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Classic Pediatric Rashes

VIEWS: 17 PAGES: 27

									                                                        (+)Ghazala Q. Sharieff, MD, FACEP
                                                        Clinical Professor, University of
                                                        California, San Diego; Director, Pediatric
                                                        Emergency Medicine, Palomar-Pomerado
                                                        Hospital/California Emergency
                                                        Physicians, San Diego, California




          Classic Pediatric Rashes

    Do children with rashes still stump you? The
    speaker will review pediatric rashes, from
    classic childhood exanthemas to unusual and
    life-threatening cutaneous disorders. Measles,
    varicella, roseola, Kawasaki's disease, impetigo,
    and staphylococcal scalded skin syndrome will
    be discussed using a case-based format.

    Review the common and not so common
    pediatric exanthems.
    Differentiate among benign and life-threatening
    pediatric rashes.
    Discuss the various treatment choices for these
    conditions.


SU-99
10/16/2011
10:00 AM - 10:50 AM
Moscone Convention Center


(+)No significant financial relationships to disclose
                                               9/7/2011




    CLASSIC PEDIATRIC RASHES


    Ghazala. Q Sharieff, MD FACEP, FAAEM




                Definitions
•   Macule <1cm vs Patch >1cm
•   Papule <1cm vs Plaque >1cm
•             <3mm,
    Petechiae <3mm Purpura >3mm
•   Vesicle <1cm, Bullae >1cm
•   Pustule = pus
•   Wheal= comes and goes
•   Enanthem= rash inside the body(Koplik's)
•   Exanthem=eruption on the skin




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          Seborrhea Dermatitis
•   Greasy yellow scale on salmon patch
•   May become thick and adherent
•   Intertriginous areas often involved first
•   Scalp involved in infants AKA Cradle Cap
•   Transient post inflammatory
    depigmentation common




         Seborrheic Dermatitis
• Associated with Pityrosporum infection.
• Treatment
     -Comb scale after applying emollients
     such as mineral oil
     -Keratolytic shampoos
     -Low potency local steroids
     -May need ketoconazole 2%
• Can become superinfected with bacteria or
  candida




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           Atopic Dermatitis
• Chronic condition
• Associated with + Family history, asthma or
  allergies
• 60% of pts present in first year of life and
  up to 95% by age 5
• Infants: extensor surfaces, scalp, face
• Children: Flexor surfaces, wrists & ankles,
  antecubital and popliteal fossae




           Atopic Dermatitis
• Up to 93% of pts are colonized with Staph
  Aureus
• Impetigo can occur in eczematous areas
• Avoid bubble baths
• Short nails




           Atopic Dermatitis
• Daily bathing no longer considered harmful
  but lukewarm water and emollients
  immediately
   – Aveeno or Dove Soap
   – Aquaphor, Vaseline
   – Topical steroids
      • Low potency= hydrocortisone 1%, 2.5%
      • Highest Potency=Betamethasone 0.05%
• Hydroxazine to help with sleep
• Keflex, Augmentin, clindamycin,
  azithromax




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                                              9/7/2011




         Eczema Herpeticum
• Severe herpetic virus infection
• Vesicles develop abruptly in eczematous
  areas
• Fever can be high and secondary infection
  can occur
• Disease varies from mild to fatal
• Treatment: acyclovir ( IV or PO)
  – Add anti-staphyloccal agent




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                                                9/7/2011




              Pityriasis rosea
• Herald patch followed in 1-2 weeks by
  generalized rash lasting up to 6 weeks
• Pruritic, X-mas tree pattern parallel to
  posterior ribs
• Cause unknown, but ? herpesvirus 7
• Low grade fever, nausea and fatigue
• Treatment: anti-histamines,
  erythromycin,?Steroids
• UV light helpful if used in first week
• 2% of patients have recurrent disease




             Tinea Versicolor
•   Malassezia furfur
•   Causes direct damage to melanocytes
•   Children: facial lesions common
•   10% KOH reveals spaghetti and meatball
    pattern ( budding yeast and stubby hyphal
    form)




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                                                9/7/2011




            Tinea Versicolor
• Ketoconazole 2% Shampoo, 1-2X/day for
  3-14 days ( Nizoral)
• Miconazole, 2X/day for 2-4 weeks
• Clotrimazole 2x/day for 2 4 weeks
  Clotrimazole,           2-4




             Pityriasis Alba

• Often mistaken for tinea versicolor
• Skin scraping reveals no budding yeast
• Common on the face during warm weather
• Selenium sulfide lotion, 5-10 minutes for 7
  days
• Selenium sulfide shampoo, 1x/day




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  Head Lice-Pediculosis Capitus
• Pruritus intensifies 3 to 4 weeks after the
  initial infestation
                        p      y
• Bites can be seen, especially in the neck of
  long-haired individuals when the hair is
  pushed aside.
• Itch /scratch cycle can lead to secondary
  infection
• Lymphadenopathy and fever are rare




          Pediculosis Capitus
• Permethrin, malathione,?vaseline
• Benzyl alcohol lotion (5%);
  Brand name product: Ulesfia lotion
• No lindane due to toxicity
• Wash all clothes, brushes, blankets
• Repeat treatment in 7-10 days
• May require multiple treatments




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                IMPETIGO
Epidemiology
• Common in Summer
Etiology
• Group A strep
• S. aureus also possible




                IMPETIGO
•   Honey crusted rash
•   Streptococcus or Staph aureus ( bullous)
•   Cellulitis possible
•   Acute Glomerulonephritis: uncommon
•   Nephritis- may be seen in up to 28% of
    patients with nephritogenic strep strain




                IMPETIGO
                  Treatment
• Topical mupirocin
• Keflex, Augmentin, bactrim or clindamycin
• Intranasal mupirocin for patients with
  recurrent episodes as prophylaxis




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                                                          9/7/2011




           SCARLET FEVER
• Group A beta-hemolytic streptococcus
• Sand paper rash first in the skin folds of the
  axillae, groin, and antecubital area (Pastia’s lines)
• Circumoral pallor, palatal petechiae
• Rash develops 12-48 hours after sore throat, and
  lasts 4-5 days
• Desquamation over the next 2 weeks
• Rx: Pen VK. No school until abx for 24 hrs




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                                                    9/7/2011




                 CA-MRSA
•   Occurs in healthy patients
•   Abscesses or cellulitis
•   Septra or clindamycin
•   No double dose Septra/Bactrim




PERIANAL STREPTOCOCCUS
•   Group A beta-hemolytic streptococcus.
•   Occurs in children less than 10 years of age.
•    Males> females
•    Well-marginated erythematous ring
    extending evenly around the anus




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                                               9/7/2011




PERIANAL STREPTOCOCCUS
• No induration, fever, or lymphadenopathy
• Perianal itching or pain with defecation
• Positive culture/recent GABHS infection or
  has a +throat culture
• Rx: Oral penicillin




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 ERYTHEMA MULTIFORME
• Hypersensitivity reaction
• Recurrent herpes simplex infections occur
  10 days before lesions
• Mycoplasma pneumoniae
• Drugs-PCN, Dilantin, cephalosporins




 ERYTHEMA MULTIFORME
• Target lesions evolving over days and not
  hours
• Symmetric on elbows knees, and extensor
                 elbows, knees
  surfaces
• EM major involves mucous membranes
• Remove offending agent, symptomatic Rx
• May need hospitalization




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                                                     9/7/2011




     HENOCH-SCHOENLEIN PURPURA
              “ARENA”
 •    A- abdominal pain, +/- bloody stools
 •    R- purpuric rash
 •    E edema
      E-
 •    N-nephritis
 •    A- arthralgias/ arthritis




       Henoch-Schonlein Purpura

• Diagnosis
     – Classic rash, abdominal pain, microscopic
       hematuria, arthralgias in non toxic patient
                 ,       g                 p
     – Screening tests: CBC, UA, Blood cultures,
       ESR, PT/PTT




        Henoch-Schonlein Purpura

 • Management
      – Symptomatic with close follow up
      – Steroids are controversial and only
        for severe cases




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                      SCABIES
• Sarcoptes scabiei
• Pruritic lesions especially
  in web spaces,
  groin,hands, feet, elbows,
  knees
• Facial involvement in
  infants
• Mite feces or eggs on
  scraping of the lesions in
  oil immersion
• Permethrin overnight,
  avoid lindane
• Treat the whole
  household!




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                                                        9/7/2011




                  CANDIDA
• Diaper dermatitis
    – Use topical antifungal cream
    – Add 1% hydrocortisone cream sparingly for
      severe cases
    – The dermatologists disapprove of Lotrisone!
• Oral Thrush
    – Use nystatin 100,00units/cc- 2cc po qid




            TINEA CAPITUS
• Trichophyton tonsurans most common
• Person to person transmission via fomites
• Alopecia, black dot sign, Kerion
•                                             weeks
  Treat with Griseofulvin 20mg/kg/day for 6 weeks.
  Give with a fatty meal
• Trials with ketoconazole, itraconozole, fluconazole
  and terfinafine show success
• May add prednisone for kerion
• Selenium sulfide shampoo 2X/week




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                                           9/7/2011




               VARICELLA
•   Macules, papules, vesicles
•   Spread over 24 hours
•   Trunk, face to extremities
•   Often in scalp, mouth
•   Highly contagious until crusted




               VARICELLA
              Complications
•   Cellulitis
•   Pneumonia
•                  seizures
    Encephalitis: seizures, coma (early)
•   Cerebellitis: benign ataxia (late)
•   Reye syndrome




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                                                       9/7/2011




               VARICELLA
                Treatment
• Antipruritics
• APAP
• 20mg/kg/dose qid acyclovir
• VZIG for kids at high risk within 72 hours of
  exposure
• Varicella vaccine 12-18 months of age
• After 13 years of age, need 2 shots




               VARICELLA
                Treatment
• Acyclovir for healthy kids?
    – Reduction in days of fever
    – 80 fewer lesions
    – No difference between acyclovir and placebo in
      terms of varicella complications
    – Importance of treating healthy kids with
      acylovir is still uncertain




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                                                    9/7/2011




      Molluscum Contagiosum
• Pox virus
• Transmitted by direct contact
• Genital lesions are typically sexually
  transmitted and can develop 2-3 months
  t      itt d d       d l 23            th
  after exposure
• Smooth, pearly to flesh-colored, dome-
  shaped papules. Center becomes soft and
  umbilicated with a white curdlike core.




      Molluscum Contagiosum
• Rx: supportive, curettage or cold
  cryotherapy
• May need ABX for secondary infection
  Tretinoin
• T ti i cream, b           l       id
                    benzoyl peroxide,
  podofilox, salicylic acid, silver nitrate, oral
  cimetidine




             Herpes Simplex
• May be primary or recurrent
• Incubation period 2 days to 2 weeks
• Secondary bacterial superinfection=most
  common complication
• Herpetic gingivostomatitis, keratitis,
  encephalitis, whitlow, labialis, progenitalis




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                                                9/7/2011




          Herpetic stomatitis
• 6 months to 5 years of age
• Vesicular lesions on tongue, palate, buccal
  mucosa,
  mucosa gingiva
• Gums may be friable, exudative and
  ulcerative
• Tender submandibular and cervical nodes
• Dehydration is common
• Treatment: supportive care, acyclovir




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                                              9/7/2011




           Herpetic whitlow
• Occurs in up to 10% of thumbsuckers
• Vesiculopustules vary from superficial to
  deep
• Initially confused with cellulitis
• Rx: Topical or oral acylovir




     Hand-Foot-Mouth Disease
• Coxsackievirus A16 or Enterovirus 71
• 3-6 day incubation period
• Incubation 2-6 days
• Peaks in late summer / early fall.
                             y
• Pts contagious 2 days before eruption and
  up to 2 days after
• Typically disappears by day 7 of disease
• Small macules that spread into vesicles
• Buccal mucosa, tongue, palate, gingiva,
  anterior tonsillar pillars




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                                            9/7/2011




    ERYTHEMA INFECTIOSUM
•   AKA Fifth Disease
•   Parvovirus B 19
•   Incubation 4 – 20 days
•   Sickle cell patient aplastic crisis




    ERYTHEMA INFECTIOSUM
• Fever in 15 – 30%: low grade
• Rash
    – Slapped cheeks on face
    – Lace-like rash on arms, trunk
    – Recurrent with heat, sunlight
• Adults and teens: arthralgia, arthritis




                                                 21
                                             9/7/2011




    ERYTHEMA INFECTIOSUM
          Treatment
• Supportive
• No labs
• Contagious for few days before and after
  rash
• Isolate inpatients: pregnant at risk




               ROSEOLA
•   Human herpes virus 6
•   Exanthem subitum (“sudden onset”
•   Children 6 months – 2 years
•   Incubation 5 – 15 days
•   Contagious: unknown




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                                                  9/7/2011




                  ROSEOLA
             Signs and symptoms
•   High fever 3 – 5 days
•   Febrile seizures possible
•   Irritability
•   Rash: sudden onset after defervescence
•   No specific therapy




      ERYTHEMA TOXICUM
         NEONATORUM
• Erythema toxicum neonatorum
    – Occurs in up to 50% of infants
    – Small, yellow papules or pustules with an
      erythematous base
    – Gram stain shows eosinophils
    – Self-resolves in 5-7 days




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                                            9/7/2011




What makes you think that a rash
   may be life-threatening?
1.Mucous membrane involvement
2.Extensive blisters or peeling of skin
3.Extensive erythema and fever
4. Severe pain that appears to be out of
  proportion to the physical examination
5.ALOC
6. Persistent fever
7. Petechial or purpuric lesions




    STAPHYLOCOCCAL SCALDED
      SKIN SYNDROME (SSSS)
• Age less than 5 years
• Irritability when skin is touched
• Fever
• Generalized erythema followed by bullae
  formation and desquamation
• Nikolsky’s sign
• No mucous membrane involvement!




                                                 24
                                                   9/7/2011




    STAPHYLOCOCCAL SCALDED
      SKIN SYNDROME (SSSS)
             Treatment
• IV hydration
• Admit for nafcillin or cefazolin
• Admit all newborns regardless of clinical
  condition!
    – Burn treatment protocols due to fluid loss




      Stevens Johnson Syndrome
• Age: 2-10 years
• NSAID’s, sulfonamides, anticonvulsants
• Mycoplasma pneumoniae and HSV
• 1-14 day prodrome with fever, HA, sore
  throat, malaise, V/D, cough
• Severe mucosal membrane involvement
  with at least 2 sites-oral and eyes common




                                                        25
                                            9/7/2011




    Stevens Johnson Syndrome
• Typical SJS-only a few red macules
  accompanying mucous membranes
• SJS-TEN overlap 10 30% skin involvement
  SJS TEN overlap-10-30%
• Toxic epidermal necrolysis (TEN) >30%
  body surface area involvement




    Stevens Johnson Syndrome
• Burn protocols
• Aggressive IV hydration
• Removal of offending agents
• Close fluid and electrolyte monitoring
• May need opthalmologic consult for eye
  involvement
• ?IV immunoglobulin therapy 1.5-
  2gm/kg/day for 3 days




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