Download Pediatric Visual Diagnosis

CHILDHOOD DERMATOLOGY
Dr. SATAM ALSHAMMARI
ASSISTANT PROFESSOR OF PEDIATRIC MEDICINE
CONSULTANT OF PEDIATRIC PULMONOLOGY
MOH.KSA
Introduction
-There are more than 3000 dermatologic
diagnoses
-Approximately 5% of ED visits are for a
dermatologic complaint
The structure and function of the
skin
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Epidermis
Dermis
Subcutaneous tissue
Functions
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Thermal control : regulates body temperature
Excretion : by regulating the volume and chemical content of
sweat.
Makes vitamin D
Immunity (Defenses)
sensation: the widespread of the millions of different somatic
sensory receptors that detect stimuli.
History
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Age
Onset
Is the rash raised (papular) or flat (macular)?
Is the rash red?
Is the rash scaly?
Is the rash itchy?
When did the rash start?
Where did the rash start, and how did it spread?
Duration
Body location
Any change of individual lesions
Did the patient present with other symptoms
(Fever ,Pruritus ,Conjunctivitis, Swollen extremities, Sore throat, Abdominal
pain)
Involvement of palms and soles, mucous membranes, conjunctiva
 Was the lesion caused by trauma/insect bite?
 Is there any associated discharge or odour?
 What makes the skin condition better or worse?
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History (cont)
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Past Medical History (asthma, eczema)
Family Medical History: Has the patient had close contact
with someone else with the same symptoms?
Social History : Has the patient travelled recently?, animals
contact
Immunizations History
Allergies History
Medications History: Has the patient been exposed to new
topical applications
Physical Exam
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General Appearance: (well, uncomfortable, toxic)
Vital signs: (pulse, respiration, temperature, etc)
Skin exam: (entire skin should be inspected, including mucous membranes,
genital/anal regions).
Remember SCALDA to describe a lesion4
S Site/Size/Shape/texture (centripetal,centrifugal)(morbilliform,varicelliform)
C Colour (Erythematous,Hypopigmented,Hyperpigmented,Depigmented)
A Arrangement (Solitary, Grouped, Linear)
L Lesion type (primary, secondary)
D Distribution(eg.Symmetrical, dermatomal,extensor surfaces,intertriginous
(between body folds), dependent areas, sun-exposed skin)
A Always check involvement of:
 nails
 hair
 mucous membranes
feel the lesion raised or flat? wet or dry ,what dose it feel like? blanchable
Terminology
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Macules, Papules, Nodules
Patches and Plaques
Vesicles, Pustules, Bullae
Erosions
Ulcerations and excoriations
Primary &Secondary Lesions
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Primary Lesions:
Those lesions that are the direct result of a pathologic
process
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Secondary Lesions:
Lesions that are the result of alteration of a primary lesion
(e.g. rubbing, scratching, infection)
Common Primary Lesions
Profile
<1 cm
>1 cm
Flat
Macule
Patch
Elevated
Papule
Plaque
Palpable, deep
Nodule
Tumor
Fluid filled
Vesicle
Bulla
Common Primary Lesions
Common Primary Lesions
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hemorrhages into the skin.
Not blanch on pressure
petechiae (< 1-2 mm )
Purpura spots (3-10 mm in diameter)
palpable: vasculitic
HSP
meningococcaemia
non-palpable: ITP
 ecchymoses (>1 cm bruises).
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Telangiectasia
is the name given to prominent cutaneous blood vessels.
Common Primary Lesions
Secondary skin lesions
Scale:
Flakes of keratin that can be fine or coarse; loose or
adherent.
Example: Dandruff
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Lichenification:
thickened and rough epidermis with accentuation of skin
markings.
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Excoriation:
Traumatized or abraded skin, usually due to scratching or
rubbing.
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Secondary skin lesions
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Fissure
A fissure is a thin crack within epidermis or epithelium,
and is due to excessive dryness
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Ulcer
Deep open wound extending into the dermis or
subcutaneous tissue. May lead to scar formation.
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Erosion
Superficial open wound involving only epidermis or
mucosa. Does not extend into the underlying dermis, so
healing occurs without scar formation
Secondary skin lesions
Causes of maculopapular rash
Remember blanch on pressure
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Measles
Rubella (macular)
Erythema infectiosum (fifth’s disease)
Roseola HHV6/7
Enrerovirus (coxsackie,echo,polio viruses)
-more 90% aysymptomatic
-faecal oral route
-effective vaccine for polio
Scarlet fever
Kawasaki disease
Durgs
Measles
Measles
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• Incubation period 8-14 days
• Prodromal illness 3-4 days Fever, conjunctivitis,
runny nose & cough
• Koplik spots
-white spot on buccal mucosa
- 24-48 hours before rash
- pathognomonic
-difficult to see
Rash:
◦ begins on face & behind ears
◦ usually with onset high fever
◦ spreads to body
◦ Usually spares palms/soles
Measles
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Complications
◦ Otitis media
◦ Febrile convulsion
◦ Bronchopneumonia
◦ Encephalitis (1/5000)
◦ Myocarditis/pericarditis(ECG abnormalities)
◦ SSPE (rare) after years
◦ Other hepatitis corneal ulceration
Measles
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Diagnosis
IgG and IgM serologies, acute and convalescent titers
Treatment Symptomatic.
Antipyretics.
In severe disease, vitamin A
in immunocompromised ribavirin
 Prevention - immunization at 1year
-10% failure of vaccine
-at school age
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Rubella
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Mild disease
IP:14-21 days
Spread by respiratory route
s/s
Fever low grade or none at all
Maculopapular rash first sign on face (Fade in 3-5 days)
LAP especially suboccipital and postauricular
Complication are rare
Arthritis,
Encephalitis,
Myocarditis,
Thrombocytopenia
Diagnosis by serology
No effective anti viral
Erythema Infectiosum
Fifth Disease
known as ‘slapped cheek disease’ or 5th disease
 Features
◦ Parvovirus B19
◦ Incubation period 4-14 days
◦ Mostly preschool age
◦ Fever in 15-30% for 1-2 days
◦ Slapped cheek appearance
◦ Generalised maculopapular rash for 7-10 days
◦ transmission is via respiratory secretion
 Management
◦ Supportive
Roseola
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Roseola Infantum
Human herpesvirus 6
Most Children are infected by 2 years
Abrupt onset of high fever for 3 days
Followed by generalized macular Rash
which appears as the fever wane
Is common cause of Febrile seizures
Rarely associated aseptic meningitis,
hepatitis.
Scarlet fever
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Cause
◦ Group A beta-haemolytic Streptococcus
Features
◦ Incubation 2-4 days
◦ Bright red blanching rash (sandpaper)
 First in axilae/groins, then widespread
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◦ Red face with circumoral pallor
◦ Strawberry tongue (white then red)
Treatment
◦ Symptomatic relief
◦ Penicillin V 7-10 days
Kawasaki Disease
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Affect children 6 months-4 years
Cause unknown
Clinical diagnosis
Vasculitis affecting small and medium size
vessels
Affect coronary arteries about one third
Mortality 1%
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
Illness can’t be explained by other disease
Kawasaki Disease
Lab Features
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 WBC
 ESR, positive CRP
Mild  transaminases
 albumin
Sterile pyuria, aseptic meningitis
 platelets by day 10-14
Kawasaki Disease
Treatment
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IV Ig 2 g/kg as single dose
◦ Expect rapid resolution of fever
◦ Decrease coronary artery aneurysms from 20% to < 5%
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ASA
- reduce risk of thrombosis
- Repeat echocardiogram at 6 weeks
Causes of vesicular rash
Chickenpox
 Shingles
 Herpes simplex
 Hand foot mouth disese
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Chickenpox
Causes
◦ Varicella zoster virus
 Features
◦ Very common
◦ Incubation period 14-21 days
◦ Prodrome mild fever & malaise
◦ Vesicles on erythematous base
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 Change to macule→papule→vesicle→crust
 Last 3-4 days
 Mainly on trunk
 Can appear in mouth/genital region
 Usually no scarring
◦ Infectious for 1-2 days before rash & 5
days afterwards
Chickenpox
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Complications
◦ Always look carefully at child if fever persists >
5 days after appearance rash
 ?secondary bacterial infection staphlococcal,strptococcal
toxic shock syndrome
necrotising fascitis
◦ Pneumonitis
◦ Encephalitis
◦ Cerebellar ataxia(cerebelitis)
◦ Eczema herpeticum
 Management
◦ Supportive – fluids/paracetamol/calamine lotion
◦ Admit if complications suspected
Herpes Simplex
Gingivostomatitis most common 1º
infection in children
 10 months – 3 years
 There are Vesicular lesion on lips, gums ,
ant surface of tonge and hard palate
 progress to painful ulceration and bleeding
 High Fever, irritability, miserable child
 Eating and drinking are painful lead to
dehydration
 Treatment: supportive
severe (IVF,aciclovir)
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Herpetic Whitlow
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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
Coxsackie Virus
Hand-Foot-and-Mouth
Painful, shallow, yellow ulcers
 Found on buccal mucosa, tongue, soft
palate, uvula and anterior tonsillar pillars
 Exanthem involves palmar, plantar and
interdigital surfaces of the hands and feet
+/- buttocks
 Cause
◦ Coxsackie viral infection
◦ Can be complicated by aseptic meningitis
 Management
◦ Supportive
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peticheal &purpuric rash
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hemorrhages into the skin.
Not blanch on pressure
petechiae (< 1-2 mm )
Purpura spots (3-10 mm in diameter)
palpable: vasculitic
non-palpable: ITP
 ecchymoses (>1 cm bruises).
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Causes of purpuric & peticheal
rash
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Meningococcal infection
Idiopathic thrombocytopenia purpura
Henoch-Schonlein Purpura (HSP)
Viruses - particularly enterovirus infection
Leukemia
Excessive vomiting
Extreme crying
Violent coughing
Trauma or injury
Defect in blood clotting factor
Durgs
Meningococcemia
Caused by Neisseria meningitides
 Although there are vaccines against groups
A,C
 No vaccine against group B
 Meningococcal septicemia can kill children
in hours
 Any febrile child with purpuric rash should
given
treatment immediately
 Petechial rash develops in 75% of cases
 Fever, rash, hypotension, shock, DIC
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Henoch-Schonlein Purpura
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Usually occurs 3-10 years
More common in boys
Often Preceded by URTI
Clinical features
Skin rash:
Palpable purpura of extremities
cornerstone of the diagnosis
 Arthralgia or non-migratory arthritis
◦ No permanent deformities
◦ Mostly ankles and knees
◦ Periarticular oedema
 Abdominal pain
◦ May develop intussusception
 Renal involvement
◦ Hematuria, hypertension, renal failure,NS
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MACULOPAPULAR RASH
MACULOPAPULAR RASH
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Viral Exanthem - Measles, Rubella, Fifths, etc, self-limiting,
supportive care
Lyme Disease - Tick bite, erythema migrans, arthralgias,
headache, doxycycline
Pityriasis - scaly lesions, herald patch, Christmas tree pattern,
treatment includes: UV light, moisturizing lotion, oatmeal
bathes, antihistamines
Stevens-Johnson Syndrome - mucosal involvement, remove
drug/treat illness, supportive therapy, hospital admission
EM = Erythema Multiforme - treat illness/stop drug,
supportive care, topical steroids and outpatient follow-up for
minor cases
Meningiococcemia - ill appearing, mental status change,
lumbar puncture,
ceftriaxone, isolation, treat close contacts, hospital admission
RMSF = Rocky Mountain Spotted Fever - tick bite, endemic
area, headache, arthralgias, doxycycline
Scabies - excoriated burrows, itches worse at night,
permethrin
PETECHIAL/PURPURIC RASH
PETECHIAL/PURPURIC RASH
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Meningiococcemia - ill appearing, mental status change,
lumbar puncture,
ceftriaxone, isolation, treat close contacts, admission
Disseminated GC= Gonococcemia - purple vesicles, sparse,
peripheral, associated urethritis/cervicitis/septic arthritis,
ceftriaxone
Endocarditis – new murmur, vegetations on valves, positive
blood cultures
RMSF = Rocky Mountain Spotted Fever - tick bite, endemic
area, headache, arthralgias, doxycycline
HSP = Henoch Schonlein Purpura – children, associated
arthralgias, hematuria andGI symptoms, supportive therapy
TTP= Thrombotic Thrombocytopenic Purpura - low platelet
count, fever, neuro sx, hemolytic anemia, renal failure, ICU
admission, treat underlying cause,
plasmapheresis, splenectomy, selective transfusion, NO
platelets
Vasculitis – treat the underlying process if possible, may
require steroids
ITP – Idiopathic Thrombocytopenic Purpura - transfuse
platelets if bleeding or less than 5000/mm3 – 10000/mm3,
emergent Hematology consultation
VESICULO-BULLOUS RASH
VESICULO-BULLOUS RASH
Varicella/Chicken Pox – excoriated lesions in multiple stages,
starts centrally,isolate, rare hospitalization, symptomatic
treatment, antipyretics (not Aspirin)
 Small Pox – all lesions in one stage, more peripheral distribution,
isolate, notify office of public health and CDC
 Disseminated GC= Gonococcemia - purple vesicles, sparce,
peripheral, associated urethritis/cervicitis/septic arthritis,
ceftriaxone
 Purpura Fulminans/DIC = Disseminated Intervascular Coagulation
- treat the underlying cause, fresh frozen plasma, platelet
transfusions, ICU admission
 Necrotizing Fasciitis – surgical emergency, debridement, IV antistreptococcal broad spectrum antibiotic, hyperbaric oxygen
therapy
 Hand, Foot and Mouth Disease – children, vesicles on palms, soles
and in mouth,self-limited, symptomatic treatment
 Bullous Pemphigus -chronic autoimmune blistering, elderly,
usually benign, steroids
 Pemphigus Vulgaris – mucous membrane involvement, much
higher mortality than Bullous Pemphigus, steroids, admission
 Zoster – acyclovir, analgesia, steroids
 Contact Dermatits - symptomatic treatment, long taper of steroids
for severe cases
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Causes of napkin rash
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Irritant(contact dermatitis)
flexure are spared
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Seborrhoeic dermatitis
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Candida infection
Napkin dermatitis
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Features
◦ Usually due to irritant contact dermatitis which spares groins
◦ Treat with barrier cream, frequent nappy changes
Napkin rash
Satellite lesions and skin-fold involvement
may indicate candida
 Look for mouth lesions as well
 Treat with anti-fungal cream
Atopic Dermatitis
superficial inflammation of the skin
characterized by
redness
edema
oozing
crusting
scaling
(vesicles)
Atopic Dermatitis
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12-26% of children
Onset usually in first year
Uncommon in first 2 months
Diaper area spared
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
Atopic Dermatitis
The
diagnosis is made clinically
The patient must have each of the following
1-pruritis
2-Typical morphology and distribution
 Facial and extensor involvement in infant and children
 Flexural in adult
3-Tendency toward chronic and relapsing
complications
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Flare-up are common
Infection (strep,staph,herpes)
lymphadenopathy
Treatment
Avoidance or elimination of predisposing
factors
(nylon,long nail. Cow milk)
 Hydration and lubrication of dry skin
 Anti-pruritic agents
 Topical steroids
 Antibiotic or antiviral
 Dietary elimination (egg , cow milk)
occurs in 6% of infant
with eczyma
4-6 weeks required to
detect response
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Seborrheic Dermatitis
Its cause remains unknown
Most frequent present in first 2 months of
life.
 erythamatous scaling eruption
 The scales form thick yellow adherent layer
(cradle cap)
 The rash causes no discomfort or itching
like eczema
• Treatment
-mild case resolve with
emollient
-scales treated with ointment
contain sulphur and salicylic acid
-Topical steroids
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Urticaria
Transient, well-demarcated wheels
Pruritic
Due to increase premeablity of capillaries and
venules
 May involve deep tissue to produce angioedema
 Etiology are
- idiopathic common
- drugs penicillin's, cephalosporin's
- food egg ,cheese, strawberries, fish,
peanut
- physical agent heat,cold pressure
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Impetigo
Localized ,highly contagious
Common in infant
It is common where underlying skin disease
eczema
 Strep or Staph
 Honey-coloured crust
 Mostly face, extremities, hands and neck
 Treatment: topical (mild)
systemic antibiotics
flucloxacillin,erythromycin.(severe)
 Nasal carriage is important source of infection
chlorhexidine,neomycin,mupirocine (cream)
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Thank you