Chapter 107. Neonatal, Pediatric, and Adolescent Dermatology

Just as dermatology cannot be separated from internal medicine, pediatric dermatology is inseparable from general pediatrics. Since most dermatologists have experience and training in internal medicine but less exposure to pediatrics and neonatology, an introduction to the special issues that can arise in pediatric dermatology is presented herein. As it is impossible to discuss all of pediatric dermatology in one chapter, the focus is instead on certain methods, diseases, and issues divided by three age divisions: neonates and infants, children, and adolescents. Topics of special importance such as pediatric medication use and biopsy pitfalls are discussed. Methods to enhance success in outpatient procedures in pediatric dermatology are also reviewed.

Successful care of the pediatric patient is best achieved via comanagement with the neonatalogist, pediatrician, or primary care physician. In addition, an understanding of the parental or family situation is important. For example, children living in two households (due to divorced parents) may do best with two sets of medications, one in each home, to enhance compliance. Table 107-1 reviews ten helpful tips in practicing pediatric dermatology. As an example, if Internet access exists, patients or parents will likely search online for medical information before or after the office encounter. Parents and patients should be warned that medical information on the Internet is often inaccurate.1 It is wise to direct them to specific Internet Web sites, support groups, or pamphlets, but these resources should be reviewed before recommending them.

Lastly, the aphorism, “To cure sometimes, to relieve often, to comfort always,” should always be kept in mind when delivering pediatric care. Parents often have higher expectations, and a heightened level of worry and concern for their children and the office visit cannot be rushed.

The neonatal period is defined as the first 30 days of life. Neonatal skin diseases evolve much more rapidly than adult skin diseases, and some conditions that initially appear to be serious turn out to be trivial, whereas in others, the opposite is true. Infancy is defined as beginning after the first 30 days of life.

Neonatal Skin

After birth, the neonate's skin undergoes a series of changes in adaptation to the extrauterine environment. In utero, the skin of the fetus is protected by the vernix caseosa and is immersed in amniotic fluid. After birth, the vernix is wiped off, and the skin is exposed and adapts to the dry ambient air. For example, desquamation of the upper layers of the stratum corneum occurs normally in all infants and is believed to be a normal adaptive process.

Research regarding the maturation of the neonatal stratum corneum in neonates has produced varying results, and the question of when full barrier function is achieved is not fully answered. Barrier stabilization appears to be a dynamic process, one dependent upon a balance between different biologic and environmental parameters. Postnatal life is believed to accelerate stratum corneum maturation in premature and term infants. Parameters such as skin thickness, skin pH, and stratum corneum hydration indicate that neonatal skin is continuously adjusting to the extrauterine environment, in contrast to the adult skin, which remains in a steady state.2

In vivo studies of human skin show that infant stratum corneum and epidermis is thinner than adult skin and has higher transepidermal water loss (TEWL) rates, but infant stratum corneum has higher water content. Infant corneocytes and granular cells are smaller than adult corneocytes suggesting a more rapid cell turnover than in adults.3

Infants have an increased risk for systemic toxicity from topically applied substances. This is due in large part to the great surface area–body mass ratio in the infant. In addition, the infant's metabolism, excretion, distribution, and protein binding of substances can be significantly different from those of an adult and add to increased risk of toxicity.4

The postmature infant (>40 weeks’ gestation) typically has dry and cracked or peeling skin noted soon after birth (Fig. 107-1). Shedding of the dry peeling skin of postdates infants occurs spontaneously in the first month of life, leaving normal, healthy skin. Topical care should include moisturizers and avoidance of overbathing.

Premature infants, particularly those born before 34 weeks of gestation, have markedly decreased epidermal barrier function and an even greater surface area–body mass ratio than term infants. In addition, the immature organs of the premature infant may affect the metabolism, excretion, distribution, and protein binding of chemical agents. Local or systemic toxicity can occur in the premature infant not only from topical medications, but also soaps, lotions, or other cleansing solutions.4,5

Increased skin fragility is a hallmark of prematurity (gestational age less than 37 weeks). Epidermal and dermal injury may lead to significant cutaneous pain even with routine handling and nursing care. The premature infant is at risk for infection and sepsis from skin-associated organisms entering through breaks in the thin and fragile skin and via iatrogenic portals of entry. Sweating in the premature infant is functionally reduced and contributes to poor thermal regulation. Heat regulation is dysfunctional due to a thin subcutaneous fat layer for insulation, poor autonomic control of cutaneous vessels, and a large surface–body ratio. In the nursery, the premature infant is usually placed in a temperature and humidity-controlled isolette until the infant matures and temperature and fluid regulation stabilizes.

In the 1990s researchers reported application of petrolatum-based emollient therapy to be beneficial in hospitalized preterm infants, decreasing transepidermal water loss.6 Subsequently, various emollients and regimens have been tested in infants of variable prematurity and birthweight. Improved skin integrity consistently improved in these studies, however, a threefold increase in the incidence of systemic candidiasis was reported after emollient therapy was implemented in extremely low birthweight (≤1,000 g) premature infants in one neonatal intensive care unit.7 Another outbreak of systemic candidiasis occurred in very low birthweight neonates (≤1,500 g) in a different neonatal intensive care unit.8 A 2004 Cochrane review concluded that prophylactic application of topical ointments increased the risk for nosocomial infection and advised against their routine use in preterm infants. In contrast, randomized, controlled studies in impoverished Bangledeshi preterm neonates have demonstrated decreased mortality rates when sunflower seed oil or Aquaphor ointment was applied by massage, compared to premature infants not receiving massage or emollients.9 Until prospective, controlled trials are performed, neonates receiving petrolatum-based emollient therapy should be carefully monitored for infections, particularly those infants with birthweights less than 1,500 g.

Once at home, bathing once or twice a week in plain water is sufficient for most infants; if bathing is more frequent, moisturization with unscented, simple emollients is recommended. The face, hands, and diaper area may be cleansed daily using a small amount of a mild, unscented, pH-neutral cleanser. Well-meaning parents often bathe their infants too frequently and use a multitude of products on their infant's skin. In addition to irritation and asteatosis, these practices may increase the risk of allergic contact dermatitis in infants. It has been estimated that the average newborn is exposed to approximately 10 skin care products in the first month of life, leading to exposure to more than 50 different chemicals ranging from mildly toxic to toxic.10 Parents should be taught that “less is best.”11

Examination Techniques

A complete history includes gestational and birth history as well as family history. Exposures during pregnancy, including medications, illicit drugs, and infectious diseases such as varicella and sexually transmitted diseases, should be reviewed. Obstetric data, including placental appearance and cultures, can be invaluable. In examining an infant, the most important element is thoroughness. Whether the infant is examined in the lap of the parent or on the examination table, all surfaces, including the creases and valleys of body folds and the diaper region (including the genitalia), deserve close examination. A vascular stain, vasoconstricted macule, or erosion can be the presenting sign of a hemangioma.12 A stray hair may later strangulate an appendage and should be removed. Infants with digital tourniquet (pseudoainhum) and clitoral tourniquet have been described.13,14 Congenital lesions of all classifications (e.g., pigmented, vascular, aplasias) warrant closer inspection to rule out associated findings. Midline lesions on the face, scalp, or spine may have central nervous system (CNS) connections and should not be biopsied without proper evaluation (see Table 107.7). The diaper area has its own unique set of problems and deserves examination at every visit.

The infant is vulnerable and completely dependent on the caretakers. The social support system and family structure must be considered when implementing a medical plan. There are times when the parents’ desire for treatment may not be in the best interest of the patient.

Medical and surgical decision making for the infant is based primarily on function rather than cosmesis. For example, extraction of a natal tooth is indicated if breast-feeding is impaired; whether or not the tooth is a component of a genetic syndrome is a separate issue.

Diseases of Neonates and Infants

Transient Dermatoses of the Neonate

Skin conditions encountered in newborns that tend to resolve by 30 days of age are considered to be transient. They are very common and many are expected in newborns.

Caput Succedaneum and Cephalohematoma

Caput succedaneum is subcutaneous edema over the presenting part of the head and is a common occurrence in newborns. Cephalohematoma is a subperiosteal collection of blood and is less common. Both lesions are due to shearing forces on the scalp skin and skull during labor.

Caput succedaneum is soft to palpation, and borders are ill-defined. Cephalohematoma is bounded by the suture lines of the skull and often feels fluctuant. If purpura is extensive, it can lead to hyperbilirubinemia. Congenital lymphedema or lymphatic malformations (such as in Turner syndrome) can mimic caput succedaneum. Both caput succedaneum and cephalohematoma resolve spontaneously; however, caput usually fades in 7–10 days, whereas cephalohematoma slowly resolves over several weeks.

Milia

Milia are multiple pinpoint- to 1-mm papules representing benign, superficial keratin cysts. They are seen most commonly on the nose of infants and may be present in the oral cavity as well, where they are called Epstein's pearls. They are expected findings in the newborn and resolve spontaneously within a few weeks of life.

Sebaceous Gland Hyperplasia

At least 50% of normal newborns have sebaceous gland hyperplasia (Fig. 107-2). Tiny (<1-mm) yellow macules or papules are seen at the opening of each pilosebaceous follicle over the nose and cheeks of term newborns. It is a benign condition that clears spontaneously by 4–6 months of age.

Erythema Toxicum Neonatorum

Erythema toxicum neonatorum (ETN) is an idiopathic, common condition seen in up to 75% of term newborns. It is rarely seen in premature infants. Blotchy erythematous macules 1–3 cm in diameter with a 1–4-mm central vesicle or pustule are seen in ETN (Fig. 107-3). They usually begin at 24–48 hours of age, but delayed eruption as late as 10 days of age has been documented.15 These follicular-based lesions can be located anywhere but tend to spare the palms and soles. A smear of the central vesicle or pustule contents will reveal numerous eosinophils on Wright-stained preparations. A peripheral blood eosinophilia of up to 20% may be associated, particularly in infants, with numerous lesions. Transient neonatal pustular melanosis (TNPM) lesions conrail neutrophils rather than eosinophils, and individual lesions heal with residual pigmentation, which is not seen in ETN. Bacterial infections, Pityrosporum folliculitis, and congenital candidiasis also may mimic ETN. Bacterial and fungal culture of lesions and Gram staining will help differentiate among these entities. ETN is benign and clears spontaneously by 2–3 weeks of age without residua.

Transient Neonatal Pustular Melanosis

TNPM is an idiopathic pustular eruption of the newborn that heals with tiny brown-pigmented macules (Fig. 107-4). It is less common than ETN and is more prevalent among newborns with darkly pigmented skin. Lesions are usually present at birth or shortly thereafter, but may appear as late as 3 weeks of age, as superficial vesicles and pustules, with ruptured lesions evident as collarettes of scale. Pigmented macules are also often present at birth or develop at the sites of resolving pustules or vesicles within hours or during the first day of life; occasionally babies are born with the tiny melanocytic macules, suggesting in utero vesiculation. Lesions can occur anywhere but are common on the forehead and mandibular area. The palms and soles may be involved. Smear of the vesicle or pustule contents will reveal a predominance of neutrophils with occasional eosinophils on Wright-stained preparations.16

Miliaria rubra is frequently confused with ETN and TNPM. The erythema around miliaria rubra is small in area (1–2 mm versus 20–30 mm in ETN). The central pustule of TNPM may mimic congenital candidiasis, Pityrosporum folliculitis, or bacterial folliculitis lesions. Herpes simplex should be considered if lesions are vesicular. A Gram-stained slide of the pustules of ETN or TNPM will not show organisms. A Wright-stained slide usually will show a predominance of neutrophils. TNPM is a harmless condition that requires no treatment. The pustules usually disappear within 5–7 days of age, leaving residual pigmented macules that resolve over 3 weeks to 3 months.

Mottling

Mottling is a blotchy or lace-like pattern of dusky erythema over the extremities and trunk of neonates that occurs with exposure to cold air. Virtually all babies demonstrate mottling at some time during the newborn period due to immaturity of the autonomic control of the cutaneous vascular plexus. This physiologic mottling disappears on rewarming, differentiating it from cutis marmorata telangiectatica congenita and livedo reticularis. Normal mottling resolves spontaneously by 6 months of age.

Harlequin Color Change

Harlequin color change is a rare vascular phenomenon occurring in low-birthweight infants. When the infant is placed on one side, an erythematous flush with a sharp demarcation at the midline develops on the dependent side, and the upper half of the body becomes pale. The color change usually subsides within a few seconds of placing the baby in the supine position but may persist for as long as 20 minutes. The exact mechanism of this unusual phenomenon is not known, but it may be due to immaturity of autonomic vasomotor control. Harlequin color change is seldom seen after 10 days of age.

Sucking Blisters

Sucking blisters may be present at birth as the result of intrauterine sucking, but are more commonly seen during the first weeks of life. Sucking blisters are usually solitary, intact oval or linear blisters, erosions, or drying crusts, arising on noninflamed skin of the dorsal-radial aspect of forearms, wrists, or fingers or on the upper lip. They resolve within a few days. If the affected extremity is brought up to the infant's mouth, the infant will often commence sucking at the site, confirming the diagnosis. Herpesvirus infection is often considered when sucking blisters are encountered, but lesions of Herpes simplex infection are grouped vesicles occurring on an erythematous base or punched out, hemorrhagic erosions.

Benign Cephalic Pustulosis

Neonatal acneiform facial lesions usually develop within the first 30 days of life and are estimated to occur in 50% of newborns (Fig. 107-5). This benign eruption appears to be hormonally mediated (see Chapter 80) and has been attributed to overgrowth of Malassezia sp., and termed “benign neonatal cephalic pustulosis.”17 Most cases resolve spontaneously, but the eruption can be treated topically with ketoconazole, benzoyl peroxide, or erythromycin. True neonatal acne is probably much less common than benign cephalic pustulosis and can be distinguished by the presence of comedonal lesions. Similarly, infantile acne usually shows true comedones, sometimes with papules, pustules, and even cysts. An example of infantile acne is seen in Figure 107-6.

Hair Loss in the Infant18

Telogen Effluvium

Telogen effluvium occurs frequently in newborns and is often overlooked. The hair loss may be gradual or sudden, and may occur as soon as the first few days of life, with the telogen hairs shed by 3–4 months of age. No treatment is indicated as spontaneous resolution is the rule.

A transient circumscribed patch of nonscarring alopecia develops at the occiput in many infants. Thought to be due to a combination of physiologic telogen effluvium and localized pressure from lying in the supine position, occipital alopecia spontaneously resolves.

Triangular Temporal Alopecia

Triangular temporal alopecia is a form of nonscarring hair loss noted at 2–5 years of age as a triangular-, oval-, or lancet-shaped area of alopecia at the frontotemporal scalp. Often, a thin row of hair separates the affected area from the forehead. The terminal hairs are replaced by vellus hair. The condition is often mistaken for alopecia areata; however, distinguishing features include the typical location and shape, the presence of vellus hairs, and the absence of exclamation point hairs or histologic findings of alopecia areata. There is no known treatment, and the condition persists unchanged. However, triangular temporal alopecia is benign and will not expand.

Alopecia Areata

Alopecia areata occurs in all ages (see Chapter 88). All forms of alopecia areata occur in infants and children (patchy, universalis, etc.), with the same disease presentation and treatment challenges as in adults. Onset at younger than 2 years of age is estimated to occur in 1%–2% of alopecia areata patients; however, it may be under-recognized and more common. Several cases of congenital alopecia areata have been documented. Early onset is considered to be a poor prognostic marker. Total alopecia during the first year of life after having hair at birth should be distinguished from genetic disorders, such as congenital atrichia with papular lesions and vitamin D resistance.

Tinea Capitis

Tinea capitis can occur at any age, including infancy (see Chapter 188). Hair loss associated with scaling, broken hairs, pustules, or black dots should prompt a potassium hydroxide scraping and fungal culture to confirm the diagnosis. Just as in older children, Trichophyton tonsurans is the most common dermatophyte, and oral griseofulvin is the treatment of choice. Tinea capitis and fungal infections are discussed in Chapter 188.

Birthmarks

Birthmarks represent an excess of one or more of the normal components of skin per unit area: blood vessels, lymph vessels, pigment cells, hair follicles, sebaceous glands, epidermis, smooth muscle, collagen, or elastin. Although most birthmarks are of little medical or psychosocial consequence, the social and cultural impact of a disfiguring birthmark should not be underestimated, from both the patient's and the parents’ perspectives.19 The age-old theory of maternal imprinting is still widely accepted in many countries, including the United States, and the mother may be subtly or actively blamed for congenital conditions in the newborn. With selective photothermolysis offered by lasers and advances in surgical and topical therapies, therapeutic options are increasing.

The two most common birthmarks are the nevus simplex (see Chapter 172) and Mongolian spots (see Chapter 122). Nevus simplex (also known as salmon patch, nevus flammeus, angel's kiss, or stork bite) represents a capillary malformation of the skin. It occurs most commonly on the glabella, upper eyelids, and nuchal area. Nevus simplex appears with high frequency in all races, occurring in 70% of white infants and 59% of black infants. Mongolian spots, which represent collections of dermal melanocytes, are seen in 80%–90% of infants of color but in only 5% of white infants.20,21 Solitary café-au-lait macules are extremely common and benign, however, the appearance of multiple café-au-lait macules raises the possibility of neurofibromatosis type 1 (see Chapter 141). Other common birthmarks are listed in Table 107-2.

Hemangiomas

Infantile hemangiomas are the most common tumors of infancy. They must be differentiated from vascular malformations and other vascular anomalies. Hemangiomas are discussed in detail in Chapter 126.

Lymphangiomas

Both types of lymphatic malformations, microcystic (lymphangiomas) and macrocystic (cystic hygromas), are discussed in Chapter 172.

Uncommon Dermatoses of the Neonate

Selected dermatoses of the neonate are discussed in the following sections. Table 107-3 lists differential diagnoses for selected cutaneous conditions encountered in neonates and infants.

Cutis Marmorata Telangiectatica Congenita

Cutis marmorata telangiectatica congenita is characterized by persistent coarse cutis marmorata, telangiectasia, and sometimes associated underlying cutaneous atrophy and ulceration (Fig. 107-7). Its incidence is sporadic, and its etiology is obscure. Theories of vascular malformation are currently favored. Diagnosis is usually evident on clinical examination. Usually a lower extremity is involved, but location on the trunk or upper extremity is not uncommon. A multitude of associated anomalies can occur, including limb asymmetry, hemangiomas, other vascular birthmarks, pigmented nevi, and aplasia cutis congenita (ACC). However, the majority of patients have a good prognosis, with half demonstrating improvement of the mottled appearance over the first 2 years.22

Subcutaneous Fat Necrosis of the Newborn

Subcutaneous fat necrosis of the newborn is characterized by firm, circumscribed, reddish or purple subcutaneous nodules or plaques that appear over the back, cheeks, buttocks, arms, and thighs (Fig. 107-8; see Chapter 70). The lesions usually begin within the first 2 weeks of life and resolve spontaneously over several weeks.23

Sclerema Neonatorum

Sclerema is diffuse hardening of the skin in a sick premature newborn that is now rare because of improved neonatal care. The onset is characteristically after 24 hours of age. The skin feels hard and immobile and looks yellow and shiny. The trunk is always involved. Severely ill premature newborns that have suffered sepsis, hypoglycemia, metabolic acidosis, or other severe metabolic abnormalities are at risk. Biopsy sections show edema of fibrous septa surrounding fat lobules, but no fat necrosis, differentiating it from subcutaneous fat necrosis of the newborn. The etiology of this rare condition is unclear, and infant mortality is high.

Aplasia Cutis Congenita (ACC)

ACC represents a failure of skin to fully develop, most often on the scalp, and less commonly elsewhere (Fig. 107-9). It is often an isolated finding, but a multitude of associated conditions have been described. ACC has no single underlying cause. Some cases may represent a forme fruste of a neural tube defect.24 In the most common form of ACC, oval, sharply marginated atrophic macules are seen on the midline of the posterior scalp. They are usually solitary, but may be multiple. Aplasia cutis is always hairless, and may appear vesicular, ulcerated, or covered by a thin epithelial membrane. When healed, lesions are usually atrophic scars, but sometimes develop a keloidal scar. Epidermis, dermis, and fat all may be missing, or a single layer may be absent. Lesions may range from a few millimeters to many centimeters in diameter. Lesions at birth of epidermolysis bullosa (see Chapter 62) may resemble ACC, especially on one or both legs. Scalp ulcers at birth of aplasia cutis may be mistaken for obstetric trauma. Other forms of congenital circumscribed hair loss should be considered. Midline blisters or erosions should not be biopsied, scraped for herpes cultures, or otherwise traumatized. After a careful examination to rule out associated malformations, ACC is treated conservatively to allow healing. Surgical revision of the scar later in childhood or adolescence can be done electively to improve cosmesis.

Hair Collar Sign

The “hair collar sign” is a ring of darker and/or coarser terminal hairs on the scalp, typically surrounding ACC, dermoid cyst, encephalocele, meningocele, or heterotopic brain tissue.25 The hair collar sign itself is a marker of cranial dysraphism and its presence, like aplasia cutis, mandates careful examination of the infant, particularly of midline structures and fusion planes.

Anetoderma of Prematurity

A specific form of iatrogenic anetoderma (see Chapter 67) has been described in extremely premature infants (born at 24–30 weeks’ gestation) with very low birthweight and prolonged neonatal intensive care hospitalization.26 A retrospective review of 11 cases noted the appearance of round, flat atrophic patches on the chest and abdomen (including the periumbilical region), developing at age 6 weeks to 5 months. Eight patients had lesions at sites where adhesive monitoring leads had been removed, and five patients had circular ecchymotic patches from removal of adhesive monitoring leads prior to the occurrence of the anetoderma. The anetoderma did not improve with time. One child underwent surgical excision of the disfiguring lesions at age 7 years. Given the presumed relationship of the development of anetoderma and skin trauma mainly from adhesive leads, avoidance of pressure (e.g., placing leads on the ventral chest when the infant slept on the back) markedly reduced the risk of occurrence.27

Infections of the Neonate

Infants younger than the age of 2 months are less able to localize infection due to immature immunologic function, and life-threatening sepsis can develop insidiously. Subtle clues such as a decrease in body temperature, poor feeding, or other nonspecific signs are taken seriously by the pediatrician, and a “rule out sepsis” admission is implemented when suspicions are high. At a minimum, blood, cerebrospinal fluid, and urine cultures are obtained, and intravenous antibiotic therapy begun pending cultures.

Congenital Viral Infection

Petechiae, purpura, jaundice, hepatomegaly, splenomegaly, microcephaly, encephalopathy, ocular abnormalities, anemia, thrombocytopenia, conjugated hyperbilirubinemia, or elevated serum hepatic transaminases should prompt the consideration of congenital viral infection, particularly if these signs arise in combination. Cutaneous infections of the neonate are listed in Table 107-4. Bacterial infections, such as staphylococcal scalded skin syndrome; and viral infections, such as varicella, are discussed in Chapters 193 and 194.

Neonatal Herpes Simplex Virus Infection

(See Chapter 193.) It is estimated that untreated neonatal herpes simplex virus (HSV) has a 50% mortality rate, with three-fourths of survivors suffering neurologic sequelae. The greatest risk of neonatal herpes occurs when the delivery is vaginal and the mother has primary genital herpes (as opposed to recurrent herpes, in which the mother has antibodies protective to the neonate), the herpes infection involves the cervix, and the infant is premature and delivered with instrumentation (e.g., scalp electrodes).

The vast majority of cases are due to HSV type 2. The typical lesions of herpes are present in the skin, eye, or mouth in a large majority of infected neonates, but some patients with CNS or disseminated disease never have skin lesions (Fig. 107-10).28 Vesicles present during the first 24 hours of life suggest in utero acquisition of HSV, but onset during the first week to 10 days of life is more common, representing exposure to the virus during the delivery.28

A high index of suspicion should be maintained even in the absence of maternal infection or history of genital herpes. Specimens for Tzanck smear, direct fluorescent antibody assays, and/or viral cultures for HSV should be obtained. Cultures require 12–120 hours to grow, and in all infected or suspected neonates, cultures of skin lesions, urine, nasopharynx, eyes, and cerebrospinal fluid are indicated. If available, a polymerase chain reaction test can be very helpful in rapid diagnosis. Intravenous acyclovir should be instituted as soon as possible after specimens are collected to minimize the chance of replication of virus in the CNS and systemic dissemination of HSV. Prompt recognition and early therapeutic intervention lead to an improved outcome in the HSV-infected infant.28

Congenital Malformations of the Skin

Minor Anomalies

Congenital malformations are developmental defects and are frequently observed in newborns. Single minor anomalies occur in approximately 15% of all newborns and are, by definition, of no functional significance. The supernumerary digit (Fig. 107-11), supernumerary nipple and the accessory tragus are common examples of minor malformations. The occurrence of two is less common, however, and the presence of three or more is unusual; a complete thorough physical examination is indicated to rule out other congenital abnormalities.29,30

Cutaneous Markers of Dysraphism

The skin and the nervous system are both derived from the ectoderm. The neural ectoderm separates from the epithelial ectoderm during the third to fifth week of gestation, occurring simultaneously with the formation and closure of the neural tube. Hence, errors in neural tube development [i.e., dysraphism (incomplete fusion)] can be associated with cutaneous lesions. Midline facial lesions, such as dermoid cysts, nasal gliomas (Fig. 107-12), and ACC (Fig. 107-9), can be markers of cranial dysraphism, whereas cutaneous lesions seen on the lumbosacral midline can signify underlying spinal dysraphism (Fig. 107-13). Imaging studies should be considered for midline nasal lesions before biopsy to rule out intracranial connections.31

A retrospective review of 54 cases of congenital lumbosacral skin lesions (including deviated gluteal cleft)32 demonstrated that the highest risk of occult spinal dysraphism occurs with the presence of two or more congenital midline lumbosacral skin lesions, or if spinal cord dysfunction exists in the presence of one lumbar skin lesion. In addition, lumbosacral lipoma, human tail, and dermal sinus (as isolated findings) were highly associated with occult spinal dysraphism. Lumbosacral magnetic resonance imaging is indicated when these high-risk congenital lesions are present. An intermediate risk of occult spinal dysraphism was associated with atypical sacral dimple (≥5-mm diameter, or location ≥2.5 cm away from the anus), ACC, overlying hamartoma, or deviated gluteal cleft. In the presence of any of these lesions, ultrasound can be used to screen for occult spinal dysraphism if the infant is less than 4 months of age. If the infant is older, magnetic resonance imaging is needed to rule out dysraphism. Low-risk lesions that do not require imaging include isolated lumbosacral hemangioma, port-wine stain, focal, mild hypertrichosis, pigmented nevus, Mongolian spot, or simple sacral dimple (≤5-mm diameter and location 2.5 cm or closer to the anus).32 These findings are summarized in Table 107-5.

Evaluation Techniques

Observing the play of a child allows for a quick assessment of his or her neurologic development. Interactions between caregivers and child are also informative. Early prolonged or intense eye contact with the young child should be avoided because this can be threatening to the child. If an elective biopsy or procedure is needed, it is often more acceptable for the parent (especially if a neonate) or child if the procedure is scheduled for a second visit rather than the initial one.

If a language barrier exists between the parents and physician, one should resist the urge to have the bilingual patient serve as interpreter for the parents. This practice places an inappropriate burden of responsibility on the child and may increase fear and anxiety in the child. In addition, inaccurate transmission of information may occur.

Examination of young children may be performed with the child on the parent's lap or while playing with toys on the examination table. If needed, examination of the perineum and genitalia can be accomplished with the child in the knee-chest position on the examination table (eFig. 107-13.1) or the parent's lap. Alternatively, the child may sit on the parent's lap with legs held apart by the parent. eFig. 107-13.2 illustrates anatomic terminology of the young female genitalia for accurate documentation, and can be helpful in conditions such as lichen sclerosus. Caution must be used in interpreting the genital examination in the young female so as not to underdiagnose or overdiagnose disease or abuse. For example, the presence of labia minora adhesions is not diagnostic of trauma or abuse because they occur in as many as one-third of girls who are not abused.33 The diastasis ani is a normal structure that can be mistaken for perianal scarring.34 The infantile perianal pyramidal protrusion may be mistaken for condyloma acuminata but is a harmless normal finding (discussed later in this chapter in Infantile Perineal Protrusion).35,36 Child abuse is discussed in Chapter 106.

Performing Procedures on the Young Child

Historically, there has been a widespread reluctance to biopsy skin lesions in infants and children. This often leads to a delay in diagnosis in conditions such as childhood melanoma, for example. In addition, many skin conditions in children have a paucity of dermatopathologic information in the literature due to this reluctance. Parents may be anxious about causing pain or scarring, and children may be fearful because of their experience with immunizations, or an age-appropriate fear of bodily mutilation. However, with proper preparation of the parent and child, skin biopsies and other outpatient procedures are easily performed (see Table 107-6). Note that there are certain situations in which a biopsy can be detrimental; examples of these “biopsy pitfalls” are outlined in Table 107-7.

Eutectic mixtures of lidocaine and prilocaine (EMLA cream) or lidocaine alone (LMX cream) are useful in minimizing the pain of intralesional injections or local anesthetic injections for biopsies. As EMLA use has become widespread, reports of toxicity in children have appeared, including methemoglobinemia and seizures. The maximum dose, body surface area exposed to drug, and application time should not be exceeded; these parameters are age dependent and are 1 g for 1–3 month old, 2 g for a 3–12 month old, 10 g for a 1–6 year old, and 20 g was a 7–12 year old.40 The application of ice or anesthetic cryospray is another option to numb the skin before injections.

Before and during procedures, young infants can be soothed with a pacifier dipped in a sucrose solution. A randomized, controlled, double-blinded study of 201 newborns found that orally administered glucose solution was superior to topical EMLA cream in reducing pain with venipuncture.41 Infants may be swaddled with a blanket for comfort and immobilization. The young child can be effectively immobilized and comforted with a restraining “hug,” by a parent or assistant. Distraction techniques are invaluable as well. For example, instructing the child to blow a colorful toy windmill, blow soap bubbles, or “wiggle” his or her toes during an injection or procedure helps to decrease pain. Older children may be effectively soothed by listening to music with headphones or by watching a movie during procedures.

Alkalinizing local anesthetics to a pH of 7.0 (0.1 mEq/mL sodium bicarbonate or a 1:10 bicarbonate–anesthetic ratio by volume) minimizes the pain of cutaneous infiltration without limiting anesthetic effects.42 Alkalinization decreases the solution's shelf life to approximately 1 week 43 due to more rapid oxidation of epinephrine. Warming lidocaine also lessens the pain of injection.42

Vibrational motions applied with the surgeon's nondominant hand adjacent to injection site and infiltrating slowly are additional helpful techniques to reduce the pain of injection of anesthetic.

Instruments and materials should be laid out ahead of time to ensure rapid performance of the procedure, and are less frightening if kept out of sight by covering with a drape. Needles, instruments, and blood-stained gauze should be kept out of view and out of reach of the patient.

Children sense their parents’ anxiety and nervous energy. Parents who are overly anxious can be asked to sit farther away from the operating table, or sometimes are best positioned outside the procedure room.

The use of general anesthesia for dermatologic procedures in healthy pediatric patients is very safe when properly performed. Fears of general anesthesia should not be a barrier to delivering necessary surgical or laser procedures to healthy children.44

Diseases of Infancy and Childhood

Infantile Perineal Protrusion

Also known as infantile pyramidal protrusion, infantile perineal protrusion (IPP) is a benign condition that occurs almost exclusively in female prepubertal girls. It appears as a pyramidal, soft-tissue, “tongue-like,” smooth, or velvety pink protrusion. It is usually located in the midline just anterior to the anus. IPP is usually asymptomatic, but painful defecation has been reported. It occurs in three settings: constitutional, functional (after constipation, diarrhea, or other irritant exposure), or associated with lichen sclerosus et atrophicus. Often, IPP is misdiagnosed as condyloma acuminatum, hemorrhoids, or as a sign of trauma. Conservative management is indicated. Spontaneous resolution as well as resolution following high-fiber diet to relieve constipation has been noted.35,36

Diaper Dermatitis

Diaper dermatitis, like hand dermatitis, denotes a group of region-specific dermatoses. Diaper dermatitis is one of the most common dermatologic conditions in infants and children, noted in approximately 1 million pediatric outpatient visits each year.45 With the advent of superabsorbent disposable diapers in the last decade, severe forms of diaper dermatitis have diminished in incidence. Irritant and candidal diaper dermatitis comprises the vast majority of diaper dermatitides in diaper-wearing individuals of all ages.

The etiology of diaper dermatitis is multifactorial. The initiating factor is prolonged and increased wetness to the skin. This leads to increased frictional damage, decreased barrier function, and increased reactivity to irritants. Other interrelated etiologic factors include contact with urine and feces, fecal proteolytic and lipolytic digestive enzymes, increased skin pH, and superinfection with Candida and, less commonly, bacteria.46

Irritant Diaper Dermatitis

By far the most common type of diaper dermatitis is irritant diaper dermatitis. This dermatitis occurs in any person who wears diapers, regardless of age. Irritant diaper dermatitis appears as erythematous, moist, and sometimes scaly patches on the convexities of the genitalia and buttocks, beginning in areas in closest contact with the diaper. Shallow erosions are sometimes present on the convex surfaces. It can be asymptomatic or tender.

Candida Diaper Dermatitis

(See Chapter 189). Candida diaper dermatitis is the second most common type of diaper dermatitis and presents with bright red erythematous, moist papules, patches, and plaques that tend to involve body folds as well as convex surfaces. Satellite lesions are very characteristic. Oral thrush can be associated. Candida from intestinal flora frequently contaminates any type of diaper dermatitis present for greater than 3 days, and Candida levels increase with the clinical severity of the dermatitis.47

Miliaria Rubra (“Heat Rash”)

(See Chapter 84.) Miliaria rubra tends to occur at sites where plastic components of the diaper cause occlusion of eccrine ducts of the skin. It is also seen in the folds of the neck and upper torso, and is particularly common when there is a rapid shift to warm weather, and the child is overdressed.

Pseudoverrucous Papules and Nodules

Pseudoverrucous papules and nodules occur in the diaper and perianal areas in patients of any age with exposure to prolonged wetness. Children who wear diapers due to chronic urinary incontinence are prone to this type of dermatitis for example.

Infantile Granular Parakeratosis

Infantile granular parakeratosis represents an idiopathic form of retention keratosis in diaper-wearing infants. There are two clinical patterns: bilateral linear plaques in the inguinal folds and erythematous geometric plaques underlying pressure points from the diaper. A thick, flake-like scale is present in both forms and is characteristic. Therapeutic responsiveness to topical agents is ambiguous; however, spontaneous clearance after months to 1 year appears to be the rule.48

Jacquet Erosive Dermatitis

Jacquet erosive dermatitis is an uncommon, severe diaper dermatitis that can occur at any age. It is characterized by well-demarcated, punched-out ulcers, or erosions with elevated borders. Prolonged contact with urine and feces under occlusion leads to this condition.49 It is seen less commonly since the advent of superabsorbent disposable diapers.

Granuloma Gluteale Infantum

Granuloma gluteale infantum is an uncommon condition characterized by reddish purplish nodules of different sizes (0.5–3.0 cm) occurring on the convexities of the diaper area in 2- to 9-month-old infants. It arises within preexisting diaper dermatitis. Biopsy shows dense dermal infiltrates of lymphocytes, plasma cells, neutrophils, and eosinophils, but no true granulomas. It appears to be an unusual reaction to the usual irritant factors, candidal infection, and, in some cases, topical steroid use in the diaper region.49 Treatment consists of avoidance of irritants, use of barrier pastes, and avoidance of topical steroids. Resolution occurs over several months.

Dermatoses Not Etiologically Related to Diaper Wearing

Seborrheic dermatitis, atopic dermatitis, psoriasis (Fig. 107-14), bullous impetigo, acrodermatitis enteropathica, scabies, hand-foot-and-mouth disease, herpes simplex infections, and Langerhans cell histiocytosis are conditions that occur in the diaper region but are not primarily due to the wearing of diapers and should be considered in the differential diagnosis. Skin biopsy is indicated to rule out Langerhans cell histiocytosis (see Chapter 147) if nonhealing erosions or petechiae are seen in the diaper area (Fig. 107-15).

Treatment of Diaper Dermatitis

The treatment of diaper dermatitis is outlined in Table 107-8.50 Irritant diaper dermatitis and Candida diaper dermatitis (or a combination of both) comprise the vast majority of diaper rashes. Candida is more likely to complicate diaper rash if present for more than 3 days.

Education of parents and primary care physicians should include instructions regarding the use of topical steroids in the diaper area. Because of greatly increased percutaneous absorption of steroids from moisture and occlusion from diapers, topical steroid use in this anatomic region should be limited to a short course (3–7 days) of hydrocortisone (1% or 2.5%) ointment. This is effective in nearly all cases when a topical steroid is needed. Similarly, use of the combination products containing steroids, such as nystatin plus triamcinolone, and clotrimazole plus betamethasone dipropionate, should be avoided due to increased risks of steroid atrophy and hypothalamic–pituitary axis suppression when used in the diaper area.

Last, parents will be reassured by the fact that even the most problematic diaper dermatitis will resolve when toilet training is achieved, and diapers are not worn.

Tinea Capitis

(See Chapter 188.) Scrapings for potassium hydroxide examination and fungal culture should be obtained before administration of systemic antifungal therapy. In children, collection of specimens for tinea capitis may be accomplished by the use of a toothbrush, ring curette, moistened cotton swab, a scalpel, or by collection of infected hairs. Alternatively, a media plate with nonslanted agar may be applied directly to the infected areas of the scalp to collect material.

Dermatologic diagnoses of adolescents overlap with those of general adult dermatology; however, caring effectively for the adolescent patient requires different interviewing skills and strategies to enhance compliance.

Evaluation Techniques

Greeting the adolescent first and the parents second, and interviewing the adolescent patient alone at the beginning of the visit help to earn the patient's trust.51 The confidentiality laws of each state should be considered and the patient's right to privacy respected. Many states protect the adolescent's right to confidential medical care for problems such as drug abuse, sexually transmitted diseases, contraception, pregnancy, and abortion.

The open-ended questioning style used for adults frequently fails with adolescents. Phrasings using the third person and giving choices when asking questions are more effective techniques to obtain information. For example, “Many women on oral contraceptives forget to take their pill once in a while. How often do you forget to take your birth control pills: often, sometimes, or almost never?” will yield a more accurate reply than, “Do you take your birth control pills every day?”

Adolescents lack a well-developed sense of future time and long-term consequences are less valued than immediate outcomes. Goals should be concrete, short term, and relevant to the present. Rather than using goals related to more distant benefits, such as the reduction of potentially serious disease complications (e.g., smoking causes increased risk of lung cancer), emphasis should be placed on immediate and concrete effects (e.g., smoking causes your clothes, hair, and breath to smell bad and your teeth to turn yellow). Body image is a more powerful motivator, and messages such as “tanning salons cause premature wrinkles and ugly skin” are more effective than future health concerns (e.g., “tanning salons increase your risk of skin cancer”). Any treatment that is disfiguring or has visible side effects will meet with resistance.51

Physical and psychosocial development may not be congruent. An adolescent should not be expected to shoulder all medical responsibilities for himself or herself or for younger siblings. The physician's role is not to befriend, nor is it to parent the adolescent patient, but rather it is to be a trusted, valuable authority.

Acne and the Adolescent

(See Chapter 80.)

Acne vulgaris is an extremely common and variable disorder that can have far-reaching detrimental effects on self-image and self-esteem. Increased unemployment has been documented among patients with a history of severe acne.52 For adolescents, a single- or two-drug regimen will optimize compliance and cost-effectiveness.

Females with treatment resistant acne, signs of virilization (including irregular menstrual cycles, hirsutism, and/or obesity) should have evaluation for androgen excess states including polycystic ovary syndrome (see Chapters 80 and 151).

Several oral contraceptives (Yaz®, Yazmin®, and Ortho-Tricyclen®) have Food and Drug Administration (FDA) labeling for the treatment of acne and are an important therapeutic option for adolescent females with recalcitrant acne. The effectiveness of oral contraceptives often allows discontinuation of chronic oral antibiotic therapy. Patients should be counseled that adherence to three cycles of oral contraceptives are often needed to establish treatment efficacy for acne. Oral contraceptives with a higher androgenic component and lower estrogenic component tend to worsen acne. Topical acne medications such as retinoids may need to be continued for best results.

Isotretinoin has been a valuable, unique, and effective agent for nodulocystic acne since 1982. Isotretinoin's teratogenicity is well known. The question of psychopathology induced by isotretinoin is more controversial. The Adverse Drug Event Reporting System of the United States FDA has received reports of depression, suicide, and other psychiatric side effects (e.g., aggression, psychosis) in patients using isotretinoin. The question of isotretinoin-induced depression is complicated by the high baseline incidence of depression and suicide in the adolescent population and by the depression and stress associated with severe acne.53,54 Case reports, including positive cases of positive dechallenge and rechallenge, have suggested that isotretinoin may induce depression and other psychiatric adverse effects, but larger retrospective and prospective studies have not demonstrated causation.55 In some studies, depression scores improved when patients’ acne improved with isotretinoin therapy.56 Double-blind, placebo-controlled isotretinoin studies have not yet been done. To date, animal studies have shown conflicting results. Although a causal link has not been established between isotretinoin and depression/suicide at this time, it is likely that uncommon idiosyncratic psychiatric reactions to isotretinoin may occur in predisposed individuals. Pretreatment evaluation and, if cleared to proceed, subsequent comanagement by a psychiatrist or psychologist should be considered for vulnerable patients. If mood changes arise, the drug should be stopped until the patient is evaluated by the pediatrician or psychiatrist. If deemed appropriate, a rechallenge can be done cautiously.

A second unanswered question is whether the risk of inflammatory bowel disease increases with isotretinoin use. Studies have shown conflicting results thus far. It is possible that isotretinoin may trigger inflammatory bowel disease in predisposed individuals. Until we have better data, patients and parents should be counseled that a rare but potentially real risk might exist. If bowel symptoms develop, discontinuation of isotretinoin is advisable until the patient is evaluated by a gastroenterologist.57,58

Axillary Hyperhidrosis

Idiopathic focal hyperhidrosis is a common condition that has been long been under recognized. Axillary hyperhidrosis is much more common but palmar and/or facial sites can be affected as well. It can be familial or sporadic. Although all ages may be affected, patients commonly present during adolescence when the condition becomes socially troubling and impacts significantly on quality of life. The management of focal idiopathic hyperhidrosis is similar to that of adults. If topical and oral treatments fail, injection of botulinum toxin A should be considered. Hyperhidrosis is reviewed in Chapter 84.

Indoor Tanning

The WHO Cancer Group has classified tanning beds as “carcinogenic to humans.” Extensive evidence has linked sunlamp or sun bed exposure to increased risk of melanoma and nonmelanoma skin cancers. Nevertheless, approximately 50,000 tanning salons exist in the United States and tanning bed use is increasing among adolescents and young adults. In addition to the desire for tanned skin and the socialization of the tanning salon, some individuals feel more relaxed, and have improved mood following tanning. Evidence is mounting that tanning bed use is physiologically and psychologically addictive. A study demonstrated that frequent tanners developed a preference for functional UV beds compared to otherwise identical sham light beds.59 In addition, physiologic withdrawal symptoms arose in some subjects who were given naltrexone prior to their tanning sessions, suggesting that an opioid-mediated mechanism of dependency may exist in frequent tanners.60

Psychiatric studies, using modified tools originally used for substance abuse screening, confirm addictive behaviors of people who frequent tanning salons. Among 229 college students who had used indoor tanning facilities, 90 (39.3%) met diagnostic and statistical manual of mental disorders IV-TR criteria and 70 (30.6%) met CAGE (Cut down, Annoyed, Guilty, Eye-opener) criteria for addiction to indoor tanning. In addition, these students also reported greater symptoms of anxiety and greater use of alcohol, marijuana, and other substances than those who did not meet these criteria.61

The fight against indoor tanning is becoming similar to the fight against the tobacco industries. Stronger legislation banning tanning bed use in minors, control of false safety claims in advertisements, and extensive education of parents and our youth are needed to wage this war.

Drug Labeling for Pediatric Patients

The lack of FDA labeling for pediatric use does not imply that a drug is contraindicated or disapproved; it simply means that insufficient data are available to grant approval status. Although attempts have been made to equate off-label prescribing with recklessness in the medical malpractice arena, the American Academy of Pediatrics has stated that failure to prescribe medications for off-label uses when the medication is appropriate under standard of care may constitute malpractice.

The thalidomide tragedy (see Chapter 235) led to more stringent regulation of drugs in the early 1960s, and manufacturers began omitting drug studies in infants and children. In the 1970s, pediatric dosage information in package inserts tended to exclude children from therapeutic benefit. Performing research in healthy children is problematic because of ethical and logistic questions, medicolegal risk, and cost. It has been estimated that approximately 50%–75% of drugs used in pediatrics have not been studied adequately to provide accurate labeling information, and the younger the patient, the more likely the lack of information.62 Safety and effectiveness information for drug use in children under 2 years of age is particularly lacking. The absence of pediatric testing and labeling poses significant safety risks for children. Additionally, children may be denied the benefits from therapeutic advances because physicians choose to prescribe existing, less effective medications in the face of insufficient pediatric information about new medications. In 1997, as part of the FDA Modernization Act, Congress enacted a law known as the Pediatric Exclusivity Provision that provides marketing incentives (i.e., 6 month extension of patent protection) to manufacturers who conduct studies of drugs in children. This law was effective in generating pediatric studies on many drugs, and an increase in labeling information has occurred for some. Unfortunately, many studies have centered on children greater than 6 years of age, and many drug studies were stimulated by market concerns rather than medical need.

Hopefully, with new incentives such as the Pediatric Research Equity Act of 2003, significantly more pediatric drug research will proceed forward. Ideally in the future, physicians caring for children will no longer need to prescribe drugs “off label,” and children will no longer be “therapeutic orphans.”

Topical Medications

While topical medications often have excellent safety and efficacy profiles, one must be aware that infants and young children are at increased risk for toxicity from topically applied agents because of increased surface area:body mass ratio compared to adults. In addition, at times infants and children have altered metabolism of drugs compared to adults. Patients with disorders of cornification (e.g., lamellar ichthyosis) or other forms of skin barrier disruption (e.g., Netherton syndrome) have a much higher risk of toxicity due to increased percutaneous absorption. Patients with Netherton syndrome treated with topical tacrolimus may develop immunosuppressive or toxic blood levels of tacrolimus, without clinical signs or symptoms of toxicity.63 A heightened awareness of this problem is important because Netherton syndrome is often misdiagnosed as atopic dermatitis, and both conditions often improve with topical tacrolimus therapy. In addition, a patient with Netherton syndrome developed Cushing syndrome after application of hydrocortisone 1% ointment for over 1 year.64 Examples of inadvertent percutaneous poisoning from topical agents are listed in Table 107-9.

Systemic Medications

Drug Dosages

Pediatric doses of systemic medications are calculated according to body weight (mg/kg) or body surface area to account for size variations between patients of the same age and to account for a child's growth. Prescriptions for liquid medications (syrups or suspensions) must indicate concentration (e.g., milligrams per 5 mL, or teaspoon) to avoid serious error. In addition, the appropriate measuring instrument should be dispensed, along with education on its use. One study demonstrated that dosing cups (commonly provided in OTC children's medications) were associated with a large error in one in four doses—some of which were overdoses of 100%–300%.76

For guidelines on indications and dosing of antimicrobials and other medications, the reader is directed to excellent references including the Red Book77 published by the American Academy of Pediatrics, and The Harriet Lane Handbook.78

Systemic Glucocorticoids

Hypothalamic–pituitary axis suppression, osteonecrosis, and other adverse effects of systemic glucocorticoid therapy affect patients of all ages and are reviewed in Chapter 224. The potential risk of growth suppression is unique to childhood. Exogenous glucocorticoids disrupt the secretion of growth hormone (GH), causing abnormal spontaneous GH secretion with reduced pulse amplitude of GH release and reduced response to provocative stimuli.79,80 There is also decreased local production of insulin-like growth factor 1. These and other effects of glucocorticoids act to cause delayed growth at the bony epiphyses, with the most noticeable reduction in growth velocity occurring during early childhood and adolescent growth spurts. There is a linear relation between the daily dose and growth suppression. Alternate-day dosing, with single morning doses, may decrease the risk of glucocorticoid growth suppression. Most children will have adequate catch-up growth eventually with reduction of doses, alternate-day therapy, or cessation of therapy.81 For the pediatric patient on long-term systemic steroid therapy, charting height and weight on a standardized growth curve is the best method for the pediatrician to screen for decreasing growth velocity.

Children taking immunosuppressive doses of systemic glucocorticoids should not be vaccinated with live-virus vaccines (e.g., measles, oral polio, varicella). A dosage equivalent to 2 mg/kg/day or greater of prednisone or a total of 20 mg/day or greater for children weighing more than 10 kg, when given for more than 14 days, is sufficient to warrant withholding immunization with live-virus vaccines.82 Systemic steroids should not be given to a healthy child if he or she has had recent varicella exposure and is not varicella-immune because varicella infection can be fatal in this situation. In addition, children with ocular herpes simplex and untreated tuberculosis should not be given systemic steroids, and patients with underlying diabetes, hypertension, peptic ulcer disease, renal insufficiency, or psychosis should be treated with great caution or with an alternative agent.77

Antimicrobials

Use of tetracycline family medications is contraindicated in children younger than 8 years of age because it causes brown discoloration of developing teeth and decreased bone growth. Ciprofloxacin and quinolone use in children younger than 18 years of age is restricted because the fluoroquinolones have been shown to cause cartilage damage in juvenile animal models at therapeutic doses. The mechanism is unknown. It is recommended that its use be restricted to relatively serious infections for which no other oral agent is available or intravenous antibiotics would be impractical and for certain pathogenic infections or situations such as multidrug resistance.78

Griseofulvin doses of 20 mg/kg/day of the (125 mg/5 mL) liquid and 15 mg/kg/day of the ultramicrosized tablets for 6–8 weeks have long been considered first-line therapy for tinea capitis. In 2007, terbinafine oral granules (sprinkled on nonacidic food) were approved for the treatment of tinea capitis in children age 4 years and older. Currently, griseofulvin and terbinafine are the only FDA-approved agents for tinea capitis in children. Griseofulvin appears to be superior against M. Canis however if access and/or cost prevent the use of the oral granule form of terbinafine, crushed generic terbinafine tablets off-label can be substituted. Although further studies are needed, itraconazole also appears to be effective with a good safety profile. Fluconazole was not very effective in pediatric tinea capitis in a large multicenter, double-blinded randomized trial of 880 children.83

Child Abuse

In the United States in 2003, 906,000 children were determined to be victims of child abuse and neglect by child protective agencies; an estimated 1,500 children died of child abuse. Ninety percent of all abused children are said to have suggestive or confirmative dermatologic findings.84 Ideally, due to the sensitive medical and legal aspects of this important problem, any case of suspected child abuse should be referred to a specialized team specializing in pediatric abuse, however, appropriate evaluation should not be delayed in the absence of such a resource. Child abuse is discussed in Chapter 106.