Treat, watch, or refer: A pediatrician’s guide to common infectious skin diseases

Skin infections are among the most common reasons children present to pediatric primary care offices, urgent care clinics, and emergency departments. Although many infectious skin conditions are mild and self-limited, others may progress rapidly, recur frequently, or mimic inflammatory and systemic disease. Early recognition and appropriate treatment can reduce complications, limit transmission, and improve quality of life for children and families.

Pediatricians frequently diagnose and manage bacterial, viral, fungal, and parasitic skin infections without subspecialty involvement. However, determining when to refer a child to dermatology can be more challenging. Referral decisions often depend on disease severity, treatment response, recurrent infections, diagnostic uncertainty, cosmetic concerns, or concern for underlying immune dysfunction.

The following review highlights 5 of the most common infectious skin diseases seen in children and outlines situations in which referral to a dermatologist should be considered.

Impetigo

Impetigo remains one of the most frequently encountered bacterial skin infections in childhood, particularly among preschool- and school-aged children.¹ The condition is typically caused by Staphylococcus aureus or Streptococcus pyogenes and spreads through direct skin-to-skin contact or contaminated surfaces.¹

Nonbullous impetigo accounts for most cases and classically presents with “honey-colored crusts on the face and extremities.”¹ Bullous impetigo, more commonly associated with toxin-producing strains of S aureus, produces fragile blisters that rupture easily.¹ Minor trauma, eczema, insect bites, and humid weather increase susceptibility.²

Diagnosis is usually clinical. Limited disease often responds well to topical mupirocin or retapamulin, whereas more extensive disease may require oral antibiotics targeting methicillin-sensitive S aureus and streptococci.¹ Community prevalence of methicillin-resistant S aureus may influence antibiotic selection.²

Although many cases resolve quickly, referral to dermatology may be appropriate in several settings. Children with recurrent impetigo despite appropriate therapy may require evaluation for bacterial colonization, atopic dermatitis, or other predisposing skin barrier disorders. Extensive disease, treatment failure, or concern for resistant organisms may also warrant
specialty consultation.²

Dermatology referral should also be considered when lesions are atypical or diagnostic uncertainty exists. Conditions such as herpes simplex virus infection, contact dermatitis, scabies, and autoimmune blistering disorders can occasionally resemble impetigo.³ Persistent crusted lesions that fail standard therapy may require bacterial culture or biopsy.

Children with recurrent bacterial skin infections involving multiple body sites may benefit from evaluation for immunodeficiency, especially when infections are severe or associated with poor wound healing.⁴

Molluscum contagiosum

Molluscum contagiosum is a common viral skin infection caused by a poxvirus and primarily affects children younger than 10 years. Transmission occurs through skin contact, autoinoculation, and the use of shared objects such as towels and athletic equipment.⁵

The condition presents with small, “smooth, dome-shaped papules with central umbilication.” Lesions are commonly found on the trunk, extremities, axillae, and groin.⁵ Many children remain asymptomatic, although associated dermatitis and pruritus are common.

Most cases resolve on their own within months to years, and monitoring is often appropriate.⁵ Treatment may be considered for cosmetic concerns, discomfort, secondary inflammation, or transmission risk. Therapeutic options include cantharidin, cryotherapy, curettage, and topical agents, although no single approach is universally effective.⁶

Referral to dermatology may be appropriate when lesions are widespread, persistent, or associated with significant eczema. Molluscum dermatitis can be particularly bothersome in children with atopic dermatitis and may complicate management.⁶

Facial involvement, eyelid lesions, or genital lesions may also justify specialty referral depending on severity and family concern. Dermatologists may provide procedural treatment for children whose lesions are painful, cosmetically distressing, or refractory to conservative management.

Children with extensive molluscum contagiosum should also be evaluated for possible immune compromise. Severe or disseminated disease has been associated with primary immunodeficiency and acquired immune suppression.⁷ Although this presentation is uncommon in otherwise healthy children, persistent diffuse lesions merit further assessment.

Diagnostic uncertainty is another reason for referral. Molluscum contagiosum can occasionally resemble verruca vulgaris, milia, keratoacanthoma, or basal cell lesions in unusual presentations.⁶

Tinea infections

Dermatophyte infections are among the most common fungal skin conditions in pediatric populations.⁸ Tinea corporis, tinea capitis, and tinea pedis are seen frequently in primary care, particularly among school-aged children and adolescents.

Tinea corporis typically presents as annular plaques with central clearing and an advancing scaly border.⁸ Tinea capitis may produce scalp scaling, alopecia, broken hairs, lymphadenopathy, or inflammatory kerion formation.⁹ Tinea pedis is more common in adolescents and often affects the interdigital spaces.⁸

Diagnosis may be clinical, although potassium hydroxide preparation, fungal culture, or dermoscopy can assist when findings are unclear.⁹ Topical antifungals are generally effective for localized tinea corporis, whereas tinea capitis requires systemic therapy because topical medications do not adequately penetrate hair follicles.⁹

Referral to dermatology should be considered when the diagnosis is uncertain or when lesions fail to respond to standard antifungal treatment. Eczema, psoriasis, granuloma annulare, pityriasis rosea, and seborrheic dermatitis may mimic dermatophyte infection.⁸

Children with inflammatory kerion may benefit from dermatology consultation because delayed treatment can increase the risk of permanent scarring alopecia.⁹ Severe scalp inflammation may also require adjunctive anti-inflammatory therapy.

Recurrent or treatment-resistant fungal infections may raise concern for inadequate adherence, reinfection from household contacts or pets, or antifungal resistance. Dermatologists can help guide fungal culture interpretation and management strategies in refractory cases.¹⁰

Referral is also reasonable when extensive disease causes significant psychosocial distress. Scalp involvement and visible alopecia can affect school participation and self-esteem, particularly in older children and adolescents.

Viral warts

Cutaneous warts caused by human papillomavirus are common throughout childhood and adolescence.¹¹ Verruca vulgaris often affects the hands, fingers, knees, and periungual skin, whereas plantar warts occur on weight-bearing areas of the feet.¹¹

Most warts resolve spontaneously due to host immune responses. However, spontaneous clearance may take months or years.¹¹ First-line therapies commonly include topical salicylic acid and cryotherapy.¹²

Although warts are generally benign, they may become painful, numerous, cosmetically concerning, or functionally limiting. Plantar warts can interfere with sports and physical activity, whereas periungual warts may disrupt nail growth.

Referral to dermatology is appropriate for recalcitrant warts that fail standard treatment after several months. Dermatologists may offer additional interventions, including immunotherapy, laser treatment, topical chemotherapeutic agents, or combination approaches.¹²

Children with extensive or rapidly progressive warts may require evaluation for underlying immune dysfunction. Persistent diffuse human papillomavirus infection has been associated with inherited and acquired immunodeficiency syndromes.¹³

Referral should also be considered when lesions are atypical or painful, particularly if diagnostic uncertainty exists. Corns, calluses, pyogenic granulomas, and squamous proliferations may occasionally resemble warts.¹²

Facial warts and lesions involving cosmetically sensitive areas may benefit from specialized management to reduce scarring and pigment alteration. Younger children who cannot tolerate office procedures may also require pediatric
dermatology expertise.

Scabies

Scabies is a highly contagious parasitic infestation caused by Sarcoptes scabiei var. hominis.¹⁴ Infestation occurs through prolonged skin contact and spreads efficiently within households, schools, and childcare settings.¹⁴

Children typically present with intense pruritus that worsens at night. Common findings include papules, burrows, nodules, and excoriations involving the wrists, interdigital spaces, axillae, waistline, and groin.¹⁴ Infants may develop more diffuse involvement affecting the scalp, face, palms, and soles.¹⁵

Secondary bacterial infection is a frequent complication due to scratching and skin barrier disruption.¹⁵ Diagnosis is usually clinical, although dermoscopy and microscopic confirmation may occasionally assist.

Permethrin 5% cream remains first-line therapy for most children, and simultaneous treatment of household contacts is essential to prevent reinfestation.¹⁴ Environmental cleaning recommendations include laundering bedding and recently worn clothing.

Referral to dermatology should be considered when symptoms persist despite appropriate therapy. Ongoing pruritus after treatment is common and does not necessarily indicate treatment failure, but persistent active lesions or recurrent infestation may require further evaluation.¹⁵

Crusted scabies, although uncommon in children, requires urgent specialty involvement due to its heavy mite burden and high transmissibility.¹⁴ Dermatology consultation may also help distinguish scabies from eczema, papular urticaria, contact dermatitis, or other pruritic eruptions.

Children with recurrent infestations may benefit from evaluation of treatment adherence, household transmission patterns, and environmental control measures. Social determinants of health, crowded living conditions, and limited access to treatment can complicate
eradication efforts.¹⁵

Recognizing referral patterns

Most pediatric skin infections can be diagnosed and managed effectively within primary care settings. However, several themes consistently support referral to dermatology regardless of the infectious cause.

Diagnostic uncertainty remains one of the most important indications for referral. Infectious eruptions may mimic inflammatory, autoimmune, or neoplastic skin disorders, and delayed diagnosis can prolong morbidity.

Failure of standard treatment is another common reason for consultation. Persistent lesions may reflect resistant organisms, incorrect diagnosis, inadequate medication delivery, or underlying host factors affecting immune response.

Children with recurrent, severe, or unusually widespread infections may warrant evaluation for immunodeficiency or chronic skin barrier dysfunction. Pediatric dermatologists often collaborate with immunologists and infectious disease specialists in these cases.

Cosmetic concerns and psychosocial effects should not be overlooked. Visible skin disease can affect self-esteem, social participation, sleep, and school functioning, particularly in adolescents.

Finally, early referral may help prevent complications such as scarring, pigment changes, permanent alopecia, or bacterial superinfection. Collaborative care between pediatricians and dermatologists can improve outcomes while supporting families navigating chronic or recurrent skin disease.

References

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10. Nenoff P, Verma SB, Ebert A, et al. Spread of Terbinafine-Resistant Trichophyton mentagrophytes Type VIII (India) in Germany-"The Tip of the Iceberg?". J Fungi (Basel). 2020;6(4):207. Published 2020 Oct 5. doi:10.3390/jof6040207

11. Lipke MM. An armamentarium of wart treatments. Clin Med Res. 2006;4(4):273-293. doi:10.3121/cmr.4.4.273

12. Sterling JC, Gibbs S, Haque Hussain SS, Mohd Mustapa MF, Handfield-Jones SE. British Association of Dermatologists’ guidelines for the management of cutaneous warts 2014. Br J Dermatol. 2014;171(4):696-712. doi:10.1111/bjd.13310

13. Zampella J, Cohen B. Consideration of underlying immunodeficiency in refractory or recalcitrant warts: A review of the literature. Skin Health Dis. 2022;2(1):e98. Published 2022 Feb 9. doi:10.1002/ski2.98

14. Engelman D, Yoshizumi J, Hay RJ, et al. The 2020 International Alliance for the Control of Scabies consensus criteria for the diagnosis of scabies. Br J Dermatol. 2020;183(5):808-820. doi:10.1111/bjd.18943

15. Chandler DJ, Fuller LC. A review of scabies: an infestation more than skin deep. Dermatology. 2019;235(2):79-90. doi:10.1159/000495290