Pediatric Dermatology Flashcards
Varicella (Chickenpox) dermatologic presentation
- Generalized pruritic vesicular rash beginning on face, neck, or
upper trunk & spreads outward - Mucous membranes may be involved
- Lesions are in different stages of healing (crops)
- Other symptoms may include fever & malaise
- Hx of contact with another infected person within
previous 10-21 days
What is a superinfection?
infection occurring after or on top of an earlier infection, especially following treatment with broad-spectrum antibiotics.
Varicella (Chickenpox) management
usually supportive
* Acyclovir may be useful in immunocompromised patients & pregnant
women
* Varicella Zoster Immune Globulin (VZIG) may be given to patients
exposed to varicella who are at risk for severe disease
* Vaccination does not prevent the disease 100% (more mild)
When are patients non infectious for Varicella (chickenpox)
Contagious from 1-2 days prior to onset, until ALL the lesions have crusted
How is Small Pox different than Chicken Pox?
- Highly contagious/fatal infection due to variola virus
- Abrupt onset of prodrome fever, malaise, & other symptoms about 10-14
days after respiratory exposure & lasting 1-4 days (patients often bedridden) - Rash follows prodrome ~1-4 days later, with lesions on mucous
membranes of mouth, tongue, & oropharynx (enanthem) appearing first
rash follows eruptive phase about 1-4 days later. - Skin lesions (exanthem) begin on face & appear on all parts of body within
24-48 hours (NO CROPS), lesion crusting complete in 2-3 wks
Rubeola (Measles) pathophysiology and transmission
- Direct viral infection of the epidermis
- Highly contagious
- Person-to-person via respiratory droplets
Rubeola (Measles) survives up to ____ hours on surfaces or in air spaces
2
Incubation period of Rubeola (Measles) =
12 days to onset of fever, & 14 until rash
Rubeola (Measles) presentation
- ↑fever, dry cough, rhinitis, conjunctivitis (clear discharge), distinctive rash
- Koplik spots are pathognomonic
- White dots on red base, buccal mucosa 1-2 days prior to onset of rash
- Rash is brick-red (dusky), raised macules & papules (morbilliform) & begins
at hairline & spreads to involve trunk, arms, legs, & eventually hands & feet
Rubeola (Measles) management
- Supportive care
- No specific antiviral therapy available
- Vitamin A 200,000 units orally once daily for 2 days may ↓ mortality in
hospitalized children with measles (mechanism unknown)
Erythema Infectiosum, Fifth Disease pathophysiology
- Multiple synonyms:
- Erythema infectiosum, “slapped cheek” disease
- Caused by Parvovirus B19 (endemic worldwide)
Erythema Infectiosum, Fifth Disease presentation
- Illness usually mild & may include low-grade fever, URI symptoms, & mild malaise-or asymptomatic
- Rash is flat, lacy, reticular, often pruritic, located on cheeks, trunk, & extremities
- Children are NOT contagious once the rash appears
Erythema Infectiosum, Fifth Disease management
- Supportive & symptomatic care
- In pregnancy, infection can lead to hydrops fetalis caused by severe fetal
anemia or fetal loss - Consider perinatology consult
Roseola presentation
– Abrupt onset of high fever which lasts for 3-7 days (occasionally
respiratory or GI symptoms are present)
– Resolution of fever is followed by development of erythematous
maculopapular rash that spontaneously resolves
– May appear 1-2 days after fever breaks
Roseola pathophysiology
- Typically results from HHV-6 (aka “6th disease”)
- Acute, benign infection
- Very common, especially in children <3 years old
- Seroprevalence in most countries approaches 100% in children over 2 years of age
Roseola management
- Supportive & symptomatic care
- Antipyretics & hydration
- Antivirals are not recommended
for an immunocompetent patients
Oral Candidiasis (Thrush)
- Most common fungal infection in
humans - Mainly affects infants or older
children in debilitated state - May occur in patients taking broad
spectrum antibiotics or steroids
(including patients taking inhaled
steroids)
Oral Candidiasis (Thrush) presentation/exam
- Symptoms: mouth soreness, refusal of feedings
- Physical exam: white curd-like plaques predominantly on buccal mucosa
- Lesions easily bleed & CAN be scraped away
Oral Candidiasis (Thrush) Management
- Treatment: Fluconazole or Nystatin oral suspension
- Remove plaques prior with moistened cotton-tipped applicator or piece
of gauze
Diaper Rash types
– Irritant diaper dermatitis
– Candidal diaper dermatitis
Candidiasis - Diaper dermatitis presentation
marginal scaling,
& “satellite pustules” in the area covered
by a diaper in an infant.
Diaper Rash management + ABCDE
Air (allow diaper-free time)
Barrier (creams/pastes)
Cleansing (only after stools)
Diapering (frequent Δ’s)
Education
- Topical medications
- Irritant diaper dermatitis
complicated by secondary
bacterial infection - Fungal diaper dermatitis
suspected to be due to
Candida albicans
Pityriasis Rosea
- Common, acute, self-limited papulosquamous skin rash of childhood
- First sign of disease is often a “herald patch” which may resemble
psoriasis or tinea corporis - Following the herald patch (1-2 weeks later) multiple, similar but
smaller scaling lesions distributed along cleavage (Langer) lines of
trunk, neck, & proximal limbs
Pityriasis Rosea presentation
- Lesions are often oval with long axis paralleling the lines of skin stress
(results in “pine tree appearance”) - Lesions resolve in 6-10 weeks & may be pruritic
- “This rash appeared but it hasn’t gone away”
Verruca (Warts)
- HPV infection of epithelial tissues
- Causes benign cutaneous papilloma
- Different subtypes of HPV can affect different areas
- Most commonly occur in children & young adults
Verruca Vulgaris features & morphologies
- Spontaneous remission in ~2/3 of cases within 2 years
- Several different morphologies:
- Common (flesh-colored or grayish white with a papillate,
hyperkeratotic surface) - Flat
- Mosaic (a confluent presentation)
- Filiform (threadlike)
Verruca Vulgaris presentation
- Can present as either a single lesion or coalesced together
- Paring down a wart will cause pinpoint bleeding
- Penetration to the dermis
Verruca treatment
- Observation
- Imiquimod (Aldara®)
- Occlusion
- Liquid Nitrogen
- Salicylic acid
- Cantharadin (black blister beetle)
If the lesion starts small & grows then it is likely _____
fungal
Most fungal infections DO NOT ____
fluoresce under Wood’s lamp
Superficial Fungal Infections
- Dermatophyte Infections
- Tinea Versicolor
- Intertriginous candida
Superficial Fungal Infections presentation
- Presentation
- scaly, erythematous lesions
with defined margins. - Candidal infections tend to
occur in creases with satellite
lesions & may or may not be
scaly
Dermatophyte infections
- Tinea is the word to describe a
dermatophyte infection
– Tinea cruris (jock itch): groin &
inner thighs
– Tinea pedis (athlete’s foot): feet
– Tinea corporis (ringworm): body
– Tinea faciei: face
– Tinea capitus: on the scalp
(mostly affects children)
Dermatophyte infections characteristics
- Annular, scaly, erythematous
plaque(s) with central clearing,
may be itchy
Tinea capitis
with kerion
* Inflammatory, pus -filled sore that
sometimes oozes. Immune system
overreaction to a fungal infection
Dermatophyte infections management
– Antifungal medications
* Most topical agents work well
* Azoles [clotrimazole (Lotrimin®)] tend to have better activity against candidal infections than Allylamines (terbinafine)
* Polyenes (Nystatin®)
* Primarily anticandidal
* Azoles (E.g. Diflucan®)
* Better for systemic infections
* Allylamines (eg Lamisil AT®)
* Better against dermatophyte infections (tinea) than Azoles
Tinea Versicolor
- Common superficial infection caused by Malassezia species
(saprophytic yeast, part of the normal skin flora)
A number of factors may trigger Tinea Versicolor conversion to the hyphal form that is associated with clinical disease, including:
– Hot & humid weather
– Use of oils
– Hyperhidrosis
– Immunosuppression
Tinea Versicolor Presentation
- Brown, pink, red, or white scaly patches or slightly elevated plaques on the chest, back & shoulders
- Most patients do NOT have pruritus (some may have mild itching)
- During the summer, may present as areas of hypopigmentation
& be mistaken for vitiligo
The key with differentiating tinea versicolor from vitiligo
scratching the macular region will elicit scaling in tinea versicolor
Tinea Versicolor Diagnosis
- Fluorescence with Wood’s light
- Scraping a scaly lesion & performing KOH prep reveals short hyphae & spores
Tinea Versicolor Treatment
- 2.5% selenium sulfide (Selsun)
- Pyrithione zinc shampoo (Head & Shoulders)
- Apply treatment with rough washcloth, leave for 10 minutes & then rinse off, qd x 1 week
- Ketoconozole shampoo also very effective
- Depigmentation may persist until going back into the sun
- Often until the next season
Oral antifungals considered in patients who are immunocompromised
or who have very widespread disease with ____
Tinea Versicolor
Atopic Dermatitis (Eczema) - Pathophysiology
The “itch that rashes”
* Pathogenesis incompletely understood
* Genetic predisposition fillagrin gene (FLG ) mutation
* Environmental irritants
* Humidity, dress & hydration status of the child’s skin, that is, too many baths, drying soaps, exposure to cold air
The “Atopic Triad”
Asthma
Hayfever
Eczema
Atopic Dermatitis (Eczema) presentation
– Intense itching → scratching, eczematous change, &
lichenification
– Children: commonly on the cheeks, but can be in neck, wrists,
behind the ears, & antecubital/popliteal flexure areas
A typical localization of atopic dermatitis in children is ___
the region around the mouth.
In this child, there is lichenification & fissuring & crusting.
Atopic Dermatitis (Eczema) Treatment
- Eliminate possible triggers or irritants
- Hydration, hydration, hydration!
- Emollients (moisturizers) should be an integral part of applied
soon after bathing to improve skin hydration in patients with atopic dermatitis - Topical steroids: -Ointments > creams > lotions
Topical steroid side effects in treating Atopic Dermatitis (Eczema)
- Atrophy, telangiectasia, purpura, striae, & acneiform eruption
- ↑potency = ↑side effects
- Especially high potency steroids & prolonged use
Molluscum Contagiosum epidemiology
- Common
- Peak incidence in children
aged 2-5 years - Sexually active young adults
- Immunocompromised
Transmitted by direct contact
Molluscum Contagiosum Clinical presentation
- Firm, flesh-colored or pearly skin
papules of 1 mm to 1 cm size - Often umbilicated
- Occur over several weeks
- Average 11-20 lesions
Molluscum Contagiosum diagnosis
- Clinical
- Biopsy can confirm
Molluscum Contagiosum treatment
- Not always necessary
- Lesions generally resolve within 6-9 months
- Curettage
- Cryotherapy
- Cantharidin
- Podophyllotoxin 0.5% topical BID x 3 days
- Immiquimod cream 3x/week
Complications of Molluscum Contagiosum
- Bleeding
- Inflammation (sign the lesion is recognized by the immune
system) - Eczematous dermatitis around lesions 10-30%
Hand-Foot-and-Mouth Disease
- Acute viral illness
- Coxsackievirus A
- Epidemics generally occur in the
summer to early fall - Affects children < 10 years
Hand-Foot-and-Mouth Disease Presentation
- Incubation period is approx. 1 week
- Sore mouth and/or throat Malaise
- Skin lesions
- Fever may be present for 24-48 hours
Hand-Foot-and-Mouth Disease exam
- Macular lesions appear on the buccal mucosa, tongue, and/or hard palate
- Rapidly progress to vesicles that erode and become surrounded by an
erythematous halo - Skin lesions develop in 75% of patients
- Hands, feet, buttocks, and genitalia
Hand-Foot-and-Mouth Disease Diagnosis
- Dx based on clinical findings
- Vesicle swabs, prn
Hand-Foot-and-Mouth Disease treatment
- Supportive
- Hydration
- Rest
- Antipyretics
- Magic mouthwash
Kawasaki Disease
acute, self-limited, systemic vasculitis of unknown etiology
* Likely infectious
* Consider Kawasaki disease in children with ≥ 5 days of high fever &
any of 5 typical findings:
Kawasaki Disease Presentation
- Asymmetric anterior cervical adenopathy
- Bulbar conjunctivitis
- Changes in lips & oral cavity
* strawberry tongue, red cracked lips - Hand & foot redness & swelling, or periungual peeling
- Morbilliform rash
Kawasaki Disease treatment
- Goal of treatment for Kawasaki disease is to
prevent coronary artery disease & relieve symptoms
