Lecture 11 - Derm/ID Flashcards
Milia
keratin filled papules usually found on the face, without erythema
benign, self-limiting after papules open up
often confused with sebaceous hyperplasia (on nose), or neonatal acne (but milia is without erythema)
Sebaceous hyperplasia
related to maternal androgens causing increase in number of sebaceous cells (similar to neonatal acne)
regression occurs when hormone levels decline
often mistaken for milia
Neontal acne
does NOT put the child at risk for early puberty
due to maternal androgenic hormones (like sebaceous hyperplasia)
-causes sebaceous gland blockage —> comedones, pustules
-no scarring
presents around 2 weeks
resolves with decline in maternal hormones in 3-4 months
tx: self resolves
-can use soaps or benzoyl peroxide
Seborrheic dermatitis
caused by malassezia furfur
“Cradle cap”
presentation:
-yellow/pink greasy appearing scale on scalp and erythematous scaling on neck and face
-in older children/adults: often itchy, erythematous scaly rash on face
tx:
Ketoconazole 2% cream/shampoo 2x/week
OR
topical hydrocortisone 1% cream (if mostly erythematous)
What is the treatment for seborrheic dermatitis?
Ketoconazole 2% cream/shampoo 2x/week
OR
topical hydrocortisone 1% cream (if mostly erythematous)
Harlequin color change
transient well defined color change in neonates
hypothesized to be due to immaturity of autonomic nervous system causing transient vasodilation
benign
associated with prematurity, use of prostaglandin or certain types of anesthesia and even meningitis
can be confused with port wine stains (but harlequin is transient)
Mottling
otherwise known as “cutis marmorata”
appears as pink marble or “lacy” pattern, usually bilaterally, symmetrical
benign if transient
typically caused by capillary constriction in response to a cold trigger
occasionally can be congenital “cutin marmorata telangiectasia congenita” which is usually more severe, only on one extremity which is asymmetric in size to others
Livedo Reticularis
umbrella term for pink purple lacy pattern that is mottling
if related to cold –> cutis marmorata
if unresolved with warming –> can indicate shock or poor cardiac output
Erythema toxicum
unknown cause
appears in 50% newborns in 2-5 days of life –> spontaneously resolves
ddx: HSV, staph pustulosis
path: eosinophils
no treatment
What is the treatment for erythema toxicum?
none
Pustular Meanosis
vesicles with cloudy fluid (at birth) –> denuded, forming white crust –> hyperpigmented macules (within hours to few days)
cause unknown
path: neutrophils
benign
sometimes mistaken for HSV (difference is pustular melanosis lacks erythematous base, is less clustered, and less likely on a presenting part –presenting part like during labor and delivery (was the head first or butt, etc))
self resolves
Allergic contact dermatitis?
cause: exposure to irritant –> recruits pre-sensitized cutaneous T-cells to skin –> inflammation
tx:
avoid contact with irritant
keep skin surface dry
for diaper area, use emollients as barrier (zinc oxide cream, petrolatum)
hydrocortisone 1% or 2.5% ointment (for face; can use in severe diaper dermatitis)
mometasone (trunk/extremities)
Candidal diaper dermatitis
candidal (diaper) dermatitis
- satellite lesions
- beefy red
- affects folds/creases
tx: topical nystatin
Contact diaper dermatitis
spares inguinal folds
rx: barrier cream
zinc oxide
Slate grey patch
mongolian spot
benign hyperpigmented (usually blue/back) patches, usually on sacrum but can be over back and extremities (usually not on face)
not associated with any condition
can be mistaken for ecchymoses, so document
Cafe au lait spot
benign hyperpigmented (usually brown) irregularly shaped macule or patch
found anywhere on body
if >6 spots, >5mm, it supports the likely dx of neurofibromatosis
Infantile hemangioma
vascular overgrowth due to dysregulation of endothelial stem cells
present at birth but grows rapidly throughout the first 6-12 months of life
then, it begins to spontaneously involute
tx: usually since they self resolve, its only a cosmetic issue
options tx are: propranolol (oral), steroids, and laser therapy
When to treat? (=when to worry)
if they are in a location where vision, breathing, or feeding can be affected
if they are very large (they can ulcerate and be prone to infeciton)
if they are midline over the sacrum along with a dimple (occult spinal dysraphism is more likely)
When should you be worried about hemangioma?
if they are in a location where vision, breathing, or feeding can be affected
if they are very large (they can ulcerate and be prone to infeciton)
if they are midline over the sacrum along with a dimple (occult spinal dysraphism is more likely)
What are you worried about for a child with hemangioma on the eyelid?
occludes vision, leading to amblyopia
Why are you worried about a child with hemangioma on sacral dimple or tuft of hair?
could indicate spinal dysraphism
obtain spinal US
If you are going to treat hemangioma, what is the treatment?
usually since they self resolve, its only a cosmetic issue options tx are: propranolol (oral), steroids, laser therapy
Port Wine Stain
blanchable capillary malformation
usually are isolated lesions, but can be associated with genetic conditions (Sturge-Weber, Klipple-Trenaunay)
When to refer?
-if segments 1 and 2 of trigeminal nerve are affected (upper and lower eyelids):
its more likely to be associated with Sturge Weber sydnrome (if both the top and bottom eyelid are affected)
-if neurologic signs (seizures)
-can be associated with glaucoma
Congenital Melanocytic Nevus
rare tan-black color hamartomas made of melanocytes, present at birth
can be small, medium, large, or giant sized
ofentimes are irregularly shaped and have pilosebaceous glands (have hair)
when to refer:
- large or giant 3-5% chance of melanoma –may require excision and grafting for cosmetic and oncologic purposes
- small or medium: recommend routine monitoring by PMG and family for melanoma potential (1%) that occurs mostly after puberty
Measles (Rubeola)
caused by measles virus (a paramyxovirus)
epi: prior to vaccine in 1963, affected >500,000 people per year
declined to <500
spread by respiratory transmission
contagious for 4 days prior to rash onset and 4 days after the rash
When is measles contagious?
contagious for 4 days prior to rash onset and 4 days after the rash
How does Measles present?
incubation period (10-12 days)
-occurs after virus is spread to the respiratory mucosa
prodrome (2-4 days)
-high fever (103-105F), malaise
-“cough, coryza, conjunctivitis”
-enanthem: Koplik’s spots (1-3mm grey/blue/white bumps on an erythematous base, usually in buccal and labial mucosa)
Exanthem - (begins 2-4 days after fever)
-erythematous maculopapular (initally blanching, then darkens and coalesces) rash beginning on forehead –> spreading down
rash starts 2-4 days after fever onset. usually not pruritic
-generalized lymphadenopathy; possible splenomegaly
-fever lasts 2-4 days into rash, then self-resolves
What age do you get the measles vaccine?
12 months
Incubation period of measles
incubation period (10-12 days)
-occurs after virus is spread to the respiratory mucosa
prodrome (2-4 days)
Prodrome period of measles
prodrome (2-4 days)
- high fever (103-105F), malaise
- “cough, coryza, conjunctivitis”
- enanthem: Koplik’s spots (1-3mm grey/blue/white bumps on an erythematous base, usually in buccal and labial mucosa)
Koplik’s spot
seen in prodrome of measles pts
Exanthem phase of measles
Exanthem - (begins 2-4 days after fever)
-erythematous maculopapular (initally blanching, then darkens and coalesces) rash beginning on forehead –> spreading down
rash starts 2-4 days after fever onset. usually NOT pruritic
-generalized lymphadenopathy; possible splenomegaly
-fever lasts 2-4 days into rash, then self-resolves
How do you dx measles?
a high level of suspicion
consider in immunocompromised, under-immunized children with possible exposure
appears “sick”
testing: detecting measles RNA with RT-PCR
positive measles IgM or rise in measles IgG during acute and convalescent stages
if suspected:
place child in airborne isolation room
-call health department
What are the complications of measles?
secondary infections (PNA, diarrhea, encephalitis)
SSPE (subacute sclerosing panencephalitis)
-occurs 7-10 years after infection, progressive CNS degenerative disease
What is the treatment of measles?
supportive care
vitamin A (2 doses) for children -decreases mortality for children under 2 years
best treatment is prevention: vaccinate! (age 1 and 4 years)
Mumps
caused by mumps vius (a paramyxovirus)
epid:
prior to vaccine in 1967, was a common cause of encephalitis, orchitis, parotitis, and sensorineural hearing loss
spread by respiratory droplets and direct contact
How to pts present with mumps?
nonspecific prodrom: fever, malaise, HA, myalgias
Parotitis: usually 48 hours after prodrome not always present can last up to 10 days
How do you dx mumps?
clinical dx:
parotitis along with fever
labs:
elevated amylase, lymphopenia
no lab tests are necessary in clear cut cases
can do:
mumps IgM
increased mumps IgG titers between acute and convalescent stages
PCR of mumps DNA
How can you tell parotitis from lymphadenitis?
if you can’t see the angle of the jaw then it is most likely parotitis
What are the complications of mumps?
orchitis (unilateral painful inflammation and swelling of the testicle; can lead to impaired fertility)
oopheritis
sensorineural hearing loss (can be acute or gradual)
encephalitis, aseptic meningitis
What is the treatment of mumps?
droplet precautions recommend isolation (At home) for at least 5 days after onset of sxs
supportive care
vaccinate! (1 and 4 years,)
Rubella
caused by rubella virus (togavirus family)
epi: spread by respiratory droplets
How do pts with rubella present?
these kids don’t look sick (minus the obvious rash)
low-grade fever and lymphadenopathy (posterior auricular or suboccipital) for 1-5 days
rash appears from head and spreads down, faint pink maculopapules
it resolves quickly (within 2 days) starting from the head down
arthralgias and arthritis (occur in most adolescents and adults)
What is the Ddx of rubella?
roseola parvovirus enterovirus EBV measles associated with vaccine
How do you dx rubella?
rubella IgM or RT-PCR
What is the treatment for rubella?
supportive care, prevent with vaccine
What are the complications of rubella?
encephalitis (rare)
risk of congenital rubella syndrome is pregnant pts are exposed
Congenital rubella syndrome
toRch infection causing significant disease in fetus if acquired in the 1st trimester
in 3rd trimester, only causes IUGR (growth restriction)
presentation (if 1st trimester acquisition):
cataracts, cardiac defects, deafness
heaptosplenomegaly, jaundice, “blueberry muffin lesions” (purpura), microcephaly, and sometimes meningoencephalitis
How do you dx congenital rubella syndrome?
obtain pregnancy hx
rubella IgM, PCR, or persistent IgG
consider other TORCH infections (CMV - can present with blueberry muffin baby)
What is the treatment for congenital rubella syndrome?
due to 20$ mortality, should transfer to a NCIU setting for comprehensive evaluation
no disease specific treatment
Blueberry muffin baby
congenital rubella syndrome
typically the classical presentation is cataracts, cardiac defects, deafness
“Fifth Disease”
erythema infectiousum
caused by parvovirus B19
epi:
spread by respiratory droplets
more common in the young (up to 60% of adults have IgG evidence of prior infection)
How to pts with erythema infectiousum present?
“slapped cheeks”
prodrome of fever, malaise, HA
erythematous, vonfluent plaques on malar face - slapped cheeks - appear first and fade over 1-4 days
Body rash appears after facial lesions
erythematous macules and papules become confluent giving lacy or reticular appearance
best seen on extensor arms; also trunk and neck
rash fades after 5-9 days, but reticular rash may recur for weeks - months
arthralgias in 10% of cases
more common in adolescents and adults
How do you dx fifth disease?
erythema infectiosum (parvovirus)
usually clinical - can confirm with:
Parvovirus B19 by PCR
demonstration of IgM parvovirus B19 antibodies
IgG seroconversion
What are the complications of erythema infectiosum?
aplastic crisis (typically for children who already have problems with their RBCs) -due to infection of RBC precursors in pts with underlying hemolytic anemia (presents as reticulocytopenia, worsening anemia, +/- transfusion requirement)
hydrops fetalis
What is the treatment for parvovirus?
(aka fifth disease, aka erythema infectiosum)
supportive care
Sixth disease
roseola infantum
caused by human herpesvirus - 6 (HHV-6)
usually occurs in children <2 year
spread by secretions to close contacts
super high fever –one of the reasons for febrile seizures in kids
the fever breaks and then BAM -rash
How to pts with roseola infantum present?
sixth disease
3-5 days of high fever (>40C)
fever subsides, then…
rash (blanching pink, maculopapular) starting on the neck/trunk –> spreading to the face and extremities
What is the treatment of roseola infantum?
supportive care
just reassure the parents that this is a virus, it will pass
Eczema herpeticum
infection cased by HSV-1
usually occurs in children with atopic dermatitis or other skin conditions, or in immunocompromised people
medical “urgency”
How do pts with eczema herpeticum present?
acute onset fever with rapid PAINFUL eruption of “punched out” pustular/vesicular lesions
may be difficult to distinguish from baseline eczema if poorly controlled
may also have swelling and erythema which can indicate bacterial superinfection
medical “urgency”
How can you counsel a family in regards to febrile seizures?
don’t worry if it lasts less than 5-10 minutes (time it)
dont worry if its generalized
worry if it lasts longer than 15 minutes
worry if they have had more than 1 in 24 hours
worry if its a focal seizure
What are the risks of eczema herpeticum?
sig morbidity and mortality secondary to bacterial superinfection
What is the treatment for eczema herpeticum?
medically “urgency”
PO acyclovir (unless ill appearing or immunocompromised, may use IV) while awaiting HSV confirmatory testing concurrent anti Staph ABX +/- IVFs (clinda)
Varicella Zoster
caused by varicella zoster virus (VZV), a hepresvirus
epi: highly contagious; spread by airborne particles
incubation 10-21 days prior to onset of rash
“dewdrops on a rose petal” appearance
How do pts with varicella zoster present?
malaise, low grade fever precede rash by 1 day
pruritic crops of macules that turn into vesicles on an erythemaotous base “dewdrops on a rose petal” that crust over within hours to days
new crops appear for 3-4 days resulting in vesicle in different stages of healing
start on trunk, then head and face, then extremities
pruritus is marked
What are the complications of varicella zoster?
bacterial superinfection
PNA
primary varicella can be fatal in immunocompromised (mortality approaches 15% in children with leukemia who do not receive prophylaxis or therapy)
How do you dx varicella?
clinically
or by scraping base of vesicle for PCR or DFA exam
What is the treatment for varicella zoster?
place in airborne isolation room if suspected and have pregnant caregivers avoid contact
PO acyclovir or valcyclovir for children >12 yo or immunocompromised
supportive care
- NO APSIRIN
- oatmeal baths
- careful hygeine
Shingles
herpes zoster
caused by reactivation of varicella zoster virus (VZR) in the sensory ganglia of the nerve
presentation: initial tingling –> painful dermatomal distribution of erythematous vesicular lesion
What are the complications of shingles?
if anywhere on the face (trigeminal distribution), could indicate ocular involvement *treat aggressively
What is the treatment for shingles?
topical antipurutitics, PO analgesics
acyclovir only in cases affecting trigeminal nerve, immunocompromised, or >12 y/o
Molluscum contagiosum
caused by molluscum contagiousum virus, a poxvirus
epi: occurs in healthy children and immunocompromised adults
spread by skin contact (sports, sexually transmitted)
What is the presentation of molluscum contagiousm?
flesh colored umbilicated, fluid filed pusutules
occurs anywhere on the body EXCEPT palms/soles
What is the treatment for molluscum contagiosum?
self limiting
reassure parents that it’s benign
cryotherapy (with liquid nitrogen)
curettage
cantharidin (blistering agent)
SSSS
staphylococcal scalded skin syndrome
caused by: toxin produced by staph aureus that is hematogenously spread ot skin, causing blistering
presentation:
do NOT affect mucosal surfaces
usually children <5y/o
fever and skin with generalized erythema and initial flaccid bullae usually in the skin fold –> bullae rupture and create area of erosion
How do you tell the difference between SSSS from SJS?
SJS affects multiple mucosal surfaces
How do you treat SSSS?
Nafcillin
Clindamycin
Vancomycin
Neisseria meningitis
MC cause of bacterial meningitis in children - 13% mortality
higher rates in areas of crowding
How do pts with neisseria meningitis present?
rapid onset of fever, HA, vomiting, intense myalgias (leg pains are often worse than viral myositis)
petechial/purpuric rash (does NOT blanch) often on trunk/extremities
progress quickly to altered mental status, shock, and IDC
How do you treat neisseria meningitis?
early dx is key
blood, CSF, and coags should be evaluated
IV ABX (IV ceftriaxone) x 7 days
ABX should not be delayed >30 minutes to obtain CSF studies
Lyme disease
Borellia burgdorferi
spread by tick bite
presentation: (you can start at any stage)
early localized:
erythema migrans - spreading erythemaotus target like rash from the site of the tick bite, occurs 7-14 days after bite
early disseminated:
multiple erythema migrans
neurological sx: HA, Bell’s palsy (bilateral is almost always Lyme), meningitis, encephalitis
cardiac sx: carditis (complete heart block)
nonspecific sx: fever, maliaise, myalgia
late:
arthritis (affected 1 or few large joints, usually knee)
What is the treatment of lyme disease?
Erythema migrans (early logalized) Doxycycline )if >8y.o) or amoxicillin (<8y/o) PO x 10-21 days
early disseminated (neuro, cardiac) facial nerve palsy: doxyclycine or amoxicllin PO x 14-21 days Meningitis: IV Ceftriazone 21-28 days
Late disease (arthritis):
Doxycycline PO x 28 days (if not neuro disease)
IV ceftriaxone x 28 days (if some neuro disease)
basically
for <8y/o Amoxicillin PO if early disease or IV ceftriaxone if severe
for >8y/o doxy
Fever defined
> /= 38C (100.4F)
Hyperthermia from fever, tissue damage?
no evidence for tissue damage (brain injury) until sustained temperatures between 41-42C
When can you transition from rectal to oral thermometers in children?
rectal from birth - 3 years
oral 4+ years
What education can you provide a parent in regards to fever in their child?
recognize that fever itself is unlikely to be harmful
beneficial in fighting infection
treat fever only if improve childs comfort
How do you treat fever in a child?
Acetaminophen
-15mg/kg every 4-6 hours PO, PR (Max 90mg/kg q 24 hrs)
pay attention to formulation and strength when dosing
dont use Ibuprofen in children <6 months
10mg/kg q 6-8 hours (Max 40mg/kg q 24 hours)
risk of nephrotoxicity with dehydration
Infants <28 days old with a fever
most fevers caused by viral illness
most common bacteria: GBS, E.Coli, listeria
HIGHEST risk group for invasive bacterial infection (IBI - bacteremia, meningitis)
Infants 29-90 days old with fever
still high risk for IBI
What do you do for all children un 3 months with a fever?
any febrile infant <3 months of age who appears ill and ALL febrile infants <28 days of age should: be admitted to the hospital get a work up: -blood, urine, CSF for culture -chest X-ray if resp sxs -stool studies if diarrhea -consider HSV in febrile infants <4 weeks of age Be treated with broad spectrum IV ABX
When do you get blood and urine cultures in children <3 years?
if they have a fever and no source
UTI is MC cause
occult bacteremia less common since HIB and prevnar vaccines
