From the Departments of Dermatology and Sexually Transmitted Disease and *Pediatrics, Lady Hardinge Medical College and associated S.S.K. and K.S.C. Hospitals, New Delhi 110 001, India.
Reprint requests: Dr. Srikanta Basu, c/o Mrs. C. Sarkar, 9, Teachers’ Flat, PGIMER, Sector 12, Chandigarh 160 012, India.

Manuscript received: June 18, 1999;
Initial review completed: August 6, 1999;
Revision accepted: October 8, 1999

Dermatological problems manifesting as primary and secondary cutaneous complaints, constitute at least 30% of all outpatient visits to a pediatrician and 30% of all visits to dermatologists involve patients of pediatric age group(1).

With the objective of finding out the nature of the pediatric dermatological emergencies seen in an exclusive children’s hospital, we did a prospective study of dermatological emer-gency referrals in the pediatric age group at Kalawati Saran Children’s Hospital, New Delhi, an exclusive children’s hospital having all the specialities including dermatology unit. For the purpose of this study, only dermatological conditions in the pediatric age group which could be potentially severe or life threatening, were classified as emergencies. Though majority of the conditions were provisionally diagnosed or classified by the pediatricians at referral, the definite classi-fication was made by the dermatologist on consultation. Any such case which appeared to be a dermatological emergency by the pediatrician but was not confirmed by the dermatologist, was omitted from the study. Pediatric dermatological emer-gencies, are also manifestations of systemic complications and require the urgent attention of the dermatologist and the pediatrician.

The study was conducted from January 1998 to December 1998. The pediatric dermato-logical emergencies observed during this period were carefully recorded. The history was recorded followed by detailed dermatological, systemic and general physical examination. Relevant investigations were done whenever indicated to confirm the diagnosis. Histo-pathological confirmation was done in all unusual case such as epidermolysis bullosa and scleredema. For compiling our observations, the patients were divided into four groups–one to thirty days (neonates), one month to one year (infants), one to five years (preschool) and more than five years (school going). Drug eruptions were clinically identified based on subjective criteria(2).

During the study period, pediatric dermato-logical emergency referrals were requested in 103 patients. There were 61 males and 42 females (M:F ratio 1.51:1). The study included sixteen (15.5%) neonates, ten (9.7%) infants, thirty eight (36.9%) preschool and thirty nine (37.9%) school going children who were referred by the pediatricians for the management of dermatological emergencies.

The spectrum of pediatric dermatological emergencies in neonates and post neonatal age which required the immediate attention of the dermatologist and had to be carefully monitored and managed by the pediatrician and the der-matologist together is shown in (Tables I & II). Hereditary conditions such as collodian baby, Harlequin’s icthyosis and epidermolysis bullosa formed the largest group (37.5%) of neonatal emergencies, followed closely (31.3%) by the staphylococcal scalded skin syndrome (SSSS). There were some dermatological emergencies associated with the neonatal intensive care such as chemical burns due to antiseptics and phototherapy induced erythema.

The main pediatric dermatological emer-gency referrals in infants (beyond neonatal age) were severe cases of atopic and infantile seborrheic dermatitis (Table II). In the preschool age, infections (42.1%) formed the largest group and in the school going age group drug induced cutaneous reactions (56.4%) were the most frequent.

Table I - Neonatal Dermatological Emergencies

  Figures within the parenthesis depict percentage within the groups

Table II - Post Neonatal Dermatological Emergencies

The spectrum and importance of pediatric dermatology in the dermatology department of a general hospital(3), as also the dermatological emergencies seen in the casualty department of a general hospital(4) have been studied before. However there are hardly any studies conducted on exclusively pediatric dermatological emergency referrals in an exclusively pediatric hospital, as in our study.

Neonatal dermatological emergencies accounted for 15.5% of total referrals in our study. Neonates form a special group of interest to us, as their skin is more susceptible to several infections and their immature intestinal tract to allergens(5). Earlier studies have been mainly on benign cutaneous lesions in newborns(6–9) or on erythrodermas of neonatal period as well as of infancy which are dermatological emergencies(5). As observed by Barker(5), we also observed erythrodermas attributed to staphylococcal scalded skin syndrome, infantile seborrheic dermatitis, collodian baby and Harlequin’s icthyosis, which presented as neonatal dermatological emergencies. Dermato-logical consultation was important in cases of hereditary condition for proper classification, confirmation by skin biopsy and careful monitoring. In cases of staphylococcal scalded skin syndrome (31.3%) dermatology consulta-tion resulted in intervention in the form of timely institution of antibiotics. In cases of dermato-logical emergencies exclusive to the neonatal intensive care unit (18.7%) which included cases of chemical burns induced by antiseptics and phototherapy induced erythema, interven-tion by the removal of the offending agents and management with topical medications resulted in dramatic improvement as also observed elsewhere(10).

In infants beyond neonatal age, the im-portant dermatological emergencies comprised severe atopic and infantile seborrheic dermatitis which were severely disabling for the patients. These severe dermatitic conditions required careful observation and dermatological therapy, and the dermatologist was able to sufficiently reassure and clear the doubts in the minds of the patient’s parents and the pediatrician. Infections formed the largest (42.1%) group in the preschool age children whereas it was the second largest (28.2%) dermatological emer-gency in school going children. Both these groups are exposed to all sorts of infections which they pick up from fellow students or playmates during sporting activities; therefore infections presenting as dermatological emergencies were expected(11). On classifica-tion of the infections by the dermatologist, an appropriate antibiotic could be decided by both the pediatrician and dermatologist for the timely management of the patient. Drug induced cutaneous reactions formed the largest group (56.4%) in the school going age group whereas it was the second largest (34.2%) in the preschool going age. Phenytoin, phenobarbi-tone, sulfonamides, ampicillin and antituber-cular drugs were the chief implicated drugs, as also observed elsewhere(12). Both antiepileptics and antibiotics have to be prescribed when necessary by the pediatricians, thus accounting for the large number of drug induced cutaneous reactions observed in these two groups. The pediatrician may be the first person to pro-visionally diagnose these frightening looking infections and drug induced cutaneous reactions, as the patients first present to him and he subsequently refers them to the dermatologist for expert opinion. In drug induced cutaneous reactions, a child may be receiving several drugs simultaneously for the underlying infection or systemic disease and it will be the dermatologist who decides the possible drug or drugs implicated in this condition. On doing so, he may request their total stoppage or with the pediatrician’s help decide a likely substitute, if the drug must be prescribed. There is substantial improvement in some of the cases. In addition, severe reactions often require the use of sys-temic corticosteroids for managing the patients. Thus dermatological consultation in the cases of drug reactions in pre-school (34.2%) and school going (56.4%) children was necessary for active intervention as highlighted.

Thus, as observed earlier(4), it is of utmost importance to have an open access dermatology referral system in a pediatric hospital, so that the pediatrician can confirm his clinical suspicion, be reassured that some of the emergency conditions may not be as frightening as they appear; they merely need close monitoring and minimal interference at times. The close liaison between the pediatrician and the dermatologist may allow early prevention and treatment and thus work for the overall betterment of the pediatric patients. The knowledge and expertise of the dermatologist may allay overanxiety of the parents and the pediatrician. The overall management and intensive care of the patients may be in the hands of the pediatricians, but the dermatologist definitely has the role of a psychotherapist(13), by clearing all doubts in the child’s parent’s minds by explaining the nature and course of a frightening condition. The pediatrician and dermatologist must work hand in hand to manage pediatric dermato-logical emergencies as early institution of treatment and observation may be life saving.

1. Schachner LA, Hansen RG. Preface. In: Pediatric Dermatology, 2nd edn. Eds. Schachner LA, Hansen RC. New York, Churchill Livingstone, 1995; p IX.

2. Blacker KL, Stern RS, Wintroub BU. Cutaneous reactions to drugs. In: Dermatology in General Medicine, 4th edn. Eds. Fitzpatrick TB, Eisen AZ, Wolff K, Freedberg IM, Austen KF. New York, Mc Graw Hill, 1993; pp 1783-1785.

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5. Barker LP, Gross P, Mc Carthy JT. Erythrodermas of infancy. Arch Dermatol 1958; 77: 201-209.

6. Nanda A, Kaur S, Bhakoo ON, Dhall K. Survey of cutaneous lesions in Indian newborns. Pediatr Dermatol 1989; 6: 89-42.

7. Jacobs AH, Walter RG. The incidence of birth marks in the neonate. Pediatrics 1976; 58: 218-222.

8. Osburn K, Schosser RH, Everett MA. Congenital pigmented and vascular lesions in newborn infants. J Am Acad Dermatol 1987; 16: 788-792.

9. Hirdano A, Purwako R, Jitsukawa K. Statistical study of skin changes in Japanese neonates. Pediatr Dermatol 1986; 3: 140-144.

10. Wagner AM, Hansen RC. Neonatal skin and skin disorders. In: Pediatric Dermatology, 2nd edn. Eds. Schachner LA, Hansen RC. New York, Churchill Livingstone, 1995; pp 263-346.

11. Graham Brown RAC. The ages of man and their dermatoses. In: Textbook of Dermatology, 6th edn. Eds. Champion RH, Buston JL, Burns DA, Duathrach SM. Oxford, Blackwell Scientific Publications, 1998, p 3261.

12. Sharma VK, Dhar S. Clinical pattern of cutaneous drug eruption among children and adolescents in North India. Pediatr Dermatol 1995; 12: 178-183.

13. Burton JL, Champion RH. Introduction and historical bibliography. In: Textbook of Dermatology, 6th edn. Eds. Champion RH, Burton JL, Burns DA, Breathnach SM. Oxford, Blackwell Scientific Publications, 1998; p 1.