Hot Topics in Pediatric Dermatology

Lian Sorhaindo; Anthony Rossi; Andrew Alexis; Nanette B Silverberg


Expert Rev Dermatol. 2010;5(3):259-267. 

In This Article

Great Cases in Pediatric Dermatology: Exposures, Infections & Infestations

The session 'Great cases in pediatric dermatology: exposures, infections and infestations' was presented by Nanette B Silverberg. Dr Silverberg reviewed many interesting cases in pediatric dermatology with a focus on entities in patients of color. We herein summarize some of these interesting entities for the reader. Paraphenylenediamine (PPD) allergy can be precipitated by henna tattoo exposures. The prevalence of PPD allergy in the general populations is estimated to be 0.96%. It is contained in hair dyes and can occur as an occupational exposure in hairdressers, and is also used in clothing and shoes. It is also an ingredient in temporary tattoos and an allergic contact dermatitis can be seen in children with this exposure.

When considering abuse in hemorrhagic annular lesions, consider cupping. This practice can be mistaken for child abuse and involves placing hot glass cups on the upper back until they fall off. This creates a cutaneous congestion with localized petechiae in an annular pattern.

Recently, white piedra, caused by Trichosporon, is a fungal infection of the hair shaft that can present as white spots on the hair shaft of scalp hair breakage. Treatment does not have to consist of shaving of the hair, as performed in the past. An oral azole such as itraconazole and antifungal shampoos can be used.

Progressive macular hypomelanosis is a relatively new and vague entity that is possibly related to a combination of Malassezia and corynebacterium overgrowth, and often mistaken and treated as tinea versicolor. It presents as hypopigmented macules coalescing into patches on the trunk, and the pathogenesis can involve a localized reduction in melanization and melanosome size. Treatment includes sunlight exposure, benzoyl peroxide and doxycycline, as well as narrowband UVB light therapy.[34]

Another entity that can be misdiagnosed is confluent and reticulated papillomatosis (CARP), first described by Gougerot and Carteaud. It occurs as velvety reticulated pigmentation with confluence on the central chest. This generally affects the trunk and is most cosmetically obvious in skin of color due to background pigmentation. There is a linkage to actinomycete species, Dietzia papillomatosis, overgrowth. Treatment includes oral minocycline or topical calcipotriene.

Community-acquired methicillin-resistant S. aureus (MRSA) is increasingly becoming a more common entity. It is estimated that 11–70% of S. aureus isolates are MRSA. The resistance is due to the Panton–Valentine leukocidin gene. Nasal or interiginous carriage leads to recurrent pyoderma and S. aureus carriage is more likely with streptococcus vaccination.[35] It can appear clinically as intertriginous furuncles, abscesses, impetigo, folliculitus or cellulitis. Treatments include prevention with hand washing and glove usage, sodium hypochlorite and alcohol-based hand rubs. Abscesses should be drained and this may be sufficient enough to clear lesions. Antibiotics used for MRSA infections include vancomycin, bactrim, tetracycline, clindamycin and ciprofloxacin, and adding rifampin can reduce nasal carriage. Newer antibiotics include linezolid, daptomycin, tigecycline, alfopristin/quinupristin and retapamulin. Sodium hypochlorite (bleach) baths can also be used to help decrease the clinical severity of atopic dermatitis in patients with clinical signs of secondary bacterial infections.

Perianal bacterial dermatitis in infants is now mostly caused by S. aureus, but S. pyogenes and Group B streptococci can also be isolated. It is a mixed infection and dermatitis that responds to a combination of emollients, topical mupirocin, oral cephalexin and bleach baths. Netherton syndrome is a triad consisting of atopic dermatitis/atopy, ichthyosis linearis circumflexa, or double-edged scale of the skin, and trichorrhexis invaginata, colloquially called bamboo hair. The defect is in SPINK 5. A staphylococcal infection can cause disease flairs and patients can see recurrent skin eruptions.

Molluscum contagiosum virus (MCV) is a common entity encountered in the pediatric population and is caused by a pox virus. It presents as pearly papules 2–5 mm in diameter with a central dell. Pruritus is also commonly associated. Treatment includes topical corticosteroids and oral antihistamines for the pruritus. While no treatment is necessary for less than 20 lesions, when there are symptomatic lesions or they are spreading, destructive therapy can be utilized. These include curettage, cantharidin and cryotherapy. Genital MCV can occur and can be treated with lidocaine creams and curettage. A biopsy may be performed to rule out HPV. MCV lesions can become secondarily superinfected with staphylococcus, and can also induce an erythema multiforme-like reaction, which can present as lichenified extensor papules.[36]

Cutaneous common warts induced by HPV can be difficult to treat, and is the third most common pediatric dermatology diagnosis. Salicylic acid treatment has been regarded as the best evidence-based treatment option. Squaric acid dibutylester is also being used as a treatment option, with clearance rates estimated at 60–90%, and is used to treat recurrent warts. Other immunotherapy options for cutaneous warts include intralesional mumps, Candida or Trichophyton antigen injections. Topical 5-fluorouracil has also been used for recalcitrant warts; however, it should not be used for periungual warts, as it may induce onycholysis.[37]

Bed bugs have become a common infestation that is encountered. The organism is Cimex lectularis in the USA, and Cimex hemipterus outside the USA. The lesions of bites on uncovered body areas can become intensely inflamed and/or secondarily infected. Bed bugs feed on human blood, and while they do not transmit infections in the USA, they can transmit Trypanosoma cruzi, the organism responsible for Chagas disease in Brazil. Extermination is necessary to remove a bed bug infestation.


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