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  • Id reaction – itchy, fine, papulovesicular rash on trunk, face or hands caused by hypersensitivity reaction to the fungus
  • Fever for 5 or more days Presence of 4 of the following: Bilateral conjunctival injection Changes in the oropharyngeal mucous membranes injected pharynx, injected lips, dry or cracked lips, strawberry tongue Changes of the peripheral extremities – peripheral edema or erythema, desquamation, periungual dequamation Rash - mostly truncal, polymorphic but not vesicular Cervical lymph node
  • As of 1994, only one controlled study looking at steroids in HSP Mollica et al 1992 – 168 ptts , half given pred for 2 weeks – none of these dev’d nephritis; but 12% untreated dev’d nephritis

Transcript

  • 1. Pediatric Visual Diagnosis Ilana Greenstone MD Division of Emergency Medicine Montreal Children’s Hospital McGill University Health Center
  • 2. Objectives
    • Recognize common pediatric dermatologic conditions
    • Expand differential diagnosis
    • Review treatment plans
    • Identify skin manifestations of systemic disease
  • 3. Terminology
    • Macules, Papules, Nodules
    • Patches and Plaques
    • Vesicles, Pustules, Bullae
    • Colour
    • Erosions – when bullae rupture
    • Ulcerations and excoriations
  • 4.  
  • 5.  
  • 6.  
  • 7.  
  • 8. Atopic Dermatitis
    • 3-5% of children 6 mo to 10 yr
    • Described in 1935
    • Ill-defined, red, pruritic, papules/plaques
    • Diaper area spared
    • Acute: erythema, scaly, vesicles, crusts
    • Chronic: scaly, lichenified, pigment changes
  • 9.  
  • 10. Atopic Dermatitis
    • Hints to diagnosis
    • Generalized dry skin
    • Accentuation of skin markings on palms and soles
    • Dennie-Morgan lines
    • Fissures at base of earlobe
    • Allergic history
  • 11.  
  • 12.  
  • 13.  
  • 14.  
  • 15. Atopic Dermatitis Treatment
    • Moisturize
    • Baths only
    • Anti-histamine
    • Topical steroids to red and rough areas
      • Prevex HC
      • Desacort
    • Immune modulators
  • 16.  
  • 17. Superinfected Eczema
    • Red and crusty
    • Usually S. aureus
    • Cephalexin 40 mg/kg/day divided TID for 10 days
    • More potent topical steroid
    • Topical antibiotic – Fucidin
    • Anti-histamine
    • Refer to Dermatology
  • 18.  
  • 19.  
  • 20.  
  • 21.  
  • 22. Scabies
    • Intense pruritus
    • Diffuse, papular rash
      • Between fingers, flexor aspects of wrists, anterior axillary folds, waist, navel
    • May be vesicular in children < 2 years
      • Head, neck, palms, soles
      • Hypersensitivity reaction to protein of parasite
  • 23. Scabies Treatment
    • 5% permethrin cream for infants, young children, pregnant and nursing mother
      • Kwellada-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
  • 24.  
  • 25.  
  • 26. Tinea corporis Ringworm
    • Face, trunk or limbs
    • Pruritic, circular, slightly erythematous
    • Well-demarcated with scaly, vesicular or pustular border
    • Id reaction
    • Mistaken for atopic, seborrheic or contact dermatitis
    • Treament: Terbinafine (Lamisil)
  • 27.  
  • 28. Pityriasis Rosea
    • Begins with herald patch
      • Large, isolated oval lesion with central clearing
    • More lesions 5-10 days later
    • Christmas tree distribution
    • Treatment: anti-histamines
  • 29. Eczema
    • Differential Diagnosis
      • Atopic dermatitis
      • Scabies
      • Tinea corporis
      • Pityriasis rosea
    • If vesicular, check for HSV1, HSV2, VZV
    • Beware of superinfection
    • Think of immune deficiency if difficult to treat
  • 30.  
  • 31.  
  • 32. Urticaria
    • Transient, well-demarcated wheels
    • Pruritic
    • Part of IgE-mediated hypersensitivity reaction
    • May leave central clearing
    • Triggers are numerous
  • 33.  
  • 34.  
  • 35.  
  • 36.  
  • 37. Kawasaki Disease Diagnostic Criteria
    • Fever for 5 or more days
    • Presence of 4 of the following:
      • Bilateral conjunctival injection
      • Changes in the oropharyngeal mucous membranes
      • Changes of the peripheral extremities
      • Rash
      • Cervical adenopathy
    • Illness can’t be explained by other disease
  • 38. Kawasaki Disease Lab Features
    •  WBC
    •  ESR, positive CRP
    • Anemia
    • Mild  transaminases
    •  albumin
    • Sterile pyuria, aseptic meningitis
    •  platelets by day 10-14
  • 39. Kawasaki Disease Differential Diagnosis
    • Measles
    • Scarlet fever
    • Drug reactions
    • Viral exanthems
    • Toxic Shock Syndrome
    • Stevens-Johnson Syndrome
    • Systemic Onset Juvenile Rheumatoid Arthritis
    • Staph scalded skin syndrome
  • 40. Kawasaki Disease Difficulties with Diagnosis
    • Clinical diagnosis
    • No single test
    • Diagnosis of exclusion
    • Atypical KD
      • Do not fulfill all criteria
      • More common in < 1 year and > 8 years
  • 41. Kawasaki Disease Treatment
    • Admit to monitor cardiac function
    • Complete cardiac evaluation
      • CXR, EKG, echo
    • IV Ig
    • ASA
  • 42. Kawasaki Disease Treatment
    • IV Ig 2 g/kg as single dose
      • Expect rapid resolution of fever
      • Decrease coronary artery aneurysms from 20% to < 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
  • 43.  
  • 44.  
  • 45.  
  • 46. Coxsackie Virus Hand-Foot-and-Mouth
    • Painful, shallow, yellow ulcers surrounded by red halos
    • Found on buccal mucosa, tongue, soft palate, uvula and anterior tonsillar pillars
    • Oral lesions without the exanthem = herpangina
    • Exanthem involves palmar, plantar and interdigital surfaces of the hands and feet +/- buttocks
  • 47.  
  • 48. Erythema Infectiosum Fifth Disease
    • Parvovirus B19
    • Mostly preschool age
    • Recognized by exanthem
    • Contagious before rash
    • Resolution between 3 and 7 days
  • 49.  
  • 50. Roseola
    • 6 to 36 months
    • Human herpesvirus 6
    • High fever without source and irritability for 3 days
    • Rash develops as fever decreases
  • 51.  
  • 52.  
  • 53. Impetigo
    • Mostly face, extremities, hands and neck
    • Localized unless underlying skin disease
    • Strep or Staph
    • Honey-coloured crust
    • Treatment: topical and systemic antibiotics
  • 54.  
  • 55.  
  • 56. Herpes Simplex
    • Gingivostomatitis most common 1 º 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
  • 57.  
  • 58. Herpetic Whitlow
    • 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
  • 59.  
  • 60.  
  • 61.  
  • 62. Henoch-Schonlein Purpura Clinical features
    • Palpable purpura of extremities
    • Arthralgia or non-migratory arthritis
      • No permanent deformities
      • Mostly ankles and knees
    • Abdominal pain
      • May develop intussusception
    • Renal involvement
      • Hematuria, hypertension, renal failure
  • 63. 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
  • 64. HSP Indications for admission
    • R/O intussusception
    • Severe GI bleed
    • Severe renal disease
    • Need for renal biopsy
    • Hypertension
    • Pulmonary hemorrhage
  • 65.  
  • 66. Acute Hemorrhagic Edema of Infancy
    • 4-24 months
    • Recent URI or antibiotics
    • Non-toxic
    • Resolves in 1-3 weeks
    • small- vessel, leukocytoclastic vasculitis
    • Annular or targetoid pupura and edema on face and extremities
  • 67.  
  • 68.  
  • 69.  
  • 70.  
  • 71. Conclusions
    • Not all that itches is eczema
    • Treatment is often supportive for viral exanthems
    • Remember rashes as a sign of systemic illness
    • Careful history and physical essential for evaluation of bruises
  • 72.