Pediatric Dermatology: A Quick Reference Guide / Edition 3 available in Paperback
This bestselling quick reference guide from the American Academy of Pediatrics provides practical and concise guidance on the recognition and treatment of more than 100 pediatric and adolescent skin conditions. Includes more than 300 full color images that aid in accurate visual diagnosis. Coverage spans everything from dermatitis and acne to infections, pigmentation disorders, hair disorders, neonatal and infant conditions, drug eruptions, and much more.
- All chapters have been updated and resvised
- 13 new chapters:
- Acrodermatitis Enteropathica
- Aplasia Cutis Congenita
- Dermoid Cysts
- Epidermal Nevi
- Erythema Nodosum
- Henoch–Schönlein Purpura
- Juvenile Plantar Dermatosis
- Langerhans Cell Histiocytosis
- Pigmentary Mosaicism — Hyperpigmented
- Pigmentary Mosaicism — Hypopigmented
- Pityriasis Lichenoides
- Polymorphous Light Eruption
- New section on Nutritional Dermatoses
- Updated section on lice therapy
- Expanded discussion of infantile hemangioma treatments
|Publisher:||American Academy of Pediatrics|
|Edition description:||New Edition|
|Product dimensions:||5.00(w) x 11.90(h) x 3.60(d)|
About the Author
Anthony J. Mancini, MD, FAAP, is the head of the division of dermatology at Ann & Robert H. Lurie Children’s Hospital of Chicago and professor of pediatrics and dermatology at Northwestern University Feinberg School of Medicine.
Daniel P. Krowchuk, MD, FAAP, is professor of pediatrics and dermatology at Wake Forest School of Medicine in Winston-Salem, NC.
Read an Excerpt
A Quick Reference Guide
By Anthony J. Mancini, Daniel P. Krowchuk
American Academy of PediatricsCopyright © 2016 American Academy of Pediatrics
All rights reserved.
Approach to the Patient With a Rash
* Recognizing and describing skin lesions accurately is essential to the diagnosis and differential diagnosis of skin disorders.
* The first step is to identify the primary lesion, defined as the earliest lesion and the one most characteristic of the disease.
* Next note the distribution, arrangement, and color of primary lesions, along with any secondary change (eg, crusting or scaling).
Types of Primary Lesions
* Flat lesions
* Macule: a small (<1 cm), circumscribed area of color change without elevation or depression of the skin (Figure 1.1)
* Patch: a larger (>1 cm) area of color change without skin elevation or depression (Figure 1.2)
* Elevated lesions
* Solid lesions
- Papules (<1 cm in diameter) (Figure 1.3)
- Nodules: lesion measuring 0.5 to 2.0 cm in diameter, most of which resides below the skin surface (Figure 1.4)
- Tumor: deeper than a nodule and measuring larger than 2 cm in diameter
- Wheals: pink, rounded, or flat-topped elevations due to edema in the skin (Figure 1.5)
- Plaques: plateau-shaped structures often formed by the coalescence of papules; larger than 1 cm in diameter (Figure 1.6)
* Fluid-filled lesions
- Vesicles: smaller than 1 cm in diameter and filled with serous or clear fluid (Figure 1.7)
- Bullae: 1 cm or larger in diameter and typically filled with serous or clear fluid (Figure 1.8)
- Pustules: smaller than 1 cm in diameter and filled with purulent material (Figure 1.9)
- Abscess: 1 cm or larger and filled with purulent material
- Cysts: 0.5 cm or larger in diameter; represent sacs containing fluid or semisolid material (Unlike in bullae, the material within a cyst is not visible from the surface.)
* Depressed lesions
* Erosions: superficial loss of epidermis with a moist base (Figure 1.10)
* Ulcers: deeper lesions extending into the dermis or below (Figure 1.11)
Distribution of Lesions
Certain disorders are characterized by unique patterns of lesion distribution.
* Atopic dermatitis in children and adolescents typically involves the antecubital or popliteal fossae.
* Seborrheic dermatitis in adolescents commonly involves not only the scalp but also the eyebrows and nasolabial folds.
* Lesions of psoriasis are often seen in areas that are traumatized, such as the extensor surfaces of the elbows and knees.
* Acne is limited to the face, back, shoulders, and chest, sites of the highest concentrations of pilosebaceous follicles.
Arrangement of Lesions
The arrangement of lesions also may provide a clue to diagnosis. Some examples include
* Linear: contact dermatitis due to plants (eg, poison ivy) (Figure 1.12), lichen striatus, and incontinentia pigmenti; may also occur in epidermal nevi, psoriasis, and warts
* Grouped: herpes simplex virus infection (Figure 1.13), warts, molluscum contagiosum
* Dermatomal: herpes zoster (Figure 1.14)
* Annular (ie, ring-shaped): tinea corporis (Figure 1.15), granuloma annulare, erythema migrans, lupus erythematosus
* Erythematous: pink or red. When erythematous lesions are observed, it is important to note if they blanch. If the red cells are within vessels, as occurs in urticaria, compression of the skin forces the cells into deeper vessels and blanching occurs. However, if the cells are outside vessels, as occurs in forms of vasculitis, blanching will not occur. Non-blanching lesions are termed petechiae, purpura, or ecchymoses. Also note that in individuals with more deeply pigmented skin erythema may be more difficult to appreciate.
* Hyperpigmented: tan, brown, or black.
* Hypopigmented: amount of pigment decreased but not entirely absent (as seen with postinflammatory pigmentary alteration).
* Depigmented: all pigment absent (as occurs in vitiligo).
Alterations in the skin that may accompany primary lesions include
* Crusting: dried fluid; commonly seen following rupture of vesicles or bullae (as occurs with the "honey-colored" crust of impetigo).
* Scaling: represents epidermal fragments that are characteristic of several disorders, including fungal infections (eg, tinea corporis) and psoriasis.
* Atrophy: an area of surface depression due to absence of the epidermis, dermis, or subcutaneous fat; atrophic skin often is thin and wrinkled.
* Lichenification: thickening of the skin from chronic rubbing or scratching (as occurs in atopic dermatitis); as a result, normal skin markings and creases appear more prominent (Figure 1.16).CHAPTER 2
Several procedures can assist the clinician in diagnosing skin problems.
Discussed here are the potassium hydroxide (KOH) preparation, fungal culture, mineral oil preparation for scabies, and Wood light examination.
Potassium Hydroxide (KOH) Preparation
Used to identify fungal elements (eg, spores, hyphae, pseudohyphae) in skin, hair, or nail samples. The procedure is as follows:
* Using the edge of a glass microscope slide or #15 scalpel blade, scrape the skin and collect fragments or hair remnants on a second glass microscope slide. Preparing the area first with alcohol may be useful in helping debris stick to blade or slide.
* If sampling a nail, use a scalpel blade to scrape the underside of the nail (or its surface if superficial infection is suspected) and collect the debris obtained.
* Cover the specimen on the glass slide with a cover slip.
* Apply 1 to 2 drops of 10% to 20% KOH to the edge of the cover slip. Capillary action will draw the liquid under the entire cover slip.
* Gently heat the slide with an alcohol lamp or match, taking care to avoid boiling (which causes the KOH to crystallize and makes interpretation of the preparation difficult).
* Gently compress the cover slip to further separate skin fragments.
* Scan the preparation initially under low power (using the 10x objective lens).
* Examine any suspicious areas under higher power (using a 40x objective lens) for
* Branching hyphae or spores: characteristic of dermatophyte infections of the skin or nails (eg, tinea corporis, tinea pedis, tinea cruris, onychomycosis) (Figure 2.1).
* Spores within hair fragments (ie, an endothrix infection): characteristic of the most common form of tinea capitis in the United States caused by Trichophyton tonsurans (Figure 2.2). If tinea capitis is caused by Microsporum canis (approximately 5% of all cases), hyphae or spores will be seen on the outside of hair shafts (ie, an ectothrix infection).
* Pseudohyphae and spores: seen in infections with Candida species (Figure 2.3).
* Spores and short hyphae (ie, "spaghetti and meatballs"): seen in tinea versicolor (Figure 2.4).
* Sampling techniques
* If sampling the skin: Using the edge of a glass microscope slide or #15 scalpel, scrape the lesion and collect scale on a glass microscope slide.
* If sampling a nail: Use a scalpel blade to scrape the underside of the nail (or its surface if superficial infection is suspected), and collect the debris on a glass microscope slide or folded sheet of paper; alternatively, use a nail clipper to obtain nail clippings.
* If sampling the scalp
* Use the edge of a glass microscope slide or #15 scalpel to scrape the affected area, collecting scale and hair remnants (ie, black dot hairs) onto a glass microscope slide.
* Alternatively, moisten a cotton-tipped applicator with tap water, rub the affected area of the scalp, and inoculate the fungal culture medium with the swab. (If fungal culture medium is not available, a Culturette swab system may be used to collect and transport the specimen to the laboratory.)
* Transfer the material collected to the fungal medium (typically dermatophyte test medium [DTM] or Mycosel agar) and process appropriately.
* Leave the cap slightly loose to permit air entry.
* If fungal culture medium is not available, transfer the specimen in a sterile glass tube or other container to the laboratory.
* In the presence of a pathogenic fungus, DTM will change from yellow to red in 1 to 2 weeks (Figure 2.5).
Mineral Oil Preparation for Scabies
* Place a small drop of mineral oil on a suspicious burrow, papule, or vesicle that has not been traumatized by the patient.
* Using a #15 scalpel blade oriented parallel to the skin surface, scrape the lesion. Because scabies mites live in the epidermis, it is not necessary to scrape deeply; however, some bleeding is common with the procedure.
* Transfer the material to a drop of mineral oil on a glass microscope slide.
* Repeat the process for several other suspicious lesions.
* Cover the sample on the glass slide with a cover slip.
* Examine at low power for the presence of mites, eggs, or fecal material (Figures 2.6 and 2.7).
Wood Light Examination
Examination of the skin using Wood light in a darkened room may assist in the diagnosis of several conditions.
* Erythrasma (a superficial Corynebacterium infection): Affected areas fluoresce a coral-red color.
* Tinea capitis: Wood light examination is only useful in the recognition of a minority of cases (perhaps 5%) of tinea capitis caused by Microsporum species. Green fluorescence does not occur when infections are caused by T tonsurans.
* Tinea versicolor (caused by yeasts of the genus Malassezia [formerly Pityrosporum]): Affected areas may fluoresce a yellow-gold color.
* Diseases characterized by hypopigmentation or depigmentation: In lightly pigmented individuals, examining the skin with Wood light may assist in identifying lesions of vitiligo or ash-leaf macules of tuberous sclerosis.CHAPTER 3
I. Selection and Use of Topical Corticosteroids
* Topical corticosteroids exert their effect through many mechanisms, including anti-inflammatory, immunosuppressive, antiproliferative, and vasoconstrictive effects.
* Preparations may be grouped according to relative potency (Table 3.1). Differences in potency between groups are not linear. For example, hydrocortisone (group 7) has a relative potency of less than 1; triamcinolone (eg, Kenalog, group 4), 75; and clobetasol propionate (eg, Temovate, group 1), 1,869.
Selecting and Prescribing a Topical Corticosteroid
Consider the following factors when selecting a topical corticosteroid (see also Table 3.2):
* How old is the patient?
In general, a less potent preparation is required in infants than in older children or adolescents. For example, for the management of flares of atopic dermatitis, a low-potency preparation (eg, hydrocortisone ointment 1% or 2.5%) usually is sufficient in an infant, while in an adolescent, a midpotency (eg, triamcinolone 0.1%) or high-potency (eg, mometasone 0.1%) product is needed.
* What area will be treated?
* Absorption of steroids varies with the thickness of the skin in various regions of the body.
* Absorption is greatest in areas where the skin is thin (eg, face, perineum) and lowest where the skin is thick (eg, palms, soles). Thus, only a low-potency preparation should be used on the face, while a midpotency (or high-potency) product will be needed to manage dermatitis on the feet.
* What vehicle should be selected?
* Creams: tolerated by most patients but can be drying and, occasionally, their ingredients may cause contact or irritant dermatitis (C6U
* Lotions: cosmetically pleasing because they do not leave a greasy feel; tend to sting on open or damaged skin Gels: usually for hair-bearing areas; may cause stinging or burning
* How much should you dispense?
For treatment of a self-limited condition involving a small area, prescribing a small tube (eg, 15 g) will be sufficient; however, if the process is more extensive or chronic, larger amounts will be needed. Some rules that will help
* One gram of product will cover a 10-cm by 10-cm area (perhaps 30% more coverage if an ointment is used rather than a cream). Note that 0.5 g is the amount of cream dispensed from a standard tube that extends from the tip of the adult finger to the flexural crease overlying the distal volar interphalangeal joint.
* In an older child (6-10 years of age), it takes
- 1 g to cover the face and neck
- 1.25 g to cover the hand and arm
- 1.75 g to cover the chest and abdomen
- 2.25 g to cover the foot and leg
* Thus, when managing a chronic condition like atopic dermatitis that involves a significant portion of the body, prescribing amounts of 0.5 or 1 lb (227 or 454 g), rather than small tubes, may be necessary.
As with other medications, the cost of topical corticosteroids varies widely and often is influenced by the patient's insurance formulary. Although proprietary corticosteroids typically are more expensive than generics, generics are not always inexpensive. Consider the cost of these generic moderate- potency steroids: 60 g of hydrocortisone valerate costs as much as $150.12; 80 g of triamcinolone acetonide costs $4. There are insufficient data, however, to enable direct comparison of efficacy and bioavailability of branded versus generic preparations.
When used appropriately topical corticosteroids are very safe; however, using too potent a preparation, particularly in an inappropriate location or for too long, may result in adverse effects.
* Local adverse effects: atrophy, striae, pigmentary changes, easy bruising, hypertrichosis, and acne-like eruptions. To prevent these effects, use only low-potency preparations on the face, axillae, and groin (including the diaper area); limit the duration of use of all corticosteroids; and use high-potency preparations very discriminately.
* Systemic adverse effects: hypothalamic-pituitary-adrenal axis suppression, Cushing syndrome, growth retardation, glaucoma, and cataracts. Systemic adverse effects are most likely to occur when very potent agents are used (even for short periods) or when moderately potent preparations are used over large areas of the body for long periods, especially in young infants, where the ratio of skin to body surface area is larger.
Frequency of Application
* Typically twice daily as needed
II. Selection and Use of Moisturizers
* Moisturizers (also known as emollients or lubricants) are designed to hydrate the skin by creating a barrier and preventing evaporation.
* In patients who have atopic dermatitis, moisturizers can reduce the need for corticosteroids.
Selecting a Moisturizer
Traditional moisturizers are available as ointments, creams, or lotions. Barrier repair agents also are available.
* Water-in-oil emulsions are most occlusive and are the best moisturizers.
* Have a greasy feel that some patients find unpleasant.
* Because they generally are preservative-free, they are less likely to cause contact or irritant dermatitis.
* Some examples include Aquaphor ointment and petrolatum (eg, Vaseline petroleum jelly).
* Oil-in-water emulsions that often are more cosmetically pleasing than ointments.
* Some examples include Aveeno cream, CeraVe cream, Cetaphil cream, Eucerin cream, and Vanicream.
* Oil-in-water emulsions containing more water than creams.
* Cosmetically pleasing but least effective as moisturizers.
* Some examples include CeraVe lotion, Cetaphil lotion, Curel lotion, DML lotion, Eucerin lotion, Keri lotion, Lubriderm lotion, and Moisturel lotion.
* Barrier repair agents
* A variety of over-the-counter (eg, CeraVe, Cetaphil RestoraDerm) and prescription (eg, Atopiclair, EpiCeram, Hylatopic, and others) barrier repair agents exist that may help reduce the severity of atopic dermatitis and play an adjunctive therapeutic role. These agents include products with ceramides, filaggrin degradation products, natural moisturizing factor, avenanthramides, glycyrrhetinic acid, shea nut derivatives, and palmitamide monoethanolamine.
* While the exact role of these agents is not yet clarified, they may play a role in active disease (usually in conjunction with anti-inflammatory agents like corticosteroids and calcineurin inhibitors) and as maintenance agents.
* Prescription barrier repair agents typically are expensive.
Excerpted from Pediatric Dermatology by Anthony J. Mancini, Daniel P. Krowchuk. Copyright © 2016 American Academy of Pediatrics. Excerpted by permission of American Academy of Pediatrics.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Table of Contents
ForewordEditor’s NoteFigure Credits Chapter 1 – Approach to the Patient With a Rash Chapter 2 – Diagnostic Techniques Chapter 3 – TherapeuticsDermatitis Chapter 4 – Atopic Dermatitis Chapter 5 – Contact Dermatitis (Irritant and Allergic) Chapter 6 – Juvenile Plantar DermatosisAcne Chapter 7 – Acne Vulgaris Chapter 8 – Neonatal and Infantile Acne Chapter 9 – Periorificial DermatitisSkin InfectionsLocalized Viral Infections Chapter 10 – Herpes Simplex Chapter 11 – Herpes Zoster Chapter 12 – Molluscum Contagiosum Chapter 13 – WartsSystemic Viral Infections Chapter 14 – Erythema Infectiosum/Human Parvovirus B19 Infections (Fifth Disease) Chapter 15 – Gianotti-Crosti Syndrome Chapter 16 – Hand-Foot-and-Mouth-Disease (HFMD) and Other Enteroviral Exanthems Chapter 17 – Measles Chapter 18 – Papular-Purpuric Gloves-and-Socks-Syndrome (PPGSS) Chapter 19 – Roseola Infantum (Exanthem Subitum) Chapter 20 – Rubella Chapter 21 – Unilateral Laterothoracic Exanthem (ULE) Chapter 22 – VaricellaLocalized Bacterial Infections Chapter 23 – Acute Paronychia Chapter 24 – Blistering Dactylitis Chapter 25 – Ecthyma Chapter 26 – Folliculitis/Furunculosis/Carbunculosis Chapter 27 – Impetigo Chapter 28 – Perianal Bacterial DermatitisSystemic Bacterial, Rickettsial, or Spirochetal Infections With Skin Manifestations Chapter 29 – Lyme Disease Chapter 30 – Meningococcemia Chapter 31 – Rocky Mountain Spotted Fever (RMSF) Chapter 32 – Scarlet Fever Chapter 33 – Staphylococcal Scalded Skin Syndrome (SSSS) Chapter 34 – Toxic Shock Syndrome (TSS)Fungal and Yeast Infections Chapter 35 – Candida Chapter 35A – Angular Cheilitis/Perléche Chapter 35B – Candidal Diaper Dermatitis Chapter 35C – Chronic Paronychia Chapter 35D – Neonatal/Congenital Candidiasis Chapter 35E – Thrush Chapter 36 – Onychomycosis Chapter 37 – Tinea Capitis Chapter 38 – Tinea Corporis Chapter 39 – Tinea Cruris Chapter 40 – Tinea Pedis Chapter 41 – Tinea VersicolorInfestations Chapter 42 – Cutaneous Larva Migrans Chapter 43 – Head Lice Chapter 44 – Insect Bites and Papular Urticaria Chapter 45 – ScabiesPapulosquamous Diseases Chapter 46 – Lichen Nitidus Chapter 47 – Lichen Planus (LP) Chapter 48 – Lichen Striatus Chapter 49 – Pityriasis Lichenoides Chapter 50 – Pityriasis Rosea Chapter 51 – Psoriasis Chapter 52 – Seborrheic DermatitisVascular Lesions Chapter 53 – Cutis Marmorata Chapter 54 – Cutis Marmorata Telangiectatica Congenita (CMTC) Chapter 55 – Cutis Marmorata Chapter 56 – Cutis Marmorata Telangiectatica Congenita (CMTC) Chapter 57 – Infantile Hemangioma Chapter 58 – Kasabach-Merritt Phenomenon Chapter 59 – Pyogenic Granuloma Chapter 60 – Telangiectasias Chapter 61 – Vascular MalformationsDisorders of PigmentationHypopigmentation Chapter 62 – Albinism Chapter 63 – Pigmentary Mosaicism, Hypopigmented Chapter 64 – Pityriasis AlbaHyperpigmentation Chapter 65 – Acanthosis Nigricans Chapter 66 – Acquired Melanocytic Nevi Chapter 67 – Café au Lait Macules Chapter 68 – Congenital Melanocytic Nevi (CMN) Chapter 69 – Ephelides Chapter 70 – Lentigines Chapter 71 – Mongolian Spots Chapter 72 – Pigmentary Mosaicism, HyperpigmentedLumps and Bumps Chapter 73 – Cutaneous Mastocytosis Chapter 74 – Dermoid Cysts Chapter 75 – Epidermal Nevi Chapter 76 – Granuloma Annulare Chapter 77 – Juvenile XanthogranulomaBulllous Diseases Chapter 78 – Childhood Dermatitis Herpetiformis Chapter 79 – Epidermolysis Bullosa (EB) Chapter 80 – Linear IgA DermatosisGenodermatoses Chapter 81 – Ichthyosis Chapter 82 – Incontinentia Pigmenti Chapter 83 – Neurofibromatosis (NF) Chapter 84 – Tuberous Sclerosis Complex (TSC)Hair Disorders Chapter 85 – Alopecia Areata Chapter 86 – Loose Anagen Syndrome Chapter 87 – Telogen Effluvium Chapter 88 – Traction Alopecia Chapter 89 – TrichotillomaniaSkin Disorders in Neonates/Infants Chapter 90 – Aplasia Cutis Congenita Chapter 91 – Diaper Dermatitis Chapter 92 – Eosinophilic Pustular Folliculitis Chapter 93 – Erythema Toxicum Chapter 94 – Infantile Acropustulosis Chapter 95 – Intertrigo Chapter 96 – Miliaria Chapter 97 – Nevus Sebaceus (of Jadassohn) Chapter 98 – Transient Neonatal Pustular MelanosisAcute Drug/Toxic Reactions Chapter 99 – Drug Hypersensitivity Syndrome Chapter 100 – Erythema Multiforme (EM) Chapter 101 – Exanthematous and Urticarial Drug Reactions Chapter 102 – Fixed Drug Eruption Chapter 103 – Serum Sickness-Like Reaction Chapter 104 – Stevens-Johnson Syndrome (SJS) Chapter 105 – Toxic Epidermal Necrolysis (TEN) Chapter 106 – UrticariaCutaneous Manifestations of Rheumatologic Diseases Chapter 107 – Juvenile Dermatomyositis (JDM) Chapter 108 – Morphea Chapter 109 – Systemic Lupus Erythematosus (SLE)Nutritional Dermatoses Chapter 110 – Acrodermatitis Enteropathica (AE) Chapter 111 – KwashiorkorOther Disorders Chapter 112 – Erythema Nodosum Chapter 113 – Henoch-Schönlein Purpura Chapter 114 – Kawasaki Disease Chapter 115 – Langerhans Cell Histiocytosis Chapter 116 – Lichen Sclerosus et Atrophicus (LSA) Chapter 117 – Polymorphous Light EruptionIndex