Case 32
Case 32
Case 32
Case 32
5-YEAR OLD WITH RASH - LAUREN
Author: Ashley Brunelle, M.D, Dartmouth Medical School & Mark Fergeson, M.D.,
The University of Oklahoma College of Medicine
Learning Objectives
1. Describe both primary dermatological lesions and secondary changes
commonly seen in pediatric patients in a systematic manner using
appropriate medical terminology.
2. Outline the key history and physical findings associated with the following
common pediatric dermatologic conditions: Urticaria, seborrheic dermatitis,
contact dermatitis, acne, superficial fungal infections, and scabies.
3. List a prioritized differential diagnoses for an urticarial rash.
4. Discuss the diagnosis and management of acne.
5. Discuss the general approach to choosing a topical steroid and the common
side effects associated with their use.
6. Discuss treatment options for common warts.
7. List at least three conditions in the differential diagnosis of diaper rash.
1. Lauren is a 5-year-old girl with a family history of atopy who presents with
an evanescent rash on her arms, legs, and trunk that is sometimes pruritic.
On physical examination, the rash is erythematous and slightly edematous.
There are multiple plaques with surrounding clearing and some wheals.
After considering the differential, she is diagnosed with acute urticaria,
advised to avoid potential allergens, and given antihistamine for
symptomatic relief.
2. Three-month-old Clara is brought to the physician for evaluation of a scalp
lesion. Physical examination reveals a waxy yellow scale and mild erythema.
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Case highlights: This case reviews the accurate description of primary and
secondary skin lesions. In addition to the above clinical scenarios, the student
completing this case learns about the differential diagnoses and treatment of
warts and diaper rash. The case is replete with photographs demonstrating classic
presentations of many common pediatric dermatology conditions.
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Scabies:
Tineas:
Tinea versicolor
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Warts (verrucae):
Mulloscum contagiosum:
Diaper rash:
Irritant dermatitis
Most common
Due to prolonged exposure to moisture, friction, and/or digestive enzymes
(worse with diarrhea)
Irregular areas of erythema with skin maceration on convex surfaces of the
skin
Typically spares the intertriginous creases
Diaper candidiasis
Bacterial infection
Less common
Usually in perianal area
Often caused by Group A Strep (Streptococcus pyogenes)
Potentially serious, leading to cellulitis and even dissemination via
bacteremia
Infant may be irritable
May see streaks of blood on stools
Zinc deficiency
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Skills
History:
Duration
Rate of onset
Location
Associated symptoms
Family history of similar symptoms
Patients allergies
New exposures
Previous treatments
Physical exam:
Skin exam:
Have patient disrobe completely (even if she/he says it looks the same
everywhere!)
Thoroughly examine every part of the skin, including mucous membranes.
Characterize by:
Size
Shape (flat, raised, domed, umbilicated)
Surface changes
Overall distribution
Primary lesions:
Description Size
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Differential diagnosis:
CASE 1 (Lauren)
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Triggers:
Drug
Food ingestion
Insect sting
Infection
Dog saliva (a more significant allergen than dander)
Viral exanthem
Starts on the face with a "slapped-cheek appearance followed by a
reticular, lacy erythematous rash on trunk and extremities.
Caused by parvovirus B19.
Erythema migrans:
Roseola:
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Viral exanthem that classically follows three to five days of a febrile illness.
Pink, maculopapular rash that starts on the trunk and may spread to the
face and extremities.
Caused by human herpes virus-6 (HHV-6)
CASE 2 (Clara)
CASE 3 (Lonnie)
1. Acne Vulgaris:
Reason for > 4.5 million doctors visits a year
85% of patients are age 1224 years
Caused by keratinous material and excess sebum (due to
androgens) plugging pilosebaceous glands
Increased sebum provides growth medium for superinfection with
proponiobacterium acnes
Located in neck, face, chest, upper back, and upper arms (areas with
greatest number of sebaceous glands)
Course of disease:
1. Starts as open comedones (blackheads) or closed comedones
(whiteheads)
2. Lesions can then become inflamed, which may lead to larger,
erythematous lesions called papules or pustules.
3. If lesions continue to progress, may lead to nodulo-cystic acne
2. Staphylococcal folliculitis and furunculosis:
May look similar to nodular or cystic acne
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CASE 4 (Kevin)
1. Contact dermatitis:
Common delayed type IV hypersensitivity reaction
Onset within 2472 hours from start of contact
Can occur despite prior tolerance to exposure
Resolves within days to weeks of avoidance
Causes:
Wide variety
Topical antibiotics such as the common generic "triple antibiotic
ointment" or bacitracin
Plants in the toxicodendrons (or Rhus) genus (poison ivy, oak,
and sumac)
Nickel
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CASE 7
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Management
Topical steroids
Acute urticaria:
Seborrheic dermatitis:
Infants: Use baby oil and a small brush to remove the scales.
May try medicated shampoos or a topical steroid, such as hydrocortisone
Older children and adults: Ketoconazole cream.
Most children grow out of it whether treated or not.
Acne:
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Overzealous cleaning
Important to consider how much acne affects teenager's quality of life when
deciding on a treatment.
Side effects:
Retinoids
Can cause photosensitization resulting in significant sunburn.
Direct patients to use this at night.
Inactivated by oxidation of BPO. Direct patients apply BPO
cream in the morning.
Must be applied to bone-dry skin or it may be significantly
irritating.
Can make acne transiently look worse.
Doxycycline:
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Photosensitivity
Dental staining in children under age nine
Teratogenicity
Pseudotumor cerebri
Pediculosis capitis:
No need to treat lice unless they are actually found on the patient.
Reassure families that lice infestation is not a reflection of poor hygiene.
Prevent lice by discouraging school-aged children from sharing belongings
such as hats, coats, combs, and barrettes.
Managing lice infestation:
Rinsing hair with vinegar or using ointments to "suffocate" the lice are
ineffective.
Comb wet hair with a fine-toothed comb.
Wash bedding, stuffed animals, hats, combs and brushes, and other
contaminated items in hot water or dry in high heat in the dryer.
Seal unwashable items in an airtight bag
Over-the-counter shampoos and rinses (permethrin or pyrethrins):
Increasing resistance to these agents.
Do not kill the ova (nits), so should use two or three times in weekly
intervals.
Prescription:
Malathion 0.5% topical is currently considered the most effective
drug.
Lindane used to be the treatment of choice, but is no longer effective
because of resistance.
Scabies:
Cover body from the hairline down with permethrin 5% cream at night
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before bed
Wash it off in the morning after 812 hours.
Repeat once more in a week.
After bathing, wash all bed linens and clothing worn during treatment.
Itching may persist for a few weeks.
May use a moderate potency topical steroid
Over-the-counter diphenhydramine
If itch persists > four weeks, may need to retreat
If patient does not respond well to permethrin or has an allergic response,
may give ivermectin orally (Food and Drug Administration [FDA] approved
for children greater than 15 kg).
Warts:
Tinea capitis:
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Diaper rash:
Irritant dermatitis
Diaper candidiasis
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