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Assessing skin disease in initial assessment of a child will distinguish between those
children that are systemically well with a rash and those that are
PAEDIATRICS AND CHILD HEALTH 21:3 105 Ó 2010 Elsevier Ltd. All rights reserved.
SYMPOSIUM: DERMATOLOGY
Figure 1
Descriptive terms
Table 1
PAEDIATRICS AND CHILD HEALTH 21:3 106 Ó 2010 Elsevier Ltd. All rights reserved.
Examination Hair itself may also be a clue to the underlying disease for
example sparse hair in ectodermal dysplasia.
Firstly a good light source is necessary. Examining all the skin,
hair, nails and oral mucosa can provide valuable information.
Accurate observation of a rash with associated features can limit Examination of the nails may identify a number of changes
the likely number of causes. Assessment of skin disease in chil- associated with various conditions e.g. pitting seen in psoriasis
dren involves more than just examination of the skin. General and alopecia areata or identify changes in the nail folds e.g.
growth provides a base line assessment and may be impaired in telangiectasia seen in dermatomyositis.
chronic disease or underlying genetic disorders. Examination for
lymphadenopathy is helpful in viral exanthems and chronic Examination of the mouth. The oral mucosa may help define
infections. Hepato-splenomegaly may be relevant in some a likely cause of a rash, whilst the absence of lesions in the mouth
metabolic conditions. Equally important is the appreciation that may indicate that a desquamating condition is more likely to be
the disease process identified in the skin may be manifested Staphylococcal Scalded Skin than Toxic Epidermal Necrolysis.
elsewhere in the body e.g. vasculitis affecting the kidney or
gastrointestinal tract.
Investigations
What can be seen? Most paediatricians are adept at deciding if Usually there is a limited requirement for investigations.
a rash is blanching or non-blanching. It is valuable to observe if
a rash is raised (papules/nodules/plaques), if there are epidermal Skin swabs can be helpful to identify infections and guide
changes, if there are pustules, vesicles or bullae (the fragility of antibiotic sensitivities.
which can be a reflection of the level of the split in the
epidermis). Colour may vary due to a variety of causes including Skin scrapings and nail clippings can help identify fungal
vasodilatation, bleeding into the skin (purpura), or pigment from infections.
melanocytes. It is important to note that erythema may some-
times be more difficult to see in pigmented skin. Woods light is an ultraviolet light source used to look for certain fungi
and corynebacterium (which cause erythrasma). Unfortunately, the
Where can it be seen? (site). Some rashes are more likely to be fungi currently commonly responsible for tinea capitis do not fluo-
seen on the face e.g. malar rash of systemic lupus eryth- resce. Woods light also emits purple light in the visible spectrum. The
ematosus, whilst others characteristically occur on the trunk e.g. purple light is absorbed by melanin and therefore hypopigmented
pityriasis rosea. The Koebner phenomenon refers to the devel- patches of vitiligo and ash leaf macules can appear more prominent.
opment of typical lesions at the site of minor trauma and is
characteristically seen in psoriasis, lichen planus and planar Patch testing can be helpful where contact allergy (type IV) is
warts. suspected.
What is the distribution? Some diseases are more likely to Skin prick testing or measurement of specific IgE for Type I,
follow a symmetrical pattern, others may be more likely to occur IgE mediated, allergy may be of benefit where there is a clear
on the extremities, some lesions follow a clear dermatomal history of an associated urticarial response but is not useful
pattern and areas of sparing may be relevant for example absence routinely in chronic urticaria or eczema.
of rash in an area not exposed to sunlight.
Skin biopsy is occasionally required to make a diagnosis with
How are the lesions arranged? It is helpful to describe the the aid of histopathology and immunoflourescence. Tissue may
relationship of individual lesions to those nearby e.g. grouped, be sent for microbiological culture, helpful to identify unusual
linear, arcuate. infections particularly in immunosuppressed patients (Table 2).
PAEDIATRICS AND CHILD HEALTH 21:3 107 Ó 2010 Elsevier Ltd. All rights reserved.
Examples of common skin complaints in children
PAEDIATRICS AND CHILD HEALTH 21:3 108 Ó 2010 Elsevier Ltd. All rights reserved.
Table 2 (continued)
Urticaria Clear temporal Pink, raised areas of
relationship may identify skin, with no surface
cause (consider potential change, may be pale
physical causes e.g. cold/ centrally, often with a
pressure/sunlight/water/ surrounding red flare.
exercise as well as recent Individual lesions should
viral illness and food resolve within 24 h,
allergens). Discriminate leaving the skin with a
between the duration of normal appearance.
the process (which may be May be associated with
ongoing for days or angio-oedema.
weeks) and the duration of
individual lesions, which
should last only 24 h. Itch
rather than pain is the
main symptom.
PAEDIATRICS AND CHILD HEALTH 21:3 109 Ó 2010 Elsevier Ltd. All rights reserved.
Table 2 (continued )
PAEDIATRICS AND CHILD HEALTH 21:3 110 Ó 2010 Elsevier Ltd. All rights reserved.
SYMPOSIUM: DERMATOLOGY
Table 2 (continued)
Child unwell for several Child may be
days with high fever. Drug hypotensive and
history important as often shocked. Sheet like
Toxic Epidermal implicated. Skin is tender. erosions involving more
Necrolysis Macules become confluent than 30% of body.
and form flaccid bullae. Involvement of eyes,
Tendency to start at the mouth and genital
head. mucous membranes.
Table 2
FURTHER READING
Bernard A. Cohen MD. Pediatric Dermatology, 2nd Edn. Mosby Practice points
International Ltd, 1999.
Harper J, Oranje A, Prose N, eds. Textbook of pediatric dermatology. C Initial assessment of children should identify those systemically
Massachusetts: Blackwell Publishing, 2000. unwell and in need of resuscitation and immediate treatment.
Lewis-Jones Sue, ed. Paediatric dermatology (Oxford Specialist Hand- C For diagnosis there is no substitute for detailed history and
books in Paediatrics). Oxford University Press, 2010. thorough examination (including hair, nails and oral mucosa).
Paller Amy S, Anthony J, Mancini MD. Hurwitz clinical pediatric derma- C Identification of the lesions seen and use of correct dermatolog-
tology: a textbook of skin disorders of childhood and adolescence. ical terms are essential to formulate accurate differential diag-
Elsevier Health Sciences, 2005. noses and to communicate clearly and safely with colleagues.
PAEDIATRICS AND CHILD HEALTH 21:3 111 Ó 2010 Elsevier Ltd. All rights reserved.