Special Considerations in the Skin of Pediatric and Elderly Patients

Overview

An individual’s age, as well as gender and ethnic background, often influences the presence and severity of various skin disorders. This chapter provides a thumbnail description of dermatologic concerns in pediatric and elderly patients that are not discussed in previous chapters. It is intended to complement the earlier descriptions of common skin disorders and to present some less common conditions and rare skin diseases that may affect a patient seeking medical attention from any health care provider.

Pediatric Skin Disorders

Basics

The overwhelming majority of pediatric skin disorders that present to pediatricians, family practitioners, and dermatologists consist of acne, atopic dermatitis, diaper rash, congenital lesions, warts, molluscum contagiosum, as well as a multitude of viral, bacterial, and idiopathic rashes.
Common as well as various rare dermatoses and congenital lesions are briefly summarized in Table 27.1.

Table 27.1 Dermatoses and Congenital Lesions in Pediatric Populations

CONDITION	DESCRIPTION	MANAGEMENT
Superficial hemangioma (formerly called “strawberry” or capillary hemangioma)	Benign proliferation of endothelial cells that starts as macule and grows into dome-shaped papule or nodule Most often followed by spontaneous involution (“graying”)	Observation or treatment with intralesional or systemic steroids, or laser ablation, especially if lesions compromise function
Deep hemangioma (formerly called “cavernous” hemangioma)	Deep dermal and subcutaneous red to violaceous nodule; regression often incomplete	Observation or treatment with intralesional, systemic steroids, or laser ablation, especially if lesions compromise function
Macular stains (“angel’s kisses,” “salmon patches”)	Red macules located on forehead, eyelids, nose, or upper lip Most often regress by 2 years of age	None indicated
Stork bites	Red macules on back of neck Persist in 25% of adults	None indicated
Nevus flammeus (port-wine stain)	Congenital malformation of blood vessels Usually appears at birth	Laser therapy
Nevus spilus (speckled lentiginous nevus)	Tan patches characterized by numerous darker macules or papules	Surgical excision for cosmetic reasons only
Becker’s nevus (pigmented hairy nevus)	Pigmented hairy nevus that is located over chest, shoulder, or back Often appears at puberty	None; surgical excision or laser ablation for cosmetic reasons only
Nevus sebaceous	Congenital hamartoma, with plaques on head or neck Thickens at puberty Small risk of malignant degeneration, mainly to basal cell carcinoma	Excision
Nevus lipomatosis	Solitary or grouped proliferation of fatty tissue Lesions are asymptomatic, soft, skin-colored to yellow papules, nodules, or plaques, with predilection for upper thighs, pelvic, lumbar, and buttock areas	Surgical excision for cosmetic reasons only
Epidermal nevi	Congenital hamartomas with various presentations: verrucous, inflammatory, linear, multiple, or comedonal	Excision, observation, or cryotherapy, with topical steroids for inflammatory type, topical retinoids for comedonal type
Mongolian spots	Macular, flat, blue or blue-gray skin markings that appear at birth or shortly thereafter on the sacral area and back Most prevalent among Asians and African Americans Often fade spontaneously	None
Nevus of Ota	Gray-blue melanin pigmentation of sclera of the eye Seen in Japanese, as well as in Africans, African Americans, and East Indians	Laser therapy
Acropustulosis of infancy	Recurrent crops of small pruritic vesicles that evolve into pustules Involves the palms and soles, most often in black newborns and infants Remits spontaneously	Topical steroids
Gianotti-Crosti syndrome (acrodermatitis papulosa)	Self-limited, sometimes pruritic exanthem associated with many viral agents and immunizations Pale, pink to flesh-colored papules (sometimes flat-topped) in symmetric distribution on extremities	None
Urticaria pigmentosum	Multiple red-brown macules, usually on the trunk	Antihistamines and/or topical steroids, if symptomatic
Solitary mastocytoma (the mastocytosis syndrome can involve multiple organs and become chronic; it is not discussed here)	Lesions become a wheal (urticate) when rubbed or stroked; this change is referred to as Darier’s sign, which is explainable on the basis of mast cell degranulation induced by physical stimulation Most cases resolve spontaneously Usually yellow-brown rubbery plaque that urticates or blisters (bullous urticaria pigmentosum) after rubbing Resolves spontaneously	No treatment necessary
Tinea amiantacea	Thick, adherent scale on scalp and in hair	Keratolytics, followed by topical steroids when scale is cleared
Talon noir (tennis heel)	Self-limited, multiple, black petechiae of heel after minor trauma	Paring, protective heel pad
Pitted keratolysis	Pits in stratum corneum of soles; caused by prolonged occlusion, hyperhidrosis, and bacterial proteinase proliferation Malodorous	Topical erythromycin, clindamycin, or oral erythromycin Wearing cotton socks to prevent moisture buildup
Lichen striatus	Idiopathic linear inflammatory eruption Consists of papules that coalesce into linear, unilateral plaques that appear most often on extremities Resolves spontaneously	Topical steroids
Perianal streptococcal dermatitis (perianal cellulitis)	Affects children 3 to 4 years of age Caused by group A beta-hemolytic streptococci Bright pink to red erythema that extends 2 to 3 cm from anus; infrequently accompanied by itching, fissuring, pain, and mucoid discharge May become more of a cellulitis, with possible pain on defecation	Penicillin V combined with topical Bactroban (mupirocin) ointment or cream twice a day
Juvenile xanthogranuloma	Occurs in infancy and early childhood Lesions composed of histiocytic cells; benign, smooth, firm, red-brown papules and nodules that change to yellow Resolves spontaneously	None necessary
Lichen nitidus	Occurs on thighs, arms, trunk, and genitalia Idiopathic, asymptomatic, small (1 to 2 mm), flat-topped, shiny, skin-colored papules	Topical steroids, if necessary
Hyperhidrosis	Usually starts in early teen years Excessive sweating, particularly axillae, palms, and soles	Topical: Aluminum and zirconium antiperspirants Topical 20% aluminum chloride hexahydrate in absolute alcohol, anticholinergics, aldehydes, and tannic acid Iontophoresis Systemic: Oral anticholinergic medications Injection: botulinum toxin Surgical: Liposuction Sympathectomy
Subcutaneous fat necrosis of newborn	Firm, erythematous nodules and plaques on trunk, arms, buttocks, thighs, and cheeks in otherwise healthy infants Self-limited	None necessary
Lymphangioma circumscriptum	Congenital hamartoma of lymphatics Consists of small clusters of vesicles (“frog spawn”)	Surgical excision, laser ablation, cryosurgery, electrocautery, or sclerotherapy
Acute hemorrhagic edema of infancy (Finkelstein’s disease)	Large, urticarial or annular, targetoid, purpuric plaques found primarily on face, ears, and extremities; presumably immune complex–mediated Self-limited	None necessary
Staphylococcal scalded skin syndrome (SSSS)	Occurs mostly in neo-nates in neonatal or day care nurseries Toxin-mediated type of exfoliative dermatitis caused by toxigenic strains of Staphylococcus aureus Lesions range from localized bullous impetigo to extensive blistering and exfoliation	Dicloxacillin