Pediatric Rashes

Kersten Milligan RIIWednesday August 7, 2013

Before we begin

• Objectives– Learn to recognize common pediatric rashes– Learn to recognize emergent rashes

So You’ve got patient with a rash

• Step 1: Don blue gloves• Step 2: History• Onset• Evolution• Associated symptoms• Prior treatment

• Step 3: Physical• Strip• Examine

Remember your anatomy…

EpidermisRashes involving the Epidermis• Eczematous• Scaling• Vesicular• Papular• Pustular• Hypopigmented

Rashes not involving the epidermis• Erythema• Purpura• Induration

Common Rashes

• Scabies

• Acne

• Contact Dermatitis• Irritant• Allergic

• Atopic Dermatitis

Scabies

Adult infection

Now what?• Permethrin• Tx household contacts• Recommend spring cleaning

Acne

Zit Pathology

Treatment

“Permanent scarring of the skin and the psyche can result...”

Contact Dermatitis

Irritant• Physical and chemical

alteration of epidermis• High concentration required• Gradual onset• Tx:

– Decrease exposure– Protective barrier

Allergic• Delayed hypersensitivity

reaction• Reaction to low

concentration• Rapid onset• Tx:

– Avoid exposure (wash skin!)– Diphenhydramine– Topical steroids

Irritant Dematitis

Irritant (Pacifier) Dermatitis

Allergic Contact Dermatitis

http://www.webmd.com/skin-problems-and-treatments/picture-of-allergic-contact-dermatitis

Allergic Contact Dermatitis

Brown henna with paraphenylenediamine (PPD) = “black henna”

Allergic Contact Dermatitis

Atopic Dermatitis (Eczema)

Infant• 4mo-5 yo• Cheeks• Extensor surfaces• Diaper area

Child• 3yo-adulthood• Antecubital and popliteal

flexion area• Neck• Face• Upper chest

Atopic Dermatitis

Atopic Dermatitis

Atopic Dermatitis

Atopic Dermatitis (Eczema) Treatment

• Cotton clothing, avoid nonessential toiletries and detergents (bounce, downy, snuggle syndrome)

• Warm baths pat dry topical steroids and moisturizers (Cetaphil or Vaseline)

• Watch for super imposed infection

Rashes that need treatment

• Impetigo

• Tinea

Impetigo

Impetigo

Impetigo

Impetigo

Impetigo

Impetigo

Bullous impetigo

• Epidermolytic toxin

• Bullae• Crust

Bullous impetigo

Bullous Impetigo

Impetigo

• Staphylococcus aureus• Group A streptococcus

• Not usually painful• Palpate for regional lymphadenopathy• Contagious• Complications: Postpyodermal acute

glomerulonephritis

Impetigo Treatment

• Mupirocin 2% ointment– Soften crusts first with wet washcloth– TID

• Erythromycin• 30 mg/kg/day x 10 days

• Cephalexin• 30-40 mg/kg/day TID x 7-10 days

Tinea Corporis

Tinea Corporis

Dermatophyte

Tinea Versicolor

Malassezia globosa

Tinea Capitis

Dermatophyte

Kerion

Treatment• Tinea Corporis

– Topical antifungals• Clotrimazole (Lotrimin), tolnaftate (Tinactin), miconazole, terbinafine,

haloprogin• Tinea Versicolor

– Topical antifungals– Selenium Sulfide shampoo

• Tinea Capitus – Systemic treatment– Griseofulvin 20 mg/kg/day x 6 wks– Selenium sulfide shampoo twice weekly

• Kerion– Treat as Tinea Capitus– Add prenisone 1 mg/kg/day x 1-2 wks

Emergent Rashes

• Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

• Neisseria meningitidis• Measles• Rocky Mountain Spotted Fever

Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

SJS/TEN

SJS/TEN

SJS/TEN

SJS/TEN

Stevens-Jonhson Syndrome/Toxic Epidermal Necrolysis

Diagnsosis• Prodrome – HA, pharyngitis,

stomatitis, conjuctivitis• Spectrum of disease from

<10% to >30% epidermal detachment

• Hypersensitivity reaction• Separation of the epidermis

from the dermis (Nikolsky’s sign)

• Death from sepsis

Treatment• Admission to Burn Unit• Supportive care• Steroids controversial

Neisseria meningitidis

N. meningitidis

N. meningitidis

N. meningitidis

N. meningitidis Treatment

Rosens. Table 173-3 -- Empirical Antibiotics for Treatment of Acute Bacterial Meningitis

Measles

• Vaccine 1963• 99% reduction in US• >150,000 deaths

annually worldwide• 90% infection rate

Measles

Measles

• Exanthem• Blanching macules and papules• Hyperpigmented patches that

desquamate

Measles

Diagnosis• Fever, malaise• Cough, coryza, conjunctivitis• Koplik’s spots• Maculopapular erythematous

lesions starting on forehead and upperneck

• Complications:– Otitis Media, encephalitis,

pneumonitis– 1/1000 encephalitis, 15%

mortality

Treatment• Supportive• Isolation ? as patient

contagious 2 days before symptom onset

• 0.25 mL/kg IM ISG (human immune serum globulin) within 6 days

• Live vaccine w/in 72 hours of exposure

• Vitamin A

Rocky Mountain Spotted Fever

RMSF

• Erythematous blanching macules

RMSF

RMSF

RMSF

Rocky Mountain Spotted Fever

Diagnosis• Mostly SE US• HA, N/V, fever• Rash on 2nd-4th day• Erythematous blanching

macules. • Wrists and ankles trunk• May become petechial

Treatment• Children <45 kg

– Doxycycline 2.2 mg/kg BID x 7-14 days

• 25% mortality without treatment

Doxycycline is the first line treatment for adults and children of all ages and should be initiated immediately whenever RMSF is suspected. -CDC

1. Cydulka RK, Garber B. Dermatologic Presentations. In Marx J, ed. Rosen’s Emergency Medicine. Philadelphia, PA: Elsevier; 2010.

2. Habif MD, Thomas P. Clinical Dermatology, 4th Edition – A Color Guide to Diagnosis and Therapy. Philadelphia, PA: Mosby; 2004.

3. Murray OMSII, Alexandra. Deadly Rashes Not to Miss in the ED. American Academy of Emergency Medicine. http://www.medscape.com/viewarticle/804255?nlid=31985_541&src=wnl_edit_medp_emed&spon=45. Accessed August 06, 2013.

4. Rampal MD, Angelika. Pediatric Rashes to Worry About: Slideshow. http://reference.medscape.com/features/slideshow/pediatric-rashes. Accessed August 06, 2013.

References