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Alterations of the Integument in Alterations of the Integument in Children Children
Chapter 45Chapter 45
Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
22Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
Acne VulgarisAcne Vulgaris Most common skin diseaseMost common skin disease Affects 85% of people between ages 12 and Affects 85% of people between ages 12 and
2525 Acne conglobataAcne conglobata
Highly inflammatory form of severe acneHighly inflammatory form of severe acne Formation of communication cysts and abscesses Formation of communication cysts and abscesses
beneath the skinbeneath the skin Sebaceous follicles sites for acne lesionsSebaceous follicles sites for acne lesions
33Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
Acne VulgarisAcne Vulgaris Noninflammatory acneNoninflammatory acne
BlackheadsBlackheads WhiteheadsWhiteheads
Inflammatory acneInflammatory acne Caused by follicular wall rupture in closed Caused by follicular wall rupture in closed
comedones (whiteheads)comedones (whiteheads) Cystic nodules develop when inflammation is Cystic nodules develop when inflammation is
deeper, may cause scarringdeeper, may cause scarring
44Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
Acne VulgarisAcne Vulgaris Physiologic factors Physiologic factors
Follicular hyperkeratinization, excessive sebum Follicular hyperkeratinization, excessive sebum production, colonization of production, colonization of Propionibacterium Propionibacterium acnes,acnes, and inflammation secondary to the action and inflammation secondary to the action of inflammatory products produced by of inflammatory products produced by P. acnesP. acnes
Excessive production of sebum is related to Excessive production of sebum is related to androgenic hormonesandrogenic hormones
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Acne Vulgaris: TreatmentAcne Vulgaris: Treatment Diet not proven to cause acneDiet not proven to cause acne
Dietary restrictions are generally not effectiveDietary restrictions are generally not effective Topical treatment: first line of therapy; if this fails Topical treatment: first line of therapy; if this fails
use systemic therapiesuse systemic therapies Acne surgery, including comedo extraction, Acne surgery, including comedo extraction,
intralesional steroids, cryosurgery usefulintralesional steroids, cryosurgery useful Severe scarring treated with dermabrasion or Severe scarring treated with dermabrasion or
subincisionsubincision Special consideration given to treatment for Special consideration given to treatment for
those with darker-colored skin due to greater those with darker-colored skin due to greater risk for hyperpigmentation and keloidal scarring risk for hyperpigmentation and keloidal scarring
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Cystic AcneCystic Acne
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Atopic DermatitisAtopic Dermatitis Most common form of eczema in childrenMost common form of eczema in children Cause unknown, but 80% demonstrate a Cause unknown, but 80% demonstrate a
personal or family history of asthma or personal or family history of asthma or allergic rhinitisallergic rhinitis
ManifestationsManifestations Increased IgE levels, positive allergen skin tests, Increased IgE levels, positive allergen skin tests,
and eosinophiliaand eosinophilia
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Atopic DermatitisAtopic Dermatitis InfantsInfants
Rash appears on the face, scalp, trunk, and Rash appears on the face, scalp, trunk, and extensor surfaces of the arms and legsextensor surfaces of the arms and legs
Children and adultsChildren and adults Rash tends to be on the neck, antecubital and Rash tends to be on the neck, antecubital and
popliteal fossae, hands and feetpopliteal fossae, hands and feet Lichenification (thickening of the epidermis Lichenification (thickening of the epidermis
from constant scratching) from constant scratching) Common in adults with chronic eczemaCommon in adults with chronic eczema
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Atopic DermatitisAtopic Dermatitis
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Diaper DermatitisDiaper Dermatitis Inflammatory disorders affecting the lower Inflammatory disorders affecting the lower
abdomen, genitalia, buttocks, and upper thighabdomen, genitalia, buttocks, and upper thigh A nonallergic contact dermatitisA nonallergic contact dermatitis
Inflammation encouraged by prolonged exposure Inflammation encouraged by prolonged exposure to irritation by urine and feces, maceration by wet to irritation by urine and feces, maceration by wet diapers, airtight plastic diaper covers, and possible diapers, airtight plastic diaper covers, and possible association with intercurrent illness and early association with intercurrent illness and early introduction of cerealsintroduction of cereals
1111Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
Diaper DermatitisDiaper Dermatitis
1212Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
Infections of the SkinInfections of the Skin
Bacterial infectionsBacterial infections Impetigo contagiosumImpetigo contagiosum
• Superficial infection usually caused by Superficial infection usually caused by StaphylococcusStaphylococcus or or group A streptococcigroup A streptococci
• High incidence in hot, humid climatesHigh incidence in hot, humid climates Bullous impetigoBullous impetigo
• Rarer variant of impetigo caused by Rarer variant of impetigo caused by Staphylococcus aureusStaphylococcus aureus• Staphylococci produce a bacterial toxin called Staphylococci produce a bacterial toxin called exfoliative exfoliative
toxin (ET),toxin (ET), which causes a disruption in desmosomal which causes a disruption in desmosomal adhesion molecules with blister formation adhesion molecules with blister formation
• Occurs in newborns and is highly contagiousOccurs in newborns and is highly contagious• Source is usually a staff member in a newborn nursery or a Source is usually a staff member in a newborn nursery or a
family member with a pustule or who is an asymptomatic family member with a pustule or who is an asymptomatic carrier carrier
1313Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
Infections of the SkinInfections of the Skin Bacterial InfectionsBacterial Infections
Vesicular impetigoVesicular impetigo• Contagious, acute, superficial, vesiculopustular form of Contagious, acute, superficial, vesiculopustular form of
impetigo caused by group A impetigo caused by group A Streptococcus pyogenesStreptococcus pyogenes (alone or in combination with (alone or in combination with Staphylococcus aureusStaphylococcus aureus))
• Microorganisms disseminated by direct physical contact Microorganisms disseminated by direct physical contact from other infected individuals or through insect bites from other infected individuals or through insect bites
1414Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
ImpetigoImpetigo
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Infections of the SkinInfections of the Skin
Bacterial infectionsBacterial infections Staphylococcal scalded-skin syndrome (SSSS)Staphylococcal scalded-skin syndrome (SSSS)
• Serious infection caused by exfoliative toxin producing group II Serious infection caused by exfoliative toxin producing group II staphylococcistaphylococci
• Exfoliative toxin attacks desmoglein and adhesion molecules; Exfoliative toxin attacks desmoglein and adhesion molecules; causes separation of the skin just below the stratum granulosum causes separation of the skin just below the stratum granulosum
• ManifestationsManifestations Fever, malaise, rhinorrhea, and generalized erythema and skin Fever, malaise, rhinorrhea, and generalized erythema and skin
tendernesstenderness Seen in infants and children younger than 5 yearsSeen in infants and children younger than 5 years
1616Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
Infections of the SkinInfections of the Skin Fungal infectionsFungal infections
Fungi causing superficial skin lesions are called Fungi causing superficial skin lesions are called dermatophytesdermatophytes
Fungal disorders are called mycoses; mycoses Fungal disorders are called mycoses; mycoses caused by dermatophytes are termed caused by dermatophytes are termed tineatinea• Tinea capitis (scalp)Tinea capitis (scalp)
• Tinea pedis (athlete’s foot)Tinea pedis (athlete’s foot)
• Tinea corporis (ringworm)Tinea corporis (ringworm)
1717Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
Tinea CapitisTinea Capitis
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Infections of the SkinInfections of the Skin Fungal infectionsFungal infections
ThrushThrush• CandidaCandida present in mucous membranes of the mouths of present in mucous membranes of the mouths of
infants, and less commonly in adultsinfants, and less commonly in adults
• CharacteristicsCharacteristics White plaques or spots in the mouth that lead to shallow White plaques or spots in the mouth that lead to shallow
ulcersulcers
• Thrush can spread to the groin, buttocks, and other parts Thrush can spread to the groin, buttocks, and other parts of the bodyof the body
1919Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
Infections of the SkinInfections of the Skin Viral infectionsViral infections
Molluscum contagiosumMolluscum contagiosum• Highly contagious pox viridae infection of the skinHighly contagious pox viridae infection of the skin
• Skin-to-skin and fomite transmissionSkin-to-skin and fomite transmission
• The virus encourages epidermal cell proliferation and The virus encourages epidermal cell proliferation and blocks the immune responseblocks the immune response
2020Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
Molluscum ContagiosumMolluscum Contagiosum
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Infections of the SkinInfections of the Skin Viral infectionsViral infections
Rubella (German measles or 3-day measles)Rubella (German measles or 3-day measles)• RNA virusRNA virus• The disease is mild in most childrenThe disease is mild in most children• ManifestationsManifestations
Enlarged cervical and postauricular lymph nodes, low-Enlarged cervical and postauricular lymph nodes, low-grade fever, headache, sore throat, runny nose, coughgrade fever, headache, sore throat, runny nose, cough
Faint pink to red maculopapular rash caused by virus Faint pink to red maculopapular rash caused by virus dissemination to the skindissemination to the skin
• Vaccination for rubella combined with mumps and Vaccination for rubella combined with mumps and rubeola (measles) (MMR)rubeola (measles) (MMR)
2222Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
Infections of the SkinInfections of the Skin Viral infectionsViral infections
RubeolaRubeola• RNA paramyxovirusRNA paramyxovirus
• High fever, malaise, enlarged lymph nodes, runny nose, High fever, malaise, enlarged lymph nodes, runny nose, conjunctivitis, barking coughconjunctivitis, barking cough
• Koplik spotsKoplik spots
RoseolaRoseola• Fever and an erythematous macular rash that lasts Fever and an erythematous macular rash that lasts
about 24 hoursabout 24 hours
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Infections of the SkinInfections of the Skin Viral infectionsViral infections
Chickenpox (varicella) and herpes zoster Chickenpox (varicella) and herpes zoster (shingles) (shingles) • Both diseases are produced by the same virusBoth diseases are produced by the same virus
• DNA virusDNA virus
• Infection occurs within keratinocytesInfection occurs within keratinocytes
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Measles and ChickenpoxMeasles and Chickenpox
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Insect Bites and ParasitesInsect Bites and Parasites ScabiesScabies
Contagious disease caused by the itch mite Contagious disease caused by the itch mite Sarcoptes scabieiSarcoptes scabiei
Transmitted by personal contact and infected Transmitted by personal contact and infected clothing and beddingclothing and bedding
Female mite tunnels millimeters to 1 cm into the Female mite tunnels millimeters to 1 cm into the stratum corneum, deposits eggs, and over a 3-stratum corneum, deposits eggs, and over a 3-week period, the eggs mature into adult mitesweek period, the eggs mature into adult mites
Primary lesions are burrows, papules, and Primary lesions are burrows, papules, and vesicular lesions with severe itchingvesicular lesions with severe itching
Patient at risk for infections from scratchingPatient at risk for infections from scratching
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ScabiesScabies
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Insect Bites and ParasitesInsect Bites and Parasites PediculosisPediculosis
Pediculus capitisPediculus capitis (head), (head), Pediculus corporisPediculus corporis (body), and (body), and Phthirus pubisPhthirus pubis (crab or pubic) (crab or pubic)
Highly contagious parasite that survives by Highly contagious parasite that survives by sucking bloodsucking blood• Acquired through personal contact and shared clothing, Acquired through personal contact and shared clothing,
combs, or brushescombs, or brushes
Female louse reproduces every 2 weeks and Female louse reproduces every 2 weeks and produces hundreds of nitsproduces hundreds of nits
2828Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
Insect Bites and ParasitesInsect Bites and Parasites Flea bitesFlea bites
Cat, dog, and human fleasCat, dog, and human fleas Occur in clusters along the arms and legsOccur in clusters along the arms and legs Characteristic lesion is an urticarial wheal with a Characteristic lesion is an urticarial wheal with a
central hemorrhagic puncturecentral hemorrhagic puncture
2929Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
Insect Bites and ParasitesInsect Bites and Parasites Bedbugs Bedbugs (Cimex lectularius)(Cimex lectularius)
Live in the crevices and cracks of floors, walls, and Live in the crevices and cracks of floors, walls, and furniture and in bedding or furniture stuffingfurniture and in bedding or furniture stuffing
3 to 5 mm long and reddish brown3 to 5 mm long and reddish brown Feed in the darknessFeed in the darkness
• Attach to the skin, suck blood, and leaveAttach to the skin, suck blood, and leave
Lesions: red macules; develop into nodulesLesions: red macules; develop into nodules
3030Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
Flea and Bedbug BitesFlea and Bedbug Bites
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HemangiomasHemangiomas
Benign tumors Benign tumors From rapid growth of vascular endothelial cells and From rapid growth of vascular endothelial cells and
formation of extra blood vesselsformation of extra blood vessels Females affected more often than malesFemales affected more often than males Superficial: strawberry hemangiomasSuperficial: strawberry hemangiomas Deep: cavernous hemangiomasDeep: cavernous hemangiomas
Etiology: embolization of fetal placental Etiology: embolization of fetal placental endothelial cellsendothelial cells related to placental trauma or related to placental trauma or loss of placental angiogenic inhibitor of placental loss of placental angiogenic inhibitor of placental and maternal originand maternal origin
3232Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
HemangiomasHemangiomas Proliferation of mast cells, thought to promote Proliferation of mast cells, thought to promote
angiogenesisangiogenesis Infiltration of fat cells, fibrosis, and rich Infiltration of fat cells, fibrosis, and rich
vascular network; females affected more vascular network; females affected more often than malesoften than males
30% of hemangiomas seen at birth; most 30% of hemangiomas seen at birth; most emerge during first few weeks of lifeemerge during first few weeks of life Grow rapidly during the first few years of life, then Grow rapidly during the first few years of life, then
shrink or involuteshrink or involute
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HemangiomasHemangiomas Strawberry hemangiomasStrawberry hemangiomas
Raised vascular lesions that usually emerge 3 to 5 Raised vascular lesions that usually emerge 3 to 5 weeks after birthweeks after birth
Lesions proliferate, become bright red, and Lesions proliferate, become bright red, and elevate with small capillary projectionselevate with small capillary projections
Cavernous hemangiomasCavernous hemangiomas Present at birthPresent at birth Involve larger and more mature vessels than Involve larger and more mature vessels than
strawberry hemangiomasstrawberry hemangiomas
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Strawberry and Strawberry and Cavernous HemangiomasCavernous Hemangiomas
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Vascular MalformationsVascular Malformations Port-wine stainsPort-wine stains
Congenital malformation of dermal capillariesCongenital malformation of dermal capillaries Flat, pink, to dark reddish-purple lesionsFlat, pink, to dark reddish-purple lesions
Salmon patchesSalmon patches Macular, pink lesions resulting from distended Macular, pink lesions resulting from distended
dermal capillaries; usually fade by 1 year of agedermal capillaries; usually fade by 1 year of age Common on the nape of the neck, forehead, upper Common on the nape of the neck, forehead, upper
eyelids, or nasolabial foldseyelids, or nasolabial folds
3636Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
MiliariaMiliaria Vesicular eruption after prolonged exposure Vesicular eruption after prolonged exposure
to perspiration, with subsequent obstruction to perspiration, with subsequent obstruction of eccrine ductsof eccrine ducts Miliaria crystallinaMiliaria crystallina
• Ductal rupture within the stratum corneumDuctal rupture within the stratum corneum
• Clear vesicles without erythemaClear vesicles without erythema
Miliaria rubra (prickly heat)Miliaria rubra (prickly heat)• Erythematous papules and papulovesiclesErythematous papules and papulovesicles
3737Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
Miliaria RubraMiliaria Rubra
3838Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
Other Skin DisordersOther Skin Disorders Erythema toxicum neonatorum Erythema toxicum neonatorum
Benign, erythematous macules, papules, or Benign, erythematous macules, papules, or pustules; appear at birth or 3 to 4 days later pustules; appear at birth or 3 to 4 days later
No treatment is requiredNo treatment is required Toxic epidermal necrolysis (TEN) and Toxic epidermal necrolysis (TEN) and
Stevens-Johnson syndromeStevens-Johnson syndrome Rare, severe drug reactions with widespread Rare, severe drug reactions with widespread
epidermal apoptosis and detachmentepidermal apoptosis and detachment Mortality rates between 20% and 60% Mortality rates between 20% and 60%