Dermatology - Peds

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 phenomenon: 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 symptoms: 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

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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



112 Pediatrics


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 associated 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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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, papules & plaques

Nail dystrophy - pitting, other

Guttate type: Drop-like lesions on trunk, often after streptococ-cal infections, URI

Localized pustular 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 corticosteroids, 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 without scarring

Antibacterial washes

Topical antibiotics if localized

Systemic antibiotics if extensive or recurrent



114 Pediatrics


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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Toxic shock syndrome

Di use maculopapular 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 systemic symptoms with rapid decompensa-tion

IV third- generation cephalosporin, PCN, chloram-phenicol

Treat contacts 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, erythematous, 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 spontaneously resolve over 23 wk

Monitor hydration status

Carafate PO


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 complications: 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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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 treatment with antivirals


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 herpeticum: 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 associated 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


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 common 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 ammatory boggy, erythematous mass with fol-licular pustules (kerion)

May be associated 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 antifungal BID

Tinea cruris (jock itch)

Pruritic, often symmetric, well-demarcated, scaly, erythematous plaques in inguinal folds, upper thighs

May spread to buttocks and perianal area

May have raised papular or pustular margin

Topical antifungal BID

Moist area aids coloni-zation

Often with concomi-tant tinea pedis



Dermatology 119 PED

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Disease DescriptionClinical course Treatment Other

Tinea versicol-or (Malassezia furfur)

Hypo- or hyperpigmented 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 dermatitis: 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, erythematous 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



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, erythema, 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 ending agent if possible; desensitization if necessary

TCS or antihistamines for pruritus

Urticaria (immediate IgE-media-ted hyper-sensitivity)

Pruritic, transient erythematous, edematous papules and plaques

May have central pallor (wheals)

PCNs, cephalosporins, 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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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 corticosteroids

Epinephrine

Avoid drug in future; desensitize if necessary

Serum sickness-like reaction

Urticarial, morbilliform, 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 annular, 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 several days with postin amma-tory pigment changes

Recurs in same location upon reexposure

Stop o ending agent

Topical corticosteroid

Acute generalized exanthema-tous pustulosis (AGEP)

Erythematous edematous plaques with small, nonfol-licular, sterile pustules favoring intertriginous areas, trunk, and extremities

May have burning, pruritus

-lactam antibiotics, macrolides, CCBs, antima-larials

122 Pediatrics


Drug reaction with eosino-philia and systemic symptoms (DRESS), drug hyper-sensitivity syndrome (DHS)

Starts morbilliform 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 corticosteroids

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 without 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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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



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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