Papules, Purpura, Petechia and Other Pediatric Problems: A Review of Peds Derm

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Papules, Purpura, Petechia and Other Pediatric
ProblemsA Review of Peds Derm

• David Chaulk
• PEM Fellow
• April 15th, 2004

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Neonatal Nasties
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Erythema Toxicum

• Bad namenot toxic
• Usually occurs in first days of life
• 50 of healthy babies
• Erythematous macules /- pustules and papules
• Etiology unknown
• No treatment necessary

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Erythema Toxicum
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Milia

• Retention of keratin and sebaceous material
• Usually disappears by 3-4 weeks
• No treatment

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Milia
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Miliaria Rubra

• Destruction of epidermal sweat ducts resulting in
  erythematous papules, vesicles or papules
• Treat with humidity/cool baths

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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

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Subcutaneous Fat Necrosis
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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 24-36 mos
• Treated with anithistamines and fluorinated
  corticosteroids if severe

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Infantile Acropustulosis
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Infantile Acne

• Closed comedones and inflammatory papules
• May last 1-2 years
• Usually family history
• Most dont require treatment
• May use topical treatment such as benzoyl peroxide

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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

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Diaper and Candidal Dermatitis
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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

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Seborrheic Dermatitis and Cradle Cap
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The Rash Relay!

• Two teams, limited info. Spot Diagnosis
• Start with Infectious Stuff

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First ones easyor 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

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What is the diagnosis? What is the infectious
agent?
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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)

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Another easy one

• Its spring, youre in the ED seeing a 6 yo girl
  with a rash. Yesterday it was only on her cheeks
  now its on her arms (extensors)

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What is this? What is the infectious agent? Extra
Credit Name two complications What about
pregnancy exposures?
Day 4
Day 5
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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 1slapped cheek
• Day 2lacy, erythematous rash on extensors
• Day 6 fading rash with lacy, marble appearance

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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

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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 isnt
  immunized

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Diagnosis? Name 1 acute complication, and one
longterm complication
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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

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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

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Diagnosis? How is it different from measles? What
is the presentation of congenital infection?
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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

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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

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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

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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?

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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

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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?
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Kawasakis 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 (gt1.5 cm, may be unilateral)
• Mucositis (bright red lips, strawberry tongue)
• Conjunctivitis (bilateral, non-purulent)

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Kawasakis 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

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Kawasakis 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

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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

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What is the diagnosis? Name two surgical
complications What long term risks are
associated with this?
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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

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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.

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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

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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

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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

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Now for the speed round

• Spot Diagnosis

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First

• 10 yo girl, very itchy rash mostly affecting web
  spaces

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Scabies

• The culprit Sarcoptes scabeii

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Scabies

• Usual locations

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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

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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

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Quick

• 6 yo African-Canadian girl with itchy scalp and
  areas of alopecia (and her brother)

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Tinea capitis

• Superficial infection caused by dermatophytes
• Annular configuration with erythema and scaling
• Treated treated with antifungals
• If not improving think secondary infection

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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.

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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

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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

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This ones really tough!
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Varicella Zosterdew drop on a rose pedal

• Wont get into a whole lot
• Watch for secondary infectionnecrotising
  fascitis
• Older children/adults more likely to have
  complicated course
• Pneumonitis, encephalitis, hepatitis, myocarditis
• Infectious before vesicles appear until all are
  crusted

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Another quickie
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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

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• What is the problem with the vaccine for this
  illness?

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Meningococcemia

• Immediate Management
• ABCs, 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

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The Rash Relay Part II

• Non-Infectious Rashes

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Start Easy

• Rash started out of the blue in this healthy 2 yo
  boy. No complaints

Diagnosis? Name 2 causes? Be sepcific
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Erythema Multiforme

• Macules, papules and pathognomonic target or iris
  lesions
• Often idiopathic, maybe secondary to drugs
  (sulfas, dilantin, barbituates). May also be
  secondary to HSV or Mycoplasma

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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?
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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

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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?
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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

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Just the picture

• Diagnosis? Name two complications

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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

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Another similar one

• Diagnosis? When does this need to be treated

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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)

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Getting close to the end!

• Diagnosis? What treatments do you think were used?

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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

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The End is Near

• Some things you should recognize but we wont
  talk about!

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Tuberous Sclerosis
Sebaceous adenoma
Ash leaf macule
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Neurofibromatosis
Café au lait macule
neurofibromas
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Pityriasis Rosea

• Classic Christmas tree distribution
• Starts with herald patch
• Larger lesion that precedes this classic rash

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Child Abuse
lighter
slap
Lamp cord
Hot water submersion
slap
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Ehlers-Danlos Party Trick

• Gorlin Sign
• The End!