The role of the primary care provider in the diagnosis and treatment of dermatologic conditions is increasingly important. This chapter provides a framework for assessing and treating the most common chronic dermatologic disorders seen in the pediatric and adolescent setting, including acne, chronic warts, and molluscum contagiosum. Because it is rarely seen in this setting, psoriasis is not discussed. The interested reader is referred to Common Dermatologic Conditions in Primary Care (1999) (the companion volume to this text) or to any standard dermatology reference.

Not every patient with a skin complaint presents in a classic textbook manner. A child may present with skin lesions as the primary complaint, or a lesion may appear as an incidental finding during the physical examination. The prevalence of skin conditions is not easy to estimate. Environmental and social factors influence both the occurrence and detection of the skin condition.

The skin is the largest of all body organs and plays a major role in maintaining the body’s homeostasis. The skin serves as a barrier to prevent the loss of important body fluids and the entrance of possible toxic or infectious agents. Skin changes of any variety may be indicative of a primary dermatologic problem, or they may signal the primary care provider to look for an underlying systemic disease. Parents are often only concerned about skin changes themselves and what can be done about them. Unless the issue of the problem underlying the lesion is addressed adequately, parents may not be receptive to the care needed, follow guidelines adequately, or return for follow-up.

One of the key aspects in the approach to dermatologic care is the use of standard nomenclature when describing skin lesions. Table 58-1 summarizes the common classification of skin lesions. Standardization of the basic dermatologic terminology allows all practitioners to improve communication and accurate diagnosing of clients. To help prevent confusion in the standard of measurement of lesions, a metric ruler is an essential tool for the provider.

Acne vulgaris is a condition that affects the pilosebaceous unit that consists of sebaceous glands and hair follicles (Color Plate 1A-E). These units are found on all skin surfaces except for the palms of the hands and the soles of the feet. The development of acne involves four principal factors:

Acne vulgaris is a disorder of the sebaceous gland, sebaceous duct, and hair follicle in areas of high sebaceous density


(the face, back, chest, and upper arms). The face is the site of greatest prevalence. Comedonal, papular, and pustular acne are the most common variants of acne vulgaris. It is an extremely common disorder with a strong genetic predisposition whose peak prevalence occurs during adolescence. Acne affects 90% of males and 80% of females in variable degrees. In males, acne usually starts in early adolescence, is more severe, and resolves in the early to mid 20s. In females, acne usually starts later, is less severe, and lasts longer (late 20s and early 30s). It accounts for the majority of medical visits in this age group to their primary care provider for referrals to the dermatologist (Greydanus, 1997).

Acne has been identified as a contributing factor to psychosocial problems, such as clinical depression, anxiety, and a negative body image (Bergfeld, 1995; Galen, 1997). Successful treatment usually corrects or improves these problems. The treatment plan should be individualized and based on the psychosocial impact the acne poses for the individual.

Criteria for diagnosing and treating acne can be guided by staging the acne, as follows:

The diagnosis of acne is fairly straightforward, but treatment involves more than simply writing a prescription. The treatment plan should be a mutual decision made between the primary care provider and the patient or family. Therefore, it is essential that patient motivation be assessed. The management plan should be outlined in detail, with realistic expectations included. An explanation of why acne develops, including a handout on the treatment of acne, should be
included with the initial assessment of the patient (Schachner, 1998). Display 58-1 lists suggestions for skin care for patients with acne. Myths about the causes and cures of acne should also be dispelled.