Pediatric Skin Disorders -1

Prepared by Dr. Darin Mathkor

General Objectives Specific Objectives • Be able to identify different skin • will be able to: disorders in children and discuss • Define the common skin disorders. nursing care management. • Differentiate between each disorder. • Apply nursing care plan and management for each skin disorders.

 Bacterial infections  Viral infections  Fungal infections  Parasitic infections/infestations  Chemicals

Staphylococci Streptococci

Congenital or acquired immune disorders (such as [AIDS]) Debilitated condition • Receiving immunosuppressive therapy, and those with a • Generalized malignancy (such as, leukemia or lymphoma)

 Impetigo contagiosa • Staphylococci • Manifestation • Begins as a reddish macular rash, commonly seen on face/extremities • Progresses to papular and vesicular rash that oozes and forms a moist, honey colored crust. • Pruritis of skin • Common in toddlers and preschoolers • Asymptomatic  Management  topical bactericidal ointment mupirocin or triple antibiotic ointment Oral  parenteral antibiotics (penicillin)  Vancomycin (MRSA)  Retapamulin 1% ointment, applied twice daily for 5 days

 Folliculitis (pimple), furuncle (boil), carbuncle (multiple boils)  Staphylococcus aureus  methicillin-resistant S. aureus (MRSA)  Manifestation  Infection of hair follicle  Systemic effects: Malaise, if severe  Management  Skin cleanliness  Local warm, moist compresses  Topical antibiotic agents  Systemic antibiotics in severe cases  Incision and drainage of severe lesions

 Cellulitis  Streptococci  Staphylococci  Haemophilus influenzae  Manifestation  Inflammation of skin and subcutaneous tissues with intense redness, swelling, and firm infiltration  Lymphangitis “streaking” frequently seen  Involvement of regional lymph nodes common  May progress to abscess formation  Systemic effects: Fever, malaise  Management  Oral or parenteral antibiotics  Rest and immobilization of both affected area and child

 Staphylococcal scalded skin syndrome  Staphylococcus. aureus  Manifestation  Macular erythema with “sandpaper” texture of involved skin  Epidermis becomes wrinkled (in 2 days or less), and large bullae appear  Localized bullous impetigo in older child  Management  Systemic antibiotics  Gentle cleansing with saline, Burrow solution, or 0.25% silver nitrate compresses

NURSING CARE Prevent the spread of infection and to prevent MANAGEMENT complications. Caution the child against touching the involved area. Hand washing is mandatory before and after contact with an affected child. Also emphasize hand washing to both the child and the family. The child should be provided with washcloths and towels separate from those of other family members. The child's pajamas, underwear, and other clothes should be changed daily and washed in hot water. Razors used for shaving should be discarded after each use and not shared. Some infectious disease specialists recommend bathing in a chlorine bath once or twice weekly.

CONT. Daily bathing or showering with an antibacterial soap. Do not squeeze follicular lesions. Limited cellulitis of an extremity managed at home with oral antibiotics and warm compresses. More extensive cellulitis, especially around a joint with lymphadenitis or on the face, or with lesions larger than 5 cm (2 inches), are usually admitted to the hospital for parenteral antibiotics, incision, and drainage. Nurses are responsible for teaching the family to administer the medication and to apply compresses.

Viruses are intracellular parasites that produce their effect by using the intracellular substances of the host cells. viruses are unable to provide for their own metabolic needs or to reproduce themselves.

 Verruca (warts)  Human papillomavirus (various types)  Well-circumscribed, gray or brown, elevated, firm papules with a roughened, finely papillomatous texture  Usually appear on exposed areas, such as fingers, hands, face, and soles  May be single or multiple  Asymptomatic  Management  Local destructive therapy, individualized according to location, type, and number—surgical removal, electrocautery, curettage, cryotherapy (liquid nitrogen)

 Cold sore, fever blister:  Herpes simplex virus (HSV) type 1  Genital herpes: HSV type 2  Grouped burning and itching vesicles on inflammatory base  Usually on or near mucocutaneous junctions (lips, nose, genitalia, buttocks)  Vesicles dry, forming a crust, followed by exfoliation  Spontaneous healing in 8 to 10 days  May be accompanied by regional lymphadenopathy  Management  Oral antiviral

 Ringworm are infections caused by a group of closely related filamentous fungi that invade primarily the stratum corneum, hair, and nails.  Superficial infections by organisms that live on, not in, the skin.

 Tinea capitis  Trichophyton tonsurans, Microsporum audouinii, Microsporum canis  Manifestation  Lesions in scalp but may extend to hairline or neck  circumscribed patches or patchy, scaling areas of alopecia  asymptomatic, but severe, deep inflammatory reaction may occur that manifests as boggy, encrusted lesions (kerions)  Pruritic

 Tinea corporis:  Trichophyton rubrum, Trichophyton mentagrophytes, M. canis, Epidermophyton organisms  Manifestation  Round or oval, erythematous scaling patch that spreads peripherally and clears centrally; may involve nails

 Tinea cruris (“jock itch”)  Epidermophyton floccosum, T. rubrum, T. mentagrophyte  Manifestation  Skin response similar to that in tinea corporis  Localized to medial proximal aspect of thigh and crural fold; may involve scrotum in males  Pruritic

TREATMENT AND  Local treatment with strong antifungal ointment NURSING CARE  Oral griseofulvin, oral ketoconazole for difficult cases MANAGEMENT  Griseofulvin and possibly oral corticosteroids for 2 weeks to achieve therapeutic effect  Should emphasize good health and hygiene.  Affected children  should not exchange personal items with other children such as grooming items, headgear, scarves that have been in proximity to the infected area  provided with their own towels and directed to wear a protective cap at night to avoid transmitting the fungus to bedding  Should emphasize to family members the importance of maintaining the prescribed dosage schedule and of taking the medication with high-fat foods for best absorption.

 Pediculosis Capitis (head lice)  An infestation of the scalp by Pediculus humanus capitis  Common parasite in school-age children.  Manifestation  Itching  Common sites of involvement are the occipital area, behind the ears, and at the nape of the neck.  Management  application of pediculicides and manual removal of nit cases.

NURSING  Nurses should emphasize that anyone MANAGEMENT can get pediculosis  Lice can be transmitted from one person to another on personal items.  Children are cautioned against sharing combs, hair ornaments, hats, caps, scarves, coats, and other items used on or near the hair.  Lice are not carried or transmitted by pets.  Nurses or parents should carefully inspect children who scratch their heads more than usual for bite marks, redness, and nits.

 Common in infants and one of several acute inflammatory skin disorders caused either directly or indirectly by wearing diapers.  The peak age of occurrence is 9 to 12 months old.  The incidence is greater in bottle-fed infants than in breastfed infants.  Causes  Prolonged and repetitive contact with an irritant (such s urine, feces, soaps, detergents, ointments, friction).  Diaper wetness  Chemical irritation from  Urine, feces, especially diarrheal stools  cDheetemrigceanlstsinordsisopaopssafbrolemwiinpaedse.quately rinsed cloth diapers or the  Ccharnodniidcadaialbpiecradnserinmfeatcittiiosn -It is seen in up to 90% of infants with  Ammonia ---- association between the strong odor on diapers and dermatitis.  The lesions represent a variety of types and configurations.  Manifested primarily on convex surfaces or in folds.

NURSING CARE Nursing interventions are aimed at altering the MANAGEMENT three factors that produce dermatitis: wetness, pH, and fecal irritants. Changing the diaper as soon as it becomes wet. Removing the diaper to expose healthy skin to air facilitates drying. Diaper construction has a significant impact on the incidence and severity of diaper dermatitis. Superabsorbent disposable paper diapers reduce diaper dermatitis. Cornstarch is effective in reducing friction.

 Keep skin dry  Use superabsorbent disposable diapers to reduce skin wetness.  Change diapers as soon as soiled especially with stool.  Expose healthy or only slightly irritated skin to air, not heat, to dry completely.  Apply ointment, such as zinc oxide or petrolatum, to protect skin, especially if skin is very red or has moist, open areas.  Avoid removing skin barrier cream with each diaper change; remove waste material and reapply skin barrier cream.  Use mineral oil; to completely remove ointment, especially zinc oxide.  Avoid over washing the skin, especially with perfumed soaps or commercial wipes.  May use a moisturizer or non-soap cleanser, such as cold cream or Cetaphil, to wipe urine from skin.  Gently wipe stool from skin using a soft cloth and warm water. Use disposable diaper wipes that are detergent- and alcohol-free

 A type of pruritic eczema that usually begins during infancy and is associated with an allergic contact dermatitis with a hereditary tendency (atopy)  AD’s manifestation based on child's age and the distribution of lesions

Infantile (infantile Child’s Age Distribution of Lesions Appearance of Lesions eczema) begins at 2 to 6 months of age, Generalized, especially cheeks, Childhood generally undergoes spontaneous scalp, trunk, and extensor Erythema, vesicles papules, weeping remission by 3 years of age surfaces of extremities oozing, crusting scaling, often symmetric Preadolescent and occurs at 2 to 3 years of age; 90% of Flexural areas (antecubital and adolescent children have manifestations by 5 popliteal fossae, neck), wrists, Symmetric involvement, Clusters of small years of age ankles, and feet erythematous or minimally scaling patches, Dry and may be Begins at about 12 years of age; may Face, sides of neck, hands, feet, hyperpigmented, Lichenification continue into the early adult years face, and antecubital and (thickened skin with accentuation of or indefinitely popliteal fossae (to a lesser creases, Keratosis pilaris (follicular extent) hyperkeratosis) common same as childhood manifestations, Dry, thick lesions (lichenified plaques) common Confluent papules

 The major goals of management are to hydrate the skin, relieve pruritus, prevent and minimize flare-ups or inflammation, and prevent and control secondary infection.  Management strategies for reducing pruritus include:  Avoiding exposure to skin irritants or allergens (e.g. soaps, detergents, fabric softeners, perfumes, and powders)  Avoiding overheating (proper dress for climatic conditions is essential)  Administrating medications such as antihistamines, topical immunomodulators, topical steroids, and (sometimes) mild sedatives, as indicated.  Enhancing skin hydration and preventing dry skin

 Assessment of the child with AD includes:  A family history for evidence of atopy  A history of previous involvement  Any environmental or dietary factors associated with the present and previous exacerbations.  Examined the skin lesions for type, distribution, and evidence of secondary infection.  Interviewed the parents regarding the child's behavior, especially in relation to scratching, irritability, and sleeping patterns.  Exploration of the family's feelings and methods of coping  Controlling the intense pruritus.  To prevent or minimize the scratching  Fingernails and toenails are cut short, kept clean.  Gloves or cotton stockings can be placed over the hands and pinned to shirtsleeves.  One-piece outfits with long sleeves and long pants also decrease direct contact with the skin.

 Proper dress for climatic conditions  Pruritus is often precipitated by exposure to the irritant effects of certain components of common products, such as soaps, detergents, fabric softeners, perfumes, and powders.  Avoid the exposure to latex products, such as gloves and balloons  Apply wet soaks and compresses and administer medications for pruritus or infection as directed.  Educate the family about the preparation and use of soaks, special baths, and topical medications  Emphasize that one thick application of topical medication is not equivalent to several thin applications and that excessive use of an agent (steroids) can be hazardous.

 Parents are assured that the lesions will not produce scarring and that the disease is not contagious..  Parents need help to understand the reason for the diet modification and the guidelines for avoiding hyperallergenic foods.  Hypoallergenic diets take time before visible effects are apparent, parents need reassurance that results may not be seen immediately.  During acute phases, the family need time to discuss negative feelings and to be reassured that these feelings are normal.  Stress tends to aggravate the severity of the condition.

1. Wong’s Essentials of Pediatric Nursing, 10th Edition, Elsevier Publication, Page No: 373-389, 656-662.