Problem Orientated Slide Quiz: Paediatric Skin Conditions

BULLETIN FOR MEDICAL PRACTITIONERS

Dr Chua Sze Hon

Senior Consultant Dermatologist, National Skin Centre

Certain skin conditions first present or are predominantly seen in the paediatric age group. They include genodermatoses such as epidermolysis bullosa, incontinentia pigmenti; inflammatory dermatoses such as atopic dermatitis, lichen striatus; infections such as bullous impetigo, molluscum contagiosum; specific viral exanthems such as Gianotti-Crosti syndrome, erythema infectiosum; tumours such as capillary haemangioma, juvenile xanthogranuloma; and naevoid malformations such as epidermal naevus, naevus sebaceum.

Knowledge of such conditions will greatly assist the dermatologist in formulating the appropriate differential diagnoses when reviewing a child with a skin problem. Understanding the natural history of the condition is also necessary in planning the management - a conservative approach being appropriate for most benign conditions with a self-resolving natural history. Should active treatment be necessary, emphasis should be on safety and comfort to the child. Adjunctive techniques of relieving anxiety, fear and pain are essential in managing patients in this age group.

In this segment of problem orientated slide quiz, the focus is on skin conditions that are usually seen in infants and children. A short case report is given. The diagnosis and a short comment on the case can be found on the following page.

	Case report 1 The patient, a 16-month-old boy, developed erythematous papules and nodules over his arms and legs with relative sparing of his trunk, of 3 weeks duration. He was initially diagnosed to have papular urticaria secondary to arthropod bites by the referring doctor and was treated with calamine lotion with no improvement. The lesions were minimally pruritic. Small non-tender cervical and inguinal lymph nodes were present. He had a mild viral illness several weeks prior to the skin eruption but had since recovered fully. The rest of his family remained well. No recent ingestion of drugs was recorded.
	Case report 2 The patient, an 11-year-old Chinese boy, with a longstanding history of atopic dermatitis, presented with a 4-day history of painful papulo-vesicles and erosions on his face. Prior to this episode, his atopic dermatitis was fairlywell controlled with topicals only (emollients and mild topical steroids). He had an associated fever of 38 degrees Centigrade. He was treated initially by the referring doctor with oral cloxacillin and combination fusidic acidbetamethasone valerate cream without any significant improvement. Diagnostic investigations were performed.
	Case report 3 The patient, a 3-year-old child, presented with a rapidly growing lesion over the vertex scalp of 3 weeks duration. The lesion was cherry-pink in colour and would bleed quite profusely after minor trauma. He was otherwise well with no systemic complaints. His parents could not recall any prior injury to the affected site.
	Case report 4 The patient, a 11-month-old infant, presented with generalised eruption of pinkish-brownish oedematous nodules and plaques on his trunk of 2 months duration. He was initially diagnosed to have scabies by his referring doctor and empirically treated with topical malathion without improvement. The lesions were persistent and would swell up after being rubbed or scratched. His general health remained well. No hepatosplenomegaly was present. His family members were unaffected.
	Case report 5 The patient, a 7-year-old Indian boy, presented with several hypopigmented patches with indistinct borders on his cheeks of 3 months duration. The patches were slightly scaly and minimally pruritic. The lesions appeared more prominent after sun-exposure during his regular swimming lessons. He was initially diagnosed by his referring doctor as having tinea versicolor and was treated with topical miconazole without improvement. He had a past history of mild asthma that required periodic treatment with steroid/salbutamol inhaler. The fungal skin scraping done was negative.
	Case report 6 The patient, a 14-month-old child, presented with a solitary hairless plaque on the occiput scalp measuring 7mm by 8mm. The lesion was present since birth and had a yellowish cobbled-stone appearance. He was delivered normally via the vaginal route without any history of early birth trauma or instrumentation. Perinatal history was unremarkable. His developmental milestones were normal.

Diagnosis: Gianotti-Crosti syndrome

This cutaneous eruption is seen in young children between the ages of 8 months to 4 years. It presents as a distinctive exanthem comprising of non or minimally pruritic oedematous pinkish-red papules and nodules that are distributed mainly over the acral regions of the body. There may be associated lymphadenopathy and hepatospenomegaly. Several aetiologies have been reported; they include the Ebstein Barr virus (EBV), Coxsackie, Echo, Hepatitis B, and Cytomegalovirus (CMV). The skin lesions will resolve spontaneously over several months leaving no scars, hence no or only mild symptomatic treatment is needed during the active phase.

Case 2

Diagnosis: Eczema herpeticum

Laboratory tests included a positive Tzanck test, which showed the presence of multinucleated giant cells and a positive HSV culture for HSV type 1. Eczema herpeticum (EH) is a form of disseminated cutaneous herpes simplex virus (HSV) infection presenting as widespread painful erosions on the skin. Intact vesicles are not usually seen. It usually occurs in patients with atopic dermatitis (AD) or other pre-existing dermatosis as the abnormal skin barrier function in such patients decreases the ability to localize the HSV infection. Systemic symptoms such as fever and malaise may be associated. A positive Tzanck test offers rapid provisional proof of diagnosis and positive viral culture is diagnostic. A high index of clinical suspicion is necessary to diagnose this complication early as systemic treatment with antivirals e.g. acyclovir must be started without delay before confirmatory laboratory investigations are validated. Superimposed secondary bacterial infection of the erosions (usually by Staphylococcal aureus) will require additional systemic antibiotic therapy.

Case 3

Diagnosis: Pyogenic granuloma

Pyogenic granuloma, also known as lobular capillary haemangioma, is a common, benign, acquired, vascular neoplasm of the skin and mucous membranes characterized by a ruby red, dome-shaped or pedunculated papule that bleeds easily. Common sites of occurrence are the scalp, lips, fingers and toes. The lesion often bleeds profusely after being traumatized, hence active treatment is warranted. Excellent results are obtained by shave excision followed by light electrocautery of the base under local anaesthesia (LA). The use of EMLA under occlusion before infiltration of LA is highly recommended as this helps greatly to minimize pain and trauma to the child.

Case 4

Diagnosis: Urticaria pigmentosa

Mastocytosis consists of a group of disorders characterized by a pathologic increase in mast cells in tissues including skin, bone marrow, liver, spleen, and lymph nodes. Urticaria pigmentosa is the commonest mastocytosis in the paediatric age group usually affecting children below the age of 3. UP is generally cutaneouslimited in children with no systemic complications. The urticarial reaction that occurs soon after rubbing the lesion is known as a positive Darier’s sign and is a useful clinical sign to elicit if the diagnosis of UP is suspected. Histological diagnosis is essential and an initial screen to exclude systemic forms of mastocytosis is warranted. Management involves avoidance of mast cell degranulators such as opiates, polymyxin and non-steroidal anti-inflammatory drugs and symptomatic relief with systemic antihistamines. A self-limiting course over several years is to be expected.

Case 5

Diagnosis: Pityriasis alba

Pityriasis alba (PA) is a relatively common skin disorder usually seen in children with underlying atopy. The hypopigmented patches of PA are most commonly present on the face and arms and are often accentuated after a period of sun-exposure e.g. swimming. There is usually minimal associated symptom and itch is usually minimal or absent. Most parents are concerned that the lesions are those of vitiligo. Larger lesions affecting the trunk require the dermatologist to exclude the differential diagnosis of hypopigmented mycosis fungoides. Histological findings are non-specific and include spongiosis, follicular plugging, focal parakeratosis and acanthosis and a superficial perivascular lymphocytic infiltrate. Therapy is asymptomatic with emphasis on sunprotection to minimize accentuation of the hypopigmented patches due to the tanning of surrounding normal skin. Spontaneous resolution may take several years.

Case 6

Diagnosis: Naevus sebaceous

Naevus sebaceous is a naevoid malformation presenting at birth as a solitary slightly raised plaque affecting the scalp or face. It has a characteristic yellowish hue and is devoid of hair if occurring on the scalp. Histologically, the sebaceous glands, hair follicles and the epidermis are involved in the malformation. At puberty, owing to the stimulation by the sex hormones, the sebaceous glands mature and the associated papillomatous epidermal hyperplasia causes the lesion to take on a more verrucous appearance. Excision of the lesion is recommended before adolescence as there is an increased risk of a basal cell carcinoma developing in an unremoved lesion (the life-time transformation risk being about 5-15%). Other benign adnexal tumours such as syringocystadenoma papilliferum may also develop in a naevus sebaceous.
 

DEDICATED TO EXCELLENCE IN DERMATOLOGY
By National Skin Centre (Singapore)
Copyright (C) 1995 - National Skin Centre (Singapore) 


 

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