Bernard A Cohen, MD, is the section editor for Dermcase and professor of pediatrics and dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Bernard A Cohen, MD

Diaper dermatitis is a common presentation seen in dermatology. The differential diagnosis is broad and varies based on numerous risk factors, including patient age, gastrointestinal disorders, diaper hygiene practices, diaper breathability, and genetics. It is essential that pediatricians and dermatologists recognize the various forms of diaper dermatitis to effectively diagnose and treat it. The following 5 instructive cases of diaper dermatitis include the differential diagnosis (Table) and treatment options.

This 18-month-old boy with a family history of psoriasis presented for evaluation of an erythematous rash on the scrotum, suprapubic skin, and perineum, consistent with infantile psoriasis. Similar to adult psoriasis, infantile psoriasis presents as well-defined, often symmetrically dis- tributed erythematous papules and plaques. In contrast to psoriasis in adults, psoriatic plaques in childhood tend to be thinner, smaller, and less scaly and are more likely to develop on the face, trunk, and flexural areas, although they can develop on any skin area. In young children, infantile psoriasis is often diagnosed with a diaper rash that is unresponsive to irritant diaper dermatitis treatment.

 Psoriasis affects approximately 2% to 3% of the population worldwide, and it is estimated that up to half of cases begin before age 20 years. The incidence increases with age. Results of one study showed that the total rate of psoriasis in children under 18 years old was 0.71%, with rates increasing linearly from 0.12% at 1 year of age to 1.2% by 18 years.

 Findings of another study were similar, showing a prevalence of 0.55% in children aged 0 to 9 years compared with 1.37% in patients aged 10 to 19 years.

 Making a diagnosis of psoriasis is often more difficult in children because of atypical characteristics. Lesions in children may be thinner, softer, less scaly, and less well-defined than in adults.

 The differential diagnosis should include tinea corporis/cruris, atopic or nummular dermatitis, irritant contact dermatitis, seborrheic dermatitis, 

 dermatitis, and inverse pityriasis rosea.

Diagnosis of infantile psoriasis is often clinical and, in unclear cases, can be aided by biopsy; however, biopsy is often not necessary and should be avoided in uncomplicated cases. Histology is similar to that of adult psoriasis and would reveal neutrophils overlying parakeratosis, loss of the granular cell layer, variable spongiosis, and elongated rete ridges.

 First-line therapy for infantile psoriasis is topical corticosteroids. Medium- to high-potency topical steroids can be used up to 4 weeks during the initial flare and then up to 2 weeks for subsequent flares.

 Using topical corticosteroids in combination and rotation with nonsteroidal topicals such as topical calcineurin inhibitors, vitamin D analogues, tar, and keratolytics can optimize efficacy while reducing the risk of adverse effects. It is important to know the ages of approval for steroid-sparing agents. Calcipotriene is approved for children 4 years or older, and topical calcineurin inhibitors are approved for patients 2 years or older. Crisaborole (Eucrisa) can be considered in patients 3 months or older. Phototherapy can also be considered for extensive or refractory disease. For moderate to severe plaque psoriasis in children, systemic therapy should be considered. Etanercept (Enbrel) is approved for children 4 years or older; ustekinumab (Stelara), ixekizumab (Taltz), and secukinumab (Cosentyx) are all approved for children 6 years or older. Studies have shown significant improvements in quality of life and psoriasis area and severity index scores for children with moderate to severe plaque psoriasis on systemic immunomodulators.

 Pediatricians should monitor patients for comorbidities associated with psoriasis, including obesity, hypertension, hyperlipidemia, rheumatoid arthritis, and diabetes. The patient in the vignette responded well to topical steroids.

This 6-month-old girl presented with an erosive diaper rash following diarrhea with viral gastroenteritis. These findings were consistent with Jacquet erosive diaper dermatitis. Jacquet dermatitis is a rare, severe form of irritant diaper dermatitis characterized by ulcerated or eroded papules and nodules in the genital and perianal areas. It is typically associated with frequent loose stools, infrequent diaper changes, and poor hygiene. It is also more common in patients with chronic diarrhea or incontinence.

Milder forms of irritant diaper dermatitis often occur in infants with short episodes of loose stools associated with viral gastroenteritis and administration of oral antibiotics for otitis media and other infections. The differential diagnosis for severe erosive diaper dermatitis includes perianal pseudoverrucous papules and nodules, granuloma gluteale infantum, diaper dermatitis with superimposed bacterial and fungal infections, cutaneous Crohn disease, Langerhans cell histiocytosis, and acrodermatitis enteropathica.

 Secondary infection with Candida and bacteria is common in Jacquet dermatitis. Potassium hydroxide (KOH) preparation and bacterial culture can be performed to help guide antimicrobial therapy. If the patient fails to respond to therapy or has systemic findings, biopsy and additional laboratory tests may be indicated.

Jacquet dermatitis treatment is similar to that of uncomplicated irritant diaper dermatitis, with the goal to reduce contact of the skin to urine and feces. This is accomplished through frequent diaper changes, use of diapers lined with absorbent gel materials, and application of barrier ointments. Low-potency topical steroids can also be used to reduce inflammation. Topical antifungal/antibacterial agents may be required in the case of secondary infection. Severe cases may require oral antibiotics and/or oral corticosteroids.

This 7-month-old boy was brought to the clinic for pustules in the diaper area. These findings were consistent with staphylococcal pustulosis, a relatively uncommon manifestation of infection with 

. It can be difficult to diagnose because there is a wide differential for pustular eruption in infants, which includes both infectious and noninfectious etiologies. It is important to be able to distinguish benign causes from more serious causes that require additional management.

Noninfectious causes of pustules in an infant include erythema toxicum neonatorum, transient neonatal pustular melanosis, neonatal acne, and neonatal pustular psoriasis.

 In this case, some of those conditions could be ruled out based on timing. Erythema toxicum neonatorum typically affects full-term infants and presents within 1 to 2 days of birth. It is self-limited and usually resolves by 2 weeks of age. Neonatal pustular melanosis affects 0.2% to 4% of neonates, with a higher prevalence in Black babies. It usually occurs within a few days of birth and resolves spontaneously over a few weeks. Neonatal acne and pustular psoriasis have a wider range of age presentations. Neonatal acne presents as pustules as well as open and closed comedones that are usually limited to the face. It can occur within 3 to 16 months of age, although it usually appears within 3 to 6 months and resolves by 3 to 4 years. Neonatal pustular psoriasis is rare but can occur at any age and has a varied presentation. Pustules typically develop symmetrically and can occur on any area of the body, with a predilection for the diaper area and skinfolds.

Infectious causes include herpes simplex infection and candidiasis. Cutaneous manifestations of vertical herpes simplex virus (HSV) infection have been reported but are relatively rare and occur within a few days of life. Anogenital HSV infection in older babies and toddlers is also rare; it has additional implications and can be a sign of abuse. Candidiasis usually presents on a base of erythema with erythematous macular satellite lesions, neither of which is seen in this case.

To confirm the diagnosis, Gram stain and culture of the pustule fluid can be performed. Gram stain is often negative even in the setting of positive cultures and should not be used alone to rule out staphylococcal pustulosis. HSV polymerase chain reaction can be performed concomitantly if suspected.

 Biopsy typically does not play a role in the diagnosis of staphylococcal pustulosis. Although biopsy is often not performed for these lesions, histology would show subcorneal pustules with neutrophils and acantholysis.

 Limited skin disease can be treated with topical mupirocin ointment. The patient in the vignette responded well to this regimen. Patients with systemic symptoms or more widespread disease may require a course of oral antibiotics. Penicillinase-resistant antibiotics such as amoxicillin are usually sufficient. Methicillin-resistant 

 (MRSA) is relatively uncommon in children. However, coverage for MRSA with antibiotics such as clindamycin and trimethoprim/sulfamethoxazole should be considered in regions with high resistance rates.

This 3-month-old boy presented for evaluation of an erythematous rash in a diaper distribution; findings were consistent with seborrheic dermatitis. This benign, self-limited condition presents as salmon-colored plaques with greasy scales and typically occurs within the first 3 months of life. Unlike seborrheic dermatitis in adults, which takes on a chronic course, seborrheic dermatitis in children is self-limited and usually resolves without treatment within the first 9 to 12 months of life. Many parents are familiar with the term cradle cap, which is infantile seborrheic dermatitis of the scalp, but the condition can also present on the face, axillae, inguinal folds, and trunk. When it occurs on the face, it tends to involve the eyebrows, nasolabial folds, and hairline. Lesions on the trunk usually involve the lower abdomen and are more sharply demarcated than those seen elsewhere on other body.

 The differential diagnosis for symmetric, well- demarcated erythematous patches and plaques on a baby’s lower abdomen includes psoriasis, candidiasis, atopic dermatitis, contact dermatitis, and nutritional deficiency. Contact dermatitis is less likely when the skinfolds are affected. It is often difficult to distinguish atopic from seborrheic dermatitis in young children, and there can be overlap of the 2 conditions. However, seborrheic dermatitis is not usually pruritic, and atopic dermatitis typically spares the groin and axillae in young children.

 Diagnosis is usually made by history and physical exam alone. In cases where the diagnosis is not clear or the patient has an unusually prolonged course or lack of response to treatment, biopsy can be performed. Seborrheic dermatitis and psoriasis have similar histopathological findings, with a few key differences. Mounds of parakeratosis with neutrophils and clubbed and evenly elongated rete ridges are seen more often in psoriasis. Neutrophilic follicular scale/crust, shoulder parakeratosis, and lymphocytic exocytosis are seen more often in seborrheic dermatitis.

 A KOH preparation can be performed to rule out candidiasis. Patients with infantile seborrheic dermatitis are otherwise healthy and do not require additional laboratory monitoring.

 The mainstay of treatment for seborrheic dermatitis in infants consists of emollients that help loosen the scale, which can then be gently wiped away with a cloth. Because this is a self-limited disease that resolves without treatment, the risk to benefit ratio of additional therapies needs to be considered. Furthermore, treatments for seborrheic dermatitis in children have not been studied extensively for safety or efficacy, and it is unclear whether these interventions alter the course of the condition.

 Short courses of low-potency topical steroids also can be used. Calcineurin inhibitors and antifungal shampoos are not approved for use in children younger than age 2 years, so they should be avoided. The patient in the vignette responded well to emollients and topical steroids. He was able to discontinue therapy and did not have recurrence on follow-up a few months later.

Figure 5. Candidiasis with irritant dermatitis and candidiasis pustules

This girl between 5 and 6 months of age presented with a red rash in a diaper distribution. Findings showed erythematous papules coalescing into plaques, satellite lesions, and a few scattered pustules consistent with candidiasis, which usually presents as red erythematous papules, plaques, and peripheral satellite lesions in the groin with a predilection for skinfolds. Pustules, vesicles, and erosions can also be seen.

 The differential diagnosis for an erythematous rash with plaques, papules, and pustules in a diaper distribution includes psoriasis and contact dermatitis.

For this case, KOH preparation was performed and showed yeast and pseudohyphae. Although biopsy is often not required, histology would show neutrophils and vertically oriented pseudohyphae in the stratum corneum. Crusting and hyperkeratosis are also commonly seen.

Treatment with anticandidal antifungals such as nystatin and clotrimazole is required to achieve clearance. This patient responded well to topical antifungals and barrier cream therapy. Parents also can be educated to use breathable disposable diapers to reduce the rate of recurrence—the survival of 

 is reduced more than 50% in breathable vs nonbreathable diapers.

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Articles

Diaper dermatitis is common and the differential diagnosis is broad. Here are 5 cases that illustrate the various diagnoses that fall within this spectrum.

Looking at the spectrum of diaper dermatitis

Pediatric dermatology involves not only treating patients’ skin but also managing the psychosocial impact a disease has on children and their families, which can be significant. Many skin conditions have a quality-of-life (QOL) effect similar to that of systemic diseases such as renal disease, cystic fibrosis, and asthma.

 Skin diseases also can have emotional and social repercussions on the parents and caregivers of children with dermatology disorders.

 For pediatricians to provide optimal patient care, family support is essential.

The widely used Children’s Dermatology Life Quality Index (CDLQI), which was developed in 1995, gives the practitioner an understanding of QOL issues in children aged 4 to 16 years.

 The latest cartoon version is easier and faster for children to complete and was shown to have a score similar to the original scale.

 The questionnaire, which uses a recall period of 1 week, assesses various issues including feelings of sadness or self-consciousness, impact on friendships, bullying as a result of the disease, effects on going out or playing sports, interference with sleep, and response to treatment.

 Based on the scoring of the responses, the effect on QOL is stratified as none (0-1), small (2-6), moderate (7-12), very large (13-18), or extremely large (19-20).

 Findings from a 2016 meta-analysis of all studies using CDLQI, which included data from 7798 children with more than 20 conditions, concluded that most skin diseases have a major impact on QOL in a small proportion of children.

 However, further review of the literature demonstrates that skin disease has a significant impact for many children and their families.

Disease-specific scoring systems have also been developed, such as the Cardiff Acne Disability Index, the Psoriasis Area Severity Index (PASI) and Physician Global Assessment, the Infants’ Dermatology Quality of Life, the Childhood Atopic Dermatitis Impact Scale, the Quality of Life Index for Atopic Dermatitis, and the Dermatitis Family Impact questionnaire.

 These scoring systems not only help with assessing severity of disease but also give insight into QOL issues that are important for physicians to address.

This brief review discusses the QOL impact of a number of skin conditions compared with other chronic systemic diseases.

Psoriasis is a chronic inflammatory disease of autoimmune etiology that is not completely curable. Seen in an estimated 0.7% of children, psoriasis has a negative impact on QOL for not only children but also their parents and caregivers, even in the presence of mild disease.

 Results show that 36% of parents and caregivers of children with psoriasis have anxiety and depressive symptoms.

Compared with systemic diseases using the corresponding Children’s Life Quality Index (CLQI), psoriasis was found to have a greater impairment in QOL com- pared with enuresis, diabetes, and epilepsy.

 Psoriasis was also found to have a negative influence on physical activity, self-esteem, bullying, and stigmatization.

Investigators of another study concluded that improvement in CDLQI scores to imply no effect (0-1) was associated with a PASI score of > 90%, (a decrease in body surface area [BSA] involvement). As a consequence, this may be advised as a reasonable therapeutic goal. It was also noted that systemic therapy including biological and conventional drugs has a better outcome compared with topical agents.

Thus, physicians are advised to follow a combined approach including clinical therapy and QOL assessment to evaluate improvement or impairment, family counseling, and support.

With an estimated in- creasing global prevalence of 15.5% to 20.0% among children,

 atopic dermatitis (AD) is a chronic skin disease with relapses and remissions characterized by a wide array of clinical presentations that vary with age, environmental triggers, and genetic predisposition. The impact on QOL was found to be greater in children with AD compared with children with systemic diseases including renal disease, cystic fibrosis, asthma, and chronic urticaria.

 AD commonly arises in early childhood, with hallmark pruritic lesions that often worsen at night. Those with active AD alone had nearly 50% greater odds of reporting sleep-quality disturbances throughout childhood compared with 80% of children who also had asthma and/or allergic rhinitis. Consequently, early diagnosis and therapeutic interventions are needed to address QOL issues.

Recent findings also revealed a relative risk of 1.4 for learning disabilities among children with AD, an association independent of sociodemographic factors and other atopic and neurodevelopmental disorders.

 Significant positive association of atopic disease and childhood AD with memory impairment, developmental delay, and cognitive dysfunction has also been identified.

 and as one of the most common skin conditions among adolescents (findings reveal prevalence from 35% to close to 100%), acne vulgaris is rightly described this way by Sulzeberger and Zaidens: “There is probably no single disease which causes more psychic trauma, more maladjustment between parents and children, more general in- security and feeling of inferiority and greater sums of psychic suffering than does acne vulgaris.”

The point estimate from 5 studies using the CDLQI to assess QOL in children with acne is 5.37; that corresponds to a small impact, but research results reveal a significant impact in terms of self-esteem, relationships, and body image.

 Further, it is noted that children with truncal and facial acne were twice as likely to report the impact as “very large” or “extremely large” on the CDLQI questionnaire compared with children with only facial acne.

Acne profoundly affects self-perception, socialization, emotional health, and occupational opportunities as well as body dissatisfaction.

 It is also associated with depression and suicidal ideation.

 With these factors in mind, it is crucial for the primary care physician to provide not only dermatological care but also psychological support and counseling.

The most common cause of depigmentation worldwide, vitiligo is an acquired disorder of unknown origin and undoubtedly immunologically mediated. The disease is associated with widespread stigmatization and psychological impairment.25 Investigators who used the CDLQI questionnaire to assess QOL impairment reported a median score of 3.0.26 They also found that nearly 45.6% of children aged 0 to 6 years and 50% of participants aged 7 to 14 years were not bothered by the lesions, but 95.9% of adolescents aged 15 to 17 years were troubled. Involvement of the face and legs was most bothersome for parents. The authors concluded that self-consciousness, difficulty with friendships and schoolwork, and teasing and bullying were associated with lesions involving more than 25% BSA. Lesions on the face and arms were associated with teasing and bullying.26 Further, other investigators reported that 42% of caregivers of pediatric patients with vitiligo were reported to have anxiety symptoms, whereas 26% had depression.9

Thus, to improve QOL and create a safe environment for children with vitiligo, it is important to not only provide care for these patients and their parents but also play a larger role in educating and sensitizing the public and peer groups in schools and communities to destigmatize the condition.

A skin condition of viral etiology, molluscum contagiosum most commonly affects children. It is commonly asymptomatic but may present with erythema and pruritus. On some occasions, bacterial superinfections with pain and inflammation may be seen.27

In a British study the mean time to resolution was 13.3 months which confirms its chronic nature and the need to consider impact on QOL.28 Molluscum contagiosum had a small effect on quality of life for most participants, although for 33 (11%) of 301 participants it had a very severe effect (CDLQI score >13). A greater number of lesions and secondary infection was associated with a greater effect on quality of life (H=55.8, p<0.0001).

In conclusion, 1 in 10 children with molluscum contagiosum is likely to have a major issue with their QOL, and treatment should be considered for these children especially those with a large number of lesions at visible sites. It is also important to reassure parents about the course of their children’s disease.

The human papillomavirus causes warts, a benign, common skin disease that may appear on any part of the body. Per the CDLQI scoring, in children who had lesions greater than 6 months, it was seen that nearly a third had a small effect on QOL, whereas in 5% of the children, warts had an extremely large effect. It was also noted that the greatest negative effect was seen on the symptoms and feeling scores.29

The dermatology QOL indices clearly demonstrate the importance of early diagnosis and treatment of skin disease in children. As a result, practitioners should have a low threshold to refer patients early in their course for diagnosis and management of persistent dermatologic findings.

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2.Vivar KL, Kruse L. The impact of pediatric skin disease on self-esteem. Int J Womens Dermatol. 2017;4(1):27-31. doi:10.1016/j.ijwd.2017.11.002

3.Pustišek N, Vurnek Živković M, Šitum, M. Quality of life in families with children with atopic dermatitis. Pediatr Dermatol. 2016;33(1):28-32. doi:10.1111/pde.12698

4.Lewis-Jones MS, Finlay AY. The Children’s Dermatology Life Quality Index (CDLQI): initial validation and practical use. Br J Dermatol. 1995;132(6):942-949. doi:10.1111/j.1365-2133.1995.tb16953.x

5.Holme SA, Man I, Sharpe JL, Dykes PJ, Lewis-Jones MS, Finlay AY. The Children’s Dermatology Life Quality Index: validation of the cartoon version. Br J Dermatol. 2003;148(2):285-290. doi:10.1046/j.1365-2133.2003.05157.x

6.Waters A, Sandhu D, Beattie P, Ezughah F, Lewis-Jones S. Severity stratification of Children’s Dermatology Life Quality Index (CDLQI) scores. Br J Dermatol. 2010;163(suppl 1):121.

7.Olsen JR, Gallacher J, Finlay AY, Piguet V, Francis NA. Quality of life impact of childhood skin conditions measured using the Children’s Dermatology Life Quality Index (CDLQI): a meta-analysis. Br J Dermatol. 2016;174(4):853-861. doi:10.1111/bjd.14361

8.Augustin M, Langenbruch AK, Gutknecht M, Radtke MA, Blome C. Quality of life measures for dermatology: definition, evaluation, and interpretation. Curr Derm Rep. 2012(l):148-159. doi:10.1007/s13671-012-0020-z

9.Chernyshov PV. The evolution of quality of life assessment and use in dermatology. Dermatology. 2019;235(3):167-174. doi:10.1159/000496923

10. de Jager ME, van de Kerkhof PC, de Jong EM, Seyger MM. A cross-sectional study using the Children’s Dermatology Life Quality Index (CDLQI) in childhood psoriasis: negative effect on quality of life and moderate correlation of CDLQI with severity scores. Br J Dermatol. 2010;163(5):1099-1101. doi:10.1111/j.1365-2133.2010.09993.x

11. Salman A, Yucelten AD, Sarac E, Saricam MH, Perdahli-Fis N. Impact of psoriasis in the quality of life of children, adolescents and their families: a cross-sectional study. An Bras Dermatol. 2018;93(6):819-823. doi:10.1590/abd1806-4841.20186981

12. Manzoni AP, Weber MB, Nagatomi AR, Pereira RL, Townsend RZ, Cestari TF. Assessing depression and anxiety in the caregivers of pediatric patients with chronic skin disorders. An Bras Dermatol. 2013;88(6):894-899. doi:10.1590/abd1806-4841.20131915

13. Bruins FM, Bronckers IMGJ, Groenewoud HMM, van de Kerkhof PCM, de Jong EMGJ, Seyger MMB. Association between quality of life and improvement in psoriasis severity and extent in pediatric patients. JAMA Dermatol. 2020;156(1):72-78. doi:10.1001/jamadermatol.2019.3717

14. Gonzalez J, Cunningham K, Perlmutter J, Gottlieb A. Systematic review of health-related quality of life in adolescents with psoriasis. Dermatology. 2016;232:541-549. doi:10.1159/000450826

15. Gilaberte Y, Pérez-Gilaberte JB, Poblador-Plou B, Bliek-Bueno K, Gimeno-Miguel A, Prados-Torres A. Prevalence and comorbidity of atopic dermatitis in children: a large-scale population study based on real-world data. J Clin Med. 2020;9(6):1632. doi:10.3390/jcm9061632

16. Nutten S. Atopic dermatitis: global epidemiology and risk factors. Ann Nutr Metab. 2015;66(suppl 1):8-16. doi:10.1159/000370220

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18.Wan J, Shin DB, Gelfand JM. Association between atopic dermatitis and learning disability in children. J Allergy Clin Immunol Pract. 2020;8(8):2808-2810. doi:10.1016/j.jaip.2020.04.032

19. Revolutionizing atopic dermatitis, 13-14 December 2020. Br J Dermatol. 2021;184(3):e56-e121. doi:10.1111/bjd.19722

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Acne, molluscum, atopic dermatitis, and other dermatological disorders can be detrimental to quality of life for children and their families.

Scrutinizing the psychosocial impact of skin diseases

A hospital’s emergency department (ED) requested that a dermatologist evaluate an 18-month-old girl who has ringed scars with hyperpigmentation on the right side of her buttocks and back (Figure). The child was referred to the ED by her primary care provider (PCP), who first noted the skin findings during a well-child visit.

The child was accompanied by her mother, who reportedly had not noticed the lesions until the PCP inquired about them. Later, in the ED, the mother stated that the child lies against the crib bars, which leave markings on her skin. The history revealed no other concerning signs or symptoms, and the child was in no acute distress. A careful physical examination revealed multiple discrete, annular scars with hyperpigmentation and well-demarcated borders on the right side of the child’s back and buttocks. There was no surrounding erythema, ecchymosis, or edema. Remaining physical exam findings were unremarkable.

During the initial evaluation, the history of the crib bars as the mechanism of injury was deemed inconsistent with the skin findings. The patterned scars were suspicious for child abuse. A report was made to child protective services (CPS), and the child was evaluated in the ED by the child maltreatment team.

CPS agencies investigate more than 2 million reports of alleged child maltreatment each year in the United States.

 In 2019, approximately 656,000 children were substantiated as victims of abuse and neglect, roughly 18% of whom endured physical abuse.

 Child neglect and abuse is the fourth leading cause of death for children between 1 and 4 years of age.

 National statistics on physical abuse represent only cases investigated and substantiated by state CPS agencies. The true prevalence is likely higher, based on hospitalization rates for physical abuse and adult reports of childhood physical abuse from other entities.

 The COVID-19 pandemic has caused loss of income and increased social isolation, both of which exacerbate the risk of child maltreatment.

Recent data reveal a decline in both official reports to CPS agencies and the number of ED visits related to maltreatment, but the percentage of hospitalizations for child abuse and neglect rose from the previous year.

 This trend in data may be attributed to decreased in-person contact between children and mandated reporters, as well as a shift in health care–seeking patterns during the COVID-19 pandemic and the resulting decline in the total number of ED visits.

 These concerning findings suggest that the severity of child abuse injuries has remained the same or worsened.

The law requires that injuries that are suspicious for neglect or abuse be reported to state CPS agencies. The Child Abuse Prevention and Treatment Act defines child abuse and neglect as “any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation” or “an act or failure to act which presents an imminent risk of serious harm.”

 This federal legislation provides a foundation for identifying child maltreatment, but each state has its own definition of child abuse and neglect that influences the recognition and reporting of child physical abuse.

 Personal and cultural experiences also influence recognition and reporting.

Child physical abuse can result in permanently disfiguring injuries.

 Children who experience physical abuse are at greater risk of developing behavioral problems including conduct disorders, aggression, and depression.

 Victims of child physical abuse are more likely to begin use of tobacco and drugs as adolescents and report chronic physical and mental health diseases as adults.

There are many factors related to the parent, child, and environment that increase the risk of child physical abuse. Infants and toddlers are most vulnerable.

 Children cared for by a single parent; parent(s) of young age; or parent(s) with a personal history of abuse as a child, substance and/or alcohol use, or depression are at higher risk of physical abuse.

Child physical abuse often goes unrecognized until it results in severe injury or death.

 Recognizing and diagnosing physical abuse can be challenging. Physical abuse typically occurs between the perpetrator and the child without a witness present. Perpetrators rarely admit to their actions, and child victims are often preverbal or too fearful to disclose the abuse.

Sentinel injuries—minor inflicted injuries identified by physicians or caretakers prior to recognizing the child as a victim of physical abuse—are common in abused infants but are sometimes underappreciated and not reported.

Child physical abuse may be suspected based on inconsistent history and suggestive physical examination findings. Specific skin injuries that may suggest physical abuse include patterned bruising, laceration, abrasions, and scars, particularly in the shape of a handprint, stick, cord, or belt.

 Other possible signs: symmetrically distributed lesions; multiple lesions at different stages of healing; and lesions on areas protected by clothing; any injury to a nonmobile infant; and severe, unexplained injuries.

When child abuse is suspected, it is critical to consider a broad differential because many skin conditions mimic physical abuse injuries.

 The arched form of certain annular lesions may resemble lesions that result from cable or cord beatings.

 For this case, the differential included tinea corporis, erythema annulare centrifugum, erythema marginatum, and urticarial viral exanthems.

Tinea corporis, a fungal infection, causes lesions that appear on the trunk or extremities and are characterized by slightly red, annular, well-demarcated, scaly patches, often with central clearing.

 Tinea corporis lesions can be differentiated by their pruritic nature and variable size.

Erythema annulare centrifugum, a reactive skin condition with lesions that also appear on the trunk or extremities, is characterized by red, annular, or arcuate patches or plaques with central clearing.

 However, erythema annulare centrifugum can be differentiated by trailing scales and advancing margins.

Erythema marginatum often occurs with acute rheumatic fever, particularly in patients with acute carditis; it is characterized by transient, pink or slightly red, well-demarcated, and somewhat elongated annular lesions with central clearing.

 These lesions can be differentiated by their disappearing and reappearing character and the presence of systemic symptoms of acute rheumatic fever.

 Urticaria multiforme is a viral exanthem characterized by red macules and plaques, typically along with a fever.

 Polymorphic distribution, serpiginous edges, and associated systemic symptoms differentiate lesions of urticarial viral exanthems.

This case’s differential also included folk remedies such as cupping and coining. In some cultures, these practices are performed on children for healing and protection and can produce transient patterned skin markings that may be misdiagnosed as physical abuse injuries.

 Thorough history taking and cultural considerations can help differentiate these lesions. In this case, these causes were ruled out by the lack of history with these practices.

As stated earlier, when a history and/or physical examination prompts reasonable suspicion for physical abuse, pediatric providers are mandated by law to make a report to local CPS agencies.

 Mandatory reporting laws do not require freedom of doubt of physical abuse, and states must provide immunity from prosecution even if the reported allegations cannot be substantiated as child abuse or neglect.

 However, failure to make a report can result in civil action or criminal charges against the provider or, worse, additional injury or death of the child.

In this particular case, the child was admitted to the hospital overnight and placed in foster care by CPS while the evaluation was completed, which was the appropriate action to safeguard the patient. It is the hope of these authors that having a heightened understanding of what determines child abuse will lead to more vigilance in protecting our pediatric populations.

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https://www.nice.org.uk/guidance/cg89/resources/child-maltreatment-when-to-suspect-maltreatment-in-under-18s-pdf-975697287109

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An 18-month-old girl presents with ringed scars with hyperpigmentation on the right side of her buttocks and back. What's the diagnosis?

Annular scars with hyperpigmentation

“Examination of the scalp and nails is an important part of any skin exam,” noted Sheilagh M. Maguiness, MD, associate professor of dermatology and pediatrics at the University of Minnesota in Minnesota at her session, “Common Hair and Nail Conditions in Children.”

Maguiness described a case of tinea capitis, a common fungal infection of the scalp in children. Swollen lymph nodes in the neck (cervical lymphadenopathy) often signal this condition. Confirm diagnosis with a fungal culture prior to treatment, she said, especially because of the “long duration of oral antifungal therapy…up to 4 to 8 weeks, depending on the agent.”

Maguiness also reviewed longitudinal melanonychia, which she described as “brown to black pigmented longitudinal bands in the nail plate [caused by] melanocyte hyperplasia or increased melanin production,” common in African American and Asian children but rare in Caucasians.

Maguiness also discussed congenital malalignment of the great toenails and psoriatic nails, which can cause pitting, onycholysis, and subungual hyperkeratosis. “When children have psoriasis, about 15% to 20% will also have nail findings,” she said.

When it comes to head lice, Maguiness advised practitioners to check the postauricular areas and nape of the neck. “That’s where the nits like to group,” Maguiness said. She outlined available treatments, OTC topicals such as permethrin and pyrethrins, prescription drugs such as topical and oral ivermectin, and topical spinosad.

Maguiness ended with this advice: review dose and duration of therapy for oral antifungal agents to treat tinea capitis; perform a fungal culture of the scalp to help diagnose tinea capitis; and know how to distinguish between several common nail disorders in children.

A presentation from the 2021 virtual American Academy of Pediatrics Conference & Exhibition urges including examination of the scalp and nails during any skin exam.

Looking at the scalp and nails during a skin exam is key

You are called to the emergency department to evaluate a healthy 9-day-old girl with erosions near her eyes, nose, and skin creases on the arm. She also has a positive Nikolsky sign (Figures A, B). The newborn is crying and uncomfortable, but is still feeding well. Upon examination, she is red from head to toe and has widespread erosions and crusting. The patient is afebrile with clear mucous membranes. 

Diagnosis: Staphylococcal scaled skin syndrome (SSSS)

Differential diagnosisfor diffuse erythema

Given these clinical skin findings, initial differential diagnoses include Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) and bullous impetigo. A history of drug intake or viral infection typically precedes SJS/TEN.

 Additionally, SJS/TEN involves the mucous membranes of the conjunctiva, mouth, trachea, esophagus, anus, and genitalia.

A healthy 9-day-old girl presents with erosions near her eyes, nose, and skin creases on the arm as well as a positive Nikolsky sign. What's the diagnosis?