Objectives Fifth s Disease (Erythema Infectiosum) (Ery

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1 Pediatric Dermatology Wendy L. Wright, MS, RN, ARNP, FNP, FAANP Adult/Family Nurse Practitioner Owner Wright & Associates Family Healthcare Partner Partners in Healthcare Education Objectives Upon completion of this lecture, the participant will: 1. Identify various pediatric dermatology conditions 2. Discuss those dermatology conditions that require an immediate referral 3. Develop an appropriate plan for evaluation, treatment, and follow-up of the various lesions Fifth s Disease (Erythema Infectiosum) Human Parvovirus B19 Occurs in epidemics Occurs year round: Peak incidence is late winter and early spring Most common in individuals between 5-15years of age Period of communicability believed to be from exposure to outbreak of rash Incubation period: 5-10 days Can cause harm to pregnant women and individuals who are immunocompromised Wright,

Fifth s Disease (Erythema Infectiosum) Low grade temp, malaise, sore throat May occur but are less common 3 distinct phases Facial redness for up to 4

only Fifth s Disease (Erythema Infectiosum) Physical Examination Findings Low grade temperature Erythematous t cheeks Nontender and well-defined borders

2 Fifth s Disease (Erythema Infectiosum) Low grade temp, malaise, sore throat May occur but are less common 3 distinct phases Facial redness for up to 4 days Fishnet like rash within 2 days after facial redness Fever, itching, and petecchiae Petecchiae stop abruptly at the wrists and ankles Hands and feet only Fifth s Disease (Erythema Infectiosum) Physical Examination Findings Low grade temperature Erythematous t cheeks Nontender and well-defined borders Netlike rash Erythematous lesions with peripheral white rims Rash-remits and recurs over 2 week period Petecchiae on hands and feet Fifth s Disease Wright,

Fifth s Disease Fifth s Disease Fifth s Disease (Erythema Infectiosum) Diagnosis/Plan Parvovirus IgM and IgG IgM=Miserable Mi and is present in the blood

3 Fifth s Disease Fifth s Disease Fifth s Disease (Erythema Infectiosum) Diagnosis/Plan Parvovirus IgM and IgG IgM=Miserable Mi and is present in the blood from the onset up to 6 months IgG=Gone and is present beginning at day 8 of infection and lasts for a lifetime CBC-May show a decreased wbc count Wright,

4 Fifth s Disease (Erythema Infectiosum) Diagnosis/Plan Was contagious before rash appeared therefore, no isolation needed Spread via respiratory droplets Symptomatic treatment Patient education-i.e. contagion, handwashing Can cause aplastic crisis in individuals with hemolytic anemias Concern regarding: miscarriage, fetal hydrops Adults: arthralgias Hand, Foot, and Mouth Disease (Coxsackie Virus) Caused by the coxsackie virus A16 Most common in children 2-6 day incubation period Occurs most often in late summer-early early fall Symptoms Low grade fever, sore throat, and generalized malaise Last for 1-2 days and precede the skin lesions 20% of children will experience lymphadenopathy Hand, Foot, and Mouth Disease (Coxsackie Virus) Physical Examination Findings Oral lesions are usually the first to appear 90% will have Look like canker sores; yellow ulcers with red halos Small and not too painful Within 24 hours, lesions appear on the hands and feet 3-7 mm, red, flat, macular lesions that rapidly become pale, white and oval with a surrounding red halo Resolve within 7 days Wright,

thick gray vesicles on a red base May feel like slivers or be itchy

5 Hand, Foot, and Mouth Disease (Coxsackie Virus) Physical Examination Findings Hand/feet lesions As they evolve may evolve to form small thick gray vesicles on a red base May feel like slivers or be itchy Hand Foot and Mouth Disease Hand Foot and Mouth Disease Wright,

6 Hand, Foot, and Mouth Disease (Coxsackie Virus) Plan Diagnostic: None Therapeutic Tylenol Warm baths Oragel or Benadryl/Maalox Hand, Foot, and Mouth Disease (Coxsackie Virus) Plan Educational Very contagious (2d before -2 days after eruption begins) Entire illness usually lasts from 2 days 1 week Reassurance No scarring Pityriasis Rosea Etiology Common, benign skin eruption Etiology unknown but believed to be viral Small epidemics occur at frat houses and military bases Females more frequently affected 75% occur in individuals between 10 and 35; higheset incidence: adolescents 2% have a recurrence Most common during winter months Wright,

of malaise, sore throat, and fever may precede Herald patch: 2-10cm oval-round lesion appears first

7 Pityriasis Rosea Symptoms Rash initially begins as a herald patch Often mistaken for ringworm 29% have a recent history of a viral infection Asymptomatic, salmon colored, slightly itchy rash Signs Prodrome of malaise, sore throat, and fever may precede Herald patch: 2-10cm oval-round lesion appears first Most common location is the trunk or proximal extremities Pityriasis Rosea Pityriasis Rosea Wright,

8 Pityriasis Rosea Signs Eruptive phase Small lesions appear over a period of 1-2 weeks Fine, wrinkled scale Symmetric Along skin lines Looks like a drooping pine tree Few lesions-hundreds Lesions are longest in horizontal dimension Pityriasis Rosea Signs (continued) 7-14 days after the herald patch Lesions are on the trunk and proximal extremities Can also be on the face Pityriasis Rosea Diagnosis History and physical examination Plan Diagnostic Can do a punch biopsy if etiology uncertain Pathology is often nondiagnostic Report: spongiosis and perivascular round cell infiltrate Consider an RPR to rule-out syphilis Wright,

9 Pityriasis Rosea Plan Therapeutic Antihistamine Topical steroids Short course of steroids although, may not respond Sun exposure Moisturize Educational Benign condition that will resolve on own May take 3 months to completely resolve No known effects on the pregnant woman Reassurance Scarlatina Etiology Caused by Group A beta hemolytic strep Rash is produced by a toxin which is excreted by the streptococcus Occurs year round; highest in winter and sping Transmission: close contact to permit the spread of large droplets Incubation period: 12 hours to 7 days Contagious during acute illness but may transmit during active subclinical infection period Family Members Contagion Up to 50% of family members living with the child will become infected as well Wright,

10 Streptococcal Pharyngitis Often one of the First Signs Group A Beta Hemolytic Streptococcus Erythematous, edematous tonsils, uvula Exudate Lymphadenopathy Palatal petecchiae Fever Scarlatina Symptoms Sudden onset of fever, chills, malaise, headache, sore throat and abdominal pain Followed by generalized lymphadenopathy Rash appears within hours Rash is called an exanthem Begins on the trunk and spreads peripherally May be itchy Scarlatina Signs Erythematous skin covered by tiny pin-head sized papules (Goose bumps on a sunburn) Sandpaper Vesicles may erupt but this is a severe case May fade but is accentuated in skin folds Wright,

Signs Scarlatina Signs White coating on tongue peels away Red, strawberry tongue Cervical adenopathy 5-7 days after onset-desquamation of

11 Scarlatina Signs Pastia s line: 1-3 days after generalized rash Petecchiae may appear in a linear distribution Skin folds and creases Flushed face with circumoral pallor Large, erythematous tonsils with petecchiae on the palate Exudate may be present Erythematous uvula Signs Scarlatina Signs White coating on tongue peels away Red, strawberry tongue Cervical adenopathy 5-7 days after onset-desquamation of finger tips Beau s lines Diagnosis Scarlet fever Rule-out staphylococcal scalded skin syndrome Rule-out mononucleosis Scarlatina Wright,

PCN VK, E-mycin, Cephalosporins Educational Good handwashing

12 White-Strawberry Tongue Beau s Lines Plan Diagnostic Scarlatina Throat culture ASO titer (antistreptolysin O titer) Therapeutic PCN VK, E-mycin, Cephalosporins Educational Good handwashing Finish 10 days of medication Prevent secondary infections Wright,

13 Scarlatina Plan Educational Moisturize peeling skin Prompt treatment is essential If someone develops a sore throat, should culture other family member Some recommend cultures on all Recheck for worsening symptoms No school or daycare for 24 hours Change toothbrush in 72 hours to prevent re-infection No sharing of utensils Chickenpox (Varicella) Highly contagious viral infection Varicella-zoster virus Affects most children before puberty Peak incidence is March-May May Spread via airborne droplets or vesicular fluid Contagious for 1-2 days before rash until lesions crust Incubation period-up to 21 days Chickenpox (Varicella) No prodrome or very mild Rash usually begins on the trunk and scalp and then spreads peripherally Moderate to intense itching Fever: Lesions erupt for 4 days Wright,

Chickenpox (Varicella) Physical Examination Findings Lesions 2-4 mm papule (rose petal) Thin walled clear vesicle (dew drop) Vesicle becomes umbilicated within 8-12 hours Followed by crusts Lesions

14 Chickenpox (Varicella) Physical Examination Findings Lesions 2-4 mm papule (rose petal) Thin walled clear vesicle (dew drop) Vesicle becomes umbilicated within 8-12 hours Followed by crusts Lesions are in all stages hallmark of this disease Chicken Pox Chickenpox (Varicella) Plan Diagnosis: None Therapeutic: Symptomatic Treatment NO ASPIRIN Clip Nails Caladryl or Benadryl Antiviral Wright,

15 Chickenpox (Varicella) Plan Education: Call immediately for worsening of symptoms Contagious until all lesions crust Caution of pregnant women and others without immunity Monitor for secondary complications Prevention: Varicella vaccine Eczema Etiology Most common inflammatory skin disease Caused by an inflammation in response to an allergen, chemical or an unidentified etiology Symptoms Intensely itchy red rash Stinging or burning Dryness Eczema Symptoms Fissuring and bleeding Habitual itching Scratching frenzies Signs Erythematous, edematous patches Indistinct borders (this helps to differentiate from psoriasis) Location: antecubital and popliteal spaces, scalp, feet, hands Wright,

16 Eczema Signs Cracking and fissuring Lichenification (Thickening of the skin) Excoriations (Caused by scratching) Eczema Eczema Wright,

Eczema Eczema Diagnosis KOH prep: R/O tinea/fungus Plan Diagnostic None Therapeutic Lubrication: Most important part Performed multiple times daily; particularly after a bath Eczema Therapeutic Limit

17 Eczema Eczema Diagnosis KOH prep: R/O tinea/fungus Plan Diagnostic None Therapeutic Lubrication: Most important part Performed multiple times daily; particularly after a bath Eczema Therapeutic Limit number of baths or showers Antihistamines: OTC or prescription Low potency topical corticosteroids Avoids soaps, bath gels, bubble baths, shower gels Intralesional injections of corticosteroids Oral corticosteroids Immunomodulator vs. Nonsteroidal cream Wright,

18 Eczema Educational Explain the chronic nature of this condition Review medications and why they are utilized Avoid harsh soaps Monitor for yellow discharge May result in impetigo Impetigo Contagious, superficial skin infection Caused by staphylococci or streptococci Staph is the most common cause Makes entrance through small cut or abrasion Resides frequently in the nasopharynx Spread by contact More common in children, particularly on the nose, mouth, limbs Self-limiting limiting but if untreated may last weeks to months Impetigo Symptoms: Rash that will not go away Begins as a small area and then increases in size Yellow, crusted draining lesions Physical Examination Findings Small vesicle that erupts and becomes yellow- brown Initially, looks like an inner tube Crust appears and if removed, is bright red and inflamed Wright,

19 Impetigo Impetigo Impetigo Wright,

20 Impetigo Physical Examination Findings 2-8 cm in size Diagnosis Diagnostic: Culture Must absolutely consider MRSA Therapeutic: Bactroban vs. Altabax 1 st generation cephalopsporin vs. TMP/SMX Let s discuss MRSA Impetigo Educational Good handwashing and hygiene No school/daycare for hours Wash sheets and pillowcases Monitor for serious sequelae Herpes Simplex Virus HSV 1 and 2 Spread in 3 manners Respiratory droplets Contact t with an active lesion Contact with fluid such as saliva 90% of primary infections are asymptomatic Symptoms usually occur 3-7 days after contact Wright,

Symptoms Herpes Simplex Virus Tenderness, pain, paresthesia, burning, swollen glands, headache, fever, irritability, decreased appetite, drooling Herpes Simplex Virus Physical Examination Findings

21 Symptoms Herpes Simplex Virus Tenderness, pain, paresthesia, burning, swollen glands, headache, fever, irritability, decreased appetite, drooling Herpes Simplex Virus Physical Examination Findings Grouped vesicles on an erythematous base Gingivostomatitis: Erythematous, edematous gingiva that bleed easily with small, yellow ulcerations Yellowish-white white debris develops on mucosa Halitosis Lymphadenopathy Herpes Simplex Virus Wright,

Herpetic Gingivostomatitis Herpes Simplex Virus Plan Diagnostic Viral Culture HSV IgG & IgM serum antibodies Most accurate: HerpeSelect Therapeutic Antiviral Pain reliever Cool rinses Oragel Herpes

22 Herpetic Gingivostomatitis Herpes Simplex Virus Plan Diagnostic Viral Culture HSV IgG & IgM serum antibodies Most accurate: HerpeSelect Therapeutic Antiviral Pain reliever Cool rinses Oragel Herpes Simplex Virus Plan Educational: Prevent contact with infected individuals Discussion regarding g asymptomatic shedding Prevent recurrences Call for worsening of symptoms (I.e. inability to drink, no urination x 8 hours) Wright,

Verruca Vulgaris Common warts Benign lesions of the epidermis caused by a virus Transmitted by touch and commonly appear at sites of trauma, on the hands, around the periungual regions from nail

23 Verruca Vulgaris Common warts Benign lesions of the epidermis caused by a virus Transmitted by touch and commonly appear at sites of trauma, on the hands, around the periungual regions from nail biting and on the plantar surfaces of the feet Verruca Vulgaris Appearance Smooth, flesh colored papules which evolve into a dome-shaped growth with black dots on the surface Black dots are thrombosed capillaries and can be visualized with a 15 blade Verruca Vulgaris Wright,

Verruca Vulgaris Verruca Vulgaris Treatment OTC product: Compound W or similar OTC cryosurgery kit Liquid nitrogen Duct tape Cryosurgery in office Cimetidine Immunomodulatory effects at high dosages;

24 Verruca Vulgaris Verruca Vulgaris Treatment OTC product: Compound W or similar OTC cryosurgery kit Liquid nitrogen Duct tape Cryosurgery in office Cimetidine Immunomodulatory effects at high dosages; effects varied Imiquimod Retin A type products Electrocautery Blunt dissection (plantar lesions) Scabies Etiology Contagious disease caused by a mite Common amongst school children Adult mite is 1/3 mm long Front two pairs of legs bear claw-shaped suckers Wright,

25 Scabies Etiology Infestation begins when a female mite arrives on the skin surface Within an hour, it burrows into the stratum corneum Lives for 30 days Eggs are laid at the rate of 2-3 each day Fecal pellets are deposited in the burrow behind the advancing female mite (Scybala)-feces are dark oval masses that are irritating and often responsible for itching Scabies Etiology Transmitted by direct skin contact with infested person either through clothing or bed linen Eruption generally begins within 4 6 weeks after initial contact Can live for days in home after leaving skin Scabies Symptoms Minor itching at first which progresses Itching is worse at night (this is characteristic of scabies) Signs Erythematous papules and vesicles Often on the hands, wrists, extensor surfaces of the elbows and knees, buttocks Burrows are often present; May see a black dot at the end of the burrow Infants: wide spread involvement Wright,

26 Scabies Scabies Scabies Wright,

petroleum or cold cream qd x 3 days) Antihistamine Educational Cut nails short

27 Scabies Diagnosis Scraping to look for mite, eggs or feces Plan Diagnostic: Scraping Therapeutic Permethrin 5% cream Scabies Plan Therapeutic Sulfur (6% in petroleum or cold cream qd x 3 days) Antihistamine Educational Cut nails short Scratching spreads the mites Itching can last for weeks Treat all family members Wright,

28 Scabies Plan Educational Wash all clothing, towels and bed linen Do not need to wash carpeting Consider animal bathing Bag stuffed animals x 1-2 weeks Molluscum Contagiosum Infection caused by the pox-virus Most commonly seen on the face, trunk and axillae Self-limiting limiting Spread by auto-inoculation Incubation period: 2-7 weeks after exposure Contagious until gone Molluscum Contagiosum Asymptomatic lumps May have 1 - hundreds Physical Examination 2-5mm papule with an umbilicated center Flesh toned - white in color Most often around the eye in children Scaling and erythema around the periphery of the lesion is not unusual If in the genital area of a child-should consider sexual abuse Wright,

Therapeutic: Conservative treatment is the best for children

29 Molluscum Contagiosum Molluscum Contagiosum Molluscum Contagiosum Plan Diagnostic: None or KOH prep looking for inclusion bodies Therapeutic: Conservative treatment is the best for children Curettage Cryosurgery Tretinoin Salicylic Acid (Occlusal) Laser TCA Wright,

30 Molluscum Contagiosum Plan Educational May resolve on own in 6-9 months Contagious until lesions are gone Benign Recurrence very common Erythema Chronicum Migrans Etiology Caused by a spirochete called Borrelia Borgdorferi Transmitted by the bite of certain ticks (deer, white-footed mouse) 1st cases were in 1975 in Lyme, Connecticut Occurs in stages and affects many systems Children more often affected than adults Erythema Chronicum Migrans Etiology Summer-highest incidence 8000 cases/year in the US 20 countries, 6 continents Can be passed to fetus in utero Wright,

flu like symptoms (50% of time) Migratory joint pain Stage 2 Neurological and cardiac symptoms

31 This is NOT a Lyme Bearing Tick Lyme Bearing Tick Erythema Chronicum Migrans Symptoms 3-21 days after bite Stage 1 Rash (present in 72-80% of cases)-slightly slightly itchy Lasts 3-4 weeks Mild flu like symptoms (50% of time) Migratory joint pain Stage 2 Neurological and cardiac symptoms Stage 3 Arthritis, chronic neurological symptoms Make take years to get to this stage Wright,

No scaling Slightly tender Arthralgias: Stage 2 Asymmetric joint erythema, warmth,

32 Erythema Chronicum Migrans Signs Rash: Stage 1 Begins as a papule at the site of the bite Flat, blanches with pressure Expands d to form a ring of central clearing No scaling Slightly tender Arthralgias: Stage 2 Asymmetric joint erythema, warmth, edema Knee is most common location Erythema Migrans Erythema Migrans Wright,

33 Erythema Chronicum Migrans Signs Systemic symptoms: Stage 3 Facial palsy Meningitis Carditis Diagnosis R/O Ringworm (Tinea Corporis) Erythema Chronicum Migrans Plan Diagnostic: Sed rate: normal until stage 2 Lyme Titer IGM: Appears first: 3-6 weeks after infection begins IGG: Positive in blood for 16 months High rate of false negatives early in the disease Lyme Western Blot Erythema Chronicum Migrans Plan Therapeutic Amoxicillin 500mg tid x 21 days Doxycycline 100 mg 1 po bid x 21 days If in endemic area and tick is partially engorged, may treat with doxycycline 200 mg x 1 dose with food Wright,

34 Erythema Chronicum Migrans Educational Half of the patients continue to experience h/a, arthralgias and fatigue after treatment Tick repellant Light clothing Check children and pets and remove promptly Closed toe shoes Comb hair Necrotizing Fasciitis Severe, deep, necrotizing infection Involves subcutaneous tissue down into the muscles Spreads rapidly Caused by Group A Beta Hemolytic Strep, Staph, Pseudomonas, E Coli Mortality: 8-70% depending upon organism and rapidity of treatment Disfigurement common Necrotizing Fasciitis Symptoms Usually occurs after surgery, traumatic wounds, injection sites, cutaneous sores Generalized body aches, fever, irritability Key: Red area of skin that is severely painful (It is out of proportion to findings) Leg is most common location Physical Examination Findings 1st appears as local area of redness that looks like cellulitis Wright,

Necrotizing Fasciitis Physical Examination Findings Tender Bullae with purulent center which ruptures quickly Black eschar appears and the pain decreases Systemic symptoms begin Necrotizing Fasciitis

35 Necrotizing Fasciitis Physical Examination Findings Tender Bullae with purulent center which ruptures quickly Black eschar appears and the pain decreases Systemic symptoms begin Necrotizing Fasciitis Bullae: Below these lesions is necrotic tissue Necrotizing Fasciitis Plan Diagnosis: Culture of wounds, blood cultures, biopsy of area, CBC with differential, urinalysis Therapeutic: HOSPITAL ADMISSION Educational: Good wound hygiene Wright,

36 Stevens-Johnson Syndrome Distinct, acute hypersensitivity syndrome Many causes: Drugs, bacteria, viruses, foods, immunizations Also known as Bullous Erythema Multiforme Stevens-Johnson Syndrome is thought to represent the most severe of the erythema multiforme spectrum Two stages Prodrome which lasts days 2nd stage: mucosal involvement where at least 2 mucousal surfaces are involved (oral, conjunctival, urethral) Stevens-Johnson Syndrome Mortality: 5-25% Long-term complications are common Face almost always involved and mouth always involved Entire course: 3-4 weeks Most common in children aged 2-10 Stevens-Johnson Syndrome Symptoms Constitutional symptoms such as fever, headache, sore throat, nausea, vomiting, chest pain, and cough Physical Examination Findings Vesicles that are extensive and hemorrhagic Bullae rupture leaving ulcerations which are covered with membranes Leave large areas of necrosis and skin peels Lesions on the conjunctiva Wright,

37 Erythema Multiforme Erythema Multiforme Stevens-Johnson Syndrome Wright,

Stevens-Johnson Syndrome Stevens-Johnson Syndrome Plan Must rule-out staphylococcal scalded skin syndrome Therapeutic: HOSPITALIZATION with early opthamological evaluation Steroids are controversial

38 Stevens-Johnson Syndrome Stevens-Johnson Syndrome Plan Must rule-out staphylococcal scalded skin syndrome Therapeutic: HOSPITALIZATION with early opthamological evaluation Steroids are controversial Others in family may be genetically susceptible Never take these medications again Bacterial Meningococcemia Caused by numerous pathogens Neisseria meningitidis is most common Spread via respiratory droplets Most cases - < 20 years of age and 1/2 are in those < 5 Most common in winter and spring Epidemics occur where crowded conditions are present Incubation: days Wright,

or purpura Kernig sign (patient flat; knee flexed, attempt to straighten leg)

39 Bacterial Meningococcemia Symptoms Fever, intense headache, n/v, stiff neck, rash (70% of patients) Sepsis Physical Examination Bulging fontanelle Petecchiae or purpura Kernig sign (patient flat; knee flexed, attempt to straighten leg) Brudzinski sign (pain with flexion of neck) Meningitis Meningococcemia Wright,

40 Bacterial Meningococcemia Diagnosis Blood Cultures, CBC with differential Lumbar Puncture Therapeutic Hospitalization Many recommend beginning IM PCN before sending to the hospital Educational Prophylaxis for those with close contact Notify public health Thank You! I Would Be Happy To Entertain Any Questions Wendy L. Wright, MS, RN, ARNP, FNP, FAANP (H) (F) 2597(F) WendyARNP@aol.com Wright,

Name That Rash or Lesion: Pediatric and Adolescent Dermatology. Disclosures. Wright, Objectives

Name That Rash or Lesion: Pediatric and Adolescent Dermatology Wendy L. Wright, MS, RN, ARNP, FNP, FAANP, FAAN Adult/Family Nurse Practitioner Owner Wright & Associates Family Healthcare @Amherst Owner