boggy, purulent eczematoid mass on scalp with alopecia and posterior cervical adenopathy. Cell mediated response to tinea capitis. Need 4 weeks of oral antifungal therapy.
2 weeks oral abx
most prevalent in kids <6 y/o
highly contagious to others and through autoinoculation
Staph or Group A B-hemolytic strep
Lesions around nose, mouth and possibly on the extremities
Small pustules or vesicles with red margins, when they rupture, they form honey colored crusts
staph aureus phage group 2
usually seen in the periumbilical area of neonates or the extremities of older children
flaccid, thin walled bullaewhich form shiny, round erosions with peeling edges (known as coin lesions) (Rivers)
Treat both with dicloxacillin, oxacillin, cephalexin, augmentin PO. Can also give mupirocin 2% as topical treatment.
Can see glomerulonephritis post strep impetigo. ABX do not prevent this complication.
Staph Scaled Skin (SSS)
children less than 5 y/o with irritability, fever, and tender erythematous skin. Nikolsky’s will be present with an intraepidermal clevage plane. Mucous membranes are not involved.. Either oral diclox or IV oxacillin
2-5 day incubation period. erythematous oral mucous membranes with scattered ptechiae. White or strawberry tongue. Circumoral pallor. Punctate, sandpaper rash starting on trunk and spreading. More intense in skin folds.
The patient was admitted and treated with IV Acyclovir and IV Cefazolin. Culture by dermatology consult revealed Herpes Simplex Virus, type 1. Final diagnosis: Eczema Herpeticum with secondary bacterial skin infection. Eczema Herpeticum describes a severe herpetic simplex virus infection of the skin. This only develops when the skin is already diseased, most commonly with atopic dermatitis. If the diagnosis is overlooked and antiviral treatment is not initiated, the disease can be fatal.In a typical severe primary attack of eczema herpeticum – formerly called Kaposis varicelliform eruption – vesicles develop abruptly in large numbers over the area of eczematous skin. They continue to appear in crops for as long as 7-9 days. The disease is most common in areas of active or recently healed atopic dermatitis, particularly the face, but normal skin can be involved. Wide denudation of the epidermis may occur. Scabs eventually form, and epithelialization occurs. High fever and adenopathy occur approximately 3 days after the onset of vesiculation. The systemic reaction varies, but temperatures of 103-105°F for 7-10 days are not uncommon. The severity of infection ranges from mild and transient to fatal. Death may result from the common complication or secondary staphylococcal infection. Complications also include profound physiologic disturbances from loss of fluid and electrolytes through the skin, and from dissemination of the virus to the brain and other organs. Children are most commonly affected. The diagnosis can be accurately established by examination of vesicular fluid with rapid viral diagnostic techniques. Recurrent disease is milder and usually without constitutional symptoms.
HSV infection involving the facial skin. Lesions include intact vesicles (V), a pustule (P) that originated as a vesicle, and crusted areas (C) where the vesicles have burst.
Eczema herpeticum is typically treated with intravenous acyclovir, although some reports note successful management with oral acyclovir (2,4). Antistaphylococcal antibiotics are an important part of treatment. Minor relapses do not require a second course of acyclovir. References: (1) Behrman: Nelson Textbook of Pediatrics, 16th ed., © 2000 W. B. Saunders Company (2) Habif: Clinical Dermatology, 3rd ed., © 1996 Mosby-Year Book, Inc. (3) Yeung-Yue KA Herpes simplex viruses 1 and 2 Dermatol Clin 2002; 20: 249-66 (4) Muelleman PJ, Doyle JA, House RF Jr Eczema herpeticum treated with oral acyclovir J Am Acad Dermatol 15:716-717, 1986.
Miliaria (heat rash)
Milia (sebaceous gland occlusion)
Transient Neonatal Pustular Milanosis-present at birth
Erythema Toxicum-not born c it, 1st day of life, looks like flea bites, disappears by 1 week
Usually seen in the winter and the spring in 1-14 y/o.
1-3 week incubation period, infectious 2 days before and 5 days after rash 1. Skin Superinfection 2. Pneumonia 3. Hepatitis 4. Pancreatitis 5. Encephalitis
One of the few rashes present in the scalp, meningococcemia should not be in the scalp. Kids with varicella before 1 year may have a second outbreak and are higher risk of shingles. Usually leukopenia. May see subclinical hepatitis.
Complications of varicella: death (data prior to 1995)approximately 100 per year, 84% immunocompetent patients; typically due to encephalitis or Reyes syndrome; bacterial superinfectionmost common complication; may present with adenitis; most often due to Staphylococcus aureus or Streptococcus pyogenes; necrotizing fasciitis rare sequela; herpes zoster 9% of children with shingles had varicella in first year; central nervous system (CNS) dysfunctionacute cerebellar ataxia most common neurologic complication; elevated protein in cerebrospinal fluid (CSF); admit to hospital for 1 to 2 days of observation; resolves spontaneously; encephalitis and cerebritis also reported (viral antigen in CSF); varicella pneumoniaadmit child and treat with acyclovir; Reyes syndromerare since vaccines available; hemorrhagic complicationsvery rare; patient cannot terminate viremia; unable to make interferon; changes in T cell subsets; 70% mortality; hemorrhage in all organs; thrombocytopenia rash looks like purpura fulminans (Audiodigest)
Motrin can give necrotizing fasciitis, aspirin can give Reye, use Tylenol and benadryl. In 1st trimester, ¼ of fetuses will get limb deformations, 2nd trimester is no problem, 3rd trimester 5 days prior and 2 days post delivery can get Varicella encephalitis
Erythema Multiforme Minor and Major
Seen in 0-20 y/o, usually in winter/spring.
caused by paramyxovirus; incubation period of 10-14 days
Prodrome of high fever and URI sx 2-4 days prior to the appearance of the rash.
Erythematous macules and papules which become confluent and turn coppery-colored. Begins in hairline and moves down the body.
Koplik spots, conjunctivitis, photophobia, cough, and pneumonia
German Measles (Rubella)
caused by rubivirus, incubation period of 14-21 days. Infective 1 week before to 1 week after the rash onset.
5-25 y/o, usually in spring. Prodrome is mild URI sx. Maculopapular rash which becomes pinpoint. Begins on face and migrates to the trunk. Tender retroauricular, posterior cervical, and occipital lymphadenopathy.
Erythema Infectiosum (Fifth Disease)
From Parvovirus B-19,
3-12 y/o or non-immune adults.
Seen in winter/spring. Prodrome of fever and malaise.
Macular erythema on face, followed ~2 days later by erythematous macular eruption, then lacy erythema. Rash progresses from face to extremities.
Once rash appears, no longer contagious
Associated with aplastic crisis, hydrops fetalis, popular-purpuric socks syndrome.
Exanthem Subitum (Sixth Disease, Roseola)
HHV-6 or HHV-7. Incubation of 10-14 days
0-3 y/o, usually in Spring or Fall. Prodrome of high fever for 3-5 days. Associated with febrile seizures. Rash of erythematous to pink macules and papules arranged in rosettes on trunk, neck, and proximal extremities. Rash appears as fever resolves.
Disease Day of Fever which Rash Develops
Very Varicella 1st day of Fever, rash develops
Sick Scarlet Fever 2nd
Pts Small Pox 3rd
Must Measles 4th
Take Typhus 5th
Double Dengue 6th
Eggs Enteric Fever 7th
enterovirus; coxsackie A 16
incubation period 0f 3-6 days.
tender vesicular rash which starts on oral mucosa then spreads tot he buttocks, hands, and feet.
infection during the first trimester may result in spontaneous abortion
Jill M. Baren, MD, FACEP, FAAP
Erythema Infectiosum (Fifth’s disease)
Other viral exanthems
3. Disease Presentation and Management
Kawasaki’s disease (mucocutaneous lymph node syndrome)
Multisystem vasculitis of unknown etiology. Consider in all children who present with rash and fever but most common under age 4 years. Diagnostic criteria: Fever > 5 days plus (1) bilateral conjunctival injection, (2) Red or fissured lips, red pharynx, or strawberry tongue, (3) Erythema of palms or soles, edema, or desquamation (especially in diaper area), (4) Erythematous rash, nonscaling, possibly morbilliform(5) Cervical lymphadenopathy (>1.5 cm). Other clinical findings: arthralgias, cough, uveitis, sterile pyuria, aseptic meningitis, hepatitis, diarrhea, vomiting, myocarditis, pericarditis, coronary artery aneurysms. Lab findings: thrombocytosis, leukocytosis, elevated ESR. Complication: coronary artery aneurysms. Rx: Aspirin 100 mg/kg/day in 4 divided doses for 14 days, IV gamma globulin 2 gm/kg once over 12 hours or 400 mg/kg once daily for 4 days, hospitalization for diagnoses and management of possible complications.
b. Erythema multiforme
Common, inflammatory disease with many etiologies including drugs, infections, physical agents, pregnancy, malignancy, and connective tissue disease but in 50% of cases, no etiology found. More common precipitants are HSV (recurrent), EBV, Streptococcal, Mycoplasma, fungal infections; sulfa, penicillin, anticonvulsant drugs. Prodrome malaise, itching, burning, but also asymptomatic. Lesions are polymorphous – red, round maculopapules on hands, feet, extensor surfaces and trunk that appear abruptly. Hallmark is target lesions that evolve over 24 hours. May heal in 1-2 weeks but may last up to a month and there may be changes in pigmentation. Rx eliminate the precipitant if identifiable. No therapy in mild cases, otherwise prednisone and antipruritics. Acyclovir if HSV is the etiology. Can be very severe with blistering forms (Stevens-Johnson syndrome, Toxic Epidermal Necrolysis) and even life threatening.
Common benign skin eruption of unknown etiology (possibly viral) often seen in older children and adolescents and more often in the winter. Herald patch appears first (single oval or round lesion on trunk or extremities that resembles tinea corporis). Followed by eruption of salmon colored papular lesions on trunk and proximal extremities, concentrated in lower abdomen. Surrounded by scaly ring (collarette scale). Numerous lesions on the back appear like “Christmas tree” pattern. Mostly asymptomatic but may be pruritic. Rx- Topical steroids and antihistamines for itching. Sunlight hastens resolution of lesions.
Highly contagious disease spread by respiratory droplets most commonly seen in preschoolers or unvaccinated individuals. Prodrome characterized by harsh cough, coryza, conjunctivitis, photophobia and fever 10-12 days after exposure. Koplik spots are bluish-white spots with a red halo found on the buccal mucosa opposite the premolar teeth. Rash begins on face and spreads to trunk and extremities and is confluent and dark red to purplish (morbilliform). Complications: pneumonia, encephalitis. Rx supportive.
e. Erythema Infectiosum (Fifth’s Disease)
Mild disease that is contagious; caused by parvovirus B19. Seen most often in children ages 5-14 years. Mild prodrome of fever, malaise, sore throat. Facial erythema (slapped cheek) is bright red, bilateral and spares the nasolabial fold and perioral region. There is also a fine fishnet like pattern on the extremities and trunk and a petechial “glove and sock” syndrome as well. Not contagious after rash appears. There may be accompanying arthritis most commonly in the knee. Complications include spontaneous abortion and aplastic anemia. Rx- reassurance, supportive.
Contagious disease produced by streptococcal erythrogenic toxin (Group A beta-hemolytic strain) originating in the pharynx or skin. Most common between the ages of 2-10 years. Sudden onset of fever and pharyngitis with nausea, vomiting, headache and abdominal pain. Oropharynx is bright red with palatal petechiae. Rash begins 1-2 days after other symptoms of illness on neck and face and spreads to trunk and extremities, spares palms and soles. Rash is red and sandpapery. May see Pastia’s lines (linear petechiae) in skin folds and strawberry tongue. Desquamation occurs on palms and soles and may last for several weeks. Can be confirmed with Rapid Strep test (high false negative rate). Rx Benzathine penicillin IM (600,000 units for patients < 60 lbs. and 1.2 million units for > 60 lbs.) or oral 10 day course (125 mg or 250 mg QID). Alternatives are erythromycin or cephalosporins. May also be caused by Staph aureus infection.
Caused by human herpes virus 6 usually in children aged 6 months to 4 years. Sudden onset of high fever (103-106\F) for several days, decreased appetite, mild URI symptoms, febrile seizures, lymphadenopathy. Rash develops as fever subsides and is pale pink, confluent slightly raised papules on trunk and neck. Complications: Associated with febrile seizures. Rx fever control and reassurance.
5. Case conclusion
Idiopathic Throbocytopenic Purpura
Other viral exanthems (infectious mononucleosis)
Disease Presentation and Management
Idiopathic Thromocytopenic Purpura
The most common thrombocytopenic purpura of childhood characterized by a profound deficiency of circulating platelets. 70% of cases have antecedent viral infections 1-4 weeks prior. Acute onset of generalized petechiae, prominent over the legs with mucous membrane hemorrhage in a well appearing patient. Platelet count < 20K, normal hemoglobin and WBCs. Complications: intracranial hemorrhage. Rx excellent prognosis even without therapy. Platelet transfusion only for life threatening hemorrhage. IV gamma globulin may induce remission, corticosteroids shorten the acute phase. Chronic form is uncommon.
Vasculitis seen in children ages 2-10 years characterized by palpable purpura on legs and buttocks, abdominal pain, GI bleeding, arthralgias, and hematuria. Lesions can begin as erythematous maculopapules. Often occurs in the spring with clustering of cases, often preceded by a viral prodrome. May be recurrent. Lesions usually spare the trunk, fade in several days and are worsened with ambulation. GI symptoms in 40-60%, joint symptoms in 60-80%, nephritis in 20-50% with proteinuria and hematuria. Angioedema of the scalp, eyelids, lips, ears, hands, feet, back, scrotum, and perineum may be seen. RX supportive, referral for long term follow. Complications: GI bleed, intussuception, chronic renal failure, CNS involvement, hepatosplenomegaly.
Rickettsial disease (RMSF)
Febrile illness caused by Rickettsia rickettsii (tick bite) seen in spring to early fall in south Atlantic states and Oklahoma. Multisystem manifestations including fever, headache, myalgias and vomiting. Rash erupts on wrists and ankles and involves palms and soles and then the trunk. Starts as pink, blanching macules, then becomes petechial. 15% of cases do not develop the rash. Mortality is > 30% without treatment. Skin biopsy for confirmation of diagnosis. Rx-supportive care, broad-spectrum antibiotics and tetracycline, doxycycline, or chloramphenicol for definitive therapy.
Purpura fulminans is a nonspecific sign of sepsis that appears rapidly and occurs in association with several infections (Group A Strep, Strep pneumo, Staph, RMSF, Meningococcus. Patients are ill appearing and should receive a full sepsis work-up and broad-spectrum antibiotic coverage (ampicillin and gentamycin for infants, ampicillin and ceftriaxone or cefotaxime for older children plus chloramphenicol for very ill patients in whom RMSF is suspected.
Other viral exanthems
Other viruses with associated petechial rash include Herpes Simplex, Epstein-Barr, CMV, Hepatitis, and enteroviruses.
5. Case conclusion
1. Case presentation (Varicella, Impetigo, SSSS)
Varicella Zoster (chicken pox)
Staphylococcal Scalded Skin Syndrome
Hand, foot and mouth disease (Coxsackie infection)
Disease Presentation and Management
Highly contagious viral illness seen in late winter to spring. Patients contagious from 2 days before onset of rash until complete crusting of lesions. Prodrome of fever, headache, malaise. Rash starts on trunk and spreads to face and extremities and is very pruritic. Lesions are in different stages of eruption. Begins as a red papule and becomes a thin walled clear vesicle (dewdrop on rose petal). Then becomes umbilicated and cloudy and ruptures to crust over. Oral and genital mucosa can be involved. Complications: skin infection, encephalitis, Reyes syndrome, pneumonia. Rx: supportive, antipruritics (diphenhydramine or hydroxyzine), cool baths (Aveeno), keep fingernails short to prevent scratching and superinfection, oral Acyclovir if seen within first 24 hours or for siblings, adolescents, immunocompromised individuals.
b. Staphylococcal scalded skin syndrome
A Staph toxin syndrome seen in children under age 5 years where the epidermis is cleaved. Follows a localized S. aureas infection. Rash is diffuse, erythematous with a sandpapery texture and tender with accentuation in the flexural areas. With fever, bullae form and peel off in large sheets. Look for radial fissuring and crusting around the mouth. Children ,may be irritable but not seriously ill. Minor pressure (Nikolsky’s signs) induces peeling. Can be associated with dehydration. Rx- hospitalization and IV antibiotics for extensive cases, otherwise oral antibiotics (dicloxicillin or cephalexin), skin lubrication after skin has started to exfoliate, avoidance of tape. Must differentiate from Toxic Epidermal Necrolysis (TEN).
Common contagious skin infection produced by Group A, alpha hemolytic streptococci or staphylococci or both. Bullous (mainly Staph) and nonbullous forms. Typically found on the face and around the nares. Starts as a bulla, pustule or vesicle that collapses and becomes a flat, honey crusted lesion. Commonly confused with Herpes Simplex virus which may precede it. Rx- application of 2% mupirocin ointment TID until lesions have cleared if disease is localized, otherwise 5-10 day course of dicloxicillin or cephalexin.
Hand, foot, and mouth disease
Common contagious viral illness from infection with Coxsackie viruses, strain A16 most common, or enterovirus 71. Associated with fever, malaise, soreness of the oral mucosa. Vesicles are found in the mouth first and easily rupture to become erosions. Skin vesicles erupt 1-2 days later on hands, feet, genitals, buttocks, and skin folds. Rx reassurance, supportive, topical, oral analgesics (magic mouthwash).
e. Herpes Zoster
Can occur in any age patient with a prior Varicella infection. Tingling, itching or pain precedes the eruption of a red papule which evolves into a vesicle. Vesicles coalesce in a dermatomal distribution. Lesions can appear red, purple or gray. Common areas are face, scalp, and torso. Can be disseminated in immunocompromised individuals. Rx pain control, antivirals may shorten course if given early.
4. Case conclusion
1. Case presentation
2. Differential Diagnosis
3.Disease Presentation and Management
Skin manifestation of a Type 1 hypersensitivity reaction which produces significant itching. Significant number of causes: penicillin, sulfa, food allergies, insect bites, viral infections, analgesics, physical factors, chemicals. Lesions are edematous papules and plaques with pink color (wheals). They come and go rapidly. Rx avoidance or withdrawal of precipitant, oral antihistamines (sedating and non-sedating), prednisone or H2 blockers for refractory cases.
4. Case conclusion
Edwards L. Dermatology in Emergency Care. Churchill Livingstone Inc., New York. 1997.
Fleisher GR and Ludwig S (eds.) Textbook of Pediatric Emergency Medicine, fourth edition. Lippincott Williams and Wilkins, Philadelphia. 2000.
Feigin RD and Cherry JD (eds.) Pediatric Infectious Diseases, third edition. W.B. Saunders Company, Philadelphia. 1992.
Barkin RM (ed.). Pediatric Emergency Medicine Concepts and Clinical Practice, second edition. Mosby, St. Louis, 1997.
Nelson WE (ed.). Textbook of Pediatrics, 15th edition. W.B. Saunders Company, 1996.
Habif, TP (ed.) Clincal Dermatology A Color Guide to Diagnosis and Therapy, third edition. Mosby, ST. Louis, 1996.
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