Pediatric Derma-Ophthal-Ortho

Pediatric Specialties Reference

Welcome to the comprehensive Pediatric Specialties Reference guide, designed for medical students, residents, fellows, and healthcare professionals working with children. This resource provides detailed information on the evaluation, diagnosis, and management of pediatric ophthalmology, dermatology, and orthopedic conditions.

Pediatric patients present with unique manifestations of diseases that differ from adults. This reference tool serves as a quick access point for understanding pediatric-specific conditions, their clinical features, diagnostic approaches, and evidence-based management strategies.

Select a topic from the table below to view comprehensive information, including clinical presentations, diagnostic approaches, treatment modalities, and special considerations for different pediatric populations. This resource is regularly updated to reflect the latest evidence-based practices and guidelines.

Pediatric Ophthalmology
Congenital & Developmental Disorders


Strabismus & Amblyopia


Refractive & Common Disorders

Pediatric Dermatology
Neonatal Dermatoses


Inflammatory Dermatoses


Infections & Infestations

Pediatric Orthopedics
Developmental Dysplasias


Spinal Disorders


Growth & Sports Related

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Congenital Cataracts

Etiology & Classification

Classification	Subtypes	Characteristics
By etiology	• Idiopathic (40-60%) • Hereditary (25-30%) • Associated with syndromes (15-20%) • Secondary to intrauterine infections (5-10%)	• Majority are isolated with no identifiable cause • AD, AR, or X-linked patterns of inheritance • TORCH infections (particularly rubella) • Drug or radiation exposure during pregnancy
By morphology	• Total/complete cataract • Nuclear cataract • Lamellar/zonular cataract • Sutural cataract • Polar cataract (anterior/posterior) • Membranous cataract	• Specific patterns provide clues to etiology • Visual impact varies by location and density • Posterior cataracts generally more visually significant than anterior • Central cataracts more visually significant than peripheral
By laterality	• Unilateral (60-70%) • Bilateral (30-40%)	• Unilateral: Higher risk of amblyopia, often sporadic • Bilateral: More likely hereditary or syndromic

Associated Systemic Conditions

Category	Examples	Cataract Features
Chromosomal abnormalities	• Trisomy 21 (Down syndrome) • Trisomy 13 (Patau syndrome) • Trisomy 18 (Edwards syndrome) • Turner syndrome	• Down: Snowflake or "Christmas tree" cataracts • Often bilateral • Variable morphology
Metabolic disorders	• Galactosemia • Galactokinase deficiency • Wilson disease • Lowe syndrome • Hypocalcemia • Fabry disease	• Galactosemia: Oil-droplet central opacity • Lowe: Discoid/dense nuclear • Typically bilateral • May be progressive
Congenital infections	• Congenital rubella • Toxoplasmosis • Cytomegalovirus • Herpes simplex • Varicella zoster	• Rubella: Dense nuclear cataract • Often associated with microphthalmia • Other ocular abnormalities common
Genetic syndromes	• TORCH syndrome • Alport syndrome • Cockayne syndrome • Conradi-Hünermann syndrome • Hallermann-Streiff syndrome • Marfan syndrome • Nance-Horan syndrome	• Syndrome-specific patterns • Often bilateral • Associated with other ocular anomalies

Clinical Presentation & Diagnosis

Clinical Signs:

Absence of red reflex or white/abnormal reflex
Leukocoria (white pupillary reflex)
Strabismus or nystagmus (in unilateral cases)
Visual inattention or poor fixation behavior
Searching or wandering eye movements
Abnormal visual behaviors for age

Diagnostic Approach:

Assessment Method	Findings & Significance
Red reflex examination	• Essential screening tool for all newborns and infants • Dark spots, opacities, or absence of red reflex indicate potential cataract • Should be performed at routine well-child visits
Direct ophthalmoscopy	• Can detect lens opacities • Limited in providing detailed view • Useful for initial screening
Slit-lamp examination	• Gold standard for detection and classification • Provides detailed view of cataract morphology, density, and location • May require general anesthesia in infants for comprehensive exam
Retinoscopy/refraction	• Assess refractive error • High myopia often associated with posterior lenticonus • Determines need for optical correction
Biometry/keratometry	• Axial length and corneal curvature measurements • Essential for IOL power calculation if surgery planned • Helps identify microphthalmia
Ultrasound (B-scan)	• When fundus not visible due to dense cataract • Assess posterior segment for anomalies • Rule out retinal detachment or tumors (e.g., retinoblastoma)

Systemic Evaluation & Workup

Comprehensive evaluation for bilateral cataracts or cases with systemic features:

Investigation Category	Specific Tests	Indications
Basic screening	• Complete physical examination • Detailed family history • Growth parameters • Developmental assessment	• All cases of bilateral cataracts • Unilateral cases with dysmorphic features
Metabolic screening	• Urine reducing substances • Urine for galactose-1-phosphate uridyl transferase • Serum calcium, phosphorus • Blood glucose	• Bilateral, symmetric cataracts • Suspected metabolic disorder • Failure to thrive
Infectious disease	• TORCH titers (toxoplasmosis, rubella, cytomegalovirus, herpes) • Varicella zoster virus IgG/IgM • PCR testing as indicated	• History of maternal illness during pregnancy • Associated microcephaly or growth retardation • Other stigmata of congenital infection
Genetic testing	• Karyotype • Chromosomal microarray • Targeted gene panels for cataract-associated genes • Whole exome/genome sequencing	• Familial cases • Bilateral symmetric cataracts • Associated systemic abnormalities • Suspected genetic syndrome
Additional imaging	• Brain MRI/CT • Renal ultrasonography • Cardiac echocardiography	• CNS abnormalities • Suspected syndromic association • Multi-system involvement

Management Principles

Decision-making factors:

Laterality (unilateral vs. bilateral)
Density and location of opacity
Visual significance (central vs. peripheral)
Age at presentation
Associated ocular anomalies
Systemic conditions

Management Options:

Approach	Indications	Considerations
Observation	• Small, peripheral, non-progressive cataracts • Minimal visual impact • Normal visual development	• Regular monitoring for progression • Visual acuity assessment • Monitor for amblyopia development
Pharmacological dilation	• Small central cataracts • Cases where surgery is deferred • Temporary visual improvement	• Limited utility • May provide temporary visual axis clearing • Not a definitive solution
Surgical intervention	• Visually significant cataracts • Dense/central opacities • Evidence of amblyopia development • Progressive cataracts	• Timing critical for visual development • Bilateral: Usually by 6-10 weeks of age • Unilateral: Earlier intervention (4-6 weeks) • Emergent for white intumescent cataracts
Optical rehabilitation	• Post-surgical aphakia • Refractive error correction • All pediatric cataract patients	• Contact lenses vs. spectacles vs. IOL • Age-dependent approach • Family capability and compliance
Amblyopia treatment	• Post-surgical management • Unilateral cases • Asymmetric bilateral cases	• Patching therapy • Critical for visual rehabilitation • Long-term commitment required

Surgical Management

Surgical Approach:

Technique: Pediatric lens aspiration with primary posterior capsulotomy and anterior vitrectomy
Incision: Clear corneal or scleral tunnel approaches
Capsulotomy: Manual continuous curvilinear capsulorhexis or vitrectorhexis
Lens removal: Bimanual or coaxial irrigation/aspiration
Posterior capsulotomy: Essential in children under 6-8 years to prevent posterior capsule opacification
Anterior vitrectomy: Prevents vitreous prolapse and secondary membrane formation

IOL Considerations:

Age Group	Approach	Rationale
<6 months	• Primary aphakia with contact lens correction • Rarely primary IOL implantation	• Rapid eye growth and myopic shift • Higher complication rates with IOLs • Difficult IOL power calculation • IATS study supports aphakia approach
6-24 months	• Consider primary IOL in selected cases • Individualized approach • Surgeon and family preference	• Slowing of axial growth • Still significant myopic shift expected • Under-correction typically by 6-8D • Family/social factors important
>2 years	• Primary IOL implantation preferred • Target mild hyperopia (age-dependent)	• More predictable refractive outcomes • Slower axial elongation • Better tolerance of spectacle correction • Improved visual rehabilitation

IOL Power Calculation:

Undercorrection based on age due to expected myopic shift
General guideline: target +6D for infants, +4D for toddlers, +2D for preschoolers, emmetropia for school-age
SRK/T, Holladay II, or pediatric formulas preferred
Axial length and keratometry measurements critical
Intraoperative aberrometry may improve accuracy

Post-Surgical Management

Medication Protocol:

Antibiotics: Topical fluoroquinolones QID for 1-2 weeks
Steroids: Prednisolone acetate 1% starting QID and tapered over 4-6 weeks
Cycloplegics: Cyclopentolate 0.5-1% BID for 1-2 weeks
Anti-glaucoma: Prophylactic in high-risk cases

Visual Rehabilitation:

Approach	Implementation	Considerations
Contact lenses	• Silicone elastomer lenses for infants • RGP or soft lenses for older children • Extended wear options for younger patients	• Fitted within 1 week post-surgery • Requires caregiver training and compliance • Regular replacement schedule • Higher cost and maintenance burden
Spectacles	• Aphakic glasses (+12 to +20D) • Bifocal or progressive designs • Polycarbonate lenses for safety	• Less compliance in infants • Optical aberrations with high powers • Limited for unilateral aphakia (aniseikonia) • Regular updates as child grows
Amblyopia therapy	• Patching of better eye (2-6 hours daily) • Atropine penalization in select cases • Compliance monitoring	• Critical for unilateral cases • May continue for years • Intensity based on severity • Regular visual acuity assessment

Follow-up Protocol:

First week: POD 1, 3-5, 7
First month: Weekly
First year: Monthly then quarterly
Long-term: Every 3-6 months for amblyopia monitoring and refractive management
Annual examinations under anesthesia may be required for young or uncooperative children

Complications & Management

Complication	Incidence	Management Approach
Glaucoma	• Aphakic: 15-45% • Pseudophakic: 5-15% • Higher risk in surgery <4 months of age	• Regular IOP monitoring • Medical therapy (beta-blockers, CAIs) • Surgical options (trabeculotomy, goniotomy, tube shunt) • Lifelong monitoring required
Visual axis opacification	• Without PPC/AV: 80-95% • With PPC/AV: 10-25%	• Nd:YAG laser capsulotomy in older children • Surgical membranectomy in younger children • May require EUA for procedure
Amblyopia	• Unilateral: 80-90% • Asymmetric bilateral: 30-50% • Higher with delayed treatment	• Aggressive patching • Consistent optical correction • Regular visual acuity assessment • May require years of therapy
IOL decentration	• 5-15% (higher in younger children)	• Observation if mild • Surgical repositioning if visually significant • IOL exchange if necessary
Refractive surprise	• 30-50% >2D from target	• Spectacle correction • Contact lens options • IOL exchange rarely necessary
Inflammation	• Severe: 10-20% • Fibrinous: 5-10%	• Intensive topical steroids • Subconjunctival/periocular steroids • Systemic steroids in severe cases • Fibrinolytic agents for fibrin response
Endophthalmitis	• 0.04-0.1%	• Vitreous tap and intravitreal antibiotics • Consider vitrectomy • Systemic antibiotics

Prognosis & Outcomes

Visual Outcomes:

Category	Typical Outcomes	Prognostic Factors
Bilateral cataracts	• 20/40 or better: 70-80% • 20/60 to 20/200: 15-20% • <20/200: 5-10%	• Age at surgery (<10 weeks better) • Compliance with optical correction • Absence of other ocular abnormalities • Timely surgical intervention
Unilateral cataracts	• 20/40 or better: 30-50% • 20/60 to 20/200: 30-40% • <20/200: 20-30%	• Very early surgery (4-6 weeks) • Aggressive amblyopia therapy • Consistent optical correction • Absence of strabismus

Factors Affecting Outcomes:

Age at diagnosis: Earlier diagnosis leads to better outcomes
Timing of surgery: Critical window for visual development
Laterality: Bilateral generally better than unilateral
Associated abnormalities: Presence of microphthalmia, persistent fetal vasculature, etc.
Compliance with therapy: Consistent optical correction and amblyopia treatment
Family support: Caregiver understanding and participation
Systemic associations: Underlying syndromes may impact development

Developmental Dysplasia of the Hip

Risk Factors & Etiology

Category	Risk Factors	Relative Risk
Demographic	• Female gender • First-born status • Caucasian ethnicity • Family history of DDH	• 6× higher in females • 2.5× higher in firstborns • 2× higher with positive family history • 10× higher with affected parent
Obstetric	• Breech presentation • Oligohydramnios • Large birth weight • Multiple gestation	• 5-10× higher in breech • 3× higher with oligohydramnios • 1.5× higher in macrosomia • 2× higher in twins/triplets
Associated conditions	• Congenital torticollis • Metatarsus adductus • Congenital foot deformities • Neuromuscular disorders	• 8× higher with torticollis • 4× higher with foot deformities • 2-5× higher with neuromuscular conditions
Genetic/Syndromic	• Ehlers-Danlos syndrome • Down syndrome • Arthrogryposis • Larsen syndrome	• Ligamentous laxity predisposition • Compound genetic influence • Variable penetrance

Proposed Mechanisms:

Mechanical factors: Intrauterine positioning and postpartum positioning causing capsular stretching and joint deformation
Hormonal factors: Maternal relaxin affecting ligamentous laxity
Genetic factors: Polygenic inheritance pattern with variable penetrance
Developmental factors: Primary acetabular dysplasia leading to secondary changes

Pathoanatomy & Classification

Anatomical Spectrum:

Category	Features	Anatomical Changes
Physiologic instability	• Transient neonatal hip laxity • Positive Barlow but negative Ortolani • Typically resolves spontaneously	• Normal acetabulum • Capsular laxity • No fixed displacement
Acetabular dysplasia	• Shallow, oblique acetabulum • Normal location of femoral head • No instability or subluxation	• Increased acetabular index • Insufficient coverage of femoral head • Normal joint congruity
Subluxable hip	• Hip positioned within acetabulum • Can be partially displaced with stress • Positive Barlow test	• Ligamentous laxity • Normal or mild dysplastic acetabulum • Partially reducible under stress
Subluxated hip	• Femoral head partially displaced • Incomplete contact with acetabulum • May be reducible	• Lateral and superior displacement • Capsular stretching • Progressive acetabular dysplasia
Dislocated hip	• Complete loss of joint contact • Femoral head outside acetabulum • May be reducible or teratologic	• Superior and posterior displacement • False acetabulum formation • Limbus inversion • Capsular stretching • Adductor/psoas contracture • Secondary acetabular changes
Teratologic dislocation	• Present at birth • Often associated with syndromes • Fixed dislocation	• Severe acetabular dysplasia • Major soft tissue abnormalities • Irreducible without intervention

Classification Systems:

Graf Classification: Based on ultrasound anatomy (types I-IV)
Tönnis Classification: Based on ossification center position on radiographs (grades I-IV)
IHDI Classification: Based on femoral head position relative to acetabulum on imaging

Clinical Presentation & Diagnosis

Age-Specific Clinical Findings:

Age Group	Clinical Signs	Diagnostic Approach
Newborn (0-4 weeks)	• Positive Barlow test (provocative hip instability) • Positive Ortolani test (reducible dislocation) • Asymmetric thigh/gluteal folds • Limited hip abduction	• Clinical examination is primary • Ultrasound for high-risk or positive clinical findings • Physical exam sensitivity ~60%, specificity ~70%
Infant (1-6 months)	• Limited hip abduction (most reliable sign) • Asymmetric thigh/gluteal folds • Apparent limb length discrepancy • Positive Galeazzi sign • Ortolani/Barlow less reliable after 3 months	• Ultrasound (≤6 months) • Static and dynamic assessment • Universal screening at 6-8 weeks in some countries • Focused screening for high-risk infants in others
Late-presenting (>6 months)	• Limited hip abduction • Positive Galeazzi sign (apparent femur shortening) • Asymmetric skin folds • Trendelenburg gait (if walking) • Telescoping/pistoning of femur • Delayed walking or abnormal gait	• Radiography (>6 months) • AP pelvis and frog-leg lateral views • Advanced imaging with CT/MRI for complex cases • Assessment of acetabular development and femoral head position

Physical Examination Techniques:

Barlow test: Attempts to dislocate an unstable but reduced hip; posterior directed force with adduction
Ortolani test: Attempts to reduce a dislocated hip; anterior directed force with abduction
Limited abduction test: Asymmetric abduction <60° indicates potential DDH
Galeazzi/Allis sign: Asymmetric knee heights with hips flexed to 90° and feet flat on table

Imaging Evaluation:

Imaging Modality	Utility and Timing	Key Measurements
Ultrasound	• Primary imaging for infants ≤6 months • Visualizes cartilaginous structures • Dynamic assessment possible • Optimal at 6 weeks of age • May have high false positive rate before 4 weeks	• Graf angle: α angle (bony roof) and β angle (cartilage roof) • Femoral head coverage percentage • Dynamic stability • Graf classification: - Type I: Normal (α ≥60°) - Type II: Dysplastic/immature (α 43-59°) - Type III: Subluxated (α <43°) - Type IV: Dislocated
Radiography	• Primary imaging for children >6 months • AP pelvis and frog-leg lateral views • Limited value in early infancy due to unossified femoral head • Allows assessment of ossification and remodeling	• Hilgenreiner's line and Perkin's line • Acetabular index (normal <30° at birth, <25° at 1 year) • Shenton's line continuity • Center-edge angle of Wiberg (in older children) • Ossification center development and position • Tönnis classification (grades 1-4)
MRI	• Secondary imaging for complex cases • No radiation exposure • Excellent soft tissue contrast • Evaluates cartilaginous structures • Often requires sedation in young children	• Femoral head relationship to acetabulum • Labral integrity • Pulvinar tissue • Ligamentum teres status • Limbus evaluation • Cartilage morphology
CT scan	• Used for complex or post-treatment evaluation • 3D reconstruction capabilities • Radiation exposure concern • Helpful for surgical planning in older children	• Femoral head coverage • Acetabular version • Femoral version • 3D anatomy for surgical planning • Post-reduction position assessment

Screening Recommendations

Approach to DDH Screening:

Population	Recommended Screening	Timing
All newborns	• Clinical examination with Barlow/Ortolani tests • Serial examinations through first year	• Initial exam at birth • Follow-up at 2, 4, 6, 9, and 12 months
High-risk infants (breech, family history, foot deformity)	• Clinical examination • Ultrasound screening	• Ultrasound at 4-6 weeks of age • Earlier if severe clinical findings
Infants with positive clinical exam	• Immediate ultrasound • Orthopedic referral	• At time of detection • Prompt treatment initiation
Countries with universal screening	• Clinical examination • Universal hip ultrasound	• Typically 4-8 weeks of age

Clinical Practice Guidelines:

AAP: Universal clinical screening, selective ultrasound for high-risk factors
AAOS: Universal clinical screening, selective ultrasound for high-risk factors or abnormal exam
POSNA: Universal clinical screening, selective ultrasound for high-risk factors
European approach: Many countries implement universal ultrasound screening

Management Principles

Age-Based Treatment Algorithm:

Age at Diagnosis	Primary Treatment Approach	Duration and Follow-up
0-6 months	• Pavlik harness (first-line) • Dynamic flexion-abduction orthosis • Maintains hip in "safe zone" position • 90% success rate in early treatment	• Full-time wear (23 hours/day) • Weekly monitoring initially • Treatment until stable hip and normal ultrasound • Typically 6-12 weeks • Gradual weaning after stability achieved
6-12 months	• Closed reduction attempt under anesthesia • Adductor tenotomy if needed • Hip spica casting post-reduction • Consider traction in some cases	• Spica cast for 12 weeks (may require cast change) • Post-cast abduction orthosis for 6-12 weeks • MRI or CT to confirm concentric reduction • Radiographic follow-up every 3-6 months
12-18 months	• Closed reduction with adductor tenotomy • Open reduction if closed reduction fails • Medial (anterior) or anterolateral approach • Hip spica casting post-reduction	• Spica cast for 12 weeks • Post-reduction imaging to confirm position • Abduction orthosis after cast removal • 3-4 month radiographic follow-up • Monitor for AVN and residual dysplasia
18 months-3 years	• Open reduction via anterolateral approach • Capsulorrhaphy and obstacle removal • Consider concurrent femoral shortening osteotomy • Consider pelvic osteotomy for acetabular dysplasia	• Spica cast for 6-12 weeks • Post-cast abduction orthosis in some cases • Radiographic follow-up every 3-6 months • Monitor for AVN, residual dysplasia, and redislocation
3-8 years	• Open reduction • Femoral shortening osteotomy • Pelvic osteotomy (Salter, Dega, Pemberton) • Combined procedures common	• Spica cast for 6-8 weeks • Implant removal at 6-12 months • Long-term radiographic follow-up • Monitor for residual dysplasia, AVN, and early arthritis
>8 years	• Salvage procedures often needed • Pelvic osteotomy (triple, periacetabular) • Femoral osteotomy • Shelf procedures • Total hip arthroplasty in adulthood	• Individualized rehabilitation protocol • Long-term follow-up through skeletal maturity • Lifelong monitoring for secondary arthritis • Variable outcomes based on severity and treatment timing

Specific Treatment Modalities

Pavlik Harness:

Mechanism: Maintains hip in flexion and abduction while allowing dynamic movement
Indications: Primary treatment for infants 0-6 months with reducible hips
Application: Anterior straps maintain flexion (100-110°), posterior straps prevent adduction
Monitoring: Weekly initial visits to check position and for complications
Success rates: 90-95% for properly selected patients
Contraindications: Irreducible dislocations, infants >6 months, stiff/fixed dislocations
Complications: Femoral nerve palsy (excessive flexion), AVN (excessive abduction), inferior dislocation

Closed Reduction & Spica Casting:

Technique: Gentle reduction under anesthesia, often with arthrogram guidance
Safe zone assessment: 20-30° from full abduction to allow safe positioning
Percutaneous adductor tenotomy: Often performed to release adductor contracture
Casting: Human position (100-110° flexion, 45-50° abduction)
Duration: 12 weeks (typically with cast change at 6 weeks)
Success factors: Concentric reduction, stable reduction within safe zone
Complications: AVN, redislocation, residual dysplasia

Open Reduction:

Indications: Failed closed reduction, older infants/children, presence of reduction obstacles
Approaches:
- Medial (anterior): Less invasive, limited exposure, for children <18 months
- Anterolateral (Smith-Petersen): Better exposure, older children, allows concurrent procedures
Obstacles to reduction: Pulvinar, ligamentum teres, transverse acetabular ligament, contracted capsule, inverted limbus, psoas tendon
Techniques: Capsulotomy, ligamentum teres excision, pulvinar removal, limbus preservation when possible
Post-reduction stability: Assessed intraoperatively to determine need for additional procedures

Femoral Osteotomies:

Indications: Children >18 months, high dislocation, excessive femoral anteversion
Types:
- Shortening: Reduces pressure on femoral head, facilitates reduction
- Varus: Improves containment and deepens acetabulum
- Derotational: Corrects excessive anteversion
Fixation: Plate and screws or pediatric hip nail
Outcomes: Improved stability, reduced AVN risk in older children

Pelvic Osteotomies:

Osteotomy Type	Mechanism & Technique	Indications & Age Range
Salter innominate	• Single innominate bone cut • Redirectional osteotomy • Rotates entire acetabulum • Anterolateral coverage improvement	• 18 months to 6 years • Global deficiency with concentric reduction • Requires adequate acetabular depth • Triradiate cartilage must be open
Pemberton pericapsular	• Incomplete osteotomy hinged on triradiate • Reshaping osteotomy • Changes acetabular volume • Anterior and lateral coverage	• 18 months to 8 years • Shallow dysplastic acetabulum • Maintains posterior column • Requires open triradiate cartilage
Dega/San Diego	• Incomplete supraacetabular osteotomy • Hinged on sciatic notch/medial cortex • Creates lateral/posterior coverage • Graft placed in superior osteotomy site	• 18 months to 10 years • Posterolateral deficiency • Neuromuscular conditions • Requires open triradiate cartilage
Triple innominate	• Three pelvic cuts (ischial, pubic, iliac) • Completely frees acetabular fragment • Allows multiplanar correction • Requires internal fixation	• 8-16 years (adolescents) • Closed/closing triradiate cartilage • Acetabular dysplasia without deformity • Minimal arthritic changes
Periacetabular (Ganz)	• Complete acetabular mobilization • Preserves posterior column • Complex 3D acetabular reorientation • Maximum correctional potential	• Adolescents and adults • Skeletally mature patients • Residual acetabular dysplasia • Early degenerative changes
Shelf procedure	• Augmentation not reorientation • Creates shelf of bone above acetabulum • Capsular metaplasia forms fibrocartilage • No formal osteotomy of pelvis	• 4-8 years (salvage procedure) • Older children with incongruent joints • Failed previous treatments • Neuromuscular conditions

Complications & Outcomes

Major Complications:

Complication	Risk Factors	Management
Avascular necrosis (AVN)	• Forceful reduction • Extreme abduction position • Tight spica cast • Age >18 months at reduction • Lateral approach (vs medial) • Reported incidence: 5-30%	• Prevention is primary strategy • Safe zone positioning • Avoid extreme positions • Regular post-reduction monitoring • Femoral shortening in older children • If occurs: observation, containment, salvage procedures
Redislocation/subluxation	• Inadequate initial reduction • Residual acetabular dysplasia • Premature treatment discontinuation • Excessive femoral anteversion • Neuromuscular conditions • Inadequate follow-up	• Re-reduction (closed or open) • Consider femoral shortening/derotation • Pelvic osteotomy if acetabular deficiency • More prolonged immobilization • Careful radiographic monitoring
Residual dysplasia	• Late diagnosis (>18 months) • Inadequate treatment duration • Persistent acetabular deficiency • Failure to address all components • Growth disturbance	• Long-term radiographic surveillance • Secondary procedures at appropriate age • Pelvic osteotomy for significant dysplasia • Shelf procedure for salvage • Combined procedures in older children
Growth disturbance	• Damage to physis during surgery • AVN sequelae • Multiple surgical procedures • Infection	• Monitoring of growth patterns • Leg length discrepancy management • Epiphysiodesis of contralateral side • Limb lengthening in severe cases
Early osteoarthritis	• Late diagnosis (>3-4 years) • Residual dysplasia • AVN sequelae • Incongruent reduction • Instability	• Joint preservation procedures • Periacetabular osteotomy in young adults • Hip arthroscopy for labral pathology • Total hip arthroplasty (eventual) • Activity modification

Age-Related Outcomes:

Early diagnosis (0-6 months):
- Excellent outcomes in 95% with proper treatment
- Normal hip development expected
- Low complication rates (<5% AVN)
- Low reoperation rates
Intermediate diagnosis (6-18 months):
- Good to excellent outcomes in 80-90%
- Higher AVN risk (10-15%)
- Residual dysplasia in 10-20%
- Reoperation rate 15-25%
Late diagnosis (>18 months):
- Fair to good outcomes in 60-80%
- Higher AVN risk (20-30%)
- Residual dysplasia in 30-50%
- Reoperation rate 30-50%
- Early OA common (40-60% by age 40)
Very late diagnosis (>3-4 years):
- Unpredictable outcomes
- High complication rates
- Multiple procedures often required
- Early OA inevitable in most cases
- THA often needed in early adulthood

Long-Term Surveillance:

Clinical and radiographic follow-up until skeletal maturity
Monitor for residual dysplasia, subluxation, and AVN
Consider secondary procedures for significant residual dysplasia
Adult surveillance for early arthritic changes
Patient education regarding signs/symptoms of hip deterioration

Pediatric Psoriasis

Etiopathogenesis

Factor	Mechanism
Genetic factors	• Multiple susceptibility loci (PSORS1-9) • PSORS1 on chromosome 6p21.3 (strongest association) • IL-23/Th17 axis gene variants • Epidermal barrier function genes (LCE3B, LCE3C deletions)
Immunologic dysregulation	• Aberrant Th1/Th17 cell activation • Increased IL-17, IL-22, IL-23, TNF-α • Dendritic cell activation • Neutrophil accumulation (Munro's microabscesses)
Environmental triggers	• Streptococcal infections (guttate psoriasis) • Physical trauma (Koebner phenomenon) • Stress and psychological factors • Medications (lithium, beta-blockers, antimalarials) • Climate factors (cold, dry conditions)
Microbiome alterations	• Skin dysbiosis with decreased microbial diversity • Increased Staphylococcus and Streptococcus • Gut microbiome dysbiosis • Tonsil microbiota alterations

Clinical Presentations & Subtypes

Subtype	Clinical Features	Pediatric Considerations
Plaque psoriasis (Psoriasis vulgaris)	• Well-demarcated erythematous plaques • Silvery-white scale • Symmetrical distribution • Extensor surfaces, scalp, trunk	• Thinner, smaller plaques than adults • Less scale, more facial involvement • Common in diaper area, scalp • May present with pruritus
Guttate psoriasis	• Small (2-10mm) droplet-shaped lesions • Widespread on trunk, extremities • Acute onset, often post-streptococcal • May resolve spontaneously in weeks	• Most common childhood-onset variant (15-30%) • Strong association with strep throat (70-80%) • May transform to plaque psoriasis (30%) • Recurrence common
Inverse psoriasis	• Smooth, erythematous plaques • Minimal scaling • Intertriginous areas (axillae, groin, inframammary)	• Diaper area common in infants ("napkin psoriasis") • Moist, macerated presentation • Often misdiagnosed as fungal infection
Scalp psoriasis	• Well-defined plaques with adherent scale • May extend beyond hairline ("corona seborrheica") • Potential hair loss	• Present in 50-60% of pediatric cases • Often initial manifestation • Difficult to distinguish from seborrheic dermatitis • Treatment adherence challenges
Pustular psoriasis	• Sterile pustules on erythematous base • Localized (palmoplantar) or generalized	• Rare in children (<1%) • Generalized form may be medical emergency • IL36RN mutations in some cases • Higher incidence of systemic symptoms
Erythrodermic psoriasis	• Widespread erythema (>90% BSA) • Systemic symptoms (fever, malaise) • Potential hemodynamic compromise	• Extremely rare in children • Medical emergency requiring hospitalization • Risk of thermoregulatory disturbances • Associated with withdrawal of steroids
Nail psoriasis	• Pitting, onycholysis, oil spots • Subungual hyperkeratosis • Splinter hemorrhages	• Present in 15-40% of pediatric cases • Associated with PsA and more severe disease • Often overlooked in clinical assessment • Distressing due to cosmetic impact

Diagnostic Approach

Diagnosis is primarily clinical, based on characteristic lesion morphology and distribution.

Clinical Assessment:

Complete skin examination including scalp, nails, genital and intertriginous areas
Family history of psoriasis and other autoimmune conditions
Recent infections, particularly streptococcal pharyngitis
Medication history (potential triggers)
Joint examination for signs of psoriatic arthritis
Growth parameters and developmental assessment

Diagnostic Features:

Clinical Sign	Description	Significance
Auspitz sign	Pinpoint bleeding when scale is removed	Indicates papillary capillary dilation and thinned suprapapillary epidermis
Koebner phenomenon	Development of lesions at sites of trauma	Present in 25-30% of pediatric cases; indicates active disease
Woronoff ring	White halo surrounding psoriatic plaques	Less common in children; indicates vasoconstriction
Nail pitting	Multiple small depressions in nail plate	Most common nail finding in pediatric psoriasis

Laboratory Studies:

Not routinely required for diagnosis
Consider throat culture or ASO titer with suspected streptococcal trigger
CRP, ESR if systemic symptoms or suspected psoriatic arthritis
Consider HLA-Cw6 in research or atypical presentations
Baseline labs before systemic therapy

Biopsy:

Rarely needed in children with typical presentations
Consider in atypical, refractory, or diagnostically challenging cases
Histopathology shows:

Acanthosis with regular elongation of rete ridges
Parakeratosis with absent granular layer
Munro microabscesses (neutrophils in stratum corneum)
Dilated, tortuous capillaries in dermal papillae
Perivascular lymphocytic infiltrate

Differential Diagnosis:

Condition	Distinguishing Features
Seborrheic dermatitis	• Greasy, yellowish scale (vs. silvery-white) • Distribution: scalp, eyebrows, nasolabial folds • Less defined borders • Responds rapidly to mild antifungals
Atopic dermatitis	• Intense pruritus • Distribution: flexural surfaces • Personal/family history of atopy • Spongiosis on histology
Tinea corporis/capitis	• Annular configuration with active border • Central clearing common • KOH preparation shows hyphae • Responds to antifungals
Pityriasis rosea	• Herald patch precedes eruption • "Christmas tree" distribution on trunk • Self-limiting (6-12 weeks) • Collarette scale
Nummular eczema	• Coin-shaped lesions • More vesicular and weeping • Intense pruritus • Often triggered by dry skin
Candidal diaper dermatitis	• Beefy red eruption with satellite pustules • Predominantly in skin folds • KOH preparation shows pseudohyphae and budding yeast • Responds to antifungals

Disease Assessment & Severity Metrics

Assessment Tool	Description	Interpretation
Psoriasis Area and Severity Index (PASI)	• Combines erythema, induration, scaling • Weighted by body surface area involvement • Range: 0-72	• Mild: <5 • Moderate: 5-10 • Severe: >10 • PASI-75: 75% improvement (treatment goal)
Body Surface Area (BSA)	• Percentage of affected skin • Uses "palm method" (palm = 1% BSA) • Range: 0-100%	• Mild: <3% • Moderate: 3-10% • Severe: >10%
Physician Global Assessment (PGA)	• Static assessment of overall severity • Scale: 0 (clear) to 5 (severe)	• Simple for clinical practice • Less sensitive to change than PASI • PGA ≤1 often used as treatment target
Children's Dermatology Life Quality Index (CDLQI)	• 10-item validated questionnaire • Assesses QoL impact over previous week • Range: 0-30	• 0-1: No effect • 2-6: Small effect • 7-12: Moderate effect • 13-18: Very large effect • 19-30: Extremely large effect
PedsQL™	• Generic QoL measure • Age-specific versions • Physical, emotional, social, school functioning	• Higher scores indicate better QoL • Allows comparison with other chronic conditions • Useful for research and comprehensive assessment

Comorbidities & Associations

Comorbidity	Prevalence	Screening/Management Considerations
Psoriatic arthritis (PsA)	• 5-10% of children with psoriasis • Can precede skin manifestations in 15-20%	• Regular joint examination • Morning stiffness, enthesitis, dactylitis • Lower threshold for rheumatology referral • Earlier systemic intervention when present
Obesity & metabolic syndrome	• 30-40% higher risk in pediatric psoriasis • Bidirectional relationship	• Regular BMI monitoring • Lifestyle counseling • Consider weight-based dosing for medications • May influence treatment selection
Psychological comorbidities	• Depression: 20-25% • Anxiety: 15-30% • Social isolation: 25-35%	• Regular psychological screening • Age-appropriate counseling • School support strategies • Early mental health referral when indicated
Inflammatory bowel disease	• 3-5x higher risk than general population • More common with pustular variants	• GI symptom assessment • Lower threshold for GI referral • Consider TNF inhibitors when both present
Cardiovascular risk factors	• Hypertension: 4-8% • Dyslipidemia: 10-20% • Insulin resistance: 15-25%	• Annual blood pressure monitoring • Consider lipid screening in severe cases • Fasting glucose/HbA1c with risk factors • Prevention-focused approach
Uveitis	• 2-10% of children with psoriasis • Higher with PsA (10-15%)	• Annual ophthalmologic examination • More frequent with PsA • Symptom education for family
Celiac disease	• 2-3x higher risk than general population	• Low threshold for screening in refractory cases • Consider with concurrent gastrointestinal symptoms

Management Principles & Treatment Approach

Treatment Goals:

Achieve and maintain disease control with minimal side effects
Prevent/minimize comorbidity development
Optimize growth and development
Improve quality of life
Support normal psychosocial development
Educate and empower the patient and family

Treatment Selection Factors:

Disease severity, location, and morphology
Patient age and developmental stage
Impact on quality of life
Presence of comorbidities (especially PsA)
Previous treatment responses
Patient/family preferences and treatment burden
Risk-benefit considerations unique to pediatrics

Treatment Approaches by Severity:

Severity	First-line Approach	Second-line Options
Mild (<3% BSA)	• Topical corticosteroids (appropriate potency) • Topical calcineurin inhibitors (face, intertriginous) • Topical vitamin D analogs • Emollients	• Combination products • Targeted phototherapy • Coal tar preparations • Consider systemic for recalcitrant, high-impact cases
Moderate (3-10% BSA)	• Combination topicals • Phototherapy (NB-UVB) • Consider early systemic for high-impact cases	• Methotrexate • Acitretin (selected cases) • Cyclosporine (crisis management) • Biologics (especially with PsA)
Severe (>10% BSA)	• Methotrexate • Biologics (especially TNF-α or IL-12/23 inhibitors) • Combination systemic + targeted topicals	• Alternative biologics • Combination systemic approaches • Acitretin for pustular forms • Cyclosporine for crisis management

Topical Therapies

Agent	Efficacy & Indications	Pediatric Considerations
Topical Corticosteroids	• First-line for most presentations • Potency selection by location and severity • Low: face, intertriginous areas • Medium-high: trunk, extremities • Ultra-high: thick plaques, palmoplantar	• Increased absorption risk due to higher surface area:weight ratio • Limited duration of use (2-4 weeks) • Risk of striae, atrophy, HPA axis suppression • Consider weekend or pulse therapy for maintenance • Max 15-30g/week of potent steroids (age-dependent)
Vitamin D Analogs (Calcipotriene, calcitriol)	• Monotherapy or combination with steroids • Anti-proliferative and anti-inflammatory • Steroid-sparing effect • Once or twice daily application	• Calcipotriene FDA-approved for ages ≥12 years • Limited BSA coverage (<30%) to avoid hypercalcemia • Irritation common, especially on face/intertriginous • Compatible with phototherapy • Fixed combination with betamethasone preferred
Topical Calcineurin Inhibitors (Tacrolimus, pimecrolimus)	• Preferred for face, genital, intertriginous areas • Steroid-sparing agent • No risk of atrophy or striae • Twice daily application	• Off-label use for psoriasis • Tacrolimus 0.03% ointment approved for ages ≥2 years • Initial burning/stinging common but transient • No limitation on duration of use • Avoid with active infections
Coal Tar	• Antiproliferative and anti-inflammatory • Available in multiple formulations • Useful for scalp psoriasis • Often combined with salicylic acid	• Limited acceptance due to odor and staining • Consider in recalcitrant cases • Lower concentrations (1-5%) better tolerated • Avoid in acute or inflamed lesions • Photosensitizing potential
Salicylic Acid	• Keratolytic agent • Enhances penetration of other topicals • Effective for thick, scaly plaques • Concentrations: 2-10%	• Risk of systemic absorption and salicylism • Limit to <10% BSA in children • Lower concentrations (2-5%) for pediatric use • Avoid on excoriated or inflamed skin • Not for use in infants
Combination Products	• Calcipotriene/betamethasone dipropionate • Steroid + salicylic acid • Greater efficacy than monotherapy • Simplified regimen	• Calcipotriene/betamethasone approved for ages ≥12 years • Improved adherence • Lower steroid exposure • Cost considerations • Age-appropriate vehicle selection
Emollients & Moisturizers	• Adjunctive therapy for all patients • Reduces scaling and pruritus • Improves barrier function • Enhances efficacy of other treatments	• Ointments preferred for dry lesions • Non-irritating, fragrance-free formulations • Apply after bathing • Can improve adherence to overall regimen • Patient preference crucial for compliance

Phototherapy

Modality	Efficacy & Protocol	Pediatric Considerations
Narrowband UVB (311-313 nm)	• First-line phototherapy option • Efficacy: 60-80% achieve PASI-75 • 2-3 sessions weekly • Initial dose based on minimal erythema dose or skin type • Maintenance phase after clearing	• Well-tolerated in children >4 years • Eye protection mandatory • Shorter treatment times advantage • Potential photodamage with long-term use • Compliance challenges with frequent visits • Consider home phototherapy units in selected cases
Broadband UVB (290-320 nm)	• Less effective than NB-UVB • Longer treatment course required • 2-3 sessions weekly • Higher cumulative doses needed	• Rarely used in pediatric practice • Higher risk of erythema • Less predictable response • Consider only if NB-UVB unavailable
PUVA (Psoralen + UVA)	• Systemic or topical psoralen followed by UVA • High efficacy in resistant cases • 2-3 sessions weekly • Maintenance after clearing	• Generally avoided in children • Significant long-term photocarcinogenic risk • Reserved for severe recalcitrant cases in adolescents • Requires strict photoprotection • Gastrointestinal side effects with oral psoralen
Targeted Phototherapy (Excimer laser/light)	• Focused 308 nm UVB delivery • Higher intensity allows fewer sessions • 2 sessions weekly • Rapid response in localized disease	• Ideal for localized or recalcitrant plaques • Spares uninvolved skin • Lower cumulative dose • Well-tolerated in children • Expensive and less accessible

Systemic Non-Biologic Therapies

Agent	Mechanism & Efficacy	Pediatric Considerations
Methotrexate	• Anti-proliferative, immunomodulatory • Folate antagonist • Efficacy: 40-60% achieve PASI-75 • Once weekly dosing (oral or subcutaneous) • Onset: 4-8 weeks	• Most widely used systemic agent in pediatrics • Starting dose: 0.2-0.4 mg/kg/week (max 25mg) • Folic acid supplementation mandatory • Baseline: CBC, LFTs, renal function, hepatitis serology • Monitoring: CBC, LFTs every 2-4 weeks initially, then every 3 months • Avoid live vaccines • Pregnancy test before initiation in adolescents (Category X) • Cumulative dose monitoring not required
Cyclosporine	• Calcineurin inhibitor • Blocks T-cell activation • Efficacy: 50-70% achieve PASI-75 • Rapid onset (2-4 weeks) • Twice daily dosing	• Reserved for severe, recalcitrant, or crisis cases • Short-term use (3-6 months) recommended • Starting dose: 3-5 mg/kg/day • Baseline: BP, renal function, electrolytes, lipids, magnesium • Monitoring: BP, renal function, electrolytes every 2-4 weeks • Drug interactions common (check medications) • Not suitable for long-term management • Bridging therapy to slower-acting agents
Acitretin	• Synthetic retinoid • Normalizes keratinocyte differentiation • Efficacy: 25-50% achieve PASI-75 • Daily dosing • Onset: 4-8 weeks	• Particularly effective for pustular and erythrodermic forms • Starting dose: 0.5-1 mg/kg/day • Baseline: LFTs, lipids, pregnancy test • Monitoring: LFTs, lipids every 1-3 months • Teratogenic (Category X): contraception for females of childbearing age • Mucocutaneous side effects universal • Long-term skeletal toxicity concerns • Synergistic with phototherapy
Apremilast	• PDE4 inhibitor • Reduces inflammatory cytokines • Efficacy: 30-40% achieve PASI-75 • Twice daily dosing • Onset: 4-12 weeks	• Limited pediatric data • FDA-approved for adults only • Off-label use in adolescents reported • No laboratory monitoring required • Gastrointestinal side effects common initially • Weight loss and mood changes potential concerns • Consider in older adolescents with moderate disease • Dose titration required

Biologic Therapies

Agent Class/Name	Mechanism & Efficacy	Pediatric Approval & Considerations
TNF-α Inhibitors Etanercept Adalimumab Infliximab	• Block tumor necrosis factor-α • Efficacy: - Etanercept: 50-60% PASI-75 - Adalimumab: 70-80% PASI-75 - Infliximab: 70-80% PASI-75 • Rapid onset (2-4 weeks)	• Etanercept: FDA-approved ≥4 years (0.8 mg/kg/week, max 50mg) • Adalimumab: FDA-approved ≥4 years (weight-based dosing) • Infliximab: Off-label for pediatric psoriasis (5-10 mg/kg) • Baseline: TB screening, hepatitis serology, CBC, LFTs • Monitoring: CBC, LFTs every 3-6 months • Injection site reactions common • Increased risk of infections • Caution with history of demyelinating disorders • Annual TB screening • Avoid live vaccines
IL-12/23 Inhibitors Ustekinumab	• Blocks p40 subunit shared by IL-12 and IL-23 • Efficacy: 70-80% achieve PASI-75 • Convenient dosing (every 12 weeks after induction) • Onset: 4-8 weeks	• FDA-approved ≥6 years • Weight-based dosing: - <60kg: 0.75 mg/kg - 60-100kg: 45mg - >100kg: 90mg • Baseline: TB screening, hepatitis serology • Minimal laboratory monitoring • Excellent safety profile • Infrequent dosing improves adherence • Effective for scalp and nail disease • Less effective for PsA
IL-17 Inhibitors Secukinumab Ixekizumab Brodalumab	• Block IL-17 cytokine pathway • Efficacy: 80-90% achieve PASI-75 • Rapid onset (2-4 weeks) • Monthly dosing after loading	• Secukinumab: FDA-approved ≥6 years (weight-based) • Ixekizumab: FDA-approved ≥6 years (weight-based) • Brodalumab: Not approved for pediatric use • Baseline: TB screening, hepatitis serology • Minimal laboratory monitoring • Candida infections more common • Caution with inflammatory bowel disease • Highly effective for nail and scalp disease • Effective for PsA
IL-23 Inhibitors Guselkumab Risankizumab Tildrakizumab	• Block p19 subunit of IL-23 • Efficacy: 85-95% achieve PASI-75 • Onset: 4-8 weeks • Dosing every 8-12 weeks after loading	• Not yet FDA-approved for pediatric use • Clinical trials in adolescents ongoing • Off-label use reported in adolescents • Baseline: TB screening, hepatitis serology • Excellent safety profile in adults • Long dosing intervals advantageous • Limited data on PsA efficacy • Consider in adolescents with severe disease

Special Considerations in Pediatric Management

Age-Specific Considerations:

Age Group	Presentation	Management Approach
Infants (<2 years)	• Diaper area involvement common • Facial/seborrheic distribution • May be misdiagnosed as dermatitis • Often pruritic	• Mild topical steroids (class 6-7) • Tacrolimus 0.03% for face/intertriginous • Frequent diaper changes • Limited duration of steroid use • Consider rebound with discontinuation • Increased absorption risk
Young Children (2-6 years)	• Guttate pattern common • Streptococcal triggers • Scalp involvement • Facial lesions more common	• Treat streptococcal infections • Topical agents first-line • Consider phototherapy for widespread guttate • Methotrexate for severe cases • Formulation acceptance important • Caregiver education crucial
School-Age (7-11 years)	• Plaque psoriasis predominates • Scalp/nail involvement increases • Psychosocial impact emerges • Guttate flares with infections	• Combination topicals • Phototherapy viable option • Systemic therapy for moderately severe disease • School accommodations • Peer support/education • Attention to adherence
Adolescents (12-17 years)	• Adult-like presentation • Higher burden of comorbidities • Significant psychosocial impact • Inverse and genital involvement • Stress-triggered flares	• More aggressive treatment approach • Earlier consideration of biologics • Increased involvement in treatment decisions • Transition planning to adult care • Mental health support • Adherence strategies

Special Clinical Situations:

Scenario	Management Approach
Guttate psoriasis with streptococcal infection	• Confirm streptococcal infection (throat culture, rapid strep) • Appropriate antibiotic therapy (typically penicillin/amoxicillin) • Topical steroids for symptomatic relief • Consider phototherapy for widespread disease • Tonsillectomy controversial (consider with recurrent severe flares) • Monitor for transition to plaque psoriasis
Recalcitrant scalp psoriasis	• Keratolytics (salicylic acid) to remove scale • Oil-based preparations overnight under shower cap • High-potency steroid solutions/foams/shampoos • Consider calcipotriene/betamethasone suspension • Intralesional steroids for focal plaques (adolescents) • Systemic therapy if causing significant distress • Mechanical scale removal with careful combing
Psoriasis with psoriatic arthritis	• Multidisciplinary approach with rheumatology • Early aggressive intervention • Prefer methotrexate for mild-moderate disease • TNF inhibitors or IL-17 inhibitors for severe disease • More frequent monitoring • Physical therapy assessment • Pain management strategies • School accommodations for physical activities
Psoriasis in obese children	• Weight loss counseling as adjunctive therapy • Dietitian referral • Consider weight-adjusted dosing • Avoid cyclosporine if metabolic syndrome features • Monitor for treatment failures with standard dosing • Early intervention to prevent comorbidities • Consider IL-17 or IL-23 inhibitors with comorbidities
Psoriasis with significant psychological impact	• Lower threshold for systemic therapy • Mental health referral • Selection of visibly effective treatments • Consider QoL metrics in treatment decisions • Peer support groups • School accommodations as needed • Camouflage techniques

Patient & Family Education

Key Educational Components:

Disease nature: Chronic, relapsing condition requiring long-term management
Triggers: Identification and avoidance of individual triggers
Treatment expectations: Realistic goals, timeframes for improvement
Proper application techniques: Demonstration of topical application
Monitoring: Signs of flares, treatment complications, comorbidities
Psychosocial support: Coping strategies, school integration
Lifestyle modifications: Healthy weight, stress management, sleep hygiene

Age-Appropriate Education:

Age Group	Educational Approach
Parents/Caregivers (for all ages)	• Comprehensive disease information • Treatment rationale and expectations • Side effect monitoring • Importance of adherence • Application techniques • When to seek medical attention • Advocacy in school settings • Insurance and financial resource navigation
Young Children (2-6 years)	• Simple explanations ("special cream for special spots") • Positive reinforcement for cooperation • Incorporation into daily routine • Picture schedules for treatments • Distraction techniques during application • Age-appropriate books about being different
School-Age (7-11 years)	• Basic disease explanation • Gradual responsibility for self-care • Simple explanations for peers • Treatment calendars with rewards • Identifying safe adults for assistance • Strategies for handling questions from others • Focus on activities they can participate in
Adolescents (12-17 years)	• More detailed disease pathophysiology • Active involvement in treatment decisions • Digital tools for tracking and adherence • Connect with peer support groups • Self-advocacy skills • Transition planning to self-management • Addressing body image concerns • Education about lifestyle factors

Resources for Families:

National Psoriasis Foundation: Age-appropriate materials, patient support network
Camp Discovery: Dermatology camp for children with skin conditions
PsoMe: Digital application for adolescents with psoriasis
School resource kits: Educational materials for teachers and school nurses
Financial assistance programs: For medications and treatments
Online communities: Moderated forums for parents and teens

Pediatric Conjunctivitis

Etiology & Classification

Classification	Common Causes	Epidemiology
Infectious	Bacterial: • Haemophilus influenzae • Streptococcus pneumoniae • Staphylococcus aureus • Moraxella catarrhalis Viral: • Adenovirus (types 3, 4, 7, 8, 19, 37) • Enterovirus 70 • Herpes simplex virus • Varicella zoster virus	• Bacterial: 50-75% of infectious conjunctivitis in children • Viral: More common in school-age children and adolescents • Highly contagious, spreads through direct contact • Outbreaks common in schools and daycare centers
Allergic	• Seasonal allergens (pollen, grass) • Perennial allergens (dust mites, animal dander) • Vernal keratoconjunctivitis • Atopic keratoconjunctivitis	• 15-40% of pediatric conjunctivitis cases • Often associated with atopic conditions • Seasonal variations based on allergen exposure • Increasing prevalence worldwide
Neonatal	• Chemical (silver nitrate) • Bacterial (S. aureus, E. coli) • Chlamydia trachomatis • Neisseria gonorrhoeae • Herpes simplex virus	• Chemical: 24-48 hours after birth • Bacterial: 2-5 days after birth • Chlamydial: 5-14 days after birth • Gonococcal: 2-4 days after birth • HSV: 6-14 days after birth
Other	• Irritant/toxic (chlorine, smoke) • Contact lens-related • Foreign body • Tear deficiency/dry eye • Associated with systemic diseases	• Less common in pediatric population • Contact lens complications increasing in adolescents • Environmental exposures vary by geography • May indicate underlying systemic condition

Clinical Features & Differential Diagnosis

Type	Key Clinical Features	Distinguishing Characteristics
Bacterial Conjunctivitis	• Mucopurulent discharge (yellow-green) • Crusting of eyelids, especially upon awakening • Bilateral or unilateral involvement • Mild to moderate conjunctival injection • Normal or slightly reduced vision • Mild photophobia	• Copious purulent discharge • Lids often stuck together in morning • Rapid onset (24-48 hours) • Responds quickly to antibiotic treatment • Usually self-limiting within 7-10 days
Viral Conjunctivitis	• Watery or serous discharge • Follicular reaction on tarsal conjunctiva • Often starts unilaterally, spreads to other eye • Marked hyperemia • Pre-auricular lymphadenopathy • Subconjunctival hemorrhage (common)	• Often associated with URI symptoms • More common in school-age and older children • Highly contagious • May have corneal involvement (epithelial keratitis) • Longer duration (1-3 weeks)
Allergic Conjunctivitis	• Intense itching (hallmark symptom) • Watery or mucoid discharge • Bilateral involvement • Conjunctival chemosis • Papillary reaction • Eyelid swelling • Cobblestone appearance in severe cases	• Seasonal patterns or known allergen triggers • History of atopy (eczema, asthma) • Itching is predominant symptom • Often recurrent • Responds to antihistamines/mast cell stabilizers
Neonatal Conjunctivitis	Chemical: Mild injection, watery discharge Bacterial: Purulent discharge, marked injection Chlamydial: Mucopurulent discharge, pseudomembrane Gonococcal: Hyperacute purulent discharge, lid edema HSV: Watery discharge, vesicular lid lesions	• Timing of onset after birth critical for diagnosis • Maternal history important • Gonococcal: Can rapidly progress to corneal perforation • HSV: May have systemic symptoms • Emergency evaluation required

Important Differential Diagnoses to Consider:

Preseptal/orbital cellulitis: Fever, toxic appearance, lid swelling with limited mobility
Keratitis: Corneal involvement, photophobia, reduced vision, pain
Anterior uveitis: Photophobia, pain, circumcorneal injection, miosis
Foreign body: Unilateral, history of trauma, localized injection
Nasolacrimal duct obstruction: Tearing without significant injection, very young age
Corneal abrasion: History of trauma, localized pain, fluorescein staining
Glaucoma: Eye pain, halos around lights, reduced vision, firm globe

Diagnostic Approach

History:

Onset and duration of symptoms
Unilateral vs. bilateral involvement
Character of discharge (purulent, mucoid, watery)
Associated symptoms (itching, pain, photophobia)
Recent upper respiratory infection or exposure to conjunctivitis
Contact with persons having red eyes
History of allergies or atopic conditions
Recent swimming pool exposure
Contact lens use (adolescents)
For neonates: maternal STI history, delivery method

Physical Examination:

Examination Component	Findings to Assess	Clinical Significance
Visual acuity	• Age-appropriate assessment • May be slightly reduced due to discharge • Should normalize with blinking/wiping	• Significant vision reduction suggests more serious pathology • Normal VA common in uncomplicated conjunctivitis • Important baseline for follow-up
External examination	• Eyelid swelling • Type and amount of discharge • Periorbital skin changes • Pre-auricular lymph nodes	• Marked lid swelling suggests possible preseptal cellulitis • Discharge character helps determine etiology • Lymphadenopathy suggests viral etiology
Conjunctival examination	• Pattern of injection (diffuse vs. localized) • Presence of follicles or papillae • Presence of membranes/pseudomembranes • Chemosis (conjunctival edema)	• Follicles: Common in viral and chlamydial conjunctivitis • Papillae: More common in allergic conjunctivitis • Membranes: Severe bacterial or adenoviral infection • Chemosis: Prominent in allergic reactions
Corneal assessment	• Clarity and integrity • Fluorescein staining • Epithelial or subepithelial infiltrates	• Corneal involvement suggests more serious condition • Subepithelial infiltrates: Adenoviral conjunctivitis • Dendritic lesions: Herpes simplex keratitis
Anterior chamber	• Presence of cells and flare • Depth and clarity	• Anterior chamber reaction suggests uveitis, not simple conjunctivitis • May indicate more serious condition requiring different treatment
Pupillary assessment	• Size, shape, and reactivity • Direct and consensual response	• Normal in uncomplicated conjunctivitis • Abnormalities suggest anterior uveitis or other conditions

Laboratory Studies:

Routine culture: Not typically indicated for mild/moderate conjunctivitis
Indications for culture:
- Neonatal conjunctivitis
- Hyperacute purulent conjunctivitis
- Severe or recurrent conjunctivitis
- Immunocompromised patients
- Conjunctivitis unresponsive to therapy
Culture techniques: Conjunctival swabs of inferior fornix
PCR testing: Available for adenovirus, HSV, chlamydia
Giemsa stain: May identify inclusion bodies in chlamydial infection
Gram stain: Useful in hyperacute cases to identify organism

Management Approach

Treatment strategy depends on the suspected etiology, severity, and age of the patient. In many cases, the diagnosis is made clinically without laboratory confirmation.

Type	First-line Treatment	Alternative Options & Notes
Bacterial Conjunctivitis	• Broad-spectrum topical antibiotics: - Polymyxin B-trimethoprim drops QID x 5-7 days - Erythromycin ointment BID-TID x 5-7 days - Moxifloxacin 0.5% drops TID x 5-7 days • Warm compresses to remove crusts • Frequent hand washing • Separate towels and pillowcases	• Most cases resolve in 7-10 days with or without antibiotics • Treatment may reduce duration and contagion period • Avoid aminoglycosides as first-line due to hypersensitivity • Consider fluoroquinolones for severe cases • May return to school 24 hours after starting antibiotics
Viral Conjunctivitis	• Supportive care: - Cold compresses - Preservative-free artificial tears q2-4h - Topical vasoconstrictors (short-term) • Strict hand hygiene • No sharing of personal items • School exclusion during acute phase	• Antibiotics NOT indicated for uncomplicated viral cases • Self-limiting over 1-3 weeks • Topical steroids rarely indicated and only under ophthalmologist supervision • Warn about potential contagiousness for 10-14 days • Consider ophthalmology referral if subepithelial infiltrates develop
Allergic Conjunctivitis	• Allergen avoidance when possible • Cold compresses • Topical antihistamines/mast cell stabilizers: - Olopatadine 0.1% BID - Ketotifen 0.025% BID - Cromolyn sodium 4% QID • Preservative-free artificial tears	• Oral antihistamines for severe symptoms or associated rhinitis • Short course of mild topical steroids for severe cases (ophthalmologist supervision) • Longer-term management for recurrent cases • Consider allergen testing in chronic cases • Immunotherapy for identified allergens in severe cases
Neonatal Conjunctivitis	Chemical: Artificial tears, observation Bacterial: Erythromycin ointment QID, systemic antibiotics if severe Chlamydial: Erythromycin ointment QID + oral erythromycin 50 mg/kg/day divided QID x 14 days Gonococcal: EMERGENCY - Ceftriaxone 25-50 mg/kg IV/IM (max 125 mg) single dose + topical saline lavage HSV: Ophthalmology consult, topical and systemic antivirals	• All cases of neonatal conjunctivitis require prompt evaluation • Gonococcal conjunctivitis is an ophthalmologic emergency • Mandatory reporting for suspected STI-related cases • Consider concurrent systemic infection with chlamydia and HSV • Parents and possibly other caregivers may require treatment • Close follow-up essential in all cases

General Hygiene Measures (for infectious conjunctivitis):

Frequent hand washing with soap and water
Avoid touching or rubbing eyes
Separate towels, washcloths, and pillowcases
Daily disinfection of surfaces like doorknobs and shared toys
Discard eye makeup if used during infection
Replace contact lenses and cases after resolution (adolescents)
Avoid swimming pools during active infection

Complications & Follow-up

Complications:

Bacterial conjunctivitis:
- Corneal epithelial defects
- Marginal keratitis
- Preseptal cellulitis (rare)
- Systemic spread in neonates
Viral conjunctivitis:
- Subepithelial corneal infiltrates (adenovirus)
- Symblepharon (severe cases)
- Chronic dry eye
- Conjunctival scarring
Allergic conjunctivitis:
- Keratoconus (with chronic eye rubbing)
- Shield ulcers (in vernal keratoconjunctivitis)
- Steroid-related complications if prolonged use
Neonatal conjunctivitis:
- Corneal perforation (gonococcal)
- Systemic infection (chlamydia, gonorrhea, HSV)
- Permanent visual impairment

Indications for Referral to Ophthalmologist:

Urgency	Clinical Findings
Emergency (Same day)	• All neonatal conjunctivitis cases • Suspected gonococcal conjunctivitis • Corneal involvement or opacity • Severe pain or marked photophobia • Visual acuity reduction • Hyperacute purulent discharge • Suspected HSV infection with corneal involvement
Urgent (24-48 hours)	• Membranous or pseudomembranous conjunctivitis • Moderate to severe conjunctivitis unresponsive to 72 hours of treatment • Recurrent conjunctivitis episodes • Conjunctivitis in immunocompromised patient • Conjunctivitis with significant anterior chamber reaction
Non-urgent (1-2 weeks)	• Persistent viral conjunctivitis with subepithelial infiltrates • Chronic allergic conjunctivitis unresponsive to standard treatment • Recurrent episodes of conjunctivitis without clear etiology • Vernal or atopic keratoconjunctivitis • Suspected ocular surface disease contributing to conjunctivitis

Follow-up Recommendations:

Bacterial conjunctivitis: Follow-up in 3-5 days if not improving; sooner if worsening
Viral conjunctivitis: Follow-up in 5-7 days if symptoms persist or worsen
Allergic conjunctivitis: Follow-up in 2-4 weeks for chronic cases or if treatment changes needed
Neonatal conjunctivitis: Daily follow-up until improving; coordinate with pediatrician

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Pediatric Derma-Ophthal-Ortho

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Pediatric Derma-Ophthal-Ortho

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Congenital Cataracts

Overview & Epidemiology

Etiology & Classification

Associated Systemic Conditions

Clinical Presentation & Diagnosis

Systemic Evaluation & Workup

Management Principles

Surgical Management

Post-Surgical Management

Complications & Management

Prognosis & Outcomes

Long-term Follow-up

Developmental Dysplasia of the Hip

Overview & Epidemiology

Risk Factors & Etiology

Pathoanatomy & Classification

Clinical Presentation & Diagnosis

Screening Recommendations

Management Principles

Specific Treatment Modalities

Complications & Outcomes

Key Takeaways

Pediatric Psoriasis

Overview & Epidemiology

Etiopathogenesis

Clinical Presentations & Subtypes

Diagnostic Approach

Disease Assessment & Severity Metrics

Comorbidities & Associations

Management Principles & Treatment Approach

Topical Therapies

Phototherapy

Systemic Non-Biologic Therapies

Biologic Therapies

Special Considerations in Pediatric Management

Patient & Family Education

Pediatric Conjunctivitis

Overview & Epidemiology

Etiology & Classification

Clinical Features & Differential Diagnosis

Diagnostic Approach

Management Approach

Complications & Follow-up

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