Peds Derm 101 HH Handout

Peds Derm 101 Cases Itching to be Solved

May 22, 2015 HILTON HEAD ISLAND, SC

Emily Berger, MD Helen T. Shin, MD Pediatric Dermatology Joseph M. Sanzari Children’s Hospital Hackensack University Medical Center

“Eczema Coxsackium” Disseminated coxsackievirus A6 infecJng eczematous areas Perioral, extremiJes, trunk + hand, foot, buMocks Coxsackievirus A6 (CV-‐A6) emerging pathogenà atypical hand, foot,

mouth disease Reported in US and abroad Fever, systemic symptoms not uncommon In kids with AD à widespread papular or vesicular erupJon

mimicking eczema herpeJcum, chickenpox, etc. DifferenJated from eczema herpeJcum: more generalized, more

discrete (vs clustered) lesions, less well-‐circumscribed lesions Other presentaJons of CV-‐A6: GCS-‐like, purpuric, delayed

onychomadesis (nail shedding)

Lynch MD, et al. Disseminated coxsackievirus A6 affecJng children with atopic dermaJJs. Clin Exp Dermatol. 2015 Feb 10. doi: 10.1111/ced.12574. [Epub ahead of print] Mathes EF, et al. “Eczema coxsackium” and unusual cutaneous findings in an enterovirus outbreak. Pediatrics. 2013;132:e149-‐7.

Peds Derm 101 Erythema infectiosum

²  Parvovirus B19 ²  Asymptomatic infection ²  Exanthematous disorders

²  Erythema infectiosum (fifth disease) ²  Papular-purpuric gloves and socks syndrome ²  Asymmetric periflexural exanthem ²  ‘Bathing trunk’ exanthem ²  Petechial exanthems

²  Other disorders ²  Arthritis ²  Transient aplastic crises ²  Chronic anemia ²  Refractory anemia following solid organ or stem cell transplantation ²  Fetal hydrops ²  Vasculitis ²  Neurologic disease ²  Rheumatologic disease

Paller AS, Mancini AJ, eds. Hurwitz Clinical Pediatric Dermatology. 4th ed. Elsevier 2011.

Gianoh-‐CrosJ Syndrome

Described in 1955-‐1956 Edematous, erythematous, monomorphous papular (or papulovesicular) erupJon symmetrically distributed on the face, buMocks, and extensor extremiJes Children ages 1-‐6 years EJology – uncommonly HepaJJs B as iniJally described: EBV, CMV, Coxsackie, adenovirus, RSV, parainfluenza virus, parvovirus B19, rotavirus, HHV-‐6, etc VaccinaJons 8-‐12 weeks course Management is supporJve


Berger EM, Orlow SJ, Patel RR, Schaffer JV. Experience With Molluscum Contagiosum and Associated Inflammatory ReacFons in a Pediatric Dermatology PracFce: The Bump That Rashes. Arch Dermatol. 2012;148:1257-‐1264.

Gianoh-‐CrosJ Syndrome-‐Like (ID) ReacJon to Inflamed Molluscum

Immune response to molluscum contagiosum virus (MCV)

Under-‐recognized (~5% of paJents in large series of MCV)

Good prognosJc sign Average Jme unJl resoluJon of MCV= 2 months

“Id ReacJon” “AutoeczemaJzaJon” ReacJon to nickel (dermaJJs under umbilicus), Jnea capiJs, etc

Treat underlying condiJon SymptomaJc management: topical corJcosteroids, oral anJhistamines, PO corJcosteroids if severe

Treatment of Jnea capiJs: 6-‐8 week course of griseofulvin microsize 20-‐25 mg/kg/day divided BID, give with faMy food, emphasize fomite removal


Molluscum DermaJJs

More common if underlying atopic dermaJJs (AD) AD is an indicaJon to favor molluscum treatment Topical corJcosteroids for dermaJJs management

Berger EM, Orlow SJ, Patel RR, Schaffer JV. Experience With Molluscum Contagiosum and Associated Inflammatory ReacJons in a Pediatric Dermatology PracJce: The Bump That Rashes. Arch Dermatol. 2012;148:1257-‐1264.

InfanJle Eczema “Headlight sign” May be super-‐infected with S. aureus, but NOT primary process

Topical vs oral anJbioJc appropriate in many cases Irritant contact dermaJJs component (drool, foods, etc.)

Treatment: Low-‐ to mid-‐potency topical corJcosteroid, barrier cream/ointment for irritant component


“Eczema HerpeJcum”

AKA “Kaposi’s varicelliform erupJon” Skin superinfecJon w/ HSV In paJents w/ preexisJng dermatosis (most commonly AD)

Clusters of umbilicated vesicles, monomorphous “punched out” erosions

Commonly impeJginized If periocular involvement, STAT ophtho eval Associated systemic symptoms Treatment: anJviral (IV or PO) If frequent recurrences, prophylacJc PO anJviral Jen M, Chang MW. Eczema herpeJcum and eczema vaccinatum in children. Pediatric Annals. 2010;39: 658-‐64 Luca NJ, Lara-‐Corrales I, Pope E. Eczema herpeJcum in children: clinical features and factors predicJve of hospitalizaJon. J Pediatr. 2012;161:671-‐5.

Staph Scalded Skin Syndrome “RiMer’s disease” Staph aureus phage II types 3A, 3C, 55, 71à ExfoliaJve toxins

A & B àcleave desmoglein 1 Pediatric cases: premature infants, children <6 Perioral area = diagnosJc clue Prodromeà Erythema then exfoliaJon @ flexures à Skin

sloughing lasts 3-‐5 daysà Resolves in 1 to 2 weeks Culture for a source: skin, orifices Sterile bullae Treatment: Beta-‐lactamase resistant agents, clindamycin (vs.

toxin producJon) at home or inpaJent

Bolognia, et al, eds. Dermatology. 2008 Elsevier.

“UrJcaria MulJforme” aka Annular UrJcaria

Skin ErupJon: Annular and polycyclic wheals with central clearing or ecchymoJc centers N= 18 Clinical Features: Pruritus (94%) Angioedema of hands and feet or face (72%) Dermatographism (44%) Fever (44 %) Symptoms suggesJve of recent viral or bacterial illness (67%) Recent anJbioJc use (44%) Recent ImmunizaJons (11%)

Shah KN, Honig PJ, Yan AC. “Urticaria Multiforme”: A Case Series and Review of Acute Annular Urticarial Hypersensitivity Syndromes in Children. Pediatrics. 2007 May;119(5):e1177-83.

Shah KN, Honig PJ, Yan AC. “Urticaria Multiforme”: A Case Series and Review of Acute Annular Urticarial Hypersensitivity Syndromes in Children. Pediatrics. 2007 May;119(5):e1177-83.

Erythema MulJforme (EM) •  90 % of cases precipitated by infecJon, most commonly

HSV 1 or 2 •  Typical target lesions: well-‐defined, <3cm papule or

plaque with two concentric rings of color change and central zone with evidence of epidermal damage

•  Systemic symptoms: fever, weakness, arthralgias, atypical pneumonia-‐like lung changes (2/2 EM or infecJon)

•  Abrupt onset à 2 weeks typical episodeà resolves without sequelae

•  Recurrence is common in HSV-‐related EM

Bolognia, et al, eds. Dermatology. 2008 Elsevier.

SJS/TEN •  Rare, acute, potenJally fatal,

mucocutaneous reacJons •  Epidermal detachment, <10%= SJS and

>30% = TEN •  KeraJnocyte apoptosis triggered by up

regulaJon of keraJnocyte Fas ligand (FasL) expression

•  Most cases are in response to drugs: anJbioJcs (sulfonamide), anJconvulsants, NSAIDs high offenders

•  Mortality rates thought to be lower in kids (TEN ~ 50% mortality in adults)

•  PotenJal long term sequelae @ skin and eyes

•  SupporJve management in ICU, burn unit

•  IVIG > 2 g/kg advocated

Finkelstein Y, et al. Recurrence and outcomes of Stevens-‐Johnson syndrome and toxic epidermal necrolysis in children. Pediatrics. 2011;128:723-‐8. Barron SJ, DelVecchio MT, Aronoff SC. Intravenous immunoglobulin in the treatment of Stevens-‐Johnson syndrome and toxic epidermal necrolysis: a meta-‐analysis with meta-‐regression of observaJonal studies. Int J Dermatol. 2015;54:108-‐15.

Mucosal Predominant or Atypical SJS

“Mycoplasma pneumonia-‐ induced rash and mucosiJs” Likely other infecJous culprits yet to be idenJfied May respond to systemic corJcosteroids alone or in combinaJon with IVIG Unlikely to recur (8% in a systemaJc review)

Canavan TN, Mathes EF, Frieden I, Shinkai K. Mycoplasma pneumonia-‐induced rash and mucosiJs as a syndrome disJnct from Stevens-‐Johnson syndrome and erythema mulJforme: A systemaJc review. J Am Acad Dermatol. 2015: 72:239-‐45 Ahluwalia J, Wan J, Lee DH, Treat J, Yan AC. Mycoplasma-‐Associated Stevens-‐Johnson Syndrome in children: RetrospecJve review of paJents managed with or without intravenous immunoglobulin, systemic corJcosteroids, or a combinaJon of therapies. Pediatr Dermatol. 2014;31:664-‐9

Exanthematous Drug Eruption Etiologic Agents

•  Amoxicillin •  Ampicillin •  Bleomycin •  Captopril •  Carbamazepine •  Chlorpromazine •  Cotrimoxazole

•  Gold •  Nalidixic acid •  Naproxen •  Phenytoin •  Penicillamine •  Piroxicam

Litt J. Drug eruption reference manual. NY: Parthenon Publishing Group; 2000

Drug Hypersensitivity Syndrome (DRESS)

²  DRESS (drug reaction with eosinophilia and systemic symptoms)

²  1 in 1,000 to 1 in 10,000 anticonvulsant exposures ²  Clinical features

–  Triad - fever, rash, systemic involvement –  Onset 7 to 28 days, first exposure –  Periorbital and facial edema –  Generalized lymphadenopathy –  Cutaneous eruption

Husain Z et al. DRESS syndrome Part I. Clinical Perspectives. J Am Acad Dermatol 2013;68:693.e1-14 Husain Z et al. DRESS syndrome Part II. Management and Therapeutics. J Am Acad Dermatol 2013;68:709.e1-9

Drug Hypersensitivity Syndrome (DRESS)

²  Hepatitis ² Hematologic abnormalities ² Renal damage ² Pulmonary, cardiac, CNS ² Lymphomatoid changes

²  Benign lymphoid hyperplasia ²  Pseudolymphoma

² Thyroiditis - 2 months


Drug Hypersensitivity Syndrome Management

²  Discontinue medication ²  LFTs, CBC w/ smear, UA, creatinine ²  Chest x-ray ²  Skin biopsy ²  Reassess at 3 weeks, 2-3 months ²  Supportive therapy ²  1.0-2.0 mg/kg prednisone - slow taper ²  Council family members


Pityriasis Rosea Self limited exanthem “Herald patch”à few days to 3 weeksà crops of ovoid

papules and plaques with collareMes of scaleà 6 wks + for resoluJon

¼ kids are itchy CharacterisJc “Christmas tree” paMern on trunk and

extremiJes Variants: “inverse” paMern @ skin folds, face; round papules (young children, skin of color); vesicular; pustular; urJcarial; hemorrhagic

Treatment is supporJve Macrolide anJbioJcs ineffecJve Newer RCT for acyclovir

Paller AS, Mancini AJ, eds. Hurwitz Clinical Pediatric Dermatology. 4th ed. Elsevier 2011. Ganguly S. A Randomized, Double-‐blind, Placebo-‐controlled Study of Efficacy of Oral Acyclovir in the Treatment of Pityriasis Rosea. J Clin DiagnosJc Research. 2014;8: YC01-‐04.

Pediatric Psoriasis At least 1/3 of paJents with psoriasis recall having

psoriasis as children GuMate = “droplike”

2-‐6 mm round or oval papules, symmetrically distributed Preceding group A streptococcal infecJon predicts

guMate morphology but not psoriasis severity Progression to psoriasis vulgaris ~40% of kids with

guMate psoriasis AnJbioJcs needed to treat GAS but not helpful for

psoriasis Case reports of tonsillectomy for guMate psoriasis

Mercy, et al. Clinical manifestaJons of pediatric psoriasis: Results of a mulJcenter study in the United States. Pediatr Dermatol. 2013;30:424-‐8. Wu W, Debbaneh M, Moslehi H, Koo J, Liao W. Tonsillectoy as a treatment for psoriasis: A Review. J Dermatolog Treat. 2014;25:482-‐6.

Persistent Arthropod Bite ReacJon

“Papular urJcaria” HypersensiJvity reacJon Recurrent episodes if recurring bites SomeJmes requires skin biopsy (to help convince the family) Treatment: Eliminate source

SupporJve management: anJhistamines, topical corJcosteroids

Summer’s coming! Long-‐sleeved clothing Insect repellent


Scabies O{en nodular in babies: vigorous hypersensiJvity response on trunk, axillae, diaper area 5% permethrin cream, technically not for use under 2 months of age Treatment repeated in 1 wk Treat scalp in infants Signs may not clear for 2-‐6+ weeks a{er treatment Most common reason for treatment failure is not treaJng close contacts!


Neonatal Varicella Disseminated, erythematous papules, vesicles, erosions Maternal infecJon with Varicella Zoster Virus (VZV), ie

chickenpox, during last wks of pregnancy Mild disease: disease onset in mother >= 5 days before

delivery or in newborn during first 4 days of life More severe disease: disease in mother <5 days before to 2 days a{er delivery or in newborn @ 5-‐10 days of life Severe disease: Pneumonia, hepaJJs, meningoencephaliJs, coagulopathy, mortality Treatment: VZIG, IV acyclovir (especially if chickenpox in

the mother within 5 days before or 2 days a{er delivery)


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Peds Derm 101 HH Handout