CARBUNCLES DEFINITIONS Boils Boils are pus-filled lesions that are painful and usually firm. Boils are usually located in the waist area, groins, buttocks and under the arm. 68 Fig: Boils
  69. FOLLICULITIS, BOILS AND CARBUNCLES DEFINITIONS Carbuncles Carbuncles are clusters of boils. These are usually found in the back of the neck or thigh. 69 Fig: Carbuncle
  71. 71  Diagnosis of Folliculitis, boils, and carbuncles is made after a thorough medical history and physical examination.  After examining the lesions, culture of the wound is done to help to verify the diagnosis and select the best treatment. DIAGNOSIS Specific treatment for Folliculitis, boils and carbuncles may include:  Topical antibiotics (for Folliculitis).  For carbuncles and boils, a warm compress may be used to help promote drainage of the lesion.  Oral or IV antibiotics (to treat the infection).  Possible removal of the boils and carbuncles.  Incision and drainage followed by antibiotic therapy. Carbuncles heal more slowly than a single boil. The skin must be kept clean to help prevent these conditions from occurring. MANAGEMENT
  73. 73 Warts are benign epidermal neoplastic growths on the skin caused by an infection with the human papilloma virus, or HPV. DEFINITION VURRUCA (WARTS)
  74. 74 Etiology Human papilloma virus or HPV. The incubation period is1 – 6 months.  HPV type I, II and IV associated with plantar warts  Type I causes verrucae plantaris lesions  Type II causes mosaic warts  Type IV causes seed corn lesions  Type III causes genital warts Physical factors such as infectious location, weight-bearing pressure and moisture help determine the clinical appearance of the lesion Can spread through small cuts in skin May disappear spontaneously, often within 2 years of appearance Due to immune system development, are seen more commonly in children and less commonly in adults
  75. 75 General Warts Characters There are usually little black dots near the surface of the wart, representing thrombosed capillaries in elongated dermal papillae. In Immunocompromised there is a risk for squamous cell carcinoma There is epidermal thickening, with particular increase in the granular cell layer
  76. 76 Fig: Warts Fig: Warts Fig: Warts
  77. 77 Risk Factors Exposure to others who have warts Eczema Broken down skin
  78. 78 Common wart (vurruca vulgaris) Plantar wart (foot warts) Flat wart (plane warts) Filiform wart Genital wart (condylomata acuminate) Types of Warts
  79. 79 Common wart (vurruca vulgaris)  Raised, cauliflower-like lesions that occur most frequently on fingers, around the nails, and on the backs of the hands. Grow most often on the area where skin was broken, such as from biting fingernails or picking at hangnails.  Can have black dots that look like seeds (often called “seed” warts). They appear as hyperkeratotic papules with a rough, irregular surface. They range from smaller than 1 mm to larger than 1 cm.  Most often feel like rough bumps.  Common in children and early adulthood.  They may be scattered, grouped or periungual in distribution.  Common warts in children usually resolve spontaneously.
  80. 80 Plantar wart (foot warts) * Grow most often on the soles (plantar surface) of the feet * Can grow in clusters (mosaic warts) * Often are flat or grow inward (walking creates pressure, which causes the warts to grow inward) * Painful
  81. 81 Flat wart (plane warts)  These are tiny, flat-topped, flesh-coloured warts which usually occur on the dorsa of the hands and the face.  They often occur in lines due to inoculation of the virus into scratches and abrasions.  Tend to grow in large numbers, 20 to 100 at a time.
  82. 82 Filiform wart  Long slender growths, usually seen on the face around the lips, eyelids, or nares  Looks like long threads or thin fingers that stick out
  83. 83 Genital wart (condylomata acuminate) • Grow on the genitals, are usually sexually transmitted • Soft and do not have a rough surface like other common warts • Highly infectious
  84. 84 Management Immunotherapy, that causes an allergic reaction and helps destroy the wart. Vaccines like BCG, MMR etc are used. Salicylic (12-20%) & lactic acid (4-20%), to soften the infected area Freezing with liquid nitrogen (cryotherapy) Electrodessication (using an electrical current to destroy the wart) Laser surgery
  85. 85 MOLLUSCUM CONTAGIOSUM Molluscum contagiosum is a viral disease of the skin that causes small pink or skin- colored bumps on the child’s skin.  It is not harmful and usually does not have any other symptoms.  The virus is inside the bumps and is mildly contagious.  These bumps usually clear over an extended period of time. DEFINITION
  86. 86 Caused by the poxvirus. ETIOLOGY & INCIDENCE Most common in children and adolescents.
  87. Small, shiny, and smooth in appearance Flesh-colored, white, or pink 87 Firm, raised and shaped like a dome with a dent or dimple in the middle Filled with a central core of waxy material Can become red or inflamed Can cause itching sensation Size varies between 2 to 5 mm in diameter Lesions usually occur in groups or clusters , between 2 and 20 in children Seen on the genitals, face, torso, arms and lower abdomen
  88. 88 Fig: Molluscum contagiosum Fig: Molluscum contagiosum
  89. • Can become red, itchy and inflamed. • If scratched or touched, it can easily spread to other parts of the body. • If on eyelids, it can develop into pink eye (conjunctivitis). 89 COMPLICA TIONS DIAGNOSTIC EV ALUA TION MANAGEMENT • Medical history and physical examination • The lesions are unique and usually diagnosed on the basis of physical examination. • Additional tests are not routinely ordered. Heal without treatment over a period of 6 – 9 months. Additional treatment include: • Removal of the lesions (cryosurgery, curettage) • Use of topical medications (to speed the resolution of the lesions).
  91. DERMATOPHYTOSIS (RINGWORM INFECTIONS) DEFINITION 91 » Dermatophytes are aerobic fungi present in the soil. They require keratin for growth and cause superficial skin infections. » The dermatophytoses (ringworm) are infections caused by a group of closely related filamentous fungi that invade primarily the stratum corneum, hair, and nails. These are superficial infections by organisms that live on, not in, the skin. They are confined to the dead keratin layers and are unable to survive in the deeper layers.
  92. 92 Trichophyton Epidermophy ton Microspor um Etiology
  93. 93 superficial fungal infection of the skin of foot (between the toes and on the soles ) Tinea pedis (athlete’s foot) chronic non- inflammatory macular patches on the skin Tinea Vesicolor Fungal infection of the scalp . Tinea capitis Fungal infection of glabrous skin. Tinea corporis Fungal infection of nails Tinea unguium (onychomycosis) Types ungal infection peritoneal folds, extending upto upper inside of the thigh. Tine Cruris (Jock Itch)
  94. Diagnosis 94  Microscopy of skin and nail specimens may reveal hyphae and spores.  Fungal culture can identify the species but is not always reliable and it can take 6 weeks to get results.  Ultraviolet light (Wood’s light) is useful for tinea capitis specially. Fluorescence is produced by the fungus. Fluorescence is not seen with tinea corporis or tinea cruris.  Rarely, a biopsy may be needed if the case is atypical or not responding to treatment.
  95. Treatment Type Characteristics Tinea capitis:  Oral administration of griseofulvin 15 to 20 mg/kg/day for 5 to 7 days.  Topical application of antifungal cream  Selenium sulfide lotion can be used twice per weeks.  Clotrimazole, tolnaftate, etc. can be used as cream or lotions. Tinea corporis:  Application of calamine lotion and mild fungicides.  Griseofulvin is administered in severe generalized and resistant cases.  Tolnaftate (Tinaderm) is used effectively for this infection. Tinea cruris (Jock itch):  Griseofulvin or tolnaftate as topical applications. Tinea pedis:  The web space between toes to be kept dry.  Aluminium chloride and gentian violet.  Amorolfine spray can be used daily for 3 to 6 weeks to have good result. Tinea unguium:  It requires treatment for long period.  Griseofulvin or other antifungal agents can be applied for 3 to 4 months for finger nails and 6 to 12 months for toe nails.  Ciclopirox and natifine can be used for better penetration in the nails. Tinea versicolor (pityriasis):  Local application of antifungal agent (Tolnaftate) and application of selenium sulfide shampoo over affected skin 15 to 20 minutes daily for 1 to 2 weeks  Good skin hygiene. Repeated attacks are commonly found.
  96. 96 CANDIDIASIS (YEAST INFECTION) Candidiasis, sometimes called moniliasis, is an infection caused by yeast on the skin and/or mucous membranes. Candida albicans, a normal commensal, becomes pathogenic in the presence of predisposing factors such as moisture, obesity, diabetes and immunocompromised states DEFINITION ETIOLOGY
  97. 97 Types and Manifestations 1. Candidal intertrigo Area: Skin folds or navel Manifestations:  Erythematous, moist, macerated lesion with a frayed irregular edge  Patches, from which clear fluid oozes  Itching or burning
  98. 98 Types and Manifestations 2. Candidal diaper dermatitis Area: Perianal region, spreading to perineum, upper thighs, lower abdomen and lower back. Manifestations:  Well defined weeping eroded lesions with scalloped border with a collar of overhanging scales  White or yellow discharge from vagina
  99. 99 Types and Manifestations 3. Candidal paronychia Area: Nail beds Manifestations:  Nail plate is thickened and dystrophic.  There is loss of cuticle with redness and swelling of nail fold.  Small beads of pus can be expressed from under the proximal nail fold  White or yellow nail that separates from the nail bed
  100. 100 Types and Manifestations 4. Oral thrush Area: Mouth Manifestations:  Seen in new born breast fed infants.  Presents as soft, creamy white to yellow, elevated plaques that are easily wiped off to leave an erythematous, eroded or ulcerated surface.  Buccal mucosa (most frequently), tongue, palate and gingiva.
  101. DIAGNOSTIC EVALUATION  Medical history and physical examination  Skin scrapings are taken to confirm the diagnosis with a microscopic examination or culture. 101 TREATMENT  Predisposing factors should be addressed and the area should be kept dry.  Topical therapy with imidazoles (Clotrimazole, miconazole and ketoconazole), amphotericin, and nystatin is effective for thrush.  Systemic therapy with weekly fluconazole or pulse itraconazole is given for onychomycosis.
  103. 103 Scabies is an infestation of mites (tiny insects) characterized by small red bumps and intense itching. SCABIES DEFINITION  Caused by Sarcoptes scabiei  Can spread quickly through close physical contact in a family, child care group, school, class or nursing home  Mites cannot survive off the human body for more than 48 hours and cannot reproduce off the body  Scabies can affect people of all ages. Scabies occurs mostly in children and young adults. ETIOLOGY AND INCIDENCE
  106. 106 SITES OF PREDILECTION Lesions characteristically seen in ►Webs of hands ►On wrists ►Ulnar aspects of forearms ►Elbows ►Axillae ►Umbilical ►Area ►Genitalia ►Feet ►Buttocks ►Face is usually spared except in infants in whom scalp, palms and soles are also involved. ►Nodular lesions are seen on genitalia
  107. 107
  108. 108 • History taking and clinical examination. • Microscopic examination of scrapings of the lesions. DIAGNOSTIC EVALUATION MANAGEMENT  5% permethrin cream: It is safe for children as young as 1 month old and women who are pregnant.  25% benzyl benzoate lotion  10% sulphur ointment  1% indane lotion.  Antihistamine: To control itch and help to sleep  Pramoxine lotion: To control the itch  Antibiotic: To combat an infection  Steroid cream: To ease the redness, swelling and itch.
  109. 109 Prevention and care: Wash clothes, bedding towels Touch and hold child less Clean entire home
  110. 110 DEFINITION Pediculosis can be explained as infestation of lice on the scalp or body ETIOLOGY  Pediculosis humanus (P. humanus capitis, head louse and P. humanus corporis, body louse)  Phthirus pubis (pubic louse) INCIDENCE  Girls are affected twice as often as boys.  The peak incidence is in preschool and young school age children (aged 3 to 10 years). PEDICULOSIS (LICE INFESTATION)
  111. 111
  112. 112 Direct contact with an infected individual Adolescents or young adult pubic lice through sexual contact Sharing of clothing and combs or brushes Female head louse lays egg (nits), which glue onto the base of the hair shaft near the scalp 1 week: one nymph hatch from the nits 2 weeks: nymph develop to adult louse Adult louse feeds on blood and excrete saliva Skin irritation and itching Severe itching and scratching Secondary infections
  113. 113  Nits (covered with gelatinous material which hardens to semi- opaque, tiny, pearly whitish mass) are commonly visible behind the ears and at the nape of the neck  Scattered lesions on the scalp causing intense pruritus.  Posterior cervical lymph adenopathy associated with these lesions.  Excessive scratching of the infested areas can cause sores, which may become infected.  Tickling feeling Fig: Head lice infestation MANIFESTATIONS
  114. 114 DIAGNOSIS HEAD LICE/BODY LICE • Finding a live nymph or an adult louse in the scalp or hair of someone. • Finding nits no more than 6 mm from the scalp indicates a current infestation and more than 6 mm indicates a previous infestation. • Finding eggs in clothing • Finding adults crawling in clothing (generally the seams) • Finding adults crawling/feeding on the human body
  115. 115 MANAGEMENT Pediculosis capitis  Use of Pediculocides  Permethrin, 1% lotion, single 10 minute application to wet hair followed by rinsing. Second application after 7 days.  Gamma benzene hexachloride, 1% single overnight application to dry hair followed by rinsing. Second application used after 7 days.  Malathion, 0.5% water based lotion, applied on dry hair for 6 hours. Has residual effect, so 2nd application not needed. Pediculosis pubis infestation of lashes  Petrolatum (twice daily for 7-10 days) is used for eyelash infestation. The petrolatum covers the lice and their nits, preventing respiration.  The dead lice are removed mechanically with tweezers
  116. 116 o Avoid head-to-head contact o Don’t share any head garments or clothes o Don’t share combs, brushes, or towels (Disinfect them!!!) o Wash and dry clothes bedding, and other things worn or used by those who are infested o Vacuum floor and furniture o Avoid activities that are prone to spreading lice! o Bathe regularly o Change clothing regularly o Machine wash and dry infested and un-infested clothing regularly o Seal clothes in plastic bags. o Don’t share beds, clothes, towels, or bedding o Dusting with chemical insecticides may be necessary to prevent the spread of disease. PREVENTION
  118. 118 ACNE VULGARIS  Increased sebum secretion  Microbial colonization  Occlusion of pilosebaceous orifice Acne, medically known as acne vulgaris, is a skin disease that involves the oil glands at the base of hair follicles. Acne is a chronic skin condition characterized by areas of blackheads, whiteheads, pimples, greasy skin, and possibly scarring.
  119. 119 INCIDENCE & PREDISPOSING FACTORS  Usually starts during puberty and stops around 5 years later in 7 out of 10 people.  Occasionally, newborn babies can get acne in the first few weeks or months of life.  It affects approximately more than 80% of adolescents and upto 20% of neonates.  It is more common in boys. It flares up at winter and tends to improve in summer.  Genetic predisposition: Found to be familial Identical twins shows greater concordance of severity of acne.  Diet: High glycemic diet.  Cosmetics: Seen in women using oil based cosmetics for long time. Follows facial massage.  Menstrual cycle: Premenstrual edema of pilosebaceous duct.  Psychological factors
  120. PATHOPHYSIOLOGY 1.Follicular plugging 2.Increased Sebum Production 3.Acnes Proliferation 4.Inflammation 120
  122. 122 MANIFESTATION • Greasy skin and spots (whiteheads or blackheads) on face, back and chest • Inflamed spots (pustules, nodules and cysts) may be painful, tender to touch and the affected skin may feel hot. 1. Comedonal acne ⁃ Open comedones (blackheads) with a central dark keratin plugs. ⁃ Closed comedones (whiteheads) with no visible keratin plug. 2. Papular / Pustular acne ⁃ Patients present with inflamed, 2- to 5-mm papules/pustules 3. Nodular/Cystic acne ⁃ Patients present with red, firm, or fluctuant nodules (cyst like) that may drain or form sinus tracts. ⁃ These lesions may leave permanent scars.
  123. TREATMENT General measures • Oil and oil-based skin care products need to be avoided. • There is no restriction with regard to use of soaps and cleansers. • No dietary restrictions are usually needed. 123
  124. 124 DEFINITION • Common in tropical environments • Miliaria crystallina & miliaria rubra- occur at any age, but common in infants • Miliaria profunda is more common in adults INCIDENCE Miliaria is a disorder of the sweat glands where there is blockage of the sweat ducts, which results in the leakage of eccrine sweat into the epidermis or dermis MILIARA/PRICKLY HEAT
  125. 125 ETIOLOGY Immaturity of the eccrine ducts Occlusion of the skin, as with transdermal drug patches Occlusive clothing Lack of acclimatization Hot, humid conditions Drugs Miliaria is due to obstruction and rupture of sweat ducts resulting in spillage of sweat into adjacent tissue.
  126. 126 01 02 03 04 Miliaria profunda Miliaria rubra Miliaria crystallina Miliaria pustulosa CLASSIFICATION
  127. 127 Classification Description Picture Miliaria crystallina • Appears in bedridden patients, bundled children and seen during high fever. • Characterized by small, clear, superficial, non- inflamed vesicles. • Lesions are asymptomatic and rupture at the slightest trauma • Self-limited; no treatment is required
  128. 128 Classification Description Picture Miliaria rubra • Characterized by small extremely pruritic, erythematous papulo- vesicles with sensation of prickling, burning, or tingling
  129. 129 Classification Description Picture Miliaria pustulosa • Always preceded by some injury, destruction, or blocking of sweat duct • Pustules independent of hair follicle • Seen in intertriginous areas, flexure surfaces of extremities, scrotum, and back of bedridden patients • Sterile pustules
  130. 130 Classification Description Picture Miliaria profunda • Characterized by large erythematous non-pruritic, flesh-colored, deep-seated, whitish papules • Asymptomatic, usually lasting only 1 hr after overheating has ended • Concentrated on the trunk and extremities • Occlusion is in upper dermis • Only seen in tropics usually following a severe bout of miliaria rubra
  131. 131 PATHOPHYSIOLOGY Excessive Sweat and clothing that does not absorb sweat Blockages in the superficial stratum corneum Miliaria crystalline Keratin blockage or Staphylococcus in the sweat duct Bubbles in the stratum spinosum Inflammation of the skin Miliaria rubra Eruption Pus formed
  132. 132 History Physical examination Education Topical Therapy Systemic Therapy TREATMENT DIAGNOSIS
  133. 133 COMPLICATIONS Secondary infection Impetigo Heat Intolerance
  135. 135 LICHEN PLANUS (LP) DEFINITION Lichen Planus is an acute or chronic non-infectious immune mediated disorder of skin, oral mucous membrane or nails
  136. 136 Unknown RETIRE ETIOLOGY Lichenoid reactions complication of chronic hepatitis C
  137. 137 CLINICAL FEATURES Violaceous, pruritic, polygonal and flat-topped papules with white streaks (Wickhams striae) Lesions seen on wrists, around ankles and may appear at sites of trauma (Koebners phenomenon) Lesions on buccal mucosa, tongue and gingiva, annular lesions are seen on genitalia. Scalp lesions: Scarring alopecia Nail changes: Longitudinal grooves, tenting of nail plates and pterygium formation
  140. 140 PSORIASIS Psoriasis is a chronic recurrent dermatisis marked by discrete vivid red macules, papules or plaques covered with silvery lamellated scales over scalp, knees, elbows, umbilicus and genitalia. Removal of scales leads to multiple small bleeding points (Auspitz sign). DEFINITION
  141. 141 ETIOLOGY Heredity: Psoriasis is polygenic trait Immunological factors: T cells play a pivotal role in pathogenesis of psoriasis Triggers: a. Physical trauma, infections (3 hemolytic streptococci, HIV infection) b. Drugs (lithium, NSAIDS, anti-malarials) c. changes in season and climate
  142. 142 TYPES Type II: onset is in adulthood Type I: onset is during childhood and adolescents TYPE I PSORIASIS CHARACTERS  Onset in second decade.  Positive family history.  Severe disease.  Prominent Koebners phenomenon.  Prolonged course, requiring relatively more aggressive therapy.
  143. 143 CLASSIFICATION Acute Chronic Erythroderma Psoriasis vulgaris Pustular psoriasis Acute guttate
  144. 144 CLINICAL FEATURES Psoriasis vulgaris  Well demarcated, indurated, erythematous scaly (silvery, loose) lesions.  Involves knees, elbows and extensors, lower back, scalp and sites of trauma (Koebners/isomorphic phenomenon). Face and photo-exposed areas generally spared.  Auspitz sign: Removal of scales by scraping with a glass slide reveals a glistening white membrane (Burkleys membrane) and on removing the membrane, bleeding points become visible.
  145. 145 CLINICAL FEATURES Guttate psoriasis ◘Occurs in children and adolescents. ◘May be precipitated by streptococcal tonsillitis. ◘Crops as small erythematous scaly papules. ◘Predominantly on trunk.
  146. 146 CLINICAL FEATURES Pustular psoriasis Two rare variants described in children: 1. Annular pustular psoriasis: Characterized by sudden onset of fiery red erythema rapidly covered by cluster of very superficial creamy white pustules which in children form circinate/annular lesions. 2. Infantile and juvenile pustular psoriasis: Rare; seen in infants as annular/circinate lesions. Runs a benign course and often confused with seborrheic and napkin dermatitis.
  147. 147 DIAGNOSIS History and clinical features A biopsy (which is confirmatory)
  148. TREATMENT Type Treatment of choice Alternative treatment Psoriasis Vulgaris  Localized (<30% BSA) Coal tar preparations Topical steroids + Salicylic acid  Extensive (>30% BSA) Narrow band Ultraviolet B (UVB), PUVA (Psoralen + ultraviolet light A) Methotreaxate, Acitretin, Cyclosporin A  Facial lesions Topical steroids Guttate psoriasis Antibiotics + Emollients, PUVA (Psoralen + ultraviolet light A) Coal tar preparations, Mild topical steroids Pustular psoriasis Methotreaxate, Acitretin 148  PUVA : Should not be used in children <6 years of age
  149. 149 0THERS A. ECZEMATOUS DERMATITIS a) Atopic Dermatitis b) Infantile Seborrheic Dermatitis c) Diaper Dermatitis
  150. 150 ECZEMATOUS DERMATITIS Eczema is a condition where the skin gets irritated, red, dry, bumpy, and itchy. Dermatitis is inflammation of the skin, typically characterized by itchiness, redness and a rash. DEFINITION
  151. 151 Types 01 02 03 Atopic Dermatitis Infantile Seborrheic Dermatitis Diaper Dermatitis
  152. 152 Atopic Dermatitis DEFINITION INCIDENCE ETIOLOGY Atopic dermatitis (AD) is a chronic, pruritic inflammatory skin disease characterized by intense itching with episodes of exacerbation (flares which may occur as frequently as two or three per month) and remissions. Atopic dermatitis is also known as infantile or childhood eczema. It is often called “the itch that rashes”. • Affects approximately 10-20% of children worldwide • Onset is usually before 5 years of age and may not diminish until early adulthood. • Genetic predisposition • Immunological changes
  153. 153 Atopic Dermatitis: Clinical Features Pruritus Secondary lesions due to chronic rubbing and scratching Lesions appear as xerosis (dry, scaly skin), ill-defined erythema, small coalescing edematous papules or vesicles, Lichenification and/or excoriations (secondary to relentless scratching, crusts, etc.
  154. 154 Infantile pattern (3 months – 2 years): » Begins after 3 months of age as extremely itchy erythematous papulo- vesicles » Involves the cheeks, forehead, scalp and extensor surfaces. » Erythematous, ill-defined plaques on the cheeks with overlying scale and crusting. » Clears by 18 months of age in 40% and in 60% changes into childhood pattern.
  155. 155 Childhood (2 – 12 years): » Includes flexural areas of neck, elbows, knees, wrists and ankles. » Lichenified erythematous plaques » Erythematous, excoriated papules with overlying crust mainly in antecubital fossa » 70% clear by 10 years of age.
  156. 156 Atopic Dermatitis: Diagnosis Diagnosis is based on Hanifin and Rajka criteria for atopic dermatitis. Presence of 3 or more major features and 3 or more minor signs determine the diagnosis.
  157. 157 Major Features • Pruritus • Typical morphology and distribution. • Flexural Lichenification or linearity in adults • Facial and extensor involvement in infants and children • Chronic or chronically-relapsing dermatitis • Personal or family history of atopy (asthma, allergic rhinitis, atopic dermatitis)
  158. Minor Features • Xerosis • Ichthyosis, palmar hyperlinearity, or keratosis pilaris. • Immediate (type 1) skin-test reactivity • Raised serum IgE • Early age of onset • Tendency toward cutaneous infections (especially S aureus and herpes simplex) or impaired cell- mediated immunity. • Tendency towards non-specific hand or foot dermatitis • Nipple eczema • Cheilitis Minor Features • Recurrent conjunctivitis • Dennie-Morgan infraorbital fold • Keratoconus • Anterior subscapular cataracts • Orbital darkening • Facial pallor or facial erythema • Pityriasis alba • Anterior neck folds • Itch when sweating • Intolerance to wool and lipid solvents • Perifollicular accentuation • Food intolerance • Course influenced by environmental or emotional factors • White demographism or delayed blanch. 158
  159. 159 Atopic Dermatitis: Treatment Treatment General Symptomatic Avoid scratching Dietary restrictions Vaccinations Acute eczema Chronic eczema
  160. 160 SEBORRHEIC DERMATITIS (CRADLE CAP) DEFINITION CAUSE Seborrheic Dermatitis is a chronic, inflammatory reaction of the skin. It is most common in the scalp but may involve the eyelids (blepharitis), external ear canal (otitis externa), naso-labial fold and inguinal region. It is most common in infants. Malassezia furfur, a commensal yeast
  161. 161 CLINICAL MANIFESTATIONS Reddish, somewhat swollen patches of skin Greasy, yellow scale on erythematous base Itching Burning Self- limiting and usually resolves by 12 weeks
  162. 162 Sites of predilection:
  163. 163
  164. 164 The crusts of cradle cap should be pre- treated with warm olive oil. Wet compress is applied over the fissured lesion before application of ointment. Application of 2% ketaconazole shampoo, mild topical steroid or 1% pimecrolimus cream hastens subsidence. Treatment
  165. 165 DIAPER DERMATITIS Diaper dermatitis is a prototypical example of irritant contact dermatitis, caused by over hydration of the skin, maceration, prolonged contact with urine and feces, retained diaper soaps and topical preparations restricted to the area covered by diapers. DEFINITION
  166. 166  Commonly affects infants  Ages 9 – 12 months a. Irritant dermatitis in infants caused by prolonged contact with feces and ammonia (produced by the action of urea splitting organism on urine) b. Impetigo c. Perianal streptococcal disease d. Allergies INCIDENCE CAUSES
  167. 167 Pathophysiology
  168. 168 Types and Clinical Manifestation Candida diaper dermatitis ⁃ Rash begins in the creases or folds of the thighs and in the diaper area, and then spreads. ⁃ Rash is usually deep, red, shiny rash with red and satellite lesions. ⁃ Usually accompanied by the yeast infection, oral thrush.
  169. 169 Types and Clinical Manifestation Seborrheic diaper dermatitis ⁃ Affects the skin fold in the groin area and is usually pink. ⁃ May appear on the face, scalp, or neck of infants at the same time.
  170. 170 Types and Clinical Manifestation Contact diaper dermatitis ⁃ Mainly seen on the buttocks and may extend to the thighs, stomach and waist area ⁃ Does not generally involve fold areas ⁃ Rash usually red and shiny
  171. 171 Treatment  Diaper area has to be left open to air or covered with topical emollients.  The first line therapy for individuals with diaper dermatitis is zinc oxide ointment or various products containing zinc oxide  Acetyl tocopherol  Emollients – white petrolatum ointment (traps water beneath the epidermis), Aquaphor ointment  In case of candidiasis – Antifungal agents like Nystatin cream and Econazole
  172. 172  Health education to parents and caregivers – diaper education, treatment  Keep skin clean and dry  Frequent changing of diaper  Use of disposable diapers with sub absorbent materials  Rinsing washed cotton diapers well (preferably in diluted lemon juice).  Wash genitalia with warm water and mild soap  Apply bland protective topical agent after thorough washing PREVENTION
  175. CARE OF SKIN OF NEONATES 175 a)Maintain Skin Integrity b)Prevent Skin Injury in the Neonate
  176. 176 CARE OF THE DISEASED SKIN Provide Psychological Support (f) (e) Ensure Maximum Patient Comfort (d) Prevent Spread of Infection (a) (b) (c) Recognize and Prevent Secondary Infection Maintain integrity of the Skin Promote Healing of the Skin Lesions
  177. 177 RESEARCH ABSTRACT PREVALENCE OF CHILDHOOD SKIN DISORDERS ATTENDING AT OUTPATIENT PEDIATRIC HOSPITAL Thummanapally Nandini, Lawdyavath Kavitha,Guruva Charandas, Enumula, Pvk Sastry , Anchuri Shyam Objective: The objective of the study was to study the prevalence of various skin diseases in pediatric population. Methods: A prospective observational study Results: Out of 200 pediatric skin disorders, the percentage of skin disorders is allergic infections (26%), bacterial infections (23%), viral infections (11%), fungal infections (7.5%), parasitic infections (6%), autoimmune disorders (4%), and skin adnexa (2.5%). Conclusion: The study concludes that the prevalence of allergic and bacterial skin infections was found to be common among male children
  178. 178 CONCLUSION Many childhood skin problems are minor and can be treated with OTC products. Others are more complicated and may need prescription drug products or other treatments. Pathological changes may arise in epidermis, dermis and subcutaneous tissue. The pattern of changes may allow a diagnosis to be made or it may be non-specific. The appearance of many skin diseases vary at different stages of their development and may be altered by attempted treatment and secondary changes such as scratching or infection.
  179. 179