managing-pediatric-dermatology

# Managing Pediatric Dermatology

Identifies and manages common pediatric skin conditions including atopic dermatitis (eczema), diaper dermatitis, viral exanthems, tinea infections, acne vulgaris, warts, molluscum contagiosum, scabies, impetigo, and hemangiomas. Applies morphology-based diagnostic reasoning, age-specific treatment protocols, topical steroid potency selection, and referral criteria for dermatology.

## Why This Skill Exists

Skin conditions account for approximately 30% of outpatient pediatric visits. Diagnostic accuracy depends on correct morphologic description (macule vs. papule vs. vesicle vs. plaque), distribution pattern recognition, and age-specific differential diagnosis. Inappropriate topical steroid use — too potent on the face, too weak on thick plaques, too prolonged without monitoring — is a leading source of iatrogenic harm in pediatrics. This skill enforces systematic morphologic assessment, evidence-based treatment selection with appropriate steroid potency matching, and clear escalation criteria.

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## Checkpoint A — Intake Verification

### Required Intake Questions
1. What is the child's age (neonatal rashes have a distinct differential from toddler or adolescent rashes)?
2. When did the rash appear, and how has it evolved?
3. Is the rash pruritic (itchy), painful, or asymptomatic?
4. Where on the body did it start, and where has it spread?
5. Has the child been febrile or systemically ill?
6. What exposures have occurred (new foods, medications, sick contacts, animals, plants)?
7. Is there a family history of atopic disease (eczema, asthma, allergic rhinitis)?
8. What treatments have been tried (OTC creams, prescription medications)?
9. Has the child had this rash before (recurrent vs. new)?
10. Are there any immunodeficiencies or chronic conditions?

### Required Documents
- Photographs of the rash (if available) with anatomic context
- Medication list (recent antibiotics, anticonvulsants, other medications that cause drug eruption)
- Prior treatment history for this rash
- Allergy history

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## Step 1 — Morphologic Description and Classification

### Primary Lesion Morphology
| Term | Definition | Size |
|------|-----------|------|
| Macule | Flat, color change only | < 1 cm |
| Patch | Flat, color change only | > 1 cm |
| Papule | Raised, solid | < 1 cm |
| Plaque | Raised, solid, flat-topped | > 1 cm |
| Nodule | Raised, solid, deeper | > 1 cm, extends into dermis/subcutis |
| Vesicle | Fluid-filled, clear | < 1 cm |
| Bulla | Fluid-filled, clear | > 1 cm |
| Pustule | Pus-filled | Any size |
| Wheal (hive) | Transient, erythematous, edematous | Variable |
| Petechiae | Non-blanching, red-purple | < 2 mm |
| Purpura | Non-blanching, red-purple | > 2 mm |

### Distribution Patterns
- **Generalized**: consider viral exanthem, drug eruption, systemic disease
- **Flexural** (antecubital, popliteal fossae): atopic dermatitis
- **Extensor** (elbows, knees): psoriasis
- **Dermatomal**: herpes zoster
- **Acral** (hands, feet, mouth): hand-foot-mouth disease, erythema multiforme
- **Diaper area**: candidal vs. irritant dermatitis
- **Exposed skin**: contact dermatitis, insect bites
- **Scalp**: cradle cap (seborrheic), tinea capitis

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## Step 2 — Atopic Dermatitis (Eczema)

### Diagnosis (Hanifin-Rajka Criteria Adapted)
Must have pruritus plus ≥ 3 of: typical morphology and distribution, chronic/relapsing course, personal or family history of atopy, early age of onset

### Age-Specific Distribution
| Age | Distribution |
|-----|-------------|
| Infant (< 2 years) | Face (cheeks), scalp, extensor surfaces |
| Childhood (2-12 years) | Flexural (antecubital, popliteal fossae), wrists, ankles |
| Adolescent/adult | Flexural, hands, eyelids, neck |

### Severity Classification
| Severity | Features | Treatment Approach |
|----------|----------|--------------------|
| Mild | Limited areas, minimal erythema, no sleep disruption | Emollients + low-potency TCS PRN |
| Moderate | Widespread, moderate erythema, excoriation, some sleep disruption | Regular mid-potency TCS, emollients, ± TCI |
| Severe | Extensive, lichenification, fissuring, significant sleep/QOL impairment | High-potency TCS (body), TCI, wet wraps, consider systemic |

### Treatment Ladder
1. **Emollients** (foundation for ALL severity levels): apply within 3 minutes of bathing; ointment > cream > lotion; fragrance-free; minimum BID, ideally after every hand wash
2. **Topical corticosteroids (TCS)**: apply to active lesions only

| Potency Class | Examples | Use On |
|---------------|---------|--------|
| Low (VII) | Hydrocortisone 1%, desonide 0.05% | Face, eyelids, groin, axillae, infants |
| Medium (IV-V) | Triamcinolone 0.1%, fluocinolone 0.025% | Body, extremities (children) |
| High (II-III) | Fluocinonide 0.05%, desoximetasone 0.25% | Thick plaques (palms, soles); short courses only |
| Super-high (I) | Clobetasol 0.05%, betamethasone dipropionate 0.05% | NOT for routine pediatric use; specialist only |

3. **Topical calcineurin inhibitors (TCI)**: tacrolimus 0.03% (age ≥ 2), pimecrolimus 1% (age ≥ 2); use on face and sensitive areas to avoid steroid atrophy; FDA black box (theoretical lymphoma risk — clinical data reassuring)
4. **Wet wrap therapy**: for severe flares; apply TCS, then wet layer, then dry layer; 2-3 hours or overnight
5. **Systemic therapy** (specialist-directed): dupilumab (age ≥ 6 months for moderate-severe), oral JAK inhibitors (upadacitinib, abrocitinib — ages 12+), cyclosporine (off-label), methotrexate (off-label)

### Infection Recognition (Eczema Herpeticum Emergency)
- Monomorphic punched-out vesicles/erosions on eczematous skin with fever → eczema herpeticum (HSV superinfection)
- Medical emergency: admit; IV acyclovir
- Bacterial superinfection: honey-crusted lesions (impetigo from S. aureus or GAS) → topical mupirocin or oral cephalexin

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## Step 3 — Diaper Dermatitis

### Irritant Contact Dermatitis (Most Common)
- Erythema in convex surfaces (spares creases/folds)
- Caused by prolonged contact with urine/stool, friction
- **Treatment**: frequent diaper changes, barrier ointment (zinc oxide, petrolatum), low-potency TCS for severe inflammation (hydrocortisone 1% BID × 3-7 days)

### Candidal Diaper Dermatitis
- Beefy red erythema WITH satellite papules/pustules, involves creases/folds
- Often follows antibiotic use
- **Treatment**: topical nystatin or clotrimazole with every diaper change × 7-14 days
- If concurrent with irritant dermatitis: combination therapy (nystatin + barrier cream); AVOID combination products containing high-potency steroids (e.g., Lotrisone)

### Allergic Contact Dermatitis
- Consider if resistant to standard treatment: fragrance in wipes, rubber in diapers, preservatives
- Patch testing by dermatology if suspected

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## Step 4 — Infectious Dermatoses

### Tinea (Dermatophyte Infections)
| Type | Presentation | Treatment |
|------|-------------|-----------|
| Tinea corporis (body) | Annular, scaly, raised border, central clearing | Topical antifungal (clotrimazole, terbinafine) × 2-4 weeks |
| Tinea capitis (scalp) | Scaly patches, broken hairs, +/- kerion; **must use KOH prep or culture** | Oral griseofulvin 20-25 mg/kg/day × 6-8 weeks (must be systemic; topicals do not penetrate hair follicle); terbinafine as alternative |
| Tinea pedis (feet) | Interdigital maceration, scaling on soles | Topical antifungal × 2-4 weeks |

> Tinea capitis ALWAYS requires oral antifungal therapy. Topical therapy alone is ineffective.

### Impetigo
- **Non-bullous**: honey-crusted lesions; S. aureus or GAS
  - Limited disease: topical mupirocin BID × 5 days
  - Widespread: oral cephalexin 25-50 mg/kg/day ÷ TID × 7 days
- **Bullous**: flaccid bullae; S. aureus toxin-mediated
  - Oral cephalexin or clindamycin (if MRSA concern) × 7 days

### Molluscum Contagiosum
- Flesh-colored, dome-shaped papules with central umbilication; poxvirus
- Self-limited (resolves in 6-18 months typically)
- Treatment optional: cantharidin (office-applied), curettage, cryotherapy
- Avoid aggressive treatment in young children — scarring risk exceeds disease burden

### Scabies
- Intensely pruritic; worse at night; burrows, papules, vesicles in web spaces, wrists, axillae, groin
- Infants: may involve face, scalp, palms, soles (unlike older children/adults)
- **Treatment**: permethrin 5% cream — apply neck to toes (head to toes in infants < 2 months), leave on 8-14 hours, rinse; repeat in 1 week
- Treat ALL household contacts simultaneously regardless of symptoms
- Wash all bedding and clothing in hot water; items that cannot be washed — seal in plastic bag × 72 hours

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## Step 5 — Viral Exanthems

### Common Viral Rashes in Children
| Condition | Agent | Rash Description | Key Features |
|-----------|-------|-----------------|--------------|
| Roseola (exanthem subitum) | HHV-6 | Maculopapular, starts on trunk after fever breaks | High fever × 3-5 days, then rash as fever resolves; age 6-24 months |
| Fifth disease (erythema infectiosum) | Parvovirus B19 | "Slapped cheek" → lacy reticular rash on trunk/extremities | No longer contagious when rash appears; concern in pregnancy and sickle cell |
| Hand-foot-mouth | Coxsackie A16, EV71 | Vesicles on palms, soles, oral mucosa | May cause nail shedding (onychomadesis) weeks later |
| Measles | Paramyxovirus | Maculopapular, starts at hairline, spreads caudally | Koplik spots (buccal mucosa), cough, coryza, conjunctivitis |
| Varicella | VZV | Vesicles on erythematous base, crops in different stages | "Dew drop on a rose petal"; lesions in various stages simultaneously |

### Red Flag Rashes (Urgent)
- **Petechiae/purpura with fever**: meningococcemia until proven otherwise → blood culture, antibiotics immediately
- **Target lesions + mucosal involvement**: Stevens-Johnson syndrome / toxic epidermal necrolysis → stop offending drug, ICU transfer
- **Diffuse erythroderma + desquamation + fever**: staphylococcal scalded skin syndrome or toxic shock → admit, IV antibiotics
- **Eczema herpeticum**: punched-out vesicles on eczema → IV acyclovir

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## Step 6 — Adolescent Acne

### Classification
| Severity | Description | Treatment |
|----------|-------------|-----------|
| Mild (comedonal) | Open/closed comedones; few inflammatory papules | Topical retinoid (adapalene 0.1%) ± benzoyl peroxide |
| Moderate (inflammatory) | Papules and pustules | Topical retinoid + benzoyl peroxide + topical antibiotic (clindamycin) |
| Moderate-severe | Numerous papules/pustules, some nodules | Oral antibiotic (doxycycline 50-100 mg BID) + topical retinoid + BP |
| Severe (nodulocystic) | Nodules, cysts, scarring | Refer for isotretinoin consideration |

### Acne Treatment Rules
- Topical retinoids are the foundation (comedolytic + anti-inflammatory); use nightly; warn about initial worsening and photosensitivity
- Benzoyl peroxide: bactericidal; prevents antibiotic resistance; use as combination with topical antibiotics, never topical antibiotics alone
- Oral antibiotics: limit duration to 3 months when possible; always combine with topical retinoid + BP
- Isotretinoin: requires iPLEDGE program enrollment (pregnancy prevention), monthly pregnancy tests, lipid/LFT monitoring
- Hormonal therapy: combined OCP or spironolactone for females with hormonal acne pattern (jawline, flaring with menses)

### Neonatal and Infantile Acne
- Neonatal acne (< 6 weeks): small closed comedones, cheeks; benign, resolves spontaneously; no treatment needed
- Infantile acne (3-6 months): may be inflammatory; can scar; topical retinoid + BP; referral if severe or persistent (rule out androgen excess)

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## Checkpoint B — Dermatology Management Review

- [ ] Morphology described using standard dermatologic terminology
- [ ] Distribution pattern documented
- [ ] Age-appropriate differential diagnosis generated
- [ ] Diagnosis established with supporting clinical rationale
- [ ] Treatment selected with appropriate potency/formulation for location and age
- [ ] Topical steroid potency matched to body site and severity
- [ ] Infection recognized and treated (bacterial, fungal, viral, parasitic)
- [ ] Red flag rashes identified and escalated appropriately
- [ ] Parent/patient education provided (application technique, expected timeline)
- [ ] Follow-up plan established (2-4 weeks for treatment response assessment)
- [ ] All [VERIFY] flags resolved or escalated

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## Quality Audit

| Item | Requirement | Pass? |
|------|-------------|-------|
| Morphologic description | Standard terminology used (not just "rash") | |
| Distribution documented | Body sites specifically listed | |
| TCS potency matching | Correct potency for body site (low for face, medium for body) | |
| Eczema management | Emollient-first approach documented; TCS not sole treatment | |
| Tinea capitis | Oral antifungal prescribed (not topical alone) | |
| Red flag recognition | Petechiae, SJS, eczema herpeticum flagged for urgent management | |
| Scabies treatment | All household contacts treated simultaneously | |
| Acne antibiotic stewardship | No topical antibiotic monotherapy; oral antibiotics time-limited | |
| Age-appropriate treatment | Medications and formulations suitable for patient age | |
| No unexplained [VERIFY] tags | All flagged items resolved or escalated | |

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## Guidelines

- Follow AAP/AAD guidelines for atopic dermatitis management (stepwise approach)
- Apply Hanifin-Rajka diagnostic criteria for atopic dermatitis
- Follow AAD guidelines for acne vulgaris management (updated 2024)
- Topical steroid potency: use the lowest effective potency; National Eczema Association and AAD provide potency classification (Class I-VII)
- Dupilumab: FDA-approved for moderate-severe atopic dermatitis ages ≥ 6 months
- Tacrolimus/pimecrolimus: FDA-approved for ages ≥ 2; FDA black box regarding theoretical malignancy risk; use as steroid-sparing agent
- Griseofulvin remains first-line for tinea capitis in children per AAP; terbinafine is an alternative with shorter course
- Permethrin 5% is first-line for scabies; ivermectin oral (200 µg/kg) is alternative for age ≥ 15 kg or refractory cases
- Isotretinoin: iPLEDGE program mandatory; pregnancy test monthly; monitor CBC, lipids, LFTs
- Eczema herpeticum is a dermatologic emergency requiring immediate antiviral therapy
- Non-blanching petechiae or purpura with fever = meningococcemia workup until excluded
- This skill produces clinical documentation; it does not replace clinical judgment