Pediatric dermatology may pose a challenge to pediatricians and dermatologists alike, because pediatricians may be unfamiliar with certain dermatologic diagnoses, and general dermatologists may not be accustomed to dealing with children and their parents. When making dermatologic diagnoses, it is important to examine the skin carefully, paying special attention to distribution of lesions; morphology; and hair, nail, and mucosal changes. Possible differential diagnoses also need to be kept in mind.

For physicians who do not have routine experience with pediatric conditions, it may be difficult to adjust the patient-physician interaction to the appropriate level. For infants, obviously the majority of physician interaction occurs with parents or other caretakers. With increasing age of the patient, the physician should focus the visit more toward the patient. Patients should also be allowed to provide more input into treatment decisions as they become older. These factors are especially important when evaluating and managing teenage patients because compliance may become a major issue.

Some more specific points need to be kept in mind when evaluating and managing cutaneous disease in children. Skin biopsies are usually a last resort because they may be traumatic for young children and leave unnecessary scarring. If the diagnosis is truly in question and the information provided by a biopsy would alter management of the patient, then it is imperative to perform this diagnostic test. For children who fear needles, the eutectic mixture of lidocaine and prilocaine (EMLA) may be applied to anesthetize the biopsy site before more definitive anesthesia with infiltration of lidocaine. When performing biopsies or any other procedures in a child, distraction is an important tool in allaying fear. At the authors' hospital, a Child Life service is specifically devoted to providing distraction and comfort to children during procedures, by using books, games, music, and toys.

Therapeutic options are weighed according to the age and maturity of each individual child. For a disease that is benign and self-limited, the physician, parent, and child may opt for no therapy at all except for watchful waiting; the same disease in an adult might be treated more aggressively. Traumatizing a child unnecessarily should be avoided. A common example of such a situation is the treatment of warts, which is discussed in more detail later.

Systemic medications should be prescribed in liquid formulations whenever possible, until the child is able to tolerate swallowing pills or tablets, usually by 8 years of age. If a medication is not available in a liquid formulation and there is no other choice for treatment, tablets may be crushed and mixed with food or drink, and capsules may be opened for mixing as long as appropriate dosing can be maintained.

Topical medications are used frequently in the treatment of dermatologic disease. Topical corticosteroids comprise a large portion of the medications prescribed in dermatology on a daily basis. They are classified according to potency, and different vehicles may change the potency of a particular steroid. Ointments are generally more potent than the same medications in cream preparations. Topical steroids used by the authors are listed according to potency ranking in Table 1. Physicians and patients must be vigilant for side effects of long-term topical steroid use, especially when using the more potent formulations. Adverse effects include atrophy of the skin, telangiectasia, and striae. Only class VII topical steroids should be used for treatment of inflammatory conditions on the thin skin of the face, underarms, and groin. Topical antibiotics are often used in the treatment of infectious dermatologic conditions. Specific topical medications that should be avoided in children are neomycin because of a high risk of contact sensitization, topical lidocaine, and topical diphenhydramine.

Another important factor in management of the pediatric patient is education about the disease process, both for the parents and for the mature child. For example, in chronic diseases such as atopic dermatitis and acne, it is important for the parents and the patient to understand the chronic nature of the disease, the importance of long-term management, and the need for acute treatment when appropriate. In the management of benign skin lesions such as warts, it is important for the parents and child to understand the cause and self-limited nature of the infection, whether treated or not. Education enhances rapport and increases compliance.

This article discusses specific common dermatologic entities within the broad categories of infectious disease, papulosquamous and eczematous disorders, inflammatory disease, and neoplastic disease. To begin, diagnostic techniques used in pediatric dermatology are discussed.