Dermatologic Conditions in Children
Emily Croce
Meghan O’Neill
OBJECTIVES
After studying this chapter, the reader will be able to:
Recognize the skin conditions commonly seen in the pediatric population, including a variety of transient cutaneous conditions in newborns, miliaria, oral candidiasis, ichthyosis, and hemangiomas.
Describe the factors that may precipitate or contribute to these pediatric skin disorders.
Discuss the therapeutic interventions frequently used in these pediatric dermatology conditions.
Identify the important patient teaching issues for these pediatric skin disorders.
KEY POINTS
Many skin conditions in newborns are transient, selflimiting problems that do not require intervention other than to provide reassurance to parents.
Genetic skin disorders may present lifelong problems for affected individuals.
Transient, self-limiting problems that generally do not require intervention other than to provide reassurance to parents include acne neonatorum, acropustulosis of infancy, erythema toxicum neonatorum, harlequin color change, cutis marmorata, sebaceous gland hyperplasia, subcutaneous fat necrosis (if small affected area), sucking blisters, and transient pustular melanosis.
Miliaria crystallina (self-limited), miliaria rubra (common prickly heat), and miliaria profunda (found in patients who have had several bouts of miliaria rubra) are all sweat-retention diseases related to heat exposure. Miliaria crystallina and rubra are the most common forms seen in the neonatal period.
Oral candidiasis, also known as oral thrush, is an infection of the oropharyngeal cavity with Candida albicans, a yeast commonly seen in the infant period.
Ichthyosis, which means “fish scale,” is a broad category of dermatologic conditions involving varying presentations of excessive scaling of the skin. Major hereditary types, which have been described, include two autosomal recessive congenital ichthyoses (epidermal ichthyosis and lamellar ichthyosis types), ichthyosis vulgaris, and X-linked ichthyosis. Several other, rarer forms exist but are not covered in this chapter.
Hemangiomas of infancy are common, benign, vascular tumors comprised of endothelial cells. They may be isolated, small, and uncomplicated or may lead to significant cosmetic and/or medical complications and require intervention.
TRANSIENT CUTANEOUS CONDITIONS IN THE NEWBORN
I. OVERVIEW
A. Definition: transient skin conditions that appear and disappear during the first few days to weeks or months of life.
II. EPIDEMIOLOGY
A. Many infants will experience one or more of these conditions.
II. ETIOLOGY AND PATHOGENESIS
A. Infant skin differs from adult skin in that it seems to reflect bodily changes more readily.
B. These conditions are related to one or several of the following influences:
1. Events occurring during birth
2. Immaturity of various physiologic systems
3. Influence of maternal hormones
IV. ASSESSMENT
A. Clinical manifestations
1. Acne neonatorum (neonatal acne or neonatal cephalic pustulosis) (Figure 13-1)
a. Presents as multiple, discrete, inflammatory papules and/or pustules on the face, particularly on the cheeks. Occasionally, lesions are also present on the chest, back, and/or groin.
b. Not considered a true form of acne vulgaris, which also presents with comedones and larger, inflammatory papules
c. Appears at 2 to 4 weeks of age and may persist for up to 6 months of age. Present in 20% of infants
d. Thought to be the result of transient, benign increases of circulating androgens in the newborn.
Also potentially related to an inflammatory reaction to Pityrosporum (Malassezia) species
Also potentially related to an inflammatory reaction to Pityrosporum (Malassezia) species
 FIGURE 13-1. Neonatal acne (benign cephalic pustulosis) with multiple uniform red papules. (From Lugo-Somolinos, A., et al. (2011). VisualDx: Essential dermatology in pigmented skin. Philadelphia, PA: Wolters Kluwer.) |
e. A careful history must be obtained to determine whether other virilizing features are present, such as axillary/pubic hair and/or body odor. If present, the child must be referred to a pediatric endocrinologist for further workup.
2. Acropustulosis of infancy (Figure 13-2)
a. Presents as pustules or vesicles on the palms and soles in recurrent crops and rapidly become pruritic
b. Pruritus in the neonate may present as an irritable, fretful child.
c. Lesions may recur every 2 to 4 weeks until 2 to 3 years of age.
 FIGURE 13-2. Scattered papules and pustules on the dorsum of the foot in acropustulosis of infancy. (From Lugo-Somolinos, A., et al. (2011). VisualDx: Essential dermatology in pigmented skin. Philadelphia, PA: Wolters Kluwer.) |
d. Sometimes mistaken for scabies infestation
e. Etiology is unknown.
3. Erythema toxicum neonatorum (Figure 13-3)
a. A central, 1 to 3 mm, yellowish papule or pustule with a 1 to 3 cm, irregular, macular flare.
b. Present at 24 to 72 hours of age in approximately half of term infants and typically clear in 4 to 7 days
c. Lesions are typically seen on the face, may spread to the torso and extremities, and can be seen anywhere except for the palms and soles.
d. Etiology is unknown.
4. Harlequin color change
a. Occurs in approximately 10% of healthy infants when placed on one side. Also associated with low birth weight/preterm birth. The gravity-dependent skin develops an erythematous flush, with a simultaneous blanching of the upper side.
b. A distinct line of demarcation runs along the midline of the body.
c. Usually subsides within a few seconds of placing the baby in the supine position but may persist up to 30 minutes
d. Attributed to the immaturity of autonomic vasomotor control. May last up to approximately 3 weeks of age
 FIGURE 13-3. Erythema toxicum neonatorum showing the usual pattern, with most of the lesions on the trunk and face and fewer on the extremities. (From Fletcher, M. A. (1998). Physical diagnosis in neonatology. Philadelphia, PA: Lippincott-Raven Publishers.) |
 FIGURE 13-4. Milia. (From Jensen, S. (2010). Nursing health assessment. Philadelphia, PA: Wolters Kluwer.) |
5. Milia (Figure 13-4)
a. Small retention cysts
b. One- to two-millimeter pearly white or yellow papules, most commonly on the nose, cheeks, chin, and forehead. Occasionally occur on the torso/extremities
c. May also occur on the oral mucosa, particularly the palate. These are called Epstein pearls.
d. Occurs in 40% to 50% of newborns
e. Usually resolve spontaneously in the first 3 to 4 weeks of life
f. Milia that are in a widespread or unusual distribution that persist may be associated with other genetic conditions.
6. Cutis marmorata (Figure 13-5)
a. A physiologic reaction to cold in the newborn with the development of blanching, bluish, reticulated mottling of the skin on the trunk and extremities. Vasoconstriction may also lead to blue hands, feet, and lips, known as acrocyanosis.
b. Caused by constricted capillaries and venules. Disappears on rewarming
c. Thought to be caused by immaturity of the autonomic control of skin vascular plexus. More common in preterm infants
d. Mottling that persists beyond the 6 months of life may be a sign of cutis marmorata telangiectatica congenita, a genetic skin condition that may have additional implications.
 FIGURE 13-5. Cutis marmorata in a 2-month-old baby. (From Salimpour, R. R., Salimpour, P., & Salimpour, P. (2013). Photographic atlas of pediatric disorders and diagnosis. Philadelphia, PA: Wolters Kluwer.) |
7. Sebaceous gland hyperplasia
a. Follicular, evenly spaced, yellow-white papules where sebaceous gland density is greatest, typically around the nose and upper lip
b. Differs from milia, which are usually solitary, more discrete, and whiter
c. Occurs in 21% to 48% of infants.
d. Resolves by 4 to 6 months.
e. Hypertrophy of sebaceous glands thought to be the result of maternal and/or fetal stimulation of adrenal glands.
8. Subcutaneous fat necrosis (Figure 13-6)
a. Sharply circumscribed, indurated, reddish or purple nodules and/or plaques in apparently healthy fullterm newborns and young infants. Most commonly on cheeks, back, buttocks, arms, and thighs
b. Appears within the first 2 weeks of life and resolves over several weeks to months
c. May heal with atrophy, leaving a skin depression
d. Extensive subcutaneous fat necrosis can be associated with significant hypercalcemia.
e. Etiology is unknown. May be related to hypothermia, trauma, asphyxia, or hypercalcemia
9. Sucking blister (Figure 13-7)
a. Solitary, intact blister or erosion on noninflamed skin of the fingers, dorsum of the dominant hand or wrist, or upper lip
b. Results from vigorous sucking in the prenatal period
c. Resolves within a few days
 FIGURE 13-6. Subcutaneous fat necrosis of the newborn. (Image provided by Stedman’s.) |
10. Transient pustular melanosis (Figure 13-8)
a. Presents at birth as vesicles, pustules, or pigmented macules with a collarette of scale
b. Seen in less than 1% of newborns. More commonly seen in infants with darker pigment
c. Pustular lesions typically resolve within 23 to 48 hours, with resultant hyperpigmentation fading over several weeks to months.
d. Cause is unknown.
 FIGURE 13-7. Sucking blister. The lesion on the left hand of this newborn is the result of sucking that occurred in utero. (Courtesy of Denise A. Salerno, MD, FAAP.) |
 FIGURE 13-8. Transient neonatal pustular melanosis. (Courtesy of Paul S. Matz, MD.) |
B. Diagnostic tests
1. Diagnosis is generally made by the lesions’ clinical features.
2. Occasionally, a gram stain or Tzanck preparation may be used to rule out infectious causes.
3. In general, due to the benign nature of these conditions, additional diagnostic studies usually are not required.
4. Extensive subcutaneous fat necrosis may warrant a biopsy and serum calcium levels.
V. NURSING CONSIDERATIONS (TABLE 13-1)
A. Interventions
1. Maintain an adequate fluid balance and nutrition in the infant.
2. Instruct and demonstrate appropriate skin care techniques that will keep the skin clean, moisturized, and protected.
3. The majority of these conditions resolve spontaneously and do not require treatment.
a. In acne neonatorum, most cases require no treatment. For severe and persistent comedonal lesions, azelaic acid 20% cream or the mildest topical retinoid preparations may be considered with close follow-up. Mild inflammatory lesions may be treated with ketoconazole cream. For inflammatory severe and persistent lesions, 2% erythromycin, 1% clindamycin, or 2.5% benzoyl peroxide may be considered with close follow-up. Systemic therapy is avoided when possible, though scarring acne may warrant treatment with oral antibiotics, such as erythromycin.
b. If acropustulosis of infancy is symptomatic, oral sedating antihistamines (0.6 mg/kg/dose every 4 to 8 hours) may provide relief of itching and may be used in older infants. Potent topical steroids may also be used sparingly for severe cases.
B. Follow-up
1. Follow-up is only necessary if the condition worsens or parents have additional questions.
TABLE 13-1 Nursing Care of Children with Skin Disorders | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
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PATIENT EDUCATIONTransient Skin Conditions
Reassure parents regarding the benign nature of these conditions.
Assure that the child is kept adequately warm, but avoid overdressing or occlusive clothing.
MILIARIA
I. OVERVIEW
Eccrine sweat glands are not associated with hair follicles and are found everywhere on the body except for mucocutaneous junctions. Eccrine sweat glands function to help regulate the body’s temperature. This is accomplished by the production of eccrine sweat that flows to the skin surface and cools by evaporation. Eccrine sweat is an odorless, colorless, hypotonic solution and is excreted during periods of stress and heat. Miliaria crystallina (self-limited), miliaria rubra (prickly heat, most common in tropical climates), and miliaria profunda (found in patients who have had several bouts of miliaria rubra) are all sweat-retention diseases related to heat exposure. Miliaria crystallina and rubra are the most common forms seen in the neonatal period. Precipitating factors of these conditions include warming in incubators, fevers, occlusive clothing, dressings, or devices.
A. Definition: Miliaria is an itchy rash caused by inflammation following obstruction and rupture of eccrine sweat glands (Figure 13-9).
II. EPIDEMIOLOGY
A. Age: occurs predominantly in neonates, with a peak in those aged 1 week; but may occur in any age if febrile or recently moved to hot, humid climate
B. Sex: No sex predilection exists.
C. Race: in all races; Asian races produce less sweat and are thus less likely to have miliaria rubra.
D. Other factors
1. Wearing synthetic clothing, which may irritate the skin
2. Swaddling too much in clothing or blankets
3. Lying for prolonged periods in bed or near heat sources (i.e., incubators, heaters, lights, etc.)
 FIGURE 13-9. Miliaria in a 7-day-old infant. (From Salimpour, R. R., Salimpour, P., & Salimpour, P. (2013). Photographic atlas of pediatric disorders and diagnosis. Philadelphia, PA: Wolters Kluwer.) |
II. ETIOLOGY AND PATHOGENESIS
A. Known causes
1. Conditions of high heat and humidity that lead to excessive sweating and occlusion of skin. For example, clothing and casts
2. Normal skin bacteria, such as S. epidermidis and S. aureus, thought to play role by producing sticky substance, which blocks sweat ducts
3. Leakage of sweat through walls of duct behind blocked duct responsible for production of miliaria and for further aggravation
4. Blockage of sweat ducts by dead skin
IV. ASSESSMENT
A. Clinical manifestations
1. Miliaria crystallina (asymptomatic and self-limited) (Figure 13-10)
a. Clear, superficial vesicles that are 1 to 2 mm in diameter
b. Confluent crops without surrounding erythema
c. On head, neck, and upper part of trunk in infants
d. On trunk in bedridden, overheated individuals
e. Lesions rupture easily and resolve with superficial desquamation.
f. Older lesions will scale.
2. Miliaria rubra (prickly heat, heat rash) (Figure 13-11)
a. Uniform, small, erythematous papules and vesiculopapules on a background of erythema
b. The most common of sweat-retention diseases
c. Nonfollicular distribution; do not become confluent
d. Can cause great discomfort; treatment is warranted.
e. On the neck, groin, and axillae in infants
f. On covered skin where friction occurs in adults
(1) Neck
(2) Scalp
 FIGURE 13-10. Miliaria crystallina. Multiple tiny-walled, clear vesicles of varying sizes. (From Burkhart, C., Morrell, D., Goldsmith, L. A., Papier, A., Green, B., Dasher, D., & Gomathy, S. (2009). VisualDx: Essential pediatric dermatology. Philadelphia, PA: Wolters Kluwer.) |
 FIGURE 13-11. Prickly heat in a 6-week-old infant. (From Hall, J. C. (2000). Sauer’s manual of skin diseases (8th ed., p. 407). Philadelphia, PA: Lippincott Williams & Wilkins.)
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