WE-216 Classic Pediatric Rashes

(+)Randolph J.
Cordle, MD, FACEP Medical Director, Levine Children's Hospital, Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina; Fellowship Director, Pediatric Emergency Medicine Fellowship
Classic Pediatric Rashes

Do children with rashes still stump you? The speaker will review pediatric rashes, from classic childhood exanthemas to unusual and life-threatening cutaneous disorders. Measles, varicella, roseola, Kawasaki's disease, impetigo, and staphylococcal scalded skin syndrome will be presented using a case-based format. Review the common and no-longer common pediatric exanthems. Differentiate among benign and life-threatening pediatric rashes. Discuss the various treatment choices for these conditions.
WE-216 Wednesday, October 7, 2009 1:30 PM - 2:20 PM Boston Convention & Exhibition Center
(+)No significant financial relationships to disclose
Randy Cordle MD, FACEP, FAAP, PEM.
Classic Rashes: Infants and Children

Randy Cordle FACEP, FAAP, PEM
Medical Director: Division of Pediatric Emergency Medicine Program Director: Pediatric Emergency Medicine Fellowship
Mandatory Objectives Slide

Provide Visual Review Benign vs. More Serious Rashes Identify Common Childhood Rashes Broad Brush Strokes Re: Treatment A Few Can Cant Miss Miss Rashes
Levine Children Childrens Hospital Carolinas Medical Center
Bottom Line Objective

Put a picture in your brain. Make it easier to Google Google the rash. Things I Ive Seen Confused. Improve Communication: Colleagues. Decrease Over Testing. The Phone Call .. Call..
Communication
Sick or Not Distribution Pattern of Lesions Level(s) of skin effected Primary and Secondary Lesions
Communication
Macule <1cmPatch >1cm Papule <1cmPlaque >1cm Nodule small deeper, Tumor big Petechia <3mm, Purpura >3mm Vesicle <1cm, Bullae >1cm Pustule = pus Wheal= comes and goes Enanthem= Mucous membrane c Exanthema
Classic Exanthems
1st- Measles 2nd- Scarlet Fever 3rd- Rubella 4th-Duke Dukes diseasedisease- mixed viral causes. 5th- 5ths disease disease Parvovirus th 6 - Roseola
Zitelli Teaching Slide Set
Subcutaneous Fat Necrosis

Occurs at sites of trauma Often follows forceps trauma to face. Firm nodule follows erythematous mark. Usually goes away over a months.
Erythema Toxicum Neonatorum

Full term infants on day 22-3 of life Up to 50% of newborns will have this 1-2 mm firm yellowyellow-white papules surrounded by erythema Blanches with pressure
Erythema Toxicum Neonatorum

Lesions sterile but may contain Eos Not on palms and soles Fades in 77-10 days Flea bite bite dermatosis of newborn
Acropustulosis of infancy
Off and on 3 week pruritic episodes. Makes them fussy. Wanes by 3 years. Usually starts in first 3 months. Effects palms and soles (+others areas) Intraepidermal sterile pustules. Treat locally applied steroids.
Contributed by Dr. Randolph Cordle
Transient Neonatal Pustular Melanosis

Unknown etiology. Usually present at birth. 1-2 mm vesiculopustules first. Followed by hyperpigmented macules with collarette of scale. Most frequent on forehead and neck.
Transient Neonatal Pustular Melanosis

Occur anywhere on body. Lesions sterile. Many neutrophils if stained. Fades in a few weeks to months. No treatment necessary.
Miliaria Crystallina
A normal baby rash Very superficial 11-2 mm vesicles. Secondary to obstructed eccrine glands. Contain retained sweat. Common on head, trunk, and neck in infants and areas of sunburn in kids. Leave a thin white scale after rupture.
Miliaria Rubra
AKAAKA- Prickly Heat A normal baby rash. Basically miliaria crystallina but the sweat in the eccrine ducts ruptures out into the surrounding tissue. Flexural areas Exacerbated by heat and humidity Spontaneous resolution
Copyright 2009 Challenger Corporation. All rights reserved.
Sebaceous Gland Hyperplasia

Normal full term baby rash Reaction to maternal androgens. Usually 11-2 cm papules Usually located in places on the face where teenagers get zits. zits. Resolve by 44-6 months of age.
Seborrheic Dermatitis
Greasy yellow scale on salmon patch. Intertriginous areas often first effected. Scalp involved in infants. Can become thick and adherent. Weeping and fissuring Transient post inflammatory depigmentation common.
Seborrheic Dermatitis
Associate with Pityrosporum infection. Treatment
Comb scale after emollients. Keratolytic shampoos (H and S). Low potency local steroids. Sometimes azole antifungals. Secondary bacterial and candidal infection?
Diapers
2 month old with a diaper rash Mother states, She lets me know when she needs changed by crying like she is in pain. pain.
Irritant Diaper Dermatitis

Red and Raw Not in skin folds Superficial with light scale Only in areas of diaper contact History is important
Irritant Diaper Rash

Treatment
Diaper off or changed more frequently Barrier ointment qid 1% hydrocortisone cream
Irritant Diaper Rash

If rash there greater than 5 days, any hint of satellite lesions or if they have thrush, then treat with nystatin or clotrimazole orally and on skin. Apply barrier cream last. Always look in the mouth.
Candidal Diaper Dermatitis

Rash greater than 5 days. Satellite lesions. Intertriginous areas. Expands outside the diaper. Associated with thrash. thrash.
Candidal Diaper Dermatitis

Treatment
Common
Nystatin cream or ointment qid. Treat 33-4 days after rash gone. Azoles work well also.
New ideas
Always treat orally if thrush or persistent. Consider oral nystatin in all cases. Consider miconazole orally for thrush. Consider fluconazole if suppressed.
Seborrheic Diaper Dermatitis

Usually face, scalp, or posterior auricular areas will also be affected. Salmon colored greasy lesions. Often yellow scale Mostly intertriginous areas Dandruff of the diaper area
Contributed by Dr. Bernard Cohen: Derm Atlas
Seborrheic Diaper Dermatitis

Starts 33-4 weeks of age. Usually gone by 33-4 months of age. Possibly due to Pityrosporum yeast. Tx of choice = ketoconazole cream
antifungal and antianti-gram positive.
Hydrocortisone cream also useful Bid. Persistent: consider immunodeficiency.
Acrodermatitis Enteropathica
Due to Zn deficiencydeficiency- Give Zn Brain atrophy! Periorofacial, acral and diaper areas. Irritable with behavior changes. Autosomal recessive form rare. Nutritional form not so rare
Especially if parenteral nutrition.
Cutis Marmorata
A vascular pattern with cold stress. Key: Symmetric and wide spread. Goes away with warming skin. If persistent consider trisomies.
cutis marmorata telangiectatica congenita
Heel stick pustules

Can occur after heel stick sampling. Present days to couple week later. Watch for secondary infection. Typically clear with time.
Harlequin Color Alteration

A vascular phenomena of young infants. Side down turns red lasting 55-20 min. Often recurs until about 4 months. No known serous associations. Blanches with palpation
Umbilical Cord
Simple Granulomas: Cauterize
Stay off the skin.
Omphalitis
Can progress to myonecrosis, necrotizing fascitis, sepsis and death. Polymicrobial: G+, GG- and anaerobes. Culture blood and wound. Consider Nafcillin and Gentamicin.
Add Clindamycin for anaerobes
Especially if necrotizing fascitis.
Differentiate from
Patent UrachusUrachus- urine output Omphalocele Hernia OmphalitisOmphalitis- life threatening infection
Consider vancomycin.
Check child for neutropenia.
Rhus Contact Dermatitis

Type 4 TT-Cell mediated reaction. Does not spread. Timing depends on contact concentration and area of body. Rash occurs only after prior exposure. Erythema, vesicles, itching. Can cause great deal of swelling.
Rhus Contact Dermatitis

Treatment
Calamine (no diphenhydramine). Oral antihistamine. Wash off immediately after exposure! Rarely steroids needed.
When used give at least 2 weeks with taper.
Socks on hands at night.

Impetigo Contagiosum
Group A B Hemolytic Strep
Occasionally Staph
Moist hot areas Erythema pustules yellow crusts Mupirocin to small areas (intranasal?) Antistreptococcal antibiotics orally
Copyright 2009 Challenger Corporation. All rights reserved. Copyright 2009 Challenger Corporation. All rights reserved.
Impetigo Bullosa
Generally phage group II Staph Typically seen on extremities Primarily seen in infants and toddlers At granular layer layer easily ruptures Antistaphylococcal antibiotics MupirocinMupirocin- intranasal if recurrent Local wound care
Staphylococcal Scalded Skin

Exfoliative toxintoxin- Phage II S. aureus Binds to desmogleindesmoglein-1 in epidermis. Superficial separation plane
+ Nikolsky sign Fragile blisters Relatively minimal fluid loss
Staphylococcal Scalded Skin

Fever, irritability and skin pain. Sand paper rash exfoliates. Mucosa typically spared (not SJS) Axillae typically involved. Most under 5yo. Treat like a second degree burn. IV antibiotics (consider MRSA)
<5% mortality
Staph Toxic Shock Syndrome

Starts: flu with macular rash Flexural areas accentuation Conjunctival hyperemia Nikolsky negative Often tachycardic then hypotension Often platelets drop: petechiae Follows retained foreign bodies or URI Peel after 5 daysdays- hands and feet especially Edema, cyanosis, pulmonary edema, myocarditis

At least 3 organ systems involved
Mucous membranesmembranes- erythema MuscularMuscular- CPK >2X normal GIGI- nausea, vomiting, pain, diarrhea RenalRenal- Bun or Cr >2X normal Platelets <100K HepaticHepatic- SGOT, SGPT, TB >2X normal CNSCNS- altered

Treatment
Fluids, fluids, fluids Remove foreign body / pus AntiAnti-staphylococcal antibiotic
Cover MRSA, GNR, anaerobe until DX certain Clindamycin for ribosomal / protein effects
Case
18 month old presents with decreased PO intake, irritability, apparent sore throat, mostly shoddy anterior cervical nodes on left side and one that is 1.7 cm in size and nonnon-tender. Seen by PCP twice= Viral syndrome Now with red cracked lips and tongue.
IVIG often used PressorsPressors- assess SVR and CO Admission ICU
You consider possibilities

WBC 19,000/uL CRP 8 mg/dL Urine with leukocytes 15/HPF
Negative nitrite and Gram stain.
Hgb 9.5 Platelet count 460,000/uL LP with 22WBCs

Atypical Kawasakis
Primarily in infants.
Risk of aneurisms higher as well.
Classic Criteria
Fever greater than 390C (102.20F) +4/5
ConjunctivitisConjunctivitis- bulbar, bilateral, no exudate Mucous membrane changes RashRash- variable local or diffuse Enlarged cervical nodesnodes- often nontender/unilateral Peripheral changeschanges- swelling and peeling.
Consider in infants>children with

5+ days of unexplained fever 2 or more clinical features of Kawasaki Kawasakis
Also consider in infants <6 months with

6+ days unexplained fever and evidence of systemic inflammation.
If CRP >3mg/dL or ESR 40mm/Hr then Supplemental Lab and Echocardiogram

Albumin 3 g/dL or less. Anemia for age ALT elevation over normal for age Platelets >450,000/uL after 7 days WBC >15,000/mm3 Urine WBC 10+/HPF
Work Up Result
Echo += treat Echo but 3+ supp. labs += treat. Echo and <3 supp. labs +=
Fever abates: unlikely Kawasaki's Fever persists: repeat echo and consult.
Kawasaki Tidbits
Number 1 acquired cause of heart disease in preschool age. Vasculitis
Gallbladder hydrops Pancreatic lesions Renal lesions Pulmonary lesions ArthritisArthritis- sometimes persistent.
Kawasaki Treatment
IVIG 2g/kg as single infusion
Give slowly to prevent headache (12 Hr)
High dose aspirin 2020-25mg/kg q 6 Hrs.

Generally 14 days then decrease dose to 335mg/kg/day until platelet count normal.
1515-25% untreated aneurisms Steroids/IIbIIIa inhibitors etc. not standard first line treatment.
Rocky Mountain Spotted Fever

Dermacentor andersoni (wood) tick Dermacentor variabilis (dog) tick Amblyomma americanus (lone star) tick Rickettsia rickettsii South central US All year (most AprilApril-September) Many without known tick exposure

Present with N, V, HA, F Malaise, Photophobia, Abd. Pain Blanching rash on wrists and ankles Rash to palms/soles centripetal Becomes petechial over days

Common Findings
Hyponatremia, thrombocytopenia, leukopenia Relative bradycardia, splenomegaly SerologySerology- IgM often negative early on
Treatment
Doxycycline Second line likely quinolone Chloramphenicol still listed by many
Keratosis pilaris
Typically seen in young children. Medial thighs, upper arms and face. PalpablePalpable- like 80 grit sandpaper. Due to perifollicular scale build up. More common in those with atopy.
Molluscum
Endemic in children A poxvirus
Briefly consider Monkey Pox and Small Pox
Spread by contact Often linear distribution. Can be sexually transmitted Curette or cantharidin if symptomatic
Pityriasis alba vs. T. versicolor

P. alba
Atopic patients; post inflammation Poorly demarcated (blots) Usually improves with time.
T. versicolor
Pityrosporum fungusfungus- spaghetti and meatballs. Light to dark pigmentation. Well demarcated rain drops drops Selenium sulfide shampoo or azole antifungal. Zitelli Teaching Slide Set
Scabies
You know these critters! Face often involved in infants. Norwegian scabies impressive with secondary inflammation and even scarring. Diagnosis: should be by scrapping! Treatment: 5% permethrin
A family affair!
Contributed by Patricia Treadwell M.D.
Measles
AKA: Rubeola, Red measles, 9 day measles, Didn Didnt get your shot measles. 9-10 d incubation Late winter and early spring Prodrome: Fever, malaise, coryza, dry cough, conjunctivitis (more injection than drainage), photophobia, lethargy. Koplik spots: 11-2 days after onset.
Measles
Rash first seen on day 33-4 of prodrome. Blanching, blotchy, red, maculopapular rash which starts at hair line. Cephalocaudad spread over 33-4 days. Palms and soles involved (Syphilis, RMSF, Ehrlichiosis, Lyme Lymes disease, Neisseria, etc.) Older lesions do not blanch.
Measles
Rash fades after about 3 days and is clear about 3 days after starts fading. May show desquamation. May have adenopathy. Contagious 4 days before till 4 days after rash presents. Attack rate >90%
Why Vaccinate?
Otitis Pneumonia Effusions Encephalitis Obstructive laryngotracheitis. Subacute sclerosing panencephalitis.
Varicella
Year round availability. Incubation: 1010-20 days. Prodrome: malaise, coryza, low grade fever occur in some cases. Rapidly changing painful lesions. ThinThin-walled vesicles to ulcers to crusts. Rash in crops (usually 3).
Varicella
Centrifugal from scalp and trunk. Scales typically gone by 10 days. All stages present at the same time. Scar secondary to infection. Contagious: 1 day before rash till all lesions completely crusted (7 days).
Why Vaccinate?
Increase risk of mortality and morbidity in adults compared with children.
Secondary bacterial infection common.
Flesh eating bacteria.
Pneumonia, hepatitis, encephalitis, and Reye syndrome, disseminated hemorrhagic disease all occur.
Exposure:
Consider immunizing close contacts. VZIG for immunosuppressed.
Hand Foot and Mouth Disease

Coxsackie A16 (non(non-polio enterovirus) Incubation 22-6 days Peaks in late summer / early fall. Contagious
Primarily fecalfecal-oral with early respiratory. Fomite transmission.

Prodrome:
Brief: Enanthem within 2 days of prodrome Low grade fever Malaise Soreness in mouth Anorexia

Enanthem
Painful shallow yellow ulcers / red halos. Typically on labial and buccal mucosa. Occasionally on tongue, uvula, palate, etc. May appear vesicular at first. If no exanthem = herpangina.

Exanthem
Starts after enanthem. Red macules on palmar and plantar aspect of distal extremities. Occasionally elsewhere (buttocks). Quickly become grey vesicles on red base. May be pruritic.

NOT HSV
Usually more pain, fever, wide spread in mouth with associated bleeding. Usually more systemic toxicity and adenopathy as well.
Erythema Infectiosum
AKAAKA- Fifth Disease Parvovirus B 19 Preschool and young children. Rash is most striking part of infection. Constitutional symptoms mild if present.
HA, N, arthralgias and myalgias.
Erythema Infectiosum
Day 1 Slapped Cheeks Day 2 Slapped Cheeks start to fade Day 2 Macular / slightly papular lacy rash develops on extensor surfaces. Day 3 Rash extends to flexor surfaces. May involve buttocks and trunk Resolves in about a week Can cause aplastic crises in those with hemoglobinopathies/hemolytic anemia.
Year round but peaks in winter.
Contributed by Dr. Randolph Cordle Contributed by Dr. Randolph Cordle
Ex-Lax Burns
Looks like scald injury Seems more common in over dose Each square 15 mg of Senna Irritant contact dermatitis Pathology unclear
Likely anthraquinone related effect leading to higher concentration of digestive enzymes.
Roseola Infantum
Human Herpes Virus 6 (most common). Febrile illness in irritable child. May cause febrile seizure. 3 months to 3 years most common. Incubation: 1010-15 days. Fever lasts 3 days. (> 102F) Rash within one day of defervescence.
Roseola Infantum
RoseRose-colored maculopapules. Centrifugal rash starts on trunk. Rash lasts 3 hours to 3 days. Commonly seen late fall / early spring. =Exanthem subitum and Sixth disease.
Pityriasis rosea
Self limited harmless rash. All ages but primarily young adults. Peak incidence in winter. Cause: probably viral. Occasional cold symptoms as prodrome
Pityriasis rosea
Herald patch
Usually singular and large. Oval pink and scaly lesion. May have central clearing. May look like T. corporis.
Pityriasis rosea
Subsequent Exanthem
About 1 week later smaller scaly lesions occur in arborarbor-like pattern on trunk. These reach 11-2 cm size. Slowly fade away over 4 months.
Cold Panniculitis
Due to adiponecrosis. Common upper thighs and legs
Young ladies in skirts waiting on the bus. Kids playing in the snow.
Treatment symptomatic. Popsicle panniculitis
Kerion
An inflammatory reaction to tinea. EndothrixEndothrix->black dot= T. tonsurans. ExothrixExothrix->Wood lamp+=Microsporum Griseofulvin 88-12+weeks. Can use terbinafine or azoles. Do not I and D. Can culture with tooth brush/swab. Consider 4 weeks of steroids with taper.
Contact Dermatitis
Many types
Irritant Allergic Photodermatitis Atopic Dyshidrotic eczema Nummular Seborrheic Others Zitelli Teaching Slide Set
Treatment
Treat Itch Steroids
1mg/kg prednisone for 2 weeks with taper. Local steroids in small areas. Not Dose Packs
Autoeczematization
Dyshidrotic Eczema
n n n n n n n n
A special form of hyperhidrotic eczema. Often seen in winter. Itches and burns. Vesicles on palms and soles. Can effect tops and sides of hands/feet. Lateral aspects of fingers and palms. Treat with drying and steroids. Recurs
They have normal sweat glands.
Creeping Eruption
Natural Host Dead End Host
Eggs in Stool
Eggs-->Larva Eggs--->Larva
Larva into dermis

Creeping Eruption
Cutaneous Larva Migrans. Cat and Dog Hookworms (nematode).
Ancylostoma braziliense Ancylostoma caninum (eosinophilic colitis)
Creeping Eruption
Usually a self limited dermal disorder. Rarely the larvae penetrate into deeper tissues leading to systemic toxicity such as fever, pulmonary infiltrates (Loeffler (Loefflers syndrome), eosinophilic enteritis, muscle infiltration etc. Usually spontaneously resolves: months
Endemic in SE USA and Caribbean. Found primarily in damp sandy soil. Pruritus worse in previously exposed.
Creeping Eruption Treatment

Typically none except antipruritic agent. Ivermectin (0.2mg/kg)(0.2mg/kg)- Single Dose
Itching resolves completely and parasite dies within a few days.
Creeping Eruption
Diagnosis is usually a clinical one Biopsy not needed If occult infection suspected ELISA and Western Blot tests are available.
ThiabendazoleThiabendazole- Topical and/or oral

Often GI side effects.
AlbendazoleAlbendazole200mg BID X 3 days
Causes of Eosinophilia
Allergies Drug Hypersensitivity Parasitic Infections/Infestations Neoplasia Dermatologic Diseases Digestive Diseases CollagenCollagen-Vascular Diseases
Causes of Eosinophilia
Hematologic Disorders Bacterial Infections (few) Adrenal Insufficiency Radiation Therapy Chronic Renal Disease Sarcoidosis Loeffler Loefflers Syndrome
Pubic Lice
Pubic Lice
Entire life cycle on host
approximately 3030-40 days.
Pediculosis pubispubis- Phthirus pubis

May be found in any hairy body area. Intense pruritus of the anogenital area is the most common symptom.
Transferred via sexual / fomite contact. Maculae caeruleaecaeruleae- hyperpigmented macules secondary to chronic infestation.
Vagabond Vagabonds disease disease
Pubic Lice
Has not been incriminated as a vector in the spread of other diseases. Should be sentinel to look for other STDs and to consider child sexual abuse. Incubation periodperiod- 6-10 days
Pediculosis Treatment
Pediculosis. h. corporis
Improve hygiene and wash / dry clothing at high temperature is all that is necessary.
Phthirus pubis
Any of the above drugs will work, but reretreatment at 77-10 days is a must. DOC = 1% permethrin If eyelashes are involved, use petrolatum ointment 33-4 times daily for 88-10 days.
alternative 1% mercuric oxide Mechanically remove nits from eye lashes
Control Measures
Washing, dry cleaning, or storing (10 days) clothes may be a good idea. Soaking for 10 minutes (128 F) or washing with pediculicidal shampoo will disinfect combs and brushes. Environmental insecticides are not helpful.
Control Measures
P. pubispubisTreat all sexual contacts. Examine all individuals with close contact to individual or their personal articles.
Suggested Readings/ References

Habif T.: Clinical Dermatology: A Color Guide to Diagnosis and Therapy. Challenger Corporation www.chall.com Cohen B.: Pediatric Dermatology http://dermatlas.med.jhmi.edu/derm/ http://www3.dermis.net/index_e.html http://www.emedicine.com/ Zitelli Atlas of Pediatric Physical Diagnosis: A must have reference. Many slides used from this teaching slide set.
LaxativeLaxative-Induced Dermatitis of the Buttocks Incorrectly Suspected to Be Abusive Burns. www.pediatrics.org

WE-216 Classic Pediatric Rashes

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(+)Randolph J.

Classic Pediatric Rashes

(+)No significant financial relationships to disclose

Randy Cordle MD, FACEP, FAAP, PEM.

Classic Rashes: Infants and Children

Mandatory Objectives Slide

Levine Children Childrens Hospital Carolinas Medical Center

Bottom Line Objective

Randy Cordle MD, FACEP, FAAP, PEM.

Zitelli Teaching Slide Set

Subcutaneous Fat Necrosis

Zitelli Teaching Slide Set

Erythema Toxicum Neonatorum

Zitelli Teaching Slide Set

Randy Cordle MD, FACEP, FAAP, PEM.

Erythema Toxicum Neonatorum

Transient Neonatal Pustular Melanosis

Randy Cordle MD, FACEP, FAAP, PEM.

Transient Neonatal Pustular Melanosis

Zitelli Teaching Slide Set

Randy Cordle MD, FACEP, FAAP, PEM.

Sebaceous Gland Hyperplasia

Zitelli Teaching Slide Set

Zitelli Teaching Slide Set

Zitelli Teaching Slide Set

Randy Cordle MD, FACEP, FAAP, PEM.

Zitelli Teaching Slide Set

Randy Cordle MD, FACEP, FAAP, PEM.

Irritant Diaper Dermatitis

Irritant Diaper Rash

Irritant Diaper Rash

Zitelli Teaching Slide Set

Zitelli Teaching Slide Set

Randy Cordle MD, FACEP, FAAP, PEM.

Candidal Diaper Dermatitis

Candidal Diaper Dermatitis

Seborrheic Diaper Dermatitis

Seborrheic Diaper Dermatitis

Hydrocortisone cream also useful Bid. Persistent: consider immunodeficiency.

Randy Cordle MD, FACEP, FAAP, PEM.

Zitelli Teaching Slide Set

Randy Cordle MD, FACEP, FAAP, PEM.

cutis marmorata telangiectatica congenita

Heel stick pustules

Contributed by Dr. Bernard Cohen: Derm Atlas

Harlequin Color Alteration

Contributed by Dr. Bernard Cohen: Derm Atlas

Randy Cordle MD, FACEP, FAAP, PEM.

Contributed by Dr. Randolph Cordle

Contributed by Dr. Bernard Cohen: Derm Atlas

Check child for neutropenia.

Zitelli Teaching Slide Set

Zitelli Teaching Slide Set

Randy Cordle MD, FACEP, FAAP, PEM.

Rhus Contact Dermatitis

Rhus Contact Dermatitis

Socks on hands at night.

Randy Cordle MD, FACEP, FAAP, PEM.

Randy Cordle MD, FACEP, FAAP, PEM.

Staphylococcal Scalded Skin

Staphylococcal Scalded Skin

Staph Toxic Shock Syndrome

Staph Toxic Shock Syndrome