COMMON SKIN

CONDITIONS
IN CHILDREN
By
Dr.Ahmed Noureldin Ahmed
MBBS,DCH,DTM&H (Cairo)
Introduction
• The conditions to be described are everyday
occurrences in paediatric primary care. Yet, as
applies to so many commonly seen conditions,
there are many controversies and unanswered
questions regarding aetiology and treatment.
Question 1
• This infant is 24
hours old. There are
red patches on the
trunk. What is the
rash likely to be?
Answer 1
• Erythema toxicum neonatorum (neonatal
urticaria)
– Despite its impressive title this is a harmless
skin condition seen in most neonates at and soon
after birth. The commonest lesion is an
erythematous macule with a central tiny papule,
occurring anywhere on the body except the
palms and soles.

Continued...
Answer 1 (Contd…)
Sometimes there may small pustules at the
centre of lesions and the danger then is that
they are regarded as signs of sepsis, which is
not the case. The lesions are packed with
eosinophils, and there may be accompanying
eosinophilia in the blood count. The cause is
unknown, and no treatment is required as the
rash disappears after 1-2 weeks.
Question 2
• What lesions do you
see on this infant's
face?
Answer 2
• Milia are tiny cysts of the sebaceous glands.
They are seen in about half of all neonates in the
early weeks of life, as firm pearly white papules
about 1-2 mm in size, in areas like the nose and
forehead where sebaceous glands are abundant.
They disappear at about 4 weeks. No treatment
is required apart from avoiding greasy
preparations.

Continued...
Answer 2 (Contd…)
• Lesions just like adolescent acne may also be
seen in the first month or two of life. Papules
and pustules are seen mainly on the cheeks,
presumably due to stimulation of the sebaceous
glands by maternal androgen. Again, treatment
is unnecessary as the condition is almost always
self-limiting.
Question 3
• What is miliaria?
Answer 3
• Sweat rash, or
miliaria, results from
obstruction to the
sweat gland openings
with retention of
sweat. It is seen in
two forms:

Continued...
Answer 3 (Contd…)
• In Miliaria crystallina there are numerous tiny
clear vesicles, usually on the forehead. It is
probably caused, or aggravated by plugging of
the pores with vaseline or other greasy
ointments.

Continued...
Answer 3 (Contd…)
• In Miliary rubra there is obstruction of the
sweat ducts at a deeper level in the skin. Many
red macules with central papules, vesicles or
pustules are present. These may be on the
trunk, nappy area, head or neck. The rash is
caused by heat and overdressing. Plastic pants,
the overuse of vaseline and the under-use of
bathing probably play a part.
Question 4

• Describe the
problem here.
Answer 4
• Sepsis. The umbilical stump is an excellent
culture medium. Any infant with a smelly stump,
purulent discharge, redness, or swelling around
the cord should be evaluated for sepsis, and an
antibiotic is indicated. The local infection can
spread rapidly to any organ, including the brain,
and there is the danger of portal vein
thrombosis. Remember the possibility of
neonatal tetanus also.
Question 5
• What is the cause of
the lesion in the
umbilical stump?
Answer 5
• Granuloma. When the cord drops off, a small
pink or red polyp-like lesion may form in the
base of the cord. The cause is unknown - it may
result from a foreign body reaction to talcum
powder. It is easily dealt with by cauterising it
with silver nitrate.
Question 6
• What is the cause of a watery discharge from
the umbilicus?
Answer 6
• Persistent discharge, if watery, may signify a
patent urachus (connection with the bladder),
and referral is essential.
• Types of umbilicus. There are 3 types,
depending on how the skin of the abdominal wall
meets the umbilicus:
– (1) flat - the skin meets the cord at the level of
the wall

Continued...
Answer 6 (Contd…)
– (2) indented - the abdominal skin does not
reach the base of the cord, and the gap is filled
in by amniotic sac. This results in an
indentation
– (3) the abdominal skin extends up the cord,
resulting in a protruding umbilicus. This last
type does not result in a hernia as there is no
defect in the abdominal wall
Question 7
• What causes an umbilical hernia?
Answer 7
• An umbilical hernia results from incomplete closure
of the umbilical ring, and often a defect in the
abdominal musculature. Most close spontaneously
by the age of 12 months, and even moderate and
big ones will eventually disappear by puberty. No
treatment is required as strangulation is extremely
rare. The exception is in adult female, where
there is a risk of incarceration or strangulation
during pregnancy. A persisting hernia should
therefore be repaired in girls during puberty.
Question 8
• This infant is
thriving, but has a
widespread, non-itchy
rash. What is it?
Answer 8
• Seborrhoeic dermatitis - This is a common,
generally self-limiting condition in infants
affecting the scalp, trunk and flexures. Its
cause remains ill-understood. There is
undoubtedly a genetic basis to 'seborrhoea' and
in affected families it occurs also in older
children and adults. Seborrhoeic dermatitis is
most frequent between the ages of 1 to 6
months.

Continued...
Answer 8 (Contd…)
The rash has erythematous and a scaly
components; scaling is particularly prominent on
the scalp, producing thick greasy crusts ('cradle
cap'), the sides of the nose, glabella and ears.
Red scaly patches of quite startling appearance
may be present on the trunk. The flexures of
the neck, axillae and groins may become
reddened and weepy, and are then prone to
secondary yeast or bacterial infection. The rash
causes no discomfort or itching
Question 9
• What types of 'nappy rash' do you know?
Answer 9
• Nappy rash or napkin dermatitis, is not a single entity
and refers to a number of different conditions which
may affect the area covered by the napkin:
– non-specific (generic)
– minilial
– nodulo-ulcerative
– seborrhoetic dermatitis
– impetigo
– folliculitis
– intertrigo

Continued...
Answer 9 (Contd…)
• Some of them will be explained with an image.

Continued...
Answer 9 (Contd…)
• Non-specific - there is erythema and later
dryness and wrinkling of the exposed parts of
the nappy area - the buttocks or thighs.
Because of the depths of the folds these are
usually spared. This type of rash was long
attributed to production of ammonia by urea
splitting organisms ('ammoniacal dermatitis'),
but this theory has been disproved

Continued...
Answer 9 (Contd…)
• Candidal - This form starts off in
the deep flexures which show
diffuse inflammation. There are
also rounded red spreading lesions
with a typical scale round the
edges. It is uncommon for the
rash to spread beyond the
margins of the nappy as moisture
and warmth are required by the
yeasts for growth. However
persistent more widespread
candidal rashes are now
increasingly being seen in HIV
infected infants.

Continued...
Answer 9 (Contd…)
• Nodulo-ulcerative -
Largish nodules with
central erosions but
no pus formation.
Usually on the labia,
penis, scrotum or
anterior thighs.

Continued...
Answer 9 (Contd…)
• Infantile seborrheic dermatitis. Here
the nappy rash is part of the picture
described earlier. A beefy red sharply
marginated rash without pustules or
erosions appears rapidly. The rash
spreads by peripheral extension of
satellite lesions. The skin is unbroken.
The infant is virtually asymptomatic
and the parents are disturbed more
than the child. There is also
involvement of flexures elsewhere and
usually scalp crusting is present.

Continued...
Answer 9 (Contd…)
• Impetigo - there are many superficial bullae,
most of which rupture quickly
• Folliculitis - tiny inflamed follicles and
superficial pustules - also generally
staphylococcal
• Intertrigo - involvement predominantly of the
groin flexures. Causative organism(s) uncertain.

Continued...
Answer 9 (Contd…)
• Less commonly the nappy rash may be due to
atopic or contact dermatitis, with sensitivity to
elastic, fabric softener, or soap powder
• It may be the first manifestation of psoriasis
Question 10
• What are the causes of nappy rash?
Answer 10
NAPKIN DERMATITIS
AETIOLOGY
• Maceration
• Friction
• Irritation
• Ammonia formation (??)
• Candidiasis
• Bacterial overgrowth
• Zinc deficiency
• Cloth vs. disposable

Continued...
Answer 10 (Contd…)
• Maceration of the skin, friction, heat and
diarrhoea play a major part in the cause of
napkin dermatitis
• Candida albicans. The role of yeasts is
controversial. C.albicans can frequently be
recovered from infants with a variety of nappy
rashes and the role of candida is probably vastly
overplayed

Continued...
Answer 10 (Contd…)
• Bacterial overgrowth. The napkin area is a
marvellous culture medium and the normal
density of aerobic bacteria in cases of napkin
dermatitis increases three or four fold.
However it is well known that bacteria will
proliferate on inflamed skin and the role of
bacteria is still not well established

Continued...
Answer 10 (Contd…)
• Cloth vs. disposable napkins. Undoubtedly a
higher incidence of rashes is seen in those using
home laundered (or unlaundered!) cloth napkins.
On the other hand, the use of disposable napkins
in association with lack of personal hygiene is no
guarantee to an unblemished nappy area.
Recently biotechnology has produced disposable
napkins which are far less liable to retain
moisture

Continued...
Answer 10 (Contd…)
• Zinc deficiency. Premature infants fed
intravenously on zinc deficient formulae may
develop severe erythematous nappy rashes, with
similar lesions in skin folds elsewhere and around
the mouth. Zinc deficiency may also play a part
in the severe rashes seen in kwashiorkor.
Persistent rashes are also due to zinc deficiency
in the rare condition of acrodermatitis
enteropathica
Question 11
• What serious conditions may present with napkin
dermatitis?
Answer 11
• Children with protein-energy malnutrition often
have severe rashes.
• Persistent nappy rashes are a feature in
HIV/AIDS.
• Two rare causes are:
– Langhans cell histiocytosis
– and acrodermatitis enteropathica

Continued...
Answer 11 (Contd…)
• This child with
Langhans cell
histiocytosis
presented first with a
severe and resistant
napkin dermatitis
Question 12
• What is the Treatment?
Answer 12
• Most first episodes can be managed easily by
the following:
– Increased frequency of changing and thorough
cleansing between nappy changes. Warm tap
water and a mild neutral soap should be used
(Johnson's Baby Soap). The skin should then
be dried and simple protective cream used -
Desitin, zinc oxide ointment, Lassar's Paste or
Nivea

Continued...
Answer 12 (Contd…)
– Impetigo and folliculitis should be treated with
an appropriate antibiotic.
– Seborrheic dermatitis. This responds promptly
to 1% hydrocortisone cream together with
exposure to sunlight.
– Intertrigo responds promptly to Vioform and
hydrocortisone cream.
– Candida: Vioform and hydrocortisone cream is
also extremely effective. Give nystatin cream
t.d.s. only if typically candidal

Continued...
Answer 12 (Contd…)
• For more severe rashes the importance of good
hygiene and exposure to sunlight should be
emphasised. One cream is effective for all
cases - Vioform and hydrocortisone. The former
has mild antibacterial, and anti-fungal, and the
latter anti-inflammatory properties
• Kwashiorkor and vitamin and trace mineral
deficiencies may well be present in some cases.
Neglect frequently manifests with the presence
of severe nappy rash
Question 13
• Describe these
lesions.
Answer 13
• Staphylococcal and streptococcal impetigo -
impetigo is a superficial infection of the skin
manifested by blisters or pustular lesions which
rapidly become crusted. It is caused by
coagulase positive Staph. aureus, or by certain
strains of Group A beta-haemolytic strep. Both
organisms are found together in 50% of cases.
Staphylococcal infection is more likely if the
intact skin is affected (especially the face), and
if bullae are present.
Question 14
• What are these
lesions on the legs?
Answer 14
• Streptococcal impetigo. Strep. impetigo tends
to complicate eruptions such as scabies and
insect bites (papular urticaria), to involve the
lower limbs more often, and to produce deeper
lesions (ecthyma). If draining glands are
enlarged Strep. is more likely
• TREATMENT
– All cases of impetigo should be treated with a
systemic antibiotic.

Continued...
Answer 14 (Contd…)
Community studies in Cape Town have
demonstrated the universal resistance of
Staph. pyogenes to penicillin. The treatment
of choice in community settings should
therefore be erythromycin 25mg/kilo/day 3
times a day for 5 days, or cotrimoxazole, 2.5-
10ml twice daily for 5 days. Local treatment
is of lesser importance. Use vioform emulsion
or povidine-iodine cream, but NEVER
antihistamine or antibiotic creams.

Continued...
Answer 14 (Contd…)
• Other manifestations of these common skin
pathogens are seen in the following slides:

Continued...
Answer 14 (Contd…)
• Recurrent folliculitis
and boils

Continued...
Answer 14 (Contd…)
• Streptococcal perianal
cellulitis. This results in
an angry red eruption
around the anus.
– NB Scalded skin
syndrome is caused by
certain strains of
staphylococci. The
surface layer of the
skin rapidly separates
over large areas.
Question 15
• What conditions could you confuse with
impetigo?
Answer 15
IMPETIGO
DIFFERENTIAL DIAGNOSIS
• Impetigenisation
– Scabies
– Pediculosis
– Eczema, etc
• Herpes simplex
• Varicella/zoster

Continued...
Answer 15 (Contd…)
• Hand foot and mouth disease
• Fungal infection
• Contact dermatitis

Continued...
Answer 15 (Contd…)
• Varicella. Blisters are uniform in size, come
out in crops, and are widespread. The may
become secondarily infected, i.e. there is
superimposed impetigo.

Continued...
Answer 15 (Contd…)
• Herpes simplex - The
lips and oral mucosa
are commonly
primarily affected.
Again, there may be
secondary infection
of these viral lesions.

Continued...
Answer 15 (Contd…)
• Herpes zoster. The blisters are in a
characteristic pattern over the distribution of a
nerve or ‘dermatome’.
• Hand foot and mouth syndrome. This viral
infection (usually Coxsackie A) causes a crop of
blisters symmetrically situated over the hands,
feet, knees or elbows, with a few in the oral
cavity.

Continued...
Answer 15 (Contd…)
• Tinea corporis. This fungal lesion is usually a
single plaque with a well demarcated slightly
raised edge. Management will be discussed in
the next programme.
Question 15
• This 6 month old baby
has an itchy rash over
the trunk for 3
weeks. What is the
likely cause?
Answer 15
• SCABIES is a highly itchy eruption caused by
sensitisation to sarcoptes scabeii mites, their
eggs and excreta. The mites burrow in the
epidermis, and have a prediliction for the chest
and abdomen, genitalia and extremities,
particularly the wrists and hands. The mature
female mite is shown in the next slide:
Answer 15 (Contd…)
• In hot climates the mites
remain in the superficial
layers, producing only small
papules, and linear burrows
are not present. Herd or
individual immunity is never
produced.
• Personal skin contact is the
predominant factor in
infectivity, and the
importance of clothing and
bed-linen has been
exaggerated.
Question 16
• What is the treatment?
Answer 16
• Benzyl benzoate is the most commonly used form
of treatment in SA. It is not dangerous when
taken systemically. However the ointment
causes burning in full strength (25%) and must
be diluted to 12.5% in children. There are
concerns about its safety in infancy, and it
should only be used at quarter strength in
infants under 6 months.

Continued...
Answer 16 (Contd…)
• Lotions and creams containing 1% gamma-benzene
hexachloride (GBHC) have been use for many years,
but concerns have recently been expressed about CNS
toxicity, both as a result of oral intake, and from
absorption through the skin when used excessively.
The treatment however is effective and pleasant.
– DO’S with GBHC:
• apply to cool dry skin
• only leave on for 6 hours

Continued...
Answer 16 (Contd…)
– DONT’S with GBHC:
• not in children under two
• not in malnourished
• not in sick children
• not on inflamed skin.
• Alternative therapies are crotamiton (Eurax),
sulphur cream, and Tetmosol soap. None of
these is curative in severe cases.

Continued...
Answer 16 (Contd…)
• An extremely effective, safe , and cosmetically
acceptable treatment for both scabies and head
lice is the synthetic pyrethrin Permethrin. This
is not yet available in South Africa.
Question 17
• What do you see in
this child's hair?
Answer 17
• The characteristic eggs of headlice (nits) can be
seen as little white specks, glued to the scalp
hairs. Pediculosis capitis is a common infestation
of the scalp in children. The adult louse feeds on
blood by biting into the scalp. Itchy papules result
and these often become infected from scratching,
resulting in impetigo of the scalp. Posterior
cervical and occipital nodes are frequently
enlarged. The eyelids can also be involved. In
adolescents, pubic and axillary hair may be
infested.

Continued...
Answer 17 (Contd…)
• These are adult
headlice (pediculus
humanis) attached to
the teeth of a comb.
Question 18
• What is the appropriate treatment?
Answer 18
• Malathion 0.4% in alcohol is a cheap, safe and
effective treatment. This kills lice as well as nits, so
that the hair need not be removed.
• Permethrin 1% lotion, is a pleasant and effective
preparation which also kills the eggs.
• Benzyl benzoate, still widely used, is messy and less
effective
• Gamma benzene hexachloride 1% - effective but
poisonous when swallowed!
• NB!!! Treat the whole family is the condition is highly
contagious.
Question 19
• Describe what you
see, and what is the
likely cause?
Answer 19
• There are many itchy papules on the back, some
of which have become infected from scatching.
The condition, papular urticaria, is common in
the hot months. Repeated bites from fleas, or
sometimes bed bugs, result in hypersensitivity
and marked itching at the site of both fresh and
old bites. Haemolytic streptococci are a
frequent secondary invaders.
Question 20
• What treatment would you prescribe?
Answer 20
• A blitz on fleas within the house is essential -
spray the bed mattress and the cracks in the
floor with a good insecticide. However, outdoor
sandfleas are often responsible.
• Crotamiton cream (Eurax) is helpful - it is both
anti-pruritic and antiseptic (as well as having an
anti-scabies action). Apply it three times a day.
.