Paediatric dermatology

Whether it is the primary complaint or a symptom of the underlying disease many children present to healthcare practitioners with skin conditions.

The Skin Deep Project is a collection of photographs and descriptions of paediatric skin lesions led by Don’t Forget The Bubbles and the Royal London Hospital, with contributors worldwide. The project focuses on providing high-quality, accessible images that improve the diversity available in online paediatric skin images. This will improve identification and patient care.

But first, it is helpful to know the right terms to use to help identify skin lesions. So, let’s start there.

Basic skin anatomy

The skin is made up of three layers: the epidermis. the dermis and a layer of subcutaneous fat. The epidermis is made of many layers of epithelial cells. Near the bottom of the epidermis are melanocytes. These are a special type of cell that produces melanin, a dark pigment responsible for giving skin its colour. The dermis is made up of connective tissue and contains hair follicles, sweat glands, sebaceous glands, branches of blood vessels, and nerve endings. The subcutaneous fat layer below the dermis helps to protect our bodies, regulate temperature, and anchor the dermis to structures below, such as muscle or bone. It also contains blood vessels.

Skin forms a protective barrier for the body but also has multiple other functions, including immunological protection, temperature regulation, vitamin D synthesis, sensation, secretion, and excretion.

Whilst history is very important, paediatric dermatology is often truly down to the spot diagnosis. It would be great if we could just send pictures straight to the electronic medical record, but this is not always possible.

Distribution pattern

Some rashes are easily diagnosed by location – why do you think it is called Hand, Foot and Mouth? These are LOCALIZED rashes. Are they in a DERMATOMAL distribution, like in shingles or in a sun-exposed area? PHOTOSENSITIVE ares. Others are harder to place and are more GENERALIZED in their location.
The skin changes associated with eczema are more commonly seen on FLEXURAL surfaces (i.e. the creases), whereas psoriatic plaques are more likely to be found on EXTENSOR surfaces.

Configuration

After determining the distribution of the lesion, it is time to determine the configuration, which is the pattern or shape.

Are the lesions DISCRETE (separate) or CONFLUENT (joined together)? Are they LINEAR or not? Are they TARGET lesions, ANNULAR, or DISCOID?

Primary skin lesions

Skin lesions can be primary or secondary. Primary lesions arise directly from a disease process/cause. Secondary lesions progress from a primary lesion or due to transformation caused by interacting with the environment (e.g., heat, chemicals) or a patient’s actions (e.g., picking, rubbing).

Primary skin lesions include:

CRUST: The skin is covered in a layer of dried matter – usually serum, blood, pus, or a combination.

CYST: A closed cavity filled with semi-solid or liquid material such as fluid or blood. It can be lined with epithelium or endothelium. A cyst filled with pus is a PUSTULE.

MACULE: A small, flat, non-palpable skin lesion that is less than 1 cm diameter in size. Note that this type of lesion which is >1cm is usually referred to as a PATCH.

PUSTULE: A pus-filled elevated skin lesion, often with surrounding erythema.

ULCER: A defect in the skin or mucous membranes (loss of epidermis +/- deeper layers. They are deep and often leave a scar when they heal.

VESICLE: A well-rounded, raised, fluid-filled lesion which is <1cm in diameter (a BULLA is >1cm in size)

WHEAL/HIVE: A pink, oedematous papule from swelling in the dermis that can vary in size and shape. They are usually erythematous but can have a paler centre.

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