Severe Pediatric Dermatoses: Diagnostic Pitfalls and Early Systemic Therapy

In hospitalized or systemically ill children, diagnostic clarity for inflammatory skin disease can be challenging, and misclassification has meaningful therapeutic consequences. Adelaide Hebert, MD, professor and director of pediatric dermatology at McGovern Medical School at UTHealth Houston, describes how severe infections and systemic inflammation can obscure distinctions among conditions such as staphylococcal scalded skin syndrome, severe atopic dermatitis with secondary infection, and pustular psoriasis. When morphology is atypical or the disease course is unexpectedly aggressive, she advises a low threshold for dermatology consultation and, in select cases, skin biopsy to secure the diagnosis and guide therapy.

From the primary care perspective, Autumn Atkinson, MD, associate professor in the Department of Pediatrics at McGovern Medical School at UTHealth Houston, outlines common management pitfalls prior to dermatology referral, including inadequate escalation of therapy, overreliance on topical corticosteroids without adjunctive barrier repair, and delayed recognition of treatment resistance. Hebert underscores the importance of ceramide-containing emollients in atopic dermatitis to address the underlying barrier defect and enhance pharmacologic treatment. She also highlights the growing role of systemic agents, particularly biologics, in children with moderate to severe disease, noting that dedicated biologic coordination is often necessary to navigate prior authorizations and complex regimens.

In this segment, Hebert and Atkinson focus on shared responsibility between pediatricians and pediatric dermatologists for timely escalation of care in refractory or severe pediatric atopic dermatitis and psoriasis. They emphasize that early recognition of treatment failure, attention to barrier-directed therapy, and awareness of when systemic or biologic therapy is appropriate can reduce morbidity, hospitalization, and cumulative steroid exposure.