Upload
others
View
6
Download
0
Embed Size (px)
Citation preview
1
Pediatric Visual Pediatric Visual Dermatological DiagnosisDermatological Diagnosis
Fernando Vega, M.D.
Objectives
• Recognize common pediatric dermatologic conditions
• Expand differential diagnosisExpand differential diagnosis• Review treatment plans• Identify skin manifestations of systemic
disease
Terminology
• Macules, Papules, Nodules• Patches and Plaques• Vesicles Pustules Bullae• Vesicles, Pustules, Bullae• Colour• Erosions – when bullae rupture• Ulcerations and excoriations
2
Atopic Dermatitis
• 3-5% of children 6 mo to 10 yr• Described in 1935• Ill defined red pruritic papules/plaques• 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• Accentuation of skin markings on palms
and soles• Dennie-Morgan lines• Fissures at base of earlobe• Allergic history
3
Atopic DermatitisTreatment
• Moisturize• Baths only• Anti histamine• 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 p g g y
days• More potent topical steroid• Topical antibiotic – Fucidin• Anti-histamine• Refer to Dermatology
4
Scabies
• Intense pruritus• Diffuse, papular rash
– Between fingers, flexor aspects of wrists, g , p ,anterior axillary folds, waist, navel
• May be vesicular in children < 2 years– Head, neck, palms, soles– Hypersensitivity reaction to protein of
parasite
ScabiesTreatment
• 5% permethrin cream for infants, young children, pregnant and nursing mother– Kwellada-P or NixKwellada 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
5
Tinea corporisRingworm
• Face, trunk or limbs• Pruritic, circular, slightly erythematous• Well-demarcated with scaly, vesicular orWell 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
clearingg• More lesions 5-10 days later• Christmas tree distribution• Treatment: anti-histamines
Eczema• Differential Diagnosis
– Atopic dermatitis– Scabies
Tinea corporis– Tinea corporis– Pityriasis rosea
• If vesicular, check for HSV1, HSV2, VZV• Beware of superinfection• Think of immune deficiency if difficult to treat
6
Urticaria
• Transient, well-demarcated wheels• Pruritic• Part of IgE mediated hypersensitivity• Part of IgE-mediated hypersensitivity
reaction• May leave central clearing• Triggers are numerous
7
Kawasaki DiseaseDiagnostic Criteria
• Fever for 5 or more days• Presence of 4 of the following:
1. Bilateral conjunctival injection2. Changes in the oropharyngeal mucous
membranes3. Changes of the peripheral extremities 4. Rash 5. Cervical adenopathy
• Illness can’t be explained by other disease
Kawasaki DiseaseLab Features
• ↑ WBC• ↑ ESR, positive CRP• Anemia• Anemia• Mild ↑ transaminases• ↓ albumin• Sterile pyuria, aseptic meningitis• ↑ platelets by day 10-14
Kawasaki DiseaseDifferential Diagnosis
• Measles• Scarlet fever• Drug reactions
• Stevens-Johnson Syndrome
• Systemic Onset g• Viral exanthems• Toxic Shock
Syndrome
Juvenile Rheumatoid Arthritis
• Staph scalded skin syndrome
Kawasaki DiseaseDifficulties with Diagnosis
• Clinical diagnosis• No single test• Diagnosis of exclusion• Diagnosis of exclusion• Atypical KD
– Do not fulfill all criteria– More common in < 1 year and > 8 years
Kawasaki DiseaseTreatment
• Admit to monitor cardiac function• Complete cardiac evaluation• Complete cardiac evaluation
– CXR, EKG, echo• IV Ig• ASA
Kawasaki DiseaseTreatment
• IV Ig 2 g/kg as single dose– Expect rapid resolution of fever– Decrease coronary artery aneurysms from 20% to
< 5%< 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
8
Coxsackie VirusHand-Foot-and-Mouth
• Painful, shallow, yellow ulcers surrounded by red halos
• Found on buccal mucosa, tongue, soft palate, uvula and anterior tonsillar pillarsuvula and anterior tonsillar pillars
• Oral lesions without the exanthem = herpangina
• Exanthem involves palmar, plantar and interdigital surfaces of the hands and feet +/-buttocks
Erythema InfectiosumFifth Disease
• Parvovirus B19• Mostly preschool age• Mostly preschool age• Recognized by exanthem• Contagious before rash• Resolution between 3 and 7 days
9
Roseola
• 6 to 36 months• Human herpesvirus 6• High fever without source and irritability• 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 y gdisease
• Strep or Staph• Honey-coloured crust• Treatment: topical and systemic
antibiotics
10
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 perythematous base
• Painful• Tend to coalesce, ulcerate and then
crust• May require topical or oral acyclovir
11
Henoch-Schonlein PurpuraClinical features
• Palpable purpura of extremities• Arthralgia or non-migratory arthritis
– No permanent deformitiesp– 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
HSPIndications for admission
• R/O intussusception• Severe GI bleed• Severe renal disease• Severe renal disease • Need for renal biopsy• Hypertension• Pulmonary hemorrhage
Acute Hemorrhagic Edema of Infancy
• 4-24 months• Recent URI or antibiotics• Non toxic• Non-toxic• Resolves in 1-3 weeks• small- vessel, leukocytoclastic vasculitis• Annular or targetoid pupura and edema
on face and extremities
12
Conclusions
• Not all that itches is eczema• Treatment is often supportive for viral
exanthemsexanthems• Remember rashes as a sign of systemic
illness• Careful history and physical essential
for evaluation of bruises