Pediatric Visual Diagnosis

Ilana Greenstone MD
Division of Emergency Medicine Montreal Childrens Hospital McGill University Health Center

Objectives
Recognize common pediatric dermatologic conditions Expand differential diagnosis Review treatment plans Identify skin manifestations of systemic disease

Terminology
Macules, Papules, Nodules Patches and Plaques Vesicles, Pustules, Bullae Colour Erosions when bullae rupture Ulcerations and excoriations

Atopic Dermatitis
3-5% of children 6 mo to 10 yr Described in 1935 Ill-defined, red, pruritic, papules/plaques Diaper area spared Acute: erythema, scaly, vesicles, crusts Chronic: scaly, lichenified, pigment changes

Atopic Dermatitis
Hints to diagnosis Generalized dry skin Accentuation of skin markings on palms and soles Dennie-Morgan lines Fissures at base of earlobe Allergic history

Atopic Dermatitis
Treatment
Moisturize Baths only Anti-histamine Topical steroids to red and rough areas
Prevex HC Desacort

Immune modulators

Superinfected Eczema
Red and crusty Usually S. aureus Cephalexin 40 mg/kg/day divided TID for 10 days More potent topical steroid Topical antibiotic Fucidin Anti-histamine Refer to Dermatology

Scabies
Intense pruritus Diffuse, papular rash
Between fingers, flexor aspects of wrists, anterior axillary folds, waist, navel

May be vesicular in children < 2 years

Head, neck, palms, soles Hypersensitivity reaction to protein of parasite

Scabies
Treatment
5% permethrin cream for infants, young children, pregnant and nursing mother
Kwellada-P or Nix Cover entire body from neck down Include head and neck for infants Wash after 8-14 hours

Can use Lindane for older children

Tinea corporis
Ringworm
Face, trunk or limbs Pruritic, circular, slightly erythematous Well-demarcated with scaly, vesicular or pustular border Id reaction Mistaken for atopic, seborrheic or contact dermatitis Treament: Terbinafine (Lamisil)

Pityriasis Rosea
Begins with herald patch
Large, isolated oval lesion with central clearing

More lesions 5-10 days later Christmas tree distribution Treatment: anti-histamines

Eczema
Differential Diagnosis
Atopic dermatitis Scabies Tinea corporis Pityriasis rosea

If vesicular, check for HSV1, HSV2, VZV Beware of superinfection Think of immune deficiency if difficult to treat

Urticaria
Transient, well-demarcated wheels Pruritic Part of IgE-mediated hypersensitivity reaction May leave central clearing Triggers are numerous

Kawasaki Disease
Diagnostic Criteria
Fever for 5 or more days Presence of 4 of the following:
1. Bilateral conjunctival injection 2. Changes in the oropharyngeal mucous membranes 3. Changes of the peripheral extremities 4. Rash 5. Cervical adenopathy

Illness cant be explained by other disease

Kawasaki Disease
Lab Features
WBC ESR, positive CRP Anemia Mild transaminases albumin Sterile pyuria, aseptic meningitis platelets by day 10-14

Kawasaki Disease
Differential Diagnosis
Measles Scarlet fever Drug reactions Viral exanthems Toxic Shock Syndrome Stevens-Johnson Syndrome Systemic Onset Juvenile Rheumatoid Arthritis Staph scalded skin syndrome

Kawasaki Disease
Difficulties with Diagnosis
Clinical diagnosis No single test Diagnosis of exclusion Atypical KD
Do not fulfill all criteria More common in < 1 year and > 8 years

Kawasaki Disease
Treatment
Admit to monitor cardiac function Complete cardiac evaluation
CXR, EKG, echo

IV Ig ASA

Kawasaki Disease
Treatment
IV Ig 2 g/kg as single dose
Expect rapid resolution of fever Decrease coronary artery aneurysms from 20% to < 5%

ASA - low dose vs high dose

80-100 mg/kg/day until day 14 3-5 mg/kg/day for 6 weeks

Repeat echocardiogram at 6 weeks

Coxsackie Virus
Hand-Foot-and-Mouth
Painful, shallow, yellow ulcers surrounded by red halos Found on buccal mucosa, tongue, soft palate, uvula and anterior tonsillar pillars Oral lesions without the exanthem = herpangina Exanthem involves palmar, plantar and interdigital surfaces of the hands and feet +/buttocks

Erythema Infectiosum
Fifth Disease Parvovirus B19 Mostly preschool age Recognized by exanthem Contagious before rash Resolution between 3 and 7 days

Roseola
6 to 36 months Human herpesvirus 6 High fever without source and irritability for 3 days Rash develops as fever decreases

Impetigo
Mostly face, extremities, hands and neck Localized unless underlying skin disease Strep or Staph Honey-coloured crust Treatment: topical and systemic antibiotics

Herpes Simplex
Gingivostomatitis most common 1 infection in children
Fever, irritability, cervical nodes Small yellow ulcerations with red halos on mucous membranes

Involvement more diffuse easy to differentiate from herpangina and exudative tonsillitis Treatment: supportive

Herpetic Whitlow
Lesions on thumb usually 2 to autoinoculation Group, thick-walled vesicles on erythematous base Painful Tend to coalesce, ulcerate and then crust May require topical or oral acyclovir

Henoch-Schonlein Purpura
Clinical features
Palpable purpura of extremities Arthralgia or non-migratory arthritis
No permanent deformities Mostly ankles and knees

Abdominal pain
May develop intussusception

Renal involvement
Hematuria, hypertension, renal failure

HSP
Management
Supportive NSAIDs may control the pain and do not increase the risk of bleeding Steroids controversial
Efficacy not proven re: abdo pain No effect on purpura, duration of the illness or the frequency of recurrences Unclear of protective effect on renal disease

HSP Indications for admission

R/O intussusception Severe GI bleed Severe renal disease Need for renal biopsy Hypertension Pulmonary hemorrhage

Acute Hemorrhagic Edema of Infancy

4-24 months Recent URI or antibiotics Non-toxic Resolves in 1-3 weeks small- vessel, leukocytoclastic vasculitis Annular or targetoid pupura and edema on face and extremities

Conclusions
Not all that itches is eczema Treatment is often supportive for viral exanthems Remember rashes as a sign of systemic illness Careful history and physical essential for evaluation of bruises