Pediatric Rashes

Question 1

Name 5 bioterrorism agents that may have skin manifestations

Answer 1

Smallpox
Anthrax
Tularemia
Plague
Viral hemorrhagic fever

Smallpox:
Maculopapular rash on face, forearms, MM that becomes vesicular/pustular in 48h

Anthrax:
Painless pruiritic papule on skin that develops into a painless ulcerated black eschar within days

Tularemia:
Painful maculopapular lesion that ulcerates, associated with painful inflamed regional lymph nodes

Plague:
Acutely swollen lymph nodes called buboes

Viral hemorrhagic fever:
Maculopapular rash on trunk following by mucosal bleeding

Question 2

What are the skin findings associated with syphilis?

Answer 2

Chancre
Rash
Condylomata lata
Gumma

Chancre (painless ulcer of skin and MM at site of inoculation)
Rash (maculopapular rash of secondary syphilis - palms/soles of hands)
Condylomata lata (cauliflower appearing warts on penis, labia and rectum)
Gumma (painless pink-dusky red nodules of various sizes that may necrose and ulcerate)

Question 3

Describe perianal streptococcal dermatitis

Answer 3

6 mo to 10 years
Sharply circumscribed superficial perianal erythema
Bright red with wet surface OR dry and pink
No fever

Question 4

What’s the diagnosis of chronic eczema and a painful vesicular eruption?

Answer 4

Eczema herpeticum
Herpes simplex virus
Can be complicated by a secondary bacterial infection
Viremia can progress to meningitis and encephalitis
May need to treat with Acyclovir IV for rapidly progressive or super sick kids

Question 5

What are the features of measles?

Answer 5

Fever
Cough
Coryza
Conjunctivitis
Erythematous maculopapular rash that begins on the forehead and behind the ears, spreading to the face, neck, torso, and extremities
Koplik spots - bright red punctae with central white flecks on the buccal mucosa near the 2nd molars (pathognomonic)

Question 6

Differentiate between EM, SJS, TEN

Erythema Multiforme
Stevens-Johnson syndrome
Toxic epidermal necrolysis

Answer 6

EM
Erythematous maculopapular rash - target lesions that coalesce into an annular or serpiginous border
Resolves in 2 weeks

SJS
Severe drug eruption
Febrile erosive stomatitis
Ocular involvement
Diffuse rash or discrete dark red macules
Sometimes necrotic center
<10% BSA

TEN
Severe drug eruption
Extensive loss of epidermis due to necrosis
Leaves skin looking scalded
>30% BSA

Question 7

How does the rash of Rocky Mountain spotted fever change over time?

Answer 7

Starts as an erythematous macular rash –> becomes papular and frequently petechial
First appears on the wrist/ankles –> spreads centrally within hours to involve the proximal extremities and trunk and palms/soles

Question 8

Describe phytophotodermatitis

Answer 8

Toxic photoreaction
When exposed to psoralen (photosensitizing agent in plants, perfumes, grasses, fruits and veggies - celery, limes, parsley) and then immediately to sunlight
Usually appears as hyperpigmentation

Question 9

Describe pityriasis rosea

Answer 9

Begins with a large solitary oval lesion (herald patch) - on trunk or upper thighs
Followed by eruption of smaller, oval, slightly raised papules that are pink-brown and have peripheral scales
Christmas tree pattern on trunk
Spares the face, scalp and distal extremities
Eruptions usually last 4-8 weeks

Question 10

Differentiate HSP (Henoch Schonlein Purpura) from Purpura Fulminans

Answer 10

HSP
Distribution usually limited to extremities (lower legs/buttocks, sometimes upper extremities)
Infants sometimes have facial involvement
Associated Sx: Arthralgias, abdo pain, hematuria
Otherwise kids look well
Normal platelets and coags

PURPURA FULMINANS
Widespread purpura
Associated Sx: lethargy, hypoventilation, shock
Child appears ill and can be toxic
Thrombocytopenia
Abnormal coags

Question 11

Name 5 skin manifestations of Kawasaki

Answer 11

1) Dry, cracked erythematous lips
2) Erythematous polymorphic truncal rash - morbilliform or scarlinatiform
3) Red, swollen hands and feet
4) Peeling nails and fingers
5) Desquamating perineal rash

Question 12

Name 4 skin findings mistaken for child abuse

Answer 12

Lichens sclerosis
Mongolian spots
Coining
Accidental ecchymoses

Lichens sclerosis - indurated and shiny atrophic plaques found in vulvar and perinanal areas
Mongolian spots - hypermigmentation over the sacrum and back
Coining - asian remedy to rid body of “bad winds”
Accidental ecchymoses - normal childhood bruises over bony prominences (shins, knees, forearms, elbows, forehead, chins)

Question 13

Name the cutaneous manifestations of disseminated gonococcemia

Answer 13

Small macules that progress to papules on the extremities and over involved joints
May develop a vesicle and grey umbilicated center

Question 14

How does poison ivy spread

Answer 14

Only through contact with the sap

Not from person to person

Question 15

How do you treat poison ivy

Answer 15

Supportive care
Bland creams - glaxal base, calamine lotion
Baths
Cool compresses
Oral antihistamines for itch
Steroids only for severe cases

Topical steroids and antihistamines have minimal effect

Question 16

Describe a pyogenic granuloma

Answer 16

Rapidly growing vascular proliferation
Develops in the site of an obvious or unnoticed trauma
Not infectious
Can have spontaneous bleeding - control with silver nitrate sticks
Ultimate treatment - electrodessication and curretage

Question 17

Differentiate between transient pustular melanosis and erythema toxicum neonatorum

Answer 17

TRANSIENT PUSTULAR MELANOSIS
Benign newborn rash
Superficial vesiculopustular lesions
Present at birth
Lesions rupture easily with the first bath - leaves fine white scales and brown hyperpigmented macules
Lesions fade in several weeks to months

ERYTHEMA TOXICUM NEONATORUM
Benign newborn rash
Appears during the first 3-4 days of life (up to day 10)
Blotchy erythema –> develops into pale yellow or white papules/pustules
Individual lesions last 2 days

Question 18

How do you treat herpetic whitlow?

Answer 18

Single or mutliple vesicles localized to distal fingers/toes
Avoid I&D
Local care and PO acyclovir if it involves herpetic gingivostomatitis

Question 19

What condition is associated with recurrent pustules on the feet of infants?

Answer 19

Infantile acropustulosis
7-10 day episodes of pruiritic pustules and papulovesicles on the hands and feet
Usually in infants 2-10 months - resolves at 2-3 years
Tx with mild-mod potency topical steroids

Question 20

What is the diagnosis for a rash of diffuse papular, scaly and fissuring eruptions that does not respond to anti-inflammatory or anti-fungal agents?

Answer 20

Histiocytosis X

Proliferation of Langerhan’s histiocytes in the skin and other organ systems
Consider a biopsy in difficult to treat diaper rashes

Question 21

What is the term for when skin can be rubbed off with minimal trauma?

Answer 21

Nicholsky’s sign

Seen in blistering epidermal diseases - scalded skin, pemphigus vulgaris, TEN

Question 22

How long do you isolate kids with Parvovirus B19 (5th disease or erythema infectiousum) - slapped cheek and lacelike rash on arms and legs

Answer 22

No isolation

By the time the rash becomes clinically obvious the infectious period is over
Rash resolves in 3-5 days

Question 23

Differentiate between granuloma annulare and tinea corpis

Answer 23

Both have:
Circular plaques consisting of a ring of papules around a depressed center

GRANULOMA ANNULARE
Non-scaly
Dorsal surface of hands and feet
Self-resolve in months to a year

TINEA CORPIS
Scaly
Multiple lesions 
All over the body
Superficial fungal infection

Question 24

Describe Roseola

Answer 24

Acute febrile illness 
Affects young kids 6 - 36 months
Caused by human herpes virus 6 and 7
3 or more days high fever
Fever goes away
Rash develops - erythematous, morbilliform rash with discrete rose-pink macules 
Trunk to extremities, neck and face

Question 25

List the findings of Gianotti-Crosti syndrome

Answer 25

Self-limiting
Symmetrical erythematous papules
Extremities, cheeks and buttocks
Rash may last 2-8 weeks
Can be recurrent
Associated with viral infection - EBV, CMV, coxsackie

AKA papular acrodermatitis

Question 26

Which organisms cause bullous and and nonbullous impetigo?

Answer 26

BULLOUS - toxin producing strains of Staph aureus

NON-bullous - GAS (Grp A Streptococcus)

Question 27

What are the dermal manifestations of zinc deficiency?

Answer 27

Acrodermatitis enteropathica
Erythema, crusting and fissuring of the perioral skin and cheeks
Diffusely erythematous diaper rash
Psoriasiform lesions on the anus and buttocks and feet

Tx with dietary Zinc supplements - dramatic improvement

Question 28

Compare and contrast smallpox and chickenpox

Answer 28

SMALLPOX
Presn: Febrile with systemic symptoms for several days prior to the rash
Severity: Very ill from the start
Lesions: Hard circumscribed pustules
Distribution: face and distal extremities, involving palms and soles
Lesion development: Slow, with all lesions at the same stage of development

CHICKENPOX
Presn: Mild fever with minimal Sx for 1-2 days prior to rash
Severity: Not severely ill unless complications develop
Lesions: vesicles on erythematous base
Distribution: face and trunk, with no involvement of the palms or soles
Lesion development: rapid, with lesions at different stages

Question 29

Describe the name of the skin finding with lyme disease

Answer 29

Erythema chronicum migrans
Develops 4-20 days after a tick bite
1st sign may be a red papule from the tick bite
Then an annular ring with a flat border grows with a white central clearing
Some develop multiple annular rings

Question 30

What is the skin finding following a bite from a brown recluse spider?

Answer 30

Painful hemorrhagic blister

Over several days a dry gangrenous eschar develops

Question 31

Define morbilliform

Answer 31

“Measles-like”
Eruptions that are generalized, discrete red to pink macules
Seen in several viral infections - rubella, enterovirus, adenovirus, roseola, parvovirus, EBV

Question 32

What are the diagnostic criteria for neurofibromatosis

Answer 32

Type 1:

6 or more cafe au lait spots > 5mm in diameter (prepubertal kids) or >15mm diameter (older kids)

Question 33

What skin features are present in kids with scarlet fever?

Answer 33

Flushed face with perioral pallor
Diffuse, blanching, erythematous rash that has a sandpaper consistency with accentuation in the axilla and groin
Pastia’s lines in the flexural surface of the elbow
Desquamation as the acute phase of the illness resolves

Question 34

Distinguish irritant contact diaper rash from candidal diaper dermatitis

Answer 34

DIAPER RASH
Due to contact of skin with urine/feces in moist closed environment
Red papules or patches in diaper exposed areas

CANDIDAL DIAPER DERMATITIS
Due to gut flora Candida albicans
Perianal erythema and maceration spreading to produce moist, bright red, confluent plaques in the diaper area, esp. interriginous folds
Satellite lesions are common

Question 35

How long does acne neonatorum last?

Answer 35

Start at 3 weeks of age
Last for 4 months
Most resolve by 6 months

Question 36

Name 5 cutaneous manifestations of lupus

Answer 36

1) Erythematous maculopapular butterfly facial rash
2) Discoid lesions - chronic persistent skin changes that progress to scarring and pigmentary changes
3) Photosensitive rash - Transient annular papulosquamous lesions in sun exposed areas
4) Erythema on the palms and pulps of fingers and diffuse erythematous scaly macules on the dorsum of the fingers
5) Raynaud’s - pallor and cyanosis of the digits when exposed to the cold

Question 37

What are the two main types of epidermolysis bullosa (EB)?

Answer 37

Inherited condition of blisters after mild trauma
2 categories:
1) Nonscarring types (EB simplex and junctional type EB)
2) Scarring and dystrophic forms of EB

Question 38

Name 5 signs/Sx of scabies in infants

Answer 38

1) Irritability
2) Eczematous lesions
3) Characteristic burrows on the hands and feet
4) Axillae, groin, palm, and sole involvement
5) Dermatitis - trunk, face, neck, scalp