Papules, Purpura, Petechia and Other Pediatric Problems:

A Review of Peds Derm

David Chaulk

PEM Fellow

April 15th, 2004

Neonatal Nasties…

Erythema Toxicum

Bad name…not toxicUsually occurs in first days of life50% of healthy babiesErythematous macules +/- pustules and

papulesEtiology unknownNo treatment necessary

Erythema Toxicum

Milia

Retention of keratin and sebaceous material

Usually disappears by 3-4 weeksNo treatment

Milia

Miliaria Rubra

Destruction of epidermal sweat ducts resulting in erythematous papules, vesicles or papules

Treat with humidity/cool baths

Subcutaneous Fat Necrosis

Secondary to pressure in utero or during labour

Occurs during first days or weeksCircumscribed erythematous or violaceous

plaques Infrequently associated with

hypercalcemia

Subcutaneous Fat Necrosis

Infantile Acropustulosis

As it says…Pustules (vesicles) on the hands, feet and

dorsal surfacesIntensely pruritic and recurrentOccurs between 2-10 mos and resolves 24-

36 mosTreated with anithistamines and

fluorinated corticosteroids if severe

Infantile Acropustulosis

Infantile Acne

Closed comedones and inflammatory papules

May last 1-2 yearsUsually family historyMost don’t require treatmentMay use topical treatment such as benzoyl

peroxide

Diaper and Candidal Dermatitis

Contact diaper dermatitis is caused by irritants, soaps detergents etc.

Candida is differentiated by satellite lesions– Widespread, pinpoint raised erythematous

lesions with white scales– GI source and frequently post antibiotics

Diaper and Candidal Dermatitis

Seborrheic Dermatitis and Cradle Cap

Mainly involves scalp, face, trunk and intertriginous areas

Greasy, scaly, patch erythemaUnknown etiologyTreatment is hydration, mineral oil,

petroleum, shampoos

Seborrheic Dermatitis and Cradle Cap

The Rash Relay!

Two teams, limited info. & Spot Diagnosis

Start with Infectious Stuff…

First one’s easy…or is it?

3 yo girl, second visit to ED in four days. First time, high fever without clear focus. No other symptoms.

Now returns with rash and fever has resolved

What is the diagnosis?

What is the infectious agent?

Roseola Infantum

Macular or maculopapular rash appearing after defervescence on 3rd or 4th day of illness

Child usually looks well despite high fever and it is often associated with febrile seizure

Human herpes virus 6 (HHV-6)

Another easy one…

It’s spring, you’re in the ED seeing a 6 yo girl with a rash. Yesterday it was only on her cheeks now it’s on her arms (extensors)

Day 4

Day 5

What is this?

What is the infectious agent?

Extra Credit:

Name two complications

What about pregnancy exposures?

Parvovirus B19

Aka: erythema infectiosum and fifth diseaseUsually affects kids aged 3-12 yearsMost common is spring6-14 day incubation period

Day 1:slapped cheekDay 2:lacy, erythematous rash on extensorsDay 6 fading rash with lacy, marble appearance

Parvovirus B19

Complications:– Arthritis, aplastic anemia and hemolytic

anemiaPregnancy

– 50% of women seropositive before pregnancy– Likelihood of transmission if exposed 30-50%– If fetus infected 2-10% rate of loss– Thus risk is actually fairly low

Now for a couple of hard ones…

3 yo girl with high fever, cough, runny nose, looks unwell. Rash started on face initially and is now spreading.

Parents are granola types and the child isn’t immunized

Diagnosis?

Name 1 acute complication, and one longterm complication

Measles (Rubeola)

Starts with cough, coryza and conjunctivitis, then Koplik spots and morbilliform rash

Rash fades after 3-7 days in same order that it started

Acute complications: OM and pneumomiaLong term: SSPE

Another tough one…

This time a 2 year old unimmunized child, presents with 3 days history of URT symptoms. Parents bring him in because they notice his glands are swollen and he has a rash

Diagnosis?How is it different from measles?What is the presentation of congenital infection?

Rubella

Generalized maculopapular rash with cervical, postauricular and occipital LN

3-5 days of viral prodrome followed by mobile rash that goes from head to toe in 24h

May get petechiae on the palateEssentially not as sick/ not as high fever as

measlesThese are the blueberry babies

Back to stuff we actually see…

7 yo child presents in October with vomiting and diarrhea

On exam you find…

Name 2 serious complicationsHint, they start with M

Coxsackie

Hand, Foot and Mouth DiseaseHighly contagious and usually occurs in late

summer, fallViral illness precedes rash, start as macules and

evolve into vesicles25-65% get lesions on hands and feetUsually get lymphadenopathy and may get

dehydration Serious but rare complications include myocarditis

and meningoencephalitis

Next…

7 yo boy with few days of cough and cold, now has sore throat and rash

Diagnosis, infectious agent and treatment?What is the pathognomonic rash associated with it?

Scarlet Fever

Exotoxin mediated rash secondary to GAS infection of the pharynx or skin

Oral mucosal rash (petechial), strawberry tongueErythematous, blanchable, generalized rash Intense in skin folds with linear, petechial

eruptions – Pastia LinesMay get desquamation 5 days postTreat with Penicillin

Gotta know this one…

4 year old girl, sick for a week now, cough runny nose, rash. Parents bring her in because she cries all the time

Name the diagnostic criteria

What is the treament

What are we trying to prevent with treatment?

Kawasaki’s Disease

FEEL My Conjunctivits

Fever – greater than 5 days plus four of:Extremitity changes (erythema, edema)Erythematous Rash (can be any rash except

petechial)Lymphadenopathy (>1.5 cm, may be unilateral)Mucositis (bright red lips, strawberry tongue)Conjunctivitis (bilateral, non-purulent)

Kawasaki’s Disease

Other frequently associated findings:– Irritability (~90%)

– Urethritis/sterile pyuria (70%)

– Aseptic meningitis (50%)

– Hepatitis (30%)

– Arthralgia/arthritis (10-20%)

– Hydrops of the gallbladder (10%)

– Myocarditis/CHF (5%)

– uveitis

Kawasaki’s Disease

Untreated 20% will develop coronary aneurysms with treatment less than 5%

Treatment– IVIG 2 g/kg – High dose ASA 80-100 mg/kg until afebrile

then:– Low dose ASA 5 mg/kg for 6-8 weeks if no

evidence of aneurysms

Case I had last week…

Todd no comments:4 yo girl with one week history of rashStarted on steroids by fp, not improving,

thinks they are getting worse. Also complaining of ankle pain and swelling

What is the diagnosis?

Name two surgical complications

What long term risks are associated with this?

Henoch-Schonlein Purpura

Unknown etiology but frequently follows viral infection ? Autoimmune

Rash is erythematous papules followed by purpura

Frequently associated with joint pain and swelling

Abdo pain not uncommon, sometimes as presenting feature

Henoch-Schonlein Purpura

Surgical Complications Include:– Intussusception

– Testicular torsion

Long term complications:– Glomuerulonephritis/renal disease

– Hypertension

No effective treatment.– Soft evidence for steroids reducing abdominal pain

and risk of torsion. Not effective for rash.

Last case in this round!

Previously well 3 month old boy, presents with this very tender rash. By the next day he has the 2nd photo appearance

Staphylococcal Scalded Skin Syndrome

AKA TEN (toxic epidermal necrolysis)Exotoxin mediated reaction to coagulase

positive staphylococcal infectionIn adults more commonly caused by drug

reactionRash is initially erythematous, sandpaper

like and very tender

Staphylococcal Scalded Skin Syndrome

After 2-3 days skin will peel (Nikolsky sign)

Pathognomonic facies, crusting perioral erythema with fissures at the nasolabial folds and corner of mouth

Spares MM, palms and soles

Now for the speed round

Spot Diagnosis

First

10 yo girl, very itchy rash mostly affecting web spaces

Scabies

The culprit Sarcoptes scabeii

Scabies

Usual locations

Scabies

Spread by skin to skin contact and causes extreme pruritis

Frequent secondary infectionsThe mite tunnels into the stratum corneum

and lives in burrows

Scabies

Treatment is 5% permethrim, underwear and sheets need to be washed in hot water

Family needs to be treated as wellPregnant women and children less than 6

mos treated with sulfur

Quick…

6 yo African-Canadian girl with itchy scalp and areas of alopecia (and her brother)

Tinea capitis

Superficial infection caused by dermatophytes

Annular configuration with erythema and scaling

Treated treated with antifungalsIf not improving think secondary infection

Starting to feel itchy yet…

7 yo Oriental girl was playing in sandbox last week. Given topical antibiotics. Not improving. Rash now spreading to other areas of the body. Some look like blisters that have broken open according to the mom.

Impetigo

Caused by strep or staphMainly face, head neck and extremities

affectedClassically honey crusted appearanceMay be bullous or vesiculopustular formTreated systemically with 1st or 2nd gen

cephalosporinAlso important to treat topically

Herpes Simplex

Vesicular lesions on an erythematous baseKids usually get primary gingivostomatitisHeals within 2-4 weeksRecurrence not usually as severe unless

immunocompromised

This one’s really tough!

Varicella Zoster“dew drop on a rose pedal”

Won’t get into a whole lotWatch for secondary infection…necrotising

fascitisOlder children/adults more likely to have

complicated course– Pneumonitis, encephalitis, hepatitis, myocarditis

Infectious before vesicles appear until all are crusted

Another quickie

Molluscum Contagiosum

Viral (DNA pox virus)Dome shaped umbilicated papuleHighly contagious and auto-inoculableTreatment is curettage, freezing, or they

will resolve on there own in 6-9 mos

What is the problem with the vaccine for this illness?

Meningococcemia

Immediate Management– ABC’s, Labs (w/coags), IV access– Less than 1 mo amp and cefotaxime– More than 1 mo, cefotax and vanco– Supportive Measures

Close/high risk contacts prophylactic ciproVaccine covers A,C,Y, W135 but 35-40%

of cases are due to B

The Rash Relay Part II

Non-Infectious Rashes

Start Easy…

Rash started out of the blue in this healthy 2 yo boy. No complaints

Diagnosis?

Name 2 causes? Be sepcific

Erythema Multiforme

Macules, papules and pathognomonic target or iris lesions

Often idiopathic, maybe secondary to drugs (sulfa’s, dilantin, barbituates). May also be secondary to HSV or Mycoplasma

The other end of the spectrum…

9 yo girl recently started on Septra for her UTI. Now presents hypotensive and tachycardic.

Besides skin, what other organ may be severely affected?

Stevens-Johnson Syndrome

Also known as EM majorSevere bullous erythema with

mucocutaneous involvementCan have severe eye involvement – corneal

ulcerations, uveitisCauses the same as EM, often due to HSVTreatment is supportive care and wound

management

Next…

14 yo boy with a chronic illness and recently noticed the following painful rash on his legs

Diagnosis

What chronic disease does this boy likely have?

Erythema Nodusum

Deep, tender erythematous, nodules on extensor surfaces of extremities

Often secondary to infections (strep is common), IBD, sarcoidosis and drugs (commonly OCP)

Treat underlying cause

Just the picture…

Diagnosis? Name two complications

Sturge-Weber Syndrome

Nevus Flammeus or port wine stain in V1 trigeminal distribution

Made up of mature, dilated dermal capillaries

Associated with seizures, hemiparesis, intracranial calcifications and glaucoma

Another similar one…

Diagnosis? When does this need to be treated

Strawberry Hemangioma

Dilated capillaries present at birthUsually worse in first 6 mos and resolve by

5 yearsMay be multiple and associated with

thrombocytopenia and consumptive coagulpathy

Treatment only required if interfering with vital structure (eg., vision)

Getting close to the end!

Diagnosis? What treatments do you think were used?

Atopic Dermatitis/Eczema

Pruritic inflammation of the epidermis in a patient who has or a family history of atopy

Commonly secondarily affectedTreatment includes moisturizers and

emollients, topical steroids, systemic steroids in more severe cases and immune modulators like tacrolimus

The End is Near…

Some things you should recognize but we won’t talk about!

Tuberous Sclerosis

Sebaceous adenoma

Ash leaf macule

Neurofibromatosis

Café au lait maculeneurofibromas

Pityriasis Rosea

Classic Christmas tree distribution

Starts with herald patch– Larger lesion that

precedes this classic rash

Child Abuse

Lamp cord

lighter slap

slapHot water submersion

Ehlers-Danlos Party Trick

Gorlin Sign

The End!