By Ashley Chakales, Ryan Wealther, Marie Vu and John Browning, MD, FAAD, FAAP, MBA

A Guide to Common Pediatric Skin Conditions

By Ashley Chakales, Ryan Wealther, Marie Vu and John Browning, MD, FAAD, FAAP, MBA

kin conditions are commonly encountered in the primary care clinic. In this article, we highlight four common pediatric skinS conditions often encountered by primary care physicians, including clinical pearls and when a referral to a dermatologist is warranted. Atopic Dermatitis

Atopic Dermatitis (AD) affects 11-12% of children in the United States. Several mechanisms have been proposed for the pathophysiology of AD, including epidermal barrier dysfunction, immune dysregulation, genetic predisposition, as well as environmental triggers.6 The classic lesion is a pruritic, erythematous rash (Figure 1). The distribution differs with age, with the face and extensors primarily affected in children ages 0-2 years and flexural surfaces primarily affected in adolescents. Common treatments for AD include gentle skin care practices (mild cleansers and bland emollients), topical corticosteroids and non-steroidal topicals (topical calcineurin inhibitors, topical phosphodiesterase-4 inhibitors).

Figure 1:

Clinical Pearls: A common mistake in the management of AD is undertreatment. 5 “Topical steroid phobia” is prevalent among patients because misinformation regarding potential side effects is often overemphasized on the internet.9 Providers play an important role in debunking inaccurate information to increase treatment adherence. Additionally, the diagnosis of AD in skin of color patients is challenging because erythema may be difficult to visualize.2 It is always important to ask about pruritus, as it is the hallmark symptom of AD. When to refer: A referral to a dermatologist is recommended when attempts at initial management have not been successful, the patient has frequent flare-ups or the condition is causing psychosocial disturbance. Allergic Contact Dermatitis Allergic contact dermatitis (ACD) is a type four hypersensitivity reaction consisting of two phases: sensitization followed by elicitation. During sensitization, a hapten penetrates the skin and forms an antigen complex, inducing an immune response. Upon re-exposure to the same culprit, immune cells recognize and process the allergen and induce a local inflammatory response. The classic lesion is a localized, pruritic, eczematous eruption (Figure 2). Common culprits include poison ivy, nickel, topical antibiotics (neomycin, bacitracin), fragrance and preservatives.10

Image: Procedural Pediatric Dermatology8 Figure 2:

Clinical Pearls:

It can be difficult to elicit the cause of ACD when it is from an everyday product. Fragrance, preservative and topical antibiotic allergy are notoriously difficult to diagnose. Allergy to neomycin or bacitracin often resembles an infection and can lead to inappropriate use of oral antibiotics. When the cause of ACD is unknown, a gentle skin care routine can be recommended. This includes use of a fragrance-free bar soap, a bland emollient, and hypoallergenic shampoo and conditioner. Once the dermatitis subsides, slow reintroduction of normal products can begin until the allergen is determined.

When to refer: When the offending agent causing ACD cannot be identified, a referral to a dermatologist will be beneficial. An extended patch testing can be performed to determine the underlying allergies and develop a treatment plan.

Tinea Tinea infections are caused by fungi known as dermatophytes and are classified by the involved site. The classic lesion is an erythematous, scaly plaque with an active border that spreads centrifugally and is followed by central clearing (Figure 3). This is where tinea gets its common name: ringworm. While most tinea infections are more common in adults, tinea capitis is more common in children.3 It usually presents as localized alopecia with scaling. Tinea capitis requires prolonged treatment with oral antifungals, as topical antifungals do not reach the root of the hair follicle.

Figure 3:

Image: Centers for Disease Control and Prevention 4

Clinical Pearls: Griseofulvin for 6 to 12 weeks is the first-line therapy for tinea capitis;11 however, the effective dose for griseofulvin (20 to 25 mg/kg/day) has increased from what was previously recommended (10 to 15 mg/kg/day).7 It is not uncommon to see sources still list the lower dose (e.g., Epocrates). Utilization of this low dose is a common reason for treatment failure and referral to dermatologists. It is also important to recommend that griseofulvin be given in a single daily dose (better compliance than with BID dosing) and with a fatty meal11 (better absorption). Additionally, hepatic monitoring with griseofulvin is unnecessary unless treatment extends beyond 8 weeks.7 When to refer:

Most tinea infections respond well to antifungal medications. Referral to a dermatologist should be considered when the presentation is severe or recalcitrant, such as a kerion with tinea capitis or Majocchi’s granuloma with tinea corporis.

Acne Vulgaris

Acne is very common among adolescents and young adults, with nearly 85% of teenagers affected at some point (Figure 4). The understanding of acne is constantly evolving, but is thought to involve a combination of factors such as follicular hyperkeratinization, sebum production, genetic factors, and diet, among other causes. There is currently no universal grading system to assess severity of acne; however, classifying acne based on number, type and location of lesions can help facilitate therapeutic decisions. The treatment for acne depends on the severity.12

Figure 4:

Image: Procedural Pediatric Dermatology8

Clinical Pearls: Topical retinoids, which are some of the most effective treatment options for acne, are often underutilized. Many providers tend to reserve topical retinoids for comedonal acne, even though they have a role in effectively treating inflammatory acne.1 Counseling patients on the purpose of medications prescribed, how to correctly use them, side effects to expect, and the time frame for which they can expect noticeable results is important for medication adherence. Irritation from topical retinoids is common and expected, often resolving after a few weeks of treatment.

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When to refer:

The following all warrant a referral to a dermatologist: abrupt onset of extensive acne, no improvement with conservative management, cystic or nodular acne that is considered moderate to severe, new onset of acne after initiation of systemic medication, and acne that is negatively affecting psychosocial well-being.12

References: 1. Balkrishnan, R., Fleischer Jr, A., Paruthi, S., & Feldman, S. (2003).

Physicians underutilize topical RETINOIDS in the management of acne vulgaris: Analysis of U.S. National practice data. Journal of

Dermatological Treatment, 14(3), 172-176.doi:10.1080/095466 30310012037 2. Ben-Gashir, M., Seed, P., & Hay, R. (2002). Reliance on erythema scores may mask severe atopic dermatitis in black children compared with their white counterparts. British Journal of Dermatology, 147(5), 920-925. doi:10.1046/j.1365-2133.2002.04965.x 3. Bolognia, J., Schaffer, J. V., Duncan, K. O., & Ko, C. J. (2014). Dermatology essentials. Oxford: Saunders/Elsevier. 4. Centers for Disease Control and Prevention [Ringworm]. (2021).

Retrieved from https://www.cdc.gov/fungal/diseases/ringworm/ symptoms.html. 5. Fishbein, A. B., Hamideh, N., Lor, J., Zhao, S., Kruse, L., Mason,

M., . . . Kaye, B. (2020). Management of atopic DERMATITIS in children younger than two years of age by COMMUNITY PE-

DIATRICIANS: A survey and chart review. The Journal of Pediatrics, 221. doi:10.1016/j.jpeds.2020.02.015 6. Kim, J., Kim, B. E., & Leung, D. Y. (2019). Pathophysiology of atopic dermatitis: Clinical implications. Allergy and Asthma Proceedings, 40(2), 84-92. doi:10.2500/aap.2019.40.4202 7. Kimberlin, D., Barnett, E., Lynfield, R., & Sawyer, M. (2021). Red

Book (2021): Report of the Committee on Infectious Diseases, 32nd Ed. Itasca, IL: American Academy of Pediatrics. 8. Krakowski. (2021). Retrieved from Procedural pediatric dermatology. 9. Li, A. W., Yin, E. S., & Antaya, R. J. (2017). Topical corticosteroid phobia in atopic dermatitis. JAMA Dermatology, 153(10), 1036. doi:10.1001/jamadermatol.2017.2437 10.Novak-Bilić, G. (2018). Irritant and allergic contact dermatitis –skin lesion characteristics. Acta Clinica Croatica. doi:10.20471/ acc.2018.57.04.13 11.Treat, J.R. (2021). Tinea Capitis. UpToDate. Retrieved August 8, 2021, from https://www.uptodate.com/contents/tinea-capitis 12.Zaenglein AL, Pathy AL, et al. (2016). Guidelines of care for the management of acne vulgaris. Journal of the American Academy of Dermatology. 74, 945-973. doi:10.1016/j.jaad.2015.12.037

Ashley Chakales, Ryan Wealther and Marie Vu are medical students at the UT Health San Antonio Long School of Medicine. They all serve as leaders of the school’s Dermatology Interest Group.

John Browning, MD, FAAD, FAAP, MBA is board-certified in pediatrics, dermatology and pediatric dermatology. He is an adjunct associate professor at UT Health San Antonio, assistant professor at Baylor College of Medicine and clinical faculty at the UIW School of Medicine.