paediatric dermatology. objectives common paediatric dermatologic conditions common paediatric...

PAEDIATRIC PAEDIATRIC DERMATOLOGYDERMATOLOGY

OBJECTIVESOBJECTIVES

Common paediatric dermatologic Common paediatric dermatologic conditionsconditions

Dermatologic presentation of Dermatologic presentation of systemic diseasesystemic disease

Conditions which may require Conditions which may require urgent/emergent managementurgent/emergent management

ASSESSMENT OF SKIN ASSESSMENT OF SKIN PROBLEMSPROBLEMS

HistoryHistory

DESCRIBE WHAT YOU SEE!DESCRIBE WHAT YOU SEE!


HistoryHistoryOnset, progression, changeOnset, progression, change

blister, bleed, drainblister, bleed, drainDistributionDistributionDurationDurationAggravating/relieving factorsAggravating/relieving factorsItch, pain, triggersItch, pain, triggersTreatmentTreatmentAssociated S & S e.g. feverAssociated S & S e.g. fever


Past Medical HistoryPast Medical HistoryAsthma, atopyAsthma, atopyIllnessesIllnesses

AllergiesAllergiesFood, drugs, seasonal, environmentalFood, drugs, seasonal, environmental


Family HistoryFamily HistorySkin diseaseSkin diseaseSystemicSystemic

SocialSocialOthers affected at home, school or Others affected at home, school or

daycaredaycareCrowding, povertyCrowding, poverty

5 ITCHES5 ITCHES

1.1. DermatitisDermatitis

2.2. VaricellaVaricella

3.3. UrticariaUrticaria

4.4. ScabiesScabies

5.5. Insect bitesInsect bites

DERMATITISDERMATITIS

Itching, redness, swelling, oozing, Itching, redness, swelling, oozing, scabbing, scaling, lichenification, scabbing, scaling, lichenification,

++blistersblisters

DERMATITISDERMATITIS

Atopic (eczema)Atopic (eczema)Diaper dermatitisDiaper dermatitisSeborrheic dermatitis (cradle cap)Seborrheic dermatitis (cradle cap)

ATOPIC DERMATITIS ATOPIC DERMATITIS (ECZEMA)(ECZEMA)

Site:Site:Infant - face, scalp, extensor surfacesInfant - face, scalp, extensor surfacesChild - flexor surfacesChild - flexor surfaces

FH atopy (asthma, hayfever, FH atopy (asthma, hayfever, anaphylaxis, allergies)anaphylaxis, allergies)

Inheritance:Inheritance:1 parent >60%1 parent >60%2 parents >80%2 parents >80%

ATOPIC DERMATITIS ATOPIC DERMATITIS (ECZEMA) (ECZEMA)


Complications:Complications:Secondary bacterial infectionsSecondary bacterial infectionsEczema herpeticum (herpes infecting Eczema herpeticum (herpes infecting

the lesionsthe lesions))

Prognosis:Prognosis:50% clear by age 1350% clear by age 13

MANAGEMENT OF MANAGEMENT OF DERMATOLOGICAL DERMATOLOGICAL

PROBLEMSPROBLEMS

If it’s dry – wet itIf it’s dry – wet it

If it’s wet – dry itIf it’s wet – dry it

And if you don’t know what to do And if you don’t know what to do give steroids!!give steroids!!


ManagementManagementBathingBathingBath oil (e.g. Aveeno, Keri)Bath oil (e.g. Aveeno, Keri)Pat dryPat dryOintments when wetOintments when wet


ManagementManagementTopical corticosteroidsTopical corticosteroidsVaselineVaselineAntihistaminesAntihistaminesWarn about course!Warn about course!

TOPICAL STEROIDSTOPICAL STEROIDS

Weak = 1% hydrocortisoneWeak = 1% hydrocortisoneModerate = 0.05% betamethasoneModerate = 0.05% betamethasone

3 times a day and reduce…3 times a day and reduce…

BEST ANTI-ITCHBEST ANTI-ITCH

Hydroxyzine 0.5 mg/kg QIDHydroxyzine 0.5 mg/kg QID(max 400 mg/day)(max 400 mg/day)

DIAPER DERMATITISDIAPER DERMATITIS


Contact iirritationContact iirritation


ManagementManagementKeep area dry – expose to airKeep area dry – expose to airProtect Protect

CANDIDIASISCANDIDIASIS

CANDIDIASISCANDIDIASIS

FoldsFoldsManagement:Management:

Nystatin – 4 times a day/every diaper Nystatin – 4 times a day/every diaper changechange

Consider oral tooConsider oral tooNystatin – 1 mL PO 4-6 times a day Nystatin – 1 mL PO 4-6 times a day afterafter

foodfood7-10 days7-10 days

SCALP SEBORRHEIC DERMATITIS (CRADLE

CAP)

SEBORRHEIC DERMATITIS SEBORRHEIC DERMATITIS (CRADLE CAP)(CRADLE CAP)

Occurs in any babyOccurs in any babySebaceous glands pump out greasy Sebaceous glands pump out greasy

substance that keeps the old skin substance that keeps the old skin cells attached as it driescells attached as it dries

GreasyGreasyYellowYellow

SEBORRHEIC DERMATITIS SEBORRHEIC DERMATITIS (CRADLE CAP)(CRADLE CAP)

Onset most commonly in first 3 Onset most commonly in first 3 monthsmonths

gone by 8 to 12 months gone by 8 to 12 months Teens often have a similar scalp Teens often have a similar scalp

condition = dandruff!!condition = dandruff!!

SEBORRHEIC DERMATITIS SEBORRHEIC DERMATITIS (CRADLE CAP) (CRADLE CAP)

Management:Management:Oil to soften/loosen scalesOil to soften/loosen scalesSoft brush or dry terry cloth to brush Soft brush or dry terry cloth to brush

awayawayConsider mild topical Consider mild topical steroidsteroid, if , if

red/inflamedred/inflamed

Rarer now because cleanerRarer now because cleaner

SCABIESSCABIES

Management:Management:Permethrin 5% dermal cream – single Permethrin 5% dermal cream – single

applicationapplicationNeck down for 12 hours adultsNeck down for 12 hours adultsInclude head and scalp in prepubertalInclude head and scalp in prepubertal

Hot launder clothes from last 3 days or Hot launder clothes from last 3 days or Seal for 48 hoursSeal for 48 hoursSafety under 3 months not establishedSafety under 3 months not establishedHydroxyzineHydroxyzineIVERMECTINIVERMECTIN

HEAD LICEHEAD LICE

Nix (shampoo) cream rinse Nix (shampoo) cream rinse Nits = dead Nits = dead School after treatmentSchool after treatment

http://www.cps.ca/ENGLISH/http://www.cps.ca/ENGLISH/statements/ID/id08-06.htmstatements/ID/id08-06.htm

BIRTH MARKSBIRTH MARKS

Mongolian SpotsMongolian SpotsCafé-au-lait spotsCafé-au-lait spots- Transient macular stains (Salmon Transient macular stains (Salmon

patches)patches)- Port wine stainsPort wine stains

MONGOLIAN SPOTSMONGOLIAN SPOTS

Blue/grey maculaBlue/grey maculaAppear at or shortly after birthAppear at or shortly after birthBase of spine, buttocks and backBase of spine, buttocks and backNot associated with any conditions or Not associated with any conditions or

illnessesillnessesGradually disappearGradually disappear

MONGOLIAN SPOTSMONGOLIAN SPOTS

CAFÉ-AU-LAIT SPOTSCAFÉ-AU-LAIT SPOTS


Well-circumscribed, homogenously Well-circumscribed, homogenously pigmented, light brown maculespigmented, light brown macules

1.5 - 15 cm in diameter1.5 - 15 cm in diameterFrequently present at birth, are Frequently present at birth, are

almost always present by 1 year of almost always present by 1 year of ageage

May increase in number during early May increase in number during early childhoodchildhood


Approximately 2% of all newborn Approximately 2% of all newborn infantsinfants

Up to 25% of the normal adultsUp to 25% of the normal adultsMore common in darker-pigmented More common in darker-pigmented

racesraces ≥≥66 with diameter > 0.5 cm before with diameter > 0.5 cm before

puberty, and 1.5 cm after puberty puberty, and 1.5 cm after puberty suggests neurofibromatosissuggests neurofibromatosis

SALMON PATCHSALMON PATCH

SALMON PATCHSALMON PATCH

Transient, macularTransient, macularPresent in up to 70% of newbornsPresent in up to 70% of newbornsEyelids, nape of neck, glabellaEyelids, nape of neck, glabellaMost fade by 1 year of ageMost fade by 1 year of ageThose in nape of neck persist in 25% Those in nape of neck persist in 25%

of adultsof adults

PORT WINE STAINPORT WINE STAIN

PORT-WINE STAINPORT-WINE STAIN

Malformation of superficial capillaries Malformation of superficial capillaries of skinof skin

Pinkish/red maculesPinkish/red maculesWell defined edges in infancyWell defined edges in infancyFacial most commonFacial most common

PORT-WINE STAINPORT-WINE STAIN

Present at birthPresent at birthPermanentPermanentVariable sizeVariable sizeDo not proliferate but enlarge as Do not proliferate but enlarge as

child growschild growsLesions darken to purple and may Lesions darken to purple and may

develop a pebbly or slightly develop a pebbly or slightly thickened surface with timethickened surface with time

MANAGEMENTMANAGEMENT

Most are uncomplicatedMost are uncomplicatedLaser therapy may help fade the Laser therapy may help fade the

lesion, best done in infancylesion, best done in infancyAround eye innervated by branch 1 Around eye innervated by branch 1

of trigeminal nerve – need of trigeminal nerve – need ophthalmology assessment ophthalmology assessment /neuroimaging/neuroimaging

VASCULAR VASCULAR MALFORMATIONSMALFORMATIONS

HemangiomasHemangiomasCapillary (strawberry)Capillary (strawberry)CavernousCavernous

HEMANGIOMASHEMANGIOMASCAPILLARY CAPILLARY

(STRAWBERRY)(STRAWBERRY)

HEMANGIOMASHEMANGIOMAS

Begin as flat, pale white spots & later Begin as flat, pale white spots & later become larger & elevated, bright become larger & elevated, bright red, non compressiblered, non compressible

mm - several cmmm - several cmUsually solitaryUsually solitaryFemales 3:1Females 3:155% present at birth, rest develop 55% present at birth, rest develop

laterlater

CAVERNOUS CAVERNOUS HEMANGIOMASHEMANGIOMAS

HEMANGIOMASHEMANGIOMASCAPILLARY (CAVERNOUS)CAPILLARY (CAVERNOUS)

Lie deeper in in skin with a slightly Lie deeper in in skin with a slightly bluish discolorationbluish discoloration

Growth until 1 year of lifeGrowth until 1 year of life Involute over 3-10 yearsInvolute over 3-10 years

COMPLICATIONSCOMPLICATIONSPeri-orbitalPeri-orbital

risk to vision ( amblyopia)risk to vision ( amblyopia)EarEar

decreased auditory conduction, speech decreased auditory conduction, speech delaydelay

Multiple cutaneous/large facial may Multiple cutaneous/large facial may be associated with visceral be associated with visceral hemagiomashemagiomas

SubglotticSubglottichoarseness, stridor, respiratory failurehoarseness, stridor, respiratory failure

CosmeticCosmetic

CASECASE

5 week old with croup5 week old with croup6 day history of cough-initially 6 day history of cough-initially

harsh,looseharsh,loosenow high pitched seal-like coughnow high pitched seal-like coughno distress, Ono distress, O22 sat 99%, HR 130, RR sat 99%, HR 130, RR

3030erythema of left anterior tongue, left erythema of left anterior tongue, left

posterior palate with ? thrushposterior palate with ? thrush

……reassessment...reassessment...

1 hour post epi1 hour post epimoderate-severe respiratory distressmoderate-severe respiratory distressclassic “croupy” cough, RR40classic “croupy” cough, RR40severe intercostal indrawing, abd severe intercostal indrawing, abd

breathing, tracheal tugbreathing, tracheal tug improved with 2nd dose epiimproved with 2nd dose epi

““let’s bring her in…”let’s bring her in…”

admissionadmissionNPO/IV/epi/steroids/ ONPO/IV/epi/steroids/ O22 unable to discontinue steroidsunable to discontinue steroidsbreast feeding well limited to 10 breast feeding well limited to 10

minsminsno better by day 10no better by day 10

SIDE EFFECTS STEROIDSSIDE EFFECTS STEROIDS

CushingoidCushingoidhypernatremia/hypertension/wt gainhypernatremia/hypertension/wt gainhyperglycemiahyperglycemiaadrenal suppression/adrenal suppression/immunityimmunitybone densitybone densitycataractscataracts

MANAGEMENTMANAGEMENT

Natural history of haemangiomataNatural history of haemangiomata Oral systemic steroids were the Oral systemic steroids were the

mainstay of Rx if complications arisemainstay of Rx if complications arisePropranolol 2 mg/kg/dayPropranolol 2 mg/kg/day

INFECTIONSINFECTIONS

FungalFungalBacterialBacterial

TINEA CAPITISTINEA CAPITIS


Non-scarring alopecia with scalesNon-scarring alopecia with scalesRound, scaly patches of alopecia, Round, scaly patches of alopecia,

+/- broken hairs+/- broken hairs++ Boggy, elevated, dischargingBoggy, elevated, discharging

May be secondarily infected +/- May be secondarily infected +/- scarringscarring


Etiology: Fungal Etiology: Fungal Investigations: Investigations:

Wood’s light: green fluorescence only Wood’s light: green fluorescence only for microsporum infectionsfor microsporum infections

Culture of scales/hair shaftCulture of scales/hair shaftMicroscopic exam of KOH preparation Microscopic exam of KOH preparation

showing hyphaeshowing hyphae


Management:Management:Terbinafine (Lamisil) for 1 monthTerbinafine (Lamisil) for 1 month10-20 kg 62.5 mg daily10-20 kg 62.5 mg daily20-40 kg 125 mg daily20-40 kg 125 mg daily

TINEA CORPORIS TINEA CORPORIS (RINGWORM(RINGWORM))

TINEA CORPORIS TINEA CORPORIS (RINGWORM(RINGWORM))

Etiology: fungalEtiology: fungalPruritic (not severe), scaly, Pruritic (not severe), scaly,

round/oval plaque(s) with round/oval plaque(s) with erythematous margin(s) and erythematous margin(s) and central clearingcentral clearing

Peripheral enlargement of lesionsPeripheral enlargement of lesionsMostly trunk, limbs, faceMostly trunk, limbs, faceContact with infected animals/petsContact with infected animals/pets

TINEA CORPORIS TINEA CORPORIS (RINGWORM)(RINGWORM)

Management Management Clotrimazole (Canesten) creamClotrimazole (Canesten) cream

BACTERIAL INFECTIONSBACTERIAL INFECTIONS

ImpetigoImpetigoStaphylococcal scalded skin Staphylococcal scalded skin

syndrome (SSSS)syndrome (SSSS)CellulitisCellulitisFuruncle/boilFuruncle/boil

IMPETIGOIMPETIGO

IMPETIGOIMPETIGOPurulent, vesicular lesion Purulent, vesicular lesion golden golden

yellow crustyellow crustPre-school & young adultsPre-school & young adultsCrowded conditions, poor hygiene, Crowded conditions, poor hygiene,

minor traumaminor traumaDDx: infected eczema, HSV, DDx: infected eczema, HSV,

varicellavaricellaOrganisms: Staph. Aureus, GAS, Organisms: Staph. Aureus, GAS,

bothbothPotential complication: post-Potential complication: post-

streptococcal glomerulonephritisstreptococcal glomerulonephritis

IMPETIGOIMPETIGOOrganisms: Staph. aureus, GAS, Organisms: Staph. aureus, GAS,

bothbothPotential complication: post-Potential complication: post-

streptococcal glomerulonephritisstreptococcal glomerulonephritis

TREATMENT TREATMENT TopicalTopical

e.g. 2% mupirocin or fucidin tide.g. 2% mupirocin or fucidin tidSystemic 7-10 daysSystemic 7-10 days

e.g. cephalexin 50 mg/kg divided e.g. cephalexin 50 mg/kg divided tid/qidtid/qid

BULLOUS IMPETIGOBULLOUS IMPETIGOScattered, thin-walled bullae Scattered, thin-walled bullae

containing yellow/turbid fluidcontaining yellow/turbid fluidStaph. aureus Staph. aureus Complications:Complications:

Generalized skin peelingGeneralized skin peelingStaphylococcal Scalded Skin Staphylococcal Scalded Skin

SyndromeSyndrome

STAPHYLOCOCCAL STAPHYLOCOCCAL SCALDED SKIN SCALDED SKIN

SYNDROME (SSSS)SYNDROME (SSSS)

STAPHYLOCOCCAL STAPHYLOCOCCAL SCALDED SKIN SCALDED SKIN

SYNDROME (SSSSSYNDROME (SSSS))

CELLULITIS

CELLULITISCELLULITIS

Erythematous, flat, poorly-Erythematous, flat, poorly-demarcated lesions, not uniformly demarcated lesions, not uniformly raisedraised

TenderTenderWarmWarmGroup A Strep, Staph. aureusGroup A Strep, Staph. aureusDifferential diagnosis:Differential diagnosis:

necrotizing fasciitisnecrotizing fasciitis

CELLULITIS

TREATMENTTREATMENT

Cephalexin 50 – 100 mg/kg/d Cephalexin 50 – 100 mg/kg/d divided q6h POdivided q6h POSecond line = cloxacillin or Second line = cloxacillin or

clindamycinclindamycin

Cefazolin IV +/- clindamycin for Cefazolin IV +/- clindamycin for severesevere

FURUNCLES (BOILS)FURUNCLES (BOILS)Red, hot, tender, inflammatory Red, hot, tender, inflammatory

nodulesnodulesTense for 2-4 days, then fluctuantTense for 2-4 days, then fluctuantYellowish point ruptures with Yellowish point ruptures with

discharge of pusdischarge of pusCommonly around hair follicles at Commonly around hair follicles at

areas of friction & sweat areas of friction & sweat nose, neck, face, axillae, buttocksnose, neck, face, axillae, buttocks

MANAGEMENTMANAGEMENT Incision and DrainageIncision and Drainage

Relieves pressure & painRelieves pressure & painHot packsHot packs

Antibiotic PO:Antibiotic PO:e.g. cloxacilline.g. cloxacillin

Consider:Consider:Culture blood/pusCulture blood/pus

SYSTEMIC ILLNESSSYSTEMIC ILLNESS

Erythema multiformeErythema multiformeBullous erythema multiformeBullous erythema multiformeToxic epidermal necrolysis (Stevens Toxic epidermal necrolysis (Stevens

Johnson)Johnson)Henoch Schonlein purpuraHenoch Schonlein purpuraKawasaki diseaseKawasaki disease

ERYTHEMA MULTIFORMEERYTHEMA MULTIFORME

Target lesions (3 rings)Target lesions (3 rings)HERPES SIMPLEX VIRUSHERPES SIMPLEX VIRUSFixed (not transient e.g. giant urticaria)Fixed (not transient e.g. giant urticaria)

No painNo painNo pruritusNo pruritusNo scale/crustNo scale/crust

May include palms/solesMay include palms/solesMay include mucosaMay include mucosa

ERYTHEMA MULTIFORMEERYTHEMA MULTIFORME

Management:Management:Herpes isolationHerpes isolationOral acyclovirOral acyclovirTopical steroidsTopical steroids

BULLOUS ERYTHEMA BULLOUS ERYTHEMA MULTIFORMEMULTIFORME

Atypical targetsAtypical targetsCentral vesicleCentral vesicle

Vesicles without targetsVesicles without targetsDiscreteDiscrete lesions lesionsErosions & crustsErosions & crustsMucous membranes involvedMucous membranes involvedMYCOPLASMAMYCOPLASMA

BULLOUS ERYTHEMA BULLOUS ERYTHEMA MULTIFORMEMULTIFORME

Management:Management:AdmitAdmitMycoplasma isolationMycoplasma isolationAntibiotics for mycoplasmaAntibiotics for mycoplasmaOphthalmology, dermatology/wound Ophthalmology, dermatology/wound

oral careoral careSystemic steroids often neededSystemic steroids often needed

STEVENS JOHNSON STEVENS JOHNSON SYNDROMESYNDROME

TOXIC EPIDERMAL TOXIC EPIDERMAL NECROLYSISNECROLYSIS

(STEVENS JOHNSON)(STEVENS JOHNSON) Vesicles & bullaeVesicles & bullae May begin as dusky papuleMay begin as dusky papule Rapid progressionRapid progression Develops Develops confluenceconfluence Mucous membrane involvementMucous membrane involvement Systemic involvementSystemic involvement DRUG CAUSE USUALLYDRUG CAUSE USUALLY

AntiepilepticsAntiepileptics SulphursSulphurs Penicillins Penicillins

TOXIC EPIDERMAL TOXIC EPIDERMAL NECROLYSISNECROLYSIS

(STEVENS JOHNSON)(STEVENS JOHNSON)Management:Management:Life threatening Life threatening ICU/burns unit ICU/burns unitSupportive treatmentSupportive treatmentHistory for all infections/medicinesHistory for all infections/medicines IVIG (0.75-1 g/kg/d x 3 days)IVIG (0.75-1 g/kg/d x 3 days)CyclosporinCyclosporinSteroids are controversialSteroids are controversial

COURSECOURSE< 5% mortality overall< 5% mortality overallRegrowth of epidermis by 3 weeksRegrowth of epidermis by 3 weeks

COMPLICATIONSCOMPLICATIONS

•corneal scarring/blindness, corneal scarring/blindness, •phimosis, vaginal synechiae phimosis, vaginal synechiae (stenosis)(stenosis)• renal tubular necrosisrenal tubular necrosis•renal failurerenal failure•esophageal stricturesesophageal strictures•respiratory failurerespiratory failure•scarring/cosmetic deformityscarring/cosmetic deformity

HENOCH-SCHONLEIN HENOCH-SCHONLEIN PURPURAPURPURA

““Anaphylactoid purpura”Anaphylactoid purpura”Autioimmune vasculitisAutioimmune vasculitisSkin – petichiae, palpable, purpuraSkin – petichiae, palpable, purpura Joints – arthralgia/arthritisJoints – arthralgia/arthritisRenal – hematuria, Renal – hematuria, ↑↑BP, BP,

((glomerulonephritis)glomerulonephritis)GI – pain secondary to edema, GI – pain secondary to edema,

intussusceptionintussusception

KAWASAKI DISEASEKAWASAKI DISEASE

>80% less than age 4>80% less than age 4Seen in all racesSeen in all racesAsian>Black>WhiteAsian>Black>WhiteMost common cause of acquired Most common cause of acquired

heart disease in childrenheart disease in childrenTypical vs atypicalTypical vs atypical

DIAGNOSTIC CRITERIADIAGNOSTIC CRITERIAFEVER > 38.5FEVER > 38.5C > 5 days PLUS 4 of:C > 5 days PLUS 4 of:1.1. EYESEYES

Bilateral non-purulent conjunctivitisBilateral non-purulent conjunctivitis2.2. ‘‘CENTRAL’CENTRAL’

Oral mucosal changes – fissured red lips, strawberry Oral mucosal changes – fissured red lips, strawberry tonguetongue

3.3. NECKNECK Asymmetric cervical lymphadenopathy >1.5 cmAsymmetric cervical lymphadenopathy >1.5 cm

4.4. PERIPHERALPERIPHERAL Desquamation (edema, erythema)Desquamation (edema, erythema)

5.5. RASHRASH PolymorphicPolymorphic

Illness not explained by other (e.g. Strep/measles)Illness not explained by other (e.g. Strep/measles)

ASSOCIATED FEATURESASSOCIATED FEATURES

Irritability ***Irritability ***ArthritisArthritisAseptic meningitisAseptic meningitisHydrops of the gallbladderHydrops of the gallbladderHepatic dysfunctionHepatic dysfunctionDiarrheaDiarrheaPneumonitisPneumonitisUveitisUveitis

COMPLICATIONSCOMPLICATIONS

Coronary artery ectasia/dilatationCoronary artery ectasia/dilatation20% if untreated20% if untreated2% treated2% treated

Myocarditis/pericarditisMyocarditis/pericarditisArrhythmiasArrhythmias

TREATMENTTREATMENT

IVIG infusionIVIG infusionHigh dose then low dose aspirinHigh dose then low dose aspirinSupportiveSupportive

SUMMARYSUMMARY

Assessment of skin problemsAssessment of skin problems Itchy (2/5)Itchy (2/5) Birth MarksBirth Marks Vascular malformationsVascular malformations InfectionsInfections Systemic illnessesSystemic illnesses

REFERENCESREFERENCES

E.O. 021.08, 021:09 and 021:11E.O. 021.08, 021:09 and 021:11Nelson’s Essentials of PediatricsNelson’s Essentials of PediatricsColor Atlas/Synopsis of Clinical Color Atlas/Synopsis of Clinical

DermatologyDermatologyClass HandoutClass HandoutCanadian Paediatric Society Policy Canadian Paediatric Society Policy

StatementsStatementshttp://www.aboutkidshealth.cahttp://www.aboutkidshealth.ca

paediatric dermatology. objectives common paediatric dermatologic conditions common paediatric...

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