Color Atlas and Synopsis of Pediatric Dermatology Sandipan Dhar, Sahana M Srinivas
Page numbers followed by b refer to box, f refer to figure, and t refer to table
Abacavir 426
Abrasions 482
Abscess 2
Acantholysis 255
Acanthosis nigricans 459, 459f
Acetaminophen 188
Acetazolamide 228, 396
Acetylsalicylic acid 359
Acid mucopolysaccharides 473
Acitretin 26, 90, 465, 503
Acne 416, 420, 472
cheloidalis 421f
conglobata 416
excoriée 420, 420f, 483
fulminans 416
infantile 416
juvenile 416
keloidalis 380, 421f
nuchae 420, 421f
mechanical 416
neonatal 3, 4f, 416
occupational 416
scars 417f
senile 416
types of 416
vulgaris 416, 421, 441
management in 417
Acneiform eruptions 416, 418, 419f
Acneiform lesions 466
Acquired immunodeficiency syndrome 158, 514
Acral necrosis, prognosis in 348
Acral peeling skin syndrome 250
Acrochordans 496
Acrocyanosis 473
Acrodermatitis continua 227f
Acrodermatitis enteropathica 23, 304, 304f, 305f, 473
diagnosis of 304
treatment of 305
Acropustulosis 21
Actinic keratosis 447
Actinic lichen planus 238
gerencseriae 158
israelii 158
Actinomycosis 158
Acute febrile mucocutaneous lymph node syndrome 174, 175
Acute graft-versus-host disease 468f
Acute hemorrhagic edema, lesions of 371f
Acute respiratory distress syndrome 433
Acyclovir 169
Adalimumab 367, 479
Adams-Oliver syndrome 84
Addison's disease 275, 292, 294f, 309, 333, 334, 335f
diagnosis of 334
Addisonian crisis 335
Adenitis 179
Adenoma sebaceum 260, 260f
classical lesions of 261f
deaminase 494
triphosphate 397
Adenovirus 184
Adrenal hyperplasia, congenital 397
Adrenal insufficiency
primary 334
symptoms of 334
Adrenaline 437
Adrenocorticotropic hormone 334, 398
Adverse drug eruptions 426
Aedes aegypti 171
Aedes mosquito 179
Aerosol challenge craze 482
Airway compromise, potential of 316
Albinism 288
white and brown hairs in 289f
Aldosterone 334
Alitretinoin 215
Alkaptonuria 333
Allergen specific immunotherapy 215
Allopurinol 347
Alopecia 315, 356, 449
areata 149, 275, 306f, 376
extensive 377f
patch of 376f
mucinosa 380
scarring 248f, 353f, 379
totalis 377, 378f
universalis 377
Alpha feto-protein 510
Aluminum chloride 424
Ambisexual hair, loss of 334
Ambras syndrome 395
Aminoglutethimide 228
Aminoglycosides 26
Aminolevulinic acid 343
Aminopenicillins 439
Amiodarone 228
Ammoniacal ulcers 192
Amniotic band syndrome 26, 27f
Amoxicillin 217, 228, 432
Amphotericin B 156
Ampicillin 228
Anaerobic organisms 492
Anagen effluvium 386, 388f
Anakinra 464, 479
braziliense 111
caninum 111
Androgenetic alopecia 380, 386, 388f
Anemia 344, 393, 433, 479
Anetoderma 446, 446f, 447f
depression in skin in 447f
Angioedema 316, 476
ACEI-induced 321
acquired 320, 321
allergic 321
hereditary 320
idiopathic 321
of eyelid 319f
treatment of 318
types of 316, 320t
Angiofibroma 260, 263
Angioid streaks 77
Angiokeratoma 346
circumscriptum 43
corporis diffusum 345
lesions over trunk 43f
Angioleiomyoma 64
Angiolymphoid hyperplasia 44
Angiosarcoma 478, 478f
Angiotensin-converting-enzyme inhibitors 321, 442
Angular stomatitis 313
Anhidrotic ectodermal dysplasia 66
Annular erythema 358
Annular erythematous
plaques 229f
urticarial lesions 437f
Annular scaly lesions 257f, 304f
Anonychia 227
Anorexia 473
nervosa 389, 473
Anthralin 230
Antibiotics 122
therapy, adequate 182
Antibody 369
defects 486
role of 356
Anticardiolipin 369
Anticonvulsants 432
systemic 145, 152, 158
topical 5, 26, 145
Antigen mapping 246
Antihistamines 254, 437
ketotifen 442
Antinuclear antibody 352, 354
Anti-parvovirus B19 187
Antiphospholipid antibody syndrome 368, 368f, 369
Antipruritics agent 368
Antistreptolysin O 224
Antitubercular drugs 418
Anxiety disorder 484
Aorta, coarctation of 41
Apert syndrome 416
Aphonia 348
Aphthous ulcer 506, 506f
treatment of 506
APLA syndrome 369f
Aplasia cutis 18, 22, 84, 274, 379, 393
congenita 22, 22f, 23f
Apocrine cystadenoma 62
Appetite, loss of 310
Apremilast 90
Argininosuccinic aciduria 390
Argyria 333
Armor appearance, coat of 96
Arnold-Chiari malformation 84
Arrhythmia 382
Arsenic poisoning, chronic 503, 503f, 504f
Artefactual lesions 482
Arterial anomalies 41
Arthralgia 179, 186, 438
and exanthema, symptoms of 187
Arthritis 361, 466
chronic 188
juvenile idiopathic 358
migratory 472
Ascorbic acid 333
Ash leaf macules 261
Aspiration cytology 511
Aspirin 228, 375
Astrocytoma 398
Astrointestinal tract 38
Asymmetric periflexural exanthem 184, 185f
Ataxia 382
telangiectasia 45, 487
mutated protein 488
Atenolol 228
Atopic cataract 206f
Atopic cheilitis 205f, 208f, 209f
Atopic child, dirty neck of 207f
Atopic dermatitis 23, 194, 199, 299f, 203f, 208f, 210f, 215, 244, 411, 414, 456, 513
acute eczema in 200f
adult phase 201
childhood phase 200
infantile phase 200
infected lesions of 201
infra-auricular fissuring in 206f
management of 204
nipple eczema of 207f
proactive management 210
severe 204, 212f
treatment of 204
Atopic diathesis 25, 239
Atopic dirty neck 201
Atopic eczema 201
Atopy 199
Atrichia congenital 401, 401f
Atrophic scarring 252
Atrophie blanche 363
Atrophodermas 444
Atrophy 2
Autoantibody abnormalities 354
bullous diseases 513
cytopenias 495
enteropathy 491
hepatitis 275
hypothesis 420
polyendocrine syndrome 492
polyendocrinopathy candidiasis ectodermal dystrophy 157
thyroiditis 275
Autoinflammatory disorders 471
Autoinflammatory syndromes 471t
types of 471
Autologous tissue 363
Autonomic neuropathy 485
Autosomal syndromes 87
Axillary freckling 266f
Axillary hyperhidrosis 501
Azathioprine 212, 256, 275, 366, 375, 464, 514
Azelaic acid 418, 422
Azithromycin 186, 190, 418
Azole antifungals 124
Bacillus Calmette-Guérin 397
vaccination 127
Bacillus proteus 423
Bamboo hair 25, 391, 391f
Bannayan-Zonana syndrome 54
Barbiturates 430
Barrier function 1
Bartonella henselae 369
Basal cell carcinoma 62, 63
Basal metabolic rate 228
Basaloid cells, triad of 394
Basidiobolus ranarum 159
Bathing suit ichthyosis 91f
Bazex-Dupré-Christol syndrome 389
deficiency 515
lymphoma 374, 438f
Beaded hair 382
Beau's line 184, 404
Becker's melanosis 51, 54
Becker's nevus 5153, 395
etiology of 53
Behçet's disease 449, 461, 464, 466b
family history of 466
Behçet's syndrome 506
Benoxaprofen 396
Benzoyl peroxide 123, 418
Beta-lactam-induced exanthems 428
Betamethasone dipropionate cream 351, 361
Beta-thalassemia trait 393
Biallelic mutation 350
Bile duct 460
Bindi leukoderma 282f
Binding protein 2 486
Biotin metabolism, disorders of 23
Biotinidase deficiency 311, 311f
Birt-Hogg-Dube syndrome 63, 496
Black dot tinea 150f
capitis 147
Bladder 460
Blau syndrome 470
Blistering distal dactylitis 125, 125f
Blood-stained sweat over palms 500f
Bloom syndrome 80
Blue nevus 45
Blue rubber bleb nevus syndrome 38, 39f, 45
Blue to black punctiform macules 39
Blueberry muffin lesions 168
Bockhart's impetigo 113
Body dysmorphic disorder 483
Body louse infestation 109
Bohn's nodules 20
Bone marrow
stem cell transfer 253
transplantation 494
Borderline lepromatous leprosy 130
Borderline tuberculoid leprosy 130, 132f
Borrelia burgdorferi 464
Botulinum toxin A 424
Bourneville's disease 260
Bowen's disease 410
Box-jellyfish stings 440
Breakthrough varicella 169, 170f
Breast carcinoma 374
Brunsting-Perry, chronic pemphigoid of 242
BTD gene 311
Bulimia 473
Bullosis diabeticorum 336
Bullous dermatosis, chronic 241
Bullous dermolysis 251
Bullous disease 336
Bullous ichthyosiform erythroderma 23, 92
Bullous impetigo 10
over palms 115f
Bullous pemphigoid 242, 502
Burrowing bug pigmentation 111
Burrows over finger webspaces 107f
Bursitis 179
Butcher's wart 126
Butterfly erythema 353f
Café-au-lait macule 264, 264f, 265f, 295
Calcineurin inhibitors 254
Calciphylaxis 347, 348f
risk of 348
Calcipotriol 90, 92, 105
Calcium-sensing receptor 315
Calmette-Guérin vaccine 515
Campylobacter 369
Canakinumab 464, 479
Cancrum oris 122f
Candida 329, 406, 415, 473
albicans 5, 154, 191, 418
infection 414
ciferri 154
glabrata 154
parapsilosis 154
tropicalis 154
Candidal diaper dermatitis 191f
Candidal intertrigo 105, 150
Candidiasis 153
chronic localized 157
chronic mucocutaneous 156, 486
congenital cutaneous 23, 154, 156
Canines, peg-shaped 68f
Capecitabine 438
Capillary fragility test 171
Capillary malformation 40, 46, 274
Capillary morphogenesis gene 481
Captopril 437
Carbamazepine 346, 432, 437
Carbon baby syndrome 296, 296f
Carboxymethylcellulose 507
Carbuncle 120
Caregiver-fabricated illness 484, 484f
Carotenemia 473, 511, 511f
Carotenodermia 511
Carpet tack sign 354
Cartilage-hair hypoplasia syndrome 486, 488
Carvajal syndrome 382
Cataracts 84
Cat-scratch disease 461
Cayler cardiofacial syndrome 489
Ceftriaxone 23
Cell-based techniques 249
Cellulitis 116, 158, 179
Central nervous system 341, 464, 472
abnormalities 84
Cephalic histiocytosis, benign 329, 329f
Cephalosporins 26, 428, 432
Cerebellar hypoplasia 42
Cerebral atrophy 41
Cerebro-oculofacioskeletal syndrome 76, 85
Cerebrospinal fluid 274
Cervical lymph nodes 127
Cetirizine 196, 319
Cetuximab 396, 418
Chancre 449
Chancroid 450
Checker-board pattern 272
Chédiak–Higashi syndrome 399, 400f, 488
Cheilitis granulomatosa 469, 470
etiology of 469
exfoliative 485
Chemotherapy 514b
discontinuation of 439
Chickenpox 168
rash over palm 169f
Chikungunya 179
arbovirus 179
diagnosis of 179
dystrophic calcification 179
fever 179
classical rash of 180f
pigmentation 179
Chilblains 496, 496f, 497f
erythematous swollen edematous fingers 497f
treatment of 497
CHILD syndrome 103
Child sexual abuse 449t
Childhood vitiligo 275
Chlamydia 449
mouthwash 506
solution 423
Chloroquine 228, 351
low-dose 345
Chlorpheniramine 319, 326
Cholecystitis 344
Cholelithiasis 344
Cholesterol 340
Chondrodysplasia punctata 358
Chorea 369
Choreoathetotic movements 347
Chorioretinal colobomas 84
Choristomas 58
Chromhidrosis 501
Chromobacterium violaceum 489
Chromomycosis 161
Chronic bullous dermatosis of childhood 241, 242
Chronic granulomatous disease 486488, 488f
Chronic granulomatous disorder 467
Chronic mucocutaneous candidiasis 156, 156f, 157f, 486, 487, 489
oral lesions of 157f
Churg-Strauss granuloma 127, 363
Chylomicrons 340
Cicatricial alopecia 379f
Cicatricial pemphigoid 242
Cimetidine 228
Cladosporium carrionii 161
Clarithromycin 186
lip 84
palate 84
Clindamycin 124, 186, 418
Clobetasol propionate 351, 361
Clofazamine 134, 355, 464
Clopidogrel 375
Cloxacillin 174, 217
Clustered black comedo-like lesions 63f
Cockayne syndrome 74, 75, 80
Collagen vascular diseases 351, 431, 438, 513, 514
Collagenoma 262f
Collodion baby 93
Comedones 2
Common warts 134
Complement deficiency disorders 487, 489
Complete heart block 358
congenital 356
Compression therapy 442
Condyloma 512
acuminata 451
Condylomata 450
Congenital hemangioma 37
Congenital rubella
rash of 168f
syndrome 167
Conidiobolus coronatus 159
Conjunctivitis 165, 179, 455, 465
Connective tissue disorder 363
Conradi-Hünermann syndrome 23
disease 93
syndrome 102
Constipation 452
Contact dermatitis 184, 192, 218f, 219f, 220, 282f, 455
allergic 192, 217
Contact leucoderma 282, 283
Contagious disease 168
Conventional cyst excision 507
Copper penny bodies 161
Coproporphyria, congenital erythropoietic 343
Cornea verticillata 346
Corneal opacities 346
Cornelia de Lange syndrome 17
Corona virus infection, novel 188
Coronary artery vasculitis 437
Corpus callosum
agenesis of 84
calcification of 348
Corticosteroids 228, 254, 256, 375, 396
Corticotropin-releasing hormone 334
Cortisol 334
Corynebacterium 501
diphtheriae 5
minutissimum 123
Cosmetic function 1
Cough syrups 462
diagnosis of 189
infection, skin rash of 189
symptoms of 189
Cowden syndrome 54
Coxsackie virus 172, 220
Crab louse 109
Crab-like bald patch 379f
Cradle cap 194
Craniopharyngioma 398
Crohn's disease 312, 464, 470t, 512
cutaneous 467
Crust 2
Crusted scabies 109
Cryoglobulinemic vasculitis 187
Cryopyrinopathies 471
Cryosurgery 262
Cryotherapy 442
Cubital fossae 220f
Cushing's disease 336, 337f
Cushing's syndrome 154, 410
Cutaneous disorders 23, 48
Cutaneous horn 446, 447f
Cutaneous leishmaniasis 161, 162f, 163, 163f
ulcerated lesion of 163f
Cutaneous lesions 38, 308, 482
treatment of 179, 356
Cutaneous manifestations 334, 356
Cutaneous periarteritis, benign 367
Cutis laxa 77, 78f
Cutis marmorata 17
telangiectasia 19f
congenital 17, 18
Cutis verticis gyrate 401, 401f
Cyanocobalamin deficiency 308, 310f
Cyclophosphamide 256, 366, 479, 514
Cyclosporine 41, 212, 229, 236, 275, 366, 378, 397f, 418, 437, 464, 479, 514
role of 236
Cylindromas 403
Cyst 2
Cystic fibrosis 216
Cystic renal dysplasia 84
Cytokine 486
Cytostatic drugs 418
Dandy-Walker malformation 42
Dapsone 355, 464
Darier's disease 60, 78, 79f, 80f, 105, 219, 239, 240
Darier's sign 25, 324, 324f
Dartoic leiomyomas 65
Dectin-1 deficiency 157
Deformed joints 346
Degos disease 374, 374f
Dehydroepiandrosterone 3
Delusional parasitosis 482
Demodex mites 418
arboviral 171
confluent rash 171
fever 171, 182
flagellate purpura 171
hemorrhagic rash of 171f
maculopapular rash of 171f
rash 171f
virus 171, 172
Dennie-Morgan infraorbital folds 201, 203f
Dental malocclusion 81f
Deoxyribonucleic acid 295
Depression 483, 484
Dermabrasion 262
Dermal aplasia 84
Dermal hypoplasia, focal 83
Dermal melanocytic nevus 283
Dermal-fat grafts 363
Dermatitis 191, 192
acute irritant 19f, 219f
artefacta 482, 483f
herpetiformis 242, 244
type of 192
Dermatofibroma 329, 330f, 403
Dermatologic diseases 455, 458
Dermatomyositis 358, 359, 359f, 440f
juvenile 358
Dermatophyte 414f, 473
infection 358
miscellaneous 496
neonatal 3
Dermoepidermal junction 345, 440, 502
Dermographism 316
Dermoid cyst 274, 395
Dermoscope 402
Desmoplakin gene 382
Desquamative gingivitis 258, 258f
diagnosis of 335
insulin-dependent 479
mellitus 231, 338, 347, 374, 473, 511
mellitus, type 1 358, 496
Diabetic bulla 336
Diabetic dermopathy 335, 335f
Diaper care 31
Diaphragm 30
Diarrhea 186, 324, 466
Diascopy test, positive 45
Diastematomyelia 273
DiGeorge syndrome 487, 489
Dilapidated brick wall appearance 105
Diltiazem 229, 437, 439
Dimples 274
sign 329, 330f
Diphtheria 508
tetanus, and pertussis 322
Dipyridamole 375
Dirty warty papules 79f
Dispel stigma 457f
Disseminated superficial actinic porokeratosis 106
Dithranol 229, 230, 378, 379
Dizziness 324
Docetaxel 438
Dominant dystrophic epidermolysis bullosa 251, 253
Dowling-Degos disease 299, 300
Down syndrome 17, 377, 393, 444
Doxorubicin 438
dermatomyositis 440
Doxycycline 182, 418, 422
D-penicillamine therapy 404
DRESS syndrome 437
maculopapular rash of 437f
Drug rash 182
Drug reactions, pathogenesis of 426
Drug-induced hypersensitivity syndrome 427
Dry xerotic skin 314f
DSRAD gene 298
Dupilumab 215, 255
Dymium-doped: yttrium aluminum garnet laser 447
Dyschromatosis symmetrica hereditaria 297, 298f
Dyschromatosis universalis hereditaria 299, 299f
Dyskeratosis congenita 460, 461f
Dyslipidemia 231
Dysostosis multiplex 350
Dyspnea 324
Dysrhythmias 357
Dystocia 510
Dystrophia unguis mediana canaliformis 406
Dystrophic calcification 180f
Dystrophic epidermolysis bullosa 247f, 250f, 253
Ears 31
cartilage 472
Ecchymosis 373, 373f
Eclabium 95f
Ecthyma 115
gangrenosum 116
over leg 117f
Ectodermal dysplasia 23, 66, 389
Ectopic sebaceous glands 503
Ectropion 95
Eczema 105, 191, 215, 219, 220f, 291, 405, 486, 490, 492, 493f, 497
coxsackium 220, 221f, 222
herpeticum 208, 219, 220f
vaccinatum 220
Eczematoid dermatitis, infectious 217, 217f
Eczematous dermatitis 492
Eczematous eruptions 497
Eczematous hyperpigmented patches 311f
Eczematous lesions 214f, 217, 476, 490f, 498f
Edema, acute hemorrhagic 371
Edematous papules 463
Ehler-Danlos syndrome 77, 78, 79f, 401, 442
phrynoderma over 308f
scars 349f
Elejalde syndrome 400, 401f
Elephantiasis verrucosa nostra cutis 50
Emollients 32
Empyema 179
En coup de sabre 362
Encephalitis 165
Endocrine disorders 396, 473
Endocrine organs 486
End-stage renal disease 347
Enterovirus 156, 182, 184
biotinidase 311
immunoassay 182
Eosinophilia 44
Eosinophilic leukemia 475
mucocutaneous manifestation of 475
Ependymoma 398
Ephelides 55
Epibulbar dermoids 58
Epidermal hyperplasia 479
Epidermal nevus syndrome 56, 60, 60f
Epidermolysis bullosa 10, 156, 246, 246f, 247f, 248, 502, 503f
cell based techniques 249
classification of 250t
dystrophic 251, 502f
acral 251
nails 251
pretibial 251
future therapies of 248
junctional 251
pruriginosa 253, 253f
simplex 250
acantholytic 250
generalized intermediate 250
generalized severe 250
localized 250
migratory circinate 250
mottled pigmentation 250
muscular dystrophy 250
pyloric atresia 250
superficialis 250
types of 251t
Epidermolytic ichthyosis 92
Epidermophyton floccosum 144
Epiloia 260
Epiphyses 358
Epithelioma 394
Epstein's perals 20
Epstein-Barr virus 172
Erlotinib 396
after skin grafting 247f
over back 247f
Erosive and vesicular dermatosis, congenital 26
Eruptive histiocytosis, generalized 331
Eruptive vellus hair cyst 402, 402f, 403f
Erysipelas 116
Erythema 220f, 438f
annulare centrifugum 329, 331f, 476
elevatum diutinum 373
induratum 462
infectiosum 184, 187, 188f
marginatum 358, 472, 473f
mild 225f
multiforme 178, 371, 431, 433f, 434f
target lesions of 435f
nodosum 460, 462f, 466
leprosum 129, 134
toxicum neonatorum 4, 156
Erythematous boggy plaques of 118f
Erythematous follicular papules 119f
Erythematous maculopapular eruption 165
Erythematous papular lesions 359f
Erythematous papules 497f
Erythematous patches 10f
Erythematous perifollicular papules 97
Erythematous plaque 354
Erythematous swollen
legs 172f
palms 172f
Erythrasma 122, 282
over axilla 123f
Erythrocyte sedimentation rate 121, 355
Erythroderma 228, 426, 475
neonatal 23, 24f, 25f
Erythrokeratodermas 71
Erythrokeratodermia variabilis 71
Erythromycin 124, 186, 418, 419, 464
Erythropoietic porphyria 343, 344f
congenital 342, 344f, 345f
prognosis of 343
Erythropoietic protoporphyria 343, 345f
Eschar 181
Escherichia coli 423
Esophageal erosions 433
Esophageal strictures 466
Esophagus 460
Essential fatty acid deficiency 23
Etanercept 178, 367, 424, 464, 471
Everolimus 263
Exanthematous pustulosis 428, 439f
acute generalized 439
Exanthems of infective etiology 165
Excoriated papules 199f
Excoriation mark 2
Exfoliative cheilitis 485, 485f
Exfoliative dermatitis 245
Extravasation injuries 31f
Eyebrows 386
persistence of 134
Eyelashes 386
Eyelid 348
beading sign 348, 349f
Eyes 513
Fabry's disease 345
angiokeratoma lesions in 346f
Facial asymmetry 84
Facial hemiatrophy 362
pathogenesis of 363
Facial melanosis 293f
Familial chronic nail candidiasis 157
Familial cold autoinflammatory syndrome 471
Familial Mediterranean fever 471
Fanconi anemia 295, 296f
Farber's disease 346, 346f
Fatty aldehyde dehydrogenase gene 101
Faun tail nevus 273
Fenoterol 396
Ferrochelatase gene 343
Fetal heart block, treating 358
Fetal hydronephrosis 510
Fibromatoses 444, 480
Fibrous papule of nose 62
Filariasis 48
Filiform 3
Finger nails 409
Fingertip eczema 201
Fixed drug eruption 429, 430f
Flagellate hyperpigmentation 439
Flagellate purpura 439, 440, 440f
Flat-topped violaceous papules 232f
Flaviviridae 171
Flexural eczema, secondary infection in 211f
Flu 514
Fluconazole 149, 432
Fludrocortisone acetate 334
Fluorescence in situ hybridization 490
Fluoroquinolones 430
Flushed cheek 171f
Focal neurological deficits 39
Follicle-stimulating hormone 396
Follicular atrophoderma 444
Follicular keratosis 70f
Follicular keratotic papules 202f
Folliculitis 113, 466
decalvans 380
superficial 113
ulerythematosa reticulata 444
Fonsecaea pedrosoi 161
Food allergy 99, 201, 317
Footwear leukoderma 282f
Forchheimer spots 167
Fordyce disease 503
Fordyce spots 503
over buccal mucosa 504f
over lips 504f
Foreign body reaction 161, 441
Fossa malformations, posterior 41
Fowler's solution 503
Fox-Fordyce disease 424
Fragrance-free 219
Freckling 289
axillary 264
inguinal 266
Frictional lichenoid dermatitis lesions 499, 499f
Frontal baldness 388f
Fulminant hepatic necrosis 338
Fungal infections 113, 161
Furunculosis 113
Fusobacterium necrophorum 122
Gallbladder hydrops 186
Gamma-benzene hexachloride 109, 215
Gardner-Diamond syndrome 484
Gastroenteritis 165
Gastrointestinal manifestations 39
Gastrointestinal symptoms 184, 360
Gastrointestinal tract 252, 342, 489
Gefitinib 396, 418
Gemcitabine 438
Gene therapy 248, 346
Genetic disorders 496
Genital trauma 449
Genital ulceration 466
Genitourinary tract 253
Genodermatoses 66, 456
Geographic tongue 201
German measles 166, 166f
subsiding rash of 167f
Gianotti-Crosti syndrome 172, 173f
Giant lesions 139f
Giant molluscum contagiosum lesions 139f
Gingiva, erythema of 258
Gingival erythema 327
Gingival hyperplasia 395
Glans penis, vitiligo of 278f
Glaucoma 41
Glomerulonephritis 108
Glomus tumor 45
Glottic edema, severe 437
Glucocorticoids, high-dose 516
Gluten sensitive enteropathy 244
Glycoprotein 481
Glycopyrronium bromide 501
Golgi apparatus 105
Goltz syndrome 83, 83f
Gorlin's sign 78, 79f, 360f
Gottron's papules, erythematous 358f
disease 465
reaction 23, 25, 26
Gram stain 113
Granulation tissue 252
Granuloma annulare 508
lesions 509f
multiple lesions of 509f
over dorsum 509f
Granuloma gluteale infantum 21, 192
Granulomatous disease 495
Graves’ disease 473
Greasy papulonodular lesions 61f
Green eccrine
chromhidrosis 502f
hyperhidrosis 501
Griscelli syndrome 399, 399f, 400, 487, 488
Griseofulvin 149
Gross inguinal lymphadenopathy 490f
Growth retardation 342
Growth spurts 441
Guillain-Barré syndrome 169
Günther's disease 342, 343
H syndrome 479
H1N1 influenza 513
Habit tic deformity 408
Haemophilus 321
ducreyi 449
influenzae 321
type B 515
Hailey-Hailey disease 104, 104f
acquired progressive kinking of 389
and nail, diseases of 376
conditioners 391
hypoplasia syndrome 486
in premature canities 387f
loss 460
neonatal 386
regrowth of 376f
shaft 390
abnormalities 392
Hairy pinna 16
Hairy tragus 17f
Halo nevus 283
Hamartomas 511
formation, genetic disorders of 260
yellowish-brown 266
Hand bandages 347
Hand foot syndrome 438
Hand-foot-and-mouth disease 182, 182f, 405
Hansen's disease 133f
Harlequin baby 97f
Harlequin color change 28, 28f
Harlequin fetus 96
Hashimoto-Pritzker disease 327
Headache 165, 324, 369
Healed bullae 503f
Healed livedoid vasculopathy 365f
Hearing defects 84
block, congenital 444
congenital 84, 393
ischemic 406
Helicobacter pylori 369
Hemangioma 34, 41
cutaneous 42
infantile 34, 35f
over face 35f
rectal prolapse 512
Hematohidrosis 500, 500f
diagnosis of 500
Hematological malignancy 473
Hematopoietic stem cell 322
transplantation 486
Heme biosynthesis pathway 343
Hemochromatosis 333
Hemolacria 500
Hemolytic anemia 342, 343
Hemorrhage 324
Hemorrhagic blister 258f
Hemorrhagic bullae 242f
Hemorrhagic lesions 368, 493f
over face 493f
Hemorrhagic papules over face 498f
Henna tattoo 219f
Henoch-Schönlein purpura 187, 312, 369, 369f, 370f
Heparin and warfarin 375
Hepatic abnormalities 344
Hepatitis 186, 302, 357, 374
A 515
B 186, 508, 514, 515
C 508
Hepatoerythropoietic porphyria 343
Hereditary sensory 485
Hermansky-Pudlak syndrome 289, 289f
Hernias 84
Herpangina 184
Herpes genitalis 141
infection 451
serpiginous ulcer of 453f
Herpes infection 141f
Herpes labialis 142f
vesicular lesions of 140f
Herpes lesions, mucocutaneous localization of 10f
Herpes simplex 140
grouped vesicles of 10f
infection 140
lesions 141f
neonatal 10
virus 113, 156, 451
infection, diagnosis of 220
Herpes zoster 141, 179, 291, 441
ophthalmicus 143f
Herpetic gingivostomatitis 141
Herpetic lesions 10f
Herpetiform 3
configuration 506
Heterochromia iridis 382, 385f
Hidradenitis over axilla 423f
Hidradenitis suppurativa 416, 423, 423f, 489
Hidradenoma 62
Hidrotic ectodermal dysplasia 66
Hirschsprung's disease 382
Hirsutism 397
Histiocytic disorders 316
Histiocytosis over scalp 328f
Histoid leprosy 131, 135f
Histoid lesions 135f
Hodgkin's disease 472
Hodgkin's lymphoma 48
Homogentisate dioxygenase gene 333
Honeycomb atrophy 444
Horseshoe kidney 84
Howel-Evans syndrome 70, 71
Human herpesvirus 137, 186
Human immunodeficiency virus 329, 426, 451, 464, 472, 506, 508
infection 107, 374
consideration for 158
Human papillomavirus 134, 451
infection 478
Hutchinson-Gilford syndrome 80
Hyaline fibromatosis, juvenile 481
Hyalinosis cutis et mucosae 348
Hydrocortisone 321
Hydroxy acid 90
Hydroxychloroquine 229, 345, 351, 439
Hydroxyzine 319, 326
Hyper IgE syndrome 491
Hypercalcemia 347
Hypercarotenemia 511
Hypercholesterolemia 339
Hyperemia 178
conjunctival 178
Hypereosinophilic syndrome 438, 475
Hyperhidrosis 501
Hyperimmunoglobulin E syndrome 215, 486, 487, 490
Hyperkeratosis 312
epidermolytic 92, 93f, 94f, 95f
Hyperkeratotic lesions 98f, 99f
Hyperlipidemia, control of 341
Hyperlipoproteinemia 511
Hyperostosis 416
Hyperphosphatemia 347
Hyperpigmentation 199f
Addison's disease 292, 294f
causes of 179
familial, tongue 294
Fanconi anemia 295
idiopathic eruptive macular 297
knuckle and interphalangeal joints in atopics 295
over interphalangeal joints 309f
postinflammatory 238, 291, 292
Hyperpigmented patches 302f
Hypersensitivity syndrome 426
Hypersplenism 344
Hypertension 231, 366
family history of 376
Hyperthyroidism 384
Hypertrichosis 343f, 395, 396
congenital 395
drug induced 396
generalised 395
idiopathic 396
lanuginosa 395
nevoid 395
X-linked dominant 395
Hypertrophic scar 441, 443f
Hypertrophied papillae 178
Hypoalbuminemia 182, 411
Hypocalcemia 489
Hypochondriasis 312
Hypoglycemia 38
Hypohidrotic ectodermal dysplasia 66f
Hypomelanosis of Ito 271, 271f
Hypomelanotic streaks over abdomen 271f
Hypopigmentation, postinflammatory 7f, 138, 275, 292f
Hypopigmented patches 302f
Hypoplastic kidney 84
Hypotension 178, 182, 324
Hypothyroidism 338
Hypotrichosis 389
Hypoxanthine-guanine phosphoribosyltransferase, deficiency of 346
Ibuprofen 433
Ice-pick scars 417
Ichthyosiform erythroderma, congenital 156
Ichthyosis 23, 390
self-improving congenital 93
vulgaris 86, 88f, 206f
Idiopathic eruptive macular hyperpigmentation 297, 297f
Idiopathic eruptive macular hypomelanosis 291
Idiopathic guttate hypomelanosis 284, 284f
Idiopathic striae distensae 441, 441f, 442f
over axilla and shoulders 441f
Idiopathic thrombocytopenic purpura 371, 372f
deficiency, congenital 516
dysregulation 492
mediated cutaneous reactions 426
thrombocytopenia 488
thrombocytopenic purpura 312
Immunodeficiency disorder 464, 472, 486
Immunodeficiency syndrome 215
Immunofluorescence antibody test 182
Immunoglobulin 11
deficiencies 487
intravenous 178, 358
replacement 486
Immunological function 1
Immunosuppressants 464
Immunosuppressive drugs 494
Impetigo 114, 161
bullosa 116f
Incontinentia pigmenti 156, 268, 269f
papulovesicular of 270f
patches of 270f
verrucous stage of 270f
Indeterminate leprosy 130
Indirect immunofluorescence testing 255
Indirect immunoperoxidase test 182
Indomethacin 229
Infantile digital fibromatosis 497, 498f, 499f
lesions 499f
Infantile gluteal granuloma 21, 21f
Infantile perianal pyramidal protrusion 511
Infantile pustular psoriasis 229
Infantile pyramidal perineal protrusion 512f
Infantile seborrheic dermatitis 2325, 194, 196f, 197f
prognosis of 195
Infantile systemic hyalinosis 85, 480, 480f
bacterial 431
candidal 158
secondary 197
severe 11
Infiltrated asymptomatic plaque 163f
Infiltrated red scaly papules 327f
Inflammatory bowel disease 374, 492
Inflammatory dermatosis 449
Inflammatory linear verrucous epidermal nevus 60
Inflammatory papules 107f
and pustules 4f, 113f, 148f
Inflammatory skin 199
ulcers 492
Infliximab 367
Influenza 515
immunization 515
vaccine 515
Infraorbital folds 201
Ingrown toe nail 406
Inherited ichthyosis 86, 86f
classification of 87t
Inorganic arsenic 503
Insect bite
blister 258f
reaction 142f, 258
Insomnia 448
Insulin injection 473
Intermediate density lipoproteins 340
Internet generation 458
Intertrigo 5
Candida 150
of inguinal folds 7f
Intractable diarrhea 480
Intralesional steroids 464, 470
Intralesional triamcinolone 411
acetonide 421
injection 332
Ipex syndrome 487, 491
Irritable bowel syndrome 422
Irritant contact dermatitis 217
Irritant dermatitis 192, 193f
neonatal 18
treatment of acute 192
Isoniazid 433
Isotretinoin 418
Itchy papules 200
Itraconazole 149
Jacquet's dermatitis 191, 191f
development of 192
Jadassohn-Pellizzari anetoderma 446
Janus kinase inhibitors 379
Japanese encephalitis 515
Jewels appearance, cluster of 241, 243f
Jewels sign, cluster of 241
Job's syndrome, extensive abscesses in 490f
Junctional epidermolysis bullosa 251
generalized 251
inversa 251
late onset 251
pyloric atresia 251
severe generalized 251
subtypes of 252t
Juvenile plantar dermatitis 204f
classical lesion of 204f
Juvenile systemic sclerosis 360
diagnosis of 362t
Kaposi sarcoma 48
hemangiopericytoma 478
Kaposi varicelliform eruption 208
Kawasaki disease 124, 174, 175, 175f177f, 182, 405, 438
atypical 178
incomplete 178
Kawasaki syndrome 178
Keloid 442
over abdomen 443f
over chin 443f
Keloidal lesions in acne 417
Keratinization, disorders of 86, 513
Keratinocytes 218, 279, 439
apoptosis, intravenous immunoglobulin 433
Keratitis 157
ichthyosis-deafness syndrome 98, 100f
Keratoacanthoma 447
Keratoconjunctivitis 141
Keratoderma 252
diffuse 67
focal 70
Keratolysis exfoliativa 209f
congenita 104
Keratosis pilaris 201, 202f
atrophicans 380
Keratosis rubra pilaris 201
Keratotic papules 308f
Kerion, multiple lesions of 149f
KID syndrome 98
Kidney 460
Killed and component vaccines 514
Kimura's disease 44
Kindler syndrome 81, 82f, 246, 251
Klippel-Trénaunay syndrome 40, 40f, 393
Klippel-Trénaunay-Weber syndrome 43
Koenen's tumor 263f
Koilonychia 405
Koplik's spots 165
Kwashiorkor 305f, 306f
Kytococcus sedentarius 123
Labia minora hypoplasia 84
Lamellar ichthyosis 23, 90, 90f
Lamotrigine 437
Langerhans cell 218
histiocytosis 156, 327
nodular lesions of 328f
over back 327f
Large cavernous lesions 38
Large necrotic aphthous ulcer 507f
Laron syndrome 389
Larva migrans 111
cutaneous 111
Laryngo-oculo-cutaneous syndrome 251
Laryngotracheobronchitis 165
ablation 40
therapy 262
Laterothoracic exanthema, unilateral 184
Lax skin, elasticity of 77f
Legionella 489
Legius syndrome 266
Leiner's disease 23, 26, 156
Leiomyoma 45, 62, 65
cutaneous 63, 64
Leishmania braziliensis 161
Leishmania donovani 161, 163
Leishmania mexicana 161
Leishmania tropica, leishmania major 161
Leishmaniasis 161
disseminated cutaneous 131
Lentigines 54, 336
Leopard syndrome 54, 55f
Lepromatous leprosy 130, 133f, 134f
diffuse 130
infiltrated 130
Lepromatous nodules 134
Leprosy 127, 128, 291
borderline lepromatous 130
borderline tuberculoid 130
histoid 131
indeterminate 130
lepromatous 130
Lesch-Nyhan syndrome 346, 347f
Leser-Trélat sign 479, 480f
classical 341f
over knee 509f
over shoulder 493f
primary 2
secondary 2
special 2
chemical 282
punctate 403
Leuconychia, total 403
lymphoblastic 474f, 475f
myelogenous 295
myeloid 474
eosinophilic 476f
myelogenous 475
cutis 473
Leukocyte adhesion
defect 486
deficiencies 487, 492, 493
Leukocytoclastic vasculitis 369, 371
Leukoderma syphiliticum 449
Leukonychia 68, 98, 225, 227f
Leukopenia 354
Leukoplakia 460
Lichen nitidus 237
lesions 238f
Lichen planopilaris 240
Lichen planus 232, 234f, 236, 239f, 275, 380, 513
actinicus 238
classical lesions of 232f
lesions 233f
nail 233
oral 233
Lichen sclerosus et atrophicus 285, 286f, 512
vulva 288f
lesions of 287f
Lichen scrofulosorum 237
Lichen spinulosus 238, 239f
Lichen striatus 60, 289, 290f
Lichenification 2
Lichenified eczema, chronic 210f
Lichenoid component 291f
Lichenoid keratosis 480
Lichenoid skin-colored papules 499f
Limb edema 358
Linear lichen planus 60, 291
Linear morphea 362
Linear porokeratosis 60, 105f
Lines of Blaschko 102, 272
licker's dermatitis 194, 195f
vitiligo 277f
Lipid profile, abnormal 496
Lipoatrophy 350
Lipodystrophy 350, 358
Lipofilling 363
Lipoid proteinosis 131, 348, 348f
Lipomas 511
Lipoprotein defects 340t
Lisch nodules 266
Listeria monocytogenes 156
Lithium 229
Live vaccines 514
Live-attenuated vaccines 515, 516
Live-attenuated virus 515
Livedo reticularis 369, 473, 476
Livedoid vasculopathy 363, 365f
Liver 341, 342
disease 511
Localized scleroderma 380
Loose anagen hair syndrome 391, 392f
Louse infestation 109
Low back pain
chronic 510
symptoms of 510
Low blood
glucose 335
pressure 335
Low-calcium dialysate 347
Low-density lipoproteins 340
Low-grade fever 184
Lumbar syndrome 36
Lung 127, 341
Lupus erythematosus 240, 351, 352, 355, 377, 380
acute cutaneous 352, 355
bullous 356
chilblain 354
chronic cutaneous 352, 354
discoid 351, 351f, 352, 352f, 353f, 354
lichenoid discoid 354
linearis 354
neonatal 356
nonspecific lesions 356
panniculitis 354
pigmented 354
plaque of discoid 478f
subacute cutaneous 357f
systemic 351, 353f, 354, 464, 475
telangiectoides 354
tumidus 354
Lupus hair 356
Lupus nephritis 356
Lupus vulgaris 125, 126f
Lusterless brownish hairs and alopecia 311f
Luteinizing hormone 396
Lyell's syndrome 433
Lymphadenopathy 179, 186
dermatopathic 231
Lymphangioma circumscriptum 48, 48f, 49f
Lymphangitis 48, 118, 119f
acute 118
over forearm 119f
Lymphedema 48
congenital 48
praecox 48, 50
primary 48
secondary 48
tarda 48, 50
Lymphocytic infiltrative pneumonia 495
Lymphoedema 404
Lymphoepithelial kazal-type-related inhibitor 99
Lymphogranuloma venereum 48
Lymphohistiocytosis, hemophagocytic 477
Lymphoma 438
Lymphomatoid papulosis 475
Macrocheilitis 469
Macroglossia 473
Macular dystrophy, juvenile 389
Macule 2
Maculopapular eruptions 428
Maculopapular lesions 166f
Maculopapular rash 178f, 429f
Majocchi's granuloma 113
Mal de Meleda 68
Malaise 165
Malassezia furfur 194
Malformed hair bulbs 391
Malignancies, cutaneous 459
Malignant melanoma 477, 477f
Malignant peripheral nerve sheath tumors 267
Marasmic kwashiorkor 307
Marasmus 305
dry lusterless skin of 306f
Marie Unna hereditary hypotrichosis 401, 402f
Massage, role of 33
Mast cell 316
sarcoma 326
Mastocytosis 322
classification of 326b
cutaneous 326
diffuse cutaneous 23, 324, 325f
lesions 323f
types of 324
Maternal rubella 168
McCune-Albright syndrome 268, 269f, 314
Measles 165, 182, 515
management in 166
treatment of 166
Mechanobullous disorders 246
Meckel's diverticulum 11
Median nail dystrophy 406, 407f, 408
Median raphe cyst 28, 28f
Melanocyte 279
stimulating hormone 293
Melanocytic nevi, congenital 51, 283, 395
Melanocytic nevus 51, 51f
Melanoma 45
classic signs of 477
detection of 403
Melanonychia striata 410, 411f
Melkersson-Rosenthal syndrome 464, 465f
Meningitis 438
Meningomyelocele 274, 274f
management in 274
Menkes disease 389, 390, 393
Menkes kinky hair disease 393, 394f
Mental retardation 382
Metabolic disorders 23, 333, 396
Metabolic syndrome 459
Methicillin 229
Methicillin-resistant Staphylococcus aureus infection 113
Methicillin-sensitive Staphylococcus aureus 120
Methotrexate 212, 230, 275, 355, 366, 368, 375, 411, 464, 479, 514
Methylprednisolone 321
Metronidazole 418, 422, 430, 437, 464, 470
Mevalonate kinase deficiency 471
Mickey mouse ears 75
Micrognathia 392
Microphthalmia 84
audouinii 145
canis 144, 145
ferrugineum 145
gypseum 145
nanum 145
Mid-face toddler excoriation syndrome 485, 485f
Migratory glossitis, benign 201
Mikulicz ulcers 506
Milia 2, 5f, 156, 502
over pinna 502f
Miliaria 5, 156, 184
crystallina 6
rubra 6
and pustulosa 8f
Miliarial eczema 217, 218f
Milroy's disease 48, 49
Minocycline 410, 470
Minoxidil 387
lotion 386
Mites 215, 418
Mitochondrial disorders 389
Mitten-like deformity 248f
Mixed porphyrias 343
Molluscum contagiosum 134, 135, 447, 452, 453, 486
multiple umbilicated papules of 138f
perianal 452
Mongolian spot 3
Monilethrix 382
Mononuclear cell infiltrate 428
Moon's mulberry molars 13
Morbilliform rash 165, 466
Morphea 361
Motor incoordination 382
Muckle-Wells syndrome 471
Mucocutaneous candidiasis 156f
Mucocutaneous leishmaniasis 161
Mucocutaneous lymph node syndrome 175
Mucosal cysts 507
Mucosal cysts lip 508f
Mucosal ulcers 476
Mucous membranes, lesions of 460
Muehrcke's nails 410
Muehrcke's nails, white bands of 411f
Multibacillary leprosy 131
Multidrug therapy 127
Multinucleated giant cells 168, 220
Multiorgan dysfunction, disease of 491
Multiorgan hypersensitivity syndrome 437
Multiple alopecia patches 148f
Multiple carboxylase deficiency 23, 194
Multiple erythematous papules 214f
Multiple minute digitate hyperkeratosis 239
Multiple myeloma 374
Multiple proinflammatory cytokines 176
Multiple ringworm 140f
Multiple sulfatase deficiency 350, 350f
Multisystem neuroectodermal disorders 392
Mumps vaccine 515
Munchausen syndrome by proxy 484
Mupirocin 114
fusidic acid 119
Musculoskeletal system 303
Myalgia 179, 186, 452
Mycobacterial infection, atypical 127
marinum 461
tuberculosis 127, 463
Mycophenolate 514
mofetil 212, 396
Mycoplasma 439
pneumoniae 186
Mycosis fungoides 404, 475
Myelodysplasia 374
Myelodysplastic syndrome 472
Myelofibrosis 479
Myiasis 161
Myocarditis 165
Myositis 438, 466
Myxedema 473
N-acetylcysteine 214
Nail 31
disorders 406
dystrophy 433
involvement 252
pitting 406
psoriasis 225
shedding 412
Napkin dermatitis 191, 191f, 192
hypopigmentation 191
management 192
Napkin psoriasis 223
Nappy rash 31
Narrowband ultraviolet B 140
Nausea 324
Naxos disease 382, 383f
Neck lesions 79f
Necklace of Venus 449
Necrobiosis lipoidica diabeticorum 335, 336f
Necrosis, cutaneous 348f
Necrotic keratinocytes 240
Necrotic purpura 369
Necrotizing fasciitis 120
lesions of 121f
Necrotizing vasculitis 363, 365f, 476
Neisseria gonorrhoeae 448
Nekam's disease 240, 240f
Neonatal hemangiomatosis, diffuse 42, 43f
Neonatal milia 4, 4f
en plaque 5f
Neonatal varicella 11
diagnosis of 11
Neoplastic histiocytic disorder 327
Netherton's syndrome 23, 93, 99, 101f, 358, 390, 391f, 393, 394
Neuroblastomas 511
Neurocutaneous disorders 260, 303
Neurofibroma over palm 267f
Neurofibromatosis 134, 264, 267f
Neurological system 342
Neuropathy, severe 437
Neuropsychiatric abnormalities 348
Neuropsychotherapeutic drugs 418
Neutropenia 393
Nevoid basal cell carcinoma syndrome 123
Nevoid hypertrichosis 395, 396f
Nevus anemicus 285, 286f
Nevus comedonicus 62
Nevus depigmentosus 284, 284f, 285f
Nevus lipomatosus superficialis 62, 63f
Nevus of Ito 50
Nevus of Ota 50, 50f
Nevus sebaceous 60, 62, 62f
Nevus spilus 55
Newborn skin, care of 30
Nicotinic acid 310
Nifedipine 360
Nikolsky's sign 8, 436f
positive 436f
Nimesulide 433
Nipple eczema 207f, 208f
Nocardia asteroides 158
Nocardia brasiliensis 158
Nocardiosis 158, 160f
NOD2 gene 471
Nodular adrenal hyperplasia 336
Nodular lepromatous leprosy 130
Nodular lesion 192, 164f
Nodular prurigo 197
Nodules 471
Noma 121
neonatorum 122
Nonadhesive dressings 246
Nonbullous congenital ichthyosiform erythroderma 90
Nonbullous ichthyosiform erythroderma 23, 90, 92f
Nonhistaminergic angioedema 321
Nonimmune cutaneous reactions 426
Nonimmunologic reactions 427
Non-involuting congenital hemangioma 37
Nonsteroidal anti-inflammatory
agent 368, 472
drugs 143, 188, 231, 316, 355, 427, 465
Noonan syndrome 442
Norwegian scabies 107, 109
Nummular eczema 200f
Nystagmus 46, 84
Obesity 5, 347
Obsessive compulsive disorders 483
Occipital alopecia 381, 382f
neonatal 382f
Ochronotic axial arthropathy 333
Ocular choristoma 57
Oculocutaneous albinism 2, 288, 288f
Oligophrenia 444
Olmsted syndrome 68
Omenn syndrome 23
Omeprazole 396
Omphalitis 11
Onychocryptosis 406
Onychodystrophy 225
Onychogryphosis 406
Onycholysis 406, 408f
Onychomadesis 406, 412, 413f, 414f
Onychomycosis 412, 413
white superficial 414f
Onychophagia 483
Onychotillomania 483
Ophiasis 377
inversus 377
Opportunistic infections 473
Optic disc 58
Oral acitretin treatment 254f
Oral antihistamines 318
Oral antistaphylococcal antibiotics 217
Oral aphthous stomatitis 466
Oral candidiasis 157f
severe 491f
Oral corticosteroid 35f, 358
Oral mucosa
lesions 183f
lichen planus of 235f
mucosal cysts of 507
Oral poliomyelitis vaccine 515
Oral poliovirus vaccine 514
Oral prednisone 470
Oral retinoids 421
role of 236
Oral steroids 275, 355, 464
Oral thrush 154, 491
Oral ulcers 358
Orange-brown chromonychia 177f
Orchitis 438
Orofacial granulomatosis 469
Orthostatic hypotension 334
Osteopenia 393
Osteosclerosis 393
Pacemaker 358
Pachydermoperiostosis 442
Pachyonychia congenita 70, 70f
Pacinomas 511
Paederus dermatitis 258
Pain, abdominal 186, 310
Palatal hemorrhagic rash 166f
Palatal ulcer 245f
Palmar erythema 359f
Palmar keratoderma 68f
Palmar lesions 434f, 439f, 503
Palmoplantar erythrodysesthesia 438
Palmoplantar hyperhidrosis 501, 501f
Palmoplantar keratoderma 66, 67, 239, 251, 252
diffuse 71f
Palmoplantar lesions 182f
Palmoplantar psoriasis 225
Palmoplantar punctate keratoderma 123
Palmoplantar warts 123
Palms, fissuring of 438
Pancytopenia 479
Panitumumab 396, 418
Pansclerotic morphea 361, 363f
Papillary dermis 440
Papillomatous elevations 459
Papillon-Lefèvre syndrome 68, 70f
Papular acrodermatitis 172, 184
Papular purpuric gloves 186
Papular urticaria 197, 197f, 198f
lesions 197
Papular-purpuric gloves 187f
Papule 2, 438
Papuloerosive lesion 192
Papulonecrotic lesions 476
Papulonecrotic tuberculid 127
Papulosquamous disorders 223
Paraffin 363
Parainfluenza virus 172, 184
Parakeratotic cells 406
Paramyxovirus 165
Parathyroid glands, hypoplasia of 489
Parkes-Weber syndrome 40, 41f
Paronychia 152, 405
acute 153f
chronic 155f, 414, 415f
Parotitis 438
Parry-Romberg syndrome 362
Parvovirus B19 369
Pastia's lines 186
Patchy pigmentation 272
Pathergy test, positive 466
Pearls, string of 241
Pediatric internists 364
Pediatric psoriasis 231
Pediculosis 109
capitis 109
corporis 109, 111f
pubis 110, 111f
Pediculus humanus capitis 109
Pediculus humanus corporis 109
Peeling skin syndrome 103, 103f
Pellagra 310, 333
skin lesions 311f
drug induced 254
foliaceus 254, 255f, 256
vegetans 105
vulgaris 254, 255f, 256f
Penicillamine 396, 397
Penicillin 26, 229, 428, 432
Penicillinase-resistant antistaphylococcal agent 174
Penicillium 329
Pentoxifylline 464
Perianal cellulitis 124
Perianal condyloma acuminata 451f
Perianal molluscum contagiosum 452, 453f
Perianal streptococcal dermatitis 124, 125f
Pericardium 30, 341
Perifollicular erythema 201
Perifolliculitis capitis 149
Periodic blood 497
Periodic fever syndrome 471
Periodontitis 70f
Perioral dermatitis 418
Perioral skin 326f
Periorificial dermatitis 418
Peripheral neuropathy 366
Periporitis 114, 115f
Periungual fibroma 260, 263f
Pernicious anemia 275, 377, 384
Perniosis 473
Perspiration 165
Pertussis 515
Petechial eruptions 343
Petechial macules 167
Petechial spots 486
Peutz-Jeghers syndrome 54, 56, 57f, 58f
PHACES syndrome 30, 41, 42, 42f
Phakomatosis pigmentovascularis 46, 46f, 393
classification of 46t
Pharyngitis, chronic 67
Phenylketonuria 216
signs of 216
Phenytoin 346, 396, 432, 437, 462
Phialophora verrucosa 161
Phlebotomy 345
Photophobia 165, 179
Photosensitivity pigmentation 333
Phototoxic reaction, acute 289f
Phrynoderma 239, 308
Phycomycosis 159
subcutaneous 161f
Phylloid pattern 303f
Physiological exfoliation 17
Phytanoyl-coenzyme A hydroxylase 102
Piebaldism 382, 385f
treatment of 383
Pigmentary demarcation lines 300
Pigmentary disorders 275
Pigmentary mosaicism 272, 272f, 302, 302f, 303f
hyperpigmentation 302f
hypopigmentation 302f
Pigmentation persists 271
Pigmented purpuric
dermatitis 47f
dermatoses 46
Pigmented xerodermoid 76
Pili annulati 390
Pili torti 389
Piloleiomyoma 62, 64
Pilomatricoma 394
Pimecrolimus 209, 276, 419
Pinched mask facies 361f
Pitted keratolysis 123, 124f
Pityriasis alba 152, 201, 202f, 291
Pityriasis amiantacea 223, 385, 387f
Pityriasis lichenoides 367, 368
acute 368
chronic 368
chronica 367f, 368
et varioliformis acuta 127, 244, 368
etiology of 367
Pityriasis rosea 137, 152, 184
Pityriasis rubra pilaris 23, 97, 239
Pityriasis versicolor 151, 153f, 282
hypopigmented macules of 152f
Pityrosporum 424
folliculitis 424, 425f
ovale 113
yeast 417
Plane xanthoma over elbows 341f
Plantar dermatosis, juvenile 203, 203f
Plantar keratoderma 69f, 70f, 383f
diffuse 68f
Plantar lesions 183f
Plantar psoriasis 226f
Plantar warts 137f
Plaque 2
Plasma cells 479
Plethoric facies 336
Plexiform neurofibroma 265, 266
Pneumonia 165, 168, 433
Poikiloderma 358, 466, 475
Poliomyelitis, inactivated 515
Poliovirus vaccine 172
nodosa 366
prognosis of 367
Polyclonal B-cell activation 175
Polyendocrine deficiency syndrome 334
Polyhydramnios 510
Polymerase chain reaction 127
Polymorphous light eruption 505
Polymorphous rash 176f
Polythelia 17
Pompholyx 204
lesions over palms 205f
Porcelain-whitish plaque 362f
Porokeratosis 105, 106f
behind ear 105f
over palm 105f
Porphyria 342
acute 343
classification of 343t
congenital erythropoietic 342
cutanea tarda 343, 344
cutaneous 333, 343
types of 342
Port-wine stain 40
Post-burn keloid 444f
Post-hand-foot-mouth disease 405
Postinflammatory hyperpigmentation 292
Postinflammatory hypopigmentation 152, 291
Post-kala-azar dermal leishmaniasis 131, 163, 164f
Postnatal hair 386
hydroxide 453
iodide 229
Potent steroids 351
Potentially life-threatening disease 375
Pox-like scars 417
P-phenylenediamine 219
Prednisolone 359
Premature ageing syndromes 384
Premature canities 383, 387f
Premature keratinization 391
Prenatal screening 358
Pretibial myxedema 473
Prevotella intermedia 122
Primary anetoderma 446, 446f
Primary immunodeficiency 194
diseases 486
disorder 372, 486
treatment of 494
high risk for of 486b
Primidone 437
Pristinamycin 439
Progeria 80, 81f, 442
Progressive symmetric erythrokeratoderma 73, 73f
Progressive systemic sclerosis 360
Promethazine 326
Prominent hair
abnormalities 87
follicles 381f
Prominent neurologic signs 87
Prophylaxis 166, 167, 168
acnes 416
propionicum 158
Propranolol 229
Propylene glycol 90
Prosector's wart 126
Prostaglandin E1 396
Protective creams 33
energy malnutrition 305
replacement therapy 248
Proteus syndrome 82, 83f
Pruriginous papules 476
Pruritus 473
Pseudoainhum 68
Pseudolymphoma 438
Pseudomonas 329, 406
aeruginosa 113, 116, 248, 423
Pseudomonilethrix 382
Pseudopapillary growth 50
Pseudopelade 379f, 380
Pseudotumor cerebri 236
Pseudoxanthoma elasticum 77
Pseudoxanthomatous mastocytosis 324
Psoralen 332
ultraviolet-A 475
Psoriasiform lesions 357f, 492f
Psoriasis 23, 219, 224f, 230f, 275, 358, 414, 513
childhood 223
chronic plaque 223
diaper 224
drug induced 228
eruptive 223
erythrodermic 228
extensive 227f
extracutaneous involvement in 231
flexural 225f
follicular 223
generalized pustular 231
guttate 223, 225f, 226f
infantile 194
and juvenile pustular 229
inverse 123, 223
like lesions 69
napkin 223
nevoid 60
over scalp 224f
scalp 225
small plaque of 223
treatment modalities of 229
types of 223
vulgaris 223f
lesions of 223f
Zumbusch 229
Psoriatic arthritis 231, 231f
Psoriatic arthropathy 231
Psoriatic erythroderma 228f
neonatal 24
Psychiatric disorders
primary 482
secondary 482
Psychodermatoses 482
Psychogenic purpura 484, 500
Psychophysiologic disorders 482
Pterygium unguis 409, 410f
Pthirus pubis 109
Pubic hair 441
Pulmonary tuberculosis 404
Punctate leukonychia 403, 404f
Punctate palmoplantar keratoderma 71, 72f
fulminans 46, 47f, 48f
management in 48
urticaria 367
Purpuric spots 486
Pustular lesions 466
Pustular psoriasis 231
lesions 230f
juvenile 229
Pustule 2, 471
Pustulosis 416
Pyoderma 149
gangrenosum 472, 472f, 473, 492
Pyogenic arthritis 416, 472
Pyogenic granuloma 44
Pyogenic infections, chronic 67
Pyogenic lesions, multiple healed 488f
Q-switched ruby laser 54
Quarantine 190
Quinolones 439
Raccoon eye 356
Rapamycin 262
Rash over face 180f
Raynaud's phenomenon 356, 360, 366, 369
Recessive dystrophic epidermolysis bullosa 249, 253
Recurrent bacterial cellulitis 48
Red blood cell 282
Red cell aplasia 479
Red facial erythema 188
Red lunula 225
Red scaly baby 23
Red strawberry tongue 186
Redundant skin over face 77f
Refsum disease 102
Reiter's disease 67, 465, 467f, 468f
treatment for 465
Relapsing polychondritis 472
Renal angiomyolipoma 263
Renal disease 511
Renal failure 405
Repigmenting vitiligo 277f
Resolving Gottron's papules 359f
Respiratory disorders 404
Respiratory syncytial virus 172, 189
Respiratory tract 253
infections 431, 461
Restrictive dermopathy 84, 84f
Reticulate acropigmentation of Kitamura 299
Reticulocytopenia 479
Reticulohistiocytosis 131
Retinoid 236, 240
dermatitis 236
Rheumatic fever, acute 186
Rheumatoid arthritis 48
Rhinophyma 421, 422f
Rhodobacter sphaeroides 214
Riboflavin 308
deficiency 308
red lips of 308f
red tongue of 309f
Ribonucleic acid 165
Richner-Hanhart syndrome 70
Rickettsial disease 179, 181f
classical lesions of 181f
purpuric lesions of 181f
Rickettsial illnesses 179
Rickettsial infection 181, 182
Rickettsial pox lesions 181f
Rifampicin 433
Rifaximin in rosacea, role of 422
Ritter's disease 7, 156
Rituximab 464, 514
RMRP gene 488
Rosacea 48, 131, 416, 421, 422f
treatment of 421
Rosai-Dorfman disease 479
Rosenau's depression 406
Rotavirus 321
vaccines 515
Rothmund-Thomson syndrome 80
Rowell's syndrome 354
diagnosis of 355
Rubber antioxidants 194
Rubber bluish nipple lesions 39
Rubella 166
maternal 167
petechial macules, palate 167
suboccipital lymph nodes 167
vaccination 167
Rubeola 165, 515
Rubinstein-Taybi syndrome 442
Russell's sign 473
Ruxolitinib 477
Sabouraud's agar 159
Sacred ritual, part of 224f
Sacrococcygeal teratoma 510, 511, 511f
diagnosis of 510
management in 511
signs of 510
symptoms of 510
Saddle-nose deformity 13
Salivary glands, minor 507
Salmon patch 34, 34f
Salt and pepper appearance 76
Sarcoidal granuloma 420
Sarcoidosis 48, 131, 134, 161, 291, 464, 470
Sarcoptes scabiei 107, 215
Sash pattern 272
Scabetic burrows 107f
Scabies 107, 220, 244
secondary infections of 108
with eczematization 215
Scabietic eczema 216f
Scabietic nodules over scrotum 108f
Scales 2
Scalp 31, 386
dissecting cellulitis of 380
psoriasis 149, 225
Scaly eczematous
lesions 305f
plaques 333f
Scarlantiniform rash 178
Scarlet fever 178, 184, 185f
Scarring 343f
and psoriasiform scaling 248f
Scars 441
over back 349f
Scattered white hairs 386f
Schamberg's disease 46
Schizophrenia 483
Schmidt's syndrome 334
Schweninger-Buzzi anetoderma 446
Sclerema neonatorum 16, 16f
Sclerocornea 84
Scleroderma 80, 361, 361f
Sclerodermoid changes 81f
Scratch mark 2
Scrofuloderma 126
Scrub typhus 182
Scurvy 312
tongue in 312f
Sebaceous gland hyperplasia 20
Sebaceous hyperplasia 20f
Seborrheic alopecia 380, 381f
Seborrheic dermatitis 149, 225, 240, 358, 473
Seborrheic keratoses 403, 447, 480
Secretan's syndrome 49
Secretory function 1
Sedlackova syndrome 489
Segmental vitiligo 276f
Seizure 39, 41, 369
disorders 262
Self-healing collodion baby 96f
Sensorineural hearing loss 84
Septicemia 433
Serratia marcescens 489
Serum creatine phosphokinase 121
Serum sickness 436, 437f, 438
Severe acne 417
Severe acute respiratory syndrome 188, 189
Severe combined immunodeficiency 216, 487, 492
Sexual abuse 448
Sexually transmitted
disease 448, 449
infection 449
Shagreen patch 261, 262f
Short-contact dithranol therapy 230
Silicone 363
Silvery gray hair syndromes 398
Sinoatrial nodes 356
Sinopulmonary infections 487
Sinus tracts 423
Sirolimus 418
Sjögren-Larsson syndrome 93, 99, 102f
Skeletal hyperostosis, diffuse 236
Skin 513
abscesses 486
and neonatal dermatoses, basics of 1
atrophy over axilla 445f
biopsy 371, 428
care 3032
changes 390
of scurvy 312f
color of 1, 2t
diseases 457f, 459
disorders 495
eruptions 179
failure, state of 228
fragility syndromes 250
function of 1
idiopathic deciduous 104
infiltrated 349f
lesions 197, 460, 463
basic morphology of 2
classical 100f
configuration of 3
diagnosis of 448
differential diagnosis of 449t
secondary 473
malignancy, types of 74f
phototypes 2, 2t
stretching of 441
structure of 1
tags 496
types 1
waxy infiltration of 349f
Slapped cheek appearance 188, 188f
Sleep apnea 485
Small intestinal bacterial overgrowth 422
Snail-track ulcer 450
Socks syndrome 186, 187f
Sodium thiosulfate 347
Soft silky hairs 273
Solitary angioleiomyoma 64
Solitary mammary leiomyomas 64
Solitary mastocytoma 322, 323f
Sorafenib 438
Spastic paraplegia 102f
Spina bifida 51, 273, 394
Spinal dysraphism 22, 274
Spindle cell hemangioendothelioma 478
Spironolactone 387, 396
Spleen 341
Splendore-Hoeppli phenomenon 158, 160
Splinter hemorrhages 476
Spongiform pustules 257
Sporotrichosis 159
Spotted fever 179, 182
Squamous cell carcinoma 62, 253, 403, 447, 478, 478f
Staphylococcal scalded skin syndrome 7, 9f, 23, 173, 174, 174f
upper extremities in 9f
Staphylococcal scarlet fever 179
Staphylococcus aureus 7, 9, 30, 113, 179, 191, 208, 248, 489, 495
infection 220
Staphylococcus epidermidis 30, 248
STAT3 deficiency 491
Steatocystoma multiplex 507, 507f
Steatocystoma simplex 507
Sternum 30
Steroid 254
induced atrophy 445f
induced rosacea 422f
modified tinea 148f
sulfatase enzyme, deficiency of 89
therapy 514b
Stevens-Johnson syndrome 178, 412, 413f, 426, 427, 432, 435f
Stewart-Treves syndrome 50
Stiff skin syndrome 85, 85f
Stork bite 34
Strabismus 84
Strawberry tongue 178, 185f, 186
Streptococcus 185, 374
pharyngitis 186
pyogenes 184
Streptomyces mediterrane 422
Streptomycin 396
Striae 441
Sturge-Weber syndrome 41
Subacute eczema 200f, 210f
Subarachnoid hemorrhage 39
Subcorneal pustular dermatoses 256, 257f
lesions 257f
Subcutaneous fat necrosis 14, 15f
Subcutaneous nodules 346f
Subcutaneous panniculitis-like T-cell lymphoma 476
Subcutaneous phycomycosis 161f
Subcutaneous zygomycosis 159
Subepidermal bullae 245f
Subsiding miliaria 8f
Subungual hyperkeratosis 68, 227, 465
Sucking blister 10, 10f
Sulfapyridine 241, 257
Sulfasalazine 355
Sulfonamides 430, 432, 433, 439, 462
Supernumerary nipples 17
Sutton's aphthous ulcer 507f
Sutton's ulcers 506
Sweet's syndrome 371, 374, 463, 463f, 473, 506
criteria for 464t
disorders with 464t
Sycosis barbae 113, 118
Syndet soap 204
Synovitis 416
Syphilis 156, 374
congenital 12
primary 449
secondary 449
Syphilitic chancre, primary 450f
Systemic corticosteroids 366, 479
Systemic diseases 459
Systemic disorders 275
Systemic leukocytoclastic vasculitis 365f
Systemic mastocytosis 326
Systemic retinoids 411
Systemic scleroderma 380
Systemic sclerosis 362
Systemic steroids, role of 438
Systemic therapy 123, 355
Tachycardia 324
Tacrolimus 275, 283, 379
Takayasu's arteritis 472
Tannerella 122
Targetoid lesions 177, 184
Tazarotene 229, 230, 418
deficiency 515
gene 477
lymphoma 26, 475, 476f
Telangiectasia 2, 45, 45f
generalized essential 45
Telogen effluvium 387
Temporal triangular alopecia 393, 393f
Tendinous xanthomas 340
Teratomas 274
Terbinafine 149, 229, 432, 439
Terra firma-forme dermatosis 508, 510, 510f
Testes 341
Testosterone into dihydrotestosterone 380
Tetanus 508, 515
toxoid 514
Tetracycline 124, 368, 419, 422, 430, 433
Thalidomide 355
Thallium toxicity 386
Thermal burn of skin 32f
Thick-everted lips 67f
Thigh dermatitis, posterior 204
Thrombocytopenia 182
secondary 372
Thrombocytopenic purpura 168
primary 500
Thrombosis 369
Thyroid 460
disease 233, 358
disorders 406, 473
Thyroiditis 377, 438
Tin tack sign 354
amiantacea 385
capitis 113, 145, 282
inflammatory type of 147
corporis 143, 144f, 358
over hands 146f
cruris et corporis 123
faciei 143, 147f
favosa 147
incognito 145
infections 184
manuum 146f, 149
pedis 123, 146f, 149, 152f
versicolor 123
Tinidazole 430
Toad skin 308
Tocilizumab 464, 479
Toes, resorption of 81f
Tofacitinib 379
familial hyperpigmentation of 294
lesion 507f
Topical calcineurin inhibitor 145
Topical calcipotriol 90, 230
Topical capsaicin 199
Topical corticosteroid 145, 351
Topical mupirocin 124
Topical oligodeoxynucleotides 214
Topical potent corticosteroids 361
Topical rapamycin, low-dose 262
Topical steroid
induced cutaneous atrophy 444
mild 195
Topical tacrolimus 209
Topical tetracycline 506
Topical therapy 123, 355
Topical tretinoin 441
Total leukonychia 403, 405f
Toxic epidermal necrolysis 433, 466
Toxic erythema 4, 6f
Toxic palmar erythema 438
Toxic palmoplantar erythema 438f
Toxic rash, severity of 439t
Toxic shock syndrome 23, 178, 178f, 179
Toxoplasma gondii 464
Trachoma 455
Trachyonychia 411, 412
Tractional alopecia 380
Transaminitis, asymptomatic 357
Transcutaneous oxygen monitors 32
Transient neonatal pustular melanosis 20, 20f, 156
Treponema pallidum 12, 449, 464
Trichodysplasia spinulosa 239
Trichoepithelioma 508, 509f
types of 508
mentagrophytes 144
rubrum 144, 412
tonsurans 144
verrucosum 144
Trichorrhexis invaginata 100f, 391, 391f
Trichorrhexis nodosa 390, 390f
Trichoscopy 403
Trichostasis spinulosa 21, 21f
Trichothiodystrophy 76, 93, 392
Trichotillomania 149, 380, 381f, 483
Triglycerides 340
Trimethylpsoralen 275
Trisomy 18 17
True hematohidrosis 500
Tsutsugamushi disease 179
Tuberculosis 334
verrucosa cutis 126, 129f
Tuberous sclerosis 63, 263f, 496
complex 260
diagnostic criteria of 264b
management in 263
Tuberous xanthoma over elbows 338f
necrosis factor 436
alpha 379
yellowish 336
Turner syndrome 393, 442
Twenty-nail dystrophy 227, 411
Twin spotting 396
Tylosis with esophageal cancer 71
Tyrosinase kinase inhibitors 418
Tzanck smear 11, 452
U2HR gene 402
Ulcer 449, 471
traumatic 161
tropical 161
erythematous 452
Ulcerated hemangioma 36f, 37f
Ulcerative colitis 233, 377, 461
Ultraviolet light therapy 332
Umbilical granuloma 11
Umbilical polyp 11, 13f
Umbilical raphe, sternal cleft with 29
Umbilical sepsis 11, 13f
Umbilicus 31
Uncombable hair 392f
syndrome 391
Upper limb, lymphedema of 48
Uric acid 347
Urinary abnormalities 354
Urinary diverticula 393
Urinary retention 452
Urticaria 292, 316, 317f, 358, 426
chronic 316
lesions 179
multiforme 321, 322f
pigmentosa 322, 324f, 325f
with bullous lesions 326f
symptom of 324
treatment of 318
Urticarial wheals 316f
Urticarial, acute 316, 316f
Uvea, coloboma of 58
Uveitis 466
Vaccinating immunocompromised children 513b
Vaccine-derived immunity 169
Vaginal candidiasis 406, 491
Vancomycin 23
Vanishing twin syndrome 22
Varicella 168, 302, 321
immunoglobulin M 169
primary 220
types of 11
lesions 169f
polymorphic eruptions of 169f
vaccine 515
zoster virus 11, 141, 156, 168, 508, 514
type of 169
Vasculitis 351, 364, 513
eruptions 436
management in 364
VDR gene 314
Venous prominence over bridge of nose 23
Vermiculate atrophoderma 444
Vernix caseosa 30
removal of 30
Verruca plana 135, 138f
Verruca vulgaris 134, 136f, 447
classical warty lesions of 135f
Verrucous epidermal nevus 57, 59f
Very low density lipoproteins 340
Vesicle and bullae 2
Vesicular dermatitis 27f
Vesiculobullous diseases 241
Vesiculobullous lesions 473
Vinorelbine 438
Viral disease, common 166
Viral exanthem 178, 182, 428, 438
Visceral larva migrans 111
Visceral leishmaniasis 161
A 308, 418
deficiency 239, 308
B 308
B1 418
B12 308, 418, 473
B6 418
B7 311
C 312, 313
D 363
resistant rickets 314, 314f
Vitiligo 152, 275, 280f, 282, 513
congenital 279f
depigmented patches of 276f
medical therapy for 275
over vulva 279f
patch 276f
type of 275
Vohwinkel syndrome 68
Vomiting 324
Vulval condyloma acuminata 452f
Waardenburg syndrome 385f
Washing and bathing 30
Waxy skin 349f
Werner syndrome 384
Wet wrap technique 212
White blood cells 473
Wickham striae 232, 238
Wilms’ tumor 511
Wiskott-Aldrich syndrome 215, 486, 492, 493, 494f, 497, 498f
Wood's lamp 279, 282t
examination 123
Wood's light 261, 342
Wooly hair 381, 383f
nevus 393
siblings with 383f
Worms, bags of 267
care 248
infection 248
Xanthoderma 511
Xanthogranuloma, juvenile 341, 342f
Xanthoma 336, 341
development of 338
types of 339
Xanthomatous appearance 332f
Xeroderma pigmentosum 73, 74f, 75f, 477
Xerosis 308, 358
severe 200f
X-linked dominant hypertrichosis 395
X-linked ichthyosis syndromes 87
X-linked recessive ichthyosis 8
Yellow fever vaccine 515
Yellow nail syndrome 404
Zidovudine 410
Zinc supplementation 304
Zoster immune globulin 169
Zosteriform distribution, leiomyoma cutis in 64f
Zygomycosis, subcutaneous 159
Chapter Notes

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Basics of Skin and Neonatal DermatosesCHAPTER 1

Skin is the largest organ of the body. It is a very complex structure composed of three layers viz., epidermis, dermis, and subcutaneous tissue. It is also composed of various appendages. The outermost layer or the epidermis is further composed of four layers, stratum corneum, stratum granulosum, stratum spinosum, and stratum basale. There are melanocytes situated at the basal cell layer and Langerhan cells throughout the epidermis.
The dermis is predominantly composed of collagen and elastic fibers. There are cell types including fibroblasts, macrophages and mast cells in the dermis. Various structures situated in the dermis are composite structure of hair follicle with sebaceous gland known as pilosebaceous apparatus, and eccrine or sweat glands. Beneath the dermis, there is a layer of fat known as subcutaneous tissue. In the dermis, there are dermal capillaries and venules which comprise dermal vasculature. There are also lymphatics and nerve endings situated in the dermis.
The outermost layer or stratum corneum performs the barrier function and maintains the hydration of skin. It also prevents the penetration of irritants, toxins, and organisms through the epidermis into the dermal capillaries from the environment. The rest of the epidermis acts as protective layer. Melanocytes of the epidermis confer color of the skin by transferring melanin to the basal keratinocytes. It also protects the skin from deleterious effect of ultraviolet light. Langerhan cells present antigen to the immunological unit of the skin. Hence, it is considered as the first line of immunologic defense.
The collagen and elastic fibers act as a tough, leathery, mechanical barrier against cuts, bites, abrasions, and bruises. Its collagenous matrix provides structural support for various cutaneous appendages. Hair grows from follicles placed in the deep dermis and imparts beauty to the individual. It also protects the scalp from the sunlight and various environmental allergens. Sebaceous glands produce oily secretions, lubricate the skin and contribute to the protective function of epidermal barrier. Eccrine glands produce sweat which secrete on the skin surface through eccrine ducts. Thus, it acts as an important organ responsible for thermoregulation. Cutaneous capillaries, venules, and lymphatics act as perfusion unit of skin. The skin also contains specialized receptors for heat, pain, touch, and pressure. Sensory inputs from these structures help to protect the skin surface against environmental trauma and noxious agents. The subcutaneous fat acts as a protective cushion for the skin and stores energy and provides insulation to the body. To summarize, various functions of the skin are as follows:
  • Protection: It protects the body from physical, chemical, and biological injuries.
  • Perception: It perceives various sensations such as pain, touch, temperature, and vibration.
  • Temperature regulation: Eccrine sweat glands and dermal vasculature play important role in thermoregulation.
  • Barrier function: Skin acts as a permeability barrier that regulates the diffusion of substances particularly water and electrolytes, etc.
  • Secretory function: Synthesis of vitamin D3 is an important secretory function with the help of sunlight.
  • Storage function: The dermis and subcutaneous fat act as a storage center for energy and other compounds.
  • Excretory function: Some of the harmful substances are excreted through the skin.
  • Immunological function: Recognition of antigens and elicitation of immunological response is done by skin.
  • Cosmetic function: Color and texture of skin along with the hair and nail play an important role in esthetic appeal of an individual.
Skin color is of two types: Constitutive skin color and facultative skin color.
“Real knowledge is to know the extent of one's ignorance.” –Confucius
Constitutive skin color is the basic skin color of an individual and is genetically determined. Facultative skin color is the skin color that results from ultraviolet ray (UVR) 2exposure. It is basically tanning of the skin. Depending on the response of the skin to UVR, various skin phototypes (SPTs) have been described and different races with different SPTs possess different types of skin color. Table 1 highlights color of skin and response to UVR in different SPTs.
Table 1   Color of skin and response to ultraviolet ray (UVR) in different skin phototypes (SPTs).
Reaction to moderate sun exposure
Skin color
Burn and no tan
Pale white
Burn and minimal tan
Pale white
Burn but good tan
Severe tan but no burn
Light brown
Moderate tan but no burn
Minimal tan but no burn
Dark brown
Three types of melanin in humans have been demonstrated—eumelanin (brown-black melanin), pheomelanin (yellow-red melanin), and neuromelanin (black). While in most of the melanocytes there is a minimal admixture of pheomelanin and eumelanin, in red hairs exclusively pheomelanin is present. Neuromelanin is present in nerve cells. Neuromelanin is formed by an enzymatic pathway different from that of eumelanin or pheomelanin synthesis. Hence, in oculocutaneous albinism (OCA) there is presence of pigment in substantia nigra.
Various morphologies of the lesions have been divided in to three types—primary lesions, secondary lesions, and special lesions.
Primary Lesions
Different types of primary lesions are:
  • Macule: It is only the change of color of skin, texture remaining unaltered. A macule can be hyperpigmented, hypopigmented or erythematous.
  • Papule: It is a circumscribed solid lesion measuring <1 cm in diameter. A papule can be erythematous, skin-colored or of any other color. The surface may be flat, verrucous, or umbilicated.
  • Plaque: It is a solid elevation >1 cm in diameter. There may be associated follicular plugging, telangiectasia, atrophy, etc.
  • Nodule: It is a deep-seated solid three dimensional lesion which may be hard, firm, soft, fleshy, tender or nontender, fixed or mobile. The surface of the nodule can be smooth, keratotic, ulcerated or fungating.
  • Pustule: It is a circumscribed elevated lesion containing pus. Sometimes it may be sterile.
  • Vesicle and bullae: A vesicle is a circumscribed raised lesion containing fluid and <1 cm in diameter. Bulla is a circumscribed raised lesion containing fluid, >1 cm diameter. Vesicle or bullae may be tense or flaccid and on rupture leave behind raw area.
  • Wheal: It is a transient or evanescent elevated plaque-like lesion with erythema, edema, and central pallor.
  • Cyst: It is a sac that contains liquid or semisolid material.
  • Abscess: It is a collection of pus either in the dermis or subcutaneous plane or both.
Secondary Lesions
These are lesions which are basically modified primary lesions induced by scratching, rubbing or secondary bacterial infections. Various secondary lesions are:
  • Scales are formed as a result of increased or abnormal keratinization. They may be fine powder-like or large silvery white or even fish like.
  • Crust is a collection of dried exudates, dead tissues, and microorganisms. Crust may be brown/brownish-yellow, may be adherent or friable.
  • Excoriation or scratch marks are predominantly seen in pruritic disorders.
  • Erosion is a superficial ulceration covered with serous exudates and heals without scarring.
  • Ulcer is the result of breach in the continuity of skin with loss of epidermis and a part of dermis. Ulcer always heals with scarring.
  • Lichenification is thickening, increased criss-cross markings, and mild hyperpigmentation. It is the end result of chronic eczema.
  • Atrophy is thinning of skin which appears shiny wrinkled with prominent blood vessels underneath.
“In the practice of tolerance, one's enemy is the best teacher.” –The Dalai Lama
Special Lesions
Some of the lesions are pathognomonic of certain diseases as follows:
  • Burrows are tunnel-like serpiginous lesions seen in the superficial part of the skin.
  • Comedones are the result of plugging of the pilosebaceous duct by internal secretion. Comedones may be open (black) or closed (white).
  • Milia are small superficial cysts 1–2 mm in diameter, commonly seen on the face.
  • Telangiectasia means distinctly visible dilated superficial blood vessels.
3Configuration of the Skin Lesions
Characteristic configuration of lesions may suggest a diagnosis. Some classical examples are:
  • Linear: Lesions are present in a line. Examples are epidermal nevi, lichen striatus, warts, psoriasis, incontinentia pigmenti, etc.
  • Dermatomal: Lesions are present in a dermatome. Examples are herpes zoster, vitiligo, nevus depigmentosus, and PWS.
  • Serpiginous: Lesions follow a serpiginous track. Examples are cutaneous larva migrans, and elastosis perforans serpiginosa.
  • Annular: Lesions present with central clearing with peripheral border. Examples are tinea, granuloma annulare, erythema annulare centrifugum, and erythema marginatum.
  • Herpetiform: Grouped lesions or clustered lesions. Examples are herpes simplex infection, herpes zoster, and dermatitis herpetiformis.
  • Reticulated: Means net-like. Examples are cutis marmorata, livedo reticularis, and erythema ab igne.
  • Filiform: Means thread-like. Examples are filiform warts, dermatosis papulosa nigra, and skin tags/acrochordons.
  • Geographic: Examples are geographic tongue, psoriasis, and erythema annulare centrifugum.
Most of the newborn disorders are transient in nature requiring only symptomatic treatment. They can be acquired, congenital or developmental disorders.
Mongolian Spot (Figs. 1A to D)
It is the most common type of congenital dermal melanocytosis noted in 90% of Asians. It presents as macular blue-gray pigmentation at birth most commonly on the lumbosacral area in normal infants of darker-skinned races. They are rounded or oval in shape, in variable sizes and usually single or multiple. Less common sites include buttocks, flanks, and shoulders. The pigmentation develops in fetal life, increases in depth for a period after birth and then diminishes. It usually disappears in the first decade of life.
Natural History
It is considered as one of the physiological skin changes of the newborn. When Mongolian spots are associated with bilateral Nevus of Ota, they take much longer time to disappear spontaneously. Persistent and giant Mongolian spots are seen in Niemann-Pick disease, type 1 gangliosidosis, Hurler, and Hunter disease.
Explanation of the condition and its natural history to the parents helps to reassure them.
Neonatal Acne (Figs. 2 and 3)
The sebaceous glands of neonates produce a considerable amount of sebum in first few weeks of life influenced by maternal androgen. There is increased production of dehydroepiandrosterone (DHEA) by fetal adrenal glands. Neonatal acne mostly affects male infants and is seen at birth or within first week of life. Clinically presents as erythematous papules, pustules, and occasionally with comedones distributed on face, more over the cheeks and forehead. Pustular eruption in neonatal acne has been termed as neonatal cephalic pustulosis secondary to colonization of Malassezia species. Child should be evaluated for underlying virilizing tumors or adrenal cortical hyperplasia if there are other signs of hyperandrogenism.
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Figs. 1A to D: (A) Bluish-black hyperpigmented patch of Mongolian spot over back; (B) Mongolian spots over back in a newborn; (C) Mongolian spots over back; (D) Extensive Mongolian spots.
“Sharing knowledge is the most fundamental act of friendship. Because it is a way you can give something without losing something.” –Richard Stallman
The lesions are self-limiting and tend to subside by 2–3 weeks and require no treatment. It can persist for 1 year. Benzoyl peroxide 2.5% or 1% salicylic acid has been tried.
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Fig. 2: Neonatal acne (inflammatory papules and pustules).
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Fig. 3: Close-up view of neonatal acne.
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Figs. 4A and B: Neonatal milia.
Neonatal Milia (Figs. 4 to 6)
Milia are one of the most common transient findings in the cutaneous survey in neonates seen in 40–50% of healthy newborns. These consist of 2–3 mm white or yellow papules on the nose, chin, cheeks, and forehead. Milia are epidermal cysts derived from the pilosebaceous follicle of vellus hair and contain concentric layers of keratin. Widespread and persistent milia can be associated with epidermolysis bullosa, type 1 oro-facial-digital syndrome, and pachyonychia congenita.
Natural History
They are normally spontaneously extruded in a few weeks.
Toxic Erythema of the Newborn (Erythema Toxicum Neonatorum) (Figs. 7A to D)
The cause of toxic erythema of the newborn is unknown and is seen in 48–72% of full-term newborn. In majority, the onset is during the first 48 hours after birth or up to 3 weeks. The eruption can appear as a blotchy macular erythema initially and later develop multiple erythematous papules, their number varying from one to several hundred, most profuse on the anterior trunk, rapidly spreading to involve the face, chest, and extremities. They are often described as “flea bitten appearance” or papules surrounded by a sea of erythema. In severe cases, urticarial papules develop which in 10% cases are surmounted by pustules measuring 2–4 mm in diameter.
“You don't need to see the whole staircase, just take the first step.” –Martin Luther King Jr
Differential Diagnosis
These lesions have to be distinguished from milia, miliaria, transient neonatal pustular melanosis, infantile 5acropustulosis, incontinentia pigmenti, herpes simplex virus infection, varicella, and impetigo.
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Figs. 5A and B: Milia in newborn.
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Fig. 6: Neonatal milia en plaque.
Toxic erythema can be diagnosed by microscopic examination of a smear of pustular contents stained with Giemsa and in doubtful cases, cultures to rule out infective etiology can be done. The smear in case of toxic erythema reveals cluster of eosinophils. This is in sharp contrast to bacterial infections where cluster of neutrophils are seen.
As the condition is benign, self-limiting, and asymptomatic no treatment is required. It resolves spontaneously by 10−14 days.
Intertrigo (Figs. 8A to F)
Intertrigo is a term applied to an inflammatory dermatosis that is more or less confined to the major body folds and provoked by moisture and constant friction between opposing skin surfaces. Obesity, poor hygiene, overwarm clothing, hot and humid climatic conditions are the predisposing factors. Relative obesity of well-nourished infants accounts for the unusually high incidence during the early months of life. Intertrigo is likely to become colonized and secondarily infected by both bacteria and yeast, particularly Candida albicans. Clinically, it manifests as symmetrical areas of sharply marginated erythema confined to areas of skin apposition. In infants, the folds of the neck, the axillae, the genitocrural flexures, and the intergluteal cleft are the predilection sites. Miliarial lesions are readily apparent within the affected area. When C. albicans infection supervenes, erythema takes on a deep red hue along with maceration, oozing, and satellite pustules. Rarely it may become superinfected with group A streptococci and Corynebacterium diphtheriae.
Management of intertrigo is mainly removal of predisposing factors, cool environment, loose cotton clothes, and topical antibacterial and antifungals. If bacterial superadded infection is evident, a topical antibacterial-like mupirocin may be useful. Topical antifungals such as clotrimazole and miconazole are effective for candidal intertrigo.
“The invariable mark of wisdom is to see the miracles in the common.” –Ralph Waldo Emerson
Miliaria (Figs. 9A to E)
Miliaria occurs when the flow of eccrine sweat is impeded by obstruction of the intraepidermal portion of the sweat duct. 6Miliaria crystallina appears to reflect obstruction of the sweat duct within the stratum corneum. Miliaria rubra occurs when there is sweat duct obstruction deeper in the epidermis.
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Figs. 7A to D: (A) Toxic erythema of newborn; (B) Close-up view of lesions; (C) Blotchy macular erythema and satellite pustules of toxic erythema of newborn; (D) Erythema toxicum neonatorum, note bright red erythema and pustular lesions.
Miliaria crystallina presents as crops of clear thin-walled, superficial vesicles, 1−2 mm in diameter without associated erythema resembling water droplets on the scalp, forehead, neck, and upper trunk. They rupture within 24 hours followed by branny desquamation.
Miliaria rubra, seen most commonly in the neonatal period, comprises of grouped to discrete erythematous nonfollicular, papules, and papulovesicles, measuring about 1–4 mm in diameter on a background of macular erythema. Staphylococcal secondary infection of miliaria may lead to sweat gland abscesses. The symmetrical crops of miliaria rubra occur most often in flexural areas, especially around the neck, in the groins, and the axillae. The face, scalp, and upper trunk are frequently affected. These lesions subside in 2–3 days but recurrences are common.
Differential Diagnosis
Differential diagnosis includes neonatal acne, candidiasis, staphylococcal, and herpes simplex infections. Miliaria crystallina is distinguishable from viral infections of the skin by the lack of background erythema and by the absence of inflammatory cells or giant keratinocytes on cytological examination of the vesicles. Miliaria rubra can be distinguished from toxic erythema by its flexural predominance, frequent presence of vesicular lesions and by the tendency to recur.
Avoidance of excessive heat and humidity is the most important aspect of management. Cool baths, light clothing, and installation of air conditioner in the room are helpful. Topical soothing agents such as calamine lotion help in most of the cases. Systemic antibiotics can be given for secondary infection.
“The true sign of intelligence is not knowledge but imagination.” –Albert Einstein
7Staphylococcal Scalded Skin Syndrome (Ritter's Disease) (Figs. 10 and 11)
Staphylococcal scalded skin syndrome (SSSS) is caused by an epidermolytic toxin elaborated by certain strains of Staphylococcus aureus, commonly phage group II. The condition is most commonly seen in the first 5 years of life.
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Figs. 8A to F: Intertrigo. (A) Intertrigo of inguinal folds; (B) Note erythema over inguinal and perianal area; (C) Note postinflammatory hypopigmentation surrounding erythema; (D) Intertrigo, severe perianal involvement; (E) Severe intertrigo; (F) Intertrigo seen in the neck fold.
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It is particularly common during the neonatal period occurring in association with purulent conjunctivitis 8or an upper respiratory tract infection. Sites of predilection are the central part of the face (periorificial), the axillae, and groins. The orange-red, scarlatiniform eruption spreads rapidly. Tenderness of the skin is an early and striking feature. The eruption gradually becomes extensive and turns to a confluent deep erythema and edema in the next 24–48 hours. The surface becomes wrinkled before starting to separate out leaving raw red erosions. Nikolsky's sign is positive. The child is pyrexial and distressed. Radial crusting and fissuring around the eyes, angles of mouth occurs. The only differential diagnosis which poses a problem is toxic epidermal necrolysis, which is however, relatively rare in young children and is characterized by marked mucosal involvement.
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Figs. 9A to E: (A) Miliaria rubra and pustulosa in a newborn; (B) Exfoliating miliaria rubra; (C) Miliaria crystalline in newborn; (D) Miliaria pustulosa; (E) Subsiding miliaria, note fine branny scales.
“When one door of happiness closes, another opens; but often we look so long at the closed door that we do not see the other one that has been opened for us.” –Helen Keller
The diagnosis of SSSS can be established by isolation of coagulase positive Staphylococcus aureus from the pyogenic skin lesions or from nostril and areas around eyes.
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Figs. 10A to C: (A) Staphylococcal scalded skin syndrome (SSSS), early stage; (B) Impending SSSS, note extensive impetigo bullosa indicating impending SSSS; (C) Full blown SSSS.
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Fig. 11: Involvement of face and upper extremities in staphylococcal scalded skin syndrome (SSSS).
Prognosis is good with early diagnosis and appropriate treatment. The condition has a mortality of approximately 5% and fatalities occur mostly in debilitated infants.
Treatment should be started promptly with a penicillinase resistant antistaphylococcal antibiotic such as cloxacillin or a combination of amoxicillin and clavulanic acid or cefadroxil orally. Parenteral antibiotics may be required in cases of extensive skin lesions or severely ill children. Local cleaning of the skin with distilled water or normal saline soaked cotton is sufficient. Antiseptic cleaning is better avoided, so also application of prolonged topical antibiotic for fear of emergence of resistant strains of S. aureus. Parenteral vancomycin is preferred for methicillin-resistant S. aureus infection.
“It is impossible to live without failing at something, unless you live so cautiously that you might as well not have lived at all—in which case you fail by default.” –JK Rowling
10Sucking Blister (Fig. 12)
Sucking blisters are seen in newborn at birth due to vigorous sucking on the affected part by the fetus in utero. Solitary bullae or erosions of 0.5–2 cm are seen over the dorsal aspect of the fingers, thumbs, wrists, lips, and radial aspect of forearms.
Differential Diagnosis
These lesions need to be differentiated from a host of conditions such as bullous impetigo, epidermolysis bullosa, and neonatal herpes simplex.
Resolves rapidly without any treatment and sequelae.
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Fig. 12: Suckling blisters over upper lip in a newborn.
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Fig. 13: Grouped vesicles of herpes simplex on erythematous base over the trunk.
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Fig. 14: Mucocutaneous localization of herpes lesions.
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Fig. 15: Close-up view of herpetic lesions.
“Believe you can and you're halfway there.” –Theodore Roosevelt
Neonatal Herpes (Figs. 13 to 15)
Infection of the neonate by herpes simplex virus ranges from mild to potentially life-threatening condition with high mortality. The majority of these infections result from transmission of HSV-1 and HSV-2 from genital tract secretions during delivery. Transmission can occur during intrauterine, peripartum, and postpartum period. There is higher incidence of neonatal herpes (40–50%) during primary maternal infection than in recurrent infection (4–5%). Over 70% of the infection with neonatal HSV has skin or mucosal lesions. There are three distinct forms of neonatal herpes: Skin-eye-mouth (SEM), disseminated, and only nervous system involvement. Skin manifestations are in the form of multiple grouped vesicles on erythematous patches distributed over the scalp, face, trunk, and extremities. The vesicles have a tendency to localize over mucocutaneous junctions. Onset is between birth and 20 days. Oral lesions in the form of erosions of the tongue, palate, gingiva, and buccal mucosa are also common. Primary neonatal herpes simplex is a devastating life-threatening infection especially in the disseminated form involving multiple organs which must 11be diagnosed and treated with antiviral drugs promptly. Complications include pneumonia, seizures, encephalitis, keratitis, chorioretinitis, coagulopathy, and sepsis.
Diagnosis can be co-established with the help of Tzanck smear preparation, viral culture, use of monoclonal antibodies, and nucleic acid hybridization techniques.
Intravenous acyclovir is the treatment of choice. It is given at a dose of 60 mg/kg/day in three divided doses for 14–21 days. There is no role of topical acyclovir ointment application over the lesions. Prophylactic ophthalmic topical preparations such as trifluridine or vidarabine are helpful.
Neonatal Varicella (Figs. 16A to D)
Neonatal varicella occurs in the first 28 days of life and is due to infection developed by mother during the last few weeks of pregnancy or first few days postpartum or in case of similar infection acquired by other close contacts after birth. Premature infants are at increased risk for nosocomial acquisition of varicella-zoster virus (VZV) because active transfer of maternal IgG antibodies occurs primarily during the third trimester of pregnancy. Neonatal varicella is uncommon in Indian scenario, due to the presence of antibodies in the mother formed on prior exposure to illness.
Two types of varicella infection can occur in the newborn:
  1. Severe infection: When the mother has been infected less than 5 days before birth or 2 days after delivery (as varicella-associated antibodies are not transmitted to the newborn) or the onset of infection in the newborn is between 5 and 10 days of birth. Disseminated disease may ensue with poor prognosis and high risk of mortality (30%) due to pneumonia, hepatitis, coagulopathy, meningoencephalitis, and secondary severe sepsis.
  2. Mild infection: If the disease onset in the mother is 5 days prior to birth (antibodies are transmitted to the child) or in the newborn during the first 4 days of life.
Diagnosis of neonatal varicella can be made clinically from the pattern of rash and maternal history of infection. Definite diagnosis is made by virus isolation or amplification of viral DNA from the skin lesions by PCR. Management of newborns who are exposed to VZV by maternal infection (within 5 days before birth or 2 days after delivery) or contact with affected individuals includes isolation and postexposure prophylaxis with varicella-zoster immune globulin (VZIG). Healthy term neonates who are exposed to VZV postnatally (including infants whose mother's rash developed >48 hours after delivery) generally do not require postexposure prophylaxis. VZIG should be given as soon as possible and within 10 days of exposure at a dose of 125 units (1 vial) IM for neonates weighing >2.1–10 kg and 62.5 units (0.5 vial) IM for children weighing ≤2 kg. Intravenous immunoglobulin (IVIG) or IV acyclovir can be considered if VZIG is unavailable. Maternal treatment includes oral acyclovir within 24 hours of onset. Newborns with severe disseminated VZV infection should be treated with IV acyclovir (30 mg/kg/day in three divided doses) for 10 days.
Umbilical Polyp (Figs. 16E and 17)
It presents as a bright red shiny polypoidal growth over the umbilicus at birth and is the result of a partially patent omphalomesenteric duct. The lesions are usually asymptomatic and secrete serous, mucoid, and rarely serosanguinous exudate. Polyps may be accompanied by potentially serious internal omphalomesenteric remnant such as Meckel's diverticulum attached to the umbilicus by obstructing fibrous bands.
The condition is treated by surgical excision. However, underlying intestinal and urinary tract abnormalities are to be ruled out.
Umbilical Granuloma (Fig. 18)
It is basically a granuloma pyogenicum of the umbilicus. It presents as a red raw granulomatous growth over the umbilicus with purulent discharge.
Treatment is cauterization with 75% silver nitrate solution, 20% potassium hydroxide or phenol.
“Knowledge has a beginning but no end.” –Geeta Iyengar
Umbilical Sepsis (Fig. 19A)
Umbilical sepsis, also known as omphalitis, is the inflammation of the umbilical stump of newborns. Most commonly it is attributed to bacterial infection. Normally the stump separates from the skin within 5–40 days after birth. A small amount of pus-like material is commonly seen at the base of the stump and can be controlled by keeping the stump open to air to dry. Certain bacteria can grow and infect the stump during this process and as a result significant redness and swelling may develop, and in some cases the infection can then spread through the umbilical vessels to the surrounding skin. Clinically, neonates with umbilical sepsis present with visible pus 12or grossly inflamed umbilical stump with history of high grade fever, vomiting, and poor feeding. It is an emergency and needs to be managed with promptness with oral/parenteral antibiotics and topical antibiotic cream/ointment. Cleaning of umbilical stump with antiseptics is also important.
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Figs. 16A to E: (A) Neonatal varicella; (B) Neonatal varicella, note polymorphous lesions; (C) Neonatal varicella, note subsiding lesions; (D) Neonatal varicella, note subsiding lesions; (E) Shiny exudative lesion of umbilical polyp.
“Thinking is difficult, that's why most people judge.” –Carl Jung’
Congenital Syphilis [Figs. 19B(i) to B(vi)]
In congenital syphilis, the fetus becomes infected with the spirochete Treponema pallidum by way of placenta usually after 16th week of pregnancy. The clinical manifestations of early congenital syphilis (those occurring before 2 years 13of age) are anemia, fever, wasting, hepatosplenomegaly, lymphadenopathy, rhinitis, mucocutaneous eruptions, edema, desquamation, and pseudoparalysis. Of these, rhinitis or snuffles is the first sign to appear. It manifests between the 2nd and 6th week of life and is the result of an ulcerative lesion of the nasal mucosa. Deeper involvement of nasal cartilage can result in “saddle-nose deformity”. The cutaneous lesions are seen in one-third to one-half of infants affected by this disorder and appear as maculopapular or papulosquamous lesions most prominent on the face, trunk and extremities, diaper area, and palms and soles. The eruption generally develops slowly, as bright pink or red macules and papules and gradually fades to copper brown. It disappears spontaneously over 1–3 months leaving hypo- or hyperpigmented areas. The rare vesiculobullous, hemorrhagic lesions, when seen on the palms and soles, are highly diagnostic of this disorder. The palms and soles may be fissured, erythematous, and indurated. Desquamation of the skin in large dry flakes may occur over the entire body. Mucous membrane lesions, seen in one-third of the infants, are seen as weeping lesions or fissures at mucocutaneous junctions extending out from the lips in a radiating fashion over the skin. When deep, they leave residual scars (rhagades) in the adjacent circumoral region. Raised, flat, moist, wart-like lesions of condylomata lata are seen commonly over the anogenital region, around the nares, and at the angles of the mouth. About 90% of the infants show radiological evidence of osteochondritis and periostitis after the first month of life, most frequently affecting the long bones.
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Fig. 17: Umbilical polyp, note cherry red color of the growth.
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Fig. 18: Granulomatous lesion of umbilical granuloma.
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Fig. 19A: Umbilical sepsis.
In late congenital syphilis, the disease persists beyond 2 years of age. It includes various signs and stigmata of congenital syphilis in infants in whom the diagnosis was overlooked or those who were inadequately treated early in the course of the disease. These include frontal bossing, saddle nose, short maxillae, and dental changes manifested in the form of Hutchinson's teeth (peg-shaped upper incisors), Moon's mulberry molars, gummas affecting the bones in the skull or tibia, syphilitic arthritis, paroxysmal cold hemoglobinuria and ocular changes such as retinitis and optic atrophy. Diagnosis is confirmed by serological testing and darkfield examination from the skin and mucous membranes.
“Happiness can be found, even in the darkest time, if one remembers to turn on the light”. –Albus Dumbledore
Penicillin is the treatment of choice for all forms of congenital as well as acquired syphilis. Treatment should be started immediately after the diagnosis with aqueous crystalline penicillin G in a dosage of 100,000–150,000 units/kg administered intravenously every 8–12 hours 14or procaine penicillin G in dosage of 50,000 units/kg administered IM once daily for 10–14 days. Patients with congenital syphilis should have repeat quantitative, nontreponemal tests at 3, 6, and 12 months after treatment.
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Figs. 19B(i) to B(vi): B(i) Red shiny scaly lesions over palms of congenital syphilis; B(ii) Congenital syphilis, similar lesions over soles; B(iii) Congenital syphilis, trunk; B(iv) Congenital syphilis, note the scaly papules; B(v) Congenital syphilis, close-up view; B(vi) Congenital syphilis.
“All our dreams can come true, if we have the courage to pursue them.” –Walt Disney
Subcutaneous Fat Necrosis (Figs. 20A to E)
It is a benign self-limiting dermatosis which affects apparently healthy full-term newborns and young infants. It presents as single to multiple sharply circumscribed areas of indurated and nodular plaques of skin over 15back, buttocks, thighs and shoulders, arms, and trunk. Its exact etiology is not known but proposed hypotheses are pressure on bony prominences during delivery, pre-eclampsia, obstetric trauma, fetal asphyxia or hypothermia, and neonatal infections. It is also seen in infants delivered by cesarean section and infants born to diabetic mothers. The onset of fat necrosis usually occurs in the first few days to weeks of life. The lesions at times may get calcified. However, most of the lesions undergo spontaneous resolution within few weeks to months. Complications include hypercalcemia, hypoglycemia, anemia, and thrombocytopenia.
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Figs. 20A to E: (A) Close-up view of subcutaneous fat necrosis; (B) Erythematous indurated plaques of subcutaneous fat necrosis in a newborn; (C) Close-up view of the lesions; (D) Subcutaneous fat necrosis in a newborn with birth asphyxia; (E) Same child, another view.
“A ship is always safe at shore but that is not what it's built for.” –Albert Einstein
16Differential Diagnosis
The condition needs to be differentiated from sclerema neonatorum which primarily occurs in newborns with sepsis, severe diarrhea, respiratory failure or dehydration and is a fatal condition with high mortality rate. There is woody induration of the skin and subcutaneous skin sparing palms, soles, and genitalia.
Subcutaneous fat necrosis in most newborns resolves spontaneously and requires no specific therapy. Fluctuant lesions in cases of calcification should be aspirated to prevent their spontaneous rupture and secondary infection. In rare cases of hypercalcemia, restriction of calcium and vitamin D intake, systemic corticosteroids may be required. Use of furosemide diuretic, calcitonin and biphosphonates may be required in severe cases.
Sclerema Neonatorum (Figs. 21 and 22)
It is a diffuse, progressive, wax-like hardening of the skin and subcutaneous tissue that occurs in premature or debilitated infants during the first few weeks of life. In around 25% of cases, the mothers are ill at the time of delivery. Exposure to cold, peripheral chilling with vascular collapse, hypothermia, and an increase in the ratio of saturated to unsaturated fatty acids in the triglyceride fraction of the subcutaneous tissue have been hypothesized, but lack confirmation as possible causes for this disorder. This disorder is associated with underlying conditions such as sepsis, respiratory distress, dehydration or diarrhea, congenital heart disease and it is characterized by a diffuse nonpitting woody induration of the involved tissues. This disease usually starts on buttocks and legs and most of the time it progresses to involve all areas except palms, soles, and genitalia. When the disease spreads, the skin becomes mottled, cadaver-like, cold, stony hard, and yellowish white. At that time the face acquires a fixed mask-like expression and the limbs become immobile. The infants feed poorly, show clinical signs of shock, sluggish movements and in majority of cases the baby often dies.
Mortality occurs in 50–75% of affected children. Complications include sepsis, dehydration, electrolyte imbalance, respiratory distress, and gastrointestinal disease. The infants, who survive this disease, resolve without residual sequelae.
There is no specific therapy for treatment of sclerema neonatorum. Supportive care with rewarming and administration of oxygen, control of infection, treatment of the underlying disorder, and intravenous therapy for correction of fluid and electrolyte imbalance are essential. Although indications for their use are not clear and controlled studies fail to confirm their efficacy, systemic corticosteroids in addition to antimicrobial agents have been advocated for infants with this disorder. Exchange transfusion has shown decreased mortality.
Hairy Pinna (Fig. 23)
It is a Y-chromosome mediated trait. It is considered as a pathognomonic sign in infants born to diabetic mother.
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Fig. 21: Sclerema neonatorum.
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Fig. 22: Same infant (close-up view), sclerema neonatorum.
“Seek the wisdom of the ages, but look at the world through the eyes of a child.” –Ron Wild
17Polythelia (Supernumerary Nipples) (Fig. 24)
Supernumerary nipples are the remnants of the embryological milk line which runs from the anterior axillary fold to the inner thigh. Most often they are distributed over the anterior chest wall and upper abdomen as pink, umbilicated or elevated papules surrounded by a pigmented areola. A nipple may also be seen without areola and vice-versa. Usually there is only a single lesion, but occasionally multiple or bilateral nipples are present. It has been shown to be more common in male gender and on the left side. Accessory nipples have been reported to be associated with malformations of the urinary tract, in particular the kidneys. The association has been questioned recently.
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Fig. 23: Hairy tragus in a newborn.
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Fig. 24: Multiple accessory rudimentary nipples along the milk line.
The accessory breast tissue may underlay the nipple and enlarge at puberty or in pregnancy. In such cases, complete excision is recommended because of the risk of malignant change.
Physiological Exfoliation of Newborn (Figs. 25A to C)
Neonatal desquamation is seen in 72–83% of newborns. This is mostly seen in postmature neonates. The exact pathophysiology of it is not known. In full-term infants, there is fine desquamation at birth within 24–48 hours and is localized to hands, ankles, and feet. There is widespread desquamation and cracking in postmaturity. Neonatal desquamation should be differentiated from collodion baby. However, there is no ectropion, eclabium or gloved appearance. The scaling gradually subsides over a period of 4–6 weeks.
Application of oil and emollient (white soft paraffin) helps to reduce scaling and moisturize the skin of the babies.
Cutis Marmorata (Figs. 26A to C)
Cutis marmorata presents as reticulated bluish mottling of the skin seen on the trunk and extremities of newborn and infants. This phenomenon is a physiologic response to chilling with resultant dilatation of capillaries and small venules. It usually disappears as the infant is rewarmed. Although a tendency to cutis marmorata may persist for several weeks or months, this disorder bears no medical significance and no treatment is usually required. In some children, cutis marmorata may tend to recur until early childhood. In patients with Down syndrome, trisomy 18, and Cornelia de Lange syndrome, this reticulated marbling pattern may be persistent. In some infants, a white negative pattern of this phenomenon (cutis marmorata alba) may be created by a transient hypertonia of the deep vasculature. It is known as cutis marmorata alba. It is a transitory disorder and appears to have no clinical significance.
No treatment is required for this physiological condition in newborns and infants. Reassurance and counseling of the parents is important.
“Many of life's failures are people, who did not realize how close they were to success when they gave up.” –Thomas Edison
Cutis Marmorata Telangiectatica Congenita (Fig. 26D)
It is a condition which closely simulates cutis marmorata but does not disappear on rewarming. The condition presents at or shortly after birth. The pigmentation 18presents as red marbled mottled patches. The changes may be limited to a localized part of the body. The skin changes get accentuated by decrease in ambient temperature. Contrary to cutis marmorata or livedo reticularis, there may be atrophy or ulceration of the skin. There may be associated limb hypoplasia, hyperplasia or vascular abnormalities, e.g., port-wine stain, Sturge-Weber syndrome, etc. Various associated neurological disorders include seizures, hydrocephalus, and ocular abnormalities such as glaucoma, retinal pigmentation, and retinal detachment. A condition named Adams-Oliver syndrome is characterized by cutis marmorata telangiectatica congenita (CMTC) with aplasia cutis congenita and distal transverse limb defects.
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Figs. 25A to C: (A) Physiological exfoliation of newborn; (B) Close-up of neonatal exfoliation; (C) Note exfoliation over thumb and fingertips.
Within first 2–3 years of life, CMTC gradually improves on its own. When the lesions are present over face, ophthalmological evaluation is necessary. When there are neurological symptoms, referral to a neurologist is necessary.
Neonatal Irritant Dermatitis (Figs. 27A and B)
Irritant dermatitis can develop within 24–48 hours of exposure to irritant chemicals. In newborn babies often various antiseptic cleansers and lotions cause dermatitis of the soft and sensitive skin. A severe form of irritant dermatitis can result in burn in neonatal intensive care unit (NICU) setup either from phototherapy, heater, or undiluted antiseptics.
Intense erythema with formation of papules and vesicles over the areas of contact with the offending agents is seen. The newborn baby becomes restless and irritable.
“Strive not to be having success, but rather to be of value.” –Albert Einstein
Avoidance of offending agent should be prompt. Cleansing of skin with distilled water or normal saline is to be done.19
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Figs. 26A to D: (A) Cutis marmorata telangiectasia in a newborn baby; (B) Same baby, note net-like telangiectasia; (C) Cutis marmorata, close-up view; (D) Cutis marmorata telangiectatica congenita.
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Figs. 27A and B: (A) Acute irritant dermatitis, note glazed erythema; (B) Irritant dermatitis over back.
“Don't count the days, make the days count.” –Muhammad Ali
Application of emollients such as white soft paraffin 2–3 20times a day for 7–10 days clears the dermatitis in most of the newborn babies. Occasionally mild topical steroids, e.g., 1% hydrocortisone or clobetasone butyrate may be required.
Epstein's Pearls and Bohn's Nodules
Clinically these are counterpart of facial milia. These appear as multiple, discrete 2–3 mm pearly white or yellowish papules over midline of hard palate (Epstein's pearls) or gum margins (Bohn's nodules). They are seen in 64–94% of normal neonates, but less commonly affects the premature neonates.
The characteristic appearance and location clinch the diagnosis.
It is a physiological condition in newborns and usually disappears in 4–6 weeks time is to be explained to the parents.
Sebaceous Gland Hyperplasia (Fig. 28)
It manifests as multiple, tiny, pin-point yellowish papules distributed on the nose, upper lips, malar region, and chin. It is due to influence of maternal androgens. They are rarely seen in premature infants.
Diagnosis is based on its characteristic appearance and site.
Reassurance of anxious mother.
Transient Neonatal Pustular Melanosis (Figs. 29A to C)
It is a benign self-limiting disease of unknown etiology. This rare condition is mostly seen in darker skin. It is seen in less than 1% infants.
Small sterile superficial vesiculopustules develop which rupture easily within 24–48 hours and evolve in to hyperpigmentation. The commonly affected areas are forehead, area below chin, neck, lower back and shins, but can become generalized. There is no systemic involvement. Though the lesions usually disappear within 2–3 days, hyperpigmentation lasts for 3 months.
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Fig. 28: Sebaceous hyperplasia.
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Figs. 29A to C: (A) Transient neonatal pustular melanosis; (B) Transient neonatal pustular melanosis, note hypopigmented macules suggesting healed pustules; (C) Close-up view of transient neonatal pustular melanosis.
“If you cannot fly, then run; if you cannot run, then walk; if you cannot walk, then crawl but whatever you do, you have to keep moving forward.” –Martin Luther King JR
No treatment is required as it is a self-limiting condition.
Acropustulosis of Infancy
Acropustulosis of infancy is an idiopathic noninfective pustulosis affecting infants and small babies. Usually, it occurs between 2 months and 3 years of age. The lesions appear as recurrent crops for few weeks to months and subside by 3–4 years of age. Though the exact etiology is not known, a possible association with preceding scabies has been implicated.
The lesions typically appear as pinpoint erythematous papules which transform into pustules within 24–48 hours. Palms, soles, dorsa of hands, and feet are the common sites affected. Usually it is associated with moderate-to-severe pruritus.
Differential Diagnosis
Various closely simulating conditions are scabies with secondary infection, impetigo, dyshidrotic eczema, erythema toxicum neonatorum, neonatal pustular melanosis, etc.
Moderately potent topical corticosteroids such as mometasone or fluticasone may be used for 2–3 weeks. In severe cases, dapsone (2 mg/kg body weight in two divided doses) has also been used. Systemic antihistamines can be given for pruritus. Recently topical maxacalcitol has shown to improve the symptoms.
Infantile Gluteal Granuloma (Figs. 29D and E)
Infantile gluteal granuloma, also known as granuloma gluteale infantum, is a rare, benign nodular complication of irritant diaper dermatitis in infancy due to use of potent topical corticosteroid, prolonged occlusion from diapers resulting in increased exposure to feces and urine and secondary infection with candidiasis. It is seen more commonly in the age group of 4–9 months.
The disease characteristically presents as multiple erythematous to violaceous papulonodules over the gluteal region, external genitalia, inner thighs, and lower abdomen in infants.
Stoppage of topical steroid application is the first thing to be done. If there is any evidence of candidal infection, topical ketoconazole or clotrimazole should be prescribed. Otherwise, the lesions subside very slowly without any treatment over a period of 3–13 months. Reassurance of parents and their counseling is of paramount importance.
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Figs. 29D to F: (D and E) Infantile gluteal granuloma; (F) Trichostasis spinulosa.
“Opportunity is missed by most people because it is dressed in overalls and looks like work.” –Thomas Alva Edison
Trichostasis Spinulosa (Fig. 29F)
It is a common disorder characterized by comedone-like papules which represent horny plug with 25–50 telogen vellus hair embedded within it. The basic defect is infundibular hyperkeratosis of hair follicle which prevents shedding hence retention of telogen vellus hair originating from a single hair matrix. This entity can be classified into two variants. Classically the disease presents as comedone-like papules resembling black head distributed 22mainly over nose and forehead in elderly individuals. Other variant characterized by pruritic follicular papule resembling keratosis pilaris is distributed over the trunk and extremities of young individuals or newborns. Pathological condition commonly associated with this entity is renal failure. Diagnosis can be established with the use of dermoscope and microscope. Various treatment modalities are depilation, keratolytic, topical and systemic retinoids, and hydroactive adhesive pads. Pulsed diode laser shows encouraging result.
Aplasia Cutis Congenita (Figs. 30 and 31A)
Aplasia cutis congenita (ACC) is a congenital defect of unknown etiology characterized by congenital absence of skin in newborn babies. Histologically, there may be absence of either epidermis, dermis or subcutaneous tissue. It usually affects the scalp but face, trunk or extremities can also be involved. Most of the cases of ACC are sporadic. Familial cases have been reported. Antithyroid drug methimazole given to a pregnant mother is likely to produce ACC in newborn babies. However, the issue is far from being conclusive.
Aplasia cutis congenita classically presents as single or multiple, oval to circular sharply demarcated granulating ulcerations over scalp. The size of the lesions usually varies from 1 to 3 cm. Occasionally, lesions may look like either a membrane or keloid.
Although most infants with ACC are otherwise well, various associated anomalies reported are cleft lip, cleft palate, hemiatrophy of limbs, ocular abnormalities, gastrointestinal malformations, spinal dysraphism, hydrocephalus, seizures, mental retardation, trisomy 13, vascular anomalies, etc. ACC is associated with fetus papyraceus (vanishing twin syndrome).
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Figs. 30A to D: (A) Aplasia cutis congenita (ACC) at birth; (B) ACC in a newborn; (C) Close-up view of ACC, note prominent visible blood vessels; (D) Hairless patch of ACC over scalp.
“And in the end, it's not the years in your life that count; it's the life in your years.” –Abraham Lincoln
23Differential Diagnosis
Forcep injury and other types of birth injury need to be differentiated.
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Figs. 31A(i) and (ii): A(i) Aplasia cutis congenita in a newborn; A(ii) Aplasia cutis congenita at birth in a mother on methimazole during pregnancy.
By and large ACC with small defects (up to 3 cm) do not require any treatment. Proper cleansing of the area daily with betadine is required in cases of granulating lesions. Prevention of secondary infection is very important. Most of the lesions heal with scarring by 6 weeks to 6 months and occasionally by 12 months. The scars gradually become less conspicuous over next 4–5 years. However, for bigger defects (>3 cm), plastic surgery is advisable.
Venous Prominence Over Bridge of the Nose
This physiological condition is seen in 1 in 10,000 live births. A transverse superficial vein remains prominent over the bridge of the nose. This condition is usually seen in 3–9 months old babies. Subsequently it disappears. Similar prominent veins are seen over the chest of babies admitted in NICU with respiratory distress.
Explaining the condition and its benign self-limiting nature to the anxious mother is all that is necessary.
Neonatal Erythroderma (Figs. 31B to F and 32)
Erythroderma is defined as any inflammatory condition involving more than 90% of body surface area. Neonatal erythroderma, also called as “red scaly baby,” is a life-threatening entity seen at birth or during the first 1 month of life. Neonatal erythroderma can be part of genodermatosis, immune deficiency, inflammatory disorder, metabolic diseases, and infections. Atopic dermatitis presenting as erythroderma is usually observed later and hence not a common differential for neonatal exfoliative dermatitis. Various causes of neonatal erythroderma are:
Cutaneous disorders:
  • Infantile seborrheic dermatitis
  • Atopic dermatitis
  • Psoriasis
  • Pityriasis rubra pilaris
  • Diffuse cutaneous mastocytosis
  • Ectodermal dysplasia (hypohidrotic/anhidrotic)
  • Lamellar ichthyosis
  • Nonbullous ichthyosiform erythroderma
  • Conradi–Hünermann syndrome
  • Bullous ichthyosiform erythroderma
  • Netherton syndrome
  • Staphylococcal scalded skin syndrome
  • Toxic shock syndrome
  • Congenital cutaneous candidiasis
  • Omenn syndrome
  • Graft-versus-host reaction
Metabolic disorders:
  • Disorders of biotin metabolism
  • Essential fatty acid deficiency
  • Multiple carboxylase deficiency
  • Acrodermatitis enteropathica
  • Leiner's disease
  • Ceftriaxone
  • Vancomycin
“The good life is one inspired by love and guided by knowledge.” –Bertrand Russell
Infantile seborrheic dermatitis (ISD) which manifests in the neonatal period, usually presents with greasy scales on the scalp (cradle cap), skin folds such as the axilla, neck, retroauricular, and diaper areas. Atopic dermatitis may have its onset in the first month; however, it is rarely erythrodermic in neonates. The lesions usually are vesicular and exudative in nature. Sometimes there is a significant overlap between infantile seborrheic dermatitis and atopic dermatitis.
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Figs. 31B to F: (B) Neonatal erythroderma; (C) Note scaling and glazed erythema all over body; (D) Appearance justifies nomenclature of neonatal erythroderma as “red baby”; (E) Close-up view of “red baby”; (F) Another view of “red baby”, close-up.
“Failure is simply the opportunity to begin again, this time more intelligently.” –Henry Ford
Neonatal psoriatic erythroderma is a rare entity and it commonly presents as recalcitrant diaper dermatitis which may become generalized with a widespread pustular form 25of the disease. This is accompanied by periodic high fever, and the child becomes very toxic with recurrent crops of superficial pustules appearing on erythematous plaques. Psoriasis and pityriasis rubra pilaris may look similar with erythematous scaly plaques which may enlarge and become generalized to produce erythroderma. Heavy infiltration of the entire skin with mast cells results in diffuse cutaneous mastocytosis. The skin undergoes lichenification and is erythematous, producing urtication and hemorrhagic bullae formation on mild trauma. Diarrhea, flushing, and respiratory symptoms are the common accompaniments. Darier's sign, a wheal which flares on stroking the skin, is often positive. Although a life-threatening condition, it improves with age.
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Figs. 32A to C: (A) Neonatal erythroderma, note diffuse erythema; (B and C) Neonatal erythroderma.
Several varieties of ichthyoses can manifest as erythroderma. Patients of nonbullous congenital ichthyosiform erythroderma have finer scales and are more inclined to develop erythroderma. The newborns have a collodion membrane which desquamates, revealing the erythroderma. It fades in mild disease but in the severe classic form, large plate-like scales with erythema persists. Harlequin ichthyosis infants with hyperkeratotic fissured plates often die due to respiratory problems; if they survive with treatment, they manifest generalized erythroderma. Epidermolytic hyperkeratosis or bullous ichthyosis has widespread denuded areas which resolve slowly, manifesting underlying erythroderma. Netherton syndrome presents with features of generalized erythroderma, fragile hair with trichorrhexis invaginata (“bamboo hair”), and atopic diathesis such as severe rhinorrhea, asthma, anaphylaxis due to food, and increased serum IgE levels. Erythroderma at birth is often the onset and it is a diagnostic dilemma where sparse hair with shaft defects may take several microscopic examinations, especially of eyebrows and lashes, before clinching the diagnosis. These patients are atopic and often have intercurrent infective episodes with high rates of mortality. The serum IgE levels are markedly raised and are even more than seen normally in atopic subjects.
“Everything that we ask about others can lead us to an understanding of ourselves.” –Carl Jung
Because of the protective effect of maternal immunity, congenital immunodeficiency syndromes are rarely symptomatic at birth. Graft-versus-host reaction from 26maternal engraftment can, however, occur even during intrauterine development. Omenn syndrome is a familial reticuloendotheliosis with eosinophilia having erythroderma, failure to thrive, lymphadenopathy, and recurrent infections. Marked leukocytosis, eosinophilia, anemia, and hypogammaglobulinemia are some of the findings in this histiocytic disorder. Hypogammaglobulinemia can start with diarrhea and periodic fever together with erythroderma. Dermatitis begins by 4 weeks of age and rapidly generalizes. DiGeorge syndrome and severe combined immunodeficiency may also present with eczematous dermatitis leading to erythroderma.
Graft-versus-host reaction may occur in T-cell immunodeficiency or as a result of transplacental transfer of maternal lymphocytes as a sequela of exchange transfusion. An erythematous nonspecific morbilliform rash may lead to erythroderma and epidermal sloughing. Neonatal cutaneous T-cell lymphoma can present with congenital ichthyosis with atypical Sezary-like lymphoid cells in skin and lymph nodes and other immunological abnormalities.
Metabolic and nutritional disorders are suspected when the infant has failure to thrive and the dermatitis manifests periorificially at the onset before it generalizes. Severe protein malnutrition during infancy can present with widespread erythema, edema, erosion, and desquamation of the skin. Deficiency of zinc due to malabsorption as in acrodermatitis enteropathica or low concentration of zinc in breast milk can begin with psoriasiform dermatitis in circumoral or periorificial areas which may crust and spread to involve other areas; this has also been reported in children with acquired immunodeficiency syndrome. Diarrhea, failure to thrive, irritability, and photophobia can accompany such dermatitis. Essential fatty acids, mostly found in dairy products and vegetable oils, are supplemented in the diet. Diffuse desquamation, lichenification, and intertriginous dermatitis can develop in such situations. Cystic fibrosis dermatitis presents with psoriasiform diaper rash not responsive to topical steroids or antifungals. This dermatitis may spread and is associated with growth failure and irritability. Deficiency of holocarboxylase synthetase manifests with neonatal erythroderma. The children have alopecia, secondary cutaneous candidiasis, dehydration, and ketoacidosis which can lead to a fatal outcome. Deficiency of holocarboxylase synthetase in skin fibroblasts clinches the diagnosis. Deficiency of biotinidase presents with patchy alopecia and acrodermatitis enteropathica-like skin lesions. These conditions encompass the group of “multiple carboxylase deficiency” disorders. Penicillins, aminoglycosides, and cephalosporins often produce erythematous maculopapular skin lesions, but rarely erythroderma. Ceftriaxone and vancomycin in neonates may produce erythroderma, and vancomycin may also induce hypotension on account of histamine release.
Leiner's disease is literally a clinical phenotype of acquired erythroderma, diarrhea, and failure to thrive. Desquamative generalized erythema and dermatitis with weight loss was thought to be common in breast-fed infants due to the deficiency of biotin. Cases of generalized dermatitis in seborrheic pattern due to immunodeficiencies were also included in this category.
Laboratory investigations are supportive to clinical diagnosis in neonatal erythroderma. Histopathology is not diagnostic in all conditions.
Managing neonatal erythroderma is a therapeutic challenge as it is very difficult to treat this potentially life-threatening situation. Careful monitoring of the vital signs, maintenance of fluid and electrolyte balance, and prevention of hyperpyrexia are mandatory in the management. Application of emollients, wet dressings, topical steroids, and systemic antibiotics are the other modalities. Maintaining the skin barrier and proper hydration is the key to managing most of the conditions. Oral retinoids (acitretin) in dose of 0.5–1 mg/kg is indicated in congenital ichthyosis. Regular follow-up and prevention of complications reduce mortality in neonatal erythroderma.
Amniotic Band Syndrome (Figs. 33A and B)
Amniotic constriction bands are congenital anomalies characterized by constriction rings and digital amputation of one or more digits or limbs. The amniotic bands are confined to the skin, soft tissue and may extend deep into the tissue. It results from intrauterine rupture of amnion with formation of fibrous bands encircling the fetal parts resulting in constriction of the underlying tissue. The inheritance is sporadic. Constrictions can occur on limbs giving rise to swelling on the distal part, loss of distal part of one or more fingers, toes, contractures, and fracture. They can be associated with craniofacial and spinal defects. Rarely deformation of internal organs can occur.
“It is the province of knowledge to speak and it is the privilege of wisdom to listen.” –Oliver Wendall Holmes
Congenital Erosive and Vesicular Dermatosis (Figs. 34A to D)
The condition presents as vesicles and ulceration in newborns, almost exclusively in premature babies. 27The exact cause is not known but intrauterine infection and amniotic membrane adhesion are proposed hypothesis. Essentially it is a nonhereditary condition.
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Figs. 33A and B: (A) Amniotic band syndrome; (B) Close-up view of amniotic band syndrome.
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Figs. 34A to D: (A) Congenital erosive and vesicular dermatitis; (B) Congenital erosive and vesicular rash on healing; (C) Congenital erosive and vesicular dermatitis; (D) Healed pigmentary changes in congenital erosive and vesicular dermatitis, note the soft supple and reticulate scarring.
“Knowledge will give you power, but character respect.” –Bruce Lee
Extensive vesicles and erosions in a reticulate pattern over extremities, trunk involving up to 75% of body 28surface during first month of life in premature babies is the usual presentation. The lesions soon get crusted and subsequently heal with distinctive supple and reticulate scarring. The scars over the trunk have a cobblestone-like appearance. There may be associated scarring alopecia and ulceration over the tongue. Nails may be either absent or hypoplastic. Sweating is absent over the scarred areas and the baby may present with hyperthermia. Rarely neurological and ocular abnormalities may be seen.
Differential Diagnosis
The condition needs to be differentiated from epidermolysis bullosa. Lack of involvement of face, hands and feet, characteristic rippled scar on healing and progress of lesions characterize the condition and differentiates it from epidermolysis bullosa.
It is symptomatic and essentially care of the wound. Reassurance of parents is extremely important.
Harlequin Color Changes (Fig. 35)
Harlequin color change is a rare physiological phenomenon seen more commonly in preterm, low birth weight, sick infants, and with severe intracranial injury. It can affect 10% full-term infants. It is probably related to immaturity of the hypothalamic centers and autonomic control of vascular tone leading to capillary bed dysregulation. The color change occurs when the child is lying on one side; the dependent side becomes strikingly red with simultaneously blanching on the upper half of the body with a sharp line of demarcation. The mucosa and genitalia are spared. These episodes may persist for few seconds to minutes (30 sec to 20 min). The color change is rapidly reversible with a change in position, crying, and increased muscular activity. The onset of this phenomenon is seen at 2–5 days of age and may last up to 3 weeks, but can present within first few hours of birth. Repeated episodes can be present in 50% of the affected neonates. Other associated conditions that can trigger this phenomenon are meningitis, seizures, and tricuspid atresia.
The condition needs to be explained to the parents and reassured.
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Fig. 35: Harlequin color change in newborn.
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Figs. 36A to C: (A) Median raphe cyst; (B) Median raphe cyst, note beaded whitish papules; (C) Median raphe cyst, note beaded whitish papules along with ulcerated papule.
“Success is a lousy teacher. It seduces smart people into thinking they can't lose.” –Bill Gates
Median Raphe Cyst (Figs. 36A to C)
Median raphe cyst (MRC) is a rare, congenital, benign lesion that can occur anywhere along the ventral side of median raphe of male external genitalia from anus to urethral meatus. MRCs are usually asymptomatic during childhood. They become symptomatic during adolescence or adulthood following vigorous sexual intercourse. Proximal location and small size, <2 cm are 29also contributory to their asymptomatic nature. Distal location and bigger size lesions are usually symptomatic. Patients may present with pain, difficulty in voiding, difficulty in intercourse, hematuria or hematospermia. Location of MRC varies widely along the ventral midline of the perineum from anus to urethra. They do not connect with urethra. The most common location is distal penile shaft and parameatal position. Rarely do they present at scrotum, glans penis, and prepuce. Sometimes they may present as cord or series of beads (canal-like). Clinical differentials include epidermoid inclusion cyst, dermoid cyst, steatocystoma, glomus tumor, and apocrine cystadenoma. Pathogenesis is not fully elucidated. They may arise from defective fusion of urethral fold leading to tissue trapping during development of urethral fold. Developmental anomaly of periurethral gland of Littre or blockage of paraurethral ducts could be other possibilities. Lining of the cyst may vary depending upon tissue trapping. It could be pseudo stratified columnar epithelium (if proximal urethral cells get trapped), squamous epithelium (distal urethral cell), and glandular epithelium (periurethral gland get trapped). Ciliated cells are rarely present. Metaplastic change due to local irritation is the most probable explanation. Treatment is surgical excision for cosmetic reason or for symptomatic lesion. Simple aspiration may lead to recurrence therefore wide local excision and aspiration is probably the better way to approach.
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Figs. 37A to C: (A) Sternal cleft with umbilical raphe in a newborn; (B) Sternal cleft with umbilical raphe in a newborn, close-up view; (C) Milder form of the defect.
“The whole problem with the world is that fools and fanatics are always so certain of themselves, and wiser people so full of doubts.” –Bertrand Russell
Sternal Cleft with Umbilical Raphe (Figs. 37A to C)
Sternal cleft is a rare congenital malformation that can be isolated or combined with other congenital defects. It is presumed to be caused by failure of fusion of sternal bands during the sixth to ninth weeks of gestation. Studies in mice lead to the identification of impairment in the expression of Hoxb genes as a possible cause of sternal defects. The malformation is usually sporadic, but there are reports of familial inheritance (autosomal dominant). 30They can be classified as superior, subtotal, total, and inferior. Superior sternal clefts are usually isolated but may be associated with vascular abnormalities such as craniofacial hemangioma (seen almost exclusively in females) and supraumbilical midline raphe extending from the umbilicus to the lower part of the sternal defect, first described by Leiber. Coarctation of the aorta with a right aortic arch and congenital aortic aneurysm has also been described in association with cleft sternum and supraumbilical raphe. PHACE syndrome (posterior fossa anomalies, hemangioma, arterial anomalies, cardiac anomalies, and eye anomalies) is sometimes associated with ventral developmental defects (sternal cleft, supraumbilical raphe, or both) and is then called as PHACE(S) syndrome.
It may be an abortive form of Pentalogy of Cantrell. Pentalogy of Cantrell is a condition characterized by a combination of midline birth defects that can potentially involve the breastbone (sternum); the muscle that separates the chest cavity from the abdomen and aids in breathing (diaphragm); the thin membrane that lines the heart (pericardium); the abdominal wall; and other vital organs.
Prenatal high-resolution ultrasonography may diagnose the condition and helps to accurately evaluate cartilaginous parts of the sternum and possible cardiovascular malformations postnatally. Surgical correction during the neonatal period is recommended as the compliant thorax allows direct approximation of the sternal halves.
The skin is the first barrier of the newborns to counter various noxious factors/agents of the environment once the baby comes out of the safe and secured intrauterine life to the external world. Various aspects of newborn skin care will be discussed under different headings.
Need for Special Skin Care for Babies
Baby's protective but delicate cover needs to be kept in a healthy condition and it should be disturbed as little as possible. Topical agents are more rapidly absorbed into infant skin due to deficient intercellular bridges. Besides, greater body surface area to weight ratio than adults also facilitates easy absorption and toxicity of topically applied substances. Infant skin cannot withstand the toxicity of most substances as they make this delicate skin more susceptible to electrolyte imbalance, fluid imbalance, and thermal instability. Infant skin is particularly very sensitive to cleansing agents as they contain stronger chemicals and may be drying. Hence, the product should be guaranteed of safety for use on babies.
Skin problems pertaining to dryness are common in babies due to inadequacies in the epidermal barrier. The skin irritation potential toward topical applicants is also more. Maintaining skin integrity and preventing exposure to toxic substances in childhood assures healthy skin for several years ahead.
Skin of the newborns performs the most challenging task as it is the outermost cover of the body. Moreover, it is confronted with various factors, namely, temperature changes, friction, microbes, etc., of the external world once the baby is born. As the structure and functions of the skin depend on whether a child is born at term or prematurely, skin care is related to gestational age.
At birth, microbial colonization of newborn skin is almost nil. But over a few hours, aerobic flora occupies skin at different concentrations at different sites, e.g., mostly over groins, axillae, and scalp. Coagulase negative staphylococci (Staphylococcus epidermidis) are the most commonly found microorganisms. Staphylococcus aureus appears only as contamination, usually from mother or nursing staff.
Skin Care at Birth
Removal of Vernix Caseosa
At birth the baby's skin is coated with vernix caseosa, blood, meconium, and cellular debris. Vernix caseosa has a protective function, contains both epidermal (triglycerides and cholesterol) and sebaceous (squalene and waxes) fat. Premature infants tend to have less of vernix than term babies and postmature babies have little vernix. There is considerable interindividual variation in the quality of vernix caseosa. Vernix caseosa should not be rubbed or removed as it dries and falls itself by 5–7 days.
Washing and Bathing
A bath is an ideal means of cleaning an infant completely. A bath in infant should not last for more than 5 minutes. The bath of approximately 5 minutes increases the hydration of skin and, thereby, reduces the threshold for friction. Newborn temperature should be stabilized before the first bath is given. Bathing should be deferred till fifth or seventh day. Sponge bathing can be given till the cord falls. Blood and meconium can be wiped with soft cotton dipped in warm water. Temperature of bath water should be equal to skin temperature (34–36°C).
“It's amazing what you can get, if you quietly, clearly and authoritatively demand it.” –Meryl Streep
31A solid or liquid cleanser or a syndet can be used to clean baby skin. After bath, infants must be dried thoroughly, particularly over skin creases, groins, and axillae.
Diaper Care
Napkin should be changed frequently every 2 hours, at least at each nursing and feeding time. Cloth diaper should be carefully washed in lukewarm water and then rinsed off and dried thoroughly.
The diaper area is specifically vulnerable because it is a closed environment suitable for microorganisms and with frequent wetting, it is more often moist; hence the skin becomes prone to maceration and increases its permeability to other irritants.
The skin here is constantly in contact with strong alkalinizing agents, e.g., urine and feces and the pH here is prone to high alkalinity that damages the skin integrity. It is, thus, very important to be well-aware of the need to change nappies and the range of products that are available to prevent any rash or irritation in the nappy area.
Nappy rash can be reasonably prevented by reducing moisture by the frequent changing of nappies. This would reduce contact between urine, feces, and the skin. However, this does not seem feasible at most instances. In such cases, using partially occlusive agent such as petrolatum or zinc-based products on the genital area can help to form a physiological barrier that minimizes this interface. As far as possible, air exposure should be increased by allowing the child to move around the house bare-bottomed. Plastic pants should be avoided as they reduce the air circulation to the skin. Warm water and soft cotton wool should be used to wipe the nappy area. Feces have a tendency to stick and scrubbing only worsens the status of the delicate skin. Here, the use of an emulsion such as baby lotion can ease the removal by reducing the surface tension and cleaning the debris. Skin should then be thoroughly dried each time the diaper is changed by exposing it for a few minutes. The bottom should be wiped from front to back to avoid fecal matter from reaching the genitals. Soaps should be mild and should be used very rarely if a rash has developed. Use of powders in diaper areas is not recommended.
In general, the nappies should be made of cotton cloth and should be home laundered with mild detergents. Recent advances in diaper technology have led to decrease in frequency and severity of diaper rash. Diapers with highly superabsorbent acrylate gel can be used.
Regular cleansing of scalp is necessary. Shampoo helps to remove scales and crust from the scalp (cradle cap). Coconut oil or mineral oil application softens the scales.
Nail should be regularly trimmed and kept short and clean.
The Ears
Outer aspect of ear should be cleansed. Cotton swabs soaked in boiled water should be used to clean ears. Special care should be taken not to hurt auditory canals.
After birth umbilical cord dries out and drops off within 5–10 days. No topical agents should be used on umbilical cord. Dry cord care is recommended. Prophylactic use of chlorhexidine reduces the colonization and prevents sepsis.
Skin Care in the Premature Infants
After birth, skin maturation proceeds rapidly in preterm infants. These infants are kept warm and nursed in closed incubators. Environmental conditions in these units are potentially harmful for infant skin, which is subject to scarring. Cosmetically or functionally, significant lesions may be caused by needle marks, central venous catheters, transcutaneous oxygen monitoring, chest drain insertion, extravasation of intravenous fluid (Fig. 38) or skin stripping due to adhesive tape. To reduce the frequency and severity of skin damage, neonatal staff need to know that many routine procedures can lead to long-term scarring and atrophy. Heaters should be kept at a safe distance in NICU as there is a risk of burn injury (Fig. 39).
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Fig. 38: Extravasation injuries.
“As far as we can discern, the whole purpose of human existence is to kindle a light in the darkness of mere being.” –Carl Jung
32Preventive Measures
  • Disinfection: The most common infective agents causing septicemia are coagulase-negative staphylococci in relation to catheter placement. For prevention, maintain hygiene by hand washing of the staff and parents. Cleaning with chlorhexidine-alcohol and povidone-iodine, two consecutive 10-second cleaning destroys more than a single 10-second wipe.
  • The incubator: Frequent change of infants’ position in the incubator reduces the risk of skin erosion and impending bed sore. Fingers and toes must be kept visible. Catheters or needles should be secured with a transparent tape to allow easy detection of fluid extravasation. Scarring alopecia can develop following pressure ulcer. The occurrence of nonblanchable erythema and disruption of epidermis indicate impending ulcer. The occurrence of scarring alopecia has been reported in infants from pressure necrosis.
  • Transcutaneous oxygen monitors: Transcutaneous oxygen monitors should not be left in place for more than 1 hour without surveillance. Nonblanchable erythema has been reported with keeping such electrodes for prolonged period. The use of karaya electrodes has been demonstrated to be effective in cardiorespiratory monitoring with decreased trauma to the neonatal skin. Placement of electrodes on the limbs, especially in very low birth weight infants, can eliminate the need to frequently remove these pads to facilitate auscultation or other assessment of the chest wall.
  • Minimal use of tape and adhesive: The skin of the premature infants may be damaged by repeated attachment and removal of adhesive tapes to secure electrodes, IV cannulas, drains, etc. Adhesives should be used on small areas of skin and removed gently with warm water soaked gauze and diluted soap, but not alcohol, which may be irritant for baby's skin.
  • Emollients: Application of emollient is a safe and effective way to decrease neonatal peeling and scaling dermatitis. Coconut oil or vegetable oil applied gently to the skin, reduce scaling and fissuring as well as increase skin hydration.
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Fig. 39: Thermal burn of skin in a neonate in NICU from room heater.
Skin Care of the Term Baby and Infant
The large number of infant skin-care products available over the counter is at times confusing for the average consumers. These have been the gifts of media and so-called health magazines for the lay people with all rosy advertisements. By and large the principle followed by a doctor should be to advice the parents to go for a product marketed by a multinational company or a company of good repute and stature or a product, which has been in the market for a considerable period of time and thus has stood “the test of time”. Several types of products are used, namely soaps, shampoos, antiseptics, moisturizers, etc.
The term “detergent” designates a substance capable of cleaning the skin, i.e., of removing impurities (dust, grease organic secretions, microorganisms). Washing with water alone does not remove all the impurities on the skin surface. Some are only fat soluble, thus requiring the use of products capable of emulsifying the fatty substance into fine droplets, which can then, be carried away by rinsing. These products are known as surfactants, act by suppressing the surface tension, which allows fatty substances to remain on the skin surface. Detergents act by reducing the surface tension between water and air, creating a foaming effect not directly correlated with the cleaning properties of the product. As a rule, a higher foaming power increases the risk of damage to the skin. Detergents are classified as ionic or nonionic products. In infants detergents should be used cautiously, followed by a thorough rinsing. Too much removal of lipids from the stratum corneum would eliminate those essential to the surface ecosystem.
Soaps are the products of saponification, i.e., the action of alkali on a fatty substance. In hard water, soaps tend to precipitate.
“Change will not come if we wait for some other person or some other time. We are the ones we have been waiting for. We are the change that we seek.” –Barack Obama
Syndets or synthetic detergents do not have the theoretical disadvantages of soap but are subject to rapid disintegration. They can produce excessive dryness of skin, if moisturizers are not added to it. Antiseptic soaps are useful in preparation of an operative field, but are 33unsuitable for daily use in infants as they can cause irritation to infants’ skin. Moreover, antiseptic soaps remove the commensal organisms from the skin surface, thereby, making the skin prone to attack by virulent pathogenic organisms from outside.
Bubble bath products attract the infants and their parents because of its colorings and perfumes and, thereby, mask the risk of prolonging a bath and irritating the genital mucosa.
Most baby shampoos in the market contain anionic surfactant which ensures adequate cleansing. The pH should be close to that of tears and, thereby, would not cause irritation to the eyes. Special ingredients, e.g., selenium sulfide, ketoconazole or zinc pyrithione may be added to the shampoos for seborrheic dermatitis or seborrhea scalp. The basic principles of use of various antiseptics and emollients in term babies and infants are essentially the same as in preterm babies.
Protective creams: These are basically prepared to reduce the risk of irritation, particularly napkin rash, by isolating skin from numerous irritants for baby's skin. The creams contain a fatty phase, an aqueous phase, a surfactant, additives (zinc oxide), scents, and preservatives. These creams can paradoxically cause increased occlusion and irritant dermatitis to its ingredients.
Powders: Application of powders over the skin folds is not recommended.
Role of Massage
The act of touch fulfils the basic need to feel safe, comfortable and loved. Touch is also an intrinsic factor in child development. Touch is proposed to play a role in growth, development, and overall well-being. Massage is one of the most beautiful and gentle methods of touch. It is practiced in most countries and has recently been researched extensively in western countries. Indian form of infant massage is appreciated all over the world. It has been seen that massage with oil is more beneficial as compared to massage without oil. It is important to note that the oil used in such a situation ought to be smooth, of optimum viscosity, and friction free or else it would lead to abrasions on the skin surface. The oil should be nonocclusive so that it does not block the skin pores and allows the skin to breathe. It ought to be safe and mild to suit the baby's delicate skin and the ingredients should be thoroughly tested for their potential to cause contact sensitivity. Mineral oil is one of the best-known moisturizing ingredients ever found. It spreads easily and has a long-lasting tactile effect, making it an extremely efficacious emollient. Omission of low molecular weight hydrocarbons alleviates risks of carcinogenicity while the large particle size renders it incapable of blocking pores making it noncomedogenic.
Massage should be started after 1 month and can easily continue till 10 years and over. Benefits of massage are numerous. Appropriate knowledge of correct massage techniques is important in order to attain maximum therapeutic benefits from it. Complete head-to-toe massage should be a daily routine. But massage should be gentle and judicious. However, massage should be withheld for a few days in case either the baby has got any contagious infection of skin or the person offering massage has any infection over hands. Massage given by the mother increases the bondage between the mother and her baby. It helps in the physiological and psychological development of the babies.
“Don't chase people, be yourself, do your own things and work hard. The right people, the ones who really belong in your life, will come to you and stay.” –Will Smith
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