Pediatric Procedural Dermatology
Pediatric procedural dermatology is a broad and emerging field. Pediatric patients often present with unique diagnoses, and procedures in this population often require special tools. In addition, performing procedures on infants, children, and teenagers requires special considerations, skill sets, and knowledge. This article provides a brief overview of decision-making processes, common diagnoses, and common procedures performed by dermatologists in this patient population.
Practice Points
- Children who require repetitive laser or surgical procedures over time benefit from regular monitoring of psychosocial needs.
- The informed consent process for children differs from adult procedural dermatology and should be adjusted to the maturity level of the patient.
- Common diagnoses unique to procedural pediatric dermatology that may require additional investigation include congenital melanocytic nevi, vascular anomalies, epidermal nevi, and midline lesions.
- Specific measures can be performed to improve outcomes when removing accessory tragi, dermoid cysts, pilomatricomas, and congenital nevi.
Common Diagnoses
The most common diagnoses unique to procedural pediatric dermatology include congenital melanocytic nevi, vascular anomalies, midline lesions, epidermal nevi, and pilomatricomas. Prior to intervening on these lesions, it is important to consider evaluating for associated diseases.
Congenital Melanocytic Nevi
Nevus Outreach has published best practices for the management of congenital melanocytic nevi.9 In newborns with a congenital melanocytic nevus greater than 3 cm in diameter or more than 20 satellite lesions, it is recommended that magnetic resonance imaging (MRI) of the brain and spine with and without gadolinium contrast be obtained before 6 months of age. Within the first 6 months of life, these children also should see ophthalmologists, neurologists, pediatric dermatologists, and plastic surgeons. These early referrals will help to establish a baseline for the patient and plan for possible interventions, if needed. Additionally, before 3 years of age, every child should be referred to psychology, even if he/she is asymptomatic.10
Vascular Anomalies
Prior to intervening on a vascular anomaly, it is important to accurately classify the lesion. Once the lesion is classified, an evaluation and treatment plan can be developed. The International Society for the Study of Vascular Anomalies has published a detailed classification guide that is a useful starting point in the management of vascular anomalies.11 Once a diagnosis is confirmed, further evaluation may include imaging, specialty referrals, genetic testing, biopsy, or blood tests, and a pediatric dermatologist usually helps to coordinate the care of patients with complex vascular anomalies.
Midline Lesions
Certain lesions in the midline may have a higher risk for neural tube dysraphism, and imaging should be performed prior to any procedural intervention.12 Midline cutaneous findings that are highly likely to be associated with dysraphism are lipomas, acrochordons, pseudotails, true tails, aplasia cutis congenita, congenital scars, dermoid cysts, dermoid sinuses, and infantile hemangiomas that are greater than 2.5 cm in diameter. An MRI should be performed for all high-risk lesions. Intermediate-risk lesions are atypical dimples (>5 mm in diameter or >2.5 cm from the anal verge), hemangiomas less than 2.5 cm in diameter, and hypertrichosis. An ultrasound can screen for spinal dysraphism in these cases as long as imaging is performed prior to 6 months of age. If the child is older than 6 months, an MRI should be performed. Low-risk lesions that do not require imaging are simple dimples, hyperpigmentation, hypopigmentation, melanocytic nevi, port-wine stains, and telangiectases.
Epidermal Nevi
Children with epidermal nevi should have a complete physical examination, focusing on the skeletal system, central nervous system, and eyes. There are no specifically recommended imaging studies or referrals; however, several diagnostic clues can aid in the diagnosis of an epidermal nevus syndrome13:
• Schimmelpenning syndrome: extensive nevus sebaceous and bowing or pain in the legs after 2 years of age
• Phacomatosis pigmentokeratotica: nevus sebaceous and nevus spilus
• Nevus comedonicus syndrome: ipsilateral cataract
• Angora hair nevus syndrome: soft white hair within the nevus
• Becker nevus syndrome: breast hypoplasia
• Proteus syndrome: cerebriform plantar changes
• PIK3CA-related overgrowth spectrum: lipomas, macrodactyly, and/or vascular malformations
• Congenital hemidysplasia with ichthyosiform erythroderma and limb defects: inflammatory epidermal nevi, lateralization, ptychotropism, and ipsilateral limb defects
• Conradi-Hünermann-Happle syndrome: scaly red epidermal nevi without hair follicles and asymmetric limb shortening
Pilomatricomas
In addition to the tent sign—an angulated shape can be appreciated by stretching the skin overlying pilomatricomas—diagnosis of pilomatricoma can be confirmed by transillumination with an otoscope. In this case, a dark shadow typically is cast distal to where the otoscope touches the skin.14 In the case of multiple lesions, the patient should be evaluated for signs of myotonic dystrophy, Turner syndrome, and Gardner syndrome.15
Common Procedures
Pulsed Dye Laser
The pulsed dye laser is the most common laser used for red-colored lesions such as port-wine stains, facial telangiectases, and superficial hemangiomas. It also can be used to treat erythematous scars, verrucae, and psoriasis. In large vascular lesions, it typically is employed at 0.45 to 10 milliseconds every 4 to 6 weeks for 10 or more treatments. Port-wine stains preferably are treated within the first few months of life to provide the most fading without the need for general anesthesia.16 On the other hand, systemic therapy with propranolol is preferred over lasers for infantile hemangiomas.17
Long-Pulsed Alexandrite Laser (755 nm)
The alexandrite laser often is used to treat deeper vascular lesions such as venous lakes and hypertrophic port-wine stains. The operator needs to be cautious, as this laser has a higher incidence of scarring at the settings used to treat vascular lesions (typically fluences around 60–85 J/cm2).18 It also may be used for hair reduction in disorders with hypertrichosis or hidradenitis suppurativa.19
