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Photosensitivity in children

Photosensitivity is the abnormal reaction of skin to light and sunlight, often referred to as a ‘sun allergy’. Its incidence in childhood is rare, but it is during childhood that some of the more severe ‘sun allergies’ (photosensitivity disorders) can first occur, causing children and parents great distress.

Generally a ‘sun allergy’ is neither an allergy, nor caused specifically by the sun. These disorders can be caused by a range of factors; some environmental, some chemical and others unknown. For most photosensitivity disorders, a particular wavelength of light is responsible, such as visible light or invisible ultraviolet (UV) radiation. A child may be sensitive to a specific type of radiation (the longer wavelength, UVA, is most common) or to a broad range. Symptoms of photosensitivity vary considerably, but commonly include sunlight-induced rashes (photodermatoses), skin reddening and blisters or lesions.

Causes of photosensitivity

Hydro vacciniforme is a rare photodermatoses which presents in children.Diseases which can cause photosensitivity in children include:

A variety of skin disorders, called photodermatoses, including – solar urticaria, hydroa vacciniforme, actinic prurigo and polymorphic light eruption (PLE)
Genetic skin disorders, such as the rare disease xeroderma pigmentosum
Metabolic conditions – the most common of these are the porphyrias, where photosensitising chemicals (porphyrins) build up in the skin (see more on EPP, one of the more common porphyrias to present in children)
Underlying skin disease, such as eczema (atopic dermatitis) or psoriasis, can sometimes be exacerbated by sun exposure

Other potential causes of photosensitivity:

Some medicines contain substances which can photosensitise the skin of susceptible people; be sure to mention to your doctor or dermatologist any medications your child might be taking
Contact with specific plants, dyes, fragrances or other chemicals can also induce photosensitivity

Diagnosis and treatment

Assessment of a suspected photosensitivity by a dermatologist includes a description of patient/family history and a physical examination. The clinician may then require laboratory tests (such as blood, urine and faecal tests) and skin biopsies or phototests (measured tests of the skin’s response to light) to determine the cause. The specific precautions necessary and treatments available will depend on the individual condition diagnosed or the stimulus of the photosensitivity. Many people with a photosensitivity do need to avoid excessive sun exposure, though the degree varies.

Parents who believe the sun is definitely the issue should seek a referral to a physician or dermatologist who specializes in photosensitivity disorders (such as a photodermatologist), as many children go undiagnosed or misdiagnosed due to the rarity of these conditions and the difficulty of identifying UV or light as the cause.

References

Garzon, MC & DeLeo, VA 1997, ‘Photosensitivity in the pediatric patient’, Current Opinion in Pediatrics, 9(4):377-387.

It is well known that the ultraviolet (UV) radiation in sunlight can have damaging effects on human health. The vulnerable developing skin of children and babies can sunburn and scar easily. Excessive time spent in the sun can also have long-term, sometimes dangerous, effects including: eye damage (i.e. cataracts), skin cancer and premature skin aging (wrinkles; sagging; age spots and other lesions; broken blood vessels; thin, fragile, dry or leathery skin).

Importantly, the amount of sun exposure and sunburn a child incurs contributes significantly to their risk of developing skin cancer, including melanoma, later in life. Therefore, sun safety is vital for protecting the skin and reducing a child’s risk of skin cancer. There are a number of ways you can help to protect your child from the damaging rays of the sun and prevent these health problems. Furthermore, children whose parents set an example with sun safety tend to learn and carry them out more often.

Protective clothing

Light-weight, tight-weave clothing should be worn when spending time in the sun. It is best to cover as much as the body as possible, so long pants and shirts with sleeves and collars are recommended. Certain colours and types of fabric provide a better barrier between the skin and sun than others, for more information on sun safe clothes see the article on Sun protective clothing.

Hats

SunSmart Victoria recommends children and adults wear broad-rimmed hats to shade the scalp, face, ears and neck from sun damage. The hat’s brim should be at least 7 ½ cm wide, those of the bucket or legionnaire styles generally give good protection. Caps are not considered adequate protection as they don’t cover the ears and the back of the neck; common sites of sun overexposure and skin cancer development.

Sunglasses

Most government health agencies advocate the use of wrap-around, polarised sunglasses to protect eyes from sun damage. Image: Aka Hige on FlickrMost government health agencies also advocate the use of wrap-around, polarised sunglasses to protect eyes from sun damage. When choosing sunglasses for children there are a few things you can look for to ensure they will shield adequately:

• Check the label for the phrase “good UV protection”
• Numbered categories 2, 3 or 4 – this indicates the glasses guard against a high level of UV
• Text indicating that the glasses have met the Australian standard (AS/NZS 1067:2003)
• An ‘Eye Protection Factor’ (EPF) rating of 9 or 10

Sunscreen

When sun exposure is unavoidable, sunscreens can help to protect children’s skin, however it is important to remember that no sunscreen is 100% effective and should be used alongside other protective measures.

High SPF (minimum of 30+), broad-spectrum sunscreens block or absorb the most UV radiation and may be beneficial for preventing sun damage in all its forms. Proper, thorough application is essential to ensure the effectiveness of sunscreen – this means applying it regularly and liberally (roughly one teaspoon for each limb and your face). Use a generous amount of sunscreen 20 minutes prior to going out in the sun and reapply every two hours thereafter (more often if swimming or if skin is sweaty).

For more in-depth information on sunscreen use on children and babies, see the article on Sunscreen and pediatric skin on our Science of Skin website.

Avoiding the sun

Beach umbrella. Image: will ockenden on FlickrThe level of UV radiation generally spikes in the middle of the day when the sun is at its highest. Where possible, the World Health Organization (WHO) recommends limiting sun exposure during the hottest part of the day, from approximately 10am till 4pm. This may mean staying indoors, seeking shady spots outside or scheduling sports and other outdoor activities for the morning or late afternoon.

The forecast levels of UV radiation, known as the UV index, are often included as part of many weather reports. The Bureau of Meteorology provides information on the daily UV intensity throughout Australia, http://www.bom.gov.au/australia/uv/index.shtml.

References

SunSmart Victoria 2010, ‘For parents: protecting your family’, retrieved 5 April 2011, <http://www.sunsmart.com.au/sun_protection/for_parents>.

SunSmart Victoria 2010, ‘Sun protection’, retrieved 5 April 2011, <http://www.sunsmart.com.au/sun_protection>.

Insect bites and stings

Mosquitoes, bees, wasps, fleas, spiders and ticks are the most common perpetrators of insect bites and stings in children. The symptoms and extent of the reaction your child experiences following a bite or sting will depend largely on how allergic they are, but most pain and irritation is only temporary. Often there is only slight, transient inflammation (redness and irritation) of the skin in the spot where the insect has bitten or stung. The bite/sting may be sore, tender or itchy and usually resolves within a few days. More intense reactions involve redness and swelling over a larger area which can take a week or so to settle. Very occasionally a child can have a severe allergic reaction to an…
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Bruises

Bruises are one of the most common and visible injuries, often caused by intense or repeated contact of the skin with another object. Bruises frequently result from falls, accidents or sports injuries, but they may also be indicative of an underlying medical condition. For this reason, parents of children who bruise easily or experience regular, severe or unexplained bruising should seek medical treatment. What is a bruise? A bruise is a form of internal bleeding, known medically as a contusion. It is caused when muscle fibres, capillaries and venules (small veins) under the skin are damaged but the skin itself remains intact, causing blood to seep into the surrounding tissue. The skin around a bruise appears discoloured and is usually…
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Burns

In the event of a severe burn, consult emergency services immediately for professional treatment and advice. Burns are injuries to the skin caused by heat from flames, liquids, radiation, chemicals or electrical devices. The severity of a burn is determined by its depth, the age of the patient, the particular sites on the body burnt (hands, feet, face, genitals and joints are the most complicated) and the total surface area of the burns. While minor burns usually cause nothing more than temporary shock and mild discomfort, severe or widespread burns can be physically destructive, permanently debilitating and even fatal. Types of burns Burns can be classified by the depth of tissue they injure. The names for various types of burns…
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Healing cuts

Every child will, at some point, scrape a knee, cut a finger or break their skin open in some way. While more serious lacerations require medical attention, here are some basic tips for assisting in the healing of minor cuts and avoiding infection or irritation. First aid for minor cuts and abrasions Before treating a child’s injuries it is important to first wash your own hands, covering any breaks in the skin with bandages or gloves. Generally speaking, shallow cuts and abrasions stop bleeding on their own. However, if bleeding persists, it may be necessary to physically stem the flow of blood by gently holding a sterile dressing to the wound and applying pressure. Gently, but thoroughly, cleanse the cut…
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The changes that occur in the skin during pregnancy are related to different aspects of the skin’s structure. We can group these into four types:

1. changes in pigmentation (the colour of the skin);
2. changes in the function of the skin’s glands;
3. vascular changes (affecting the blood vessels beneath the skin); and
4. changes in the connective tissue which holds skin together.

Many of these changes result from the altered levels of hormones which occur during pregnancy or from the physical stretch and strain on the skin. Fortunately, most are only temporary and subside or lessen shortly after delivery.

Skin changes during pregnancy

Pigmentation (colour changes)

Changes in skin pigmentation during pregnancy may involve an increase in pigment (skin darkening), or a loss of pigment (skin lightening).

Hyperpigmentation, or darkening of the skin, is extremely common; particularly during the first trimester of pregnancy. Up to 90% of pregnant women experience an increase in skin pigmentation on various parts of their bodies. It usually occurs on areas of skin which were darker to begin with, such as moles, freckles, nipples and genitals. Most experts attribute these changes to increased hormone levels (estrogen, progesterone and α-MSH) in the blood. It is thought that skin cells, called melanocytes, are stimulated by the hormones to produce more of the brown pigment (melanin) in the skin.

Melasma is common during pregnancy. Image: Jmh649 from Wikimedia commonsIt is well known that folic acid can reduce the risk of neural tube defects in babies, but studies have also shown a link between folic acid deficiency and hyperpigmentation. Ensuring you get enough folic acid, by taking supplements and eating plenty of folate-rich foods (leafy green vegetables, citrus fruits and legumes), can therefore help to minimise unwanted skin darkening.

Melasma, a type of facial skin darkening, and linea nigra, the formation of a dark line down the centre of the abdomen, are two common pigmentary changes to occur during pregnancy.

Glands

Most women will find that they sweat (perspire) more during pregnancy; in some cases this can be quite profuse. Once again, this is due to the increase in hormones affecting the operation of the sweat glands in the skin.

The influx of hormones during pregnancy can also stimulate the oil-producing (sebaceous) glands in your skin to secrete more oil (sebum). This can lead to worsening acne, particularly in women that had a preexisting problem or suffered from acne during adolescence.

Vascular

A pregnant woman’s body also produces much more blood (some studies suggest up to 50% more) than normal to adequately supply the growing fetus. As a result, the small blood vessels beneath the skin surface dilate and become more permeable, those penetrating the skin can also become more numerous and visible. These changes in blood and vessels can cause unwanted spider and various veins, however the increased circulation is also responsible for the phenomenon of radiant skin known as the ‘pregnancy glow’.

Connective tissue

Pregnancy places a huge strain on the body, and the skin is no exception. Often the tissue beneath the skin tears if the skin is overstretched. This can create stretch marks on the abdomen as the skin is pulled over the expanding uterus, or on the breasts as they enlarge. Another change to the structure of the skin which is relatively common is skin tags, small, soft growths (usually in folds of skin) made up of collagen fibres and blood vessels.

Changes to the skin on the breasts

In addition to darker skin on the nipples, the areolas, the circular area surrounding the nipple, often expands during the first trimester. The small bumps on the areolas are actually specialised oil glands, called Montgomery’s tubercles, these may protrude more during pregnancy and lactation.

As well as stretch marks on your breasts, you may notice the veins beneath the skin become more obvious. Early in the pregnancy, your body begins to make colostrum, a thick, yellow liquid which the baby is first fed on. Small quantities of colostrum may leak from yours breasts towards the end of the pregnancy.

Skin care during pregnancy

Use a gentle cleanser that is oil and soap-free to wash your face twice each day. Rinse away any traces of cleanser with warm water and pat your face dry with a clean towel.
Avoid harsh chemicals, vigorous scrubbing or cleansing too often, as these can remove the natural oils from your skin, making it produce excess to compensate.
After cleansing, apply a mild, oil-free moisturising lotion to keep your skin soft, supple and hydrated.
Stay properly hydrated by drinking plenty of water; this helps your skin maintain its water content and appear smooth and bright.

References

BabyCenter 2010, ‘Breast changes during pregnancy’, retrieved 24 March 2011, <http://www.babycenter.com/0_breast-changes-during-pregnancy_262.bc>.

Boutros, S, Régnier, S, Nassar, D, Parant, O, Khosrotehrani, K & Aractingi, S 2009, ‘Dermatological Manifestations Associated With Pregnancy’, Expert Review of Dermatology, 4(4):329-340.

Gentili, A & Vohra, M 2009, ‘Folic Acid Deficiency’, eMedicine, retrieved 30 March 2011, <http://emedicine.medscape.com/article/200184-overview>.

Pomeranz, MK 2010, ‘Physiologic changes of the skin, hair, nails, and mucous membranes during pregnancy, UpToDate, retrieved 24 March 2011, <http://www.uptodate.com/contents/the-skin-hair-nails-and-mucous-membranes-during-pregnancy>.

When it comes to nutrition, our skin often reflects what’s going on inside our body. Feeding children a balanced diet, high in essential vitamins and minerals, can have beneficial effects on the health of their skin. The following is a list of skin-friendly foods and the nutrients that they contain.

*It is important to note that excess supplementation with some of these vitamins and minerals (vitamin A, copper, zinc and selenium) can be dangerous. Always speak to your child’s doctor before commencing dietary supplements.

**Nuts, dairy products and shellfish are some of the most common foods to induce allergic reactions. Introduce these foods to your child’s diet gradually and seek immediate medical attention if a reaction occurs.

References

Fraser, J 2006, ‘The top five foods for healthy skin’, retrieved 15 August 2011, <http://www.naturalnews.com/020409.html>.

Bouchez, C 2006, Foods for Healthy Skin: You Are What You Eat, WebMD, retrieved 15 August 2011,<http://www.webmd.com/healthy-beauty/features/skin-food>.

Caring for skin from birth to 18 months

No longer protected inside its mother, a newborn child must adjust to a host of changes in their new environment. The world outside the womb can be harsh and, as the external barrier, the skin is the body’s first defense against these conditions. An infant’s skin must adapt to tackle a variety of chemicals, weather conditions, physical stresses, skin disease and attack from microorganisms, such as bacteria or viruses.

Until recently, little has been known about the structure of babies’ skin due to ethical issues of using certain experimental methods on infants. With the advent of newer, noninvasive techniques, however, we are beginning to learn more about the unique qualities of young skin and how best to care for it.

Skin structure

An infant’s skin can be up to 5 times thinner than that of an adult, so it is far more delicate and sensitive – even compared to that of older children. At birth, babies have quite dry skin which quickly becomes hydrated within the first few weeks. This continues to such a point that older infants (8-24 months) actually have skin which is generally better hydrated than adults. Similarly, the skin of a baby is quite rough when they are first born, but quickly softens and smoothes out by around one month of age; this is linked to the increase in the water content of the skin.

While the amount of water is generally higher in baby skin, it does fluctuate more than in adult skin. One of the reasons for this is that skin cells contain a mixture of molecules called the NMF, or Natural Moisturising Factor. These molecules attract and absorb water, keeping the cells hydrated. Baby skin has less of these molecules, making it less able to retain moisture.

Babies have fewer lipids (fats) in their skin than adults. Lipids are important for creating a solid barrier of the skin, which could be one reason that infant skin does not function as such an effective defense against physical and chemical damage. Their skin is more vulnerable because this barrier role of the skin is still developing. Premature babies, in particular, have skin which is less well developed and are therefore more susceptible to a number of environmental factors, such as abrasion and water loss. Before 30 weeks gestation, the top layer of skin (called the epidermis) is weak, thin and relatively immature; its formation is mostly completed by 34 weeks.

Babies have smaller skin cells than adults and these are closely crowded together. This is because their skin cells multiply at a high rate, being more quickly renewed and sloughed off at the surface.

Caring for baby skin

The following guidelines for infant skin care are provided by the Royal Children’s Hospital in Melbourne.

Bathing a baby

It is recommended that a baby be bathed approximately 2-3 times per week in warm water; excessive bathing may remove the skin’s natural oils (sebum) and cause their skin to dry out. It is also advised that the use of harsh soaps be avoided as they may contain irritants or allergens.

When a cleanser is necessary, many brands offer gentler options. The skin should be dried carefully, particularly in the creases of the neck, groin and armpits. An emollient (a substance which moisturises and softens skin), in the form of a cream or lotion, should then be applied within three minutes. This can be applied up to three times daily and is particularly important for babies with dry, flaky or sensitive skin.

For babies with eczema or other dry skin conditions it best to avoid the use of soaps altogether, using moisturisers as a substitute when bathing, as well as applying them frequently at other times. Colder temperatures can also lead to excessively dry skin, at these times it may be necessary to wash less frequently and apply moisturiser more often.

Nappies (diapers)

Nappies should be changed regularly, and the skin in these areas cleansed with warm water and a small amount of mild soap or moisturiser. Given the sensitive nature of babies’ skin, along with its tenancy to absorb substances more easily, it is advised that the number of products you expose your baby to is minimised, sticking only to the essentials described above.

Where possible, babies should be kept out of the sun. Where sun exposure or time outdoors is unavoidable, infants can be protected using sun protective clothing, hats, sunscreen, sunshades and ambient shade.

Temperature control

The skin and bodies of infants are not able to regulate temperature as well as adults. As a result, they are more vulnerable to over-heating or becoming too cold in extreme conditions. This is particularly important for babies and young children who are not capable of removing their bedding or adding an extra layer of clothing themselves.

References

The Royal Children’s Hospital Melbourne n.d., ‘Clinical Guidelines (Hospital): Skin care of the term baby and infant’, retrieved 26 July 2010.

Stamatas, GN et al. 2011, ‘Infant skin physiology and development during the first years of life: a review of recent findings based on in vivo studies’, International Journal of Cosmetic Science, 33(1):17-24.

St. Vincent’s Hospital Melbourne 2002, ‘Skin care in babies and young children’, retrieved 11 May 2011,

From the early stages of pregnancy and new motherhood to growing children and the independence of adolescence, skin faces a host of challenges – from healing wounds and keeping out foreign invaders to shielding against the ravages of light, heat and dehydration. As the largest organ of the body, the skin plays many important roles: it protects our bodies, senses physical stimuli, regulates temperature and helps to maintain a healthy balance of fluids and nutrients.

‘Atopic Mothers & Children’ offers unique insight into the functioning and health of skin throughout childhood and motherhood from the most common skin conditions to some of the rarest disorders.