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Pediatric Visual Diagnosis
Ilana 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
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Macules, Papules, Nodules
Patches and Plaques
Vesicles, Pustules, Bullae
Colour
Erosions – when bullae rupture
Ulcerations and excoriations
Atopic Dermatitis
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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
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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
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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
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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
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Illness can’t be explained by other disease
Kawasaki Disease
Lab Features
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 WBC
 ESR, positive CRP
Anemia
Mild  transaminases
 albumin
Sterile pyuria, aseptic meningitis
 platelets by day 10-14
Kawasaki Disease
Differential Diagnosis
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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
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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
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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 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
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R/O intussusception
Severe GI bleed
Severe renal disease
Need for renal biopsy
Hypertension
Pulmonary hemorrhage
Acute Hemorrhagic Edema
of Infancy
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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