pediatric visual diagnosis

Pediatric Visual DiagnosisPediatric Visual DiagnosisIlana Greenstone MD

Division of Emergency Medicine

Montreal Children’s 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 DermatitisTreatment

• 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

ScabiesTreatment

• 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 corporisRingworm

• 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 DiseaseDiagnostic 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 can’t be explained by other disease

Kawasaki DiseaseLab Features

WBC ESR, positive CRP

• Anemia

• Mild transaminases albumin

• Sterile pyuria, aseptic meningitis platelets by day 10-14

Kawasaki DiseaseDifferential Diagnosis

• Measles• Scarlet fever• Drug reactions• Viral exanthems• Toxic Shock

Syndrome

• Stevens-Johnson Syndrome

• Systemic Onset Juvenile Rheumatoid Arthritis

• Staph scalded skin syndrome

Kawasaki DiseaseDifficulties 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 DiseaseTreatment

• Admit to monitor cardiac function

• Complete cardiac evaluation – CXR, EKG, echo

• IV Ig

• ASA

Kawasaki DiseaseTreatment

• 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 VirusHand-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 InfectiosumFifth 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 1º 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 PurpuraClinical 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

HSPIndications 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