Core Content In Urgent Care Medicine
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1 Pediatric Rash Emory Petrack, MD, FAAP, FACEP President, Petrack Consulting, Inc. Associate Clinical Professor of Pediatrics Case Western Reserve University School of Medicine Cleveland, Ohio Disclosure: President, Petrack Consulting The Challenge 5 year old started amoxicillin for otitis media this morning, now with rash. 2 year old with new onset generalized rash on trunk for 2 hours. 9 year old with rash off and on for 1 year... What s going on?? Supported by an Educational Grant from Goals Develop approach to pediatric rash in the urgent care setting Differentiate between serious (life-threatening) and benign rashes Discuss treatment options Initial Approach 2 Major Categories Petecchiae/ Purpura/ Major blistering Meningococcemia, RMSF, ITP, etc Staph Scalded Skin Syndrome Perfusion/ systemic concerns All others Identify if possible; emphasize benign Petecchiae/Purpura Significant Meningococcemia Idiopathic Thrombocytopenic Purpura Rocky Mountain Spotted Fever Other viruses Leukemia/ Lymphoma Child Abuse 1
2 Petecchiae/Purpura Benign Henoch Schonlein Purpura Cough, Vomiting Minor trauma Well-appearing Petecchiae/ Purpura Approach to Care Ill-appearing or febrile Transfer Not obviously benign, workup and/or transfer CBC, PT/PTT Beware mild purpura Generalized rash Round lesions Discrete lesions Blisters In the hair In the diaper area Benign Rashes Viral Exantham Most common rash Non-specific Trunk/ extremities Constitutional Sx Well appearing Rx: reassurance 2
3 Roseola 6 months - 3 years old Human herpesvirus 6/7 4-5 days high fever Defervescence Erythematous rash with discrete macules Starts on trunk, then extremities, face Benign; no treatment needed Group A Strep Sandpaper rash Coated tongue Pharyngitis Fever, H/A Vomiting, Abdominal Pain Scarlet Fever Scarlet Fever- Treatment Pen VK- older children Amoxicillin- younger children Consider Cephalexin (Keflex ) or Azithromycin (Zithromax ) if allergic Supportive care Atopic Dermatitis/Eczema Very common Dry, lichenified skin Itchy FH asthma, hayfever Superinfection with scratching Improves with age 3
4 Atopic Dermatitis/Eczema Infants Cheeks Forehead Sparing of nose More extensor than flexor surfaces Sparing of diaper area Atopic Dermatitis/Eczema Treatment General Moisturizers. Apply after bathing (short baths) Use mild soap: Dove No bubble baths Humidifier Trim nails Atopic Dermatitis/Eczema Treatment Topical Corticosteroids Ointment better than cream Use Hydrocortisone (1% or 2.5%) on face Use medium potency steroid during flare or if lichenified (Aristocort, Elocon ) BID x 1 week Follow up with primary provider 1 week Other Atopic Dermatitis/Eczema Treatment Diphenhydramine (Benadryl ) or Hydroxyzine (Atarax ) for itching Cephalexin (Keflex ) for superinfection Consider Prednisone, 2 mg/kg/d x 5 days if very severe Follow up with dermatology if severe Use moisturizing cream frequently 4
5 Pityriasis Rosea Probably viral in origin; 5 years old Typically on trunk, with Christmas tree distribution (but can be atypical) Can extend to arms/ legs/ face Discrete oval papules along skin lines Herald patch sometimes seen Pruritus common Reassurance Moisturizers Anti-histamines Oatmeal bath OK for school May last several weeks Pityriasis Rosea Treatment Urticaria IgE mediated Pruritic; wellcircumscribed Etiology unknown in 50% of cases Can occur anywhere Check airway! Urticaria - Treatment ABCs Try to identify etiology If severe, epi, 0.01 ml/kg SQ (0.3ml max) 1:1000 Diphenydramine, 1 mg/kg IM or IV (or po if mild) Steroids Methylprednisolone or hydrocortisone IV Dexamethasone (Decadron ) or Prednisone po 5
6 Erythema Multiforme Etiology: Infection, Medications (sulfa, barbiturates, penicillin),? Macules, papules Target lesions Usually resolves over 1-2 weeks Remove inciting factor if known Ibuprofen, diphenydramine Steroids controversial Follow up with PCP Erythema Multiforme 6
7 Scabies Scabies Mite: Sarcoptes Scabiei Papules/ Vesicles Burrows infrequent in children Intense itching Other family members Pruritus increases at night Wrists, web spaces, genital area Infants: scalp, palms, soles, torso Diff Dx: Bug bites, eczema, impetigo Scabies Treatment Wash clothes, linens hot water Permethrin (Nix, Elimite ) 5% cream neck down; leave on overnight Head and neck in infants, toddlers Repeat in 1 week; itching may continue 4 weeks; may use anti-histamine Treat family Treat superinfection Kawasaki Disease Mucocutaneous Lymph Node Syndrome Fever for 5 days plus 4 out of 5: Conjunctivitis Lymphadenopathy Rash: generalized, desquamation Red oral pharynx; strawberry tongue Erythema/ Edema extremities Coronary artery abnormalities Kawasaki Disease If suspected Salicylates IV IG therapy Referral for admission 7
8 Round Lesions Tinea Corporis (Ringworm) Tinea Corporis Treatment Sharp round border Central clearing Clinical diagnosis Solitary or multiple Topical anti-fungal (Lotrimin ) Apply BID for days Use for 5-7 days after clearing If very extensive, consider griseofulvin Nummular Eczema Coin-shaped areas of eczema Chronic; waxes and wanes Same treatment as eczema Prone to superinfection 8
9 Granuloma Annulare May affect any site, but more common around ankles, foot, back of hand Well-circumscribed, raised border May be small or large May last weeks-months; harmless Usually no treatment needed Discrete Lesions Contact Dermatitis Many etiologies, frequently unclear Chemicals, plants, foods, soaps, etc. Well demarcated Redness, itching, swelling, non-specific Ask about pets Diaper area 9
10 Contact Dermatitis Treatment Remove offending agent Emollient creams/ moisturizers Topical steroids Oral steroid if severe (poison ivy) Oral anti-histamine Antibiotic for superinfection Varicella Varicella-Zoster virus Direct contact/ Airborne spread Late winter/ early spring Visual diagnosis Varicella Incubation range: days Rash, constitutional symptoms Vesicular rash with multiple stages of healing Macule Papulae Vesicle Pustule Centripetal distribution Lasts 5-7 days Contagious 1-2 days before rash until healed Supportive care Consider acyclovir >12 years old Pulm, Skin disease 80 mg/kg div QID No salicylates Oatmeal baths Varicella Treatment 10
11 Molluscum Contagiosum Pearly, umbilicated papules; 3-16 years Viral No other symptoms Direct contact Self limited Lasts 6-9 months Impetigo Strep, Staph Common in toddlers Honey-colored crusting, bullous May lead to APGN, but not Rheumatic Fever Impetigo Bullous Impetigo Topical mupirocin (Bactroban ) TID Cephalexin (Keflex ) x 7-10 days Always assume strep and staph Staph aureus Start as vesicles and spread Can be large Intact skin Treatment same Possible complications 11
12 Child Abuse Discrete lesions Burns, rope, bruises History conflicting or inconsistent Referral Rashes in the Scalp Tinea Capitis Trichophyton tonsurans et al Person to person or fomites Lymphadenitis, alopecia, infection Kerion 12
13 Tinea Capitis Treatment Topicals ineffective Griseofulvin 20 mg/kg/day with milk/ fatty meal 6 weeks Labs not needed Kerion: add Prednisone, 1 mg/kg/day x 1 week Cephalexin for superinfection Selenium sulfide shampoo 3x/ week Return to school; don t share brushes Follow up PMD 1 month Seborrheic Dermatitis Inflammatory disorder Most common rash in 1st month Greasy scales; red papular dermatitis Other sites: face, intertriginous areas, diaper area Also in adolescents Seborrhea Dermatitis Treatment Infants: - Sebulex shampoo - Mineral oil compresses - Comb scales out Older: - Selenium sulfide shampoo - Topical steroid Diaper Rashes 13
14 Candida Frequent cause of diaper rash Satellite lesions?antibiotic use Look for thrush Mycostatin topical Keep area dry Peri-anal Strep Well-demarcated Painful, itchy Often missed diagnosis Treat with PCN, Amoxicillin, or Cephalexin Henoch-Schonlein Purpura Peaks 4-7 years old Diffuse vasculitis Purpura buttocks, legs Arthralgias, abdominal pain, GI bleeding Nephritis 14
15 Henoch-Schonlein Purpura Instussuception Acute scrotum Treatment R/O GI, GU Self limited Discharge: follow-up Steroids only for complications Henoch-Schonlein Purpura Henoch-Schonlein Purpura Buttocks, lower legs Arthralgias, abdominal pain, hematuria Uncomfortable, but well appearing Overall normal labs Purpura Fulminans Widespread Systemic findings Appears ill, toxic CBC, coag abnormalities Red Flags Petecchial/ Purpuric rashes Systemic findings, general appearance Vital sign abnormalities Abuse considerations Conclusion Acknowledge parental anxiety/concerns If able to identify rash, offer basic help, with subsequent referral for follow-up care If unable to identify rash, discuss basic categories of worrisome and non-worrisome rash, and reassure, with follow-up as appropriate. References Steven Selbst, Kate Cronan, Pediatric Emergency Medicine Secrets, Second Edition, Mosby, Tanise Edwards, Thom Mayer, Urgent Care Medicine, McGraw-Hill, Binita Shah, Michael Lucchesi, Atlas of Pediatric Emergency Medicine, McGraw-Hill, All Pictures: Used with Permission from Petrack Consulting, Inc. 15
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