Paediatric dermatology

Notes
29 October 2010
Descriptive terms for
skin lesions
 Macule
• Non palpable, w/o
elevation or depression
• Various in size, normally <1
cm
• Vary in surrounding skin
pigmentation
• E.g drug allergy,
neuroectodermal rash
(neuroectoderm includes
neural crest and neural
tube), measles
 Patch
• Large macule, >1cm in
diameter
• Non palpable, flat lesion
• The picture shows
mixed presentation of
macule and patch.
 Plaque
• palpable lesions,
elevated compared to
the skin surface
• > 10 mm in diameter,
diameter is greater than
the thickness
• may be flat topped or
rounded
• E.g psoriasis, granuloma
annulare
Psoariasis, plaques covered with thick, silvery,
shiny scales
 Papule
• Palpable, elevated lesions
• < 5 mm in diameter
• Maybe isolated or grouped
• E.g early chicken pox.
nevi, warts, lichen planus,
insect bites, seborrheic
and actinic keratoses,
some lesions of acne, and
skin cancers

Lichen planus
 Nodule
• Palpable, papules or
lesions that extend into
the dermis or
subcutaneous tissue.
• =/> 6mm in diameter
• Maybe isolated or
grouped
• E.g erythema nodosum,
cysts, lipomas, fibromas.
 Pustule
• Small, circumscribed skin
papules containing purulent
material
• Vesicle + pus
• <1 cm in diameter
• >1 cm in diameter = abscess
• Commonly due to infection,
others in inflammatory
disease
• E.g chicken pox, impetigo,
pustular psoarisis

Pustule complicated with acne

 Vesicle
• Papule + serous
• Small, circumscribed (5mm
in diameter)
• E.g characteristic of herpes
infections (herpes rash,
herpes simplex, chicken pox)
• Others - acute allergic
contact dermatitis,
autoimmune blistering
disorders (dermatitis
herpetiformis)

Dermatitis herpetiformis
 Bullae
• Large (=/> 6 mm) vesicles
• E.g impetigo, severe bacterial
skin infection
• Other causes - burns, bites,
irritant or allergic contact
dermatitis, and drug
reactions.
• Classic autoimmune bullous
diseases - pemphigus vulgaris Bullous pemphigoid - characterized by eruptions
of tense bullae on normal-appearing or reddened
and bullous pemphigoid. skin in elderly patients.
• may occur in inherited
disorders of skin fragility.
 Wheal / Urticaria / Hives
• elevated lesions caused by
localized oedema.
• Typically last very short time
– up to hours – then
disappear
• common manifestation of
hypersensitivity to drugs,
stings or bites, autoimmunity
• less commonly, physical
stimuli including
temperature, pressure, and
sunlight.
Urticaria (wheals or hives) are migratory, elevated, pruritic,
reddish lesions caused by local dermal edema.
 Scales
• heaped-up accumulations of
epithelium (specifically,
outermost layer so called
stratum corneum which filled
with keratin) or
desquamating skin cells
• E.g. psoriasis, seborrheic
dermatitis, and fungal
infections.
• characteristic feature of
many dermatophytoses,
including tinea capitis
noticeable at the back side of the neck.
 Crusting (scabs)
• Accumulation of dried
exudate/transudate i.e
serum, blood, or pus
• Usually mixed with
epithelial
• occur in inflammatory
or infectious skin
diseases (e.g. impetigo).
 Erosion
• open areas of skin that result
from circumscribed loss of
epidermis.
• lesions heal without scarring -
does not extend to the dermis
• can be traumatic or with
various inflammatory or
infectious skin diseases.
• excoriation – hollow, crusted
or linear erosion caused by
scratching, rubbing, or picking.
 Ulcer
• Lesion involve epidermis and
dermis.
• Deep and irregular in shape that
may bleed and leave a scar
• Causes - trauma, bacterial
infection, certain condition such
as disorder involving peripheral
arteries and veins (venous
stasis, PAD, vasculitis)
• E.g. Pressure sores or decubitus
ulcer, chancres and stasis ulcer.
 Fissure
• Linear crack with edges
in inflamed or thickened
skin
• crack extends into the
dermis
• E.g Athlete’s foot,
cracks at the mouth or
in the hand
 Atrophy
• Thinning of one / several layer of
skin (can be epidermis, dermis and
subcutaneous)
• Epidermal atrophy - dry, translucent,
thin, sometimes wrinkled surface
resulting from wasting of the skin
due to collagen and elastin loss.
• Causes - chronic sun exposure, Steroid atrophy
aging, inflammatory illness,
neoplastic skin diseases (cutaneous
T-cell lymphoma, lupus
erythematosus)
• May result from long-term use of
potent topical corticosteroids.
 Lichenification
• thickening and
induration of
the skin with
accentuated
normal skin markings
• secondary to chronic
inflammation caused by
scratching or other
irritation (chronic
eczema)

lichenification during the chronic phase of atopic dermatitis .

 Scars
• Areas of fibrosis that replace
normal skin after injury.
• New scar – purple or red
• Older scar – white brown or silver
• E.g. from acne, surgical wound
injury
• Keloid - very thick, raised and
irregular hypertrophic scar that
extend beyond the original wound
margin
• darkened area is caused by
excessive collagen formation during
healing.
• E.g. from piercing and surgery
 Petechiae
• Small (1-2mm), non - blanchable red
or purple spot on the body, caused
by a minor haemorrhage
• Smallest of the three purpuric skin
eruptions
• Causes – physical trauma i.e hard
coughing (most common, completely
harmless, disappear within days),
platelet abnormalities
(thrombocytopenia, platelet
dysfunction), vasculitis, infections
(meningococcemia, Rocky Mountain
spotted fever, other rickettsioses,
dengue).

Meningococcal petechiae on the back

 Purpura
• Non – blanchable, red or purple
discolouration of skin that may be
palpable.
• One of the purpuric skin condition with 3-
10mm in diameter,
• Palpable purpura is considered the
hallmark of leukocytoclastic vasculitis.
May indicate a coagulopathy.
• Common presentation in typhus and
meningococcal meningitis or septicaemia.
• Endotoxin released by meningococcus
when it lyses, activates the Hageman
factor (clotting factor XII) and causes
disseminated intravascular coagulation.
(DIC)

Schonlein-Henoch purpura
 Ecchymoses
• Non – blachable
subcutaneous purpura larger than 1
cm or a hematoma, commonly called
a bruise.
• can be located both in the skin as well
as in a mucous membrane.
• After local trauma, RBC are
phagocytosed and degraded
by macrophages. The blue-red colour
is produced by the enzymatic
conversion of hb into bilirubin, which
is more blue-green. The bilirubin is
then converted into hemosiderin, a
acute myelogenous leukemia
golden brown colour, which accounts
for the colour changes of the bruise.
 Telangiectasias
• Small, permanently dilated blood vessels
near the surface of the skin or mucous
membrane
• Present as tiny spider-like superficial blood
vessles, usually red to blue, that radiate
out from a centrifugal point.
• On their own they don’t cause damage,
however they are another indicator of
venous hypertension
• Most often idiopathic
• Others in:
– Rosacea (chronic condition
characterized by facial erythema)
– systemic diseases (esp. scleroderma)
– inherited diseases (e.g, ataxia-
telangiectasia, hereditary
hemorrhagic telangiectasia)
– long-term therapy with topical
fluorinated corticosteroids.
Conjunctiva ataxia-telangiectasa
 Eschar
• Slough or piece of dead tissue that is cast
off from the surface of the skin
• Seen in - burn injury, gangrene, ulcer, fungal
infections, necrotizing spider bite wounds,
and exposure to cutaneous anthrax.
• Sometimes called a black wound because
the wound is covered with thick, dry,
black necrotic tissue.
• Rx - allowed to slough off naturally, or
debridement to prevent infection, especially
in immunocompromised patients (require
skin graft post op)
• Important to assess peripheral pulses of the
affected limb to make sure blood and
lymphatic circulation is not compromised. If
circulation is compromised - escharotomy
multiple petechial rashes seen and a solitary
well demarcated lesion with erythematous edge
and a central necrotic area known as eschar.
Preferential diagnosis is Scrub Typhus