Child Dermatology

The ability to recognise common skin conditions is an extremely valuable skill in all areas of medicine. In child dermatology in particular, it is important to have the ability to identify skin lesions, as such knowledge will enable the identification of potentially important systemic diseases, such as meningococcaemia or chickenpox.

The skin serves as a critical barrier to infection and dehydration, and as such it is important to keep in mind that disease or impairment of the skin’s normal function can lead to significant morbidity and mortality, especially in infants who are more vulnerable to heat loss, dehydration and infection. Furthermore, skin diseases are so common that approximately 1/3 of visits to doctors being for dermatologic concerns.

Certain diseases that affect the skin, hair, or nails are more common in children, and some of these occur only in children.

Skin Diseases in Children that are common and can be possibly treated by a paediatrician-dermatologist include:

• Atopic dermatitis (also called atopic eczema)
• Congenital birth marks, including pigment spots
• Psoriasis
• Congenital skin disease
• Skin infection
• Vitiligo
• Warts

Paediatric Dermatology and Sun Protection in Children

Everybody needs some sun exposure, which is the primary source of vitamin D, and helps our body absorb calcium for strong, healthy bones. However, itdoes not take much time in the sun to get the vitamin D we need, and repeated unprotected exposure to the sun’s ultraviolet (UV) rays can cause skin damage, eye damage, immune system suppression, and skin cancer. Even people in their twenties can develop skin cancer.

Most children rack up most of their lifetime sun exposure before age 18, so it is important that parents teach their children how to enjoy fun in the sun safely. With the right precautions, the chances of developing skin cancer can be greatly reduced.

Infants up to 6 months have no melanin at all, which makes them particularly sensitive to the sun and skin diseases. Up to the age of 2 years, the produced melanin is distributed in the skin, i.e. some protection is achieved, but not at a satisfactory level.

This is why avoiding the sun and takin sun protection measures, such as the use of sunscreen and the right clothes and hat are essential to avoid dermatological disorders in children. Unprotected sun exposure is even more dangerous for children with:

• Moles on the skin or with a tendency to develop moles (due to hereditary reasons)
• Very fain skin and hair colour
• Family history of skin cancer, including melanoma

You should be particularly careful when it comes to sun protection if your child has one or more of the above high-risk factors.

Paediatric Dermatology and Birthmarks

Newborns often have temporary spots or blemishes, which disappear soon as they get used to life outside the womb. In addition, the presence of spots on the skin during birth or shortly after is quite common, too. These spots may be from almost invisible to disfiguring.

Common birthmarks

Mongolian spots or grey nevus of childhood or dermal melanosis

• Bluish grey patches over the buttocks or back or legs
• May look like bruises
• Common in dark skinned infants
• They appear due to atypical presence of melanocytes within the dermis
• Tend to fade over 1^st year of life, but can also occur early in adulthood
• Requires no treatment, just monitoring

Haemangioma of infancy or capillary haemangioma

• Raised pink or red or purple lesion, soft and compressible
• Most common lesion of infancy; up to 10% in Caucasians
• Develop during the first weeks of life
• Represents clonal expansion of endothelial cells
• Usually grow rapidly from 6 months – 1 year of age
• Tend to fade or shrink over time, 50% by 5 years, 90% by 9 years, often disappearing completely
• Treatment with steroids or interferon or laser is indicated only if there are multiple, very large or if they interfere with everyday functioning and affect the psychological condition.

Port Wine Stain

• Flat pink or red or purple patches, typically on face, neck, limbs
• Present at birth
• It can be any size, it grows proportionately with the child
• It may thicken or develop bumps
• It creates social and emotional complications
• It may be associated with glaucoma & seizures
• It does not resolve
• Laser treatment may be an option

Naevusflammeus nuchae

• Small vascular malformations – Macular stains
• Flat, pink capillary haemangioma, often seen on eyelids, forehead & nape of neck
• Occurs in up to 1/3 of all newborns
• Clinical variant of Port Wine Stain
• Facial lesions usually fade over years, neck lesions may persist into adulthood
• Harmless, no treatment required

Skin Diseases in Children – Warts

Causes and Types of Warts in Children

Warts are caused by the human papilloma virus or HPV are benign skin tumours.

They appear when the virus invades the skin, usually through a tiny wound or scratch. The virus causes rapid growth of cells on the outer layer of skin.

Warts are usually skin-coloured but can be dark. They can be rough or smooth.

The different types of warts are presented below:

• Common warts found are most often on the fingers and the backs of hands.
• Palmar warts are on the palms, as the name suggests.
• Plantar warts grow on the feet, usually the soles.
• Flat warts are typically smaller and smoother than other warts; they can grow in large numbers, even as much as 20 to 100 at a time. Flat warts on children are typically found on the face.
• Filiform warts are more likely to appear on the face.

Reducing the risk of warts spreading in children

Once the virus infects the skin, it typically takes several months for the wart to become visible.

Some children are more susceptible to warts than others. Children with a compromised immune system are more likely to get warts. Children who bite their nails creating tiny cuts in the skin are also more likely to get warts.

But even children with healthy immune systems may be more susceptible to getting warts, just as some people are more likely than others to catchcoldsoften.

Children pick up the virus in many ways. However, there are ways to reduce the odds of your child developing warts.

Below you may find some tips to avoid this skin condition in children:

• Encourage your child to wear flip-flops around a public swimming pool and in public showers.
• At home, if someone else has a problem with plantar warts, spray a dilute bleach solution in the shower stall or bathtub after each use and then rinse.
• Each child with warts should have his/her own towel, and children should be advised not to share towels.

Treatment of warts in children is mainly performed with  laser and cryotherapy. Often remissions are evident, and the treatment of warts in children may be long-term to achieve permanent elimination.

Paediatric Dermatology and Alopecia in Children

Hair Loss, or alopecia, is not just a problem for adults. Whether your child has thinning hair or distinct bald spots, the loss of hair can be significant. The good news is that, with a proper diagnosis, most cases of hair loss can be treated successfully.

Medical Causes of Hair Loss in Children

In children with hair loss, one of the following conditions is the cause. The paediatric dermatologist should be able to diagnose these conditions and prescribe the appropriate treatment.

Tinea capitis, commonly known as ringworm of the scalp, is a fungal infection often seen in children. It can show up in a number of ways, but often as scaly patches of hair loss on the head. The patches are usually round or oval. The hairs may be broken off at the surface of the skin and look like black dots on the scalp.

If the doctor suspects tinea capitis, a microscopic examination can confirm the diagnosis. Treatment usually involves an oral antifungal agent. In addition, an antifungal shampoo should be used, such as selenium sulphide or ketoconazoleto decrease shedding of the fungus.

As this condition is contagious, the child should be careful not to share any objects that touch the head such as hats, brushes etc.

Alopecia areata. Alopecia areata is a non-contagious condition thought to be caused by a local autoimmune disorder. It appears when the immune system attacks the hair follicles.

It appears suddenly with round or oval patches. The patches are slick or smooth, without scaling or broken hairs. About one fourth of children also have pitting and ridging of the nails.

While there is no perfectly effective treatment for alopecia areata, topical treatment can keep the disease under control and lead to regrowth, without preventing recurrences or extension in other areas.

Many have their hair back within a year, although regrowth is unpredictable and many will lose hair again.

For about 5% of children, the disease progresses to alopecia totalis — loss of all of the hair on the scalp. Some of these will develop alopecia universalis — a total loss of body hair.

For younger children, treatment that is mainly recommended consists of strong corticosteroid ointments or creams applied to the bald areas. Teenagers, due to the psychological effects, may tolerate steroid injections into the scalp to enhance hair growth.

Minoxidil is often used in additional to topical steroid treatment. Anthralin applied to the skin for a short time and then washed off may also be used.

Hair growth may come back in 8-12 weeks. Mesotherapy is another method that can enhance hair growth and it involves the infusion of a medical mixture of different medicines, vitamins and amino acids at the area hair loss.