Keywords

FormalPara Key points

  • Certain skin conditions are more common in children (e.g. atopic eczema, warts, molluscum contagiosum and keratosis pilaris).

  • Children’s skin barrier function and immune system is less well developed than adults and they are more prone to irritants, allergens and infections.

  • Children are more likely to present with congenital abnormalities (e.g. haemangioma and congenital naevi) and inherited diseases than adults.

  • Treating skin disease in children can be more challenging as many of the treatment we use in adults such as potent topical steroids or oral anti-fungal tablets are more likely to cause side effects in children or are not licensed to use in children.

  • Infantile seborrhoeic dermatitis behaves differently from adult seborrhoeic dermatitis and may be a completely different condition.

  • Infantile psoriasis usually presents like seborrhoeic dermatitis but the rash is more deeply red, inflamed, extensive and difficult to treat.

  • Scabies in babies can include burrows on these soles of the feet and lesions on the face. This is not seen in older children or adults.

FormalPara What to tell the patient (parents)

  • Nappy rash should be managed by removing all irritant chemicals that might aggravate the problem and replacing them with a bland soap substitute and a simple moisturiser combined with a barrier cream such as zinc and castor oil.

  • Infantile acne usually resolves spontaneously after 6–12 months but if troublesome may require treatment with topical agents such as benzoyl peroxide or a topical antibiotic.

  • Keratosis pilaris often runs in families and usually improves as the child gets older.

  • Impetigo contagious is as the word implies, very contagious. Careful hand washing and using a separate towel for the infected child is important to protect the rest of the family. The child needs to be kept out of school or crèche till the crusts dry out.

1 Introduction

Children may suffer from many of the common dermatology problems that affect adults such as eczema, psoriasis, urticaria, scabies and pityriasis rosea. However, certain skin conditions are more common in children (e.g. atopic eczema, warts , molluscum contagiosum and keratosis pilaris). There are other skin conditions that occur almost exclusively in childhood or behave differently in childhood and this chapter will deal specifically with these problems. Febrile rashes are dealt with in the chapter of childhood exanthems (see Chap. 27).

Infants and children’s skin is different from adult skin. Their skin barrier function and immune system is less well developed and they are more prone to irritants, allergens and infections. In addition, children are more likely to present with congenital abnormalities (e.g. haemangioma or congenital naevi) and inherited diseases (see Chap. 28 on genodermatoses ).

2 Neonatal Milia

Milia (milk spots) are very common and can be found in up to 50% of newborns. They are caused by blocked eccrine sweat gland and are common around the eyes, nose, cheeks, forehead and chest. Each papule is about 1 or 2 mm across and are pearly-white or yellowish. Clusters and crops are common in newborns. They are harmless, cause no symptoms and will resolve spontaneously as the child gets older. Isolated milia can occur in adults especially on the cheeks and around the eyes. If they need to be removed for cosmetic reasons it is best to puncture the surface with a small needle under sterile conditions and gently squeeze out the contents or remove the contents with a micro-curette.

3 Napkin Dermatitis

Napkin dermatitis is probably one of the most common skin complaints that doctors see in babies. This arises as a result of a number of factors such as irritation from urine and stool, sensitivity to various wet wipes, nappies, washes and creams and sometimes infections. If the rash is confined to the nappy area and does not involve the flexures (creases), then it is most likely just simple napkin dermatitis. If the rash involves the creases and there are patches of red eczematous, scaly skin on other parts of the body, then the nappy rash may be a sign of more generalised skin problem such as seborrhoeic dermatitis or psoriasis. Ironically, napkin dermatitis is unusual in children with atopic eczema. This may be because of the urea in urine, combined with the occlusive effects of the nappy, may help hydrate the skin and prevent eczema in the nappy area.

The management of nappy rash involves removing all irritant chemicals that might aggravate the problem (soaps, perfumed baby wipes, nappy changing creams with a lot of perfumes or preservatives). These should replaced with bland soap substitutes (e.g. “Elave®” wash or aqueous cream) or clean the delicate perianal skin with water and a wet flannel (bidet). Use a simple moisturiser combined with a barrier cream such as zinc and castor oil with each nappy change. Use eco friendly nappies that are not bleached with chemicals containing chlorine.

If there is still a lot of redness and inflammation, 1% Hydrocortisone cream or ointment may have to be applied, once daily at night time, for not more than five nights until the condition settles. Some children may develop a group a streptococcal infection in the nappy area. If they are in pain, are off their feeds or have a fever they may need treatment with a topical and/or an oral antibiotic (e.g. mupirocin ointment and/or flucloxacillin). Bizarre or unusual rashes on the nappy area might make one think of non-accidental injury.

Sometimes there is a secondary yeast infection , such as candida . This usually presents with a flexural rash in the groin creases and satellite lesions spreading out beyond the main body of the rash. If candida is suspected then a topical anti-yeast agent such as miconazole nitrate cream (“Daktarin® ”) or clotrimazole cream (“Canestan® ”) should be used for at least 2 weeks. If the yeast infection is associated with a lot of inflammation, then combining 1% Hydrocortisone with an anti-yeast agent should help (e.g.: “Daktacort®” or “Canestan HC®”). These can be applied once a day for about 2 weeks. All irritants should also be removed and the area moisturised with zinc and castor oil with every nappy change. Antifungal topical products can be irritating themselves especially in occlusive areas and should be stopped after 1–2 weeks. Leaving the nappy area open for a few minutes or a few hours may help but is usually impractical in a baby that is not toilet-trained. Changing to cloth nappies may help but may be impractical for a busy parent with other young children. Breast fed babies tend to have more runny stools but are less likely to develop nappy rash. Apart from lactose intolerance, food allergies are rarely the cause of nappy rash so changing the child’s diet is unlikely to help.

4 Infantile Seborrhoeic Dermatitis

Infantile seborrhoeic dermatitis behaves differently from adult seborrhoeic dermatitis and may be a completely different condition. Infants who develop seborrhoeic dermatitis do not necessarily go on to develop seborrhoeic dermatitis in adulthood. The most common presentation with seborrhoeic dermatitis is ‘’cradle cap” where the small baby develops non-itchy, thick scales on the top of the scalp. This is harmless and a self-limiting condition. Bland emollients or almond oil and lifting off the scales with a fine comb will help. Tar based shampoo such as “T gel®” or “Capasal®” may also help. If there is a lot of inflammation, 1% Hydrocortisone may be required for a few weeks. Ointments containing salicylic acid such as “Cocois ®” should be diluted or used very sparingly or left on for a shorter period of time than in adults as large quantities can cause systemic absorption and toxic reactions.

Children with seborrhoeic dermatitis often develop a more generalised eczematous rash similar to atopic eczema (See Chap. 16). Unlike atopic eczema these children have little or no itch and rarely scratch. The napkin area is usually involved in seborrhoeic dermatitis but is usually spared in atopic eczema. Some children may have an erythematous patch over the sternum, which is quite typical of seborrhoeic dermatitis.

Fortunately, seborrhoeic dermatitis will resolve spontaneously as the child gets older and is usually cleared by the time they get out of nappies. Treatment is with bland emollients, soaps substitutes and 1% Hydrocortisone ointment for any inflamed areas. It is important to reassure the parents that the child does not have atopic eczema, which is a much more serious and troublesome disease. They are usually happy to know that the child is in no distress as the rash does not itch. It is also comforting for them to know that the rash will clear completely, usually by the time the child is 2 years old.

5 Infantile Psoriasis

Some doctors believe seborrhoeic dermatitis and psoriasis are related conditions and may be part of a spectrum. Infantile psoriasis usually presents like seborrhoeic dermatitis but the rash is more deeply red, inflamed, more extensive and more difficult to treat. It is more likely if there is a family history psoriasis and may be triggered by stress or infection. In infancy it often appears in the nappy areas as napkin dermatitis but can progresses into a more generalised, non-itchy, slightly scaly rash on the scalp, chest, elbows, knees or flexures. The scales are not usually as pronounced as in adults. Instead, the rash is usually deeply red, shiny, macular with a sharp demarcation between the involved and uninvolved skin, just like flexural psoriasis in adults. The infant or child may later develop more classical features of plaque psoriasis on the body and scalp (Fig. 26.1a, b). Nail involvement is rare in infants and children but can sometime occur in isolation without any skin signs.

Fig. 26.1
figure 1

(a) Psoriasis in a 5 year old. (b) Psoriasis in a 5 year old on the face

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Older children may present with classical guttae psoriasis with multiple non itchy scaly plaques spread throughout the body in a symmetrical distribution but often sparing the face. It may follow a sore throat.

Treatment in infants and young children should be individualised to the child’s age, as well as the extent, distribution, type and severity of the psoriasis (see also Chap. 15). However, most mild to moderate cases will respond to bland emollients, soap substitutes and mild to moderate topical steroids. Tar preparations, calcipotriol and dithranol are all safe to use in children but weaker concentrations may be required. “Dovobet® ” and “Enstilar Foam®”, which are a combination of calcipotriol and betamethasone, should be avoided in infants and children less than 12 years old, as the steroid component is too potent for this age group.

For more troublesome psoriasis in children, calcipotriol (“Dovonex®”) can be applied in the morning and a moderately potent topical steroid such as clobetasone butyrate (“Eumovate® ”) can be applied at night for 4–6 weeks. The topical steroid can then be stopped and the calcipratol continued till the psoriasis clears.

Tacrolimus (“Protopic®” ) can be helpful particularly for psoriasis on the face, flexures and nappy area but this in an unlicensed indication. Occasionally systemic treatment with methotrexate, cyclosporine biological agents or phototherapy may be necessary in severe cases under specialist supervision.

Some children can develop pityriasis amiantacea where there are thick scaly plaques adherent to the hair on the scalp in localised patches. This is often associated with seborrhoeic dermatitis or psoriasis. Scalp ringworm (tinea capitis) and head lice should be excluded. Pityriasis amiantacea can usually be managed with ointments containing tar and salicylic acid such as “Cocois® ”. This may have to be diluted down 50% for small children and should only be applied on relatively small areas of the scalp. The ointment is normally left on for an hour or two and then washed off with tar based shampoo. Fine combing may help to lift off the scale. There may be temporary alopecia but the hair will grow back once the rash resolves. If there is a lot of inflammation, 1% Hydrocortisone or a moderately potent topical steroid such as clobetasone butyrate (“Eumovate® ”) may be applied once daily for a few weeks.

6 Infantile Acne

Small babies are prone to infantile acne. This is thought to be due to maternal androgens passing onto newborn baby, who then develops comedones (blackheads and whiteheads), papules and pustules usually on the cheeks and nose (Fig. 26.2). This usually resolves spontaneously after 6–12 months but if troublesome may require treatment and topical agents such as benzoyl peroxide or a topical antibiotic such as erythromycin . More severe cases may require referral to a specialist for systemic treatment such as erythromycin or trimethoprim for a few weeks or few months. It is important to note that oral tetracycline antibiotics should not be used in children under the age of 12 years old as they are associated with impaired bone growth, permanent discoloration of teeth and enamel hypoplasia in children [1,2,2]. Very severe resistant cases with scarring may need referral to a paediatric dermatologist for oral isotretinoin (“Roaccutae®” ).

Fig. 26.2
figure 2

Infantile acne

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It is unclear if children with infantile acne are more prone to developing troublesome acne in their teens. If pre-pubertal children over the age of 2 years old present with acne they should be referred to a paediatrician for investigations for possible underlying hormone abnormalities such as Congenital Adrenal Hyperplasia, Cushing syndrome or an androgen secreting tumour.

7 Keratosis Pilaris

This is a form of localised folliculitis caused by a disorder of keratinisation. This is very common in children and young adults. Cells get stuck in the hair follicles causing tiny plugs of keratin and gives a ‘’goose pimple” appearance to the skin. This causes a coarse texture like sandpaper and is most commonly found in the outside of the upper arms, the outside of the thighs and on the cheeks (Fig. 26.3a, b). On the face there can be considerable erythema (Fig. 26.4). It often runs in families and is more common in children with atopic eczema. It usually improves as the child gets older. Treatment includes moisturisers or keratolytics such as urea, salicylic acid, tretinoin, adapaline or vitamin D analogues such as calcipotriol . A cream or lotion with 10% urea or higher for the body and 3% for the face can be tried. This can be applied, rubbing it downwards twice a day and can take months to see a good improvement. If this does not help, adapaline jel (“Differin Gel® ”) can be tried but this can cause dryness and irritation in some patients so it should be applied sparingly to the affected areas on the face and body on alternate days initially.

Fig. 26.3
figure 3

(a) Keratosis pylaris. (b) Keratosis pylaris

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Fig. 26.4
figure 4

Keratosis pylaris with ulerythrema affecting the lateral eyebrows

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8 Impetigo

This is more common in children than in adults. It is usually caused by Staphylococcus aureus or Streptococcus pyogenes. It usually presents as an asymmetrical ‘’sore” with a yellowy gold coloured crust and exudate on exposed areas. It can spread to other parts of the body and to other children. As is it contagious, careful hand washing and using a separate towel for the infected child is important to protect the rest of the family. The crusty plaques are usually round, oozing and expand as the infection progresses. Milder cases will usually respond to topical antibiotics such as fusidic acid cream (“Fucidin Cream®”), which should be applied after gently removing the crust with an antiseptic wash. All orifices of the body should be treated regardless of impetigo location to ensure a focus for re-infection is cleared. More severe or extensive cases such as bullous impetigo may require oral or systemic antibiotics usually with flucloxacillin . Children should be kept out of school until the crusts have dried out.

9 Tinea Capitis (Scalp Ringworm)

Tinea capitis is a dermatophyte infection that is far more common in children than adults. Although there is a wide local variation of the causative organisms throughout the world, T.tonsurans (human spread) and T.canis (cat or dog ringworm) are the most common fungus causing scalp ringworm. It usually presents with a round patch of hair loss (alopecia) with associated redness, scaling, inflammation and possible pustules on the involved area of the scalp. Diagnosis is by taking skin scrapings or plucking hair from the involved area and sending them for fungal stain and culture. As it can take 2–4 weeks to get results back, treatment is normally initiated on clinical grounds alone. Tinea capitis always requires systemic treatment because topical anti-fungal agents do not penetrate down to the deepest parts of the hair follicle. Oral anti-fungals such as griseofulvin 10–15 mg/kg/day to be taken with food for 6–12 weeks may be required to clear scalp ringworm [3]. However, it is difficult to source this drug. Other anti-fungals that can be effective include terbinafine and itraconazole. Oral terbinafine (“Lamisil® ”) is not licenced for children under 2 years of age (usually <12 kg) and the use of oral itraconazole (“Sporanox Capsules® ”) in paediatric patients is not recommended unless it is determined that the potential benefit outweighs the potential risks. These oral agents work faster than griseofulvin, but still take 4–6 weeks to clear fungal scalp infections. All children in the family should be checked for scalp ringworm and also treated. Topical antifungal such as ketocanozal (“Nizoral shampoo® ”) or terbinafine cream may reduce the risks of transmission while the systemic treatment is working. If tinea canis is diagnosed then the animal source should be identified and treated.

Some children can develop a more deep-seated fungal infection of the scalp with a secondary severe inflammatory response causing a large, boggy, oozing mass on the scalp known as a kerion . There may be localised enlarged lymph nodes and a lower grade fever which could be mistaken for an abscess. A kerion needs to be diagnosed and treated quickly because neglected cases can cause permanent scaring alopecia in the affected area of the scalp. The child will need to be treated with oral anti-fungals for at least 6–12 weeks. If there are signs of secondary bacterial infection, antibiotics may be necessary such as flucloxacillin for 1–2 weeks. The role of oral steroids is controversial but may be required if there is a lot of inflammation (1 mg/kg/day for 7 days). There is no role for incision and drainage or any other surgery procedures for a kerion.

10 Scabies in Babies

Scabies can present as a generalised itchy eczematous rash in babies. It can often be confused with other itchy rashes such as atopic eczema. There is usually history of the child being in contact with somebody else with an itch. The classical signs of scabies in babies is burrows on these soles of the feet. Infants with scabies can have lesions in the face too. This is not seen in older children or adults. The diagnosis can be confirmed by seeing the mite at the end of a burrow with a dermatoscope or removing the mite from the end of a burrow with a number fifteen scalpel blade or a green needle and lifting it onto a microscope slide. It can then be viewed by the doctor and parents. This usually guarantees 100% compliance with the treatment once the parents see the mite.

Treatment is similar to adults except the scalp and face should also be covered with a scabieside in children less than the age of 2 years old. Permethrin 5% cream (“Lyclear Dermal cream®”) is safe to use in children over the age of 2 months old. Like adults, it should be applied for 8–12 hours and then washed off. One further application should be applied 1 week later. All close household contacts and babysitters should also be treated simultaneously regardless of whether they are itching or not (see Chap. 35). For children under 2 months of age, the recommendation is 7% sulfur preparation for three consecutive nights and this may have to be repeated weekly for a few weeks.

Infantile acropustulosis causes small, itchy blisters and pustules on the palms and soles of infants in the first 2–3 years of life. It can occur with scabies or post scabies but in some cases there is no history of scabies. Dermoscopy is very helpful to try to identify scabies mites. When it occurs without scabies it usually responds to emollients, moderately potent topical steroids and sedating antihistamines if it is very itchy. Most cases resolve by the time the child in 3 years old.

11 Conclusion

Children are more prone to congenital and allergic diseases. They are also more prone to infectious illnesses. Treating skin disease in children can be more challenging as many of the treatment used in adults such as potent topical steroids or oral anti-fungal tablets are more likely to cause side effects in children or are not licensed to use in children.