Pediatric Visual Dermatological Diagnosis Fernando Vega, M.D. Objectives Recognize common pediatric dermatologic conditions Expand differential diagnosis Review treatment plans Identify skin manifestations of systemic disease Terminology Macules, Papules, Nodules Patches and Plaques Vesicles Pustules Bullae Vesicles, Pustules, Bullae Colour Erosions when bullae rupture Ulcerations and excoriations 1
Atopic Dermatitis 3-5% of children 6 mo to 10 yr Described in 1935 Ill-defined, red, pruritic, papules/plaques Diaper area spared Acute: erythema, scaly, vesicles, crusts Chronic: scaly, lichenified, pigment changes Atopic Dermatitis Hints to diagnosis Generalized dry skin Accentuation of skin markings on palms and soles Dennie-Morgan lines Fissures at base of earlobe Allergic history 2
Atopic Dermatitis Treatment Moisturize Baths only Anti-histamine Topical steroids to red and rough areas Prevex HC Desacort Immune modulators Superinfected Eczema Red and crusty Usually S. aureus Cephalexin 40 mg/kg/day g divided TID for 10 days More potent topical steroid Topical antibiotic Fucidin Anti-histamine Refer to Dermatology 3
Scabies Intense pruritus Diffuse, papular rash Between fingers, flexor aspects of wrists, anterior axillary folds, waist, navel May be vesicular in children < 2 years Head, neck, palms, soles Hypersensitivity reaction to protein of parasite Scabies Treatment 5% permethrin cream for infants, young children, pregnant and nursing mother Kwellada-P or Nix Cover entire body from neck down Include head and neck for infants Wash after 8-14 hours Can use Lindane for older children 4
Tinea corporis Ringworm Face, trunk or limbs Pruritic, circular, slightly erythematous Well-demarcated with scaly, vesicular or pustular border Id reaction Mistaken for atopic, seborrheic or contact dermatitis Treament: Terbinafine (Lamisil) Pityriasis Rosea Begins with herald patch Large, isolated oval lesion with central clearing More lesions 5-10 days later Christmas tree distribution Treatment: anti-histamines Differential Diagnosis Atopic dermatitis Scabies Tinea corporis Pityriasis rosea Eczema If vesicular, check for HSV1, HSV2, VZV Beware of superinfection Think of immune deficiency if difficult to treat 5
Urticaria Transient, well-demarcated wheels Pruritic Part of IgE-mediated hypersensitivity reaction May leave central clearing Triggers are numerous 6
Kawasaki Disease Diagnostic Criteria Fever for 5 or more days Presence of 4 of the following: 1. Bilateral conjunctival injection 2. Changes in the oropharyngeal mucous membranes 3. Changes of the peripheral extremities 4. Rash 5. Cervical adenopathy Illness can t be explained by other disease Kawasaki Disease Lab Features WBC ESR, positive CRP Anemia Mild transaminases albumin Sterile pyuria, aseptic meningitis platelets by day 10-14 Kawasaki Disease Differential Diagnosis Measles Scarlet fever Drug reactions Viral exanthems Toxic Shock Syndrome Stevens-Johnson Syndrome Systemic Onset Juvenile Rheumatoid Arthritis Staph scalded skin syndrome Kawasaki Disease Difficulties with Diagnosis Clinical diagnosis No single test Diagnosis of exclusion Atypical KD Do not fulfill all criteria More common in < 1 year and > 8 years Kawasaki Disease Treatment Admit to monitor cardiac function Complete cardiac evaluation CXR, EKG, echo IV Ig ASA Kawasaki Disease Treatment IV Ig 2 g/kg as single dose Expect rapid resolution of fever Decrease coronary artery aneurysms from 20% to <5% ASA - low dose vs high dose 80-100 mg/kg/day until day 14 3-5 mg/kg/day for 6 weeks Repeat echocardiogram at 6 weeks 7
Coxsackie Virus Hand-Foot-and-Mouth Painful, shallow, yellow ulcers surrounded by red halos Found on buccal mucosa, tongue, soft palate, uvula and anterior tonsillar pillars Oral lesions without the exanthem = herpangina Exanthem involves palmar, plantar and interdigital surfaces of the hands and feet +/- buttocks Erythema Infectiosum Fifth Disease Parvovirus B19 Mostly preschool age Mostly preschool age Recognized by exanthem Contagious before rash Resolution between 3 and 7 days 8
Roseola 6 to 36 months Human herpesvirus 6 High fever without source and irritability for 3 days Rash develops as fever decreases Impetigo Mostly face, extremities, hands and neck Localized unless underlying skin disease Strep or Staph Honey-coloured crust Treatment: topical and systemic antibiotics 9
Herpes Simplex Gingivostomatitis most common 1º infection in children Fever, irritability, cervical nodes Small yellow ulcerations with red halos on mucous membranes Involvement more diffuse easy to differentiate from herpangina and exudative tonsillitis Treatment: supportive Herpetic Whitlow Lesions on thumb usually 2 to autoinoculation Group, thick-walled vesicles on erythematous base Painful Tend to coalesce, ulcerate and then crust May require topical or oral acyclovir 10
Henoch-Schonlein Purpura Clinical features Palpable purpura of extremities Arthralgia or non-migratory arthritis No permanent deformities Mostly ankles and knees Abdominal pain May develop intussusception Renal involvement Hematuria, hypertension, renal failure HSP Management Supportive NSAIDs may control the pain and do not increase the risk of bleeding Steroids controversial Efficacy not proven re: abdo pain No effect on purpura, duration of the illness or the frequency of recurrences Unclear of protective effect on renal disease HSP Indications for admission R/O intussusception Severe GI bleed Severe renal disease Need for renal biopsy Hypertension Pulmonary hemorrhage Acute Hemorrhagic Edema of Infancy 4-24 months Recent URI or antibiotics Non toxic Non-toxic Resolves in 1-3 weeks small- vessel, leukocytoclastic vasculitis Annular or targetoid pupura and edema on face and extremities 11
Conclusions Not all that itches is eczema Treatment is often supportive for viral exanthems Remember rashes as a sign of systemic illness Careful history and physical essential for evaluation of bruises 12