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Chapter 45
Alterations of the Integument in
Children
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Acne Vulgaris
Most common skin disease
Affects 85% of people between ages 12 and
25
Acne conglobata
Highly inflammatory form of severe acne
Formation of communication cysts and abscesses
beneath the skin
Sebaceous follicles sites for acne lesions
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Acne Vulgaris
Noninflammatory acne
Blackheads
Whiteheads
Inflammatory acne
Caused by follicular wall rupture in closed
comedones (whiteheads)
Cystic nodules develop when inflammation is
deeper, may cause scarring
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Acne Vulgaris
Physiologic factors
Follicular hyperkeratinization, excessive sebum
production, colonization of Propionibacterium
acnes, and inflammation secondary to the action
of inflammatory products produced by P. acnes
Excessive production of sebum is related to
androgenic hormones
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Acne Vulgaris: Treatment
Diet not proven to cause acne
Dietary restrictions are generally not effective
Topical treatment: first line of therapy; if this fails
use systemic therapies
Acne surgery, including comedo extraction,
intralesional steroids, cryosurgery useful
Severe scarring treated with dermabrasion or
subincision
Special consideration given to treatment for
those with darker-colored skin due to greater
risk for hyperpigmentation and keloidal scarring
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Cystic Acne
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Atopic Dermatitis
Most common form of eczema in children
Cause unknown, but 80% demonstrate a
personal or family history of asthma or
allergic rhinitis
Manifestations
Increased IgE levels, positive allergen skin tests,
and eosinophilia
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Atopic Dermatitis
Infants
Children and adults
Rash appears on the face, scalp, trunk, and
extensor surfaces of the arms and legs
Rash tends to be on the neck, antecubital and
popliteal fossae, hands and feet
Lichenification (thickening of the epidermis
from constant scratching)
Common in adults with chronic eczema
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Atopic Dermatitis
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Diaper Dermatitis
Inflammatory disorders affecting the lower
abdomen, genitalia, buttocks, and upper thigh
A nonallergic contact dermatitis
Inflammation encouraged by prolonged exposure
to irritation by urine and feces, maceration by wet
diapers, airtight plastic diaper covers, and possible
association with intercurrent illness and early
introduction of cereals
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Diaper Dermatitis
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Infections of the Skin
Bacterial infections
Impetigo contagiosum
• Superficial infection usually caused by Staphylococcus or
group A streptococci
• High incidence in hot, humid climates
Bullous impetigo
• Rarer variant of impetigo caused by Staphylococcus
aureus
• Staphylococci produce a bacterial toxin called exfoliative
toxin (ET), which causes a disruption in desmosomal
adhesion molecules with blister formation
• Occurs in newborns and is highly contagious
• Source is usually a staff member in a newborn nursery or
a family member with a pustule or who is an
asymptomatic carrier
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Infections of the Skin
Bacterial Infections
Vesicular impetigo
• Contagious, acute, superficial, vesiculopustular form of
impetigo caused by group A Streptococcus pyogenes
(alone or in combination with Staphylococcus aureus)
• Microorganisms disseminated by direct physical contact
from other infected individuals or through insect bites
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Impetigo
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Infections of the Skin
Bacterial infections
Staphylococcal scalded-skin syndrome (SSSS)
• Serious infection caused by exfoliative toxin producing group II
staphylococci
• Exfoliative toxin attacks desmoglein and adhesion molecules;
causes separation of the skin just below the stratum granulosum
• Manifestations
Fever, malaise, rhinorrhea, and generalized erythema and skin
tenderness
Seen in infants and children younger than 5 years
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Infections of the Skin
Fungal infections
Fungi causing superficial skin lesions are called
dermatophytes
Fungal disorders are called mycoses; mycoses
caused by dermatophytes are termed tinea
• Tinea capitis (scalp)
• Tinea pedis (athlete’s foot)
• Tinea corporis (ringworm)
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Tinea Capitis
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Infections of the Skin
Fungal infections
Thrush
• Candida present in mucous membranes of the mouths of
infants, and less commonly in adults
• Characteristics
White plaques or spots in the mouth that lead to shallow
ulcers
• Thrush can spread to the groin, buttocks, and other parts
of the body
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Infections of the Skin
Viral infections
Molluscum contagiosum
• Highly contagious pox viridae infection of the skin
• Skin-to-skin and fomite transmission
• The virus encourages epidermal cell proliferation and
blocks the immune response
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Molluscum Contagiosum
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Infections of the Skin
Viral infections
Rubella (German measles or 3-day measles)
• RNA virus
• The disease is mild in most children
• Manifestations
Enlarged cervical and postauricular lymph nodes, lowgrade fever, headache, sore throat, runny nose, cough
Faint pink to red maculopapular rash caused by virus
dissemination to the skin
• Vaccination for rubella combined with mumps and
rubeola (measles) (MMR)
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Infections of the Skin
Viral infections
Rubeola
• RNA paramyxovirus
• High fever, malaise, enlarged lymph nodes, runny nose,
conjunctivitis, barking cough
• Koplik spots
Roseola
• Fever and an erythematous macular rash that lasts about
24 hours
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Infections of the Skin
Viral infections
Chickenpox (varicella) and herpes zoster
(shingles)
• Both diseases are produced by the same virus
• DNA virus
• Infection occurs within keratinocytes
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Measles and Chickenpox
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Insect Bites and Parasites
Scabies
Contagious disease caused by the itch mite
Sarcoptes scabiei
Transmitted by personal contact and infected
clothing and bedding
Female mite tunnels millimeters to 1 cm into the
stratum corneum, deposits eggs, and over a 3week period, the eggs mature into adult mites
Primary lesions are burrows, papules, and
vesicular lesions with severe itching
Patient at risk for infections from scratching
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Scabies
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Insect Bites and Parasites
Pediculosis
Pediculus capitis (head), Pediculus corporis
(body), and Phthirus pubis (crab or pubic)
Highly contagious parasite that survives by
sucking blood
• Acquired through personal contact and shared clothing,
combs, or brushes
Female louse reproduces every 2 weeks and
produces hundreds of nits
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Insect Bites and Parasites
Flea bites
Cat, dog, and human fleas
Occur in clusters along the arms and legs
Characteristic lesion is an urticarial wheal with a
central hemorrhagic puncture
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Insect Bites and Parasites
Bedbugs (Cimex lectularius)
Live in the crevices and cracks of floors, walls,
and furniture and in bedding or furniture stuffing
3 to 5 mm long and reddish brown
Feed in the darkness
• Attach to the skin, suck blood, and leave
Lesions: red macules; develop into nodules
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Flea and Bedbug Bites
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Hemangiomas
Benign tumors
From rapid growth of vascular endothelial cells and
formation of extra blood vessels
Females affected more often than males
Superficial: strawberry hemangiomas
Deep: cavernous hemangiomas
Etiology: embolization of fetal placental
endothelial cells related to placental trauma or
loss of placental angiogenic inhibitor of placental
and maternal origin
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Hemangiomas
Proliferation of mast cells, thought to promote
angiogenesis
Infiltration of fat cells, fibrosis, and rich
vascular network; females affected more
often than males
30% of hemangiomas seen at birth; most
emerge during first few weeks of life
Grow rapidly during the first few years of life, then
shrink or involute
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Hemangiomas
Strawberry hemangiomas
Raised vascular lesions that usually emerge 3 to 5
weeks after birth
Lesions proliferate, become bright red, and
elevate with small capillary projections
Cavernous hemangiomas
Present at birth
Involve larger and more mature vessels than
strawberry hemangiomas
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Strawberry and
Cavernous Hemangiomas
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Vascular Malformations
Port-wine stains
Congenital malformation of dermal capillaries
Flat, pink, to dark reddish-purple lesions
Salmon patches
Macular, pink lesions resulting from distended
dermal capillaries; usually fade by 1 year of age
Common on the nape of the neck, forehead, upper
eyelids, or nasolabial folds
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Miliaria
Vesicular eruption after prolonged exposure
to perspiration, with subsequent obstruction
of eccrine ducts
Miliaria crystallina
• Ductal rupture within the stratum corneum
• Clear vesicles without erythema
Miliaria rubra (prickly heat)
• Erythematous papules and papulovesicles
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Miliaria Rubra
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Other Skin Disorders
Erythema toxicum neonatorum
Benign, erythematous macules, papules, or
pustules; appear at birth or 3 to 4 days later
No treatment is required
Toxic epidermal necrolysis (TEN) and
Stevens-Johnson syndrome
Rare, severe drug reactions with widespread
epidermal apoptosis and detachment
Mortality rates between 20% and 60%
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