managing-pediatric-dermatology

name	managing-pediatric-dermatology
description	Identifies and manages common pediatric skin conditions with visual diagnosis and treatment protocols. Use when evaluating pediatric rashes, managing eczema, or treating common skin conditions in children.
tags	["management","pediatrics","treatment"]
metadata	{"author":"casemark","practice_areas":["Pediatrics","Neonatology","Adolescent Medicine"],"document_types":["Management Report"],"skill_modes":["Management","Coordination"]}

Managing Pediatric Dermatology

Identifies and manages common pediatric skin conditions including atopic dermatitis (eczema), diaper dermatitis, viral exanthems, tinea infections, acne vulgaris, warts, molluscum contagiosum, scabies, impetigo, and hemangiomas. Applies morphology-based diagnostic reasoning, age-specific treatment protocols, topical steroid potency selection, and referral criteria for dermatology.

Why This Skill Exists

Skin conditions account for approximately 30% of outpatient pediatric visits. Diagnostic accuracy depends on correct morphologic description (macule vs. papule vs. vesicle vs. plaque), distribution pattern recognition, and age-specific differential diagnosis. Inappropriate topical steroid use — too potent on the face, too weak on thick plaques, too prolonged without monitoring — is a leading source of iatrogenic harm in pediatrics. This skill enforces systematic morphologic assessment, evidence-based treatment selection with appropriate steroid potency matching, and clear escalation criteria.

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Checkpoint A — Intake Verification

Required Intake Questions

1. What is the child's age (neonatal rashes have a distinct differential from toddler or adolescent rashes)?
2. When did the rash appear, and how has it evolved?
3. Is the rash pruritic (itchy), painful, or asymptomatic?
4. Where on the body did it start, and where has it spread?
5. Has the child been febrile or systemically ill?
6. What exposures have occurred (new foods, medications, sick contacts, animals, plants)?
7. Is there a family history of atopic disease (eczema, asthma, allergic rhinitis)?
8. What treatments have been tried (OTC creams, prescription medications)?
9. Has the child had this rash before (recurrent vs. new)?
10. Are there any immunodeficiencies or chronic conditions?

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

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Step 1 — Morphologic Description and Classification

Primary Lesion Morphology

Term	Definition	Size
Macule	Flat, color change only	< 1 cm
Patch	Flat, color change only	> 1 cm
Papule	Raised, solid	< 1 cm
Plaque	Raised, solid, flat-topped	> 1 cm
Nodule	Raised, solid, deeper	> 1 cm, extends into dermis/subcutis
Vesicle	Fluid-filled, clear	< 1 cm
Bulla	Fluid-filled, clear	> 1 cm
Pustule	Pus-filled	Any size
Wheal (hive)	Transient, erythematous, edematous	Variable
Petechiae	Non-blanching, red-purple	< 2 mm
Purpura	Non-blanching, red-purple	> 2 mm

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

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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

Age	Distribution
Infant (< 2 years)	Face (cheeks), scalp, extensor surfaces
Childhood (2-12 years)	Flexural (antecubital, popliteal fossae), wrists, ankles
Adolescent/adult	Flexural, hands, eyelids, neck

Severity Classification

Severity	Features	Treatment Approach
Mild	Limited areas, minimal erythema, no sleep disruption	Emollients + low-potency TCS PRN
Moderate	Widespread, moderate erythema, excoriation, some sleep disruption	Regular mid-potency TCS, emollients, ± TCI
Severe	Extensive, lichenification, fissuring, significant sleep/QOL impairment	High-potency TCS (body), TCI, wet wraps, consider systemic

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

Potency Class	Examples	Use On
Low (VII)	Hydrocortisone 1%, desonide 0.05%	Face, eyelids, groin, axillae, infants
Medium (IV-V)	Triamcinolone 0.1%, fluocinolone 0.025%	Body, extremities (children)
High (II-III)	Fluocinonide 0.05%, desoximetasone 0.25%	Thick plaques (palms, soles); short courses only
Super-high (I)	Clobetasol 0.05%, betamethasone dipropionate 0.05%	NOT for routine pediatric use; specialist 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

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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

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Step 4 — Infectious Dermatoses

Tinea (Dermatophyte Infections)

Type	Presentation	Treatment
Tinea corporis (body)	Annular, scaly, raised border, central clearing	Topical antifungal (clotrimazole, terbinafine) × 2-4 weeks
Tinea capitis (scalp)	Scaly patches, broken hairs, +/- kerion; must use KOH prep or culture	Oral griseofulvin 20-25 mg/kg/day × 6-8 weeks (must be systemic; topicals do not penetrate hair follicle); terbinafine as alternative
Tinea pedis (feet)	Interdigital maceration, scaling on soles	Topical antifungal × 2-4 weeks

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

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Step 5 — Viral Exanthems

Common Viral Rashes in Children

Condition	Agent	Rash Description	Key Features
Roseola (exanthem subitum)	HHV-6	Maculopapular, starts on trunk after fever breaks	High fever × 3-5 days, then rash as fever resolves; age 6-24 months
Fifth disease (erythema infectiosum)	Parvovirus B19	"Slapped cheek" → lacy reticular rash on trunk/extremities	No longer contagious when rash appears; concern in pregnancy and sickle cell
Hand-foot-mouth	Coxsackie A16, EV71	Vesicles on palms, soles, oral mucosa	May cause nail shedding (onychomadesis) weeks later
Measles	Paramyxovirus	Maculopapular, starts at hairline, spreads caudally	Koplik spots (buccal mucosa), cough, coryza, conjunctivitis
Varicella	VZV	Vesicles on erythematous base, crops in different stages	"Dew drop on a rose petal"; lesions in various stages simultaneously

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

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Step 6 — Adolescent Acne

Classification

Severity	Description	Treatment
Mild (comedonal)	Open/closed comedones; few inflammatory papules	Topical retinoid (adapalene 0.1%) ± benzoyl peroxide
Moderate (inflammatory)	Papules and pustules	Topical retinoid + benzoyl peroxide + topical antibiotic (clindamycin)
Moderate-severe	Numerous papules/pustules, some nodules	Oral antibiotic (doxycycline 50-100 mg BID) + topical retinoid + BP
Severe (nodulocystic)	Nodules, cysts, scarring	Refer for isotretinoin consideration

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)

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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

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Quality Audit

Item	Requirement	Pass?
Morphologic description	Standard terminology used (not just "rash")
Distribution documented	Body sites specifically listed
TCS potency matching	Correct potency for body site (low for face, medium for body)
Eczema management	Emollient-first approach documented; TCS not sole treatment
Tinea capitis	Oral antifungal prescribed (not topical alone)
Red flag recognition	Petechiae, SJS, eczema herpeticum flagged for urgent management
Scabies treatment	All household contacts treated simultaneously
Acne antibiotic stewardship	No topical antibiotic monotherapy; oral antibiotics time-limited
Age-appropriate treatment	Medications and formulations suitable for patient age
No unexplained [VERIFY] tags	All flagged items resolved or escalated

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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