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Common Pediatric Skin and Soft Tissue Conditions Sirous Partovi, M.D.

Erythema Toxicum Neonatorum Impressive title - harmless skin condition Erythematous macule with a central tiny papule, seen anywhere - except the palms and soles. The lesions are packed with eosinophils, and there may be accompanying eosinophilia in the blood count. The cause is unknown, and no treatment is required as the rash disappears after 1-2 weeks.

Miliaria Prickly heat, sweat rash Many red macules with central papules, vesicles or pustules are present. These may be on the trunk, diaper area, head or neck.

Subcutaneous Fat Necrosis Self limited, benign condition Sharply demarcated reddish to violaceous plaques or nodules Etiology uncertain Onset first few days- weeks of life Cheeks, back, buttocks, arms, and thighs

Infantile Atopic Dermatitis Cause is unknown Red, itchy papules and plaques that ooze and crust Sites of Predilection Face in the young Extensor surfaces of the arms and legs 8-10 mo. Antecubital and popliteal fossa , neck, face in older

Differential Diagnosis- Atopic Dermatitis Seborrheic dermatitis Contact dermatitis Nummular eczema Psoriasis Scabies

Eczema- Treatment Avoidance or elimination of predisposing factors Hydration and lubrication of dry skin Anti-pruritic agents Topical steroids

Seborrheic Dermatitis Common, generally self-limiting Its cause remains ill-understood There is a genetic predisposition Most frequent between the ages of 1 to 6 mo. Greasy, salmon-colored scaling eruption Hair-bearing and intertriginous areas The rash causes no discomfort or itching

Seborrheic Dermatitis-Treatment Anti-seborrheic shampoo Topical steroids

Pityriasis Rosea Mild inflammatory exanthem of unknown cause, maybe viral Benign, self limited disorder Occasionally there are prodromal symptoms including malaise, headache, sore throat, fatigue, and arthralgia. Herald patch- pink in color and scaly-mimicking tinea corporis

Candidal Dermatitis Starts off in the deep flexures which show widespread erythema on the buttocks-beefy red color There are also raised edge, sharp marginization and white scale at the border of lesions, with pinpoint pustulo-vesicular satellite lesions

Seborrheic Dermatitis Salmon-colored greasy lesions with yellowish scale and predilection for intertriginous areas Involvement of the scalp, face, neck, and post auricular and flexural areas

Irritant Dermatitis Rash confined to the convex surfaces of the buttocks,perineal area, lower abdomen, and proximal thighs, sparing the intertriginous creases Excessive heat, moisture, and sweat retention Harsh soaps, detergents, and topical medications

Smallpox- Variola Fatality 40 % First invades upper respiratory tract From lymph nodes it spreads via hematogenous spread Chills, fever, headache, delirium, SZ Face to upper arms and trunk, and finally to lower legs

Chickenpox-Varicella Herpes virus varicellae Incubation period 10-21 days Fever, malaise, cough, irritability, pruritus Papules  vesicles  crusting Spreads centripetally

Varicella Complications: Bacterial superinfection CNS involvement Pneumonia Hepatitis, arthritis Reye’s syndrome VZIG

Varicella – Treatment Oral acyclovir- indications Healthy nonpregnant teenagers and adults Children > 1 yr with chronic cutaneous or pulmonary conditions Patients on chronic salicylate therapy Patients receiving short or intermittent courses of aerosolized corticosteroids Dose: 80 mg/kg/day in four divided doses for 5 days

Varicella – Post exposure VZIG (1 vial/5 kg IM) : Pts on high dose steroids Immunocompromised without a history of CP Pregnant women Newborns exposed 5 days prior to birth and 2 days after delivery Neonates born to nonimmune mothers Hospitalized premature infants < 28 weeks’ gestation

Measles Rubeola- paramyxovirus Occurs in epidemics Incubation 8-12 days Fever, lethargy, Cough, coryza, conjunctivitis with clear discharge and photophobia Koplik spots Rash begins on the face and spreads to trunk and extremities

Measles – Post Exposure Immunoglobulin therapy- indications All susceptible contacts Infants 5 mo. To 1 year of age Immunocompromised Pregnant women <5 mo. If mother without immunity Live measles virus vaccine- contraindication Immunocompromised- excluding HIV Pregnancy Allergy to eggs, or neomycin

Rubella German Measles Epidemic nature Winter-spring Prodrome Face  neck  trunk Lymphadenopathy Serologic testing

Hand-Foot-Mouth Disease Enteroviruses coxsackieviruses A and B echoviruses Vesicular lesions, may be petechial Associated with aseptic meningitis, myocarditis

Erythema Infectiosum Fifth disease Mildly contagious, parvovirus B-19 Pre-school and young school-age children Prodrome: mild malaise Rash: “slapped cheek”, circumoral pallor, peripheral mild macular distribution Complication

Exanthem Subitum Roseola Infantum Children 6-19 months Abrupt onset of high fever Febrile seizures Rash develops after fever dissipates Mainly on trunk

Infectious Mononucleosis Acute, self limited illness Epstein-Barr virus Oral transmission – incubation 30-50 days Fever, fatigue, pharyngitis, LA, splenomegaly, atypical lymphocytosis Exanthem is seen in 10-15% Erythematous, maculopapular, morbilliform, scarlatiniform, urticarial, hemorrhagic, or even nodular

Impetigo Superficial infection of the dermis Two types: Impetigo contagiosa Bullous impetigo Etiology Group A ß hemolytic streptococcus Coagulase positive S. aureus Treatment : Keflex, erythromycin, Bactroban

Scarlet Fever Toxin producing strain of group A  -hemolytic streptococcus Strep pharyngitis with systemic complaints Rash from neck to trunk to extremities Sandpaper feel, erythema, warmth White and red strawberry tongue Petechiae in linear form Complications Treatment

Staphylococcal Scalded-Skin Syndrome Generally in less than 5 years of age Induced by exotoxin produced by staphylococci Fever, papular erythematous rash starting around mouth- not involving oral mucosa Positive Nikolsky’s sign Diagnosis: Tzanck test, bacterial culture Treatment Complications

Meningococcemia Usually sudden onset of fever, chills, myalgia, and arthralgia Rash is macular, nonpruritic, erythematous lesions Petechial rash develops in 75% of cases Neisseria meningitides Fever, rash, hypotension, shock, DIC Treatment: PCN G

Differential Diagnosis Gonococcemia HSP Typhoid fever Rickettsial disease Erythema multiforme Purpura fulminans

Rocky Mountain Spotted Fever Most common rickettsial infection in US Abrupt fever, headache, and myalgia Rash from extremities towards trunk Macules  petechiae Treatment Tetracycline Doxycycline Chloramphenicol

Cellulitis Most common organisms: S. aureus S. pyogenes H. influenza type B (HIB) Most common sites? CBC, x-ray?

Cellulitis- Treatment IV antibiotics in: Immunocompromised Ill appearing Suspected bacteremia <6 mo. Of age WBC> 15K High fever Rapidly progressing

Periorbital- Orbital Cellulitis S. aureus, S. pneumoniae , and HIB CBC, blood culture, CT LP? IV antibiotics Admit

Henoch-Schnlein Purpura No clear etiologic agent, often post viral 2-10 years of age Palpable purpura over the buttocks and LE Transient migratory arthritis Renal and GI involvement

Kawasaki Syndrome Unknown etiology Peak incidence 18-24 months Clinical findings: Fever for at least five days Conjunctivitis Polymorphous rash Oral cavity changes Cervical adenopathy

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