Common Dermatologic Problems in Children: Diagnosis and Treatment

Educational Objectives

The goal of this program is to improve diagnosis and management of common dermatologic problems (DP) of children. After hearing and assimilating this program, the clinician will be better able to:

1. Administer clindamycin in pediatric patients with armpit odor.
2. Optimize use of steroid therapy in pediatric patients with DP of the scalp.
3. Explain the effectiveness of sequential therapy in the prevention of tinea incognito in pediatric patients with DP.
4. Compare adverse effects of pimecrolimus vs tacrolimus in pediatric patients with DP.
5. Differentiate skin barrier support among various home remedies in pediatric patients with DP.

Summary

Special sites of dermatologic problems (DP): when skin lesions (eg, psoriasis) affect “special sites” of functional, social, or cosmetic importance (eg, fingertips, face, groin, genitalia, palms, soles, scalp, nails), aggressive treatment is sought

Perniosis: was previously known as chilblains; this cold-induced dermatosis often affects the toes and fingers, presenting with dusky erythema, papules or nodules on the distal digits, swelling, itching, and pain; it is persistent with gradual onset; it is rarely associated with underlying disease; in contrast, Raynaud disease in the fingers is sudden onset and extremely painful; perniosis has a more subacute onset and mild pain; Raynaud disease may be associated with underlying disease; perniosis is a lymphocytic vasculitis and responds to clobetasol; prevention involves avoiding cold exposure

Feet as a special site: feet are often exposed to extreme temperatures which can lead to skin issues; heat and sweating in shoes can lead to changes in the microbiome, overgrowth of dermatophytes (eg, athlete’s foot); overgrowth of gram-negative bacteria can lead to foot odor; contact dermatitis can be related to shoes, socks, and laundry products; the thick skin on the sole or palm makes rashes difficult to treat, so high-potency steroids or other agents are needed; nails can provide diagnostic clues; feet are prone to irritation; juvenile plantar dermatosis (aka “sweaty sock dermatosis”) is an irritant contact dermatitis; shoes can sometimes cause allergic reactions; teens can develop recurrent atopic dermatitis on the feet related to the wet-dry cycle of sweating; psoriasis on the feet often involves the soles and nails extensively

Management: if the diagnosis is uncertain and fungal tests are not available (potassium hydroxide), empiric antifungal treatment for 1 wk is advised before topical steroid (TS), but not combination therapy; moisturizers with urea (20%-40%) help manage dry skin conditions (eg, psoriasis, dermatitis); antiperspirants can also reduce sweat-related issues

Juvenile spring eruption: is a seasonal, photosensitive rash on the ears caused by sunlight during cold weather; it appears red or purple, sometimes itchy or with blisters; it is managed with sunscreens or protective measures (eg, hats)

Ears as a special site: ears are exposed to cold and sun; psoriasis often involves the external auditory meatus of the ear and tends to be symmetric; atopic dermatitis particularly involves the infra-auricular crease fissures and posterior ear areas; ear piercings can lead to complications, including keloids or nickel sensitization, so delaying piercings is advised unless culturally significant; more serious photosensitive conditions (eg, cutaneous lupus) tend to appear in the conchal bowl and lobe; broad-brimmed hats and sunscreen can help prevent photosensitive conditions; instruct parents to pull the ears back when managing retro-auricular rashes; the “butterfly” on the face is the classic photosensitive distribution; photosensitivity to doxycycline is possible; other photosensitive sites include the medial hand, lower lip, ear, neck, and the “V” of the chest

DP of armpit: armpit rashes are common and challenging to treat because of the skin’s sensitivity; asymmetric paraflexural exanthem of childhood appears as bright red, slightly itchy eczematous lesions in the armpits, also present behind the knees; this condition, often affecting older infants and toddlers, spreads from one side to other flexures and generalizes, lasting 4 to 7 wk; though hydrocortisone should initially be tried for possible atopic dermatitis, persistence signals a need for counseling as the condition resolves naturally without treatment; the armpit is a major site for scabies; the armpits are prone to occlusion, warmth, and microbiome overgrowth, leading to yeast infections, staphyliculitis, or seborrheic dermatitis; inverse psoriasis presents as uniform pink plaques with mild scaling; irritant or allergic contact dermatitis can be caused by deodorants, fabric softeners, or fabrics; molluscum contagiosum can occur in armpits; group A streptococcal intertrigo causes acute, painful, oozy rashes, sometimes accompanied by fever, requiring prompt recognition and treatment; hidradenitis suppurativa (HS) is increasingly observed in teenagers, linked to obesity but also seen in patients with normal weight; HS results from inflammation induced by hair follicle occlusion; the nidus is thought to be a foreign body reaction to hair; hair removal laser is used to prevent future lesions; early HS mimics folliculitis, but comedones, nodules, sinus tracts, and lesions in other areas (eg, the groin) help to differentiate; management involves dermatology referral for targeted therapy; surgery is usually not successful; acne-like treatments (eg, doxycycline, benzoyl peroxide wash, clindamycin gel) can be used while awaiting specialized care

Management: for armpit rashes, fragrance-free skincare products, gentle eczema soaps, and avoiding antiperspirants are recommended; short course of clindamycin can address odor caused by gram-negative bacteria; hydrocortisone is a safe topical option, progressing to desonide or beclomethasone if needed; cream preparations are usually better for folds

DP of scalp: poses challenges for diagnosis and treatment related to hair coverage and the thickness of the skin; topical treatments can be difficult to apply effectively because of the scalp's thickness and hair obstruction; strong steroids are safe for the scalp but must be applied carefully to avoid adverse effects on the face, especially near the frontal hairline; topical treatments should be applied at night, avoiding the face

DP of face: acne — on the lip line is characterized by comedones and pustules and can be particularly painful during activities (eg, eating, talking); acne can also appear on the chin, cheek or other isolated areas (eg, the ears) during early puberty; perioral dermatitis — appears concentrated around the mouth; treatment can be challenging and may require trials of multiple agents; use of strong steroids on the face alters the microbiome and triggers an inflammatory response (eg, periorificial dermatitis); perioral dermatitis can spread to the nose and eyes; drool dermatitis is common in infants with atopic dermatitis because of an immature skin barrier; wet-dry cycles from drooling, feeding, and exposure to low pH foods exacerbate irritation; the skin barrier in the cheek takes the longest to mature; older children face additional risks from dental products, cosmetics, and skin products; toxin-mediated erythema (eg, scalded skin), enterovirus, exanthum, and atypical hand-foot-mouth are other perioral conditions; lip dermatitis can be related to cosmetics, dental products, and mango allergy; mango allergy is usually related to the peel but can be the flesh; it is usually a type IV allergic contact dermatitis similar to poison oak, with redness, swelling, and oozing of subacute onset, unlike impetigo, which is more acute; patients are advised to avoid mangoes, low pH drinks (eg, juices, soda), allergenic lip balms, and skin care products, switching to neutral pH options and hypoallergenic products; hydrocortisone or stronger steroids (eg, desonide) can be used on the lip along with petrolatum; poison oak on the face, particularly the eyelids, causes significant swelling because of thin skin and fluid leakage from inflammation; many cases require prednisone; hydrocortisone may not be sufficient; a diffuse rash or swollen face likely requires a course of systemic steroids

Adverse effects of TS: using too high a dose, a potent agent for extended periods, or on large body areas can lead to systemic and local adverse effects (eg, permanent striae); social media has fueled fear-mongering about TS, discouraging their use and contributing to the undertreatment of dermatitis, particularly atopic dermatitis; undertreatment can lead to superinfections with resultant inflammation, which often requires stronger steroids for resolution; for acute conditions (eg, poison oak), high-potency TS can be effective if used short-term without refills; steroids are the best available topical anti-inflammatory agents, and the dosages and safety profiles are well understood

Alternatives of TS: pimecrolimus and crisaborole are expensive and can sting, making them less practical, particularly for chronic conditions involving wide areas requiring large quantities

Prescription of TS: TS are available as gel, oil, ointment, and cream; all strengths are available in most vehicles; while some colleagues emphasize a rigid 2-wk usage guideline, treatment should instead focus on the skin’s response; for families, framing treatment timelines, starting with a 2-wk rescue phase, followed by tapering when the condition improves, can be helpful; tapering is especially important in special sites with thin skin (eg, anterior neck, armpits, groin, inner thigh, antecubital fossa) to prevent adverse effects (eg, skin atrophy, stretch marks); families must be educated on switching to lower-potency steroids (eg, hydrocortisone) and tapering appropriately

Effects of TS on the face: the microbiome is prone to disturbance by TS; long-term use or potent steroids (eg, clobetasol) should be avoided on the lips to avoid systemic absorption; hydrocortisone is weak and can be used on the lips; families should transition to emollients as soon as possible

Effects of TS on the eyelid: is a sensitive area where anything applied is likely to reach the eye; long-term use of mid-potency TS (eg, triamcinolone) on the eyelid has been linked to risks (eg, cataracts, glaucoma) in adults; for children, hydrocortisone is typically used but must be tapered or replaced with nonsteroid treatments for prolonged use; eyelid dermatitis is a common indication for nonsteroid topicals; advise patients to stay far enough from the eye to avoid complications

Misuse of TS: of potent steroids (eg, clobetasol) over long periods can lead to visible adverse effects (eg, blood vessel prominence, striae, hypopigmentation, eventual depigmentation); initial signs like vasoconstriction can be misleading but highlight the potency of these treatments; differentiating conditions like pityriasis alba from vitiligo or steroid-induced hypopigmentation is critical; pityriasis alba presents as ill-defined, hypopigmented, slightly scaly patches, especially in children with darker skin, often related to inflammation and dryness; parents should be counseled to moisturize the child’s skin at night and use sunscreen (cream-based, not a lotion or gel) in the morning to protect the skin and support pigmentation recovery

TS with antifungal therapy: combination products that mix steroids with antifungals were historically common but caused severe adverse effects, particularly in pediatric cases; while these products are still available, their use is discouraged; instead, a layered approach is recommended, applying an antifungal first (eg, clotrimazole) followed by hydrocortisone for conditions eg, candidal diaper rash, seborrheic dermatitis; patients have unknowingly worsened conditions like tinea faciei by using inappropriate steroids obtained from family or other sources; recognizing the morphology of annular lesions is key to identifying tinea, which should first be treated with antifungals (eg, clotrimazole, terbinafine); if these fail, cultures can confirm diagnoses, allowing for targeted treatment; for facial tinea, it is also crucial to check for scalp involvement, as this requires oral antifungal therapy; misapplication of steroids on fungal infections can suppress the immune response, leading to tinea incognito, where the infection appears to improve superficially but worsens internally; sequential therapy, ie, starting with antifungals before introducing steroids, is necessary to prevent such outcomes

Systemic absorption of TS: infants have larger skin surface area relative to body weight, making them particularly vulnerable; long-term use of triamcinolone, for instance, can lead to systemic absorption, resulting in elevated blood glucocorticoid levels, stunted growth, and a decline in growth curves; the diaper area, being under occlusion and having thinner skin, facilitates greater absorption of steroids, compounding these risks; ointments, being more occlusive, enhance absorption compared with creams; while this can amplify the efficacy of certain steroids eg, triamcinolone, the increased absorption comes with risks, especially for stronger agents; hydrocortisone, a milder steroid, is safer and more suitable for infants as its absorption poses less concern

Iatrogenic Cushing syndrome: is linked to inappropriate use of TS; one documented case involved a child developing the syndrome after prolonged use of triamcinolone for diaper rash, which underscores the importance of limiting refills, avoiding large quantities, and educating families about proper use

TS withdrawal and addiction: have also sparked discussions; families, often influenced by online sources, avoid necessary treatments, leaving children vulnerable to infections, severe itching, and sleep disturbances; this avoidance can perpetuate a cycle of inadequate care and worsening symptoms

Rebound phenomena (RP): is sometimes misconstrued as steroid addiction and occurs when symptoms flare after stopping TS; per speaker’s experience, this is particularly common with systemic steroids (eg, prednisone) which were once commonly used for severe eczema but are now largely avoided because of these effects; advances in targeted therapies have reduced reliance on systemic and widespread TS use; for severe cases, urgent referral to specialists is needed; infants with severe eczema should also be evaluated for primary immunodeficiency, and older children with worsening symptoms require patch testing for contact dermatitis, as prolonged steroid use can lead to sensitization

Management of RP: the diaper area and face are particularly sensitive and prone to microbiome disturbances, which can lead to rebound dermatitis; for such cases, alternative treatments eg, doxycycline, metronidazole creams are preferred; though research on TS withdrawal in children is limited, severe cases often involve more extensive disease rather than addiction to mild treatments eg, hydrocortisone; possible explanations for rebound effects include rebound vasodilation, possibly mediated by nitric oxide, causing rosacea-like symptoms or exacerbating dermatitis; research will help address these concerns more effectively, but for now, open communication with families about treatment safety is essential; addressing concerns proactively ensures better compliance and outcomes

Recommendations for discontinuation of TS: a 2-wk rescue and taper approach is recommended, tailored by age, severity, acute vs chronic, and location of the condition; stronger agents is needed for severe rashes, but milder generics (eg, hydrocortisone, triamcinolone in various strengths) are effective for most cases; high-potency agents, eg, lidex, fluocinonide, clobetasol) are reserved for extreme cases; for younger infants or milder conditions, low-potency steroids (eg, desonide) are safer and effective, especially in sensitive areas (eg, the diaper region); long-term use should be avoided, emphasizing the importance of barrier creams for chronic conditions

Nonsteroidal topicals: calcineurin inhibitors, (eg, pimecrolimus, tacrolimus) offer alternatives; pimecrolimus stings the least, is least potent, is easy to use, is approved by the US Food and Drug Administration for children ≥2 yr of age, can be used for perioral dermatitis, has less rebound, and is a good choice for tapering; while pimecrolimus stings less and is effective for sensitive areas (eg, eyelids), tacrolimus is more potent but causes more discomfort based on the speaker’s experience; the speaker uses tacrolimus for vitiligo of the face and for chronic eyelid dermatitis; strategies like refrigerating the medication or mixing it with petrolatum can enhance tolerability; another alternative, crisaborole, is effective but often cost-prohibitive and associated with stinging; nonsteroidal treatments work best after initial inflammation has been controlled with steroids

Home remedies: virgin coconut oil has antimicrobial properties and is suitable for conditions like seborrheic dermatitis; cocoa butter appeals to older children for its pleasant scent; safflower and sunflower seed oils, which resemble natural skin lipids, are better for barrier support compared with olive oil, which can disrupt the skin barrier; for crusty or itchy conditions, cool damp compresses and diluted apple cider vinegar soaks can provide relief from itching; pramoxine creams are nonsteroidal; some families like oatmeal baths can provide relief for children with atopic dermatitis; shake lotions (eg, calamine) are helpful in the short term for poison oak; caution is necessary to avoid remedies containing irritants, allergens, or endocrine disruptors; lavender oil is a documented endocrine disruptor and is not recommended for children; some herbal products contain occult heavy metals and steroids

Readings

Abramovits W, Oquendo M. Hydrocortisone butyrate 0.1% lipocream in pediatric patients with atopic dermatitis. Skinmed. 2010;8(2):72-79; Ahuja K, Lio P. Pediatric topical steroid withdrawal syndrome: What Is Known, What Is Unknown. Pediatr Dermatol. Published online November 4, 2024. doi:10.1111/pde.15799; Choi SH, Beer J, Bourgeois J, et al. Pityriasis alba in pediatric patients with skin of color. J Drugs Dermatol. 2023;22(4):417-418. doi:10.36849/JDD.7221; Davis AE, Kennelley GE, Amaye-Obu T, et al. The phenomenon of phototoxicity and long-term risks of commonly prescribed and structurally diverse drugs. J Photochem Photobiol. 2024;19:100221. doi:10.1016/j.jpap.2023.100221; Deva M, Netting MJ, Weidinger J, et al. A systematic review of guidelines for the management of atopic dermatitis in children. World Allergy Organ J. 2024;17(12):100989. Published 2024 Nov 14. doi:10.1016/j.waojou.2024.100989; Eichenfield LF, McCollum A, Msika P. The benefits of sunflower oleodistillate (SOD) in pediatric dermatology. Pediatr Dermatol. 2009;26(6):669-675. doi:10.1111/j.1525-1470.2009.01042.x; Fukaya M. Histological and immunohistological findings using anti-cortisol antibody in atopic dermatitis with topical steroid addiction. Dermatol Ther (Heidelb). 2016;6(1):39-46. doi:10.1007/s13555-016-0096-7; Hon KL, Leung AKC, Cheng JWCH, et al. Allergic contact dermatitis in pediatric practice. Curr Pediatr Rev. 2024;20(4):478-488. doi:10.2174/1573396320666230626122135; Johnson MD, Perfect JR. Use of Antifungal Combination Therapy: Agents, Order, and Timing. Curr Fungal Infect Rep. 2010;4(2):87-95. doi:10.1007/s12281-010-0018-6; Lax SJ, Harvey J, Axon E, et al. Strategies for using topical corticosteroids in children and adults with eczema. Cochrane Database Syst Rev. 2022;3(3):CD013356. Published 2022 Mar 11. doi:10.1002/14651858.CD013356.pub2; Li J, Zhi H, Xia X, et al. A survey of 701 cases of tinea faciei in Hangzhou, southeastern China, from 2018 to 2023. Mycoses. 2024;67(6):e13755. doi:10.1111/myc.13755; Luger T, Boguniewicz M, Carr W, et al. Pimecrolimus in atopic dermatitis: consensus on safety and the need to allow use in infants. Pediatr Allergy Immunol. 2015;26(4):306-315. doi:10.1111/pai.12331; Ma L, Tao X, Liu S, et al. Efficacy and safety of crisaborole ointment 2% in Chinese patients aged ≥ 2 years with mild to moderate atopic dermatitis. Dermatol Ther (Heidelb). 2024;14(5):1229-1243. doi:10.1007/s13555-024-01156-6; Marshall HF, Leung DYM, Lack G, et al. Topical steroid withdrawal and atopic dermatitis. Ann Allergy Asthma Immunol. 2024;132(4):423-425. doi:10.1016/j.anai.2023.12.022; Mir-Bonafé JF, Piquero-Casals J, Prudkin L, et al. Use of Topical Corticosteroids in the Treatment of Noninfectious Inflammatory Dermatoses of the Scalp: A Survey of Practicing Dermatologists and Dermatology Residents Using Delphi Methodology. Clin Cosmet Investig Dermatol. 2024;17:671-681. Published 2024 Mar 18. doi:10.2147/CCID.S448016; Nowowiejska J, Baran A, Flisiak I. Tinea incognito-a great physician pitfall. J Fungi (Basel). 2022;8(3):312. Published 2022 Mar 18. doi:10.3390/jof8030312; Ramsey JT, Li Y, Arao Y, et al. Lavender products associated with premature thelarche and prepubertal gynecomastia: case reports and endocrine-disrupting chemical activities. J Clin Endocrinol Metab. 2019;104(11):5393-5405. doi:10.1210/jc.2018-01880; Sachdeva M, Mufti A, Maliyar K, et al. A review of COVID-19 chilblains-like lesions and their differential diagnosis. Adv Skin Wound Care. Published online March 12, 2021. doi:10.1097/01.ASW.0000737860.47789.3c; Saxena R, Mittal P, Clavaud C, et al. Longitudinal study of the scalp microbiome suggests coconut oil to enrich healthy scalp commensals. Sci Rep. 2021;11(1):7220. Published 2021 Mar 31. doi:10.1038/s41598-021-86454-1; Scheinfeld N. Hidradenitis suppurativa: A practical review of possible medical treatments based on over 350 hidradenitis patients. Dermatol Online J. 2013;19(4):1. Published 2013 Apr 15; Sherry DD, Sonagra M, Gmuca S. The spectrum of pediatric amplified musculoskeletal pain syndrome. Pediatr Rheumatol Online J. 2020;18(1):77. Published 2020 Oct 12. doi:10.1186/s12969-020-00473-2.

Disclosures

For this program, members of the faculty and the planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Howard was recorded at The 45th Annual Las Vegas Seminars: Pediatric Update, held December 13-15, 2024, in Las Vegas, NV, and presented by The American Academy of Pediatrics, California Chapter 4. For information about upcoming CME activities from this presenter, please visit https://aap-ca.org/events. Audio Digest thanks Dr. Howard and The American Academy of Pediatrics, California Chapter 4, for their cooperation in the production of this program.

CME/CE INFO

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The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 2.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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Lecture ID:

PD711101

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This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

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