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Daniel Tawfik, MD, PGY-3

6 November 2013

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8yo boy with 4 weeks of rash 4 weeks ago:

Erythematous, pruritic rash began over right shin.

One day later, also noted similar rash on left shin.

Slowly worsening pruritis.

2 weeks ago: Noted rash spreading to trunk, extremities, groin, and

buttocks. Saw PCP, started on Triamcinolone cream and Cetirizine. Mild

benefit noted, but stopped after 2 days.

Continued worsening pruritis and spread of rash.

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PMH: Epidural hematoma 4 years ago afterfalling down stairs

Meds: none FHx: Brother with eczema SHx: Lives with parents and 3 siblings Imms: up to date except influenza Allergies: NKDA

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VITALS: Temperature 36.5, HR 92, RR 16, weight of 23.1 kg. GENERAL: awake, alert, attentive, well-appearing. HEENT: Tympanic membranes normal. Oropharynx normal. No lesions noted

in the mouth, nares, or the conjunctival region. No conjunctival injection. NECK: No lymphadenopathy of the neck. CARDIOVASCULAR: S1 and S2 are normal without murmur, gallop, click, or rub. RESPIRATORY: Lungs are clear to auscultation throughout without rhonchi,

wheezes, grunting, retractions, or nasal flaring. GASTROINTESTINAL: Abdomen is soft and nontender without rebound,

guarding, or masses. Bowel sounds are normal. There is no organomegaly. EXTREMITIES: Warm and well perfused. DERM: Well-demarcated erythematous scaly plaques on the bilateral shins

with overlying yellow-colored crusting. Numerous pink scaly papules and

plaques scattered on the neck, chest, abdomen, back, and bilateral upper andlower extremities, many with overlying hemorrhagic crusts.

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Derm Allergic contact

dermatitis

Irritant contact dermatitis Atopic dermatitis Nummular dermatitis Bullous pemphigoid Photosensitivity

Stasis dermatitis Linear IgA Dermatosis Dermatitis Herpetiformis Granuloma annulare

ID Mycosis fungoides Scabies

Cutaneous tuberculosis Viral exanthem Gianotti-Crosti Syndrome

Heme/Onc Cutaneous T-cell

Lymphoma Other

Drug eruption

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Overview Response to an exogenous agent

Nickel, ammonium, gold, thimerosal, p-toluenediamine (hair

dyes), poison ivy, poison oak, poison sumac T-cell mediated delayed-type hypersensitivity

reaction Common association with atopic dermatitis

Erythematous plaques and pruritis most prominent Also edema, vesiculation, bullae

Usually confined to area of contact with allergen May spread by secondary transfer

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Acute, pruritic dermatitis Distant from initial focus

Pathogenesis not fully understood May be due to cytokine effect

May be due to dissemination of antigen

Treatment similar to ACD

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Avoidance of offending agent! Topical corticosteroids

First line treatment

Treat similar to atopic dermatitis

Example: Triamcinolone 0.1% ointment BID Topical calcineurin inhibitors

For failure of topical steroids or if on face/intertriginous areas

Slower onset than steroids, and may cause burning/stinging

Example: Tacrolimus 0.1% ointment BID Topical symptomatic relief

May reduce itching and discomfort

Examples: calamine lotion, oatmeal compresses, oatmeal baths Topical emollients

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Systemic corticosteroids If involving >20% of body surface area If quick relief is needed (face/hands/feet/genitalia involvement)

Systemic antibiotics If evidence of secondary bacterial infection

Systemic symptomatic relief Primarily target pruritis Examples: Cetirizine, Diphenhydramine

Systemic immunosuppression Rarely needed May be needed if allergen avoidance is impossible (aeroallergens or

photodermatitis) Examples: Azathioprine, Mycophenolate mofetil, Cyclosporine

Phototherapy Psoralen+UVA (PUVA) or narrow-band UVB If chronic dermatitis unresponsive to topical/oral steroids

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Acute treatment Avoid shin guards responsible for rash Triamcinolone 0.1% ointment BID to trunk and

extremities Cetirizine 5mg PO daily Diphenhydramine 25mg PO qHS Cephalexin 30 mg/kg/day PO divided TID for 10 days

Bathe in lukewarm water, pat skin dry, andimmediately moisturize with Eucerin cream, 1-2 timesper day

Bleach baths 2x/week (1/4 cup to half bath or 1/2 cupto a full bath)

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1 week later Had not taken full course of topical steroid or

antibiotics

Still with diffuse rash

Started Prednisolone 24mg PO daily x 7 days

Restarted Cephalexin x 10 days

Restarted Triamcinolone ointment Continued Cetirizine

Continued Diphenhydramine