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PEDIATRICS
109
CHAPTER 11
Dermatology
TYPES OF LESIONS
Primary: Specifi c changes caused directly by disease process
Macule: Nonpalpable, 1 cmPapule: Solid, palpable, 2 cmPlaque: Solid, palpable, >1 cm, width > thickness
Vesicle: Raised, clear, fl uid fi lled, 1 cmPustule: Raised, pus fi lledWheal: Transient, palpable edema
Secondary: Nonspecifi c changes caused by evolution of primary lesions
Scale: Accumulation of loosely adherent keratinCrust: Accumulation of serum, cellular, bacterial, and squamous debris over damaged epidermisFissure: Superfi cial, often painful break in epidermisErosion: Loss of epidermis; heals without scarringUlcer: Loss of epidermis and part or all of dermis; heals with scarring
Excoriation: Linear erosionLichenifi cation: Accentuated skin mark-ings caused by thickening of epidermis; usually caused by scratching or rubbingScar: Fibrous tissue replacing normal architecture of dermisAtrophy: Epidermal (thinning of epi-dermis) or dermal (decrease in the amount of collagen or causing depres-sion of skin)
CHARACTERIZATION OF SKIN LESIONS
Description Distribution Duration ExposureSigns and Symptoms
Primary vs. secondary changes
Symmetry How long? Sick contacts Local
Color Dermatomal Since birth? Recent travel Pruritus
Consistency and texture
Photodistribution Recurrent? Medications Pain and tenderness
Mobility Mucous mem- brane involvement
Personal care prod-ucts
Paresthesias
Con guration Contact areas Environ- mental exposures
Bleeding
Shape Flexor vs extensor surfaces
Occupation- al exposures
Systemic
Well vs. ill-de ned
Koebner phenom- enon: areas of previous trauma
Recreational exposures
Fever or chills
Arrangement Seasonal variation
Malaise or fatigue
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110 Pediatrics
Description Distribution Duration ExposureSigns and Symptoms
Discrete Family history
Arthritis or arthralgias
Localized
Grouped
Disseminated
ATOPIC DERMATITIS AND ECZEMA
Risk factors: Family history, other atopic diseases (asthma, allergic rhinitis), food hypersensitivity, environmental allergensClinical manifestations: Pruritic, erythematous, scaly papules and plaques edema, serous discharge, crusting lichenifi cation, hyperpigmentation, fi ssuring superinfection (primarily with Staphylococcus aureus; also with HSV)
Distribution
Infantile: Cheeks, forehead, trunk, extensor surfaces Childhood: Wrist, ankle, antecubital and popliteal fossae Adolescent and adult: Flexor surfaces, face, neck, hands, feet
ECZEMA COMPLICATIONS
Type Clinical Features Treatment or Prevention
S. aureus superinfection Honey-crusted erosions, pus-tules, weeping, acute increase in erythema
Topical or oral antibiotic
Obtain culture
Eczema herpeticum (HSV superinfection)
Source of contact often adult caretaker with cold sore
First-degree lesions: Crops of vesicles on in amed base at sites of eczema
Late: punched-out erosions
Common associated symp- toms: Fever, malaise, irritability, intense itching, eczema are
Severe: Widespread viral dissemination with multiorgan involvement
Stop TCS or TCI
Acyclovir or valacyclovir
Treat for secondary bacterial infection if indicated
Treat known contacts
Eye exam for periorbital involvement
Obtain culture &/or DFA
Long-term TCS use Skin atrophy, ecchymoses, striae, telangiectasias, poor wound healing, perioral dermatitis or steroid rosacea, hypothalamuspituitary axis suppression with systemic absorption
Limit use for ares only (usually
Dermatology 111 PED
IATRICS
Mild fl are: Class 6 to 7 TCS or TCI BID (approved for 2 yo; use for 2 weeks at a time; good for face); ointment preferred Moderate fl are: Midpotency TCS for body BID (eg, triamcinolone 0.1%); ointment preferred; class 6 to 7 TCS or TCI BID for face; oral antihistamines PRN for pruritus Severe fl are: Midpotency TCS followed by warm, wet wraps BID for at least 15 min; ointment preferred; then application of emollient; oral antihistamines PRN for pruritus and antibiotics for superinfection
CONTACT DERMATITIS
Type Description Causes Course Treatment
Irritant Acute: Erythema, scal-ing, edema, vesicles, pustules, erosions
Chronic: Licheni cation, ssures
Results from contact with a substance that chemically or physically damages skin
Urine or feces diaper rash
Lip licking or thumb sucking
Detergents or solvents
Topical medications
Battery acid
May occur after single contact with a strong irritant or after repeated contact with milder irritants
Rash minutes to hours after exposure
Avoidance of irritants
Emollients, barrier creams
May consider TCS if no im-provement (controversial)
Allergic (type IV cell-mediated immune reaction)
Acute: Erythematous, scaly, vesicular, crusted, weeping
Chronic: Licheni ca-tion, ssuring, excoriations
Poison ivy, oak, sumac
Nickel (jewelry, metal clasps, glasses)
Rubber (shoes, clothing)
Paraphenylenediamine (hair dyes, leather, black-dyed henna)
Topical antibiotics (eg, neomycin, bacitracin)
Emollients
TCS
1 exposure rechallenged by allergen dermatitis
Rhus (poison ivy, oak, sumac): patchy or linear vesicles or bullae on ex-posed surfaces 27 days after exposure, last-ing 34wk
May use patch testing to con rm diagnosis
Avoidance of allergen (may take >6 wk for complete clearing of rash)
Topical or systemic cor-ticosteroids
Data from Dermatol Ther 2004;17:334.
OTHER ECZEMATOUS OR PAPULOSQUAMOUS ERUPTIONS
Disease Description Course Treatment Other
Sebor-rheic dermatitis (infantile form)
Cradle cap: Greasy scales on scalp
Disseminated: Bilateral, well-demarcated, sym-metric pink patches and plaques with scaling in diaper area, retroauricular areas, neck, trunk, and proximal extremities, prominent in skin creases/folds
Usually begins 1 wk after birth
May persist for months
Bathing
Frequent moisturization
Ketoconazole 2% cream if extensive or persistent
Short course of low-potency TCS if in amed
Linked with sebum overproduc-tion and Malassezia spp. infection
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112 Pediatrics
Disease Description Course Treatment Other
Keratosis pilaris
Skin-colored follicular hyperkeratotic or erythematous papules on the upper arms, thighs, cheeks
May become more pro-nounced at puberty (some may improve at puberty)
Often improves with age
Improvement in summer; worsening in winter
No de nitive treatment
May try emollients, lactic acid or glycolic acid creams, urea cream, salicylic acid, short course of TCS for in amed areas
Can be asso- ciated with ichthyosis vulgaris, atopic dermatitis
Pityriasis alba
Small, ill-de ned, symmetric, hypopig-mented patches with ne scales, often on cheeks; may be seen on upper extremities
May become more obvious in summer on tanned skin
May last for months to years
Resolves spontaneously
Emollients, low-potency TCS, sunscreen
Pityriasis rosea
Herald patch: Initial 1- to 10-cm salmon-colored oval patch or plaque with collarette of ne scale, usually on trunk
Within days: Christmas tree distribution of oval, hyperpigmented, smaller, thin plaques or papules similar to a herald patch on trunk
Face, palms, soles usually spared
May see oral erosions
Inverse pityriasis rosea: Variant involving axillae and inguinal areas; more common in younger children and darker-skinned patients
Most common in adolescents and young adults
More common in spring
Reassurance
TCS PO antihistamine PRN for pruritus
Possible bene t of 14-day course of erythromycin (controversial)
UVB light treatment for severe cases
May have mild prodrome: Fever, HA, malaise
May be pruritic
Lasts 68 wk; sometimes months
May be mimicked by syphilis (check RPR if indicated)
Possible association with HHV-6, HHV-7
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Dermatology 113 PED
IATRICS
Disease Description Course Treatment Other
Psoriasis Well-demarcated erythematous papules and plaques with thick, silvery scales; often on elbows, knees, scalp, trunk, but can occur anywhere
Diaper area in infants
Scalp - scaling, pap- ules & plaques
Nail dystrophy - pitting, other
Guttate type: Drop-like lesions on trunk, often after streptococ-cal infections, URI
Localized pustu- lar type: Discrete pustules, scaly plaques on palms or soles
Generalized pustular type: Erythema with sheets of small pustules, migra-tory annular erythematous plaques on tongue, possible after corticoster-oid withdrawal, fever, arthralgias
Koebner phenomenon
Topical cor- ticosteroids, calcipotriene, coal tars, phototherapy, methotrexate, cyclosporine, acitretin, TNF- inhibitors, my-cophenolate mofetil
Never use systemic ste-roids because of psoriasis ares when stopped
Inverse psoriasis: Variant involving exural areas
Cutis 2008;82(3):177.J Am Acad Dermatol 2000;42:241.Pediatr Dermatol 2001;18(3):188.
BACTERIAL INFECTIONS
Type Description Cause Course Treatment Other
Impetigo Honey-crusted erosions, super- cial vesicles or bullae at sites of skin breakdown
May be pruritic
Usually on face, hands, genita-lia, or scalp
S. aureus (non-bullous, bullous, or pustular)
Strepto- coccus pyogenes (usually nonbullous)
Usually no constitution-al symptoms
Bullous form may occur on intact skin
Gentle cleansing
Topical antibiotics
Systemic antibiotics for extensive cases
Ecthyma: Deep impetigo with ulcer formation, often on legs, heals with scarring
Folliculitis Pustules or red papules origi-nating from hair follicles
Usually on scalp, face, chest, back, buttocks, extremities
Usually S. aureus
Benign
Heals with- out scarring
Antibacterial washes
Topical antibiotics if localized
Systemic antibiotics if extensive or recurrent
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114 Pediatrics
Type Description Cause Course Treatment Other
Abscess Erythematous, tender, puru-lent masses, fairly well-circumscribed
Usually S. aureus or GABHS
May become uctuant and spontane-ously drain
Warm, moist compresses
If uctuant, I&D
Systemic antibiotics if indicated
Recurrent: MRSA eradi-cation with intranasal mupirocin TID x 1 wk bleach bath Q2-3 d (1/2 cup bleach:20 gallons water) (for patient and contacts)
Other treat- ments: Daily chlorhexidine washes, rifampin/doxycycline x 1 wk
Cellulitis Acute, ill-de ned, suppurative in ammation of deeper subcu-taneous tissues with erythema, warmth, swell-ing, tenderness
S. aureus or GABHS through area of skin break-down or hematog-enous spread
Prodrome: Fever, chills, malaise
Systemic antibiotics
Erysipelas Progressive, super cial, well-demarcated cellulitis (primarily involving the dermis)
GABHS Prodrome: Fever, chills, malaise
May resolve with desqua-mation and post-in ammatory pigment changes
PCN for 1014 d (erythromy-cin if PCN allergy)
Rest
Elevation
Cover for S. aureus if no improve-ment or atypical (bullous)
Scarlet fever
Blanching, erythematous sandpaper rash starting on central body and spreading
Circumoral pallor, ushed cheeks
GABHS Prodrome (high fever, chills, HA, sore throat, anorexia) rash devel-ops within 1248 h exudative pharyngitis, straw-berry tongue within days 710 d: desquama-tion lasting 26 wk
PCN for 1014 d (erythromy-cin if PCN allergy)
Monitor for other GABHS sequelae: peritonsillar abscess, rheumatic fever, acute glomerulo-nephritis
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Dermatology 115 PED
IATRICS
Type Description Cause Course Treatment Other
Toxic shock syndrome
Di use maculo- papular erythro-derma on trunk with centripetal spread
Erythema or edema of palms or soles
Desquama- tion of hands or feet 13 wk after onset of symptoms
S. aureus or GABHS exotoxin
Sudden onset of high fever, myalgias, vomiting or diarrhea, headache, pharyngitis rapid progression to shock
Removal of foreign body or nidus of infection
Early, aggressive septic shock treatment including early anti-biotics (see chapter 9)
Staphy-lococcal scalded skin syn-drome
Generalized erythema, often tender su-per cial, accid bullae moist, crusty skin with desquamation
Mucus mem- branes not involved
Exfoliative toxins of S. aureus
Prodrome: Fever, malaise, irritability
Scaling or desquamation for 35 d after bullae forma-tion
Reepithelializa- tion in 1014 d
Parenteral antibiotics
Bland emollients for denuded skin
Aggressive pain control
Nikolsky sign: Mechanical pressure induces dermalepidermal cleavage
No organisms seen on skin culture or biopsy
Meningo-coccemia
Petechiae or purpura, ecchy-moses, ischemic necrosis, hemor-rhagic bullae
Neisseria menin-gitidis
Severe system- ic symptoms with rapid decompensa-tion
IV third- generation cephalosporin, PCN, chloram-phenicol
Treat con- tacts with rifampin prophylaxis
Lyme disease
Erythema migrans annular erythematous plaques, cen-trifugal spread
Usually on trunk, axilla, groin, or popliteal fossa
Borrelia burgdorferi
Rash occurs ~715 d after tick detached
Lasts 6 wk if untreated
Doxycycline (if >8 yo)
Amoxicillin (if
116 Pediatrics
VIRAL INFECTIONS
Type Description Course Treatment Other
Rubeola or measles (paramyxo-virus)
Erythematous maculopapular rash starts on face and spreads to trunk or extremities
Rash appears ~5 days after on-set of symptoms
Fades over several days in cephalocaudad direction
Supportive care
Prodrome: Malaise, fever, cough, coryza, conjunctivitis, Koplik spots (gray papules on buccal mucosa)
Rubella or German measles (rubella virus)
Discrete, erythema- tous, maculopapu-lar eruption on face with spread to body over 24 h
Rash appears within 5 d after onset of symptoms
Fades over several days in cephalocaudad direction
Supportive care
Prodrome: Fever, headache, URI symptoms
Tender poste- rior cervical and suboccipital LAD
Forscheimers spots: Pinpoint rose-colored macules or petechiae on soft palate
Roseola or exanthem subitum (HHV-6)
Pink macules and papules on trunk, neck, extremities as high fever resolves
Rash fades over a few days
Supportive care
Usually 6 mo to 3 yr age group
Erythema infectiosum or Fifths disease (parvovirus B19)
Facial erythema (slapped cheeks)
Erythematous reticular, macular, pruritic eruption on extremities, trunk
Usually asymp- tomatic
May have mild myalgias, low-grade fevers
Rash may last a few weeks
Supportive care
Rash may recur with heat (eg, showering) during course of illness
Hand-foot-mouth disease (coxsackie A16; entero-virus 71)
Erythematous patches and vesicles on hands, feet, buttocks, oral mucosa
Fever, anorexia, oral pain oral mucosal ulcers
Most spontane- ously resolve over 23 wk
Monitor hydration status
Carafate PO
Aggressive pain control
Chickenpox (primary varicella zoster virus infection)
Crops of vesicles with surrounding erythema (dew drops on rose petal) pustules rupturing with crust formation
Lesions in all stages at same time
Most commonly on trunk, face, proximal extremities
Incubation: 1021 d
Absent or mild prodrome
Resolution in 1014 d
Spread via respi- ratory route
Possible compli- cations: Pneumo-nia, encephalitis, staphylococcal superinfection
Symptom- atic relief
Immuno- compro-mised or dissemi-nated: Acyclovir therapy, VZIG within 96 h of exposure
Contagious from 24 h before onset of rash until all lesions crusted over
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Dermatology 117 PED
IATRICS
Type Description Course Treatment Other
Herpes zoster or shingles (VZV reacti-vation)
Pain, burning, pruritic grouped vesicles on an ery-thematous base
Usually unilateral, involving one der-matome
May dis- seminate in immunocom-promised patients
Postherpetic neuralgia: Pain lasting weeks to years after resolution of rash
Early treat- ment with antivirals
Aggressive pain control
Herpes sim-plex virus
HSV1: Mostly oral
HSV2: Mostly genital
Gingivostoma- titis: Vesicles erosions, regional adenopathy
Herpetic whitlow: Painful, deep-seated vesicles on ngertips
Eczema herpeti- cum: Generalized vesicles or erosions over atopic der-matitis
Genital: Venereal transmission, grouped vesicles on erythematous base; fever, malaise, LAD
Recurrent: Grouped vesicles on erythematous base, heal without scarring in 1014 d; pain, burning, tingling, most often found on lips or genitalia; often triggered by fever, trauma, sunlight, menstruation, gastroenteritis, stress
Acyclovir or valacyclovir at rst sign of disease may abort or shorten episode
Aggresive pain control
Acyclovir for primary disease in children
Valacyclovir suppressive therapy (daily) for those with frequent recurrences
Gianotti-Crosti (papular acroder-matitis of childhood)
Symmetric, skin-colored or slightly erythematous papules on face, buttocks, extensor (acral) surfaces of extremities
May be preced- ed by URI, mild constitutional symptoms
Spontaneous resolution in weeks to months
Supportive care
May be as- sociated with viral infections (eg, EBV, HBV, others), bacte-rial infections (streptococci), or postvaccina-tion
Verruca vulgaris or common warts (HPV)
Verrucous, gray- pink papules on ngers, dorsal hands, soles of feet, genitals
May occur at sites of trauma
Autoinoculation may occur by manipulating lesions
May enlarge or multiply in im-munocompro-mised patients
Salicylic acid, liquid nitrogen, trichloroa-cetic acid, cantharidin, podophyllin, imiquimod, destructive lasers, other contact immuno-therapy
Genital warts (condyloma acuminata)
In
118 Pediatrics
Type Description Course Treatment Other
Molluscum contagiosum (poxvirus)
Small, isolated, dome-shaped, skin-colored pap-ules with central umbilication
Lesions contagious and autoinoculable
May become inflamed
May involute spontaneously over months to years
Persist, multiply, and enlarge in HIV+ patients
As for com- mon warts, also gentle curettage
Clin Med Res 2006;4(4):273.Data from Dermatol Online J 2003;9(3):4 and Paediatr Drugs 2002;4(1):9.
FUNGAL INFECTIONS
Disease DescriptionClinical course Treatment Other
Tinea capitis Scaly patches of broken hair or hair loss on scalp
If becomes in am- matory boggy, erythematous mass with fol-licular pustules (kerion)
May be associ- ated with pos-terior cervical or suboccipital LAD
Kerion may lead to scarring and permanent hair loss if left untreated
Griseofulvin: 1520 mg/kg/d for 68 wk
Selenium sul de sham-poo: 2x/wk for patient and contacts to reduce viable spores and pre-vent spread
May also consider oral terbina ne, uconazole, pulse itra-conazole tx
Tinea corporis Pruritic annular plaque with clear center and scaly, papulovesicular borders (advanc-ing margin of scale)
2- to 4-wk course of topical antifungal BID (eg, clotrima-zole, terbina ne)
Oral treatment if widespread (eg, Griseofulvin)
Tinea pedis (athletes foot)
Interdigital mac- eration; dry, scaly soles; vesicles or erosions over instep
Colonization aided by warmth and hu-midity of shoes and sweating
Topical antifun- gal BID
Tinea cruris (jock itch)
Pruritic, often symmetric, well-demarcated, scaly, erythematous plaques in inguinal folds, upper thighs
May spread to but- tocks and perianal area
May have raised papular or pustular margin
Topical antifun- gal BID
Moist area aids coloni-zation
Often with concomi-tant tinea pedis
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Dermatology 119 PED
IATRICS
Disease DescriptionClinical course Treatment Other
Tinea versicol-or (Malassezia furfur)
Hypo- or hyperpig- mented macules with ne scales on upper torso or trunk and neck
Skin discolor- ation may take months to resolve
Often recurs (especially in hot, humid summer months)
Selenium sul de or ketoconazole shampoo, topical azoles for small areas
Single oral ketoconazole 400 mg dose (not FDA approved in children)
Fluconazole and Itraconazole have also been suggested
Candida Oral (thrush): super - cial, sometimes ten-der, white plaques on oral mucosa; reveals denuded, erythematous base when scraped o (contrast to oral leukoplakia from EBV that doesnt scrape)
Intertriginous: Erythematous, scaly, moist plaques
Diaper area: Beefy, erythematous plaques involving in-guinal creases, often with satellite pustules or red papules
Vulvovaginal: Thick, white discharge and white plaques on irri-tated, erythematous vaginal mucosa
Oral candidiasis in immunocom-promised patients may spread to esophagus, causing feeding di culties
Suspect candidal superinfection if irritant diaper dermatitis does not improve within sev-eral days; often painful with uri-nation, bowel movement
Vulvovaginal: May cause dysuria and itching
Oral: Nystatin solution
Intertrigo: Nysta- tin powder
Diaper dermati- tis: Topical imida-zole or nystatin, barrier creams, frequent diaper changes; low-strength topical corticosteroids if necessary
Vulvovagi- nal: topical imidazoles, oral antifungals for recurrent or refractory cases (eg, uconazole 150 mg once in adolescents)
Risk factors: Prematurity; antibiotic, corticoster-oid, or OCP use; diabetes mellitus; immuno-compro-mised state
J Dermatol Treat 2002;13(2):73.Chemotherapy 1998;44(5):364.Data from Am Fam Physician 2008;77(10):1415.
MITE INFESTATIONS
Type Description Cause Treatment Other
Scabies Pruritus (worse at night and with hot bath)
Small, erythema- tous papules with excoriations or crusting on inter-digital webs, wrist,
Sarcoptes scabiei
Permethrin 5% cream: Cover entire body overnight (include scalp in infants); repeat in 1 wk
Ivermectin: 200 mcg/kg once; may repeat in 710 d
Secondary bacterial infection common
Usually pruritus resolves within a few days after treatment but rash may last several weeks
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120 Pediatrics
Type Description Cause Treatment Other
ankles, feet, axillae, GU area, buttocks, areolae, scalp and face in infants
May see vesicles, burrows (wrists, ankles)
Wash all clothing and bed linens in hot water and dry in high heat
All contacts must be treated at least once (twice if symp-tomatic)
May use topical steroids for pruri-tus relief
Norwegian or crusted type: Highly contagious; seen in immu-nocompromised patients
Lice (Head)
Intense pruritus
Nits and lice seen on scalp
Excoriations, ery- thema, scaling of scalp and neck
Pediculus capitis
Permethrin 1% rinse or overnight application of 5% cream
Repeat in 1 wk
Wash bedding in hot water and dry in high heat
Ivermectin: 400 mcg/kg on day 1 and 8 (in >2yo)
Malathion lotion (in >6 yo)
May develop secondary bacterial infection
DRUG REACTIONS
Type Description Pathogenesis Course Treatment
Morbilliform or exan-thematous
Symmetric, erythematous macules and pap-ules on trunk and upper extremities that become con uent
May be urticarial on limbs, pur-puric on ankles or feet
Spares mucosa
PCNs, sulfa, cephalosporins anticon-vulsants, allopurinol, others
414 d after initiation
May have pruritus and low-grade fever
Resolves in 12 wk without sequelae
Stop o end- ing agent if possible; desensitization if necessary
TCS or anti- histamines for pruritus
Urticaria (immediate IgE-media-ted hyper-sensitivity)
Pruritic, transient erythematous, edematous papules and plaques
May have central pallor (wheals)
PCNs, cepha- losporins, NSAIDs, monoclonal antibodies, contrast media, others
Minutes to hours after exposure
Each lesion usually lasts 6 wk
Stop o ending agent
Antihistamines
Desensitiza- tion, if drug necessary
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Dermatology 121 PED
IATRICS
Type Description Pathogenesis Course Treatment
Drug-induced angioedema
Pale or pink sub- cutaneous edema of face, extremi-ties, genitalia
May extend to lar- ynx, oropharynx, intestinal wall
ACEIs, PCNs, NSAIDs, contrast media, monoclonal antibodies
Minutes to hours after exposure
Often lasts for few days
Protect airway
Epinephrine
Stop and avoid o ending agent
Antihistamines
Chronic: Steroids PO
Anaphylaxis Urticarial or angioedema lesions + sys-temic symptoms (hypotension, tachycardia)
PCN, latex
Rarely, local an- esthetic, topical antiseptic
Anaphylactoid: Contrast media
Minutes after exposure
Immediately stop o ending agent
Protect airway
Systemic corti- costeroids
Epinephrine
Avoid drug in future; desensitize if necessary
Serum sickness-like reaction
Urticarial, morbil- liform, purple urticaria
Fever
Joint pain
Cefaclor, bupropion, minocycline, PCNs, propra-nolol, others
13 wk after exposure
Stop o ending agent
Supportive and symptomatic care
Fixed drug eruption
One or few annu- lar, erythematous or edematous plaques
May have dusky hue or central blister
Favors face, acral sites, genitalia
TMP-SMX, NSAIDs, barbiturates, tetracyclines, pseudoephed-rine, others
First exposure: 12 wk
Reexposure: within 2448 h
Fades over sev- eral days with postin amma-tory pigment changes
Recurs in same location upon reexposure
Stop o ending agent
Topical corticos- teroid
Acute generalized exanthema-tous pustulosis (AGEP)
Erythematous edematous plaques with small, nonfol-licular, sterile pustules favoring intertriginous areas, trunk, and extremities
May have burn- ing, pruritus
-lactam antibiotics, macrolides, CCBs, antima-larials
122 Pediatrics
Type Description Pathogenesis Course Treatment
Drug reaction with eosino-philia and systemic symptoms (DRESS), drug hyper-sensitivity syndrome (DHS)
Starts morbil- liform on face, upper trunk, extremities edema with follicular accen-tuation
May have pustules, blisters, erythro-derma, purpura
Often with edema of face
Antiepilep- tics, sulfa, allopurinol, mi-nocycline, gold salts, dapsone, antiretrovirals, others
26 wk after drug initiation
Prominent eosinophilia and atypical lymphocytes
Often with lymphadenopa-thy, arthralgia or arthritis, liver involvement, myocarditis, interstitial pneumonitis, interstitial ne-phritis, thyroidi-tis, GI bleeding if allopurinol induced
Stop o ending agent
Systemic corti- costeroids
Check serial liver enzymes if elevated
Check thyroid function tests at onset of reaction and 23 mo later
May require steroid mainte-nance treatment for weeks to months because of relapses when tapered
Erythema multiforme (EM)
Acrofacial, grouped or coalescent target lesions, ery-thematous rings with dusky or crusted centers, or urticarial
Minimal (only one site) or no mucosal involve-ment or systemic symptoms
Most common: Infection (especially HSV, Mycoplasma spp.)
More rarely: Drugs
Abrupt onset within 2472 h, last 7 days
Most heal with- out sequelae
Occasional postin amma-tory pigment changes
HSV-associated EM may recur
Symptomatic: Antihistamines; bland emollients for erosions; diphenhydramine, lidocaine and Maalox in 1:1:1 mix mouthwash for mouth pain
Recurrent HSV- associated EM: Acyclovir 10 mg/kg/d in divided doses for 6 mo
Stevens-Johnson-Syndrome (SJS) (30% BSA)
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Dermatology 123 PED
IATRICS
Type Description Pathogenesis Course Treatment
Photodrug Erythematous patches, papules, vesicles or bullae over sun-exposed areas
Localized burning, itching
Tetracyclines, quinolones, NSAIDs, antiepileptics, amiodarone, thiazides, voriconazole
After variable amount of sun exposure
May cause scarring
Stop causative drug, sun protection, TCS, antihistamines
Data from J Drugs Dermatol 2003;2(3):278.
TOPICAL CORTICOSTEROID GUIDE*
Class Generic Name Brand Names Vehicles
I (superpotent)
Augmented betamethasone dipropionate 0.05%
Diprolene Gel, ointment
Clobetasol propionate 0.05% Clobex, Olux, Temovate, Cormax
Shampoo, foam, spray, solution, gel, lotion, cream, ointment
Di orasone diacetate 0.05% Apexicon, Psorcon
Ointment
Fluocinonide 0.1% Vanos Cream
Flurandrenolide 4 mcg/cm2 Cordran Tape
Halobetasol propionate 0.05% Ultravate Cream, ointment
II (high potency)
Amcinonide 0.1% Cyclocort Ointment
Augmented betamethasone dipropionate 0.05%
Diprolene Lotion, cream
Betamethasone dipropionate 0.05%
Diprosone Ointment
Desoximetasone 0.25% Topicort Cream, ointment
Di orasone diacetate 0.05% Apexicon, Psorcon Cream
Fluocinonide 0.05% Lidex Solution, gel, cream, ointment
Halcinonide 0.1% Halog Solution, cream, ointment
Mometasone furoate 0.1% Elocon Ointment
III (medium to high potency)
Amcinonide 0.1% Cyclocort Lotion, cream
Desoximetasone 0.05% Topicort Gel, cream
Fluticasone propionate 0.005% Cutivate Ointment
Flurandrenolide 0.05% Cordran Lotion, cream, ointment
Triamcinolone acetonide 0.5% Kenalog, Aristocort Cream
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124 Pediatrics
Class Generic Name Brand Names Vehicles
IV (medium potency)
Betamethasone valerate Luxiq, Beta-Val Foam, lotion, cream
Hydrocortisone valerate 0.2% Westcort Ointment
Hydrocortisone butyrate 0.1% Locoid Ointment
Mometasone furoate 0.1% Elocon Cream
Triamcinolone acetonide 0.1% Kenalog, Aristocort
Ointment
V (medium to low potency)
Fluticasone propionate 0.05% Cutivate Lotion, cream
Fluocinolone acetonide 0.025% Synalar, Synemol Cream, ointment
Fluocinolone acetonide 0.01% Derma-smoothe Oil
Hydrocortisone valerate 0.2% Westcort Cream
Triamcinolone acetonide 0.01% Kenalog, Aristocort
Lotion, cream
VI (low potency)
Aclometasone dipropionate 0.05%
Aclovate Cream, ointment
Desonide 0.05% Desonate, Desowen, Locara, Verdeso
Lotion, foam, gel, cream, ointment
Fluocinolone acetonide 0.01% Capex, Synalar Solution, shampoo, cream
Hydrocortisone butyrate 0.1% Locoid Cream
Triamcinolone acetonide 0.025%
Kenalog, Aristocort
Lotion, cream, ointment
VII (least potent)
Hydrocortisone 2.5% Hytone, Nutra-cort, Synacort
Lotion, cream, ointment
Hydrocortisone 1% Many over-the-counter brands
Spray, lotion, cream, ointment
Topical corticosteroids (particularly high-potency classes I to III) should not be used continuously for longer than 2 weeks at a time (or >15 days/mo if used intermittently) to avoid side e ects. If longer use is required, wait 2 weeks before restarting. Avoid application of high potency TCS on face, underarms, and groin.Data from Am Fam Physician 2009;79(2):135 and Nesbitt LT: Glucocorticosteroids. In Bolognia JL, Jorizzo JL, Rapini RL (eds). Dermatology. London: Elsevier Limited; 2008:1926.
Available at www.AccessPediatrics.comAcne subtypes Acne treatment
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