6/12/2015

1

Pediatric Rashes

Darwin M. Koller, MD, MSCE

Medical Director, Pediatric Emergency Department

Assistant Professor, Department of Pediatrics and Department of

Emergency Medicine

Goal

Review some common, non life-threatening

pediatric skin conditions

Scarlet Fever Scarlet Fever

All ages, most 1-10 yo, M = F, GABHS

More common late fall early spring

Rash appears 2-3 days after symptoms

Carrier states

Scarlet Fever

Fine punctate red papules

Pastia’s lines

Face flushed w/ peri-oral pallor

Sandpaper texture

Chest Ext, groin, axillae

Strep throat, palatal petechiae

Fever, malaise, HA, LAD, sore throat

Scarlet Fever

Can lead to ARF, PSGN

Benzathine PCN IM, Amoxicillin, Keflex

Zithromax or Biaxin in PCN-allergic patient

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Fifth’s Disease Fifth’s Disease

Erythema infectiosum

Parvovirus B19

Most 3-12yo, F > M

Late winter, early spring

Respiratory droplets

Begins 1-2 weeks after exposure

Prodrome – HA, malaise, fever, arthralgias

Rash appears day 3 or 4

Fifth’s Disease

Edematous plaques, macules, papules

“Slapped-cheek” appearance

Pink to red

Round to oval

Lacy reticulating appearance of lesions

Extensor surfaces, trunk, cheeks

No MM involvement

Roseola Infantum

Roseola

Exanthem subitum

HSV-6

6mo-3yo, M = F

Fever for 3-5 days Rash for 1-2 days

Well-appearing!!

Roseola

Maculopapular, 2-3mm

Rose pink

Trunk, spreads to neck and extremities

Rapid defervescence as rash appears

Self-limited

Symptomatic care

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Hand-Foot-Mouth Disease Hand-Foot-Mouth Disease

Children < 10 yo, M = F

Seasonal patterns in warmer months

Coxsackie A 16, Enterovirus 71

Highly contagious

Hand-Foot-Mouth Disease

Macules/papules vesicles

Pink to red, round/oval

Size 2 to 8 mm

Hands, feet, mouth

Fever, malaise, pain

Refusal to drink Dehydration

Hand-Foot-Mouth Disease

Self-limited 5-7 day course

Symptomatic treatment

– Miracle mouthwash

– Fluids

– Narcotic analgesia

Herpetic Whitlow Herpetic Whitlow

Any age, M = F, common

HSV – 1

Occurs 2 to 8 days post-exposure

Systemic symptoms rare (fever, LAD)

Lesions resolve over 1 to 2 weeks

Recurrences possible

Fingernail biters, thumb suckers, etc

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Herpetic Whitlow

Grouped 2-4 mm vesicles on red base

Distal fingers

Painful

Tzank smear

Self-limited

Symptomatic care

– Analgesics

– Acyclovir in severe or immunosuppressed

– Bactroban if signs of bacterial super-infection

Scabies (“Seven-Year-Itch”)

Scabies

Age < 5yo, young adults, M = F

Sarcoptes scabei

Transmitted by close proximity

Mites remain alive for 1-2 days off skin

Increased in crowded living conditions, low

SES, and immunosuppressed

Skin sensitization to mite

Scabies

Intraepidermal burrows and papulovesicles

Flesh-colored w/ surrounding erythema

Web spaces, wrists, elbows, genitals, feet

Spares face and neck

Widespread in infants

Severe pruritis!

Often close contacts with infestation/sx

Scabies

Persists for weeks even after treatment

Nodular lesions can last months

Permethrin 5% cream (Elimite)

– Apply neck to toes x 8h rinse

– Treat all close contacts & family members

– Repeat treatment in one week

– Bedding and clothes washed in hot water

Topical steroids for severe itching

Chicken Pox (Varicella)

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Chicken Pox (Varicella)

90% < 10 years old, M = F

Incidence declining due to VZV vaccine

Spread by direct contact & air droplets

Rash appears 2-3 days after exposure

Chicken Pox (Varicella)

Superficial thin vesicles, 2-5 mm

Watery yellow, crusts brown-red

Few to > 100 lesions

Face/scalp trunk/ext

Can appear on palate

Low-grade fever

Chicken Pox (Varicella)

Symptoms last 1-3 weeks

Self-limited

Severe in immunocompromised

Itching, pain and superinfection

Aveeno baths, topical antipruritics

Acyclovir if rash < 24 h old

Impetigo

Impetigo

All ages, M = F

Streptococcus

Systemic symptoms rare

Carriers are predisposed

Recurrence common

Contagious

Impetigo

Erythematous macules thin-roofed

vesicles crusts/erosions

Honey-colored yellow “stuck-on” crusts

Round or geographic

Scattered or confluent

Face, arms, legs, buttocks, digits

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Impetigo

Antibacterial soaps/washes

Topical antibacterials – uncomplicated

Oral antibiotics – complicated, face

Treat for 7 days

Treat close contacts

Ringworm

Ringworm (Tinea Corporis)

All ages, M = F, common

Exposure to kittens & puppies

Scaling, sharply marginated plaques

Size 1 to 10 cm

Pinkish red

Peripheral enlargement w/ central clearing

KOF prep or Fungal culture

Topical vs. oral treatment

Treat affected household members / pets

Tinea Capitis

Tinea Capitis

Children 1 to 10y yo, M > F, 5:1, AAF

Affects 3 to 8% of pediatric population

Trichophyton tonsurans 90% of U.S. cases

Scaly, pruritic patches on scalp w/ hair loss

LAD, low-grade fever

Endothrix

Karyon

KOH prep or fungal culture

Tinea Capitis

Trash all hair care utensils, wash pillows

Children may attend school once on meds

Antifungal shampoos decrease shedding

Need systemic therapy

– Griseofulvin (15mg/k/day) x 6 to 8 weeks

– Higher doses in refractory cases

– Newer agents: Itraconazole, Terbenafine

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Molluscum Contagiosum Molluscum Contagiosum

Children 2 to 16 yo, M > F, common

Transmitted by skin-to-skin contact

Increased incidence in young children,

swimmers, and kids who bath together

Can appear 14d to 6mo post-exposure!

Asymptomatic or mildly pruritic

Clinical diagnosis

Molluscum Contagiosum

Small (<5mm) shiny papules with central

umbilcation

Pearly white to flesh-colored, round

Isolated or multiple scattered lesions

Predilection for axillae, folds

Most self-resolve

Dermatology referral if removal desired

Pityriasis Rosea

Pityriasis Rosea

Benign, self-limited

Most common in adolescence

Viral-like prodrome

“Christmas Tree” pattern

Small round papules 1-2 cm scaly, oval

Fades over 2-3 months

Treatment – supportive, UV light

Questions?