Suzan Schneeweiss MD, MEd, FRCPC

Suzan Schneeweiss MD, MEd, FRCPC

I have nothing to disclose

1. Discuss common pitfalls in the diagnosis and management of common paediatric rashes in the ED 2. Identify dermatologic conditions requiring emergency interventions in children 3. Develop an approach to the assessment of and management of common paediatric rashes

3000 dermatologic diagnoses Represent 5 % of ED visits Outline Common presentations True emergencies Not to miss t

Children < 5 years; newborns (day 3 7) Abrupt onset Erythema, flaccid bullae or erosions Face, folds, buttocks, hands, feet Distinct radial fissuring around eyes, mouth, nose Associated symptoms: Fever, lethargy, irritability, edema Exotoxin enter blood from remote infection

Diagnosis Positive Nikolsky sign Swab possible sites for Staph e.g. nose, umbilicus, conjunctiva, rectum Bullae sterile Treatment IV Cloxacillin +/- IV Clindamyicn (anti- toxin) Pain control Compresses to healing skin Switch to oral when well

50 60 % of all bacterial skin infections More common in younger children, summer 3 types Non- bullous, bullous, ecthyma Staph aureus Spreads from nose to normal skin Group A Strept Skin colonized then infected

NON BULLOUS 70 % cases Staph aureus or Group A Strept Can t differentiate clinically More common in summer BULLOUS Infants to younger children Cause by Staph aureus toxin Local SSSS More common in summer

NON- BULLOUS Tiny pustule that quickly gets honey- crusted Usually not painful Can get regional adenopathy BULLOUS Flaccid transparent bullae Often in groin, face, buttocks, trunk, perineum, extremities Single or grouped

Group A Strept Transient vesicular lesion- > rupture - > thick and adherent crust Central area of crust becomes necrotic and periphery becomes erythematous and indurated +/- pus Slow healing Deeper ulcer leaves permanent scar Tends to occur on lower extremities

Clean with soap and water; +/- debridement Local infections: Topical therapy TID X 7 days Mupirocin (Bactroban) Effective against MSSA and GABHS No absorption, no systemic effects 3 % itching, pain or stinging Fucidic Acid Effective against MSSA, MRSA and coag neg staph Mupirocin and fucidic acid equally effective

Oral antibiotics Widespread infection or complicated Perioral lesions and ecthyma E.g. cephalexin good choice as covers staph and strept Parenteral Co- morbid conditions or immunologic impairment Rapidly progressive, severe local disease

Recurrent infection Check for nasal carriage 2 4 days of mupirocin TID eliminates MRSA and MSSA in > 90 % of patients Can recolonize

Toxic shock and necrotizing fasciitis Mortality in children 5 10% High index of suspicion Outbreaks rare occasional clusters in families Varicella important risk factor Often history of blunt trauma or minor wound

Hemodynamic stabilization Fluids, inotropes MRI helpful for diagnosis Culture focal lesions and blood culture Prompt surgical drainage and debridement Parenteral Antibiotics IV Penicillin G IV Clindamyin (synergistic) should not be used alone

Chronic, relapsing disease Chronic pruritis Chronic xerosis Patches of red, scaly, excoriated lesions Complications Sleep deprivation Scarring or lichenification Bullying, depression Pigmentary changes Infections

Seborrheic Dermatitis Scale is yellow, greasy, asymptomatic Scabies Polymorphous eruption Nutritional deficiencies Contact dermatitis Rare in infants, configuration Psoriasis Diaper area commonly involved, well demarcated plaques surrounded by silvery scale

Thick crust Yellow crust Bright red erosion with friable base Sudden significant worsening of eczema Eczema not responding to usual treatments May be infected Fever, systemically well

60 % of atopic dermatitis patients Colonized with Staph aureus Even without clinical infection Treatment of infection alone (no cortisones) May improve dermatitis by reducing driving force Patients have altered Staph- killing ability

Topical antibiotics for local infection Oral antibiotics Beneficial for significant infection (need Staph coverage) Not useful without signs of infection Bleach baths ½ cup regular household bleach to ¼ tub of water 3 times per week Significantly improves eczema and reduces bacteria

Education** www.aboutkidshealth.ca Moisturize skin Emulsified oil in bath (e.g. Alpha- keri, Aveeno) Emollient ointment or cream (e.g. petrolatum, eucerin) Manage itch Diphenhydramine or hydroxyzine Topical steroids Low potency - 1 % Hydrocortisone face, diaper area, skin folds Mid- potency - 0.05 % Betamethasone- body

A dermatologic emergency! HSV infection of underlying eczema Can be recurrent Spreads rapidly Often superinfected with bacteria Punched out erosions and vesicles On background of dermatitis Monomorphous Patients may have systemic symptoms

High index of suspicion for diagnosis Confirm with viral cultures/ PCR from lesions If unwell, < 1 year, poor fluid intake, severe: Admit and treat with IV acyclovir If well, good fluid intake, good follow- up Oral acyclovir X 10 days Add antibiotics if necessary Saline compresses help wound healing

Most common in pre- pubertal children More common in African American T. Tonsurans major agent in North America Anthrophilic (human reservoir) Easily transmitted from person- to- person M. Canis is second most common Zoophilic (cats and dogs are reservoirs) More inflammatory

NON INFLAMMATORY INFLAMMATORY Scaly patch Patchy or no alopecia black dot tinea gray patch tinea Mild increase in dandruff Non- tender adenopathy Pustules Alopecia Crusting erythema Kerion Tender, boggy, oozing Scarring Alopecia or scale with adenopathy is highly predictive of Tinea Capitus, (Hubbard TW 2000)

Generally requires oral therapy M Canis is more resistant, needs longer therapy Griseofulvin is no longer available Terbinafine, itraconazole, fluconazole Data does support use of these in tinea capitus Remains off- label indications

Need to culture before treatment! Note: M. canis does not respond to terbinafine Always treat hair- bearing areas with oral antifungals as fungus tracts down the hair follicle and cannot be treated with topicals alone

Therapy to treat tinea capitus Treat complications Secondary bacterial infection Severe kerion Management to reduce spread? Use of regular spore- inhibiting shampoo No sharing of hair- care products, hats, linen Evaluate and culture contacts +/- antifungal shampoo

Terbinafine (Lamisil) < 20 kg 62.5 mg/day 20 40 kg 125 mg/day > 40 kg 250 mg/day Course depends on organism and clinical response: 2 8 weeks Side effects Liver enzymes, taste alteration, drug interactions, decrease PMNs Consider pre- treatment liver enzymes

Children < 10 yrs Antecedant URTI Small vessel vasculitis (IgA) Etiology unclear Palpable purpura 60 % abdominal pain, 75 % arthritis 40 50 % renal disease JAMA. 2012;307(7):742

Palpable purpura Primarily on buttocks and lower legs May involve upper extremities, trunk and face Skin lesion presenting sign in 50 % Petechiae or eccymoses may predominate in some patients Edema hands, feet, scalp or face may be seen

Supportive - Analgesia Steroids No clear benefit to preventing or treating renal disease Consider if GI complications Monitor renal function (urinalysis for blood and protein) + BP

Acute eruption Significant pruritis especially at night Polymorphous eruption Dermatitis Papules and pustules Palms soles, web spaces, axillae, areola, umbilicus Classic burrow (short linear and sometimes wavy lesion) is frequently absent

Treatment of scabies Treatment of close contacts Environmental measures Treatment of pruritis Treatment of secondary infection from excoriations

Scabicide: Permethrin 5% cream most effective Infants: treat whole body (face and scalp) Children and adults; treat from chin down to soles of feet Leave on overnight and wash in am Re- treat 1 week later Low side- effect profile

Environmental: Launder linen and clothing from last 3 days Routine cleaning and vacuuming of house Non- washable items - store in sealed plastic bag X 1 week or freeze X 12 hours Pruritis: Antihistamines and topical corticosteroids Itch may last weeks after scabies gone Secondary infection: Topical or oral antibiotics

Review presentation and management of common skin disorders in children Impetigo, atopic dermatitis, scabies, Tinea capitus (kerion), HSP Recognition and management of true dermatologic emergencies Staph scalded skin, eczema herpeticum, invasive Group A Strept Parental education www.aboutkidshealth.ca

www.dermnetnz.org Golant AK and Levi/ JO. Scabies: a review of diagnosis and management based on mite biology. Pediatrics in Review 2012;22;e1. Krakowski AC et al. Management of atopic dermaffs in the pediatric poulafon. Peds 2008; 122:812-824. Feaster T and Singer JI. Topical therapies for impefgo. Peds Emerg Care 2010;26:222-231.