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CHAPTER 11
Dermatology
TYPES OF LESIONS
Primary: Specic changes caused directly by disease process
Macule: Nonpalpable, <1 cm
Patch: Nonpalpable, >1 cm
Papule: Solid, palpable, <1 cm
Nodule: Solid, palpable, 12 cm, dermal
Tumor: Solid, palpable, >2 cm
Plaque: Solid, palpable, >1 cm, width >
thickness
Vesicle: Raised, clear, uid lled,
<1 cm
Bulla: Raised, clear, uid lled,
>1 cm
Pustule: Raised, pus lled
Wheal: Transient, palpable edema
Secondary: Nonspecic changes caused by evolution of primary lesions
Scale: Accumulation of loosely adherent
keratin
Crust: Accumulation of serum, cellular,
bacterial, and squamous debris over
damaged epidermis
Fissure: Supercial, often painful break in
epidermis
Erosion: Loss of epidermis; heals without
scarring
Ulcer: Loss of epidermis and part or all of
dermis; heals with scarring
Excoriation: Linear erosion
Lichenication: Accentuated skin mark-
ings caused by thickening of epidermis;
usually caused by scratching or rubbing
Scar: Fibrous tissue replacing normal
architecture of dermis
Atrophy: Epidermal (thinning of epi-
dermis) or dermal (decrease in the
amount of collagen or causing depres-
sion of skin)
CHARACTERIZATION OF SKIN LESIONS
Description Distribution Duration Exposure
Signs and
Symptoms
Primary vs.
secondary changes
Symmetry How long? Sick contacts Local
Color Dermatomal Since birth? Recent travel Pruritus
Consistency and
texture
Photodistribution Recurrent? Medications Pain and
tenderness
Mobility Mucous mem-
brane involvement
Personal
care prod-
ucts
Paresthesias
Conguration Contact areas Environ-
mental
exposures
Bleeding
Shape Flexor vs extensor
surfaces
Occupation-
al exposures
Systemic
Well vs.
ill-dened
Koebner phenom-
enon: areas of
previous trauma
Recreational
exposures
Fever or chills
Arrangement Seasonal
variation
Malaise or
fatigue
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110 Pediatrics
Description Distribution Duration Exposure
Signs and
Symptoms
Discrete Family
history
Arthritis or
arthralgias
Localized
Grouped
Disseminated
ATOPIC DERMATITIS AND ECZEMA
Risk factors: Family history, other atopic diseases (asthma, allergic rhinitis), food
hypersensitivity, environmental allergens
Clinical manifestations: Pruritic, erythematous, scaly papules and plaques edema,
serous discharge, crusting lichenication, hyperpigmentation, ssuring
superinfection (primarily with Staphylococcus aureus; also with HSV)
Distribution
Infantile: Cheeks, forehead, trunk, extensor surfaces
Childhood: Wrist, ankle, antecubital and popliteal fossae
Adolescent and adult: Flexor surfaces, face, neck, hands, feet
ECZEMA COMPLICATIONS
Type Clinical Features Treatment or Prevention
S. aureus superinfection Honey-crusted erosions, pus-
tules, weeping, acute increase
in erythema
Topical or oral antibiotic
Obtain culture
Eczema herpeticum (HSV
superinfection)
Source of contact often
adult caretaker with
cold sore
First-degree lesions: Crops of
vesicles on inamed base at
sites of eczema
Late: punched-outerosions
Common associated symp-
toms: Fever, malaise, irritability,
intense itching, eczema are
Severe: Widespread viral
dissemination with multiorgan
involvement
Stop TCS or TCI
Acyclovir or valacyclovir
Treat for secondary bacterial
infection if indicated
Treat known contacts
Eye exam for periorbital
involvement
Obtain culture &/or DFA
Long-term TCS use Skin atrophy, ecchymoses,
striae, telangiectasias, poor
wound healing, perioral
dermatitis or steroid rosacea,
hypothalamuspituitary axis
suppression with systemic
absorption
Limit use for ares only
(usually <1- 2-wk intervals)
Use lower potency TCS for
face, underarms, and groin
If indicated, evaluate for
adrenal suppression and treat
appropriately
Postinammatory pig-
ment changes
Hypo- or hyperpigmented
macules or patches in areas
of previous involvement
Fades over months to years
Sun protection and contin-
ued treatment of ares of
dermatitis
TCS, topical corticosteroid; TCI, topical calcineurin inhibitor
Treatment
Maintenance: Short, lukewarm baths or showers under 10 minutes with mild soap;
frequent moisturization with thick, bland emollients (cream or ointment)
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Mild are: Class 6 to 7 TCS or TCI BID (approved for 2 yo; use for 2 weeks at a time;
good for face); ointment preferred
Moderate are: Midpotency TCS for body BID (eg, triamcinolone 0.1%); ointment
preferred; class 6 to 7 TCS or TCI BID for face; oral antihistamines PRN for pruritus
Severe are: Midpotency TCS followed by warm, wet wraps BID for at least 15 min; ointment
preferred; then application of emollient; oral antihistamines PRN for pruritus and antibiotics
for superinfection
CONTACT DERMATITIS
Type Description Causes Course Treatment
Irritant Acute:
Erythema, scal-
ing, edema,
vesicles,
pustules,
erosions
Chronic:
Lichenication,
ssures
Results from contact
with a substance that
chemically or physically
damages skin
Urine or feces
diaper rash
Lip licking or thumb
sucking
Detergents or solvents
Topical medications
Battery acid
May occur after
single contact
with a strong
irritant or
after repeated
contact with
milder irritants
Rash minutes
to hours after
exposure
Avoidance of
irritants
Emollients,
barrier
creams
May consider
TCS if no im-
provement
(controversial)
Allergic (type
IV cell-
mediated
immune
reaction)
Acute:
Erythematous,
scaly, vesicular,
crusted,
weeping
Chronic:
Lichenica-
tion, ssuring,
excoriations
Poison ivy, oak, sumac
Nickel (jewelry, metal
clasps, glasses)
Rubber (shoes, clothing)
Paraphenylenediamine
(hair dyes, leather,
black-dyed henna)
Topical antibiotics (eg,
neomycin, bacitracin)
Emollients
TCS
1 exposure
rechallenged
by allergen
dermatitis
Rhus (poison
ivy, oak, sumac):
patchy or
linear vesicles
or bullae on ex-
posed surfaces
27 days after
exposure, last-
ing 34wk
May use
patch testing
to conrm
diagnosis
Avoidance of
allergen (may
take >6 wk
for complete
clearing of
rash)
Topical or
systemic cor-
ticosteroids
Data from Dermatol Ther 2004;17:334.
OTHER ECZEMATOUS OR PAPULOSQUAMOUS ERUPTIONS
Disease Description Course Treatment Other
Sebor-
rheic
dermatitis
(infantile
form)
Cradle cap: Greasy
scales on scalp
Disseminated: Bilateral,
well-demarcated, sym-
metric pink patches
and plaques with
scaling in diaper area,
retroauricular
areas, neck, trunk, and
proximal extremities,
prominent in skin
creases/folds
Usually begins
1 wk after birth
May persist for
months
Bathing
Frequent
moisturization
Ketoconazole
2% cream if
extensive or
persistent
Short course
of low-
potency TCS if
inamed
Linked with
sebum
overproduc-
tion and
Malassezia
spp. infection
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112 Pediatrics
Disease Description Course Treatment Other
Keratosis
pilaris
Skin-colored follicular
hyperkeratotic or
erythematous
papules on the upper
arms, thighs, cheeks
May become
more pro-
nounced at
puberty (some
may improve at
puberty)
Often improves
with age
Improvement
in summer;
worsening in
winter
No denitive
treatment
May try
emollients,
lactic acid
or glycolic
acid creams,
urea cream,
salicylic acid,
short course
of TCS for
inamed
areas
Can be asso-
ciated with
ichthyosis
vulgaris,
atopic
dermatitis
Pityriasis
alba
Small, ill-dened,
symmetric, hypopig-
mented patches with
ne scales, often on
cheeks; may be seen
on upper extremities
May become
more obvious
in summer on
tanned skin
May last for
months to years
Resolves
spontaneously
Emollients,
low-potency
TCS, sunscreen
Pityriasis
rosea
Herald patch: Initial
1- to 10-cm salmon-
colored oval patch or
plaque with collarette
of ne scale, usually
on trunk
Within days:
Christmas tree
distribution of oval,
hyperpigmented,
smaller, thin plaques
or papules similar
to a herald patch on
trunk
Face, palms, soles
usually spared
May see oral
erosions
Inverse pityriasis
rosea: Variant
involving axillae and
inguinal areas; more
common in younger
children and darker-
skinned patients
Most common
in adolescents
and young
adults
More common
in spring
Reassurance
TCS PO
antihistamine
PRN for
pruritus
Possible
benet of 14-
day course of
erythromycin

(controversial)
UVB light
treatment for
severe cases
May have
mild
prodrome:
Fever, HA,
malaise
May be
pruritic
Lasts
68 wk;
sometimes
months
May be
mimicked
by syphilis
(check RPR if
indicated)
Possible
association
with HHV-6,
HHV-7
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Disease Description Course Treatment Other
Psoriasis

Well-demarcated
erythematous
papules and plaques
with thick, silvery
scales; often on
elbows, knees, scalp,
trunk, but can occur
anywhere
Diaper area in infants
Scalp - scaling, pap-
ules & plaques
Nail dystrophy -
pitting, other
Guttate type:
Drop-like lesions
on trunk, often
after streptococ-
cal infections,
URI
Localized pustu-
lar type: Discrete
pustules, scaly
plaques on
palms or soles
Generalized
pustular type:
Erythema with
sheets of small
pustules, migra-
tory annular
erythematous
plaques on
tongue, possible
after corticoster-
oid withdrawal,
fever, arthralgias
Koebner
phenomenon
Topical cor-
ticosteroids,
calcipotriene,
coal tars,
phototherapy,
methotrexate,
cyclosporine,
acitretin,
TNF-
inhibitors, my-
cophenolate
mofetil
Never use
systemic ste-
roids because
of psoriasis
ares when
stopped
Inverse
psoriasis:
Variant
involving
exural
areas
Cutis 2008;82(3):177.

J Am Acad Dermatol 2000;42:241.

Pediatr Dermatol 2001;18(3):188.

BACTERIAL INFECTIONS
Type Description Cause Course Treatment Other
Impetigo Honey-crusted
erosions, super-
cial vesicles
or bullae at
sites of skin
breakdown
May be pruritic
Usually on face,
hands, genita-
lia, or scalp
S. aureus
(non-
bullous,
bullous, or
pustular)
Strepto-
coccus
pyogenes
(usually
nonbullous)
Usually no
constitution-
al symptoms
Bullous form
may occur
on intact skin
Gentle
cleansing
Topical
antibiotics
Systemic
antibiotics
for extensive
cases
Ecthyma:
Deep
impetigo
with ulcer
formation,
often on
legs, heals
with scarring
Folliculitis Pustules or red
papules origi-
nating from
hair follicles
Usually on
scalp, face,
chest, back,
buttocks,
extremities
Usually
S. aureus
Benign
Heals with-
out scarring
Antibacterial
washes
Topical
antibiotics if
localized
Systemic
antibiotics if
extensive or
recurrent
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114 Pediatrics
Type Description Cause Course Treatment Other
Abscess Erythematous,
tender, puru-
lent masses,
fairly well-
circumscribed
Usually
S. aureus
or GABHS
May become
uctuant and
spontane-
ously drain
Warm, moist
compresses
If uctuant,
I&D
Systemic
antibiotics if
indicated
Recurrent:
MRSA eradi-
cation with
intranasal
mupirocin
TID x 1 wk
bleach bath
Q2-3 d (1/2
cup bleach:20
gallons water)
(for patient
and contacts)
Other treat-
ments: Daily
chlorhexidine
washes,
rifampin/
doxycycline x
1 wk
Cellulitis Acute,
ill-dened,
suppurative
inammation of
deeper subcu-
taneous tissues
with erythema,
warmth, swell-
ing, tenderness
S. aureus
or GABHS
through
area of
skin break-
down or
hematog-
enous
spread
Prodrome:
Fever, chills,
malaise
Systemic
antibiotics
Erysipelas Progressive,
supercial, well-
demarcated
cellulitis
(primarily
involving the
dermis)
GABHS Prodrome:
Fever, chills,
malaise
May resolve
with desqua-
mation and
post-
inammatory
pigment
changes
PCN for
1014 d
(erythromy-
cin if PCN
allergy)
Rest
Elevation
Cover for
S. aureus if
no improve-
ment or
atypical
(bullous)
Scarlet
fever
Blanching,
erythematous
sandpaper
rash starting on
central body
and spreading
Circumoral
pallor, ushed
cheeks
GABHS Prodrome
(high fever,
chills, HA,
sore throat,
anorexia)
rash devel-
ops within
1248 h
exudative
pharyngitis,
straw-
berry tongue
within days
710 d:
desquama-
tion lasting
26 wk
PCN for
1014 d
(erythromy-
cin if PCN
allergy)
Monitor
for other
GABHS
sequelae:
peritonsillar
abscess,
rheumatic
fever, acute
glomerulo-
nephritis
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Type Description Cause Course Treatment Other
Toxic
shock
syndrome
Diuse maculo-
papular erythro-
derma on trunk
with centripetal
spread
Erythema or
edema of palms
or soles
Desquama-
tion of hands
or feet 13 wk
after onset of
symptoms
S. aureus
or GABHS
exotoxin
Sudden
onset of
high fever,
myalgias,
vomiting
or diarrhea,
headache,
pharyngitis
rapid
progression
to shock
Removal of
foreign body
or nidus of
infection
Early,
aggressive
septic shock
treatment
including
early anti-
biotics (see
chapter 9)
Staphy-
lococcal
scalded
skin syn-
drome
Generalized
erythema, often
tender su-
percial, accid
bullae moist,
crusty skin with
desquamation
Mucus mem-
branes not
involved
Exfoliative
toxins of
S. aureus
Prodrome:
Fever, malaise,
irritability
Scaling or
desquamation
for 35 d after
bullae forma-
tion
Reepithelializa-
tion in 1014 d
Parenteral
antibiotics
Bland
emollients
for denuded
skin
Aggressive
pain control
Nikolsky sign:
Mechanical
pressure
induces
dermal
epidermal
cleavage
No organisms
seen on skin
culture or
biopsy
Meningo-
coccemia
Petechiae or
purpura, ecchy-
moses, ischemic
necrosis, hemor-
rhagic bullae
Neisseria
menin-
gitidis
Severe system-
ic symptoms
with rapid
decompensa-
tion
IV third-
generation
cephalosporin,
PCN, chloram-
phenicol
Treat con-
tacts with
rifampin
prophylaxis
Lyme
disease

Erythema
migrans
annular
erythematous
plaques, cen-
trifugal spread
Usually on trunk,
axilla, groin, or
popliteal fossa
Borrelia
burgdorferi
Rash occurs
~715 d
after tick
detached
Lasts 6 wk if
untreated
Doxycycline
(if >8 yo)
Amoxicillin
(if <8 yo or
pregnant)
Dissemi-
nated severe
disease: Third-
generation
cephalosporin
Rocky
Mountain
spotted
fever
Erythematous
macules on
wrists or ankles
with centripetal
spread
Maculopapular
lesions on palms
or soles
Severe: petechiae,
retiform purpura
Rickettsia
rickettsii
through
tick bite in
spring and
summer
Fever,
headache,
myalgia
rash appears
on day 36
May develop
severe sys-
temic symp-
toms with
progressive
worsening
Doxycycline
for all ages
Clin Infect Dis 2009;48(7):922.

Am J Clin Dermatol 2008;9(6):355.

Data from Curr Opin Infect Dis 2008;21(2):122 and Paediatr Drugs 2003;5(suppl 1):35.
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116 Pediatrics
VIRAL INFECTIONS
Type Description Course Treatment Other
Rubeola
or measles
(paramyxo-
virus)
Erythematous
maculopapular
rash starts on face
and spreads to
trunk or extremities
Rash appears
~5 days after on-
set of symptoms
Fades over
several days in
cephalocaudad
direction
Supportive
care
Prodrome:
Malaise, fever,
cough, coryza,
conjunctivitis,
Koplik spots
(gray papules on
buccal mucosa)
Rubella or
German
measles
(rubella
virus)
Discrete, erythema-
tous, maculopapu-
lar eruption on face
with spread to body
over 24 h
Rash appears
within 5 d
after onset of
symptoms
Fades over
several days in
cephalocaudad
direction
Supportive
care
Prodrome: Fever,
headache, URI
symptoms
Tender poste-
rior cervical and
suboccipital LAD
Forscheimers
spots: Pinpoint
rose-colored
macules or
petechiae on
soft palate
Roseola or
exanthem
subitum
(HHV-6)
Pink macules and
papules on trunk,
neck, extremities as
high fever resolves
Rash fades over
a few days
Supportive
care
Usually 6 mo to
3 yr age group
Erythema
infectiosum
or Fifths
disease
(parvovirus
B19)
Facial erythema
(slapped cheeks)
Erythematous
reticular, macular,
pruritic eruption
on extremities, trunk
Usually asymp-
tomatic
May have mild
myalgias, low-
grade fevers
Rash may last a
few weeks
Supportive
care
Rash may recur
with heat (eg,
showering)
during course of
illness
Hand-foot-
mouth
disease
(coxsackie
A16; entero-
virus 71)
Erythematous
patches and
vesicles on hands,
feet, buttocks, oral
mucosa
Fever, anorexia,
oral pain oral
mucosal ulcers
Most spontane-
ously resolve
over 23 wk
Monitor
hydration
status
Carafate PO
Aggressive
pain control
Chickenpox
(primary
varicella
zoster virus
infection)
Crops of vesicles
with surrounding
erythema (dew
drops on rose
petal) pustules
rupturing with
crust formation
Lesions in all stages
at same time
Most commonly
on trunk, face,
proximal
extremities
Incubation:
1021 d
Absent or mild
prodrome
Resolution in
1014 d
Spread via respi-
ratory route
Possible compli-
cations: Pneumo-
nia, encephalitis,
staphylococcal
superinfection
Symptom-
atic relief
Immuno-
compro-
mised or
dissemi-
nated:
Acyclovir
therapy,
VZIG within
96 h of
exposure
Contagious
from 24 h
before onset
of rash until all
lesions crusted
over
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Type Description Course Treatment Other
Herpes
zoster or
shingles
(VZV reacti-
vation)
Pain, burning,
pruritic grouped
vesicles on an ery-
thematous base
Usually unilateral,
involving one der-
matome
May dis-
seminate in
immunocom-
promised
patients
Postherpetic
neuralgia: Pain
lasting weeks
to years after
resolution of
rash
Early treat-
ment with
antivirals
Aggressive
pain control
Herpes sim-
plex virus
HSV1:
Mostly oral
HSV2:
Mostly
genital
Gingivostoma-
titis: Vesicles
erosions, regional
adenopathy
Herpetic whitlow:
Painful, deep-
seated vesicles on
ngertips
Eczema herpeti-
cum: Generalized
vesicles or erosions
over atopic der-
matitis
Genital: Venereal
transmission,
grouped vesicles
on erythematous
base; fever, malaise,
LAD
Recurrent:
Grouped
vesicles on
erythematous
base, heal
without scarring
in 1014 d;
pain, burning,
tingling, most
often found on
lips or genitalia;
often triggered
by fever, trauma,
sunlight,
menstruation,
gastroenteritis,
stress
Acyclovir or
valacyclovir
at rst sign
of disease
may abort
or shorten
episode
Aggresive
pain control
Acyclovir
for primary
disease in
children
Valacyclovir
suppressive
therapy
(daily) for
those with
frequent
recurrences
Gianotti-
Crosti
(papular
acroder-
matitis of
childhood)
Symmetric, skin-
colored or slightly
erythematous
papules on face,
buttocks, extensor
(acral) surfaces of
extremities
May be preced-
ed by URI, mild
constitutional
symptoms
Spontaneous
resolution
in weeks to
months
Supportive
care
May be as-
sociated with
viral infections
(eg, EBV, HBV,
others), bacte-
rial infections
(streptococci),
or postvaccina-
tion
Verruca
vulgaris or
common
warts (HPV)
Verrucous, gray-
pink papules on
ngers, dorsal
hands, soles of feet,
genitals
May occur at
sites of trauma
Autoinoculation
may occur by
manipulating
lesions
May enlarge or
multiply in im-
munocompro-
mised patients
Salicylic
acid, liquid
nitrogen,
trichloroa-
cetic acid,
cantharidin,
podophyllin,
imiquimod,
destructive
lasers, other
contact
immuno-
therapy
Genital warts
(condyloma
acuminata)
In <2-3yo:
Vertical
transmission or
from caregivers
with warts
Older kids:
Consider
sexual abuse
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118 Pediatrics
Type Description Course Treatment Other
Molluscum
contagiosum
(poxvirus)
Small, isolated,
dome-shaped,
skin-colored pap-
ules with central
umbilication
Lesions
contagious and
autoinoculable
May become
inflamed
May involute
spontaneously
over months to
years
Persist, multiply,
and enlarge in
HIV+ patients
As for com-
mon warts,
also gentle
curettage
Clin Med Res 2006;4(4):273.
Data from Dermatol Online J 2003;9(3):4 and Paediatr Drugs 2002;4(1):9.
FUNGAL INFECTIONS
Disease Description
Clinical
course Treatment Other
Tinea capitis Scaly patches of
broken hair or hair
loss on scalp
If becomes inam-
matory boggy,
erythematous
mass with fol-
licular pustules
(kerion)
May be associ-
ated with pos-
terior cervical
or suboccipital
LAD
Kerion may
lead to
scarring and
permanent
hair loss if left
untreated
Griseofulvin:
1520 mg/kg/d
for 68 wk
Selenium
sulde sham-
poo: 2x/wk for
patient and
contacts to
reduce viable
spores and pre-
vent spread
May also
consider oral
terbinane,
uconazole,
pulse itra-
conazole tx
Tinea corporis Pruritic annular
plaque with clear
center and scaly,
papulovesicular
borders (advanc-
ing margin of
scale)
2- to 4-wk
course of topical
antifungal BID
(eg, clotrima-
zole, terbinane)
Oral treatment if
widespread (eg,
Griseofulvin)
Tinea pedis
(athletes
foot)
Interdigital mac-
eration; dry, scaly
soles; vesicles
or erosions over
instep
Colonization
aided by
warmth and hu-
midity of shoes
and sweating
Topical antifun-
gal BID
Tinea cruris
(jock itch)
Pruritic, often
symmetric, well-
demarcated, scaly,
erythematous
plaques in inguinal
folds, upper thighs
May spread to but-
tocks and perianal
area
May have
raised papular
or pustular
margin
Topical antifun-
gal BID
Moist area
aids coloni-
zation
Often with
concomi-
tant tinea
pedis
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Dermatology 119
P
E
D
I
A
T
R
I
C
S
Disease Description
Clinical
course Treatment Other
Tinea versicol-
or (Malassezia
furfur)
Hypo- or hyperpig-
mented macules
with ne scales
on upper torso or
trunk and neck
Skin discolor-
ation may take
months to
resolve
Often recurs
(especially in
hot, humid
summer
months)
Selenium sulde
or ketoconazole
shampoo, topical
azoles for small
areas
Single oral
ketoconazole
400 mg dose (not
FDA approved in
children)
Fluconazole and
Itraconazole
have also been
suggested
Candida Oral (thrush): super-
cial, sometimes ten-
der, white plaques
on oral mucosa;
reveals denuded,
erythematous base
when scraped o
(contrast to oral
leukoplakia from EBV
that doesnt scrape)
Intertriginous:
Erythematous, scaly,
moist plaques
Diaper area: Beefy,
erythematous
plaques involving in-
guinal creases, often
with satellite pustules
or red papules
Vulvovaginal: Thick,
white discharge and
white plaques on irri-
tated, erythematous
vaginal mucosa
Oral candidiasis
in immunocom-
promised
patients may
spread to
esophagus,
causing feeding
di culties
Suspect
candidal
superinfection
if irritant diaper
dermatitis does
not improve
within sev-
eral days; often
painful with uri-
nation, bowel
movement
Vulvovaginal:
May cause
dysuria and
itching
Oral: Nystatin
solution
Intertrigo: Nysta-
tin powder
Diaper dermati-
tis: Topical imida-
zole or nystatin,
barrier creams,
frequent diaper
changes; low-
strength topical
corticosteroids if
necessary
Vulvovagi-
nal: topical
imidazoles, oral
antifungals for
recurrent or
refractory cases
(eg, uconazole
150 mg once in
adolescents)

Risk factors:
Prematurity;
antibiotic,
corticoster-
oid, or OCP
use; diabetes
mellitus;
immuno-
compro-
mised state
J Dermatol Treat 2002;13(2):73.

Chemotherapy 1998;44(5):364.
Data from Am Fam Physician 2008;77(10):1415.
MITE INFESTATIONS
Type Description Cause Treatment Other
Scabies Pruritus (worse at
night and with hot
bath)
Small, erythema-
tous papules with
excoriations or
crusting on inter-
digital webs, wrist,
Sarcoptes
scabiei
Permethrin 5% cream:
Cover entire body
overnight (include
scalp in infants);
repeat in 1 wk
Ivermectin: 200 mcg/kg
once; may repeat in
710 d
Secondary bacterial
infection common
Usually pruritus
resolves within a few
days after treatment
but rash may last
several weeks
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120 Pediatrics
Type Description Cause Treatment Other
ankles, feet, axillae,
GU area, buttocks,
areolae, scalp and
face in infants
May see vesicles,
burrows (wrists,
ankles)
Wash all clothing
and bed linens in
hot water and dry in
high heat
All contacts must
be treated at least
once (twice if symp-
tomatic)
May use topical
steroids for pruri-
tus relief
Norwegian or
crusted type:
Highly contagious;
seen in immu-
nocompromised
patients
Lice
(Head)
Intense pruritus
Nits and lice seen
on scalp
Excoriations, ery-
thema, scaling of
scalp and neck
Pediculus
capitis
Permethrin 1%
rinse or overnight
application of 5%
cream
Repeat in 1 wk
Wash bedding in
hot water and dry in
high heat
Ivermectin:
400 mcg/kg on day
1 and 8 (in >2yo)
Malathion lotion
(in >6 yo)
May develop
secondary bacterial
infection
DRUG REACTIONS
Type Description Pathogenesis Course Treatment
Morbilliform
or exan-
thematous
Symmetric,
erythematous
macules and pap-
ules on trunk and
upper extremities
that become
conuent
May be urticarial
on limbs, pur-
puric on ankles
or feet
Spares mucosa
PCNs, sulfa,
cephalosporins
anticon-
vulsants,
allopurinol,
others
414 d after
initiation
May have
pruritus and
low-grade fever
Resolves in 12
wk without
sequelae
Stop oend-
ing agent
if possible;
desensitization
if necessary
TCS or anti-
histamines for
pruritus
Urticaria
(immediate
IgE-media-
ted hyper-
sensitivity)
Pruritic, transient
erythematous,
edematous
papules and
plaques
May have central
pallor (wheals)
PCNs, cepha-
losporins,
NSAIDs,
monoclonal
antibodies,
contrast media,
others
Minutes to
hours after
exposure
Each lesion
usually lasts
<24 h
Chronic urti-
caria >6 wk
Stop oending
agent
Antihistamines
Desensitiza-
tion, if drug
necessary
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Dermatology 121
P
E
D
I
A
T
R
I
C
S
Type Description Pathogenesis Course Treatment
Drug-induced
angioedema
Pale or pink sub-
cutaneous edema
of face, extremi-
ties, genitalia
May extend to lar-
ynx, oropharynx,
intestinal wall
ACEIs, PCNs,
NSAIDs,
contrast media,
monoclonal
antibodies
Minutes to
hours after
exposure
Often lasts for
few days
Protect airway
Epinephrine
Stop and avoid
oending
agent
Antihistamines
Chronic:
Steroids PO
Anaphylaxis Urticarial or
angioedema
lesions + sys-
temic symptoms
(hypotension,
tachycardia)
PCN, latex
Rarely, local an-
esthetic, topical
antiseptic
Anaphylactoid:
Contrast media
Minutes after
exposure
Immediately
stop oending
agent
Protect airway
Systemic corti-
costeroids
Epinephrine
Avoid drug
in future;
desensitize if
necessary
Serum
sickness-like
reaction
Urticarial, morbil-
liform, purple
urticaria
Fever
Joint pain
Cefaclor,
bupropion,
minocycline,
PCNs, propra-
nolol, others
13 wk after
exposure
Stop oending
agent
Supportive and
symptomatic
care
Fixed drug
eruption
One or few annu-
lar, erythematous
or edematous
plaques
May have dusky
hue or central
blister
Favors face, acral
sites, genitalia
TMP-SMX,
NSAIDs,
barbiturates,
tetracyclines,
pseudoephed-
rine, others
First exposure:
12 wk
Reexposure:
within 2448 h
Fades over sev-
eral days with
postinamma-
tory pigment
changes
Recurs in same
location upon
reexposure
Stop oending
agent
Topical corticos-
teroid
Acute
generalized
exanthema-
tous
pustulosis
(AGEP)
Erythematous
edematous
plaques with
small, nonfol-
licular, sterile
pustules favoring
intertriginous
areas, trunk, and
extremities
May have burn-
ing, pruritus
-lactam
antibiotics,
macrolides,
CCBs, antima-
larials
<4 days after
exposure, lasts
12 wk, then
supercial
desquamation
Stop causative
drug
Topical corticos-
teroids
Antipyretics
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122 Pediatrics
Type Description Pathogenesis Course Treatment
Drug reaction
with eosino-
philia and
systemic
symptoms
(DRESS), drug
hyper-
sensitivity
syndrome
(DHS)
Starts morbil-
liform on face,
upper trunk,
extremities
edema with
follicular accen-
tuation
May have pustules,
blisters, erythro-
derma, purpura
Often with edema
of face
Antiepilep-
tics, sulfa,
allopurinol, mi-
nocycline, gold
salts, dapsone,
antiretrovirals,
others
26 wk after
drug initiation
Prominent
eosinophilia
and atypical
lymphocytes
Often with
lymphadenopa-
thy, arthralgia
or arthritis, liver
involvement,
myocarditis,
interstitial
pneumonitis,
interstitial ne-
phritis, thyroidi-
tis, GI bleeding
if allopurinol
induced
Stop oending
agent
Systemic corti-
costeroids
Check serial
liver enzymes if
elevated
Check thyroid
function tests at
onset of reaction
and 23 mo later
May require
steroid mainte-
nance treatment
for weeks to
months because
of relapses when
tapered
Erythema
multiforme
(EM)
Acrofacial,
grouped or
coalescent target
lesions, ery-
thematous rings
with dusky or
crusted centers,
or urticarial
Minimal (only
one site) or no
mucosal involve-
ment or systemic
symptoms
Most common:
Infection
(especially HSV,
Mycoplasma
spp.)
More rarely:
Drugs
Abrupt onset
within 2472 h,
last 7 days
Most heal with-
out sequelae
Occasional
postinamma-
tory pigment
changes
HSV-associated
EM may recur
Symptomatic:
Antihistamines;
bland emollients
for erosions;
diphenhydramine,
lidocaine and
Maalox in 1:1:1
mix mouthwash
for mouth pain
Recurrent HSV-
associated EM:
Acyclovir 10 mg/
kg/d in divided
doses for 6 mo
Stevens-
Johnson-
Syndrome
(SJS)
(<10% BSA)
Irregular, coales-
cent, erythema-
tous or dusky
macules, mucosal
(lips, oral, ocular,
genital) erosions
(two or more sites
required) and ten-
derness hours
to days later, ne-
crotic epidermal
detachment and
accid blisters,
hemorrhagic
crusting
NSAIDs
(especially
oxicams), anti-
biotics (sulfa),
antiepileptics,
antiretrovirals
Infections
(eg, HSV,
Mycoplasma),
immunizations
Prodrome: URI,
fever, skin pain,
arthralgias
Usually occurs
710 d after
initiation of
drug
May develop
LAD, hepatitis,
cytopenias,
respiratory or
GI involvement,
photophobia,
odynophagia
Risk of infection,
electrolyte and
uid imbal-
ance, insulin
resistance, mul-
tiorgan failure
Immediately stop
causative drug
Supportive care:
Wound care,
gentle cleansing,
bland emollients
with nonadher-
ent dressings
for erosions, eye
care
Diphenhy-
dramine,
lidocaine, and
Maalox in 1:1:1
mix mouthwash
for mouth pain
Monitor uids,
electrolytes, and
vitals
IVIG: 0.51g/kg/d
for 34 d
SJS TEN
overlap
(10-30%
BSA)
TEN
(>30% BSA)
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Dermatology 123
P
E
D
I
A
T
R
I
C
S
Type Description Pathogenesis Course Treatment
Photodrug Erythematous
patches, papules,
vesicles or bullae
over sun-exposed
areas
Localized burning,
itching
Tetracyclines,
quinolones,
NSAIDs,
antiepileptics,
amiodarone,
thiazides,
voriconazole
After variable
amount of sun
exposure
May cause
scarring
Stop causative
drug, sun
protection, TCS,
antihistamines
Data from J Drugs Dermatol 2003;2(3):278.
TOPICAL CORTICOSTEROID GUIDE*
Class Generic Name Brand Names Vehicles
I
(superpotent)
Augmented betamethasone
dipropionate 0.05%
Diprolene Gel, ointment
Clobetasol propionate 0.05% Clobex, Olux,
Temovate,
Cormax
Shampoo, foam, spray,
solution, gel, lotion,
cream, ointment
Diorasone diacetate 0.05% Apexicon,
Psorcon
Ointment
Fluocinonide 0.1% Vanos Cream
Flurandrenolide 4 mcg/cm
2
Cordran Tape
Halobetasol propionate 0.05% Ultravate Cream, ointment
II
(high potency)
Amcinonide 0.1% Cyclocort Ointment
Augmented betamethasone
dipropionate 0.05%
Diprolene Lotion, cream
Betamethasone dipropionate
0.05%
Diprosone Ointment
Desoximetasone 0.25% Topicort Cream, ointment
Diorasone diacetate 0.05% Apexicon, Psorcon Cream
Fluocinonide 0.05% Lidex Solution, gel, cream,
ointment
Halcinonide 0.1% Halog Solution, cream,
ointment
Mometasone furoate 0.1% Elocon Ointment
III
(medium to
high potency)
Amcinonide 0.1% Cyclocort Lotion, cream
Desoximetasone 0.05% Topicort Gel, cream
Fluticasone propionate 0.005% Cutivate Ointment
Flurandrenolide 0.05% Cordran Lotion, cream, ointment
Triamcinolone acetonide 0.5% Kenalog, Aristocort Cream
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124 Pediatrics
Class Generic Name Brand Names Vehicles
IV
(medium
potency)
Betamethasone valerate Luxiq, Beta-Val Foam, lotion, cream
Hydrocortisone valerate 0.2% Westcort Ointment
Hydrocortisone butyrate 0.1% Locoid Ointment
Mometasone furoate 0.1% Elocon Cream
Triamcinolone acetonide 0.1% Kenalog,
Aristocort
Ointment
V
(medium to
low potency)
Fluticasone propionate 0.05% Cutivate Lotion, cream
Fluocinolone acetonide 0.025% Synalar, Synemol Cream, ointment
Fluocinolone acetonide 0.01% Derma-smoothe Oil
Hydrocortisone valerate 0.2% Westcort Cream
Triamcinolone acetonide 0.01% Kenalog,
Aristocort
Lotion, cream
VI
(low potency)
Aclometasone dipropionate
0.05%
Aclovate Cream, ointment
Desonide 0.05% Desonate,
Desowen, Locara,
Verdeso
Lotion, foam, gel,
cream, ointment
Fluocinolone acetonide 0.01% Capex, Synalar Solution, shampoo,
cream
Hydrocortisone butyrate 0.1% Locoid Cream
Triamcinolone acetonide
0.025%
Kenalog,
Aristocort
Lotion, cream, ointment
VII
(least potent)
Hydrocortisone 2.5% Hytone, Nutra-
cort, Synacort
Lotion, cream,
ointment
Hydrocortisone 1% Many over-the-
counter brands
Spray, lotion, cream,
ointment
Topical corticosteroids (particularly high-potency classes I to III) should not be used continuously for longer
than 2 weeks at a time (or >15 days/mo if used intermittently) to avoid side eects. If longer use is required, wait
2 weeks before restarting. Avoid application of high potency TCS on face, underarms, and groin.
Data from Am Fam Physician 2009;79(2):135 and Nesbitt LT: Glucocorticosteroids. In Bolognia JL, Jorizzo JL, Rapini
RL (eds). Dermatology. London: Elsevier Limited; 2008:1926.
Available at www.AccessPediatrics.com
Acne subtypes
Acne treatment
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