Paediatric Dermatology is an area of dermatology which is dedicated to baby, child and teenager skin. Children are not little adults and have different needs when it comes to skin disease so they have a different approach by a paediatric dermatologist with experience on diseases which affect only children.
The most common pathologies in a consultation are eczema or atopic dermatitis, child hemangioma and vascular malformations, congenital moles, viral infections (contagious mollusc and warts), acne (neonatal, child and common), actinic keratosis, alopecia areata, fungical infections, viral and paraviral skin rash, mastocytosis, acquired ‘moles’ (as coffee and milk stains, the ‘pilomatricoma’, Spitz Nevi, Juvenile Xanthogranuloma or the granuloma), perioral dermatitis, ‘estrofulo’ and diaper rash.
Some skin lesions may be the first sign of genetic diseases which affect different organs of the body and appear later in life. Unfortunately, most of them do not have a cure but an early diagnosis allows the prevention and early treatment of many associated complications with an important improvement of the prognosis and quality of life.
Skin diseases which also appear in adults have a different expression in paediatric age. For example, in adults suffering of psoriasis, we usually see red placques covered with thick silver scales, on the body and member surfaces (mostly elbows and knees). When it comes to children, legions are pinkish, thinner, with less scales, usually on the face and genital area.
Although most of the cutaneous pathology is begnin for children, it may have a great impact on their self-esteem, body image and familiar, social and school integration. As for parents, it may also cause guilt, anxiety and frustration. We try to approach these not always obvious aspects in
the paediatric dermatology consultation.
Treatments should also be adjusted to babies and children: Their skin is more permeable, the relation surface/volume is different and the creams, lotions and ointments used in the treatment may cross the cutaneous barrier and cause potentially serious secondary effects. As a precaution, some medication is frequently avoided even when they could help in the treatment of a certain cutaneous infliction. It is important to be updated with medication and treatment during paediatric age.
Any cutaneous rash occorruring on the area covered by a diaper is called diaper dermatitis. It may have various causes and consequently different treatments.
Diaper dermitis is usually caused by humidity and friction which are usual in that area. Urine and feces may cause even more irritability as well as some products used to clean the skin. The irritaded skin is more susceptible to infection by bacteria and fungus, which makes the eruption worse. Diaper dermitis can cause or aggravate other cutaneous diseases as, for exemple, psoriasis.
It is more frequent on newborns and babies on breast milk but anyone with a diaper is subject to having a diaper dermitis. Nearly half the babies develop a diaper dermitis at some time during the first or second year of life. It is more frequent between 9 and 12 months old and when the child has diarrhea or bowel alterations (by sickness, medicine taking or diet change).
Change the diaper frequently.
Subject to the cause, the doctor may prescribe a topic antibacterial, anti fungus or anti inflammatory medicine. It is important to maintain all prevention care and follow the dosage for 1 or 2 weeks because diaper dermitis takes some time to be solved. There are some factors to take into account:
In rare cases, diaper dermitis may be associated to more serious diseases: You should go to a paediatric dermatologist when:
Child hemangioma is the most common benign tumor in a child. It originates on the accelerated proliferation of cells related to small skin blood vessels and, sometimes, also on internal organs such as the liver, the bowels or the larynx. It is estimated to affect 1 in every 15 babies, more frequent on girls, premature babies, newborn babies with low weight and babies from mothers who were subject to invasive exams during pregnancy.
It appears days to weeks after birth, emerging as a reddish or bluish stain similar to a hematoma, which grows very rapidly along the following weeks rising above the skin. The diameter can vary from a few milimeters to several centimeters (it may cover the full extension of a member).
Depending on the depth of the tumour, the colour can be a deep red like a strawberry or raspberry (superficial hemangioma) or skin coloured to bluish (deep hemangioma) – Images 1 and 2. This rapid development is a frequent motive for concern for parents. Fortunately, after a variable period of some weeks or months, the proliferation stabilizes and is followed by a period of a much slower regression which ends in an almost complete lesion reversion, leaving a minimum residue in most cases.
For centuries, vascular lesions on newborns were called nervus maternus, reflecting the popular belief that the mother was responsible for her child’s lesion.
It was believed that emotions and maternal desires could leave a “mark” on newborn babies and, depending on the culture and tradition of different regions, mothers were guilty of intaking, or not, certain red fruits or other food during pregnancy, food that caused characterized lesions like strawberry or raspberry. Despite the fact that the pathogenesis of hemangiomas are not completely clarified, we know now that these beliefs have no scientific basis and that hemangiomas develop as a response to a sudden and transitory local reduction of the levels of oxygen in the placenta, unpredictably and regardless of any maternal behaviour.
The age when it appears, the clinical evolution and the appearance of hemangiomas are so characteristic that most of them are clinically diagnosed without the need of a Cutaneous biopsy or imaging examinations (ultrasonography, doppler, magnetic resonance) for confirmation. However, other tumours or vascular malformations of the newborn may be hard to distinguish from child hemangioma in the first months of life. They are rarer lesions and potentially much more serious so a correct early diagnosis is fundamental for adequate follow-up and treatment. It is, therefore,
important to refer it to the paediatric dermatologist, paediatrician or vascular surgeon with experience on vascular lesions, in less clear situations or when the clinical evolution is not the expected.
In most cases child hemangiomas recede spontaneously without or with very few sequels, usually until 5 years of age (later in some situations) and there is no need to treat them actively. Sometimes it is difficult to predict the magnitude of the proliferation, namely the final size and whether the growth is so fast that it leads to ulceration (wound) on the superficial part of the hemangioma. For that reason there must be a frequent clinical follow-up during tthe first weeks and months of life, so that an intervention can take place if necessary.
Child hemangiomas can be associated to more or less serious complications, depending on the size, location and number of lesions:
In all cases described above and other cases with a functional impact there is a formal indication for oral treatment with propanolol, a medicine used to treat high blood pressure and heart failure, which in 2008 proved to be highly effective in the treatment of child hemangioma. The effectveness is even greater when used in the early stages during the active proliferation (5 weeks to 4 months of life).
Treatment should only be initiated after a complete clinical exam and exclusion of side effects and the first dosage should be given under clinical monitoring (blood pressure, heart beat, levels of sugar). In some selected cases, the first dosage should happen in a hospital. Some superficial hemangiomas, small and without any functional impact can be treated with a medicine from the family of propranolol with topic application. If there are permanent sequels (disfiguring scars, residual dilated blood vessels) they can be treated with laser or surgical removal.
(Pic. 3, 4 and 5)
Child hemangioma is the most common begnin tumour during childhood, it appears on the first days to weeks of life and has a characteristic evolution, rapid growth and stabilization in the first year of life followed by a spontaneous slower regression, not needing treatment in most cases. It should always be evaluated by a specialist on this kind of lesions in order to determine the best procedure and prevent possible complications.
Pic. 1: Superficial hemangioma
Pic. 2: Deep Hemangioma
Pic. 3: Big facial hemangioma at 3 months of age and 3 months after starting oral treatment still with dilated vessels.
The excessive sun exposure is particularly agressive during childhood and teenage years. On the one hand, children skin is much lighter than adults’ because it has not been stimulated by sun radiation yet. On the other hand, signs of alarm (redness, burning feeling) are also undervalued by children. Several studies demonstrate that the risk of malignant melanoma is associated to the occurrence of repeated sunburn during the first 18 years of life. Taking into account that children are usually more exposed to the sun than adults and a great part of cumulative sun exposure in life occurs in the first 18 years, sun protection will have a huge impact on the reduction of the risk of cancer in adult life.
Child hemangioma is the most common benign tumour during childhood, it appears in the first days to weeks of life and has a characteristical evolution with a rapid growth and stabilization in the first year of life and a slower spontaneous regression. It arises as a reddish or bluish stain, similar to a hematoma, which grows very rapidly during the following weeks, rising above the skin. The diameter may vary from a few milimeters to several centimeters (it may take the whole extension of a limb).
Depending on the depth of the tumour, the colour can be a bright red like a strawberry or raspberry (superficial hemangiomas) or skin to bluish colour (deep hemangiomas). It should always be evaluated by a specialist with experience in this kind of lesion in order to define the best practice and prevent possible complications.
The atopic eczema (or atopic dermitis) is a chronic inflammatory disease that can appear in the first months of life. Although in many cases there is a progressive improvement along childhood, it can develop during teenage and adult life. An early and effective control can reduce the duration of the disease and improve the child’s quality of life to a great extent. Located treatments with corticosteroids cream or ointment, associated to moisturising creams which restore the cutaneous barrier and anti imflammatory creams, are the primary treatment against imflammation. If used according to personal medical prescription they are safe and effective.
There are several possible causes for white patches (hypopigmentation) during childhood. Vitiligo (characterized by totally depigmented patches) often appears during childhood but it is an exception in the first years of life. At this age, light stains can be only “innocent signs” or have diverse genetic, inflammatory or infectious causes. Firstly, we have to differentiate between a total absence of skin pigmentation (hypopigmentation) and a reduction of the pigmentation (depigmentation), which can be done by using a special lamp, the Wood lamp. Hypopigmented patches may be the first sign of different complex genetic syndromes when different organs are affected. An early diagnosis is fundamental for adopting preventive and therapeutical measures. It is also important to diagnose and prematurely treat inflammatory diseases so as to avoid its spreading and becoming chronic.
Juvenile plantar dermatosis is a kind of eczema common during childhood and teenage years which is frequently mistaken as fungus infection. It is usually located on the front foot sole and is associated to local trauma (friction) and excessive sweating. It happens in episodes, with redness, brightness and “injured” skin appearance with a light scaling. If it is not properly treated it may last for years.