32: 5-year-old female with Rash Flashcards
1
Q
Dermatology Terminology
A
- type
- arrangement
- location
- pattern of distribution
- progression over timee
2
Q
Characteristics of Primary Lesions
A
-macule
-patch
-papule
-plaque
-vesicle
-bulla
-pustule
-nodule:
Majority of a nodule is below the skin
-wheal
-telangectasia: A dilation of superficial venules, arterioles, or capillaries visible on the skin
-petechiae-dont blanch w pressure
-purpura-dont blanch with pressure
3
Q
Characteristics of Secondary Lesions
A
- scale: Flakes of keratin that can be fine or coarse, loose or adherent.
- crust: Dried remains of serum, blood or pus overlying involved skin.
- fissure:Linear, often painful cleavage in the surface of the skin.
- erosion
- ulcer: Depressed lesion extending into the dermis or subcutaneous tissue. May lead to scar formation.
- excoriation: Traumatized, superficial loss of the skin, often linear, caused by scratching or rubbing.
4
Q
Atopic History: A family history including any or all of the following conditions called the atopic triad:
A
- atopic dermatitis (eczema)
- asthma
- allergic rhinitis (hayfever)
5
Q
Acute Urticaria (Hives)
A
A rash that comes and goes-changing almost as one watches-is very consistent with acute urticaria, also known as hives.
Often hives are caused by a histamine release triggered by allergens like drugs, foods, or pollen. The underlying cause can include viruses and even temperature. The offending trigger or agent can’t always be determined.
6
Q
Hive Treatment
A
- Avoid suspected allergens
- Symptomatic treatment:
- -Over-the-counter antihistamines (e.g., hydroxyzine, loratidine or cetirizine; these are related to diphenydramine [Benadryl] but are less sedating).
- -A course of oral prednisone is rarely used if antihistamines don’t control the symptoms. (Topical steroids don’t seem to be as effective, especially since hives can occur all over the body, be transient, and cover large areas.)
- -Keep patient cool and calm (try cool, soothing baths; heat will worsen the itching).
7
Q
The Stages of Acne
A
open comedones (blackheads) or closed comedones (whiteheads).
8
Q
The following are known to exacerbate acne lesions:
A
Make-up (unless noncomedogenic) Mechanical factors such as manipulation) Occlusion, as occurs with some sports gear Overzealous cleaning
9
Q
Chronic Nickel Contact Dermatitis
A
- -This fairly common skin condition (view photo) is an example of a delayed type IV hypersensitivity reaction.
- -The reaction requires sensitization, so onset is usually within 24-72 hours from the start of contact.
- -These reactions can occur despite prior tolerance to exposure.
- -Development of a rash depends on whether or not the skin barrier is intact or damaged.
- -The rash often resolves within days to weeks of avoidance.
- -If the allergy is difficult to control, some will refer to an allergist to consider “patch testing” to evaluate for nickel or other allergen leading to allergic contact dermatitis.
10
Q
Acute Contact Dermatitis
A
Unlike chronic reactions, acute reactions tend to have vesicles, edema, and erythema. They are also extremely pruritic.
Common causes are plants in the toxicodendron (or Rhus) genus, such as poison ivy, poison oak, and poison sumac.
11
Q
Topical steroids potency
A
Mild
Class 6 & 7
hydrocortisone acetate, 1% (OTC)
Intermediate
Class 4 & 5
triamcinolone acetonide, 0.1%
Potent
Class 2 & 3
betamethasonedipropionate, 0.05%
Super Potent
Class 1
clobetasol propionate, 0.05%
(The class 1 agent clobetasol, 0.05%, is approximately 1000 times more potent than over-the-counter hydrocortisone,1%)
12
Q
There are many potential side effects of topical steroid use. The most important are:
A
Skin atrophy
Telangiectasias
Hypopigmentation
Suppression of the hypothalamic-pituitary axis
13
Q
Treatment of Pediculosis Capitis (Head Lice)
A
- first-line treatment is 1% permethrin lotion, available in the U.S. without a prescription. Permethrin has very low toxicity, but may require two or three repeated applications in weekly intervals to achieve full effect. Pediatric providers should be aware of local resistance patterns
- Benzyl alcohol 5% (for children >6 mo) or malathion 0.5% (for children 2 yo or older) can be used in areas where resistance to permethrin or pyrethrins has been demonstrated or for a pt w/ a documented infestation that has failed to respond to appropriately administered therapy with permethrin or pyrethrins.
- Lindane 1%, formerly the tx of choice, is no longer recommended for use because of known neurotoxicity to humans. In addition, there is widespread resistance.
14
Q
Scabies presentation
A
- The scabies mite causes itching because it burrows into the skin and lays eggs.
- The most intense time of itching is often at night.
- Wrists, elbows, fingers, and toes are among the common distribution sites for scabies.
- The most classic lesion for scabies is about a 5-10 mm curvilinear thread-like lesion–the burrow; but infants often do not have burrows on presentation.
15
Q
Scabies Tx
A
- -two applications of permethrin 5% cream, 1 wk apart, for all affected household members.
- -The cream is applied at night before bed and washed off in the morning, or after around 8-12 hours.
- -Adults should apply the cream from the neck down.
- -For infants, the entire body should be covered from the hairline down, including behind the ears, being careful to avoid the areas around the eyes and mouth.
- -After bathing, wash all bed linens and clothing worn during treatment.
- -Itching (known as “post-scabetic itch”) may persist for a few wks after the mites have been killed and is due to persistent inflammation from the infestation. A moderate potency topical steroid and over-the-counter diphenhydramine may be helpful.
- -Sometimes families need to be re-treated or discover there was another hidden exposure.
16
Q
Characteristics of Ringworm: Appearance
A
The classic lesion of ringworm of the body (tinea corporis) is an annular, well-circumscribed, scaly plaque with a raised border and a center that is brown or hypopigmented.
17
Q
Other Types of Tinea: Tinea Pedis
A
As its name implies, it is found on the feet (also known as “athlete’s foot”).
18
Q
Other Types of Tinea: Tinea Versicolor
A
- actually an infection with the yeast form of a fungus (Malassezia globosa as well as other malassezia species) that is part of normal skin flora.
- First-line treatment is selenium sulfide lotion.
19
Q
Other Types of Tinea: Tinea Capitis
A
- -This is ringworm of the scalp.
- -Systemic therapy is required for this type of tinea; topical treatment is usually not successful because the hair follicles are deeper on the scalp.
- -While many oral antifungal agents have been developed, griseofulvin is still the treatment of choice.
- -Because the fungus grows slowly and is killed in the replication phase, it needs to be treated for an extended period of time–usually six to eight week; treatment should continue after it appears better to prevent recurrence.
- -Occasionally, there are resistant strains or a child who does not tolerate griseofulvin; for these cases, alternative therapies include terbinafine and itraconazole.
- -With tinea capitis, be on the watch for a significant allergic response called a “kerion” (an inflamed, weeping, boggy lesion that often requires treatment with oral steroids; although once the fungal infection in under control, the reactions go away).
20
Q
Common Warts vs. Molluscum Contagiosum
A
Warts are commonly caused by one of the human papillomaviruses (HPV).
Molluscum contagiosum, another virus, causes a similar skin condition. These lesions are small, smoother than common warts, and many have a central dimple, making them “umbilicated.”
21
Q
Common Etiologies of Diaper Rash: Irritant Dermatitis
A
–Most common cause of diaper rash.
–Due to prolonged exposure to moisture, friction, and digestive enzymes (worse with diarrhea).
–Presents as irregular areas of erythema with skin maceration on the convex surfaces of the skin
–Typically spares the intertriginous creases.
Treatment
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22
Q
Common Etiologies of Diaper Rash: Diaper Candidiasis
A
- -Starts off as erythematous papules that become confluent, bright red plaques.
- -The inflamed plaques are surrounded by more erythematous papules called “satellite” lesions.
Treatment:
The anti-fungal medication nystatin is effective against candida and is probably the most often used as it is approved for all ages by the FDA. Imidazole antifungals such as miconazole and ketoconzole can also be effective, but some of these products are not approved for use in infants.
23
Q
Common Etiologies of Diaper Rash: Bacterial Infection
A
- -A bacterial infection, especially of the perianal area with GAS (S. pyogenes) is another, less common, cause of diaper dermatitis.
- -This can be potentially serious, leading to cellulitis and even dissemination via bacteremia.
- -These infants may also be irritable and have streaks of blood on their stools.
Treatment
Standard treatment with oral antibiotics is effective.
24
Q
Diaper Rash as Presentation of Another Illness
A
- zinc deficiency
- Langerhans cell histiocytosis
25
Acne is divided into three categories based on the type(s) of lesions present:
Mild
Comedonal acne with perhaps a few papules or pustules mixed in
Moderate
Significant inflammatory lesions with concern for scarring
Severe
Nodulo-cystic type, with an even higher risk for significant scarring
26
mild acne tx
--For very mild cases, many physicians use OTC benzoyl peroxide (BPO) as a good starting point. (However, if a patient is coming to see a physician about acne, he or she usually needs something stronger.)
--BPO is available as a gel or as a skin wash.
--Retinoids (e.g., tretinoin [Retin-A] or adapalene [Differin]) work by normalizing follicular keratinization and are considered the drugs of choice for comedonal acne.

27
moderate acne tx
--For anything other than mild acne, the same initial treatments should be used with the addition of another product. (This management strategy should be familiar to you, as pediatricians often use step- wise evaluation and management plans.)
--Antibiotics can be an important adjunct in the treatment of acne.
--BPO can be combined with a topical antibiotic like clindamycin or erythromycin (antibiotics active
against P. acnes), each agent addressing a different cause for the acne.
--Topical prescription products exist in combination form or may be used in combination.
--Options for oral therapy include antibiotics such as doxycycline or tetracycline, or contraceptive pills (for females).
28
severe acne tx
- Pts with severe acne should be referred to a dermatologist.
- If all other txs have failed or haven't been tolerated, many dermatologists will then use oral isotretinoin.
- This medication carries significant risks and it is regulated very strictly by the federal gov
29
Timing of treatment with retinoids is important:
- -Retinoids need to be used at night, because they can cause photosensitization and lead to a significant sunburn.
- -Tretinoin is also inactivated by oxidation of BPO (so the BPO cream should be applied in the morning).
- -Tretinoin also must be applied to bone-dry skin or it may be significantly irritating.
- -It is important to make sure teens know that retinoids can make acne transiently look worse.
30
Treatment of Warts
- observation
- salicylic acid
- duct tape
- liquid nitrogen
- cantharidin
- candidal Ag therapy (immunotherapy)
- dig out w/ knife (curettage)
31
The following findings in a patient's history would point toward an allergic reaction:
- -FHx of atopy
- -Recurrent rapid onset and resolution of rash (suggesting an acute, repeated response to some type of trigger)
- -Pruritis (Pruritis is a helpful clinical feature as it generally rules out diagnoses such as viral exanthems. The pruritis is likely due to histamine release from mast cells during an allergic inflammation.)
- -H/o a therapeutic response to administration of antihistamine is also helpful
32
Differential Diagnosis of Rash
| 
-urticaria d/t T1HSR: Classic lesion is an intensely pruritic, circumscribed, raised, erythematous wheal, often with central pallor.
-papular urticaria: d/t insect bites
-Strep infection
-erythema multiforme: Most commonly caused by herpes simplex infections, but may be associated with medications.
-drug eruption:
May be Type 1 hypersensitivity reactions or may result from non-immunologic triggers of mast cell release (such as from opiates or NSAIDs).
-roseola (HHV6): A viral exanthem that classically follows 3-5 days of a febrile illness.
-erythema infectiosum (5th dz): Rash starts on the face with a "slapped"-cheek appearance followed by a reticular (lacy) erythematous rash on the trunk and extremities.
Caused by parvovirus B19.
-erythema migrans: Lesion associated with early localized Lyme disease.
33
Differential Diagnosis of Rash in an Infant
- Seborrheic dermatitis (cradle cap)
- eczema or atopic dermatitis: A positive history of atopic diathesis would support this diagnosis.
- candidal rash: Commonly manifests as a diaper dermatitis peaking between 7-10 months of age.
- psoriasis
34
Differential Diagnosis for Pustular Conditions: Staph
--Staphylococcal folliculitis, furunculosis: Can be very similar to nodular or cystic acne.
Often below waist or in groin area.
35
Differential Diagnosis for Pustular Conditions: Acne vulgaris
Due to several processes:
- -Keratinous material and excess sebum (due to androgenic influence) plug the pilosebaceous gland.
- -Increased sebum provides a growth medium for superinfection with Propioniobacterium acnes.
36
Differential Diagnosis for Pustular Conditions:: Hidradenitis suppurativa
--Pustular lesions caused by occlusion of the apocrine follicular units (instead of the pilosebaceous units).
--Often superinfected with Staphylococcus aureus or Streptococcus pyogenes.
--Areas most likely affected in women:
Axillae, Groin, Inframammary regions
--In men:
Perineal and perianal areas more commonly affected.
37
Differential Diagnosis for Pustular Conditions: Rosacea
- -More often seen in adults.
- -"Early" form seen in adolescents is characterized by inflammatory papules and micropustules, and redness.
- -No comedones.
- -Worsens with alcohol, spicy food, temperature extremes, and stress.
- -Can be treated with topical metronidazole and various other medications.
38
Differential Diagnosis for Pustular Conditions:: Perioral dermatitis
- -A variant of rosacea also commonly seen in adolescents, and treated the same way.
- -See erythema, scaling, and papules or pustules, but no comedones.
- -"Perioral" almost a misnomer, as this may be seen around the mouth, nose, or eyes.
39
Differential Diagnosis of Ringworm: Nummular eczema
- Consists of coin-shaped lesions commonly on the legs and buttocks.
- Has an annular configuration and scaly appearance like tinea.
40
Differential Diagnosis of Ringworm: Psoriasis
--Commonly presents with erythematous papules and plaques with a thick silver scale. --May also have an annular configuration that could be mistaken for tinea.
--A chronic disease.

41
Differential Diagnosis of Ringworm: Pityriasis alba
- -A nonspecific dermatitis characterized by patches of hypopigmentation on the face, neck, upper trunk, and proximal extremities.
- -Lesions range from 0.5 to 5 cm in diameter with well-defined, irregular borders and fine scale.
- -Associated with sun exposure.
- -May be mistaken for tinea versicolor.
common in children 3 to 16 years of age, presents as hypopigmented macules. They most often occur on the face, neck, trunk, and extremities. They have irregular borders, can vary in size, and may have a slight scale. Lesions may become more noticeable after sun exposure because of tanning of the surrounding skin. The etiology of this disorder is unknown, but ultrastructural examination of epidermal cells reveal decreased number of active melanocytes as well as decreased number and size of melanosomes.
42
Differential Diagnosis of Ringworm: Pityriasis rosea
- -Characterized by scaly papules and plaques in the hallmark "christmas tree" distribution on the back and trunk, following the lines of skin cleavage.
- -Lesions may also be found on the upper thighs and in the groin area.
- -The initial lesion, called the "herald patch," is usually the largest scaly plaque with a raised border and can easily be confused with tinea corporis.
43
A 3-year-old male presents to clinic with an annular, well-circumscribed, scaly plaque with a raised erythematous border and central hypopigmentation on the left thigh. The mother reports that the lesion is highly pruritic and that the patient has been exposed to other children with a similar rash at day care. Upon further examination, a similar lesion with boggy borders is also found on the posterior aspect of his scalp. Which of the following is the most appropriate treatment for this child's problem?
Topical antifungals are not usually successful in treating tinea capitis, because the infected hair follicles are deep within the scalp. Systemic griseofulvin is the first choice for the treatment of tinea capitis
Treatment with hydrocortisone cream will worsen the fungal infection.
Although topical antifungal therapy would be appropriate for the lesion on the leg (tinea corporis), involvement of the scalp (tinea capitis) necessitates systemic antifungals
44
A 3-year-old child is found to have a dry, pruritic rash on his face. Physical exam is notable for confluent areas of erythema and scaling. There are mild excoriations surrounding some areas and mild lichenification of the extensor surfaces of both elbows. What is the next best step in management of this child's problem?
Atopic dermatitis most often presents with dry, itchy skin in addition to erythema, scaling, vesicles, or lichenification in skin flexures. Treatment consists of emollients and topical corticosteroids
45
permethrin cream
Scabies is characterized by papules or vesicles accompanied by severe pruritis, especially at night. In addition, burrows may be evident. The wrists, ankles, palms, soles, interdigital spaces, axilla, waist, and groin are among the most common locations for lesions. Finally, there is often a positive sick contact history with similar symptoms.
46
Hyperproliferation of keratinocytes
Psoriasis can present in a variety of ways, but most commonly presents as a plaque. Plaques are often located on the scalp, external ear, and extensor surfaces presenting as a thick silvery scale and sharply demarcated borders. It may or may not be pruritic.
