Download Papules, Purpura, Petechia and Other Pediatric Problems: A

Papules, Purpura, Petechia and
Other Pediatric Problems:
A Review of Peds Derm
David Chaulk
PEM Fellow
April 15th, 2004
Neonatal Nasties…
Erythema Toxicum
Bad name…not toxic
Usually occurs in first days of life
50% of healthy babies
Erythematous macules +/- pustules and
papules
Etiology unknown
No treatment necessary
Erythema Toxicum
Milia
Retention of keratin and sebaceous
material
Usually disappears by 3-4 weeks
No treatment
Milia
Miliaria Rubra
Destruction of epidermal sweat ducts
resulting in erythematous papules, vesicles
or papules
Treat with humidity/cool baths
Subcutaneous Fat Necrosis
Secondary to pressure in utero or during
labour
Occurs during first days or weeks
Circumscribed erythematous or violaceous
plaques
Infrequently associated with hypercalcemia
Subcutaneous Fat Necrosis
Infantile Acropustulosis
As it says…
Pustules (vesicles) on the hands, feet and
dorsal surfaces
Intensely pruritic and recurrent
Occurs between 2-10 mos and resolves 2436 mos
Treated with anithistamines and fluorinated
corticosteroids if severe
Infantile Acropustulosis
Infantile Acne
Closed comedones and inflammatory
papules
May last 1-2 years
Usually family history
Most don’t require treatment
May use topical treatment such as benzoyl
peroxide
Diaper and Candidal Dermatitis
Contact diaper dermatitis is caused by
irritants, soaps detergents etc.
Candida is differentiated by satellite
lesions
– Widespread, pinpoint raised erythematous
lesions with white scales
– GI source and frequently post antibiotics
Diaper and Candidal Dermatitis
Seborrheic Dermatitis and
Cradle Cap
Mainly involves scalp, face, trunk and
intertriginous areas
Greasy, scaly, patch erythema
Unknown etiology
Treatment is hydration, mineral oil,
petroleum, shampoos
Seborrheic Dermatitis and
Cradle Cap
The Rash Relay!
Two teams, limited info. & Spot
Diagnosis
Start with Infectious Stuff…
First one’s easy…or is it?
3 yo girl, second visit to ED in four days.
First time, high fever without clear focus.
No other symptoms.
Now returns with rash and fever has
resolved
What is the diagnosis?
What is the infectious agent?
Roseola Infantum
Macular or maculopapular rash appearing
after defervescence on 3rd or 4th day of
illness
Child usually looks well despite high fever
and it is often associated with febrile
seizure
Human herpes virus 6 (HHV-6)
Another easy one…
It’s spring, you’re in the ED seeing a 6 yo
girl with a rash. Yesterday it was only on
her cheeks now it’s on her arms (extensors)
What is this?
What is the infectious
agent?
Day 4
Extra Credit:
Name two
complications
Day 5
What about
pregnancy
exposures?
Parvovirus B19
 Aka: erythema infectiosum and fifth disease
 Usually affects kids aged 3-12 years
 Most common is spring
 6-14 day incubation period
 Day 1:slapped cheek
 Day 2:lacy, erythematous rash on extensors
 Day 6 fading rash with lacy, marble appearance
Parvovirus B19
Complications:
– Arthritis, aplastic anemia and hemolytic
anemia
Pregnancy
–
–
–
–
50% of women seropositive before pregnancy
Likelihood of transmission if exposed 30-50%
If fetus infected 2-10% rate of loss
Thus risk is actually fairly low
Now for a couple of hard ones…
3 yo girl with high fever, cough, runny
nose, looks unwell. Rash started on face
initially and is now spreading.
Parents are granola types and the child isn’t
immunized
Diagnosis?
Name 1 acute complication, and
one longterm complication
Measles (Rubeola)
Starts with cough, coryza and
conjunctivitis, then Koplik spots and
morbilliform rash
Rash fades after 3-7 days in same order
that it started
Acute complications: OM and pneumomia
Long term: SSPE
Another tough one…
This time a 2 year old unimmunized child,
presents with 3 days history of URT
symptoms. Parents bring him in because
they notice his glands are swollen and he
has a rash
Diagnosis?
How is it different from measles?
What is the presentation of congenital infection?
Rubella
 Generalized maculopapular rash with cervical,
postauricular and occipital LN
 3-5 days of viral prodrome followed by mobile
rash that goes from head to toe in 24h
 May get petechiae on the palate
 Essentially not as sick/ not as high fever as
measles
 These are the blueberry babies
Back to stuff we actually see…
 7 yo child presents in October with vomiting and
diarrhea
 On exam you find…
 Name 2 serious complications
 Hint, they start with M
Coxsackie
 Hand, Foot and Mouth Disease
 Highly contagious and usually occurs in late
summer, fall
 Viral illness precedes rash, start as macules and
evolve into vesicles
 25-65% get lesions on hands and feet
 Usually get lymphadenopathy and may get
dehydration
 Serious but rare complications include
myocarditis and meningoencephalitis
Next…
 7 yo boy with few days of cough and cold, now
has sore throat and rash
 Diagnosis, infectious agent and treatment?
 What is the pathognomonic rash associated with
it?
Scarlet Fever
 Exotoxin mediated rash secondary to GAS
infection of the pharynx or skin
 Oral mucosal rash (petechial), strawberry tongue
 Erythematous, blanchable, generalized rash
 Intense in skin folds with linear, petechial
eruptions – Pastia Lines
 May get desquamation 5 days post
 Treat with Penicillin
Gotta know this one…
4 year old girl, sick for a week now, cough
runny nose, rash. Parents bring her in
because she cries all the time
Name the diagnostic
criteria
What is the treament
What are we trying to
prevent with
treatment?
Kawasaki’s Disease
 FEEL My Conjunctivits
 Fever – greater than 5 days plus four of:
 Extremitity changes (erythema, edema)
 Erythematous Rash (can be any rash except
petechial)
 Lymphadenopathy (>1.5 cm, may be unilateral)
 Mucositis (bright red lips, strawberry tongue)
 Conjunctivitis (bilateral, non-purulent)
Kawasaki’s Disease
 Other frequently associated findings:
–
–
–
–
–
–
–
–
Irritability (~90%)
Urethritis/sterile pyuria (70%)
Aseptic meningitis (50%)
Hepatitis (30%)
Arthralgia/arthritis (10-20%)
Hydrops of the gallbladder (10%)
Myocarditis/CHF (5%)
uveitis
Kawasaki’s Disease
Untreated 20% will develop coronary
aneurysms with treatment less than 5%
Treatment
– IVIG 2 g/kg
– High dose ASA 80-100 mg/kg until afebrile
then:
– Low dose ASA 5 mg/kg for 6-8 weeks if no
evidence of aneurysms
Case I had last week…
Todd no comments:
4 yo girl with one week history of rash
Started on steroids by fp, not improving,
thinks they are getting worse. Also
complaining of ankle pain and swelling
What is the diagnosis?
Name two surgical
complications
What long term risks are
associated with this?
Henoch-Schonlein Purpura
Unknown etiology but frequently follows
viral infection ? Autoimmune
Rash is erythematous papules followed by
purpura
Frequently associated with joint pain and
swelling
Abdo pain not uncommon, sometimes as
presenting feature
Henoch-Schonlein Purpura
 Surgical Complications Include:
– Intussusception
– Testicular torsion
 Long term complications:
– Glomuerulonephritis/renal disease
– Hypertension
 No effective treatment.
– Soft evidence for steroids reducing abdominal pain
and risk of torsion. Not effective for rash.
Last case in this round!
Previously well 3 month old boy, presents
with this very tender rash. By the next day
he has the 2nd photo appearance
Staphylococcal Scalded Skin
Syndrome
AKA TEN (toxic epidermal necrolysis)
Exotoxin mediated reaction to coagulase
positive staphylococcal infection
In adults more commonly caused by drug
reaction
Rash is initially erythematous, sandpaper
like and very tender
Staphylococcal Scalded Skin
Syndrome
After 2-3 days skin will peel (Nikolsky
sign)
Pathognomonic facies, crusting perioral
erythema with fissures at the nasolabial
folds and corner of mouth
Spares MM, palms and soles
Now for the speed round
Spot Diagnosis
First
10 yo girl, very itchy rash mostly affecting
web spaces
Scabies
The culprit Sarcoptes scabeii
Scabies
Usual locations
Scabies
Spread by skin to skin contact and causes
extreme pruritis
Frequent secondary infections
The mite tunnels into the stratum corneum
and lives in burrows
Scabies
Treatment is 5% permethrim, underwear
and sheets need to be washed in hot water
Family needs to be treated as well
Pregnant women and children less than 6
mos treated with sulfur
Quick…
6 yo African-Canadian girl with itchy scalp
and areas of alopecia (and her brother)
Tinea capitis
Superficial infection caused by
dermatophytes
Annular configuration with erythema and
scaling
Treated treated with antifungals
If not improving think secondary infection
Starting to feel itchy yet…
7 yo Oriental girl was playing in sandbox
last week. Given topical antibiotics. Not
improving. Rash now spreading to other
areas of the body. Some look like blisters
that have broken open according to the
mom.
Impetigo
Caused by strep or staph
Mainly face, head neck and extremities
affected
Classically honey crusted appearance
May be bullous or vesiculopustular form
Treated systemically with 1st or 2nd gen
cephalosporin
Also important to treat topically
Herpes Simplex
Vesicular lesions on an erythematous base
Kids usually get primary gingivostomatitis
Heals within 2-4 weeks
Recurrence not usually as severe unless
immunocompromised
This one’s really tough!
Varicella Zoster
“dew drop on a rose pedal”
 Won’t get into a whole lot
 Watch for secondary infection…necrotising
fascitis
 Older children/adults more likely to have
complicated course
– Pneumonitis, encephalitis, hepatitis, myocarditis
 Infectious before vesicles appear until all are
crusted
Another quickie
Molluscum Contagiosum
Viral (DNA pox virus)
Dome shaped umbilicated papule
Highly contagious and auto-inoculable
Treatment is curettage, freezing, or they
will resolve on there own in 6-9 mos
 What is the problem with the vaccine for this
illness?
Meningococcemia
Immediate Management
–
–
–
–
ABC’s, Labs (w/coags), IV access
Less than 1 mo amp and cefotaxime
More than 1 mo, cefotax and vanco
Supportive Measures
Close/high risk contacts prophylactic cipro
Vaccine covers A,C,Y, W135 but 35-40%
of cases are due to B
The Rash Relay Part II
Non-Infectious Rashes
Start Easy…
Rash started out of the blue in this healthy
2 yo boy. No complaints
Diagnosis?
Name 2
causes? Be
sepcific
Erythema Multiforme
Macules, papules and pathognomonic
target or iris lesions
Often idiopathic, maybe secondary to
drugs (sulfa’s, dilantin, barbituates). May
also be secondary to HSV or Mycoplasma
The other end of the spectrum…
9 yo girl recently started on Septra for her
UTI. Now presents hypotensive and
tachycardic.
Besides skin, what other organ
may be severely affected?
Stevens-Johnson Syndrome
Also known as EM major
Severe bullous erythema with
mucocutaneous involvement
Can have severe eye involvement – corneal
ulcerations, uveitis
Causes the same as EM, often due to HSV
Treatment is supportive care and wound
management
Next…
14 yo boy with a chronic illness and
recently noticed the following painful rash
on his legs
Diagnosis
What chronic disease does this boy
likely have?
Erythema Nodusum
Deep, tender erythematous, nodules on
extensor surfaces of extremities
Often secondary to infections (strep is
common), IBD, sarcoidosis and drugs
(commonly OCP)
Treat underlying cause
Just the picture…
 Diagnosis? Name two complications
Sturge-Weber Syndrome
Nevus Flammeus or port wine stain in V1
trigeminal distribution
Made up of mature, dilated dermal
capillaries
Associated with seizures, hemiparesis,
intracranial calcifications and glaucoma
Another similar one…
 Diagnosis? When does this need to be treated
Strawberry Hemangioma
Dilated capillaries present at birth
Usually worse in first 6 mos and resolve by
5 years
May be multiple and associated with
thrombocytopenia and consumptive
coagulpathy
Treatment only required if interfering with
vital structure (eg., vision)
Getting close to the end!
Diagnosis? What treatments do you think were
used?
Atopic Dermatitis/Eczema
Pruritic inflammation of the epidermis in a
patient who has or a family history of
atopy
Commonly secondarily affected
Treatment includes moisturizers and
emollients, topical steroids, systemic
steroids in more severe cases and immune
modulators like tacrolimus
The End is Near…
Some things you should recognize
but we won’t talk about!
Tuberous Sclerosis
Sebaceous adenoma
Ash leaf macule
Neurofibromatosis
Café au lait macule
neurofibromas
Pityriasis Rosea
 Classic Christmas tree
distribution
 Starts with herald
patch
– Larger lesion that
precedes this classic
rash
Child Abuse
lighter
slap
Lamp cord
slap
Hot water submersion
Ehlers-Danlos Party Trick
 Gorlin Sign
 The End!