1

Pediatric Visual Pediatric Visual Dermatological DiagnosisDermatological Diagnosis

Fernando Vega, M.D.

Objectives

• Recognize common pediatric dermatologic conditions

• Expand differential diagnosisExpand 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

2

Atopic Dermatitis

• 3-5% of children 6 mo to 10 yr• Described in 1935• Ill defined red pruritic papules/plaques• 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• Accentuation of skin markings on palms

and soles• Dennie-Morgan lines• Fissures at base of earlobe• Allergic history

3

Atopic DermatitisTreatment

• Moisturize• Baths only• Anti histamine• 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 divided TID for 10 p g g y

days• More potent topical steroid• Topical antibiotic – Fucidin• Anti-histamine• Refer to Dermatology

4

Scabies

• Intense pruritus• Diffuse, papular rash

– Between fingers, flexor aspects of wrists, g , p ,anterior axillary folds, waist, navel

• May be vesicular in children < 2 years– Head, neck, palms, soles– Hypersensitivity reaction to protein of

parasite

ScabiesTreatment

• 5% permethrin cream for infants, young children, pregnant and nursing mother– Kwellada-P or NixKwellada 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

5

Tinea corporisRingworm

• Face, trunk or limbs• Pruritic, circular, slightly erythematous• Well-demarcated with scaly, vesicular orWell 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

clearingg• More lesions 5-10 days later• Christmas tree distribution• Treatment: anti-histamines

Eczema• Differential Diagnosis

– Atopic dermatitis– Scabies

Tinea corporis– Tinea corporis– Pityriasis rosea

• If vesicular, check for HSV1, HSV2, VZV• Beware of superinfection• Think of immune deficiency if difficult to treat

6

Urticaria

• Transient, well-demarcated wheels• Pruritic• Part of IgE mediated hypersensitivity• Part of IgE-mediated hypersensitivity

reaction• May leave central clearing• Triggers are numerous

7

Kawasaki DiseaseDiagnostic Criteria

• Fever for 5 or more days• Presence of 4 of the following:

1. Bilateral conjunctival injection2. Changes in the oropharyngeal mucous

membranes3. Changes of the peripheral extremities 4. Rash 5. Cervical adenopathy

• Illness can’t be explained by other disease

Kawasaki DiseaseLab Features

• ↑ WBC• ↑ ESR, positive CRP• Anemia• Anemia• Mild ↑ transaminases• ↓ albumin• Sterile pyuria, aseptic meningitis• ↑ platelets by day 10-14

Kawasaki DiseaseDifferential Diagnosis

• Measles• Scarlet fever• Drug reactions

• Stevens-Johnson Syndrome

• Systemic Onset g• Viral exanthems• Toxic Shock

Syndrome

Juvenile Rheumatoid Arthritis

• Staph scalded skin syndrome

Kawasaki DiseaseDifficulties with Diagnosis

• Clinical diagnosis• No single test• Diagnosis of exclusion• Diagnosis of exclusion• Atypical KD

– Do not fulfill all criteria– More common in < 1 year and > 8 years

Kawasaki DiseaseTreatment

• Admit to monitor cardiac function• Complete cardiac evaluation• Complete cardiac evaluation

– CXR, EKG, echo• IV Ig• ASA

Kawasaki DiseaseTreatment

• IV Ig 2 g/kg as single dose– Expect rapid resolution of fever– Decrease coronary artery aneurysms from 20% to

< 5%< 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

8

Coxsackie VirusHand-Foot-and-Mouth

• Painful, shallow, yellow ulcers surrounded by red halos

• Found on buccal mucosa, tongue, soft palate, uvula and anterior tonsillar pillarsuvula and anterior tonsillar pillars

• Oral lesions without the exanthem = herpangina

• Exanthem involves palmar, plantar and interdigital surfaces of the hands and feet +/-buttocks

Erythema InfectiosumFifth Disease

• Parvovirus B19• Mostly preschool age• Mostly preschool age• Recognized by exanthem• Contagious before rash• Resolution between 3 and 7 days

9

Roseola

• 6 to 36 months• Human herpesvirus 6• High fever without source and irritability• 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 y gdisease

• Strep or Staph• Honey-coloured crust• Treatment: topical and systemic

antibiotics

10

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 perythematous base

• Painful• Tend to coalesce, ulcerate and then

crust• May require topical or oral acyclovir

11

Henoch-Schonlein PurpuraClinical features

• Palpable purpura of extremities• Arthralgia or non-migratory arthritis

– No permanent deformitiesp– 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

HSPIndications for admission

• R/O intussusception• Severe GI bleed• Severe renal disease• 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

12

Conclusions

• Not all that itches is eczema• Treatment is often supportive for viral

exanthemsexanthems• Remember rashes as a sign of systemic

illness• Careful history and physical essential

for evaluation of bruises