Atlas of Dermatoses in Pigmented Skin - Ranthilaka R. Ranawaka Ajith P. Kannangara Ajith Karawita Editors
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Atlas of Dermatoses in Pigmented Skin Ranthilaka R. Ranawaka Ajith P. Kannangara Ajith Karawita Editors 123
Ranthilaka R. Ranawaka Ajith P. Kannangara • Ajith Karawita Editors Atlas of Dermatoses in Pigmented Skin
Editors Ranthilaka R. Ranawaka Ajith P. Kannangara Consultant Dermatologist Consultant Dermatologist General Hospital Kalutara Base Hospital Balapitiya Kalutara Balapitiya Sri Lanka Sri Lanka Ajith Karawita Consultant Venereologist Teaching Hospital Anuradhapura Anuradhapura Sri Lanka ISBN 978-981-15-5482-7 ISBN 978-981-15-5483-4 (eBook) https://doi.org/10.1007/978-981-15-5483-4 © Springer Nature Singapore Pte Ltd. 2021 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore
Preface This book has been written by clinicians for clinicians to provide a clear and easy guide to identify skin diseases in pigmented skin. This book discusses Over 500 Skin Problems with Over 2700 Colour Illustrations, and more than 300 Picture-Based Questions with Answers. Common skin diseases such as psoriasis, lichen planus, eczema and ery- thrasma are darker in pigmented skin. For example in PASI (psoriasis area and severity index), erythema is always 0 or 1 in pigmented skin; lichen pla- nus is blackish rather than purplish; erythrasma is never erythematous; and lichen amyloidosis is blackish in darker skin. Therefore, it is important that dermatology trainees and general practitioners treating patients of pigmented skin (Fitzpatrick type V) use an atlas with their patients to get familiar with these diverse clinical presentations. Tropical diseases such as cutaneous tuberculosis, leishmaniasis, fungal infections, oral submucous fibrosis and leprosy are not uncommon in our routine skin clinics. Nevertheless, some of the diseases which were frequent in our clinical practice twenty years ago are rarely encountered today such as sporotrichosis, mycetoma, rhinosporidiosis, lobomycosis and subcutaneous zygomycosis. Urbanization, change of farming practices and using pesticides may play a role here. Therefore, it is imperative to document these disappear- ing diseases for the future. Hypopigmented disorders such as pityriasis alba, vitiligo, guttate hypomel- anosis, progressive macular hypomelanosis and chemical or physical induced depigmentation are more marked and a cosmetic concern in pigmented skin and are visible without any instrumental assistance, such as Wood’s light. Interestingly, hyperpigmentary changes are more a cosmetic issue in aging pigmented skin than wrinkles. Wrinkles appear ten years later in pigmented skin compared to the white skin. This atlas is meant to stimulate the interest in tropical dermatology and skin problems in pigmented skin, among medical students, postgraduate trainees, general practitioners and dermatologists from non-tropical countries. Kalutara, Sri Lanka Ranthilaka R. Ranawaka Balapitiya, Sri Lanka Ajith P. Kannangara Anuradhapura, Sri Lanka Ajith Karawita v
Acknowledgements We wish to pay tribute to all the contributors for spending their invaluable time and knowledge to the success of this atlas. We take this opportunity to show our heartiest acknowledgements to all the patients, majority Sri Lankans, who generously gave clinical photographs to this book. Finally, our thanks go to Springer for accepting this book for publication. Dr Ranthilaka R. Ranawaka Dr Ajith P. Kannangara Dr Ajith Karawita vii
Contents Part I Neonatal and Paediatric Dermatoses 1 Dermatoses of the Neonate and Infancy�������������������������������������� 3 Ranthilaka R. Ranawaka 2 Congenital Naevi and Melanocytic Naevi������������������������������������ 45 Ranthilaka R. Ranawaka 3 Vascular Tumours and Malformations���������������������������������������� 65 Ranthilaka R. Ranawaka 4 Neurocutaneous Syndromes���������������������������������������������������������� 81 Anuruddha Padeniya and Fous Lebbe Part II Inflammatory Dermatoses 5 Psoriasis������������������������������������������������������������������������������������������ 91 Kanchana Mallawaarachchi 6 Eczematous Disorders ������������������������������������������������������������������ 107 Ranthilaka R. Ranawaka 7 Inherited Disorders of Keratinization������������������������������������������ 123 Priyanka Karagaiah and Varsha M. Gowda 8 Allergic and Irritant Contact Dermatitis������������������������������������ 151 Ranthilaka R. Ranawaka 9 Occupational Dermatoses�������������������������������������������������������������� 169 Ajith P. Kannangara 10 Photodermatosis���������������������������������������������������������������������������� 183 Hiromel de Silva 11 Cutaneous Reactions���������������������������������������������������������������������� 201 Ajith P. Kannangara 12 Neutrophilic Dermatoses �������������������������������������������������������������� 213 Binari K. S. Wijenayake ix
x Contents Part III Infections and Infestations 13 Cutaneous Tuberculosis���������������������������������������������������������������� 227 Sujay Khandpur and Neha Taneja 14 Mycobacterial Infections in Sri Lanka���������������������������������������� 237 Ranthilaka R. Ranawaka 15 Leprosy�������������������������������������������������������������������������������������������� 257 Ranthilaka R. Ranawaka 16 Viral Infections������������������������������������������������������������������������������ 297 Premini Rajendiran 17 Superficial Fungal Infections�������������������������������������������������������� 319 Ranthilaka R. Ranawaka 18 Subcutaneous and Systemic Mycoses������������������������������������������ 359 S. N. Arseculeratne, Archana Singal, and Ranthilaka R. Ranawaka 19 Onychomycosis������������������������������������������������������������������������������ 381 Ranthilaka R. Ranawaka 20 Diseases Caused by Arthropods and Parasites���������������������������� 397 Hiran Gunasekera 21 Leishmaniasis in Sri Lanka���������������������������������������������������������� 417 Ranthilaka R. Ranawaka, Yamuna Siriwardana, and Shalindra Ranasinghe 22 Sexually Transmitted Infections �������������������������������������������������� 445 Ajith Karawita Part IV Systemic Dermatoses 23 Sarcoidosis�������������������������������������������������������������������������������������� 469 Katerina Damevska, Snejina Vassileva, Kossara Drenovska, Slavica Kostadinova-Kunovska, and Valeria Mateeva 24 Autoimmune Blistering Diseases�������������������������������������������������� 481 Binari K. S. Wijenayake 25 Lichen Planus and Lichenoid Dermatoses���������������������������������� 497 Ajith P. Kannangara 26 Acne������������������������������������������������������������������������������������������������ 503 Sanjeewani Fonseka 27 Rosacea�������������������������������������������������������������������������������������������� 511 Sanjeewani Fonseka 28 Disorders of Connective Tissue���������������������������������������������������� 515 Chathurarya Siriwardena
Contents xi 29 Leg Ulcers �������������������������������������������������������������������������������������� 529 Ranthilaka R. Ranawaka 30 Cutaneous Vasculitis���������������������������������������������������������������������� 547 Binari K. S. Wijenayake 31 Autoimmune Connective Tissue Diseases������������������������������������ 563 Kanchana Mallawaarachchi Part V The Skin and the Organs 32 Benign Lesions in the Oral and Maxillofacial Region���������������� 587 K. M. S. Kosgoda 33 Skin and the Ear���������������������������������������������������������������������������� 613 Ranthilaka R. Ranawaka 34 Psychocutaneous Disorders���������������������������������������������������������� 627 Ranthilaka R. Ranawaka 35 Disorders of Hair���������������������������������������������������������������������������� 637 Lidia Rudnicka and Anna Waśkiel-Burnat 36 Trichoscopy: Dermoscopy Hair���������������������������������������������������� 663 Deepani Rathnayake 37 Disorders of Nails�������������������������������������������������������������������������� 723 Eckart Haneke and Ranthilaka R. Ranawaka 38 Genital Dermatoses������������������������������������������������������������������������ 765 Ajith Karawita and Ranthilaka R. Ranawaka Part VI Pigmentary and Cosmetic Dermatoses 39 Cultural Dermatoses���������������������������������������������������������������������� 797 Felicia Srisaravanapavananthan 40 Facial Melanosis ���������������������������������������������������������������������������� 803 Ranthilaka R. Ranawaka 41 Vitiligo �������������������������������������������������������������������������������������������� 823 Ranthilaka R. Ranawaka 42 Hypopigmentary Disorders���������������������������������������������������������� 837 Ranthilaka R. Ranawaka 43 Hyperpigmentary Disorders �������������������������������������������������������� 849 Premini Rajendiran Part VII Benign and Malignant Skin Tumours 44 Oral Potentially Malignant Disorders (OPMDs)������������������������ 879 W. M. Tilakaratne and Ruwan D. Jayasinghe 45 Oral Cancer������������������������������������������������������������������������������������ 903 Ruwan D. Jayasinghe and W. M. Tilakaratne
xii Contents 46 Hypopigmented Mycosis Fungoides�������������������������������������������� 921 Ranthilaka R. Ranawaka 47 Tumours of the Skin Appendages ������������������������������������������������ 941 V. G. Abeywickrama 48 Benign Skin Proliferations������������������������������������������������������������ 955 Ranthilaka R. Ranawaka 49 Precursors of Skin Carcinoma������������������������������������������������������ 971 Ranthilaka R. Ranawaka 50 Skin Carcinomas���������������������������������������������������������������������������� 989 Ranthilaka R. Ranawaka, Kanishka de Silva, and Priyanka H. Abeygunasekara Part VIII Therapy and Complications 51 Cutaneous Adverse Reactions to Drugs �������������������������������������� 1017 Binari K. S. Wijenayake Part IX Invited Chapter 52 Dermatoses from Brazil���������������������������������������������������������������� 1049 Sinésio Talhari and Carolina Chrusciak Talhari Cortez
List of Contributors Priyanka H. Abeygunasekara, D Path, MD Path (Histopath) National Cancer Institute, Maharagama, Sri Lanka V. G. Abeywickrama, MBBS, MD District General Hospital, Matale, Sri Lanka S. N. Arsecularatne, MBBS, Dip. Bact. D. Phil. Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka Katerina Damevska, MD, MSc, PhD Clinic of Dermatology, Medical Faculty, Ss. Cyril and Methodius University, Skopje, Macedonia Kossara Drenovska, MD, PhD Department of Dermatology and Venereology, Medical Faculty, University of Medicine, Sofia, Sofia, Bulgaria Varsha M. Gowda, MD Bangalore Medical College and Research Centre, Bangalore, Karnataka, India Hiran Gunasekara, MBBS, MD Teaching Hospital, Kuliyapitiya, Kuliyapitiya, Sri Lanka Eckhart Haneke, MD, PhD Clinical professor of dermatology, consultant dermatologist (Germany), Visiting professor, Nail Diseases, Nail Surgery, Nail Pathology, Department of Dermatology, Inselspital, Universitätsspital Bern, Bern, Switzerland R. D. Jayasinghe, BDS, MS Department of Oral Medicine and Periodontology, Faculty of Dental Sciences, University of Peradeniya, Peradeniya, Sri Lanka Ajith P. Kannangara, MBBS, MD Consultant Dermatologist, Base Hospital Balapitiya, Balapitiya, Sri Lanka Priyanka Karagaiah, MD Bangalore Medical College and Research Centre, Bangalore, Karnataka, India Ajith Karawita, MBBS, Pg Dip Ven, MD, FSLCoSHH Sexual Health Centre, Teaching Hospital Anuradhapura, Anuradhapura, Sri Lanka Sujay Khandpur, MD, DNB, MNAMS Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India xiii
xiv List of Contributors K. M. S. Kosgoda, BDS, MS Consultant Oral and Maxillofacial Surgeon, Teaching Hospital Anuradhapura, Anuradhapura, Sri Lanka Slavica Kostadinova-Kunovska, MD, PhD Institute of Pathology, Medical Faculty, Ss. Cyril and Methodius University, Skopje, Macedonia Fous Lebbe, MBBS, MD Lady Ridgeway Hospital for Children, Colombo, Sri Lanka Kanchana Mallawarachchi, MBBS, MD Base Hospital Balangoda, Balangoda, Sri Lanka Valeria Mateeva, MD, PhD Department of Dermatology and Venereology, Medical Faculty, University of Medicine, Sofia, Sofia, Bulgaria Anuruddha Padeniya, MBBS, MD Lady Ridgeway Hospital for Children, Colombo, Sri Lanka Teaching Hospital Kandy, Kandy, Sri Lanka Department of Paediatrics, University of Rajarata, Mihintale, Sri Lanka Premini Rajendrian, MBBS, MD District General Hospital, Chilaw, Chilaw, Sri Lanka Shalindra Ranasinghe, MBBS, M.Phil (Keele), PhD Department of Parasitology, Faculty of Medical Sciences, University of Sri Jayewardenepura, Nugegoda, Sri Lanka Ranthilaka R. Ranawaka, MBBS, MD Consultant Dermatologist, General Hospital Kalutara, Kalutara, Sri Lanka Deepani Ratnayake, MBBS, MD, FACD Sinclair Dermatology, East Melbourne, VIC, Australia Lidia Rudnicka, MD, PhD Department of Dermatology, Medical University of Warsaw, Warsaw, Poland Hiromel de Silva, MBBS, MD Consultant Dermatologist, Base Hospital Tangalle, Tangalle, Sri Lanka Kanishka de Silva, MS, FRCS National Cancer Institute, Maharagama, Sri Lanka Archana Singal, MD, FAMS University College of Medical Sciences & GTB Hospital, New Delhi, India Faculty of Medical Sciences, University of Delhi, New Delhi, India Chaturyaya Siriwardena, MBBS, MD (Derm), MRCP (UK) District General Hospital Nuwara Eliya, Nuwara Eliya, Sri Lanka Yamuna Siriwardena, MBBS, PhD Parasitic Disease Research Unit, Department of Parasitology, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka Felicia Srisaravanapavananthan, MBBS, MD Teaching Hospital Jaffna, Jaffna, Sri Lanka
List of Contributors xv Sinesio Talhari, PhD Heitor Vieira Dourado Foundation of Tropical Medicine, Manaus, Amazonas, Brazil Carolina Chrusciak Talhari Cortez, PhD Department of Dermatology, Heitor Vieira Dourado Foundation of Tropical Medicine, Manaus, Amazonas, Brazil Neha Taneja, MD, DNB Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India W. M. Tilakaratne, BDS, MS, FDSRCS, FRCPath, PhD Department of Oral Pathology, Faculty of Dental Sciences, University of Peradeniya, Peradeniya, Sri Lanka Department of Oral and Maxillofacial Clinical Sciences, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia Snejina Vassileva, MD, PhD Department of Dermatology and Venereology, Medical Faculty, University of Medicine, Sofia, Sofia, Bulgaria Anna Waskiel-Burnat, MD, PhD Department of Dermatology, Medical University of Warsaw, Warsaw, Poland Sanjeewani Fonseka, MBBS, MD (Dermatology), PhD Department of Pharmacology, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka Binari K. S. Wijenayake, MBBS, MD Teaching Hospital Karapitiya, Galle, Sri Lanka
About the Editors Ranthilaka R. Ranawaka, MBBS, MD, from the University of Colombo, Sri Lanka. She has had extensive training towards conducting clinical tri- als in psoriasis and acne at St John’s Institute of Dermatology, London, UK, in 2006. She is cur- rently working as a consultant dermatologist at General Hospital Kalutara, Sri Lanka. Dr Ranawaka has published more than 26 scientific papers in national and international journals including six clinical trials. She is an author of six dermatology books and three chapters, academic editor in two journals and reviewer in a number of indexed journals. She was awarded a number of travel awards and scholarships (AAD 2006, EADV 2006, WCD 2007, ICD 2009, EADV 2020) and research awards including European Nail Research Grant in 2008 and SLMA-FairMed research grant in 2012 and 2014. She was awarded President’s Award for Scientific Publications in 2009, 2010, 2011, 2015, 2016 and 2017. She was the Co-Chair and Guest Speaker at the “Tropical dermatoses” symposium at the World Congress of Dermatology 2019, in Milan, Italy. Ajith P. Kannangara, MBBS, MD, Consultant Dermatologist, specialist in anti-aging medicine and cosmetic dermatology, is currently attached to the Ministry of Health, Sri Lanka. He obtained his MBBS from the University of Peradeniya and MD from the University of Colombo, Sri Lanka. Dr Kannangara gained Fellowship from National Skin Centre, Singapore and postdoctoral International Dermatology Fellowship from Wake Forest University, Baptist Medical Centre, North Carolina, USA. He also earned Diploma from the American Academy of Anti-Aging and xvii
xviii About the Editors Regenerative Medicine and American Academy of Aesthetic Medicine. Dr Kannangara also serves as editor and reviewer for various national and international journals. His research papers are published in most renowned national and international journals of dermatology. He is one of the pioneers of the proposed classification of cutaneous reactions: Koebner, Wolf isotopic, Renbok, Koebner nonre- action, isotopic nonreaction, immunocompro- mised district and other related phenomena, and introducing the concept of Sparing phenomena. Ajith Karawita, MBBS, PgDip and MD (Venereology), is currently serving as a consultant venereologist in a teaching hospital at the Ministry of Health, Sri Lanka. He qualified in MBBS at the University of Peradeniya in 1997 and subsequently obtained his postgraduate diploma and MD in Venereology from the Postgraduate Institute of Medicine (PGIM), University of Colombo, Sri Lanka. He is a fellow and past president (2015– 2016) of the Sri Lanka College of Sexual Health and HIV Medicine. Further, he is a member of the board of study, board of examinations and research proposal review committee on venereology at the PGIM. He is a Visiting Lecturer at Rajarata University of Sri Lanka and the PGIM. He is a member of the Australasian Society of HIV Medicine (ASHM); honorary member of the Research Institute of Tuberculosis and Anti- tuberculosis Association, Japan; life member of the Sri Lanka Medical Association; and a member of the Asia Pacific Association of Medical Journal Editors (APAME) and the editor-in-chief of the Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH). He has authored numerous research papers, invited articles, book chapters, reports and guidelines. He has been a guest speaker for multiple forums and presented many research papers at local and international conferences.
Part I Neonatal and Paediatric Dermatoses
Dermatoses of the Neonate and Infancy 1 Ranthilaka R. Ranawaka 1. Introduction More than 95% of newborns have cutaneous find- ings, which often are distressing to parents but frequently are benign and self-limited. Among them are milia, cutis marmorata, congenital der- mal melanocytosis and the benign neonatal pus- tular eruptions (Rayala and Morrell 2017; Zuniga and Nguyen 2013). The majority of the dermato- logic alterations in neonates are physiological and transient and do not require any treatment; thus the parents can be reassured about the good prognosis (Patrizi et al., 2017). An overview of the most common or important dermatoses pre- senting in neonatal and infant age group is illus- trated in this chapter. A 6 months old baby was brought with this skin lesion which has been there since birth, the mother is worried that it is being progres- sively enlarging. (a) What is the diagnosis? (b) What is the sequelae of the disease? The clinical photographs in this chapter are photographed by Dr. Ranthilaka R. Ranawaka, consultant dermatologist, General Hospital Kalutara, Sri Lanka R. R. Ranawaka (*) General Hospital Kalutara, Kalutara, Sri Lanka © Springer Nature Singapore Pte Ltd. 2021 3 R. R. Ranawaka et al. (eds.), Atlas of Dermatoses in Pigmented Skin, https://doi.org/10.1007/978-981-15-5483-4_1
4 R. R. Ranawaka 2. 3. A 1-year-old child came with the above lesions which were asymptomatic. He was getting these lesions frequently. His 3-year- old sister also was getting few lesions on the face. What is the diagnosis? 4. A 3 months old baby was brought with mildly erythematous hypopigmented patches on the groin, back of the trunk, neck and upper chest. They were mostly asymp- tomatic. What is the diagnosis? A 4-month-old baby was brought with itchy skin lesions on the trunk, buttocks and geni- talia for 3 weeks. (a) What is the diagnosis? (b) Who else do you want to examine?
1 Dermatoses of the Neonate and Infancy 5 5. 7. The mother of this 6 months old baby is wor- ried about these scaly lesions on the scalp which are mildly itchy. A 4 days old neonate was brought with this (a) What is the diagnosis? skin eruption. What is the diagnosis? (b) What advice would you give the mother? 8. 6. A 5-year-old boy has these asymptomatic hypopigmented patches on both cheeks for 2 months which are progressively enlarging. What is the diagnosis? A 2-year-old child has a distractible itching 9. more pronounced during the night. On direct inquiry revealed that his whole family has generalized itching without any visible skin rash. (a) What is the diagnosis? (b) What is the condition shown in this picture? This painless boggy mass has appeared and enlarged within 1 week despite antibiotics prescribed by the family physician. What is the diagnosis?
6 R. R. Ranawaka 10. 11. A 6-year-old child developed these patchy hair loss over 3 weeks which were treated with native remedies. What is the diagnosis? 12. These asymptomatic lesions had appeared over 3 weeks. What is the diagnosis? 13. This 4-year-old child’s mother is worried about these asymptomatic lesions which appeared 4 weeks ago. (a) What is the diagnosis? (b) What advice would you give the mother? A 4-year-old child came with these painful pustules localized to shown area.
1 Dermatoses of the Neonate and Infancy 7 (a) What are the differential diagnoses? (a) What are the possible causes? (b) What was the diagnosis in this child? 17. T h e 14. A 7-year-old boy had developed these lesions on the face over 3 months. (a) What are the possible diagnoses? (b) What are the other features you want to look for? (c) How do you treat this skin problem? 15. mother of this 7-year-old child complains The mother of this 6 months old baby is wor- foul smell from his feet when he removes ried about these linear hypopigmented socks after school. patches on the trunk. (a) What is the diagnosis? (a) What is the diagnosis? (b) What are the predisposing factors? (b) What advice would you give the mother? 18. 16. A newborn had this patch of alopecia.
8 R. R. Ranawaka A 4-year-old child was brought with this (a) What is the diagnosis? nail abnormality. After few weeks these nails fall spontaneously. (a) What is the diagnosis? (b) What are the predisposing factors? (c) How do you manage this? 19. 21. A 4-month-old baby was brought with this inguinal rash for 1 month. (a) What are the differential diagnoses? 22. A 20 days old baby girl who was normal at birth had developed these blisters and ero- sions for the last 3 days. (a) What are the differential diagnoses? 20. A 12-year-old child came with this linear itchy lesion on the dorsum of the hand. They noticed that the lesion is extending forward. (a) What is the diagnosis? Answers 1. Infantile haemangioma (Chap. 3). It will slowly grow over the first 12 months and then regress gradually over the next 2–3 years which almost disappears leaving some slack skin. No treatment is given unless it obstructs the function of vital organs. But there is a A 5-year-old child developed this skin erup- tendency to easy bleeding and secondary tion with fever, malaise and body aches. infection.
1 Dermatoses of the Neonate and Infancy 9 2. Infantile seborrhoeic dermatitis. 17. Pitted keratolysis. 3. Staph impetigo. Hyperhidrosis and frequent emersion of 4. Tinea infection (Chap. 17). feet in water are the predisposing factors. Close relatives who look after the child, 18. Onychomadesis (Chap. 37). e.g. parents, grandparents, nanny, etc. This not uncommon in children after viral Usually infants acquire this infection from infection, most commonly hand, foot and adults. You should treat the adult who has mouth disease. tinea infection too, to avoid reinfection. 19. Bullous impetigo and dystrophic epidermol- 5. Cradle cap. ysis bullosa (DEB). This will spontaneously clear over In DEB the child is clinically well in spite months. Treat symptomatically. of large erosions, and lesions are confined to 6. Scabies (Chap. 20). areas of friction. Scabietic nodules which have predilec- 20. Chickenpox (Chap. 16). tion to genitalia, which are very itchy and 21. Infantile psoriasis, napkin dermatitis and can persist for weeks to months after suc- infantile seborrhoeic dermatitis. cessful treatment of scabies. Involvement of the napkin area (psoriatic 7. Folliculitis. napkin eruption) may be the first presenta- 8. Polymorphic light eruption (Chap. 10). tion of psoriasis in infancy (Burden and 9. Kerion (Chap. 17). Kirby 2016). Edges of the lesions are well 10. Granuloma annulare. defined unless altered by medicaments. These are benign lesions which resolve 22. Cutaneous larva migrans. spontaneously with time. 11. Alopecia areata (Chap. 35). 12. Molluscum contagiosum (Chap. 16). 1.1 Inflammatory Conditions 13. Staph impetigo and herpes infection. Herpes infection (HSV I). 1.1.1 Cradle Cap 14. Acneiform eruption due to topical or sys- temic steroids, drug-induced acne and ade- Cradle cap may be seen in the neonate; the condi- noma sebaceum (angiofibromas) in tuberous tion is most common between the ages of 4 and sclerosis complex (TCS). 16 weeks. It can occur in isolation or in associa- Hypomelanotic macules (ash-leaf mac- tion with seborrhoeic dermatitis. Most cases of ules) and angiofibromas are pathognomonic cradle cap resolve spontaneously after a few in TCS, also look for periungual fibromas weeks (Das and Das 2014). (Koenen tumours) and shagreen patch Clinical presentation: Thick scales adherent (Chap. 4). to scalp since birth. Mild inflammation with itch- This is adenoma sebaceum (angiofibromas) ing in some, but most are asymptomatic (Fig. 1.1). in tuberous sclerosis complex (TCS) which can Management: An emollient to lift the scale, be treated with electrocautery or laser. in combination with a shampoo. 15. Pigmentary mosaicism, streaks and whorls of hypo- or hyperpigmentation follow- ing Blaschko’s lines. Infants with pig- 1.1.2 Infantile Seborrhoeic mentary mosaicism should be thoroughly Dermatitis assessed for the development, the internal organs and skeletal and ophthalmological Infantile seborrhoeic dermatitis (ISD) occurs abnormalities. between the ages of 4 and 12 weeks but most 16. This lesion is circumscribed alopecia of con- commonly before the age of 2 months. genital origin. This can be due to several Clinical presentation: macerated erythema causes, sebaceous naevus, aplasia cutis or on the skin folds, neck, axillae, inguinal region, sutural alopecia which will be obvious later. elbows and skin creases. ISD may associate with
10 R. R. Ranawaka cradle cap, rarely symptomatic (Sarkar and Garg rhoeic dermatitis or infantile psoriasis where skin 2010). Typically inflammation resolves with folds are affected) (Figs. 1.8, 1.9 and 1.10). postinflammatory hypopigmentation which is Differential diagnosis: allergic contact der- marked in pigmented skin and is a great concern matitis, intertrigo, psoriasis and atopic and sebor- to parents (Figs. 1.1, 1.2, 1.3, 1.4 and 1.5). rhoeic dermatitis (Tüzün et al. 2015). Differential diagnosis: napkin dermatitis, Management: the mainstay of management is atopic eczema, Langerhans cell histiocytosis to keep the skin dry and use barrier creams or (Leung et al. 2019). emollients to restore normal epidermis. Mild topi- Management: a combination of steroid–anti- cal steroids are used if inflamed or itchy. Treat sec- fungal creams in cases where inflammation is ondary bacterial or candida infection appropriately. marked, intermittently for short periods. Advise to wear disposable diapers which are much Hypopigmentation resolves spontaneously more absorbent, especially during the night. within weeks to months (Victoire et al. 2019). 1.1.5 Infantile Psoriasis 1.1.3 Atopic Eczema Napkin psoriasis with dissemination is the most In infants, AE characteristically begins on the face common pattern in infants (question 21). All pat- with subsequent spread to involve the torso and terns of psoriasis have been described in children: limbs. A more nummular (discoid) pattern occurs, guttate, chronic plaque, pustular and erythroder- particularly on the back and legs, especially in mic, but severe disease and joint involvement are toddlers. AE in the majority of infants clears over relatively rare (Burden and Kirby 2016). time. Nearly half of children with early AE are in Differential diagnosis: napkin dermatitis, complete remission by age 3 years. A significant infantile seborrhoeic dermatitis and irritant con- number of children were found to develop AD tact dermatitis. shortly after their ISD diagnosis. This finding Treatments: mild topical steroids, often in demonstrates a strong association in the clinical combination with an anticandidal agent, and course between the two diseases or indicates that emollients usually suffice in most children. the two diseases may be in the same clinical spec- trum (Alexopoulos et al. 2014). Clinical presentation: Mildly itchy scales 1.1.6 Miliaria mainly on the cheeks and on extensors, which change to flexural involvement when the child Miliaria is due to blockage of eccrine sweat grows (Figs. 1.6 and 1.7). ducts. Immature sweat ducts are an important Management: Exclusive breastfeeding for factor in neonates although high levels of heat the first 6 months is advisable. This is a chronic and humidity are important at any age. It is sub- recurrent problem in many. Topical steroid should divided into three subtypes dependent on the be used sparsely with frequent emollients. level of blockage: miliaria crystallina (stratum corneum), miliaria rubra (mid-epidermal) and miliaria profunda (dermal–epidermal junction) 1.1.4 Napkin Dermatitis (Paige 2016; Dixit et al. 2012). Prolonged contact with urine induces an irritant Clinical Presentation erythema, which may break down to form ero- sions if untreated. Miliaria crystallina presents as crops of clear, Clinical presentation: dermatitis is limited to thin-walled, superficial vesicles 1–2 mm in diame- the areas in contact with the irritant, while the ter, without associated erythema, resembling drops skin folds may be spared (in contrast to sebor- of water. These are exceedingly delicate and gener-
1 Dermatoses of the Neonate and Infancy 11 a b Fig. 1.1 (a, b) Cradle cap. Large flakes of brownish scale crust. There is usually minimal inflammation, but the eye- are seen on the scalp, especially over the vertex and fron- brows may be involved tal regions, and may become matted into large plaques of Fig. 1.2 Infantile seborrhoeic dermatitis. More macer- Fig. 1.3 Infantile seborrhoeic dermatitis. Typically the ated erythema occurs in the skin folds, especially the neck inflammation resolves with transient hypopigmentation, and the inguinal regions which is pronounced in children with pigmented skin
12 R. R. Ranawaka Fig. 1.5 Infantile seborrhoeic dermatitis. Postin flammatory depigmentation is marked since this Fig. 1.4 Infantile seborrhoeic dermatitis. Note skin folds child’s skin colour is very dark are affected (in contrast to napkin dermatitis where skin folds are spared) a b Fig. 1.6 (a, b) Atopic eczema. In infants, atopic eczema characteristically begins on the face
1 Dermatoses of the Neonate and Infancy 13 a b Fig. 1.7 (a, b) Atopic eczema on flexures in a 9-month-old baby girl Fig. 1.9 Napkin dermatitis in an infant. This dermatitis is usually confined to nappy areas Fig. 1.8 Napkin dermatitis in a 3-month-old infant. Note skin folds are spared in contrast to seborrhoeic der- matitis or infantile psoriasis. Dermatitis can spread up to lower back or abdomen when infants sleep on a rubber mattress
14 R. R. Ranawaka ally rupture within 24 h and are followed by bran- like desquamation. Lesions are asymptomatic. Miliaria rubra (prickly heat, sweat rash) com- prises erythematous papules and papulovesicles about 1–4 mm in diameter, on a background of macular erythema. Lesions can be itchy or sore. Miliaria pustulosa: Some of the miliaria rubra lesions are pustular, but not infected. Miliaria profunda (granulomatous giant cen- trifugal variant) is very uncommon in neonates as it usually occurs in adults where there have been repeated episodes of miliaria rubra. Management: Miliaria crystalline improves spontaneously when sweat ducts are mature. Remove from conditions of high heat/humidity Fig. 1.10 Napkin dermatitis with candida superinfection in a preterm neonate (photographed by Dr. Maduranga and any occlusive clothing or bedding (Figs. 1.11, Mendis, medical officer, neonatology unit, General 1.12 and 1.13). Hospital Kalutara, Sri Lanka) Fig. 1.11 Miliaria crystallina resembling drops of water in a 10-day-old baby on the face and the trunk
1 Dermatoses of the Neonate and Infancy 15 Fig. 1.12 Miliaria crystallina in a new born baby 1.2 Infections and Infestations 1.2.1 and, Foot and Mouth H Disease Coxsackie A viral infection, most usually A16, and infection with A6, Coxsackie B and enterovi- rus 71 have also been described. Highly conta- gious and widespread outbreaks occur every year. Clinical presentation: Mild malaise, oral ulcers and hand and foot vesicular eruption. Crops of vesicles are grouped in elbows and knees. Very rarely, a widespread vesicular erup- tion occurs over the buttocks, trunk and perioral area. In some, the eruption may be papular or maculopapular without vesicles. When it resolves it may form marked scaling or postinflammatory hyperpigmentation which settles spontaneously (Sterling 2016; Higgins and Glover 2016) (Figs. 1.14, 1.15, 1.16 and 1.17). Fig. 1.13 Miliaria pustulosa in an older child
16 R. R. Ranawaka Fig. 1.14 Hand, foot and mouth disease showing small vesicles with surrounding erythema on the sole and palms a b Fig. 1.15 (a, b) Hand, foot and mouth disease, vesicles are commonly crops around knees and elbows, but it can spread to all over the body
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