• Comedones are noninflammatory acne lesions.
  • Inflammatory lesions include papules, pustules, and nodules.
  • Grading acne based on the type of lesion and severity helps guide therapy.
  • Noninflammatory Acne
    • Topical retinoids prevent the formation of comedones and reduce their number, and are indicated as monotherapy
  • Mild to moderate inflammatory or mixed acne
    • Topical antibiotics 
  • Moderate to severe acne
    • Oral antibiotics 
  • Severe, recalcitrant acne
    • Oral isotretinoin 


Foot disorders

Calcaneal apophysitis

  • Presentation:
    • also known as Sever disease, is the most common etiology of heel pain in children, usually occurring between 5 and 11 years of age.
    • It is thought that in these children the bones grow faster than the muscles and tendons.
    • A tight Achilles tendon then pulls on its insertion site at the posterior calcaneus with repetitive running or jumping activities, causing microtrauma to the area.
    • There may be swelling and tenderness in this area and passive dorsiflexion may increase the pain.
  • Radiography
    • is usually normal and therefore does not often aid in the diagnosis, but it may reveal a fragmented or sclerotic calcaneal apophysis.
  • Treatment
    • involves decreasing pain-inducing activities, anti-inflammatory or analgesic medication if needed, ice, stretching and strengthening of the gastrocnemius-soleus complex, and the use of orthotic devices.

Plantar fasciitis and heel pad syndrome

  • cause pain on the plantar surface of the heel rather than posteriorly.

Achilles tendinopathy

  • causes tenderness to palpation of the Achilles tendon.

Tarsal tunnel syndrome

  • related to compression of the posterior tibial nerve causes neuropathic pain and numbness in the posteromedial ankle and heel.


  • Slipped capital femoral epiphysis (SCFE)
  • This is more frequent in males than in females, and is more common in African-Americans and Pacific Islanders than in whites.
  • Although some patients present with pain, many present with a painless limp or vague pain.
  • The average age of onset is 13.5 years for males and 12 years for females.
  • Obesity is strongly associated with SCFE.
  • The lack of systemic symptoms makes osteomyelitis, abscess, or a septic joint much less likely.
  • Malignancy is a possibility, but night pain would be more likely.
  • Sacroiliitis is much less likely given a negative FABER test.
  • The patient’s age makes transient synovitis or Legg-Calvé-Perthes disease less likely.
  • Although muscle strain is a possibility, the physical examination findings of external rotation deformity and limited internal rotation are more specific for SCFE.
  • Once the diagnosis of SCFE is made, the patient should not bear weight and should be referred promptly for surgery to prevent complications.



Pediatric patient presents with an asthma exacerbation and is being treated with albuterol NEB and oral prednisolone. What IV medication should be added to the patient’s current treatment to reduce the likelihood of hospital admission?

Chlamydial pneumonia

  • is usually seen in infants 3–16 weeks of age, and these patients frequently have been sick for several weeks.
  • The infant appears nontoxic and is afebrile, but is tachypneic with a prominent cough.
  • The physical examination will reveal diffuse crackles with few wheezes, and conjunctivitis is present in about 50% of cases.
  • A chest film will show hyperinflation and diffuse interstitial or patchy infiltrates.

Staphylococcal pneumonia

  • has a sudden onset.
  • The infant appears very ill and has a fever, and initially may have an expiratory wheeze simulating bronchiolitis.
  • Signs of abdominal distress, tachypnea, dyspnea, and localized or diffuse bronchopneumonia or lobar disease may be present.
  • The WBC count will show a prominent leukocytosis.

Respiratory syncytial virus

  • infections start with rhinorrhea and pharyngitis, followed in 1–3 days by a cough and wheezing.
  • Auscultation of the lungs will reveal diffuse rhonchi, fine crackles, and wheezes, but the chest film is often normal.
  • If the illness progresses, coughing and wheezing increase, air hunger and intercostal retractions develop, and evidence of hyperexpansion of the chest is seen.
  • In some infants the course of the illness may be similar to that of pneumonia.
  • Rash or conjunctivitis may occur occasionally, and fever is an inconsistent sign.
  • The WBC count will be normal or elevated, and the differential may be normal or shifted either to the right or left.

Chlamydial infections

  • can be differentiated from respiratory syncytial virus infections by a history of conjunctivitis, the subacute onset and absence of fever, and the mild wheezing.
  • There may also be eosinophilia.

Parainfluenza virus infection

  • presents with typical cold symptoms.
  • Eight percent of infections affect the upper respiratory tract.
  • In children hospitalized for severe respiratory illness, parainfluenza viruses account for about 50% of the cases of laryngotracheitis and about 15% each of the cases of bronchitis, bronchiolitis, and pneumonia.

Obstructive Sleep Apnea

Childhood obstructive sleep apnea syndrome

  • has a prevalence rate of 5.7%. It is associated with growth, cardiovascular, and neurobehavioral abnormalities.
  • Adenotonsillectomy is the treatment of choice.
  • Although CPAP can be effective, compliance is poor and it is therefore not a first-line treatment.
  • Intranasal corticosteroids may also be helpful, but the benefit appears small.