Pediatric Rashes Distinguishing the common from the uncommon

					Pediatric Rashes: Distinguishing the
   common from the uncommon

        Vidya Sharma MBBS, MPH
          Professor of Pediatrics
         Section of Dermatology
 I have no conflicts to disclose
 Since this talk is about infants
  and children I will be discussing
  off-label use of medications
 Recognize pediatric
  dermatologic conditions that
  are commonly seen in the
  pediatric clinical setting
 Determine best practice
  strategies for the treatment of
  these conditions
     Hair conditions

An 8 year old
boy who has
asthma was
noted to have
areas of missing
hair after a
  Clinical features of tinea capitis
 Seborrheic type:
    Diffuse scaling/dandruff
    Lymphadenopathy
 “Black dot” type:
    Patches of hair loss with broken hairs at
     follicular orifice
    Blond dot, red dot
 Inflammatory type:
    Pustules, abscesses or kerions
 Favus:
    crusted/matted hair
                      Tinea capitis
   Most commonly caused by Trichophyton tonsurans
   Hyphae grow down hair follicle/penetrate hair shaft
   Does not fluoresce
   Occipital or post-auricular lymphadenopathy is common
   Can result in scarring alopecia
   Widespread dermatophytid “ID” reaction
    Nonfungal, generally pruritic, papular, vesicular eruption
    Often follicular, lichenoid
    Begins on face, then spreads to trunk/extremities
    Often confused as allergic reaction to medication
                     Sudden bald spot

A 4 year old girl
was noted to have
a “bald spot” when
her mother was
combing her hair.
Otherwise healthy.
On exam she has
an area of smooth
alopecia as shown.
No scale or
erythema noted.
              Alopecia Areata
 Acquired hair loss in focal, circumscribed areas
    “Exclamation-mark” hairs!
 No underlying skin changes. Frontal, parietal areas
  commonly affected, along with eyebrows /
 Cause is unknown:
    perifollicular lymphocyte infiltrate occurs beforehand
 Male and female occurrence equal
 Nail disease occurs in 20-50% of patients
    Nail pitting is most common
    Trachyonychia, Beau’s lines, thinning, thickening, red
     spotted lunula, leukonychia, onycholysis

Madani, S. et al. “Alopecia areata update.”
JAAD. April 2000, p.549-570
                  Alopecia areata
 Family history is common (~1/3)
 Higher incidence with Down syndrome and of
  vitiligo and other autoimmune diseases
 Increased thyroid disease (thyroid ab’s)
 Treatment options:
    Active nonintervention (ie nothing), volumizing
     shampoos, supportive psychotherapy, wigs/hair
    Topical steroids/ Intralesional steroids
    Minoxidil 5%
    Topical immunomodulators (Protopic ointment)
    Contact sensitization / Short-contact anthralin

 Colombe BW et al. JAAD 1995; 33:757-764.
  His hair has gone from thick to thin
A 3 year old boy who
presents with diffuse hair
loss. Mother says that
clumps of hair are noted
on his pillow and in the
shower for a few weeks.
PMH is significant for a
previous admission for 8
days for high fever 5
months ago. Has been well
since then.
                Telogen Effluvium
          Acquired diffuse alopecia
             Sudden, diffuse, non-scarring
             Hair falls out in clumps
          Rapid conversion of scalp hairs
            Growing phase         Resting phase
          Normally: 85-90% is growing (anagen)
           10-15% is resting (telogen)
          Acute stressful events act as trigger

Headington, J.T. “Telogen effluvium. New concepts and review.” Archives of
Dermatology. 1993; 129:356.
      Causes of Telogen Effluvium

 High fever/ Severe infection/ Severe chronic illness
 Surgery
 Crash diets/Iron deficiency /Drugs
 Postpartum
 Diagnosis:
    History
    Hair mount (plucking 50+ hairs)
    >25% hairs in telogen phase is considered
 Treatment:
    Reassurance & time
          Her hair just will not grow

A 4 year old girl
who has not had
a hair cut yet.
Her mother
states her hair
never grows
beyond neck
length. She has
tried various
Loose Anagen Hair Syndrome

 Anagen hairs, loosely anchored and can
  be easily pulled from the scalp
 Sparse short scalp hairs seldom require
 Have ruffled hair shafts and misshapen
  hair bulbs
 Described in blond girls 2-5 years of age,
  not exclusively
 No treatment
 Usually improves with time
      Hint: It is still the hair category
A 7 year old boy presents
with multiple follicular
papules on his chest for a
     Eruptive Vellous Hair cysts
 Can be acquired or by autosomal dominant
 May be associated with ectodermal dysplasia
  (both anhidrotic and hypohidrotic) and
  pachyonychia congeita
 Aymptomatic developmental anomaly of hair
 Usually on chest and flexor or extensor
  surface of extremities
 Discrete follicular papules red, blue gray or
 Treatment: keratolytics, topical retinoids
A 12 year old with a nail problem for 3 months

 Less common in children than
 Starts at the distal nail and first at
  the lateral border of the distal nail
 Is insidious initially silvery, then
  yellow and later brown
 Usually does not involve all nails
       Nails are slowly getting worse

A 5 year old
who has a
and his
nails are

 Nails may be affected in 25-50% of
 Pitting most common
 Other nail changes include
  discoloration, crumbling and
  grooving of the nail plate
 Sometimes onycholysis
He has a fungus that has spread to all nails

Mother had noted a problem with
a finger nail 3 months ago and
this has spread not to all nails.
She asked for her PCP for a
“fungal medicine” and didn’t get
  Twenty – Nail Dystrophy of
 Ten or twenty nail dystrophy of
 Idiopathic Disorder
 Self-limiting resolves in a few
  years without treatment
 Etiology unknown
 Treatment not usually
   An A student with nail changes
A 10 year old boy
who is a straight
A student has been
noted to have nail
changes that were
noted on the
right hand and then
the left. On no
medications and
Otherwise healthy
       Habit-Tic dystrophy
 Injury to the base of the nail and the
  nail matrix
 Caused by continuous picking of
  the nail cuticle of the affected digit
  with a finger
 Usually thumb affected
 Usually depression on the center
  with horizontal ridges extending
  towards it
 Treatment- behavior modification
Like father like child
     Pachyonychia Congenita
 Type I – Jadassohn-Lewandowsky
 Genetic defect: K6a,16 mutations
 Inheritance: autosomal dominant
 Features:
   Nail dystrophy (markedly thickened, yellow-
   Palmoplantar keratoderma (focal symmetric)
   Hyperhidrosis/acral bullae
   Follicular hyperkeratosis
   Oral leukokeratosis
   Corneal dystrophy & cataracts
     Pachyonychia Congenita
 Type II – Jackson-Lawler
• Genetic defect: K6b, K17 mutations
• Inheritance: autosomal dominant
     Nail dystrophy (markedly thickened, yellow-
     Palmoplantar keratoderma (focal
     Hyperhidrosis/acral bullae
     Natal teeth
     Steatocystoma multiplex
     Lacks the oral mucous membrane changes
 Yellow bump or bumps
These yellow
waxy lesions are
either congenital
(20%) or acquired
(within 1st year of
life); most
commonly on the
head and neck;
biopsy shows
     Juvenile Xanthogranuloma
 Benign self-healing non-LCH characterized by
  accumulation of lipid-laden macrophages.
 Typically appear before 1 y/o; may be present at
    Number and size increase during first several
 Smooth, firm, dome shaped papules or nodules
    JXG initially red; develops typical yellow-orange
 Single or multiple, congenital (20%) or acquired
 Variable size – few mm to several cm
 Most often on head & neck
Sometimes raised / sometimes flat
A 6 month old
presents with a
1cm yellow-
brown papule
that turns red
and becomes
swollen when
rubbed or
          Solitary Mastocytoma
 Benign collection of mast cells in the dermis
 Red-brown, pink or yellow papule/nodule
 Appearance of an orange peel
    “peau d’orange”
 Round, oval
 5mm-5cm
 Noticed at birth or infancy
         Solitary Mastocytoma

 Urticate with friction: Darier’s sign
 Often itch when active
 May form overlying bullae (Bullous
 Systemic symptoms are very rare
 Treatment:
    Nothing: lesions often fade and become
     less reactive with time
    Avoid mast cell degranulators
Looks like acne, but is it?

2 year old with papules on the
cheeks and nose that looked like
acne but are not going away
         Tuberous Sclerosis
Primary Criteria          Secondary Criteria
 Fibrous plaque           Hypopigmented
  forehead                  macules
 Angofibromas face        Shagreen’s patch
 Periungual fibromas      Cardiac
 Tubercle brain cortex     rhabdomyoma
 Subependymal             Infantile spasms
  hamartomas               Bilateral renal cysts
 Multiple retinal          and
  hamartomas                angiomyolipomas
                           First degree relative
                            with TS
                           Single retinal
      Ring or ringworm?
A 6 year old
boy with a
lesion on his
ankle. It is not
painful or itchy.
He has a new
developing on
his hand
       Granuloma Annulare

 Usually in children less than 15 years of
 Etiology unknown
 Usually start as flesh colored papules
 Then enlarge to form rings with clear
  centers and elevated borders
 No treatment necessary in
  uncomplicated cases
A 13 year old girl
who acutely
developed lesions on
her legs. There are
several painful,
tender nodules on
her anterior shins.
         Erythema Nodosum
 Abrupt onset, symmetric tender
  erythematous nodules on the extensor
 Common in adolescents and females
 Associated with infections such as:
  streptococci, tuberculosis,
  histoplasmosis, coccidiomycosis
 Also drugs such as oral contraceptives
 Usually self limited treatment includes
  anti-inflammatory agents for pain
       Double trouble
- Parents come in with twin 3
  year old boys
- Both boys are complaining of
  peri- rectal pain and itching
- They have just finished a
  course of Bactrim for a “skin
Double Trouble
Perianal streptococcal disease
    sharply demarcated bright
    itching and pain may be present
    perirectal fissures may be present
    diagnosis is confirmed by perianal

    Penicillin
         Enlarging Rash
 12 year old with
  hay fever and
  recurrent rash for
  3-4 months
 Has been taking
  intermittently for
  her hay fever
 Had a varicella
  immunization 2
  weeks ago
 The rash appears
  to fade and then
  recurs, lasts longer
  and gets bigger
      Fixed Drug eruption
 A type of an allergic reaction to a
 Characteristically recur in the same site
  or sites when the medication is taken
 Well defined round patches with
  erythema and occasional blistering
 Usually in association with
  Acetaminophen, Tetracyclines,
  Sulphonamides, Non-steroidal anti-
  inflammatories, others
 Treatment: Recognition and avoidance
3 month old male
has a progressive
widespread pruritic
rash for 2 months,
many red to brown
scratching mainly
at night.

• Pruritic papules, pustules and
• Excoriated areas and crusting
• Occasionally nodules are seen in the
  inguinal area
• Lesions are present on palms, soles, and
  scalp in infants
• Usually other affected family members
• Scrapings of suspicious lesions may yield
  mites, eggs or feces
 • all family members and close contacts should
   be treated
 • 5% Permethrin cream topically - in infants
   apply on the head
 • 6% Sulphur in Petrolatum topically leave on
   for 24 hours on 3 consecutive days
 • Ivermectin 100-200 micrograms in a single
   dose has shown positive results (not
   approved for use in children under 5 years)
 • antihistamines for itching
 • treat secondary infection, if it is present
        Critter attack on legs
                             A 10 year old boy
                             woke up with these
                             bullous lesions on a

The parents have seen
 several of these critters
in their yard
 Molluscum Contagiosum
 Cutaneous infection caused by Pox virus
 Common in children
 Skin to skin transmission and
 Often seen in children with atopic
 Usually spontaneously resolve within 2
 May leave depressed scar “pit” with or
  without treatment
  Molluscum Contagiosum
 Skin colored 2-5 mm erythematous
  smooth, dome shaped papules
 Central umbilication
 Usually located on the trunk, axilla,
  or extremities
 Commonly found in intertriginous
  regions (autoinoculation)
 Molluscum Contagiosum
 Surrounding skin may be
  erythematous (molluscum
 May develop pruritus or pain
 May develop associated
  secondary infection
 Inflammation usually precedes
        Treatment Options
 Gentle skin care
   mild soap
   bland emollient
 Antipruritics
   Diphenhydramine, hydroxyzine
 Low potency topical steroid for
  molluscum dermatitis
   1% hydrocortisone ointment

   Silverberg N. Pediatric molluscum contagiosum: optimal treatment
   strategies. Paediatr Drugs 2003;5(8):505-512.
                 Treatment Options
 Active Nonintervention
   Usually Self Limited
 Physical Destruction (painful)
   Cryotherapy
   Curettage
 Local Irritation
   Cantharidin
   Topical Retinoid
 Topical Immunomodulator
   Imiquimod
  Valentine C et al. Dermatologic Therapy 2000;13:285-289.
 Chemical vesicant extracted from the
  blister beetle
 Causes release of serine proteases causing
  intraepidermal blistering and local irritation
 Used to treat molluscum and warts since
  the 1950’s
 Possible side effects
    Severe blistering
    Secondary infection
    Toxicity from oral ingestion

 Initial small studies have shown
  promising results using Imiquimod
  cream in the treatment of molluscum
 Limited small studies using Imiquimod
  nightly in children with molluscum have
  demonstrated efficacy and safety

Hengge U et al. Br J Dermatol 2000;143:1026-1031.
Barba A et al. Dermatology Online Journal 2001;7(1):20.

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