Grandma Knew, Wash Behind Those Little Ears (Pedcast)

Topic intro

21st century pediatricians are getting used to being consulted about child health problems in new and unique ways- via email, by way of video calls, and yes, with texts.  So it was the other day when I got a few texts, with photos, about my 9-month-old great nephew’s outer ear and scalp. These texts were sent by my niece, the baby’s mother. Her son had developed some redness behind his ear that looked angry to his mom. Interestingly, the previous week, both his six-year-old brother and mother came down with culture proven strep throat.  Very interesting, now little Elliott has a skin infection behind his ear. Could they be related, my niece asked? And my answer was… you bet they’re related. Which brings us to today’s pedcast topic-skin infections in children.  Specifically we are going to address the following questions:

  1. Why do children get more skin infections than adults?
  2. Are there different kinds of skin infections in children and if so, how are they classified?
  3. What are the best treatments for common skin infections in children?
  4. Can skin infections be prevented?
  5. And, was there a reason that Grandma insisted that her children wash behind their ears?

So sit back and take a listen to today’s pedcast that I call, “Grandma Knew, Wash Behind Those Little Ears”.


Musical intro

Why do kids get skin infections?

Let’s start with the first question, why do children get more skin infections than adults. If you think of your skin as a barrier to the germy outside world, the answer becomes obvious. Any situations that break that barrier and introduce germs to a broken outer protective layer of skin, you, know, the epidermis of the skin, increases the chance that the child will develop a skin infection. Remember, kids are different than adults in a number of ways: they have thinner skin than adults that is easily torn, they are much more active than adults  making injuries more likely, they definitely have more abrasions and cuts than adults because they move way more, they hang out with children who carry lots of mean germs making inoculation of their broken skin more likely, and they are just dirtier. Their fingers are in their noses, in the trash and dirt, and scratching dirty parts of their bodies far more than adults.  All of these factors increase a child’s chance of contracting a skin infection.

What germs cause most skin infections?

Which germs are most likely to infect a child’s skin you may be wondering? It turns out that two nasty germs account for almost all the skin infections in children and their names are probably familiar to you…staph aureus and streptococcus pyogenes. Yes the same strep that causes so much misery in the form of strep throat in children. Both are bacteria that have the ability to latch onto broken skin or even invade the skin and tissues below. In very rare cases, they even make it into the child’s blood and cause overwhelming life threatening illness. Fortunately, this is rare. Usually staph and strep infections of the skin stay fairly superficial. When strep is the cause of the infection, crusting of the skin is the most common feature, often with a dried honey look. Staph, on the other hand, tends to go deeper faster, causing pustules and boils along with blistering of the skin, the so-called bullous (meaning blister) type of skin infection. To be complete, I should mention that there are viruses and fungi that can infect skin but these types of infections are much less common. Staph and strep are the big bad players when it comes to skin infections.


How are skin infections classified?

Now we are going to talk about how doctors classify skin infection but to do so, we are going to get a little more technical. I’m going to teach you some doctor speak. Impetigo, or infantigo as some people call it, refers to a condition where the very surface layer of the skin becomes infected… you know, the epidermis. Actually, I always thought the term infantigo was a made up word by parents mispronouncing impetigo but as I learned while creating this pedcast, it is an actual bonafide medical term.  If the germs invade a little deeper and begin to extend into the deeper parts of the skin, the dermis and surrounding skin with redness and swelling of the skin– this is referred to as cellulitis.  And finally, if the germs get very deep into the skin and into the subcutaneous tissues and localize into a boil, this is referred to as an abscess or pyoderma– an almost 100% sign of a staph infection.

How are skin infections treated?

Now let’s talk about the  best treatment for a skin infections in a child? Which treatment is best is like a lot of things in life, it depends. First, before we go over these recommendations, I want you to keep in mind that these recommendations are only for otherwise healthy children, not those with any kind of chronic illness or is very ill. Let me make that very clear. But for healthy children with very surface staph and strep infections, washing frequently and topping the broken skin with a topical antibiotic like mupirocin (a prescription topical antibiotic) normally works well. In fact, this form of treatment has been found to be superior to the old 10 days of oral antibiotics. Antibiotics are usually not necessary for the treatment of superficial impetigo unless the child is sick or the sores are around the nose or mouth making it likely that the child also has a deeper nasal infection or throat infection. You can’t put ointment on a child’s tonsils very easily can you?  Of course not. If the infection is a cellulitis type with swelling of the skin and a lot of redness, especially if there is fever, antibiotics plus local care with washing and topical antibiotics are needed since cellulitis can lead to very serious infections. Sometimes children with cellulitis are admitted for IV antibiotic treatment. Your child’s pediatrician will make that call should that situation arise. And finally for the treatment of an abscess in a child without a fever and who is not sick… frequent warm water soaks in warm water, topical heat, and topical cleansing with drainage of the abscess for those whose abscess fails to resolve quickly is the quickest way to recovery. Having an abscess drained is unpleasant for a child but sometimes essential for the child’s quick recovery. Your child’s pediatrician will help you make that decision should it be necessary.  Whether children with an abscess also need oral antibiotics is still up for debate among doctors however. Currently, experts are leaning toward no oral antibiotics unless the child has a fever, has multiple abscesses, or is not improving with abscess draining only.

Back to the case of little Elliott

OK, let’s get back to the case of my great nephew, Elliott. What can we learn from his case? Well, first you can see that strep and staph infections are very contagious since three out the four people in their family came down with confirmed or probable strep infections. It is very likely that Elliott had strep cellulitis starting in a little skin rash called seborrhea behind his ear. People also call this rash cradle cap that is so common in babies. Secondly, it’s also interesting to note that older children and adults get their strep infections on their tonsils, presumably an easier and more hospital place for strep to grow because it is far more damp and warm than skin.  Germs need moisture. But Elliott, being only 9 months old, doesn’t have large enough tonsils to get infected so he can only get a skin infection in a place where there was a crack in his skin, some dead skin cells clinging on, and a slightly damp place. Actually, impetigo behind the ears is a common condition in children because of those reasons. It is likely that his six-year-old brother brought the infection home from school since we know from surveys of school age children, that 25% of them have strep in their throats if one child in their classroom has culture proven strep. The strep germ is very easily spread among school-aged children since it moves via spit and snot and is capable of living on surfaces for months. You heard me right, months!  Anyone who has spent much time around young children knows they are all about spit and snot and strep is literally everywhere in many classrooms.  In hindsight, poor Elliott was doomed.

Is there a way of preventing skin infections in children?

Well, I probably have you pretty frightened that your children will get skin infections, especially if they are in the young but the good news is that skin infections can often be prevented. Not a 100% but the chance that your child will get a skin infection can be greatly reduced by doing some simple things that of course, your grandmother knew about. Here they are:

–By making sure that your children wash their hands frequently especially just after they have been with other children and before they sit down to eat.

–By keeping their clothes clean and washed in bleach if possible.

–By making sure they keep their skin clean by taking a bath ever few days,

–By washing their abrasions and cuts with soapy warm water frequently and topping the broken skin with Vaseline, a band-aid, or topical antibiotic.

–By doing twice weekly Clorox baths if they have eczema or are prone to skin infections.

–And of course, by washing behind their ears when they bathe.



I hope I answered the questions that I posed in the introduction to this pedcast. Let’s go over them once again and make sure you know the answers.

  1. Why do children get more skin infections than adults? Because their skin has more breaks and they have more germs inoculated on their broken skin than older children or adults.
  2. Are there different kinds of skin infections and if so, how are they classified? Yes there are and they are classified by how deep the infection penetrates into the skin. Surface infection only is called impetigo, deeper infections are either called cellulitis or pyoderma.
  3. What are the best treatments for common skin infections in children? Remember every child is different and ultimately their treatment is up to their pediatrician, but assuming they are otherwise healthy, impetigo can be treated with frequent washing and topical antibiotics, cellulitis is treated with oral antibiotics, frequent washing, and topicals, and an abscess is treated by possibly draining the abscess, hot soaks and washing, and maybe a course of oral antibiotics.
  4. Can skin infections be prevented?Yes, yes, and yes, Good hand washing cuts the number of infections in half. Getting those clothes cleaned, taking regular baths, treating abrasions and cuts proactively, and washing behind those ears all can be very helpful.
  5. And finally, why did grandma insist that her children wash behind their ears when bathing?  Because she was a genius, that’s why.




I hope that was a good summary of the what, why, and what to do about skin infections in children. If you enjoy learning about child health with pedcasts, consider taking a moment to write a short review on iTunes or my Facebook page, or just send your comments comments to This is your pedcast host, Dr. Paul Smolen, hoping you take grandmas advise and avoid some tears, by washing behind those ears. Until next time.