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Papules, Purpura, Petechia and Other Pediatric Problems: A Review of Peds Derm

Papules, Purpura, Petechia and Other Pediatric Problems: A Review of Peds Derm. David Chaulk PEM Fellow April 15 th , 2004. Neonatal Nasties…. Erythema Toxicum. Bad name…not toxic Usually occurs in first days of life 50% of healthy babies Erythematous macules +/- pustules and papules

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Papules, Purpura, Petechia and Other Pediatric Problems: A Review of Peds Derm

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  1. Papules, Purpura, Petechia and Other Pediatric Problems:A Review of Peds Derm David Chaulk PEM Fellow April 15th, 2004

  2. Neonatal Nasties…

  3. Erythema Toxicum • Bad name…not toxic • Usually occurs in first days of life • 50% of healthy babies • Erythematous macules +/- pustules and papules • Etiology unknown • No treatment necessary

  4. Erythema Toxicum

  5. Milia • Retention of keratin and sebaceous material • Usually disappears by 3-4 weeks • No treatment

  6. Milia

  7. Miliaria Rubra • Destruction of epidermal sweat ducts resulting in erythematous papules, vesicles or papules • Treat with humidity/cool baths

  8. Subcutaneous Fat Necrosis • Secondary to pressure in utero or during labour • Occurs during first days or weeks • Circumscribed erythematous or violaceous plaques • Infrequently associated with hypercalcemia

  9. Subcutaneous Fat Necrosis

  10. Infantile Acropustulosis • As it says… • Pustules (vesicles) on the hands, feet and dorsal surfaces • Intensely pruritic and recurrent • Occurs between 2-10 mos and resolves 24-36 mos • Treated with anithistamines and fluorinated corticosteroids if severe

  11. Infantile Acropustulosis

  12. Infantile Acne • Closed comedones and inflammatory papules • May last 1-2 years • Usually family history • Most don’t require treatment • May use topical treatment such as benzoyl peroxide

  13. Diaper and Candidal Dermatitis • Contact diaper dermatitis is caused by irritants, soaps detergents etc. • Candida is differentiated by satellite lesions • Widespread, pinpoint raised erythematous lesions with white scales • GI source and frequently post antibiotics

  14. Diaper and Candidal Dermatitis

  15. Seborrheic Dermatitis and Cradle Cap • Mainly involves scalp, face, trunk and intertriginous areas • Greasy, scaly, patch erythema • Unknown etiology • Treatment is hydration, mineral oil, petroleum, shampoos

  16. Seborrheic Dermatitis and Cradle Cap

  17. The Rash Relay! Two teams, limited info. & Spot Diagnosis Start with Infectious Stuff…

  18. First one’s easy…or is it? • 3 yo girl, second visit to ED in four days. First time, high fever without clear focus. No other symptoms. • Now returns with rash and fever has resolved

  19. What is the diagnosis? What is the infectious agent?

  20. Roseola Infantum • Macular or maculopapular rash appearing after defervescence on 3rd or 4th day of illness • Child usually looks well despite high fever and it is often associated with febrile seizure • Human herpes virus 6 (HHV-6)

  21. Another easy one… • It’s spring, you’re in the ED seeing a 6 yo girl with a rash. Yesterday it was only on her cheeks now it’s on her arms (extensors)

  22. What is this? What is the infectious agent? Extra Credit: Name two complications What about pregnancy exposures? Day 4 Day 5

  23. Parvovirus B19 • Aka: erythema infectiosum and fifth disease • Usually affects kids aged 3-12 years • Most common is spring • 6-14 day incubation period • Day 1:slapped cheek • Day 2:lacy, erythematous rash on extensors • Day 6 fading rash with lacy, marble appearance

  24. Parvovirus B19 • Complications: • Arthritis, aplastic anemia and hemolytic anemia • Pregnancy • 50% of women seropositive before pregnancy • Likelihood of transmission if exposed 30-50% • If fetus infected 2-10% rate of loss • Thus risk is actually fairly low

  25. Now for a couple of hard ones… • 3 yo girl with high fever, cough, runny nose, looks unwell. Rash started on face initially and is now spreading. • Parents are granola types and the child isn’t immunized

  26. Diagnosis? Name 1 acute complication, and one longterm complication

  27. Measles (Rubeola) • Starts with cough, coryza and conjunctivitis, then Koplik spots and morbilliform rash • Rash fades after 3-7 days in same order that it started • Acute complications: OM and pneumomia • Long term: SSPE

  28. Another tough one… • This time a 2 year old unimmunized child, presents with 3 days history of URT symptoms. Parents bring him in because they notice his glands are swollen and he has a rash

  29. Diagnosis? How is it different from measles? What is the presentation of congenital infection?

  30. Rubella • Generalized maculopapular rash with cervical, postauricular and occipital LN • 3-5 days of viral prodrome followed by mobile rash that goes from head to toe in 24h • May get petechiae on the palate • Essentially not as sick/ not as high fever as measles • These are the blueberry babies

  31. Back to stuff we actually see… • 7 yo child presents in October with vomiting and diarrhea • On exam you find… • Name 2 serious complications • Hint, they start with M

  32. Coxsackie • Hand, Foot and Mouth Disease • Highly contagious and usually occurs in late summer, fall • Viral illness precedes rash, start as macules and evolve into vesicles • 25-65% get lesions on hands and feet • Usually get lymphadenopathy and may get dehydration • Serious but rare complications include myocarditis and meningoencephalitis

  33. Next… • 7 yo boy with few days of cough and cold, now has sore throat and rash • Diagnosis, infectious agent and treatment? • What is the pathognomonic rash associated with it?

  34. Scarlet Fever • Exotoxin mediated rash secondary to GAS infection of the pharynx or skin • Oral mucosal rash (petechial), strawberry tongue • Erythematous, blanchable, generalized rash • Intense in skin folds with linear, petechial eruptions – Pastia Lines • May get desquamation 5 days post • Treat with Penicillin

  35. Gotta know this one… • 4 year old girl, sick for a week now, cough runny nose, rash. Parents bring her in because she cries all the time Name the diagnostic criteria What is the treament What are we trying to prevent with treatment?

  36. Kawasaki’s Disease • FEEL My Conjunctivits • Fever – greater than 5 days plus four of: • Extremitity changes (erythema, edema) • Erythematous Rash (can be any rash except petechial) • Lymphadenopathy (>1.5 cm, may be unilateral) • Mucositis (bright red lips, strawberry tongue) • Conjunctivitis (bilateral, non-purulent)

  37. Kawasaki’s Disease • Other frequently associated findings: • Irritability (~90%) • Urethritis/sterile pyuria (70%) • Aseptic meningitis (50%) • Hepatitis (30%) • Arthralgia/arthritis (10-20%) • Hydrops of the gallbladder (10%) • Myocarditis/CHF (5%) • uveitis

  38. Kawasaki’s Disease • Untreated 20% will develop coronary aneurysms with treatment less than 5% • Treatment • IVIG 2 g/kg • High dose ASA 80-100 mg/kg until afebrile then: • Low dose ASA 5 mg/kg for 6-8 weeks if no evidence of aneurysms

  39. Case I had last week… • Todd no comments: • 4 yo girl with one week history of rash • Started on steroids by fp, not improving, thinks they are getting worse. Also complaining of ankle pain and swelling

  40. What is the diagnosis? Name two surgical complications What long term risks are associated with this?

  41. Henoch-Schonlein Purpura • Unknown etiology but frequently follows viral infection ? Autoimmune • Rash is erythematous papules followed by purpura • Frequently associated with joint pain and swelling • Abdo pain not uncommon, sometimes as presenting feature

  42. Henoch-Schonlein Purpura • Surgical Complications Include: • Intussusception • Testicular torsion • Long term complications: • Glomuerulonephritis/renal disease • Hypertension • No effective treatment. • Soft evidence for steroids reducing abdominal pain and risk of torsion. Not effective for rash.

  43. Last case in this round! • Previously well 3 month old boy, presents with this very tender rash. By the next day he has the 2nd photo appearance

  44. Staphylococcal Scalded Skin Syndrome • AKA TEN (toxic epidermal necrolysis) • Exotoxin mediated reaction to coagulase positive staphylococcal infection • In adults more commonly caused by drug reaction • Rash is initially erythematous, sandpaper like and very tender

  45. Staphylococcal Scalded Skin Syndrome • After 2-3 days skin will peel (Nikolsky sign) • Pathognomonic facies, crusting perioral erythema with fissures at the nasolabial folds and corner of mouth • Spares MM, palms and soles

  46. Now for the speed round Spot Diagnosis

  47. First • 10 yo girl, very itchy rash mostly affecting web spaces

  48. Scabies • The culprit Sarcoptes scabeii

  49. Scabies • Usual locations

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