SYMPOSIUM: DERMATOLOGY
Assessing skin disease in
children
Rachel Frost
Jenny Hughes
Abstract
Children frequently present with either a skin rash or skin lesion. It is
important to be able to differentiate between well children and those
that are systemically ill. A systematic approach with a comprehensive
history and examination, along with appropriate investigations, enables
clinicians to reach diagnosis. To support this approach a number of exam-
ples have been given.
Keywords child; diagnosis; differential diagnosis; examination; investi-
gation; skin
Skin disease is common in children. Primary skin complaints
account for up to 24% of first visits to a general paediatric
clinic. The presence of any rash or lesion on the skin of a child
raises concerns that may range from cosmetic appearance
to suspicion of an underlying systemic pathology. Apart from
acting as a physical barrier the skin plays a role in temper-
ature regulation, fluid balance and activation of the immune
system.
The aim of this article is to provide a descriptive and diag-
nostic framework for clinicians presented with a child with a skin
condition. Although the skin is visually very accessible it is
a complex organ and the appearance of a rash or lesion is
influenced by the location of the pathology within the skin.
Reviewing the skin structure aids in understanding of common
descriptive terms (Figure 1).
Generally, involvement of the epidermis results in altered
surface markings, scale, vesicles and crust, whereas involvement
of the dermis alone results in normal surface markings. Both
epidermis and dermis may be involved, and primary lesions can
evolve into secondary lesions. This may be through the natural
history of the condition or through scratching or infection which
may result in excoriation, scale and crust (Table 1).
There are a vast number of different skin conditions and more
than 8000 diagnoses are listed in the British Association of
Dermatologists’ diagnostic index. Age may be pertinent to help
determine likely causes of a skin rash or lesion, for example the
well recognized rashes appearing in newborns. However an
Rachel Frost MBChB MRPCH FRACP is a Paediatric Specialty Doctor at the
University Hospital of Wales, Cardiff, UK. Conflict of interest: none.
Jenny Hughes MBChB FRCP is a Consultant Dermatologist at the Prince of
Wales Hospital, Bridgend, Wales, UK. Conflict of interest: none.
PAEDIATRICS AND CHILD HEALTH 21:3
initial assessment of a child will distinguish between those
children that are systemically well with a rash and those that are
miserable, give a history of lethargy, anorexia and fever and
appear ill on presentation. The likely diagnosis within each group
is different.
As within any field of medicine, history, examination and
investigations are the cornerstone of further assessment, but
certain features may be particularly relevant to skin disease.
These are outlined below and illustrated in a number of clinical
cases, highlighting the relevance of identifying certain features in
the history or examination.
History
Timing of onset, duration and variation of any skin lesion or rash
over time should be sought. With viral exanthems, the timing of
the onset of the rash in relation to systemic symptoms is crucial
to try and define a likely diagnosis as well as an account of the
order of progression. For example, in measles there is
a prodromal illness 3e4 days before onset of rash with
conjunctivitis, runny nose and cough. At the time of presentation
there may only be widespread rash but there may be a history of
reddish purple macules on the face and shoulders which became
confluent and spread downwards. Kopliks spots occur in the
mouth for 24e48 h before the rash and may not have been noted.
In contrast the rose pink macular rash on the trunk seen in
Roseola Infantum appears after 3e5 days of high fever.
Associated symptoms should be sought including fever, pain
and itch. Itch may be marked in some conditions e.g. scabies,
atopic dermatitis and lichen planus.
Exposures may contribute to any rash such as drugs, contact
with infections, allergens and pets, effect of sunlight and recent
travel (particularly if considering insect bites and infections such
as Lyme disease).
Immunization history should be gained in all children as it may
illustrate susceptibility to certain infections.
Family history may identify recent illness in other family
members e.g. chicken pox or similar symptoms e.g. itch from
scabies or flea bites. It may guide diagnosis in inherited genetic
disease and help for those conditions where there is a well
recognized association e.g. family history of atopy.
Quality of life assessment gives insight into the impact of the
disease on the child, particularly on sleep, and school atten-
dance. For certain conditions this will also provide a clue to the
severity of the disorder e.g. eczema.
Developmental history is of relevance due to recognition of the
association of skin conditions with delay and behavioural prob-
lems (particularly if there is a metabolic aetiology) or neurolog-
ical symptoms such as seizures.
105 Ó 2010 Elsevier Ltd. All rights reserved.
 SYMPOSIUM: DERMATOLOGY

Figure 1

Descriptive terms

Term Appearance Example

Macule Flat, circumscribed skin discolouration. Not raised or depressed Freckle, flat naevus
Patch Macule more than 1 cm Port wine stain, vitiligo, café au lait patch
Papule Circumscribed, elevated non-vesicular, non-pustular, Molluscum, lichen planus
less than 1 cm
Plaque Broad elevated disc shape more than 1 cm Psoriasis
Naevus sebaceous
Nodule Circumscribed, elevated, solid Neurofibroma
Involves dermis, may extend into subcutis Pilomatricoma
Nodular scabies
Wheal Local, superficial, transient oedema Urticaria
Vesicle Sharply circumscribed, elevated, fluid filled Herpes simplex virus, pompholyx
Bulla Vesicle more than 1 cm Bullous pemphigoid
Epidermolysis bullosa
Pustule Circumscribed lesion containing pus Folliculitis, acne
Erythema Redness due to increased skin perfusion
Erythroderma Severe inflammation of the skin with more than 90% of body surface Causes include eczema, pustular psoriasis and
involved toxic shock syndrome
Crust Collection of debris, dried serum and blood Impetigo
Erosion Partial focal loss of epidermis; heals without scarring Bullous impetigo
Ulcer Full thickness, focal loss of epidermis and dermis; Trauma
heals with scarring
Scale Thick stratum corneum, either hyperproliferation or increased cohesion of Tinea corporis
keratinocytes

Table 1

PAEDIATRICS AND CHILD HEALTH 21:3 106 Ó 2010 Elsevier Ltd. All rights reserved.
Examination
Firstly a good light source is necessary. Examining all the skin,
hair, nails and oral mucosa can provide valuable information.
Accurate observation of a rash with associated features can limit
the likely number of causes. Assessment of skin disease in chil-
dren involves more than just examination of the skin. General
growth provides a base line assessment and may be impaired in
chronic disease or underlying genetic disorders. Examination for
lymphadenopathy is helpful in viral exanthems and chronic
infections. Hepato-splenomegaly may be relevant in some
metabolic conditions. Equally important is the appreciation that
the disease process identified in the skin may be manifested
elsewhere in the body e.g. vasculitis affecting the kidney or
gastrointestinal tract.
What can be seen? Most paediatricians are adept at deciding if
a rash is blanching or non-blanching. It is valuable to observe if
a rash is raised (papules/nodules/plaques), if there are epidermal
changes, if there are pustules, vesicles or bullae (the fragility of
which can be a reflection of the level of the split in the
epidermis). Colour may vary due to a variety of causes including
vasodilatation, bleeding into the skin (purpura), or pigment from
melanocytes. It is important to note that erythema may some-
times be more difficult to see in pigmented skin.
Where can it be seen? (site). Some rashes are more likely to be
seen on the face e.g. malar rash of systemic lupus eryth-
ematosus, whilst others characteristically occur on the trunk e.g.
pityriasis rosea. The Koebner phenomenon refers to the devel-
opment of typical lesions at the site of minor trauma and is
characteristically seen in psoriasis, lichen planus and planar
warts.
What is the distribution? Some diseases are more likely to
follow a symmetrical pattern, others may be more likely to occur
on the extremities, some lesions follow a clear dermatomal
pattern and areas of sparing may be relevant for example absence
of rash in an area not exposed to sunlight.
How are the lesions arranged? It is helpful to describe the
relationship of individual lesions to those nearby e.g. grouped,
linear, arcuate.
How much of the skin is involved (extent)? This becomes
particularly important if a child is erythrodermic and in danger of
skin failure.
Touching the skin can give further information and in some
cases can be diagnostic e.g. rubbing of a mastocytoma that can
result in urticaria and flare as a result of histamine release
(Darier’s sign), or the easy separation of the epidermis from the
dermis on lateral pressure (Nikolsky’s sign) noted characteristi-
cally in Toxic Epidermal Necrolysis.
Examination of the hair may not only yield an infestation
responsible for a patch of eczema on the neck but will hide the
scalp that may reveal for example psoriasis or a tinea infection.
PAEDIATRICS AND CHILD HEALTH 21:3
Hair itself may also be a clue to the underlying disease for
example sparse hair in ectodermal dysplasia.
Examination of the nails may identify a number of changes
associated with various conditions e.g. pitting seen in psoriasis
and alopecia areata or identify changes in the nail folds e.g.
telangiectasia seen in dermatomyositis.
Examination of the mouth. The oral mucosa may help define
a likely cause of a rash, whilst the absence of lesions in the mouth
may indicate that a desquamating condition is more likely to be
Staphylococcal Scalded Skin than Toxic Epidermal Necrolysis.
Investigations
Usually there is a limited requirement for investigations.
Skin swabs can be helpful to identify infections and guide
antibiotic sensitivities.
Skin scrapings and nail clippings can help identify fungal
infections.
Woods light is an ultraviolet light source used to look for certain fungi
and corynebacterium (which cause erythrasma). Unfortunately, the
fungi currently commonly responsible for tinea capitis do not fluo-
resce. Woods light also emits purple light in the visible spectrum. The
purple light is absorbed by melanin and therefore hypopigmented
patches of vitiligo and ash leaf macules can appear more prominent.
Patch testing can be helpful where contact allergy (type IV) is
suspected.
Skin prick testing or measurement of specific IgE for Type I,
IgE mediated, allergy may be of benefit where there is a clear
history of an associated urticarial response but is not useful
routinely in chronic urticaria or eczema.
Skin biopsy is occasionally required to make a diagnosis with
the aid of histopathology and immunoflourescence. Tissue may
be sent for microbiological culture, helpful to identify unusual
infections particularly in immunosuppressed patients (Table 2).
Summary
A child presenting with a rash may cause concern for any doctor not
familiar with dermatological conditions. Children who are unwell
will need timely intervention and consideration of the need for
antibiotics or antivirals or stopping treatments which may be
implicated in the aetiology of the rash. In addition there may be a
need to attend to the issues of skin failure, including fluid balance
and thermoregulation. Conversely, well children can often be
treated symptomatically and referred for definitive diagnosis. At all
times the clinician must remain vigilant to an atypical pattern which
may indicate more significant pathology e.g. histiocytosis as a cause
of persistent nappy rash. Generally, a systematic approach with an
initial visual assessment to facilitate a detailed but targeted history,
followed by a thorough examination, will allow the clinician to
define the problem and respond appropriately. A
107 Ó 2010 Elsevier Ltd. All rights reserved.
 Examples of common skin complaints in children
Disease Picture Key points in history
(i) Children appearing well on presentation
Sore throat, either
concurrent or preceding
the eruption
(Streptococcal infection is
implicated in the
aetiology). Often there will
Guttae psoriasis
be a family history of
psoriasis and certain
drugs, including
antimalarials, may be
implicated. May be family
history of psoriasis.
Characteristically, there is
a history of a herald patch
prior to the general
eruption which occurs in
crops every 2e3 days for a
period of approximately
Pityriasis rosea 10 days (sometimes
several weeks). Classically
there are no symptoms but
occasionally it is noted to
be itchy.
Granuloma Rash may have evolved
annulare over previous weeks.
Largely asymptomatic,
may be mildly pruritic.
PAEDIATRICS AND CHILD HEALTH 21:3 108 Ó 2010 Elsevier Ltd. All rights reserved.
Key points in
examination
Scattered,
erythematous, well
demarcated plaques.
Scaling should be
apparent, although may
be less marked in the
early stages. Located
particularly over the
trunk and proximal
limbs. May extend onto
the face, ears and scalp.
The herald patch is a well
defined red oval, usually
2e5 cm in diameter,
covered with fine scale
towards the edge but not
at the margin. The
general eruption consists
of pink papules that
spread out to produce
oval macules 1e3 cm in
size, with a characteristic
collarette of scale.
Distribution is truncal
and proximal limbs
(sometimes referred to as
T shirt and shorts).
Small papules or
nodules, lesions may be
multiple, commonly
associated with extensor
surfaces of lower legs,
feet, fingers and hands
but other areas of the
body may be involved.
As the rash evolves
nodules are apparent in
an annular
configuration. The
overlying epidermis is
usually intact, however it
may be slightly red or
hyperpigmented.
The lack of epidermal
changes helps to
clinically distinguish this
condition from tinea
corporis.
(continued on next page)
 Table 2 (continued)
Urticaria Clear temporal
relationship may identify
cause (consider potential
physical causes e.g. cold/
pressure/sunlight/water/
exercise as well as recent
viral illness and food
allergens). Discriminate
between the duration of
the process (which may be
ongoing for days or
weeks) and the duration of
individual lesions, which
should last only 24 h. Itch
rather than pain is the
main symptom.
Scabies Intense itch which is often
present in other family
members (although may
be denied). Very young
babies do not scratch and
may just be miserable and
not feeding well. More
severe infestation with
crusted scabies is
associated with children
with Downs Syndrome as
well as those with
significant developmental
problems and
immunosuppression.
PAEDIATRICS AND CHILD HEALTH 21:3 109 Ó 2010 Elsevier Ltd. All rights reserved.
Pink, raised areas of
skin, with no surface
change, may be pale
centrally, often with a
surrounding red flare.
Individual lesions should
resolve within 24 h,
leaving the skin with a
normal appearance.
May be associated with
angio-oedema.
Linear burrows
characteristically found
in the web spaces,
instep and wrist. May
involve trunk and scalp.
Papules and nodules
accompany the
development of
hypersensitivity to the
mite and are located
around the axilla,
abdomen, thighs and
genital areas. They are
intensely itchy and may
persist for weeks after
the scabies mite has
been eradicated.
Secondary lesions with
infection and extensive
eczematization may
occur. Generalized
lymphadenopathy may
be present. Examine
other family members.
 Table 2 (continued )
Hair loss with mild redness
and scaling of scalp.
Possible treatment with
topical antifungal without
improvement. Other family
Kerion members may be involved.
May be low grade fever
and malaise and previous
Erythema
viral infection. Commonly
multiforme
associated with herpes
simplex virus.
(ii) Children appearing unwell on presentation
Staphylococcal Irritable child, usually
Scalded under 5 years with fever.
Skin Syndrome Skin usually tender before
blistering.
PAEDIATRICS AND CHILD HEALTH 21:3 110 Ó 2010 Elsevier Ltd. All rights reserved.
Raised boggy plaque on
scalp, studded with
pustules. Large painful
occipital, post-auricular
and preauricular
adenopathy help to
distinguish from
seborrhoeic dermatitis
or bacterial folliculitis.
Target pattern on distal
extremities well
recognized. Can be
macular, papular or
urticarial.
May be apparent
infection localized to
conjunctivae, nose,
perioral region,
perineum or umbilicus
(sometimes occult
infection). Tender red
skin develops large
superficial fragile
blisters that rupture
easily. Blistering is
mediated by toxin and
can occur anywhere on
body but oral mucosa
spared.
(continued on next page)
 SYMPOSIUM: DERMATOLOGY

Table 2 (continued)
Child unwell for several
days with high fever. Drug
history important as often
Toxic Epidermal implicated. Skin is tender.
Necrolysis Macules become confluent
and form flaccid bullae.
Tendency to start at the
head.
Child may be
hypotensive and
shocked. Sheet like
erosions involving more
than 30% of body.
Involvement of eyes,
mouth and genital
mucous membranes.

Severe forms associated Small blisters containing

with fever, eczematous
skin more vulnerable to
infection.
Impetigo
pus easily rupture and at
the time of presentation
the dried crust of the
exudates is most
apparent. Involvement
of mucous membranes is
rare. Circular bullae that
rupture very easily are
seen in bullous
impetigo.

Herpes simplex Often acute deterioration 2e3 mm vesicles,

virus in a child with known punched out vesicles,
atopic dermatitis who is erosions and crusting.
unwell with a fever,
increased itch and
irritability. There may be a
history of cold sores or
herpetic whitlow in family
members. (The latter may
have initially been thought
to be localized
staphylococcal infection.)

Table 2

FURTHER READING
Bernard A. Cohen MD. Pediatric Dermatology, 2nd Edn. Mosby
International Ltd, 1999.
Harper J, Oranje A, Prose N, eds. Textbook of pediatric dermatology.
Massachusetts: Blackwell Publishing, 2000.
Lewis-Jones Sue, ed. Paediatric dermatology (Oxford Specialist Hand-
books in Paediatrics). Oxford University Press, 2010.
Paller Amy S, Anthony J, Mancini MD. Hurwitz clinical pediatric derma-
tology: a textbook of skin disorders of childhood and adolescence.
Elsevier Health Sciences, 2005.
Practice points
C Initial assessment of children should identify those systemically
unwell and in need of resuscitation and immediate treatment.
C For diagnosis there is no substitute for detailed history and
thorough examination (including hair, nails and oral mucosa).
C Identification of the lesions seen and use of correct dermatolog-
ical terms are essential to formulate accurate differential diag-
noses and to communicate clearly and safely with colleagues.

PAEDIATRICS AND CHILD HEALTH 21:3 111 Ó 2010 Elsevier Ltd. All rights reserved.