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Pediatric Visual Diagnosis. Ilana Greenstone MD Division of Emergency Medicine Montreal Children’s Hospital McGill University Health Center. Objectives. Recognize common pediatric dermatologic conditions Expand differential diagnosis Review treatment plans - PowerPoint PPT Presentation
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Pediatric Visual DiagnosisPediatric Visual DiagnosisIlana Greenstone MD
Division of Emergency Medicine
Montreal Children’s Hospital
McGill University Health Center
Objectives
• Recognize common pediatric dermatologic conditions
• Expand differential diagnosis
• Review treatment plans
• Identify skin manifestations of systemic disease
Terminology
• Macules, Papules, Nodules
• Patches and Plaques
• Vesicles, Pustules, Bullae
• Colour
• Erosions – when bullae rupture
• Ulcerations and excoriations
Atopic Dermatitis
• 3-5% of children 6 mo to 10 yr
• Described in 1935
• Ill-defined, red, pruritic, papules/plaques
• Diaper area spared
• Acute: erythema, scaly, vesicles, crusts
• Chronic: scaly, lichenified, pigment changes
Atopic Dermatitis
Hints to diagnosis
• Generalized dry skin
• Accentuation of skin markings on palms and soles
• Dennie-Morgan lines
• Fissures at base of earlobe
• Allergic history
Atopic DermatitisTreatment
• Moisturize
• Baths only
• Anti-histamine
• Topical steroids to red and rough areas– Prevex HC– Desacort
• Immune modulators
Superinfected Eczema
• Red and crusty• Usually S. aureus• Cephalexin 40 mg/kg/day divided TID for 10
days• More potent topical steroid• Topical antibiotic – Fucidin• Anti-histamine• Refer to Dermatology
Scabies
• Intense pruritus• Diffuse, papular rash
– Between fingers, flexor aspects of wrists, anterior axillary folds, waist, navel
• May be vesicular in children < 2 years– Head, neck, palms, soles– Hypersensitivity reaction to protein of
parasite
ScabiesTreatment
• 5% permethrin cream for infants, young children, pregnant and nursing mother– Kwellada-P or Nix– Cover entire body from neck down– Include head and neck for infants– Wash after 8-14 hours
• Can use Lindane for older children
Tinea corporisRingworm
• Face, trunk or limbs• Pruritic, circular, slightly erythematous• Well-demarcated with scaly, vesicular
or pustular border• Id reaction• Mistaken for atopic, seborrheic or
contact dermatitis• Treament: Terbinafine (Lamisil)
Pityriasis Rosea
• Begins with herald patch– Large, isolated oval lesion with central
clearing
• More lesions 5-10 days later
• Christmas tree distribution
• Treatment: anti-histamines
Eczema
• Differential Diagnosis– Atopic dermatitis– Scabies– Tinea corporis– Pityriasis rosea
• If vesicular, check for HSV1, HSV2, VZV• Beware of superinfection• Think of immune deficiency if difficult to treat
Urticaria
• Transient, well-demarcated wheels
• Pruritic
• Part of IgE-mediated hypersensitivity reaction
• May leave central clearing
• Triggers are numerous
Kawasaki DiseaseDiagnostic Criteria
• Fever for 5 or more days• Presence of 4 of the following:
1. Bilateral conjunctival injection
2. Changes in the oropharyngeal mucous membranes
3. Changes of the peripheral extremities
4. Rash
5. Cervical adenopathy
• Illness can’t be explained by other disease
Kawasaki DiseaseLab Features
WBC ESR, positive CRP
• Anemia
• Mild transaminases albumin
• Sterile pyuria, aseptic meningitis platelets by day 10-14
Kawasaki DiseaseDifferential Diagnosis
• Measles• Scarlet fever• Drug reactions• Viral exanthems• Toxic Shock
Syndrome
• Stevens-Johnson Syndrome
• Systemic Onset Juvenile Rheumatoid Arthritis
• Staph scalded skin syndrome
Kawasaki DiseaseDifficulties with Diagnosis
• Clinical diagnosis
• No single test
• Diagnosis of exclusion
• Atypical KD – Do not fulfill all criteria– More common in < 1 year and > 8 years
Kawasaki DiseaseTreatment
• Admit to monitor cardiac function
• Complete cardiac evaluation – CXR, EKG, echo
• IV Ig
• ASA
Kawasaki DiseaseTreatment
• IV Ig 2 g/kg as single dose– Expect rapid resolution of fever– Decrease coronary artery aneurysms from 20% to
< 5%
• ASA - low dose vs high dose– 80-100 mg/kg/day until day 14– 3-5 mg/kg/day for 6 weeks
• Repeat echocardiogram at 6 weeks
Coxsackie VirusHand-Foot-and-Mouth
• Painful, shallow, yellow ulcers surrounded by red halos
• Found on buccal mucosa, tongue, soft palate, uvula and anterior tonsillar pillars
• Oral lesions without the exanthem = herpangina
• Exanthem involves palmar, plantar and interdigital surfaces of the hands and feet +/- buttocks
Erythema InfectiosumFifth Disease
• Parvovirus B19
• Mostly preschool age
• Recognized by exanthem
• Contagious before rash
• Resolution between 3 and 7 days
Roseola
• 6 to 36 months
• Human herpesvirus 6
• High fever without source and irritability for 3 days
• Rash develops as fever decreases
Impetigo
• Mostly face, extremities, hands and neck
• Localized unless underlying skin disease
• Strep or Staph• Honey-coloured crust• Treatment: topical and systemic
antibiotics
Herpes Simplex
• Gingivostomatitis most common 1º infection in children– Fever, irritability, cervical nodes– Small yellow ulcerations with red halos on mucous
membranes
• Involvement more diffuse – easy to differentiate from herpangina and exudative tonsillitis
• Treatment: supportive
Herpetic Whitlow
• Lesions on thumb usually 2° to autoinoculation
• Group, thick-walled vesicles on erythematous base
• Painful• Tend to coalesce, ulcerate and then
crust• May require topical or oral acyclovir
Henoch-Schonlein PurpuraClinical features
• Palpable purpura of extremities• Arthralgia or non-migratory arthritis
– No permanent deformities– Mostly ankles and knees
• Abdominal pain– May develop intussusception
• Renal involvement– Hematuria, hypertension, renal failure
HSP Management
• Supportive• NSAIDs may control the pain and do not
increase the risk of bleeding• Steroids – controversial
– Efficacy not proven re: abdo pain– No effect on purpura, duration of the illness or the
frequency of recurrences– Unclear of protective effect on renal disease
HSPIndications for admission
• R/O intussusception
• Severe GI bleed
• Severe renal disease
• Need for renal biopsy
• Hypertension
• Pulmonary hemorrhage
Acute Hemorrhagic Edema of Infancy
• 4-24 months
• Recent URI or antibiotics
• Non-toxic
• Resolves in 1-3 weeks
• small- vessel, leukocytoclastic vasculitis
• Annular or targetoid pupura and edema on face and extremities
Conclusions
• Not all that itches is eczema
• Treatment is often supportive for viral exanthems
• Remember rashes as a sign of systemic illness
• Careful history and physical essential for evaluation of bruises
