PAPULOSQUAMOUS ERUPTIONS IN CHILDREN Dr Pearl Kwong md phd Board Certified Pediatric Dermatologist Jacksonville Fl DISCLOSURE

•Nothing to disclose

DIFFERENTIAL DIAGNOSIS OF PAPULOSQUAMOUS ERUPTIONS IN CHILDREN (MOST COMMON) • Tinea • rosea PR /lichenoides chronica PLC • Guttate /psoriasis • Nummular eczema • Cutaneous OTHER DDX TO CONSIDER

• Drug induced • • • Secondary lupus • CTCL • Other forms of viral exanthema TINEA

. • • Tinea pedis • Tinea gladiatorum SUPERFICIAL TINEA: TINEA FACIEI/CORPORIS

• Predilection for non hairy areas of the face the trunk extremities • Contact with other individuals • Tinea corporis gladiatorum: wrestlers • Domestic animals particularly young kittens and puppies. • Causative agents are Mcanis occasionally T menta or M audounii in younger kids; older kids T rubrum T verrucosum T menta T tonsurans • In children with T rubrum or Epidermophyton floccosum suspect parents with tinea pedis or TINEA CORPORIS

• Tends to be asymmetrical • Usually one or more annular well circumscribed plaques with clear center • Can have popular vesicular or pustular border • Can be polycyclic • Common in children warm humid climate and in patients with systemic diseases DM or IM • DDX: herald patch of PR , nummular eczema , psoriasis , contact , seb derm , . migrans, GA , fixed drug and LE TINEA INCOGNITO /MAJOCCHI’S GRANULOMA

• Tinea incognito: use of corticosteroids can alter the presenting features ( Lotrisone or Mycolog)

• Majocchi’s granuloma: perifollicular granulomatous disorder mainly on shaven legs , with erythematous plaques and studding the surface TINEA DX

• Morphology: many differential dx. ; partially treated. Masked morphology due to treatment • KOH: many false positive interpretations • Woods light: only if organism is Mcanis or M audouinii yellow green • Fungal culture : takes a long time but can identify the • DTM : color changes but precludes identification • PAS: costly pain not always necessary TINEA TX

Topical antifungals : butenafine ciclopirox econazole ketoconazole miconazole naftifine oxiconazole sulconazole terbinafine tolnaftate TINEA INCOGNITO /MAJOCCHI’S

• Need to start oral antifungal • Griseofulvin or terbinafine TINEA PEARLS

•Treat contacts : humans and animals! •Warn that it can be recurrent if not treated properly • can have secondary bacterial infection too! AND VARIANTS

Pityriasis rosea chronica PLEVA Pityriasis lichenoides et varioliformis acuta PITYRIASIS ROSEA

• Acute self limiting disorder • Common in children and adolescents • Only 4 % occur before age 4 • Most are well • of pharyngitis lymphadenopathy mild sx • Etiology still unknown. • Mostly viral HHV 6 and 7 PITYRIASIS ROSEA

• Herald patch , mostly on the trunk neck thigh arms. • Scaly plaque elevated border • Often misdiagnosed as tinea • After interval of 2 to 21 days generalized eruption on trunk with xmas tree pattern • Clearance usually within 6 weeks • Morphology: oval lesions with fie collarette scales • Can have other morphologies : hemorrhagic bullous or erosive DIAGNOSIS AND TREATMENT

• Clinical features • Biopsy subacute or chronic dermatitis with vascular dilatation edema superficial lymphocytic infiltrate. Mild exocytosis patchy . Non specific • Most patients do not need tx. Reassurance . Pruritus control. • UV light exposure hasten resolution • may shorten course. • Topical steroids for itching PITYRIASIS LICHENOIDES CHRONICA/PLEVA

• • Acute form PLEVA Mucha Haberman disease • Chronic form PLC guttate parapsoriasis PLEVA

• Polymorphous eruption 2-3 mm oval round reddish brown macules papules • Fine sometimes resolving with scar • Can be mistaken for chicken pox • Weeks to months • Can have asstd or constitutional sx • Rare variant with nodules and fever PLC

• Can arise from PLEVA or denovo • Lasts weeks to months to years • Dyspigmentation no scarring • Unknown cause • Associated with preceding viral infection • Seen as a benign lymphoproliferative disorder • Rare reports of CTCL arising from PLC MANAGEMENT OF PLC

• Repeated bx to confirm benign nature over the years • No response to topical CTCS • UV light : most effective • Systemic antibiotics. Erythromycin : 1-2 month tx CHILDHOOD PSORIASIS

• • Plaque type psoriasis • /diaper psoriasis • Scalp psoriasis • psoriasis • Palmoplantar psoriasis • Erythrodermic psoriasis CHILDHOOD PSORIASIS

•4 % of all dermatosis in children <16 ; 2-3 % of the population •Genetic and environmental factors •Up to 70% of ped psoriasis have a positive fhx SPECIAL CONSIDERATION : GUTTATE PSORIASIS

• Often first presentation of psoriasis in kids. • Round oval 2 to 3mm in diameter. • Often triggered by a gp A strep oropharynx or perianal area. • 2/3 of pts have URTI 1-3 weeks before • Suppressive tx with antibiotics do not stop the spread of the • Some patients with refractory psoriasis have improved following tonsillectomy SCALP PSORIASIS

• Most frequent intial site of psoriatic involvement • Well demarcated silvery scales • Can have sebopsoriasis : mixture of yellow greasy scales involving the scalp eyebrows postauricular folds. • Variant of scalp psoriasis: Tinea amiantacea (not due to a dermatophyte) • Can be associated with staph infection . Do cultures and treat the staph aggessively INVERSE PSORIASIS

• Diaper area (inguinal , intergluteal cleft , perianal , vulva , umbilicus , flexural surfaces axillary folds and toewebs • Rash can have crusting and oozing with tendernss and wetness. • Do bacterial culture. Staph aureus. • Treat the staph infection aggressively NAIL PSORIASIS

• Nails are affected in about 25 to 50 % of pediatric psoriasis • Pitting most common presentation • May be indistinguishable from pitting of nails in • May have discoloration subungual onycholysis • May have secondary bactrerial candida and dermatophyte infection TREATMENT

• Preventative measures: avoid koebner phenomenon minimize friction • Maintain weight • Avoid tight garments • Avoid long nails or excessive use of nail polish • Avoid scratching and picking and removal of scales TREATMENT OF PSORIASIS : TOPICALS

• Emollients • Topical steroids • Tar, anthralin , calcipotriene, tacrolimus, tazarotene combincation steroid and calcipotriene • Descaler : ceteal oil before topical steroids TREATMENT OF PSORIASIS

• Phototherapy • UVB light • Narrow band UV light • PUVA seldom indicated. TREATMENT OF PSORIASIS

• Biologics (FDA approved as of 2018) • Etanercept • Adalimumab • Ustekinumab

. MTX or Cyclosporine or Azathioprine . Acitretin (retinoids) PEARLS IN THE TX OF CHILDHOOD PSORIASIS

• Check for strep : throat and perianal • Check for staph infection • Prolonged anti strep and anti staph tx • Tonsillectomy NUMMULAR ECZEMA

• Coin shaped eczema • Measuring 1 cm of more in diameter • More often seen in winter dry extremely itchy • tend to be recalcitrant to topical tx. • secondary infection common TREATMENT

• More potent topical steroids • Oral antibiotics • Bleach baths • Lubrication barrier products CUTANEOUS LUPUS

• subacute cutaneous lupus erythematosus (SCLE) • Discoid lupus • Other similar overlaps eg dermatomyositis CUTANEOUS LUPUS

• Establish diagnosis by Hx and PE and Bx • Color is different • Scaling is different • Sun can be a trigger • R/O systemic involvement CASES

• PICTURES !!! Scaly scalp

 Baby 1 month old with persistent cradle cap.  Round scaly plaques on the scalp  No sx  Consulted Cardiology, consulted Rheumatology, etc

MICROSPORUM CANIS

• Resistance to griseofulvin; make sure use highest dosing and may need to use if for more than one course. • need to use other antifungal agents eg Lamisil . Clues

 DDx: Seb Derm, Neonatal lupus, Tinea, Psoriasis  Test: KOH, Wood’s lamp, Bx  Fluorescence  Complete Hx: how many animals in the house??  Dx: Tinea by Microsporum canis Click to add title Click to add title

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HERALD PATCH

Scaly on the face

 14 yo AAF with scaly rashes on face.  Non pruritic  Already treated with oral antifungal, not effective  One side fading, another one coming on

Clues

 Tinea or not?  Tinea can come and go  Black teenager: other DDx??  Psoriasis, Tinea, Lupus  Test to confirm: Bx and IF  Dx: Discoid Lupus  Need further investigation to rule out SLE ACTIVE DISCOID LUPUS SCLE SCLE NEONATAL LUPUS

SUMMARY PEARLS FOR PAPULOSQUAMOUS ERUPTIONS IN KIDS Go over the DDx of PPS conditions . Common and uncommon. Treat infections first (think of infection as a trigger ) then treat for inflammatory Don’t be afraid to bx