Common Pediatric Skin and Soft Tissue Conditions

Sirous Partovi, M.D.

Erythema Toxicum Neonatorum

Impressive title - harmless skin conditionErythematous macule with a central tiny papule, seen anywhere - except the palms and soles.The lesions are packed with eosinophils, and there may be accompanying eosinophilia in the blood count. The cause is unknown, and no treatment is required as the rash disappears after 1-2 weeks.

MiliariaPrickly heat, sweat rash Many red macules with central papules, vesicles or pustules are present. These may be on the trunk, diaper area, head or neck.

Subcutaneous Fat Necrosis

Self limited, benign conditionSharply demarcated reddish to violaceous plaques or nodulesEtiology uncertainOnset first few days- weeks of lifeCheeks, back, buttocks, arms, and thighs

Infantile Atopic DermatitisCause is unknownRed, itchy papules and plaques that ooze and crustSites of Predilection

Face in the youngExtensor surfaces of the arms and legs 8-10 mo.Antecubital and popliteal fossa , neck, face in older

Differential Diagnosis- Atopic Dermatitis

Seborrheic dermatitisContact dermatitisNummular eczemaPsoriasisScabies

Eczema- TreatmentAvoidance or elimination of predisposing factorsHydration and lubrication of dry skinAnti-pruritic agentsTopical steroids

Seborrheic DermatitisCommon, generally self-limitingIts cause remains ill-understoodThere is a genetic predisposition Most frequent between the ages of 1 to 6 mo.Greasy, salmon-colored scaling eruption Hair-bearing and intertriginous areasThe rash causes no discomfort or itching

Seborrheic Dermatitis-Treatment

Anti-seborrheic shampooTopical steroids

Pityriasis RoseaMild inflammatory exanthem of unknown cause, maybe viralBenign, self limited disorderOccasionally there are prodromal symptoms including malaise, headache, sore throat, fatigue, and arthralgia.Herald patch- pink in color and scaly-mimicking tinea corporis

Diaper Rash

Candidal DermatitisStarts off in the deep flexures which show widespread erythema on the buttocks-beefy red colorThere are also raised edge, sharp marginization and white scale at the border of lesions, with pinpoint pustulo-vesicular satellite lesions

Seborrheic DermatitisSalmon-colored greasy lesions with yellowish scale and predilection for intertriginous areasInvolvement of the scalp, face, neck, and post auricular and flexural areas

Irritant DermatitisRash confined to the convex surfaces of the buttocks,perineal area, lower abdomen, and proximal thighs, sparing the intertriginous creases Excessive heat, moisture, and sweat retentionHarsh soaps, detergents, and topical medications

Viral Exanthems

Smallpox- VariolaFatality 40 %First invades upper respiratory tractFrom lymph nodes it spreads via hematogenous spreadChills, fever, headache, delirium, SZFace to upper arms and trunk, and finally to lower legs

Chickenpox-VaricellaHerpes virus varicellaeIncubation period 10-21 daysFever, malaise, cough, irritability, pruritusPapulesvesicles crustingSpreads centripetally

VaricellaComplications:

Bacterial superinfectionCNS involvementPneumoniaHepatitis, arthritisReye’s syndrome

VZIG

Varicella – TreatmentOral acyclovir- indications

Healthy nonpregnant teenagers and adultsChildren > 1 yr with chronic cutaneous or pulmonary conditionsPatients on chronic salicylate therapyPatients receiving short or intermittent courses of aerosolized corticosteroids

Dose: 80 mg/kg/day in four divided doses for 5 days

Varicella – Post exposure VZIG (1 vial/5 kg IM) :

Pts on high dose steroidsImmunocompromised without a history of CPPregnant womenNewborns exposed 5 days prior to birth and 2 days after deliveryNeonates born to nonimmune mothersHospitalized premature infants < 28 weeks’ gestation

MeaslesRubeola- paramyxovirusOccurs in epidemicsIncubation 8-12 daysFever, lethargy, Cough, coryza, conjunctivitis with clear discharge and photophobiaKoplik spotsRash begins on the face and spreads to trunk and extremities

Measles – Post ExposureImmunoglobulin therapy- indications

All susceptible contactsInfants 5 mo. To 1 year of ageImmunocompromisedPregnant women<5 mo. If mother without immunity

Live measles virus vaccine- contraindicationImmunocompromised- excluding HIVPregnancyAllergy to eggs, or neomycin

RubellaGerman MeaslesEpidemic natureWinter-springProdromeFace neck trunkLymphadenopathySerologic testing

Hand-Foot-Mouth DiseaseEnteroviruses

coxsackieviruses A and Bechoviruses

Vesicular lesions, may be petechialAssociated with aseptic meningitis, myocarditis

Erythema InfectiosumFifth diseaseMildly contagious, parvovirus B-19Pre-school and young school-age childrenProdrome: mild malaiseRash: “slapped cheek”, circumoral pallor, peripheral mild macular distribution Complication

Exanthem SubitumRoseola InfantumChildren 6-19 monthsAbrupt onset of high feverFebrile seizuresRash develops after fever dissipatesMainly on trunk

Infectious MononucleosisAcute, self limited illnessEpstein-Barr virusOral transmission – incubation 30-50 daysFever, fatigue, pharyngitis, LA, splenomegaly, atypical lymphocytosisExanthem is seen in 10-15%Erythematous, maculopapular, morbilliform, scarlatiniform, urticarial, hemorrhagic, or even nodular

Bacterial Exanthems

ImpetigoSuperficial infection of the dermisTwo types:

Impetigo contagiosaBullous impetigo

EtiologyGroup A ß hemolytic streptococcusCoagulase positive S. aureus

Treatment : Keflex, erythromycin, Bactroban

Scarlet FeverToxin producing strain of group A -hemolytic streptococcusStrep pharyngitis with systemic complaintsRash from neck to trunk to extremitiesSandpaper feel, erythema, warmthWhite and red strawberry tonguePetechiae in linear formComplicationsTreatment

Staphylococcal Scalded-Skin Syndrome

Generally in less than 5 years of ageInduced by exotoxin produced by staphylococciFever, papular erythematous rash starting around mouth- not involving oral mucosaPositive Nikolsky’s signDiagnosis: Tzanck test, bacterial cultureTreatmentComplications

Meningococcemia

Usually sudden onset of fever, chills, myalgia, and arthralgiaRash is macular, nonpruritic, erythematous lesionsPetechial rash develops in 75% of casesNeisseria meningitidesFever, rash, hypotension, shock, DICTreatment: PCN G

Differential Diagnosis

Gonococcemia HSPTyphoid feverRickettsial diseaseErythema multiformePurpura fulminans

Rocky Mountain Spotted Fever

Most common rickettsial infection in USAbrupt fever, headache, and myalgiaRash from extremities towards trunkMaculespetechiaeTreatment

TetracyclineDoxycyclineChloramphenicol

CellulitisMost common organisms:

S. aureusS. pyogenesH. influenza type B (HIB)

Most common sites?CBC, x-ray?

Cellulitis- TreatmentIV antibiotics in:

ImmunocompromisedIll appearingSuspected bacteremia<6 mo. Of ageWBC> 15KHigh feverRapidly progressing

Periorbital- Orbital Cellulitis

S. aureus, S. pneumoniae, and HIB CBC, blood culture, CTLP?IV antibioticsAdmit

Fungal Infections

Henoch-Schnlein PurpuraNo clear etiologic agent, often post viral2-10 years of agePalpable purpura over the buttocks and LETransient migratory arthritisRenal and GI involvement

Kawasaki SyndromeUnknown etiologyPeak incidence 18-24 monthsClinical findings:

Fever for at least five daysConjunctivitisPolymorphous rashOral cavity changesCervical adenopathy