Maculopapular Eruption<\/strong><\/p>\n <\/p>\n
<\/p>\n
Differential Diagnosis<\/p>\n
a.<\/p>\n
Kawasaki’s disease<\/p>\n
b.<\/p>\n
Erythema multiforme<\/p>\n
c.<\/p>\n
Pityriasis Rosea<\/p>\n
d.<\/p>\n
Measles (Rubeola)<\/p>\n
e.<\/p>\n
Erythema Infectiosum (Fifth’s disease)<\/p>\n
f.<\/p>\n
Scarlet Fever<\/p>\n
g.<\/p>\n
Roseola Infantum<\/p>\n
h.<\/p>\n
Other viral exanthems<\/p>\n
<\/p>\n
3. Disease Presentation and Management<\/p>\n
<\/p>\n
a.<\/p>\n
Kawasaki’s disease (mucocutaneous lymph node syndrome)<\/p>\n
<\/p>\n
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.<\/p>\n
<\/p>\n
b. Erythema multiforme<\/p>\n
<\/p>\n
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 \u0096 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 \u0096 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.<\/p>\n
<\/p>\n
c.<\/p>\n
Pityriasis rosea<\/p>\n
<\/p>\n
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.<\/p>\n
<\/p>\n
d.<\/p>\n
Measles<\/p>\n
<\/p>\n
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 \u0096 supportive.<\/p>\n
<\/p>\n
e. Erythema Infectiosum (Fifth’s Disease)<\/p>\n
<\/p>\n
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.<\/p>\n
<\/p>\n
f.<\/p>\n
Scarlet fever<\/p>\n
<\/p>\n
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 \u0096 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.<\/p>\n
<\/p>\n
g.<\/p>\n
Roseola Infantum<\/p>\n
<\/p>\n
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 \u0096 fever control and reassurance.<\/p>\n
<\/p>\n
5. Case conclusion<\/p>\n
<\/p>\n
C.<\/p>\n
Petechial\/Purpuric eruptions<\/p>\n
<\/p>\n
1.<\/p>\n
Case presentation<\/p>\n
2.<\/p>\n
Differential Diagnosis<\/p>\n
a.<\/p>\n
Idiopathic Throbocytopenic Purpura<\/p>\n
b.<\/p>\n
Henoch-Sch\u00d6nlein Purpura<\/p>\n
c.<\/p>\n
Rickettsial disease<\/p>\n
d.<\/p>\n
Sepsis\/DIC<\/p>\n
e.<\/p>\n
Other viral exanthems (infectious mononucleosis)<\/p>\n
<\/p>\n
3.<\/p>\n
Disease Presentation and Management<\/p>\n
<\/p>\n
a.<\/p>\n
Idiopathic Thromocytopenic Purpura<\/p>\n
<\/p>\n
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 \u0096 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.<\/p>\n
<\/p>\n
b.<\/p>\n
Henoch-Schonlein Purpura<\/p>\n
<\/p>\n
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 \u0096 supportive, referral for long term follow. Complications: GI bleed, intussuception, chronic renal failure, CNS involvement, hepatosplenomegaly.<\/p>\n
<\/p>\n
c.<\/p>\n
Rickettsial disease (RMSF)<\/p>\n
<\/p>\n
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.<\/p>\n
<\/p>\n
d.<\/p>\n
Sepsis\/DIC<\/p>\n
<\/p>\n
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.<\/p>\n
<\/p>\n
<\/p>\n
e.<\/p>\n
Other viral exanthems<\/p>\n
<\/p>\n
Other viruses with associated petechial rash include Herpes Simplex, Epstein-Barr, CMV, Hepatitis, and enteroviruses.<\/p>\n
<\/p>\n
5. Case conclusion<\/p>\n
<\/p>\n
D.<\/p>\n
Vesicobullous eruptions<\/p>\n
<\/p>\n
1. Case presentation (Varicella, Impetigo, SSSS)<\/p>\n
2.<\/p>\n
Differential Diagnosis<\/p>\n
a.<\/p>\n
Varicella Zoster (chicken pox)<\/p>\n
b.<\/p>\n
Staphylococcal Scalded Skin Syndrome<\/p>\n
c.<\/p>\n
Impetigo<\/p>\n
d.<\/p>\n
Hand, foot and mouth disease (Coxsackie infection)<\/p>\n
e.<\/p>\n
Herpes Zoster<\/p>\n
<\/p>\n
3.<\/p>\n
Disease Presentation and Management<\/p>\n
<\/p>\n
a.<\/p>\n
Varicella Zoster<\/p>\n
<\/p>\n
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.<\/p>\n
<\/p>\n
b. Staphylococcal scalded skin syndrome<\/p>\n
<\/p>\n
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).<\/p>\n
<\/p>\n
c. Impetigo<\/p>\n
<\/p>\n
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.<\/p>\n
<\/p>\n
f.<\/p>\n
Hand, foot, and mouth disease<\/p>\n
<\/p>\n
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 \u0096 reassurance, supportive, topical, oral analgesics (magic mouthwash).<\/p>\n
<\/p>\n
e. Herpes Zoster<\/p>\n
<\/p>\n
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 \u0096 pain control, antivirals may shorten course if given early.<\/p>\n
<\/p>\n
4. Case conclusion<\/p>\n
<\/p>\n
E.<\/p>\n
Urticarial eruptions<\/p>\n
<\/p>\n
1. Case presentation<\/p>\n
2. Differential Diagnosis<\/p>\n
a.<\/p>\n
Allergic<\/p>\n
b.<\/p>\n
Infections<\/p>\n
c.<\/p>\n
Physical agents<\/p>\n
<\/p>\n
3.Disease Presentation and Management<\/p>\n
<\/p>\n
Urticaria (hives)<\/p>\n
<\/p>\n
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 \u0096 avoidance or withdrawal of precipitant, oral antihistamines (sedating and non-sedating), prednisone or H2 blockers for refractory cases.<\/p>\n
<\/p>\n
4. Case conclusion<\/p>\n
<\/p>\n
<\/p>\n
V.<\/p>\n
References:<\/p>\n
<\/p>\n
1.<\/p>\n
Edwards L. Dermatology in Emergency Care. Churchill Livingstone Inc., New York. 1997.<\/p>\n
<\/p>\n
2.<\/p>\n
Fleisher GR and Ludwig S (eds.) Textbook of Pediatric Emergency Medicine, fourth edition. Lippincott Williams and Wilkins, Philadelphia. 2000.<\/p>\n
<\/p>\n
3.<\/p>\n
Feigin RD and Cherry JD (eds.) Pediatric Infectious Diseases, third edition. W.B. Saunders Company, Philadelphia. 1992.<\/p>\n
<\/p>\n
4.<\/p>\n
Barkin RM (ed.). Pediatric Emergency Medicine Concepts and Clinical Practice, second edition. Mosby, St. Louis, 1997.<\/p>\n
<\/p>\n
5.<\/p>\n
Nelson WE (ed.). Textbook of Pediatrics, 15th edition. W.B. Saunders Company, 1996.<\/p>\n
<\/p>\n
6.<\/p>\n
Habif, TP (ed.) Clincal Dermatology A Color Guide to Diagnosis and Therapy, third edition. Mosby, ST. Louis, 1996.<\/p>\n
<\/p>\n
<\/p>\n
|\u00a0\u00a0 \u00a0\u00a0 |\u00a0\u00a0 \u00a0\u00a0 |<\/p>\n","protected":false},"excerpt":{"rendered":"
Array<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_genesis_hide_title":false,"_genesis_hide_breadcrumbs":false,"_genesis_hide_singular_image":false,"_genesis_hide_footer_widgets":false,"_genesis_custom_body_class":"","_genesis_custom_post_class":"","_genesis_layout":"","footnotes":""},"categories":[11],"tags":[],"yoast_head":"\n
Pediatric Dermatology - Crashing Patient<\/title>\n\n\n\n\t\n\t\n\t\n