What are the top diagnoses and treatments in pediatric dermatology?

Top Pediatric Dermatology Diagnoses with Treatment Approaches

Atopic dermatitis, psoriasis, and congenital melanocytic nevi are the most common pediatric dermatologic conditions requiring specialized management, with treatment approaches tailored to disease severity, location, and patient age.

Atopic Dermatitis (Eczema)

Atopic dermatitis is a chronic, relapsing inflammatory skin disease commonly seen in children, with increasing prevalence in many countries.

Clinical Features:

• Pruritus (must be present) 1
• Eczematous lesions (acute, subacute, or chronic) with age-specific patterns 1
• Typical distribution: facial, neck, and extensor involvement in infants; flexural lesions in all age groups 1
• Chronic or relapsing history 1

Associated Features:

• Keratosis pilaris 1
• Pityriasis alba 1
• Hyperlinear palms 1
• Periorbital changes 1

Treatment Algorithm:

1. First-line therapy:

   • Patient education on trigger avoidance and proper skin care 1
   • Medium to high-potency topical corticosteroids for 1-4 weeks for acute flares 1
   • Consider wet wrap therapy for severe flares 1

2. Maintenance therapy:

   • Proactive intermittent application of topical corticosteroids 2-3 times weekly to prevent flares 1
   • Topical calcineurin inhibitors (tacrolimus, pimecrolimus) for sensitive areas (face, genitals, skin folds) 1

3. For moderate-to-severe disease:

   • Consider phototherapy (narrowband UVB) 1
   • Systemic therapy when topical treatments fail and disease significantly impacts quality of life 1

4. Treatment pitfalls to avoid:

   • Topical steroid phobia leading to undertreatment 1
   • Failure to address bacterial or viral infections (especially S. aureus colonization) 1
   • Overly complex regimens that reduce adherence 1

Psoriasis

Psoriasis is a chronic inflammatory condition that can significantly impact quality of life in pediatric patients.

Clinical Presentation:

• Well-demarcated erythematous plaques with silvery scale 1
• Common locations: scalp, extensor surfaces, trunk 1
• May present with guttate pattern following streptococcal infection 1

Treatment Approach:

1. Topical therapy:

   • Topical corticosteroids (first-line for localized disease) 1
   • Vitamin D analogs (calcipotriene/calcipotriol) often used in combination with corticosteroids 1
   • Tacrolimus 0.1% ointment for facial and genital psoriasis 1

2. Phototherapy:

   • Narrowband UVB recommended for moderate-to-severe plaque and guttate psoriasis 1
   • Consider natural sunlight in moderation when in-office phototherapy isn't feasible 1

3. Systemic therapy for severe disease:

   • Methotrexate (most common systemic medication for pediatric psoriasis) 1
   • Cyclosporine for rapid control of severe disease 1
   • Biologic agents for refractory cases 1

4. Monitoring requirements:

   • Regular laboratory monitoring for patients on systemic therapy 1
   • Growth parameters should be monitored in all pediatric patients on long-term systemic therapy 1

5. Associated comorbidities to screen for:

   • Psoriatic arthritis (joint pain, swelling, stiffness) 1
   • Obesity and metabolic syndrome 1
   • Uveitis in patients with psoriatic arthritis 1

Congenital Melanocytic Nevi (CMN)

CMN are pigmented lesions present at birth or appearing within the first few months of life.

Clinical Features:

• Pigmented lesions varying in size from small to giant 1
• May have irregular borders, varied pigmentation, and hair growth 1

Management:

• Regular monitoring for changes in appearance 1
• Consider MRI evaluation for patients with multiple CMN (abnormalities found in 21% of cases) 1
• Surgical excision may be considered based on size, location, and risk of malignant transformation 1
• Sun protection is essential 1

Associated Conditions:

• CMN syndrome: facial features with CNS or endocrinologic anomalies 1
• Potential endocrine comorbidities: premature thelarche, undescended testes, insulin insensitivity 1

Pediatric Dermatologic Emergencies

Several dermatologic conditions require immediate attention to prevent significant morbidity and mortality:

• Staphylococcal scalded skin syndrome (SSSS): Characterized by widespread erythema and exfoliation 2, 3
• Eczema herpeticum: Herpes simplex virus infection in patients with atopic dermatitis, presenting as vesicles, punched-out erosions 2
• Infantile hemangiomas: Require urgent treatment when affecting vital structures or causing complications 2
• IgA vasculitis: Palpable purpura with potential systemic involvement 2

Acne Vulgaris

Acne is the most common skin disease in the pediatric and adolescent population.

Treatment Options:

• Topical therapy: Benzoyl peroxide, retinoids, antibiotics 4
• Oral antibiotics: For moderate-to-severe inflammatory acne 4
• Isotretinoin: For severe, recalcitrant nodular acne in patients ≥12 years old 5
  • Requires careful monitoring for side effects including:
    • Musculoskeletal effects (back pain, arthralgia) 5
    • Potential effects on bone mineral density 5
    • Visual problems and decreased night vision 5
    • Psychiatric symptoms 5

Impact of Specialized Care

Establishing pediatric dermatology services significantly reduces emergency department utilization for dermatologic conditions:

• 36.6% decrease in ED visits for dermatitis after establishing pediatric dermatology services 6
• 69.1% decrease in moderate dermatitis cases presenting to ED 6
• Significant reduction in healthcare costs 6