SYMPOSIUM: DERMATOLOGY
Assessing skin disease in
children
Alana Durack
Julia K Gass
Abstract
Skin disease in children is a common presentation in both primary and
secondary care. A focused history and examination in addition to appro-
priate investigations are key to reaching the correct diagnosis. This article
addresses fundamental components of the assessment of children with
skin disease, providing examples of common and important conditions.
Keywords child; diagnosis; differential diagnosis; examination; investi-
gation; skin
Introduction
Children frequently present with a skin problem. This may arise
in a variety of forms from an acute rash to recalcitrant chronic
disease. Even the most experienced clinicians will encounter a
difficult case and revisiting the basic history and examination is
necessary. An essential component of any clinical assessment is
the ability to recognise and describe the findings appropriately. A
clear understanding of the basic descriptive terminology is
invaluable (Table 1).
The aim of this article is to offer non-dermatologists a struc-
tured framework on which to base their approach to assessing
and managing children with skin disease. It will address key el-
ements of history taking, skin examination and investigations,
followed by specific mention to common chronic diseases and
their differentials, as well as conditions in neonates.
History
A good history should reveal the patient and parent’s concerns
and expectations while generating differential diagnoses.
Because the skin is visually apparent, anxiety, (even in benign
conditions) can be significant.
Associated symptoms
The child’s general health should be established in the history.
Although common acute viral exanthems may be associated with
mild systemic upset, the skin can also reflect underlying systemic
disease. Recognising early symptoms of systemic involvement or
the potential for deterioration is vital. Pruritus and pain are often
associated with skin disease and can have a significant effect on
quality of life.
Alana Durack MBChB is a Dermatology Specialist Registrar at
Addenbrooke’s Hospital, Cambridge, UK. Conflict of interest statement:
none declared.
Julia K Gass MBChB is a Consultant Dermatologist at Addenbrooke’s
Hospital, Cambridge, UK. Conflict of interest statement: none declared.
PAEDIATRICS AND CHILD HEALTH 25:2
Timing
Duration and progression over time are important and help to
differentiate conditions which have a similar clinical appearance
e.g. vascular marks in infants, where infantile haemangiomas
have a very different natural progression to vascular
malformations.
Previous treatments and efficacy
In chronic conditions, understanding previous treatments and
the clinical response will guide future management.
Family history
A family history is often present in psoriasis, and one of atopy in
eczema. Household contacts may have similar eruptions with an
infectious aetiology such as scabies or chickenpox. A skin
problem can be the presenting complaint in genetic conditions
where a history of parental consanguinity may be relevant.
General health
A general medical history should include antenatal, perinatal,
and developmental issues, as well as medication and immuni-
zation details.
Examination
The child and parent should be made comfortable during the
consultation, in a room with adequate heat and lighting.
Measuring height and weight provides an indicator of overall
wellbeing. As the skin plays a role in heat regulation, recording
the temperature is important in the presence of a widespread
rash or an unwell child. The entire skin including the hair, nails,
teeth and oral mucosa should be examined. The clinician should
look at the skin to address morphology, distribution and pattern
of the condition and palpate to assess for warmth, tenderness
and subtle elevation.
Pattern, distribution and morphology
The pattern, distribution and morphology of a rash will help to
generate a differential diagnosis. Hand, foot and mouth disease
for instance, is characterized (as its name suggests) by vesicles
on the palms and soles in association with oral mucosal macules,
vesicles and painful ulcers. In the absence of peripheral lesions, a
differential may include herpes simplex virus (HSV), herpangina
or aphthous ulcers.
Another example is guttate psoriasis, which manifests as
discrete erythematous scaling lesions, mainly on the trunk. The
history may reveal a recent sore throat suggestive of a strepto-
coccal infection or a family history of psoriasis. Pityriasis rosea,
can have a similar clinical appearance but features such as the
salmon-coloured, oval lesions oriented along skin folds in a
classic ‘Christmas tree’ pattern and the early presence of a single
‘herald patch’ with a fine collarette scale (circular rim of scale
with loose central portion) should allow differentiation.
Identifying the presence or absence of key features of a
particular condition allows the formulation of likely differentials,
although one should appreciate that not all diseases assume a
classic appearance.
49 Ó 2014 Elsevier Ltd. All rights reserved.
 SYMPOSIUM: DERMATOLOGY

Descriptive terms
Term Features Examples

Bulla Blister >5 mm, containing serous fluid Bullous impetigo

Insect bite reaction
Crust Dried exudate such as pus or blood Impetigo
Infected eczema
Erosion Focal superficial epidermal loss (above the basal layer) Trauma
Staph scalded skin
Erythema Redness due to vascular dilatation Sunburn
Cellulitis
Excoriation Area of eroded skin secondary to scratching Eczema
Lichenification Thickening of skin due to chronic scratching/rubbing Eczema
Macule Flat area of discoloured skin <5 mm Freckle
Measles
Nodule Circumscribed, solid, raised area on the skin >5 mm Pyogenic granuloma
Viral wart
Papule Circumscribed, solid, raised area on the skin <5 mm Molluscum contagiosum
Naevus
Patch Flat area of abnormal skin >5 mm Vitiligo
Plaque Palpable, flat-topped thickening of the skin >1 cm Psoriasis
Scale Fragments of the stratum corneum shed from the skin Tinea capitis
Psoriasis
Vesicle Blister <5 mm, containing serous fluid Pompholyx eczema
Herpes simplex
Wheal Superficial, transient skin oedema Urticaria

Table 1

Investigations fluoresce yellow-green, Microsporum dermatophytes fluoresce

Access to special investigations in primary care or non-
dermatological settings is limited, however there are some sim-
ple investigations that can be useful, particularly to confirm an
infective aetiology. Some skin conditions should always prompt
the clinician to question the possibility of other organ involve-
ment and investigate appropriately. For example, renal impair-
ment is a potentially serious complication of vasculitic conditions
such as Henoch Schonlein purpura. Regular urinalysis and blood
pressure monitoring should form part of follow up care.
Skin swabs and scrapings
Children with chronic inflammatory skin disease e.g. eczema, are
prone to superimposed infection (Figure 1). Repeated courses of
empiric antibiotics without confirmation of the underlying or-
ganism can result in an inadequate response and resistance.
Similarly with suspected fungal infections, a scraping from the
involved skin or clipping from the nail will identify the infective
species, which will guide management. Fungal specimens take a
number of weeks to culture and sampling the edge of the lesion is
likely to provide higher yields.
Swabs of vesicle fluid for herpes simplex PCR (in viral
transport medium) should be considered in suspected eczema
herpeticum.
Wood’s lamp
A Wood’s lamp emits ultra violet light under which certain condi-
tions will fluoresce brightly. For example, Pseudomonas species
green and depigmented areas in conditions such as vitiligo are more
obvious. The examination requires a completely darkened room.
Dermoscopy
A dermatoscope allows magnification and illumination of the
skin to increase the diagnostic accuracy of benign and malignant
pigmented lesions. With training, it can be useful in differenti-
ating pigmented from vascular lesions for example.
Skin biopsy
Where histological confirmation in children is being considered,
referral to secondary care is likely to be appropriate, particularly
as a specialist opinion may well avoid an unnecessary procedure
in a young child.
Chronic skin disease
Eczema
Most clinicians who deal with children on a regular basis will be
able to identify and treat mild eczema. However, some less
common presentations and differentials are discussed below.
Eczema herpeticum
Eczema herpeticum (see Figure 2) is a widespread herpes sim-
plex infection on the background of eczematous skin. It presents
with clusters of painful punched out erosions and possibly ves-
icles, most commonly on the face and neck. This is associated
with worsening eczema and systemic symptoms with the

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 SYMPOSIUM: DERMATOLOGY
Figure 1 Atopic dermatitis with superimposed bacterial infection.
potential for rapid deterioration. If suspected, oral aciclovir
should be commenced, even in localised lesions and an urgent
dermatology assessment arranged. Viral swabs and herpes sim-
plex antibody serology will confirm infection. An ophthalmology
review is important for ocular or periocular involvement.
Discoid eczema
Lesions in discoid (nummular) eczema have a well-defined ‘coin’
shape and similar to other types of eczema, the skin is
erythematous and usually itchy. The distribution is often over the
lower legs, differing from typical atopic eczema in which the
flexural regions are generally involved. Treatment requires reg-
ular emollients and topical steroids, but it is often more resistant
to treatment than other forms of eczema, requiring a higher
Figure 2 Eczema herpeticum.
PAEDIATRICS AND CHILD HEALTH 25:2
potency topical steroid. Given its circular appearance, differen-
tials include fungal infection, psoriasis and contact dermatitis.
Fungal infections tend to have a scaly and elevated edge while
psoriatic plaques generally arise on extensor surfaces, have a
bright red erythematous base and overlying silvery scale.
Contact allergy
Allergic contact dermatitis is a type IV (delayed) hypersensitivity
reaction occurring in previously sensitized individuals. Eruptions
appear within days of exposure to the causative agent. Common
precipitants include medicaments, nickel and plant allergens. The
history, distribution and lack of maintained response to standard
eczema treatment may suggest the diagnosis and patch testing
can confirm the allergen in children old enough to comply.
Acrodermatitis with zinc deficiency
This can have a similar appearance to severe atopic eczema,
presenting as erythematous, inflamed skin over the distal ex-
tremities, perioral and perineal areas (see Figure 3). The skin
becomes crusted, blistered and eroded with the risk of secondary
infection. The child is miserable and there may be associated
diarrhoea and alopecia. It can arise as an inherited autosomal
recessive condition, or due to malabsorption or nutritional
deficit, when it is more common in premature infants. In an ir-
ritable child with failure to thrive and a rash which has an un-
usual distribution for eczema, serum zinc levels should be
checked. Symptoms resolve within weeks of zinc replacement.
Pityriasis alba
Pityriasis alba is a common mild dermatitis presenting as round
patches of dry, scaly pink skin, more common in children with
atopy. Affected areas fade to leave hypopigmentation which is
more pronounced in darker skins. The colour will spontaneously
return to normal within months to years. Emollients and mild
topical steroids may be required if the skin is itchy or erythematous.
Hypo and depigmented conditions
Vitiligo
Vitiligo is an acquired depigmentation of the skin. It is caused by
an immunological reaction to melanocytes and is associated with
an increased risk of other autoimmune conditions e.g. type 1
diabetes and pernicious anaemia. Vitiligo typically presents as
Figure 3 Acrodermatitis secondary to zinc deficiency.
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 SYMPOSIUM: DERMATOLOGY

small, depigmented lesions with irregular borders. The skin
texture is normal and there are no surface changes, such as
scaling. Extensive involvement can cause significant embarrass-
ment. As the skin has lost the ability to form melanin patients
should be aware they are at increased risk of sunburn.
Under a Wood’s light, areas of vitiligo appear bright blue-white
with distinct borders, distinguishing it from hypopigmented con-
ditions such as post-inflammatory hypopigmentation and pityri-
asis alba, which do not fluoresce.
Repigmentation may occur but this is rarely complete. There
are no universally effective treatments and in children with fair
skin types it may be appropriate to manage conservatively with
camouflage cosmetics. Topical steroids and topical calcineurin
inhibitors are used as first line agents, although the latter is
prescribed off-label for this indication.
Post-inflammatory hypopigmentation
Both hypo and hyper pigmentation can occur in children with a
history of inflammatory skin disease such as eczema or psoriasis.
The areas of altered pigmentation correspond to sites of previously
active inflammation. In hypopigmented patches, the absence of
complete depigmentation and the preceding history of inflamma-
tion help to distinguish it from vitiligo. Complete repigmentation
usually occurs over a number of years.
Neonatal conditions
Most skin conditions in neonates are benign and self-limiting. It
is important to differentiate those that need further assessment in
an otherwise healthy infant.
appear as a bruise-like patch or raised, red swellings on the skin
within weeks. They tend to follow a characteristic course,
growing disproportionately in the first weeks and months of life,
followed by a period of slower growth and eventual resolution.
They usually reach their maximum size by 9 months of age, and
then slowly involute over several years (see Figure 4). The le-
sions may be superficial, deep or mixed and the clinical
appearance will generally reflect depth e superficial lesions
appearing bright red (known as strawberry marks) and deep le-
sions having a blue hue.
Most IH require no treatment and education for parents
regarding the natural history may relieve concern. The main in-
dications for active intervention include ulceration, functional
impairment or disfigurement, when use of the oral beta-blocker
propranolol may be appropriate.
Segmental haemangiomas are an uncommon sub-type of IH,
which arise as large, plaque-like lesions. These can be associated
with structural anomalies as part of cutaneous neurovascular
syndromes. PHACES syndrome is an acronym for the abnor-
malities associated with facial segmental haemangiomas: Poste-
rior fossa malformations, Haemangiomas, Arterial anomalies,
Cardiac anomalies, Eye abnormalities and Sternal raphe.
Segmental haemangiomas of the perineum and lumbosacral
region may also be associated with spinal dysraphism and uro-
genital anomalies. If suspected, they should be referred for
assessment.

Common, benign neonatal conditions

Erythema toxicum
Erythema toxicum appears as transitory papules, pustules or
vesicles surrounded by flat areas of erythema, in an otherwise
well child. The trunk, buttocks, and proximal limbs are often
affected. It generally resolves within 2 weeks.

Neonatal pustular melanosis

This is an asymptomatic, idiopathic condition seen more
commonly in neonates with dark skin. Transient vesicles and
pustules are present at birth. These rupture within 48 hours
leaving brown macules which may persist for several months.

Milaria
Milaria is caused by obstruction of immature sweat glands,
resulting in sweat retention. It appears as tiny, easily ruptured
vesicles, itchy red papules or pustules. Overheating from exces-
sive wrapping or phototherapy may exacerbate the condition.

Milia
These are keratin filled cysts which appear as tiny pearly white or
yellow papules. They are frequently seen on the eyelids and
cheeks and resolve spontaneously within months.

Vascular lesions
Infantile haemangiomas
Infantile haemangiomas (IH) are the most common benign
vascular tumour in infancy. IH are typically absent at birth and
Figure 4 A 6-month-old infant with a plaque-like haemangioma over the
occipital and right parietal scalp. The superficial component is prominent.
This child was investigated for possible PHACES syndrome and no asso-
ciated abnormality was found.

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 SYMPOSIUM: DERMATOLOGY

Port wine stain

Port wine stains (see Figure 5) are capillary malformations pre-
senting at birth as a well-defined pink or red patch on the skin,
most commonly on the face. They do not involute but persist into
adulthood, usually assuming a deeper purple colour and some-
times a thickened, nodular appearance. Facial port wine stains
involving the V1 distribution of the trigeminal nerve may be
associated with Sturge Weber Syndrome (SWS) and glaucoma. In
SWS, leptomeningeal angiomas can lead to epilepsy and devel-
opmental delay.

Salmon patch
Salmon patches (see Figure 6) are a more common vascular
malformation which appear as small, flat, pink or red patches
with ill-defined borders. They are commonly found at the nape of
the neck (‘stork bite’), eyelids or between the eyebrows. Most
facial lesions will spontaneously disappear within the first year of
life although ‘stork bites’ tend to be more persistent but go un-
noticed in adulthood as hair growth covers the area.

Summary
Assuming a structured approach to assessing children with a skin
complaint will enable clinicians to formulate an appropriate dif-
ferential diagnosis. With an understanding of the key descriptive
terms used in dermatology, communication with colleagues can
be more effective, allowing for appropriate triaging and manage-
Figure 5 Port wine stain. ment advice. A

FURTHER READING
Irvine A, Hoeger P, Yan A, eds. Harper’s textbook of pediatric dermatology.
3rd edn, vol. 1, 2. Oxford: Wiley-Blackwell, 2011.

Practice points

C Assessing skin disease in children requires a structured approach.

C A clear history and comprehensive examination will ensure
important details are not overlooked.
C Understanding the terms used to describe skin conditions will
enhance communication with dermatologists and enable appro-
Figure 6 Salmon patch. priate triage.
C Skin conditions in infancy can be associated with underlying
Early IH can be mistaken for vascular malformations such as structural abnormalities. If there is doubt, a dermatology opinion
port wine stains (naevus flammeus) or salmon patches (naevus should be sought.
simplex).

PAEDIATRICS AND CHILD HEALTH 25:2 53 Ó 2014 Elsevier Ltd. All rights reserved.