{"id":5354,"date":"2011-07-14T20:25:45","date_gmt":"2011-07-14T20:25:45","guid":{"rendered":"http:\/\/crashtext.org\/misc\/5354.htm\/"},"modified":"2011-09-26T22:47:23","modified_gmt":"2011-09-26T22:47:23","slug":"pediatric-dermatology","status":"publish","type":"post","link":"https:\/\/crashingpatient.com\/pediatrics\/pediatric-dermatology.htm\/","title":{"rendered":"Pediatric Dermatology"},"content":{"rendered":"

Adult Dermatology<\/a><\/p>\n

<\/h3>\n

<\/span>Tinea Capitis<\/span><\/h3>\n

Kerion<\/h4>\n

boggy, purulent eczematoid mass on scalp with alopecia and posterior cervical adenopathy.\u00a0 Cell mediated response to tinea capitis.\u00a0 Need 4 weeks of oral antifungal therapy.<\/p>\n

<\/span>Lymphadenitis<\/span><\/h3>\n

2 weeks oral abx<\/p>\n

<\/span>Impetigo<\/span><\/h3>\n

most prevalent in kids <6 y\/o<\/p>\n

highly contagious to others and through autoinoculation<\/p>\n

Contagiosa<\/h4>\n

Staph or Group A B-hemolytic strep<\/p>\n

Lesions around nose, mouth and possibly on the extremities<\/p>\n

Small pustules or vesicles with red margins, when they rupture, they form honey colored crusts<\/p>\n

Bullous<\/h4>\n

staph aureus phage group 2<\/p>\n

usually seen in the periumbilical area of neonates or the extremities of older children<\/p>\n

flaccid, thin walled bullaewhich form shiny, round erosions with peeling edges (known as coin lesions) (Rivers)<\/p>\n

 <\/p>\n

Treat both with dicloxacillin, oxacillin, cephalexin, augmentin PO.\u00a0 Can also give mupirocin 2% as topical treatment.<\/p>\n

Can see glomerulonephritis post strep impetigo.\u00a0 ABX do not prevent this complication.<\/p>\n

<\/span>Staph Scaled Skin (SSS)<\/span><\/h3>\n

children less than 5 y\/o with irritability, fever, and tender erythematous skin.\u00a0 Nikolsky’s will be present with an intraepidermal clevage plane.\u00a0 Mucous membranes are not involved.. Either oral diclox or IV oxacillin<\/p>\n

<\/span>Scarlet Fever<\/span><\/h3>\n

2-5 day incubation period.\u00a0 erythematous oral mucous membranes with scattered ptechiae.\u00a0 White or strawberry tongue.\u00a0 Circumoral pallor.\u00a0 Punctate, sandpaper rash starting on trunk and spreading.\u00a0 More intense in skin folds.<\/p>\n

 <\/p>\n

<\/span>Eczema Herpeticum<\/span><\/h3>\n

The patient was admitted and treated with IV Acyclovir and IV Cefazolin.\u00a0 Culture by dermatology consult revealed Herpes Simplex Virus, type 1.\u00a0 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.\u00a0 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 Kaposi\u0092s 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\u00b0F for 7-10 days are not uncommon. The severity of infection ranges from mild and transient to fatal.\u00a0 Death may result from the common complication or secondary\u00a0 staphylococcal infection.\u00a0 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.<\/em> 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.<\/p>\n

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.<\/em><\/p>\n

\"\"<\/a>\"\"<\/a>\"\"<\/a><\/p>\n

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.\u00a0 Minor relapses do not require a second course of acyclovir. References:<\/em> (1)\u00a0 Behrman: Nelson Textbook of Pediatrics, 16th ed., \u00a9 2000 W. B. Saunders Company (2)\u00a0 Habif: Clinical Dermatology, 3rd ed., \u00a9 1996 Mosby-Year Book, Inc. (3)\u00a0 Yeung-Yue KA Herpes simplex viruses 1 and 2<\/a>\u00a0 Dermatol Clin<\/cite>\u00a0 2002; 20: 249-66 (4)\u00a0 Muelleman PJ, Doyle JA, House RF Jr\u00a0 Eczema herpeticum treated with oral acyclovir\u00a0 J Am Acad Dermatol<\/em> 15:716-717, 1986.<\/p>\n

(EMEDhome.com)<\/p>\n

 <\/p>\n

Contact Dermatitis<\/p>\n

Allergic Dermatitis<\/p>\n

Miliaria (heat rash)<\/p>\n

Milia (sebaceous gland occlusion)<\/p>\n

Transient Neonatal Pustular Milanosis-present at birth<\/p>\n

Erythema Toxicum-not born c it, 1st day of life, looks like flea bites, disappears by 1 week<\/p>\n

<\/h3>\n

<\/span>Varicella<\/span><\/h3>\n

Usually seen in the winter and the spring in 1-14 y\/o.<\/p>\n

1-3 week incubation period, infectious 2 days before and 5 days after rash 1.\u00a0 Skin Superinfection 2.\u00a0 Pneumonia 3.\u00a0 Hepatitis 4.\u00a0 Pancreatitis 5.\u00a0 Encephalitis<\/p>\n

One of the few rashes present in the scalp, meningococcemia should not be in the scalp.\u00a0 Kids with varicella before 1 year may have a second outbreak and are higher risk of shingles.\u00a0 Usually leukopenia.\u00a0 May see subclinical hepatitis.<\/p>\n

 <\/p>\n

Complications of varicella:<\/strong> death<\/em> (data prior to 1995)\u0097approximately 100 per year, 84% immunocompetent patients; typically due to encephalitis or Reye\u0092s syndrome; bacterial superinfection<\/em>\u0097most common complication; may present with adenitis; most often due to Staphylococcus aureus<\/em> or Streptococcus pyogenes<\/em>; necrotizing fasciitis rare sequela; herpes zoster\u0097 <\/em>9% of children with shingles had varicella in first year; central nervous system (CNS) dysfunction<\/em>\u0097acute 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<\/em> pneumonia\u0097<\/em>admit child and treat with acyclovir; Reye\u0092s syndrome<\/em>\u0097rare since vaccines available; hemorrhagic complications<\/em>\u0097very 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)<\/p>\n

 <\/p>\n

Motrin can give necrotizing fasciitis, aspirin can give Reye, use Tylenol and benadryl.\u00a0 In 1st trimester, \u00bc of fetuses will get limb deformations,\u00a0 2nd trimester is no problem, 3rd trimester 5 days prior and 2 days post delivery can get Varicella encephalitis<\/p>\n

 <\/p>\n

 <\/p>\n

<\/span>Erythema Multiforme Minor and Major<\/span><\/h3>\n

<\/h3>\n

<\/span>Measles (Rubeola)<\/span><\/h3>\n

Seen in 0-20 y\/o, usually in winter\/spring.<\/p>\n

caused by paramyxovirus; incubation period of 10-14 days<\/p>\n

Prodrome of high fever and URI sx 2-4 days prior to the appearance of the rash.<\/p>\n

Erythematous macules and papules which become confluent and turn coppery-colored.\u00a0 Begins in hairline and moves down the body.<\/p>\n

Koplik spots, conjunctivitis, photophobia, cough, and pneumonia<\/p>\n

 <\/p>\n

 <\/p>\n

<\/span>German Measles (Rubella)<\/span><\/h3>\n

caused by rubivirus, incubation period of 14-21 days.\u00a0 Infective 1 week before to 1 week after the rash onset.<\/p>\n

5-25 y\/o, usually in spring.\u00a0 Prodrome is mild URI sx.\u00a0 Maculopapular rash which becomes pinpoint.\u00a0 Begins on face and migrates to the trunk.\u00a0 Tender retroauricular, posterior cervical, and occipital lymphadenopathy.<\/p>\n

 <\/p>\n

<\/span>Erythema Infectiosum (Fifth Disease)<\/span><\/h3>\n

From Parvovirus B-19,<\/p>\n

3-12 y\/o or non-immune adults.<\/p>\n

Seen in winter\/spring. Prodrome of fever and malaise.<\/p>\n

Macular erythema on face, followed ~2 days later by erythematous macular eruption, then lacy erythema.\u00a0 Rash progresses from face to extremities.<\/p>\n

Once rash appears, no longer contagious<\/p>\n

Associated with aplastic crisis, hydrops fetalis, popular-purpuric socks syndrome.<\/p>\n

 <\/p>\n

<\/span>Exanthem Subitum (Sixth Disease, Roseola)<\/span><\/h3>\n

HHV-6 or HHV-7.\u00a0 Incubation of 10-14 days<\/p>\n

0-3 y\/o, usually in Spring or Fall.\u00a0 Prodrome of high fever for 3-5 days.\u00a0 Associated with febrile seizures.\u00a0 Rash of erythematous to pink macules and papules arranged in rosettes on trunk, neck, and proximal extremities.\u00a0 Rash appears as fever resolves.<\/p>\n

 <\/p>\n

Scabies<\/p>\n

 <\/p>\n

Scarlet Fever<\/p>\n

 <\/p>\n

Disease\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Day of Fever which Rash Develops<\/p>\n

Very <\/strong> \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Varicella \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 1st day of Fever, rash develops<\/p>\n

Sick\u00a0 <\/strong>\u00a0\u00a0\u00a0<\/strong>\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Scarlet Fever\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 2nd<\/p>\n

Pts<\/strong>\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Small Pox\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 3rd<\/p>\n

Must<\/strong>\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Measles\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 4th<\/p>\n

Take<\/strong>\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Typhus\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 5th<\/p>\n

Double<\/strong>\u00a0\u00a0\u00a0\u00a0 Dengue\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 6th<\/p>\n

Eggs<\/strong>\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Enteric Fever\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 7th<\/p>\n

 <\/p>\n

 <\/p>\n

<\/span>Hand-Foot-Mouth Disease<\/span><\/h3>\n

enterovirus; coxsackie A 16<\/p>\n

incubation period 0f 3-6 days.<\/p>\n

tender vesicular rash which starts on oral mucosa then spreads tot he buttocks, hands, and feet.<\/p>\n

infection during the first trimester may result in spontaneous abortion<\/p>\n

 <\/p>\n

 <\/p>\n

Jill M. Baren, MD, FACEP, FAAP<\/p>\n

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":"

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