Peds Derm 101

Cases Itching to be Solved

Emily Berger, MD
Helen T. Shin, MD
Pediatric Dermatology
Joseph M. Sanzari Childrens Hospital
Hackensack University Medical Center

May 22, 2015

HILTON HEAD ISLAND, SC

Eczema Coxsackium
Disseminated coxsackievirus A6 infecJng eczematous areas
Perioral, extremiJes, trunk + hand, foot, buMocks
Coxsackievirus A6 (CV-A6) emerging pathogen atypical hand, foot,
mouth disease
Reported in US and abroad
Fever, systemic symptoms not uncommon
In kids with AD widespread papular or vesicular erupJon
mimicking eczema herpeJcum, chickenpox, etc.
DierenJated from eczema herpeJcum: more generalized, more
discrete (vs clustered) lesions, less well-circumscribed lesions
Other presentaJons of CV-A6: GCS-like, purpuric, delayed
onychomadesis (nail shedding)
Lynch MD, et al. Disseminated coxsackievirus A6 aecJng children with atopic dermaJJs. Clin
Exp Dermatol. 2015 Feb 10. doi: 10.1111/ced.12574. [Epub ahead of print]
Mathes EF, et al. Eczema coxsackium and unusual cutaneous ndings in an enterovirus
outbreak. Pediatrics. 2013;132:e149-7.

Peds Derm 101

Erythema infectiosum

Parvovirus B19
Asymptomatic infection
Exanthematous disorders

Erythema infectiosum (fifth disease)

Papular-purpuric gloves and socks syndrome
Asymmetric periflexural exanthem
Bathing trunk exanthem
Petechial exanthems

Other disorders

Arthritis
Transient aplastic crises
Chronic anemia
Refractory anemia following solid organ or stem cell transplantation
Fetal hydrops
Vasculitis
Neurologic disease
Rheumatologic disease

Paller AS, Mancini AJ, eds. Hurwitz Clinical Pediatric Dermatology. 4th ed. Elsevier 2011.

Gianoh-CrosJ Syndrome
Described in 1955-1956
Edematous, erythematous, monomorphous papular (or
papulovesicular) erupJon symmetrically distributed on
the face, buMocks, and extensor extremiJes
Children ages 1-6 years
EJology uncommonly HepaJJs B as iniJally described:
EBV, CMV, Coxsackie, adenovirus, RSV, parainuenza
virus, parvovirus B19, rotavirus, HHV-6, etc VaccinaJons
8-12 weeks course
Management is supporJve


Paller AS, Mancini AJ, eds. Hurwitz Clinical Pediatric Dermatology. 4th ed. Elsevier 2011.

Gianoh-CrosJ Syndrome-Like (ID)

ReacJon to Inamed Molluscum
Immune response to molluscum contagiosum
virus (MCV)
Under-recognized (~5% of paJents in large
series of MCV)
Good prognosJc sign
Average Jme unJl resoluJon of MCV= 2 months

Berger EM, Orlow SJ, Patel RR, Schaer JV. Experience With Molluscum Contagiosum and Associated Inammatory ReacFons in a
Pediatric Dermatology PracFce: The Bump That Rashes. Arch Dermatol. 2012;148:1257-1264.

Id ReacJon
AutoeczemaJzaJon
ReacJon to nickel (dermaJJs under umbilicus),
Jnea capiJs, etc
Treat underlying condiJon
SymptomaJc management: topical corJcosteroids,
oral anJhistamines, PO corJcosteroids if severe
Treatment of Jnea capiJs: 6-8 week course of
griseofulvin microsize 20-25 mg/kg/day divided
BID, give with faMy food, emphasize fomite
removal

Paller AS, Mancini AJ, eds. Hurwitz Clinical Pediatric Dermatology. 4th ed. Elsevier 2011.

Molluscum DermaJJs
More common if underlying atopic dermaJJs (AD)
AD is an indicaJon to favor molluscum treatment
Topical corJcosteroids for dermaJJs management

Berger EM, Orlow SJ, Patel RR, Schaer JV. Experience With Molluscum Contagiosum and Associated Inammatory ReacJons in a
Pediatric Dermatology PracJce: The Bump That Rashes. Arch Dermatol. 2012;148:1257-1264.

InfanJle Eczema
Headlight sign
May be super-infected with S. aureus, but NOT
primary process
Topical vs oral anJbioJc appropriate in many cases

Irritant contact dermaJJs component (drool,

foods, etc.)
Treatment: Low- to mid-potency topical
corJcosteroid, barrier cream/ointment for
irritant component
Paller AS, Mancini AJ, eds. Hurwitz Clinical Pediatric Dermatology. 4th ed. Elsevier 2011.

Eczema HerpeJcum

AKA Kaposis varicelliform erupJon

Skin superinfecJon w/ HSV
In paJents w/ preexisJng dermatosis (most
commonly AD)
Clusters of umbilicated vesicles, monomorphous
punched out erosions
Commonly impeJginized
If periocular involvement, STAT ophtho eval
Associated systemic symptoms
Treatment: anJviral (IV or PO)
If frequent recurrences, prophylacJc PO anJviral
Jen M, Chang MW. Eczema herpeJcum and eczema vaccinatum in children. Pediatric
Annals. 2010;39: 658-64
Luca NJ, Lara-Corrales I, Pope E. Eczema herpeJcum in children: clinical features and
factors predicJve of hospitalizaJon. J Pediatr. 2012;161:671-5.

Staph Scalded Skin Syndrome

RiMers disease
Staph aureus phage II types 3A, 3C, 55, 71 ExfoliaJve toxins
A & B cleave desmoglein 1
Pediatric cases: premature infants, children <6
Perioral area = diagnosJc clue
Prodrome Erythema then exfoliaJon @ exures Skin
sloughing lasts 3-5 days Resolves in 1 to 2 weeks
Culture for a source: skin, orices
Sterile bullae
Treatment: Beta-lactamase resistant agents, clindamycin (vs.
toxin producJon) at home or inpaJent

Bolognia, et al, eds. Dermatology. 2008 Elsevier.

UrJcaria MulJforme aka Annular UrJcaria

Skin ErupJon: Annular and polycyclic wheals with central clearing or
ecchymoJc centers

N= 18

Clinical Features:
Pruritus (94%)
Angioedema of hands and feet or face (72%)
Dermatographism (44%)
Fever (44 %)
Symptoms suggesJve of recent viral or bacterial illness (67%)
Recent anJbioJc use (44%)
Recent ImmunizaJons (11%)

Shah KN, Honig PJ, Yan AC. Urticaria Multiforme: A Case Series and Review of Acute Annular
Urticarial Hypersensitivity Syndromes in Children. Pediatrics. 2007 May;119(5):e1177-83.

Shah KN, Honig PJ, Yan AC. Urticaria Multiforme: A Case Series and
Review of Acute Annular Urticarial Hypersensitivity Syndromes in Children.
Pediatrics. 2007 May;119(5):e1177-83.

Erythema MulJforme (EM)

90 % of cases precipitated by infecJon, most commonly
HSV 1 or 2
Typical target lesions: well-dened, <3cm papule or
plaque with two concentric rings of color change and
central zone with evidence of epidermal damage
Systemic symptoms: fever, weakness, arthralgias,
atypical pneumonia-like lung changes (2/2 EM or
infecJon)
Abrupt onset 2 weeks typical episode resolves
without sequelae
Recurrence is common in HSV-related EM

Bolognia, et al, eds. Dermatology. 2008 Elsevier.

SJS/TEN

Rare, acute, potenJally fatal,

mucocutaneous reacJons
Epidermal detachment, <10%= SJS and
>30% = TEN
KeraJnocyte apoptosis triggered by up
regulaJon of keraJnocyte Fas ligand
(FasL) expression
Most cases are in response to drugs:
anJbioJcs (sulfonamide),
anJconvulsants, NSAIDs high
oenders
Mortality rates thought to be lower in
kids (TEN ~ 50% mortality in adults)
PotenJal long term sequelae @ skin
and eyes
SupporJve management in ICU, burn
unit
IVIG > 2 g/kg advocated

Finkelstein Y, et al. Recurrence and outcomes of Stevens-Johnson syndrome and toxic epidermal necrolysis in children. Pediatrics. 2011;128:723-8.
Barron SJ, DelVecchio MT, Arono SC. Intravenous immunoglobulin in the treatment of Stevens-Johnson syndrome and toxic epidermal necrolysis:
a meta-analysis with meta-regression of observaJonal studies. Int J Dermatol. 2015;54:108-15.

Mucosal Predominant or Atypical SJS

Mycoplasma pneumonia- induced rash and
mucosiJs
Likely other infecJous culprits yet to be
idenJed
May respond to systemic corJcosteroids alone
or in combinaJon with IVIG
Unlikely to recur (8% in a systemaJc review)
Canavan TN, Mathes EF, Frieden I, Shinkai K. Mycoplasma pneumonia-induced rash and mucosiJs as a syndrome disJnct from Stevens-
Johnson syndrome and erythema mulJforme: A systemaJc review. J Am Acad Dermatol. 2015: 72:239-45
Ahluwalia J, Wan J, Lee DH, Treat J, Yan AC. Mycoplasma-Associated Stevens-Johnson Syndrome in children: RetrospecJve review of
paJents managed with or without intravenous immunoglobulin, systemic corJcosteroids, or a combinaJon of therapies. Pediatr
Dermatol. 2014;31:664-9

Exanthematous Drug Eruption

Etiologic Agents

Amoxicillin
Ampicillin
Bleomycin
Captopril
Carbamazepine
Chlorpromazine
Cotrimoxazole

Gold
Nalidixic acid
Naproxen
Phenytoin
Penicillamine
Piroxicam

Litt J. Drug eruption reference manual. NY: Parthenon Publishing Group; 2000

Drug Hypersensitivity Syndrome (DRESS)

DRESS (drug reaction with eosinophilia and
systemic symptoms)
1 in 1,000 to 1 in 10,000 anticonvulsant exposures
Clinical features
Triad - fever, rash, systemic involvement
Onset 7 to 28 days, first exposure
Periorbital and facial edema
Generalized lymphadenopathy
Cutaneous eruption

Husain Z et al. DRESS syndrome Part I. Clinical Perspectives. J Am Acad Dermatol 2013;68:693.e1-14
Husain Z et al. DRESS syndrome Part II. Management and Therapeutics. J Am Acad Dermatol 2013;68:709.e1-9

Drug Hypersensitivity Syndrome (DRESS)

Hepatitis

Hematologic abnormalities
Renal damage
Pulmonary, cardiac, CNS
Lymphomatoid

changes

Benign lymphoid hyperplasia

Pseudolymphoma

Thyroiditis

- 2 months

Husain Z et al. DRESS syndrome Part I. Clinical Perspectives. J Am Acad Dermatol 2013;68:693.e1-14
Husain Z et al. DRESS syndrome Part II. Management and Therapeutics. J Am Acad Dermatol 2013;68:709.e1-9

Drug Hypersensitivity Syndrome

Management

Discontinue medication
LFTs, CBC w/ smear, UA, creatinine
Chest x-ray
Skin biopsy
Reassess at 3 weeks, 2-3 months
Supportive therapy
1.0-2.0 mg/kg prednisone - slow taper
Council family members

Husain Z et al. DRESS syndrome Part I. Clinical Perspectives. J Am Acad Dermatol 2013;68:693.e1-14
Husain Z et al. DRESS syndrome Part II. Management and Therapeutics. J Am Acad Dermatol 2013;68:709.e1-9

Pityriasis Rosea
Self limited exanthem
Herald patch few days to 3 weeks crops of ovoid
papules and plaques with collareMes of scale 6 wks +
for resoluJon
kids are itchy
CharacterisJc Christmas tree paMern on trunk and
extremiJes
Variants: inverse paMern @ skin folds, face; round papules
(young children, skin of color); vesicular; pustular; urJcarial;
hemorrhagic

Treatment is supporJve

Macrolide anJbioJcs ineecJve

Newer RCT for acyclovir

Paller AS, Mancini AJ, eds. Hurwitz Clinical Pediatric Dermatology. 4th ed. Elsevier 2011.
Ganguly S. A Randomized, Double-blind, Placebo-controlled Study of Ecacy of Oral Acyclovir in the Treatment of
Pityriasis Rosea. J Clin DiagnosJc Research. 2014;8: YC01-04.

Pediatric Psoriasis
At least 1/3 of paJents with psoriasis recall having
psoriasis as children
GuMate = droplike

2-6 mm round or oval papules, symmetrically distributed

Preceding group A streptococcal infecJon predicts

guMate morphology but not psoriasis severity
Progression to psoriasis vulgaris ~40% of kids with
guMate psoriasis
AnJbioJcs needed to treat GAS but not helpful for
psoriasis
Case reports of tonsillectomy for guMate psoriasis

Mercy, et al. Clinical manifestaJons of pediatric psoriasis: Results of a mulJcenter study in the United States. Pediatr Dermatol. 2013;30:424-8.
Wu W, Debbaneh M, Moslehi H, Koo J, Liao W. Tonsillectoy as a treatment for psoriasis: A Review. J Dermatolog Treat. 2014;25:482-6.

Persistent Arthropod Bite ReacJon

Papular urJcaria
HypersensiJvity reacJon
Recurrent episodes if recurring bites
SomeJmes requires skin biopsy (to help convince the
family)
Treatment: Eliminate source
SupporJve management: anJhistamines, topical
corJcosteroids

Summers coming!

Long-sleeved clothing
Insect repellent
Paller AS, Mancini AJ, eds. Hurwitz Clinical Pediatric Dermatology. 4th ed. Elsevier 2011.

Scabies
O{en nodular in babies: vigorous hypersensiJvity
response on trunk, axillae, diaper area
5% permethrin cream, technically not for use
under 2 months of age
Treatment repeated in 1 wk
Treat scalp in infants
Signs may not clear for 2-6+ weeks a{er treatment
Most common reason for treatment failure is not
treaJng close contacts!

Paller AS, Mancini AJ, eds. Hurwitz Clinical Pediatric Dermatology. 4th ed. Elsevier 2011.

Neonatal Varicella
Disseminated, erythematous papules, vesicles, erosions
Maternal infecJon with Varicella Zoster Virus (VZV), ie
chickenpox, during last wks of pregnancy
Mild disease: disease onset in mother >= 5 days before
delivery or in newborn during rst 4 days of life
More severe disease: disease in mother <5 days before to 2
days a{er delivery or in newborn @ 5-10 days of life
Severe disease: Pneumonia, hepaJJs, meningoencephaliJs,
coagulopathy, mortality
Treatment: VZIG, IV acyclovir (especially if chickenpox in
the mother within 5 days before or 2 days a{er delivery)
Paller AS, Mancini AJ, eds. Hurwitz Clinical Pediatric Dermatology. 4th ed. Elsevier 2011.