Objectives Pediatric Visual Pediatric Visual Recognize common - - PDF document

1

Pediatric Visual Pediatric Visual Dermatological Diagnosis Dermatological Diagnosis

Fernando Vega, M.D.

Objectives

• Recognize common pediatric

dermatologic conditions

• Expand differential diagnosis

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

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 Dermatitis

Treatment

• 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

Scabies

Treatment

• 5% permethrin cream for infants, young

children, pregnant and nursing mother

– Kwellada-P or Nix 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

5

Tinea corporis

Ringworm

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

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

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

Kawasaki Disease

Differential 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 Disease

Difficulties 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 Disease

Treatment

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

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 g disease

• 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

p erythematous base

• Painful
• Tend to coalesce, ulcerate and then

crust

• May require topical or oral acyclovir

11

Henoch-Schonlein Purpura

Clinical features

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

– No permanent deformities p – 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
• Severe renal disease
• Need for renal biopsy
• Hypertension
• Pulmonary hemorrhage

Acute Hemorrhagic Edema

• f 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
• n face and extremities

12

Conclusions

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

exanthems exanthems

• Remember rashes as a sign of systemic

illness

• Careful history and physical essential

for evaluation of bruises