Pediatric Visual Diagnosis Pediatric Visual Diagnosis Ilana Greenstone MD Division of Emergency Medicine Montreal Children’s Hospital McGill University Health Center
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