- Coping With Eczema Long-Term
- Seborrheic dermatitis
- Are you sure your patient has seborrheic dermatitis? What should you expect to find?
- How did the patient develop seborrheic dermatitis?
- Which individuals are of greater risk of developing seborrheic dermatitis?
- Beware: there are other diseases that can mimic seborrheic dermatitis:
- What laboratory studies should you order and what should you expect to find?
- What consult service or services would be helpful for making the diagnosis and assisting with treatment?
- Key principles of therapy
- What should you tell the patient about the prognosis?
- If the patient presents with erythroderma
- How do you develop seborrheic dermatitis and how frequent is this disease?
- What pathogens are responsible for this disease?
- How do these pathogens cause seborrheic dermatitis?
- What other additional laboratory tests may be ordered?
- WHAT'S THE EVIDENCE for specific management and treatment recommendations?
- DRG & ICD-9 CODES
- Seborrheic Dermatitis
- Seborrheic Dermatitis (Cradle Cap)
- What causes cradle cap?
- Which children are at risk for cradle cap?
- What are the symptoms of cradle cap?
- How is cradle cap diagnosed?
- How is cradle cap treated?
- What can I do to prevent cradle cap in my child?
- When should I call my child’s healthcare provider?
- Key points about cradle cap
- Next steps
- Rash – child under 2 years
- Home Care
- When to Contact a Medical Professional
- What to Expect at Your Office Visit
- An unwelcome eruption: periorificial dermatitis
Coping With Eczema Long-Term
Several skin conditions fall under the heading of eczema: Atopic dermatitis, dyshidrotic eczema, contact dermatitis, nummular eczema, and seborrheic dermatitis are some of the more commonly diagnosed forms of eczema.
Atopic dermatitis is the most common and often most severe form, though all types of eczema involve skin redness and itching.
It's often a long-term condition — 90 percent of the 30 million Americans who have eczema were diagnosed before the age of 5 and many have the condition into adulthood.
Talking to a Dermatologist About Eczema
“Atopic dermatitis is a chronic condition for which there is no cure,” says Rebecca Kazin, MD, medical director of the Johns Hopkins Dermatology and Cosmetic Center in Lutherville, Md. But your dermatologist can work with you to create a good skin care regimen to reduce flares.
There are many treatment options for eczema. Both over-the-counter and prescription medications can offer relief, but it's important to speak with a dermatologist about the best treatment for your case.
These skin specialists can answer questions about which types of cleansers and soaps to use, what to avoid — anti-bacterial soaps, for example, can cause dryness and irritation — and advise when prescription medication is necessary.
A dermatologist is also the best resource for treating other skin conditions that may be caused by eczema. “When you have eczema, you're more prone to certain conditions because your skin barrier is compromised — skin infections such as bacterial staph infections and viral warts, for example,” says Dr. Kazin.
Support for Coping With Eczema
Sometimes the best support comes in the form of knowledge from others going through the same challenges that you are. There are several resources that can help you learn about eczema and get support for living long-term with it.
The National Eczema Association, for example, offers the NEA Support Network, which is comprised of people who offer their time to listen and share insights about the long-term effects of eczema.
All contacts within the NEA Support Network are adults who either have eczema or are raising a child with eczema.
In addition, the NEA sponsors an annual patient conference designed to educate eczema patients and family members about the latest medical research and offer tips for managing this chronic skin condition.
Lifestyle Choices for Coping with Eczema
In some cases of eczema, lifestyle choices can affect symptoms. Although research has not identified a direct link to eczema, stress can exacerbate the condition, so doctors recommend that you do what you can to decrease stress levels. “Stress is not the primary cause of eczema,” says Kazin, “but stress makes everything worse.”
Exercise, which has been shown to decrease stress, can be helpful in managing eczema for that reason. In addition, weight loss from exercise can be beneficial for people whose eczema is caused by poor circulation.
Certain allergies have been also linked to eczema flares. “In children who have really bad eczema, sometimes when food allergies are addressed, the eczema becomes easier to control,” says Kazin.
The food-allergy link is less common in adults, but outdoor seasonal allergies can affect adult cases of eczema. “Sometimes when an adult moves to a new location and becomes exposed to different allergens, they get eczema,” says Kazin. “Sunnier climates are better for people with eczema because they are warmer and tend to be more humid. Eczema is worse in cold, dry climates.”
The long-term effects of eczema are both emotional and physical. But with the right strategies and support, you'll be better able to cope with all of eczema’s challenges.
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Are you sure your patient has seborrheic dermatitis? What should you expect to find?
Immunocompetent patients with seborrheic dermatitis present similarly to those without HIV infection; however, an atypical and more extensive presentation is common in those infected with HIV (Figure 1).
Eroded and scaly plaques on face; note scaling on anterior hairline
- Itching and rash: Patients commonly complain of itching of their scalp, ears, beard area, and axillae or groin if involved. Patients may complain of dandruff and/or rash around the nose, in the eyebrows, ear canals, beard and mustache, axillae, or groin. If erythrodermic, patients may complain of full-body itching along with rash.
- Scaly scalp: This is the most common clinical finding and may be the only sign in mild disease; may be fine white or greasy, yellow scale.
- Rash: Symmetrical erythematous macules, patches and thin papules or plaques with yellow, greasy scaleScalpEyebrows and glabellaPeri-alar and melolabial (nasolabial) foldExternal auditory canals and post-auricular skinBeard and mustache areaCentral chest and inframammary foldsAxillae and groin/perineumRarely, the patient will have erythroderma.
- Except those on the scalp, lesions tend to be sharply demarcated.
How did the patient develop seborrheic dermatitis?
- Seborrheic dermatitis is common.2-5% of the normal populationMore common in males
- There are two incidence peaks:Infancy, a self-limited condition (i.e., cradle cap)4-6th decades in adults
- In those with HIV:Prevalence ranges from 7 to 80%Occurs early in HIV infectionCan be seen at all stages of disease, however, atypical and more extensive involvement can be associated with worsening immunodeficiency.May be presenting sign of HIV infection
- Malassezia speciesThought to be involved in pathogenesis of diseaseReduction in density correlates with treatment success
Which individuals are of greater risk of developing seborrheic dermatitis?
Seborrheic dermatitis is more common in certain populations, some of which have been outlined in the previous section. Additional settings in which seborrheic dermatitis may be seen include:
- Underlying neurological disease: Parkinson’s disease, stroke, facial nerve injury, seizure disorder
- Obesity and diabetes
- Celiac sprue
- Intestinal malabsorption
Beware: there are other diseases that can mimic seborrheic dermatitis:
The differential diagnosis of seborrheic dermatitis includes:
- PsoriasisPlaques tend to be thicker with more pronounced erythema or redness.Scale is “silvery.”It tends to be less itchyNails, elbows, knees are involved.The scalp may be involved, similar to seborrheic dermatitis, but facial involvement is uncommon.
- Atopic DermatitisScale on scalp tends to be fine, white.Dry skin presents overall.There is involvement of antecubital and popliteal fossae.
- Intertriginous CandidaIt is beefy red.There are satellite pustules at periphery of main plaques.Lack of scalp involvement exists.
- RosaceaErythematous papules and pustules in central facial distribution occur.There is a lack of typical seborrheic dermatitis distribution.
- Langerhan’s cell histiocytosisYellow-brown perifollicular papules occur.Intertriginous fissures occur.
What laboratory studies should you order and what should you expect to find?
The diagnosis of seborrheic dermatitis is most commonly made by history and physical examination alone.
Results that confirm the diagnosis
When needed, a skin biopsy may help confirm the clinical suspicion of seborrheic dermatitis and rule out some diseases in the differential diagnosis (Langerhans cell histiocytosis).
- Skin biopsy: often nonspecific and subtleIrregular acanthosis with variable amounts of spongiosis and lymphocytic exocytosisNeutrophil exocytosisParakeratosis and scale-crust especially adjacent to follicular ostia
What consult service or services would be helpful for making the diagnosis and assisting with treatment?
If you decide the patient has seborrheic dermatitis, what therapies should you initiate?
Dermatology is often consulted, especially if the patient presents with erythroderma.
Key principles of therapy
- Seborrheic dermatitis is thought to be related to overgrowth of or an inflammatory response to Malassezia species, a fungal member of the normal skin flora.
- The mainstay of therapy remains topical antifungals with creams, gels, foams, liquids, and shampoos.The azole antifungals are commonly employed in this disease.
- Griseofulvin is not effective against Malassezia and should not be used.
- In mild disease, treating the scalp with shampoo often contributes to improvement or resolution of disease elsewhere.
- Anti-inflammatory medications, such as topical corticosteroids or calcineurin inhibitors, may also be used, especially if the disease is resistant to initial antifungal treatment.The use of topical steroids should be limited and appropriate for the body site to limit the risk of side effects, including epidermal and dermal atrophy, skin dyspigmentation, telangiectasia, and striae.The site of involvement will not only help determine which anti-inflammatory to use, but also which formulation.For example, ointments do not work well in hairy areas, because they are difficult to apply.
- If significant hyperkeratosis is present, topical keratolytics (salicylic acid) may be used to reduce the scale.
What other treatments may be helpful?
- Substitute the use of soap with a light emollient cleanser if the face is significantly scaly.
What should you tell the patient about the prognosis?
Seborrheic dermatitis is a chronic disease that tends to wax and wane in severity. Patients may see worsening of their disease with stress, changes in environment, and travel.
In general, seborrheic dermatitis is more difficult to treat in those with HIV infection and may be resistant.
These patients often have more areas involved and are at increased risk of developing erythroderma, although this is a rare complication of seborrheic dermatitis.
If the patient presents with erythroderma
- It is important to discuss the case with a dermatologist at the point of care.
- These patients are at risk of increased insensible losses, volume depletion, and high-output cardiac failure if allowed to persist for long periods of time with extensive skin disease. Treatment setting depends on the severity of illness; if the patient is tachycardic and volume depleted, it may be best to admit the patient for IV fluid resuscitation. However, most patients can be treated effectively as outpatients with close clinical follow-up.
- Initial therapy may include a medium-potency topical steroid (triamcinolone can be prescribed in a 1 pound jar) ointment applied to affected skin (avoiding facial skin) twice every day. The addition of the soak and smear method (soak in a warm water tub with no soap for 15-20 minutes; while still wet, apply the topical steroid, then dress in cotton pajamas and/or a vinyl sauna suit, preferably worn over damp cotton pajamas) will often speed improvement, as well as reduce pruritus dramatically. Patients must be cautious not to employ this modality for longer than 1-2 weeks to prevent side effects.
How do you develop seborrheic dermatitis and how frequent is this disease?
It is unclear why seborrheic dermatitis develops. As mentioned, seborrheic dermatitis is more common in men. Although the exact incidence and prevalence are unknown, seborrheic dermatitis typically begins in two age groups.
The infantile form begins at about 1 week of age and may last for several months but is a self-limited disease. The adult type begins in the 4-6th decades of life and is a chronic, waxing and waning skin condition.
There is no evidence of horizontal spread of seborrheic dermatitis.
What pathogens are responsible for this disease?
Although the exact mechanism by which this disease occurs is unknown, it is apparent that Malassezia species are involved.
Malassezia is a commensal fungus on the skin; it can be easily isolated from the skin of those with seborrheic dermatitis and, although there is no specific threshold at which seborrheic dermatitis develops, successful treatment is associated with reductions in the number of Malassezia on the skin.
How do these pathogens cause seborrheic dermatitis?
A role for immune mechanisms against Malassezia in the development of seborrheic dermatitis has been suspected but has yet to be confirmed. M. fufur specific antibodies do not seem to be increased in those with seborrheic dermatitis versus controls.
Although it may not be specific to Malassezia, is it apparent that patients with seborrheic dermatitis show upregulation of several cytokines including interleukin (IL)-6, 4, 10 and interferon (IFN)-γ, as well as increased recruitment of natural killer cells.
There appears to be a decrease in IL-2.
What other additional laboratory tests may be ordered?
The diagnosis is most often made clinically. The following tests may be useful if questions still remain:
- A PAS stain performed on a skin biopsy may reveal fungal organisms in the stratum corneum.
- A KOH preparation of scale from the skin may show characteristic “spaghetti and meatballs” appearance of Malassezia spores and hyphae.
WHAT'S THE EVIDENCE for specific management and treatment recommendations?
James, WD, Berger, TG, Elston, DM.. Andrews' diseases of the skin. 2011. pp. 188-9. (This is an excellent review of the salient features of seborrheic dermatitis, including clinical presentation, histologic findings, and treatment.)
Fritsch, PO, Reider, N., Bolognia, JL, Jorizzo, JL, Rapini, RP. “Other eczematous eruptions”. Dermatology. 2008. pp. 197-200. (This is an outstanding review of seborrheic dermatitis, including its relationship to HIV infection.)
Maniar, J, Kamath, R., Tyring, SK, Lupi, O, Hengge, UR. “HIV and HIV-associated disorders”. Tropical Dermatology. 2006. pp. 112(This is a brief review of seborrheic dermatitis in the setting of HIV infection.)
Williams, J, Coulson, I., Lebwohl, MG, Heymann, WR, Berth-Jones, J, Coulson, I. “Seborrhiec eczema”. Treatment of Skin Disease Comprehensive Therapeutic Strategies. 2010. pp. 694-6. (This book evaluates the evidence for treatments for many different diseases of the skin.)
Kastarinen, H, Oksanen, T, Okokon, EO, Kiviniemi, VV. “Topical anti-inflammatory agents for seborrhoeic dermatitis of the face or scalp”. Cochrane Database Syst Rev.. 2014 May 19. pp. CD009446(This thorough review finds no evidence for superiority of any treatment compared to topical steroids, but most of the included studies were small and short.)
DRG & ICD-9 CODES
DRG code 596: If the patient requires admission for erythrodermic seborrheic dermatitis.
, 690.10, or 690.18.
|Scalp||Shampoos – lather, leave in 5 minutes, then rinse; 2-3 times/week· Ciclopirox 1% (probably most effective; Evidence level A)· Ketoconazole 2% (Evidence level A)· Zinc pyrithione 1% (Evidence level B)· Coal tar 0.5%, 1%· Selenium sulfide 1%, 2.25% (least effective; Evidence level C)||Clobetasol 0.05% shampoo (ly not appropriate for long-term use; Evidence level A)||· Propylene glycol lotion 15% (applied to wet hair after shampooing, leave on for 5 minutes, then rinse; Evidence level A)For recalcitrant disease: · Oral itraconazole 200mg daily for 1 month, then 2 days each of the following 11 months· Oral terbinafine 250mg daily for 4-6 weeks|
|Face, ears (including EAC), intertriginous, and trunk||Ketoconazole 2% cream BID (Evidence level A)· Ciclopiroxolamine 1% cream BID (Evidence level A)· Clotrimazole 1% cream BID· Miconazole 2% cream BID· Econazole 1% cream BID||Hydrocortisone 1%, 2.5% cream, ointment BID (Evidence level A)· Desonide 0.05% cream, ointment BID· Fluocinolone 0.01% oil BID (for use in EAC)· Triamcinolone 0.1% cream, ointment BID (for persistent disease on the trunk only)||· Lithium succinate or gluconate 8% ointment BID (Evidence level A)· Topical pimecrolimus 1% cream BID (Evidence level B)· Topical tacrolimus 0.1% ointment BID (Evidence level C)For recalcitrant disease:· Oral itraconazole 200mg daily for 1 month, then 2 days each of the following 11 months (Evidence level B)· Oral terbinafine 250mg daily for 4-6 weeks (Evidence level A)|
|Erythroderma||Triamcinolone 0.1% ointment BID, using soak and smear and/or sauna suit|
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Seborrheic dermatitis is a common skin disease that causes an itchy rash with flaky scales. It causes redness on light skin and light patches on darker skin. It’s also called dandruff, cradle cap, seborrhea, seborrheic eczema, and seborrheic psoriasis.
It might look similar to psoriasis, eczema, or an allergic reaction. It usually happens on your scalp, but you can get it anywhere on your body.
Experts don't know what exactly causes seborrheic dermatitis. It seems to be a mix of things, including:
- Your genes
- A yeast that usually lives on your skin without causing problems
- Certain medical conditions and medicines
- Cold, dry weather
- An immune system response
It doesn't come from an allergy or from being unclean.
Newborns and adults ages 30 to 60 are more ly to get seborrheic dermatitis. It's more common in men than women and in people with oily skin. These conditions can also raise adults’ risk:
Babies 3 months and younger often get cradle cap: crusty yellow or brown scales on their scalp. It usually goes away before they're a year old, although it can come back when they reach puberty.
Parents might mistake seborrheic dermatitis for diaper rash.
Adults might get seborrheic dermatitis on their face, especially around their nose, in their eyebrows, on their eyelids, or behind their ears. It can show up on other parts of your body, too:
- In the middle part of your chest
- Around your navel
- On your buttocks
- In skin folds under your arms and on your legs
- In your groin
- Below your breasts
Your skin might itch or burn. The scales that flake off could be white or yellowish and look moist or oily.
Because seborrheic dermatitis can look other skin conditions, see your doctor to get a diagnosis and a treatment plan.
Your doctor will ask about your medical history and look at your skin. They might scrape off a bit of skin and look at it under a microscope to rule out conditions that affect your skin including:
- Psoriasis. This causes a lot of silvery white scales, often on your elbows and knees. It can also change how your fingernails look. You might have this at the same time as seborrheic dermatitis.
- Eczema (atopic dermatitis). This usually causes inflamed skin on your head, elbows, or knees.
- Rosacea. This can also happen along with dermatitis. It causes a red rash with few or no scales, often on your face. Rosacea can go away and come back several times.
- Allergic reaction. If your rash is itchy and doesn’t clear up with treatment, an allergy could be causing it.
- Systemic lupus erythematous (SLE). Some stages of this condition can cause a butterfly-shaped rash across the middle of your face.
Seborrheic dermatitis will sometimes clear up by itself. But often, it's a lifelong issue that clears and flares. You can usually control it with good skin care.
Talk with your doctor about a treatment plan. They’ll probably tell you to start with over-the-counter medicines and home remedies.
If you have seborrheic dermatitis on your scalp, use an over-the-counter dandruff shampoo with one of these ingredients:
- Coal tar
- Salicylic acid
- Selenium sulfide
- Zinc pyrithione
If your baby has cradle cap, shampoo their scalp daily with warm water and baby shampoo. A dandruff shampoo could irritate their skin, so talk to your pediatrician about medicated shampoos before you try one. To soften thick patches, rub mineral oil onto the area and brush gently with a baby hairbrush to help peel the scales off.
If you have seborrheic dermatitis on your face and body, keep the affected areas clean. Wash with soap and water every day.
Sunlight may stop the growth of the yeast organisms that are causing the problem, so being outdoors could help make the rash go away. Make sure to wear sunscreen.
Other treatments include:
- Antifungal products
- Corticosteroid lotions
- Sulfur products
These medicines can have side effects, especially if you use them for a long time. Follow your doctor’s advice. The best results often come from a mix of treatments.
See your doctor if your seborrheic dermatitis doesn't get better, if the area becomes painful, red, or swollen, or if it starts to drain pus. They might give you prescription cream, shampoo, or antifungal pills to clear up the symptoms.
American Academy of Family Physicians: “Seborrhea: What It is and How to Treat It.”
American Academy of Dermatology: “Seborrheic dermatitis.”
Cleveland Clinic: “Seborrheic Dermatitis.”
HealthyChildren.org: “Cradle Cap & Seborrheic Dermatitis.”
UpToDate: “Cradle cap and seborrheic dermatitis in infants,” “Seborrheic dermatitis in adolescents and adults.”
Mayo Clinic: “Seborrheic dermatitis.”
Journal of Clinical and Investigative Dermatology: “Seborrheic Dermatitis and Dandruff: A Comprehensive Review.”
© 2019 WebMD, LLC. All rights reserved.
Seborrheic Dermatitis (Cradle Cap)
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Cradle cap (infant seborrheic dermatitis) is scaly patches on a baby's scalp. Cradle cap isn’t serious, but it can cause thick crusting and white or yellow scales. Some babies can also have seborrheic dermatitis in the diaper area, and on the face, neck, and trunk. Cradle cap usually clears up within the first year.
What causes cradle cap?
Researchers don't know the exact cause of this skin condition. It is not contagious. It is not an infection or allergy. It is not caused by poor hygiene.
Which children are at risk for cradle cap?
Babies between the ages of 3 weeks and 12 months are at greater risk of getting cradle cap.
What are the symptoms of cradle cap?
Symptoms can occur a bit differently in each child. They can include dry or greasy scales on the scalp. The scalp may also appear red. It usually does not itch or cause the baby discomfort.
How is cradle cap diagnosed?
Cradle cap is usually diagnosed a physical exam of your child. The rash involved with cradle cap is unique. It can usually be diagnosed by a physical exam.
How is cradle cap treated?
Treatment will depend on your child’s symptoms, age, and general health. It will also depend on how severe the condition is.
The problem will go away on its own over time. But most parents prefer treatment because it usually helps reduce or get rid of the problem. Even with treatment, the problem may come back during the baby’s first year of life. Treatment is usually effective in helping symptoms. It may include:
- Rubbing the scalp with baby oil or petroleum jelly to soften crusts before washing
- Special shampoo, as prescribed by your child’s healthcare provider
- Corticosteroid cream or lotion for a short period of time if the problem is really bad or persistent
What can I do to prevent cradle cap in my child?
Cradle cap is common in young babies and does not point to poor hygiene or lack of care. The following may help prevent the buildup of scales on the scalp:
- Use a soft bristled brush to gently remove the scales from the scalp.
- Shampoo baby’s hair often.
- Apply baby oil to the scalp after shampooing.
When should I call my child’s healthcare provider?
Most cases of cradle cap can be treated at home. If the problem doesn’t get better, you may ask your healthcare provider to prescribe an appropriate shampoo or cream. If the problem still does not get better with the prescribed medicine, tell your healthcare provider.
Key points about cradle cap
- Cradle cap is scaly patches on a baby’s scalp.
- Babies between ages 3 weeks and 12 months are at greater risk of getting cradle cap.
- The problem will go away over time.
- Most cases of cradle cap can be treated at home by using a soft-bristled brush, frequent shampooing, and applying baby oil.
Tips to help you get the most from a visit to your child’s healthcare provider:
- Know the reason for the visit and what you want to happen.
- Before your visit, write down questions you want answered.
- At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you for your child.
- Know why a new medicine or treatment is prescribed and how it will help your child. Also know what the side effects are.
- Ask if your child’s condition can be treated in other ways.
- Know why a test or procedure is recommended and what the results could mean.
- Know what to expect if your child does not take the medicine or have the test or procedure.
- If your child has a follow-up appointment, write down the date, time, and purpose for that visit.
- Know how you can contact your child’s provider after office hours. This is important if your child becomes ill and you have questions or need advice.
Rash – child under 2 years
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A rash is a change in the color or texture of the skin. A skin rash can be:
- Red, skin-colored, or slightly lighter or darker than skin color
Most bumps and blotches on a newborn baby are harmless and clear up by themselves.
The most common skin problem in infants is diaper rash. Diaper rash is an irritation of the skin caused by dampness, urine, or feces. Most babies who wear diapers will have some type of diaper rash.
Other skin disorders can cause rashes. These are most often not serious unless they occur with other symptoms.
Causes may include:
- Diaper rash (rash in the diaper area) is a skin irritation caused by long-term dampness and by urine and feces touching the skin.
- Yeast diaper rash is caused by a type of yeast called candida, which also causes thrush in the mouth. The rash looks different from a regular diaper rash. It is very red, and there are usually small red bumps on the outer edges of the rash. This rash requires treatment with medicine.
- Heat rash, or prickly heat, is caused by the blockage of the pores that lead to the sweat glands. It is most common in very young children but can occur at any age. It is more common in hot and humid weather. The sweat is held within the skin and forms little red bumps or occasionally small blisters.
- Erythema toxicum can cause flat red splotches (usually with a white, pimple- bump in the middle) that appear in up to one half of all babies. This rash rarely appears after 5 days of age, and most often disappears in 7 to 14 days. It is nothing to worry about.
- Baby acne is caused by exposure to the mother's hormones. Red bumps, sometimes with white dots in the center, may be seen on a newborn's face. Acne most often occurs between 2 and 4 weeks of age, but may appear up to 4 months after birth and can last for 12 to 18 months.
- Cradle cap (seborrheic dermatitis) causes greasy, scaling, crusty patches on the scalp that appear in a baby's first 3 months. It most often goes away by itself, but some cases may require treatment with medicine.
- Eczema is a condition of the skin in which areas are dry, scaly, red (or darker than normal skin color), and itchy. When it goes on for a long time the areas become thickened. It is often associated with asthma and allergies, although it can often occur without either of these. Eczema often runs in families.
- Hives are red welts that appear to move around on the body. For example, if you drew a circle to mark one of the welts, a few hours later that circle would not have a welt in it, but there would be welts on other parts of the body. They differ in size and shape. Hives may last for a few weeks. The cause is uncertain.
Keep the skin dry. Change wet diapers as quickly as possible. Allow the baby's skin to air dry as long as is practical. Launder cloth diapers in mild soap and rinse well. Avoid using plastic pants. Avoid irritating wipes (especially those containing alcohol) when cleaning the infant.
Ointments or creams may help reduce friction and protect the baby's skin from irritation. Powders such as cornstarch or talc should be used cautiously, as they can be inhaled by the infant and may cause lung injury.
If your baby has a yeast diaper rash, the health care provider will prescribe a cream to treat it.
Heat rash or prickly heat is best treated by providing a cooler and less humid environment for the child.
Powders are unly to help treat heat rash and should be stored reach of the infant to prevent accidental inhalation. Avoid ointments and creams because they tend to keep the skin warmer and block the pores.
Erythema toxicum is normal in newborn babies and will go away on its own in a few days. You do not need to do anything for it.
White or clear milia/miliaria will go away on their own. You do not need to do anything for it.
For hives, talk with your provider to try to find the cause. Some causes require prescription medicines. Antihistamines may help stop the itching.
Normal washing is all that is necessary to treat baby acne most of the time. Use plain water or mild baby soap and only bathe your baby every 2 to 3 days. Avoid acne medicines used by adolescents and adults.
For cradle cap, wash the hair or scalp with water or a mild baby shampoo. Use a brush to remove the flakes of dry skin. If this cannot be removed easily, apply an oil to the scalp to soften it. Cradle cap most often disappears by 18 months. If it does not disappear, it becomes infected, or if it is resistant to treatments, consult your provider.
For skin problems caused by eczema, the keys to reducing rash are to reduce scratching and keep the skin moisturized.
- Keep the baby's fingernails short and consider putting soft gloves on the child at night to minimize scratching.
- Drying soaps and anything that has caused irritation in the past (including foods) should be avoided.
- Apply a moisturizing cream or ointment immediately after baths to avoid drying.
- Hot or long baths, or bubble baths, may be more drying and should be avoided.
- Loose, cotton clothing will help absorb perspiration.
- Consult a provider if these measures do not control the eczema, (your child may need prescription medicines) or if the skin begins to appear infected.
While the majority of children with eczema will outgrow it, many will have sensitive skin as adults.
When to Contact a Medical Professional
Call your child's provider if your child has:
- A fever or other unexplained symptoms associated with the rash
- Any areas that look wet, oozing, or red, which are signs of infection
- A rash that extends beyond the diaper area
- A rash that is worse in the skin creases
- A rash, spots, blister, or discoloration and is younger than 3 months
- No improvement after 3 days of home treatment
- Significant scratching
What to Expect at Your Office Visit
The provider will perform a physical exam. The baby's skin will be thoroughly examined to determine the extent and type of the rash. Bring a list of all the products used on the child's skin.
You may be asked questions such as:
- When did the rash start?
- Did symptoms begin at birth? Did they occur after fever was relieved?
- Is the rash related to skin injury, bathing, or exposure to sunlight or cold?
- What does the rash look ?
- Where on the body does the rash occur? Has it spread to other areas?
- What other symptoms are also present?
- What type of soaps and detergents do you use?
- Do you put anything on the skin (creams, lotions, oils, perfumes)?
- Is your child taking any medicines? How long has the child taken them?
- Has your child recently eaten any new foods?
- Has your child been in contact with grasses/weeds/trees recently?
- Has your child recently been sick?
- Do any skin problems run in your family? Does your child or anyone in your family have allergies?
Tests are seldom required but may include the following:
Depending on the cause of the rash, antihistamines may be recommended to decrease itching. Antibiotics may be prescribed if there is a bacterial infection.
The provider may prescribe a cream for diaper rash caused by yeast. If the rash is severe and not caused by yeast, a corticosteroid cream may be recommended.
For eczema, the provider may prescribe ointments or cortisone drugs to decrease inflammation.
Gehris RP. Dermatology. In: Zitelli BJ, McIntire SC, Nowalk AJ, eds. Zitelli and Davis' Atlas of Pediatric Diagnosis. 7th ed. Philadelphia, PA: Elsevier; 2018:chap 8.
Kohut T, Orozco A. Dermatology. In: The Johns Hopkins Hospital; Hughes HK, Kahl LK, eds. The Johns Hopkins Hospital: The Harriet Lane Handbook. 21st ed. Philadelphia, PA: Elsevier; 2018:chap 8.
Neil K. Kaneshiro, MD, MHA, Clinical Professor of Pediatrics, University of Washington School of Medicine, Seattle, WA. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.
An unwelcome eruption: periorificial dermatitis
» How would you treat her?
» What's the diagnosis?
An unhappy mother tells you that she is not leaving the office until you make her daughter's face normal again. The healthy 11-year-old girl has had an asymptomatic, slowly progressive eruption that started around her mouth three years ago.
|Figure 1 An asymptomatic, slowly progressing eruption around the mouth and nose. [IMAGE: DERMATLAS.ORG]|
In the last year, it has spread around her nose and eyes. (Figure 1).
Diagnosis: Periorificial dermatitis
Periorificial dermatitis (PD) is a common acneiform eruption of unknown origin most commonly found around the mouth, but lesions often spread around the nose and eyes.
1-8 Although PD may develop without antecedent use of topical steroids, it is often triggered by the chronic use of topical steroids for a pre-existing dermatosis, such as a contact dermatitis, and may persist for months to years.
This primarily facial eruption affects young women most commonly as well as children, and has an incidence of 0.5% to 1% in industrialized countries independent of geographic factors.1 Medications in use at the time of diagnosis included topical steroids (66%) and topical antifungals (20%).8
PD's clinical and histologic features overlap with acne rosacea, suggesting common triggering factors.
Clusters of follicular-bases red papules, papulo-vesicles, and papulopustules develop on a red base. They may become confluent around the mouth, but typically spare the vermillion border and the immediately surrounding skin. Similar lesions may develop around the nose and on the eye lids.
In a recent case series of about 80 affected children, erythema, scaling, or both were noted in 86% of patients, papules were noted in 66%, and pustules in 11%.
Isolated perioral involvement was seen in 39% of patients, perinasal alone in 13%, periocular alone in 1%, perioral and perinasal in 14%, perinasal and periocular in 6%, perioral and periocular in 6%, and perioral and perinasal and periocular in 10%.
8 Although PD is usually asymptomatic, mild pruritus is reported in 19% of patients, and 4% complained of burning or tenderness.8
The etiology of periorificial dermatitis is unknown; however, the chronic use of topical steroids for minor facial dermatoses has been implicated as a causative factor in many patients. Recently, neurogenic inflammation has also been proposed as a pathogenic mechanism.
For some, skin care ointments and creams, especially those with a petrolatum or paraffin base, and the vehicle isopropyl myristate may trigger the eruption.1 Gastrointestinal disturbances, such as malabsorption, may be a predisposing factor.
Although Fusiform spirilla bacteria, Candida species, and other fungi have been cultured from lesions, their role in PD is unclear.
The histopathologic findings in periorificial dermatitis are variable. Characteristic pathology described in 26 patients showed spongiotic changes in the external root sheaths of the follicles without similarity to rosacea.
9 However, many histologic findings overlap with acne rosacea.
They include follicular hyperkeratosis, edema and vasodilation of the papillary dermis, and perivascular and parafollicular infiltrates of lymphocytes, histiocytes, and polymorphonuclear leukocytes with occasional epithelioid granulomas and giant cells.5,10
The differential diagnosis for periorificial dermatitis includes acne vulgaris, contact dermatitis, rosacea, seborrheic dermatitis and folliculitis.
11 Rosacea can be distinguished by its association with frequent flushing, erythema and telangiectasia, ocular involvement (eg, blepharitis, conjunctival hyperemia, keratitis, and iritis), and associated rhinophyma.
12 In seborrheic dermatitis there is usually accentuation along the nasolabial folds. Contact dermatitis, which is most frequently caused by food, saliva and tartar control toothpaste, involves the vermillion border and immediately surrounding perioral skin.
Comedones, which are characteristic of acne vulgaris, are absent in periorificial dermatitis. Bacterial or fungal folliculitis are not restricted to a periorificial distribution.
|IMAGE: GETTY IMAGES/BLEND IMAGES/ANDERSEN ROSS|
Patients require topical and/or systemic treatment, evaluation for predisposing factors, and reassurance. Before initiating treatment, patients should be advised to discontinue predisposing cosmetic facial creams, sunscreens, and topical steroids. Rebound after discontinuation of steroids may require restarting the topical agents and tapering over two to three weeks.
Topical antibiotics including metrinidazole, erythromycin, mupirocin, and sulfacetamide have been reported to successfully treat PD.
8 However, when these agents fail or the skin is too irritated to tolerate topical therapy, oral antibiotics including erythromycin (30 mg/kg/day divided in three doses) in preadolescents and tetracycline derivatives in adolescents (at doses used for acne vulgaris) are usually effective.
Providers should emphasize that patients may require two to three months of therapy to clear, and they should not anticipate much improvement for at least two to four weeks.7
MS. FATUSIN is a fourth-year medical student at Johns Hopkins University School of Medicine, Baltimore.
DR. PUTTGEN is an assistant professor of pediatric dermatology at Johns Hopkins University School of Medicine.
DR. COHEN, who serves as section editor for Dermatology: What's your Dx?, is director, Pediatric Dermatology and Cutaneous Laser Center, and professor of pediatrics and dermatology, Johns Hopkins University School of Medicine, Baltimore. He is a contributing editor of Contemporary Pediatrics.
The authors and section editor have nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article.
Vignettes are real cases which have been modified to allow the authors and editor to focus on key teaching points. Images may also be edited or substituted for teaching purposes.
1. Guarneri F, Marini H: An unusual case of perioral dermatitis: possible pathogenic role of neurogenic inflammation. J Eur Acad Dermatol Venereol 2007;21:410
2. Kuflik JH, Janniger CK, Piela Z: Perioral dermatitis: an acneiform eruption. Cutis 2001;67:21
3. Boeck K, Abeck D, Werfel S, et al: Perioral dermatitis in children—clinical presentation, pathogenesis-related factors and response to topical metronidazole. Dermatology 1997;195:235
4. Manders SM, Lucky AW: Perioral dermatitis in childhood. J Am Acad Dermatol 1992;27:688
5. Frieden IJ, Prose NS, Fletcher V, et al: Granulomatous perioral dermatitis in children. Arch Dermatol 1989;125:369
6. Dubus JC, Marguet C, Deschildre A, et al: Local side-effects of inhaled corticosteroids in asthmatic children: influence of drug, dose, age, and device. Allergy 2001;56:944
7. Perioral dermatitis. Available at: http://dermnetnz.org/acne/perioral-dermatitis.html. Accessed Jan 5, 2009
8. Nguyen V, Eichenfield L: Periorificial dermatitis in children and adolescents. J Am Acad Dermatol 2006;55:781
9. Marks R, Black MM: Perioral dermatitis. A histopathologic study of 26 cases. Br J Dermatol 1971;84:242
10. Ramelet AA, Delacretaz J: Histopathologic study of perioral dermatitis. Dermatologica 1981;163:361
11. Hafeez ZH: Perioral dermatitis: an update. Int J Dermatol 2003;42:514
12. Hogan DJ: Perioral dermatitis. Curr Probl Dermatol 1995;22:98