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28 Clinical Rounds P E D I AT R I C N E W S • N ove m b e r 2 0 0 8

Other Conditions May Mimic Diaper Dermatitis


BY ROBERT FINN want you to use a special collection tube. job is to recognize it and refer the child to ognize it early, you can save a life,” Dr.
Southeast Bureau Langerhans cell histiocytosis (LCH) is the a pediatric oncologist. Friedlander said. “You can be the hero.”
next zebra. Thought by many to be a clon- The third zebra goes by the unwieldy The first hint often is a red perianal rash.
S A N F R A N C I S C O — Don’t ignore a al proliferative disorder, LCH has a wide name “recurrent toxin-mediated perineal Start worrying if you learn that the child has
seemingly simple case of diaper dermati- variability in presentation and prognosis. erythema.” Dr. Friedlander described one had a high fever for 4 or 5 days, has a straw-
tis, because this near-ubiquitous condition Dr. Friedlander described one case in little girl with a recurrent red, scaly erup- berry tongue, and is unusually crabby.
can mask something much more serious. which the baby had rashes in his inter- tion in her groin area that never respond- The child with Kawasaki disease will of-
In fact, there are at least four “zebras” triginous areas. Her first thought was Can- ed to the typical diaper dermatitis treat- ten have conjunctivitis but of a specific
whose hoofbeats may be sounding in dia- dida and, indeed, antifungals seemed to ments. The mother mentioned that the type. The eye will not be purulent, and
per dermatitis, Dr. Sheila Fallon Friedlan- help a little bit. Adding topical steroids eruption often was accompanied by fever there won’t be an exudate. And if you look
der said at a meeting sponsored by Skin helped a little bit more, but the rashes nev- and a red tongue. closely, you may see that the conjunctivi-
Disease Education Foundation (SDEF). er fully cleared up. On top of that, the “Well, certainly when we see a red tis is sparing the limbus—the area where
That’s why diaper dermatitis should be mother was noticing some small pink tongue, we think of a toxin-mediated dis- the cornea meets the sclera. The child may
treated. Failure to respond to treatment papules elsewhere on the baby’s body. order,” she said. “We think of strep throat, have cervical lymphadenopathy, and the
may be your first hint that something un- Upon questioning, the mother noted we think of staph, right? [We have to] rash can be variable. “It’s pretty much a
usual is happening. that the baby wasn’t growing very well make sure that [there’s] nothing more se- polymorphous eruption, but [it doesn’t]
Zinc deficiency is the first of these ze- and also was experiencing some vomiting rious going on. If the patient is febrile and blister,” she said.
bras. The baby will present with dermati- and diarrhea. When Dr. Friedlander did a looks sick, you need to get blood culture; Two lab values can be especially note-
tis in an acral distribution: hands, feet, face, physical exam, she noticed that the baby’s you need to get a [sedimentation] rate. worthy in Kawasaki disease. The C-reactive
and genitals. The parent will often men- liver was enlarged. (Other babies with And, certainly, get cultures of the pharynx, protein level will be 3 mg/dL or higher, and
tion that the baby has diarrhea and is not LCH have enlarged spleens.) And those the perianal area, and lesional skin.” the sedimentation rate will be 40 mm/hr
growing as well as she should. pink papules? Those were purpuric In a recently published case series, all 11 or more. You also should order labs to rule
If you suspect a zinc deficiency, look at al- papules of petechiae. children had positive strep cultures, and out pyuria, meningitis, hepatitis, hypoal-
kaline phosphatase while you’re waiting “When you see that, you need to see one was positive for Staphylococcus aureus buminemia, and thrombocytosis.
for zinc levels to come back from the lab. A Red Alert,” Dr. Friedlander said. “You as well. Four of the children had erythe- Dr. Friedlander disclosed serving as a
low alkaline phosphatase level should make have scaly papules; hemorrhagic, pur- ma and desquamation of the palms and consultant and a researcher for Barrier
you suspicious of zinc, said Dr. Friedlander puric, petechial lesions; and paronychial in- soles, and seven had strawberry tongues Therapeutics Inc., which makes a pre-
of the University of California, San Diego. volvement. This is a devastating zebra (Arch. Dermatol. 2008;144:239-43). scription ointment for diaper rash.
Remember to check with your lab about sometimes.” LCH sometimes looks like Of all the zebras, Kawasaki disease is the SDEF and this news organization are
their procedures for zinc analysis. They’ll seborrheic dermatitis, but the physician’s one you least want to miss. “If you rec- wholly owned subsidiaries of Elsevier. ■

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