Managing Pediatric Dermatology

Required Documents

• Photographs of the rash (if available) with anatomic context
• Medication list (recent antibiotics, anticonvulsants, other medications that cause drug eruption)
• Prior treatment history for this rash
• Allergy history

Step 1 — Morphologic Description and Classification

Primary Lesion Morphology

Distribution Patterns

• Generalized: consider viral exanthem, drug eruption, systemic disease
• Flexural (antecubital, popliteal fossae): atopic dermatitis
• Extensor (elbows, knees): psoriasis
• Dermatomal: herpes zoster
• Acral (hands, feet, mouth): hand-foot-mouth disease, erythema multiforme
• Diaper area: candidal vs. irritant dermatitis
• Exposed skin: contact dermatitis, insect bites
• Scalp: cradle cap (seborrheic), tinea capitis

Step 2 — Atopic Dermatitis (Eczema)

Diagnosis (Hanifin-Rajka Criteria Adapted)

Must have pruritus plus ≥ 3 of: typical morphology and distribution, chronic/relapsing course, personal or family history of atopy, early age of onset

Age-Specific Distribution

Severity Classification

Treatment Ladder

1. Emollients (foundation for ALL severity levels): apply within 3 minutes of bathing; ointment > cream > lotion; fragrance-free; minimum BID, ideally after every hand wash
2. Topical corticosteroids (TCS): apply to active lesions only

3. Topical calcineurin inhibitors (TCI): tacrolimus 0.03% (age ≥ 2), pimecrolimus 1% (age ≥ 2); use on face and sensitive areas to avoid steroid atrophy; FDA black box (theoretical lymphoma risk — clinical data reassuring)
4. Wet wrap therapy: for severe flares; apply TCS, then wet layer, then dry layer; 2-3 hours or overnight
5. Systemic therapy (specialist-directed): dupilumab (age ≥ 6 months for moderate-severe), oral JAK inhibitors (upadacitinib, abrocitinib — ages 12+), cyclosporine (off-label), methotrexate (off-label)

Infection Recognition (Eczema Herpeticum Emergency)

• Monomorphic punched-out vesicles/erosions on eczematous skin with fever → eczema herpeticum (HSV superinfection)
• Medical emergency: admit; IV acyclovir
• Bacterial superinfection: honey-crusted lesions (impetigo from S. aureus or GAS) → topical mupirocin or oral cephalexin

Step 3 — Diaper Dermatitis

Irritant Contact Dermatitis (Most Common)

• Erythema in convex surfaces (spares creases/folds)
• Caused by prolonged contact with urine/stool, friction
• Treatment: frequent diaper changes, barrier ointment (zinc oxide, petrolatum), low-potency TCS for severe inflammation (hydrocortisone 1% BID × 3-7 days)

Candidal Diaper Dermatitis

• Beefy red erythema WITH satellite papules/pustules, involves creases/folds
• Often follows antibiotic use
• Treatment: topical nystatin or clotrimazole with every diaper change × 7-14 days
• If concurrent with irritant dermatitis: combination therapy (nystatin + barrier cream); AVOID combination products containing high-potency steroids (e.g., Lotrisone)

Allergic Contact Dermatitis

• Consider if resistant to standard treatment: fragrance in wipes, rubber in diapers, preservatives
• Patch testing by dermatology if suspected

Step 4 — Infectious Dermatoses

Tinea (Dermatophyte Infections)

Tinea capitis ALWAYS requires oral antifungal therapy. Topical therapy alone is ineffective.

Impetigo

• Non-bullous: honey-crusted lesions; S. aureus or GAS
  • Limited disease: topical mupirocin BID × 5 days
  • Widespread: oral cephalexin 25-50 mg/kg/day ÷ TID × 7 days
• Bullous: flaccid bullae; S. aureus toxin-mediated
  • Oral cephalexin or clindamycin (if MRSA concern) × 7 days

Molluscum Contagiosum

• Flesh-colored, dome-shaped papules with central umbilication; poxvirus
• Self-limited (resolves in 6-18 months typically)
• Treatment optional: cantharidin (office-applied), curettage, cryotherapy
• Avoid aggressive treatment in young children — scarring risk exceeds disease burden

Scabies

• Intensely pruritic; worse at night; burrows, papules, vesicles in web spaces, wrists, axillae, groin
• Infants: may involve face, scalp, palms, soles (unlike older children/adults)
• Treatment: permethrin 5% cream — apply neck to toes (head to toes in infants < 2 months), leave on 8-14 hours, rinse; repeat in 1 week
• Treat ALL household contacts simultaneously regardless of symptoms
• Wash all bedding and clothing in hot water; items that cannot be washed — seal in plastic bag × 72 hours

Step 5 — Viral Exanthems

Common Viral Rashes in Children

Red Flag Rashes (Urgent)

• Petechiae/purpura with fever: meningococcemia until proven otherwise → blood culture, antibiotics immediately
• Target lesions + mucosal involvement: Stevens-Johnson syndrome / toxic epidermal necrolysis → stop offending drug, ICU transfer
• Diffuse erythroderma + desquamation + fever: staphylococcal scalded skin syndrome or toxic shock → admit, IV antibiotics
• Eczema herpeticum: punched-out vesicles on eczema → IV acyclovir

Step 6 — Adolescent Acne

Classification

Acne Treatment Rules

• Topical retinoids are the foundation (comedolytic + anti-inflammatory); use nightly; warn about initial worsening and photosensitivity
• Benzoyl peroxide: bactericidal; prevents antibiotic resistance; use as combination with topical antibiotics, never topical antibiotics alone
• Oral antibiotics: limit duration to 3 months when possible; always combine with topical retinoid + BP
• Isotretinoin: requires iPLEDGE program enrollment (pregnancy prevention), monthly pregnancy tests, lipid/LFT monitoring
• Hormonal therapy: combined OCP or spironolactone for females with hormonal acne pattern (jawline, flaring with menses)

Neonatal and Infantile Acne

• Neonatal acne (< 6 weeks): small closed comedones, cheeks; benign, resolves spontaneously; no treatment needed
• Infantile acne (3-6 months): may be inflammatory; can scar; topical retinoid + BP; referral if severe or persistent (rule out androgen excess)

Checkpoint B — Dermatology Management Review

• Morphology described using standard dermatologic terminology
• Distribution pattern documented
• Age-appropriate differential diagnosis generated
• Diagnosis established with supporting clinical rationale
• Treatment selected with appropriate potency/formulation for location and age
• Topical steroid potency matched to body site and severity
• Infection recognized and treated (bacterial, fungal, viral, parasitic)
• Red flag rashes identified and escalated appropriately
• Parent/patient education provided (application technique, expected timeline)
• Follow-up plan established (2-4 weeks for treatment response assessment)
• All [VERIFY] flags resolved or escalated

Quality Audit

Guidelines

• Follow AAP/AAD guidelines for atopic dermatitis management (stepwise approach)
• Apply Hanifin-Rajka diagnostic criteria for atopic dermatitis
• Follow AAD guidelines for acne vulgaris management (updated 2024)
• Topical steroid potency: use the lowest effective potency; National Eczema Association and AAD provide potency classification (Class I-VII)
• Dupilumab: FDA-approved for moderate-severe atopic dermatitis ages ≥ 6 months
• Tacrolimus/pimecrolimus: FDA-approved for ages ≥ 2; FDA black box regarding theoretical malignancy risk; use as steroid-sparing agent
• Griseofulvin remains first-line for tinea capitis in children per AAP; terbinafine is an alternative with shorter course
• Permethrin 5% is first-line for scabies; ivermectin oral (200 µg/kg) is alternative for age ≥ 15 kg or refractory cases
• Isotretinoin: iPLEDGE program mandatory; pregnancy test monthly; monitor CBC, lipids, LFTs
• Eczema herpeticum is a dermatologic emergency requiring immediate antiviral therapy
• Non-blanching petechiae or purpura with fever = meningococcemia workup until excluded
• This skill produces clinical documentation; it does not replace clinical judgment