Nasolabial Rings and Things Stan L

Healthy Baby Practical advice for treating newborns and toddlers.

Nasolabial Rings and Things Stan L. Block, MD, FAAP

ou are constantly fascinated by the symmetrical fashion in Y which certain dermatologic skin lesions manifest in children. As the following children presented to your office with these naso-labial and labial rashes, you still needed to consider several potential etiologies of the lesions — from bacterial to viral to fungal to irritant sources. And sometimes two distinctly different causes might become apparent either upon closer inspection or lack of response to treatment. As I have repeatedly stated, adhering strictly to the “Occam’s razor” principle of applying only the simplest diagnosis to complex cases will sometimes lead to inadequate treatment of many pediatric Images courtesy of Stan L. Block, MD, FAAP. Figure 1. A 6-month-old black male infant with nasal lesion for 5 days, unresponsive to over-the-counter cases. Children just do not read the same topical antibiotic ointment. medical text books that many of you do. The children in the following case pre- CASE 1 CASE 2 sentations were otherwise healthy with The afebrile otherwise normal The afebrile and otherwise normal normal vital signs, unless mentioned in 6-month-old black infant presented to 5-year-old white female developed this the text. your office with a 5-day history of this circular symmetrical serpinginous peri- circular rash on the philtrum under the nasolabial rash about 3 weeks ago (see nose (see Figure 1). The rash was unre- Figure 2, page 445). It began as a small Stan L. Block, MD, FAAP, is Professor of Clinical sponsive to 5 days of treatment with a papule just under the nasal septum phil- Pediatrics, University of Louisville, and University of generic over-the-counter triple antibiotic trum area, and has now spread to cover Kentucky, Lexington, KY; President, Kentucky Pedi- ointment. The rash appears to have an nearly the entire nares area and most of atric and Adult Research Inc.; and general pediatri- entire reddened base with much hon- the philtrum. It has some central clearing cian, Bardstown, KY. ey-crusting along with some dry rough along with some scaly remnants in the Address correspondence to Stan L. Block, MD, scaliness. center of the annular rash. The rash has FAAP, via email: [email protected]. Should you proceed with a topical oint- not responded to several topical treat- Disclosure: Dr. Block has no relevant financial ment or an empiric oral therapy? Is this ments, including generic triple antibiotic relationships to disclose. a bacterial, viral, fungal, or irritant rash? ointment, topical clotrimazole, hydro- doi: 10.3928/00904481-20131022-05 Should you perform a specific culture? cortisone ointment, and bacitracin.

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icles in the center of the lesion amid the termittent low-grade fevers, sore throat, otherwise clear skin. He has no history of and this heavily crusted and somewhat cold sores or staphylococcal infections. vesicular peri-oral rash for the same time Should you proceed with a topical period (see Figure 6A, page 446). Crops ointment or an empiric oral therapy? Is of this rash are similarly distributed on this a bacterial, viral, fungal or irritant her trunk (see Figure 6B, page 446). rash? She has a history of severe allergies and moderate eczema. Her rash has been un- CASE 4 responsive to oral cephalexin and topical The 4-year-old afebrile and otherwise triamcinolone for the last week as well. healthy white female came to your of- Should you proceed with a topical Figure 2. A 5-year-old white female with peculiar rash on nose-labial folds for several weeks. Ste- fice with a 4-week history of this nearly ointment or an empiric oral therapy? Is roid creams and triple antibiotics had no benefit. symmetrical peri-oral rash that began this a bacterial, viral, fungal, or irritant in September (see Figure 4). She had rash? Should you perform a specific cul- been exposed to strep throat by a sibling. ture? She has had much difficulty adjusting to her new preschool, and cries many CASE 7 mornings before school. Her father was The 2-year-old white female present- also recently incarcerated. The rash has ed with these peri-oral and oral findings. been unresponsive to triple antibiotics, She has had a fever to 102°F, dyspha- clotrimazole, and bacitracin. gia, drooling excessively, poor appetite, Should you proceed with a topical along with the few crusted lesions at the Figure 3. This 6-year-old white male developed a ointment or an empiric oral therapy? Is angle of her mouth along with several similar, almost symmetrical annular ringworm rash on the nose and lip area as in Figure 2. The rash has this a bacterial, viral, fungal, food aller- red blisters on her tongue as seen in Fig- been treated previously with topical steroids. gy, or irritant rash? ure 7 (see page 447). She has no other skin lesions. She has been recently pre- CASE 5 scribed amoxicillin clavulanate for her The 7-year-old white male presented pharyngitis and “impetigo” of the mouth to your office with a fever to 102°F, phar- as was determined by your community yngitis for 2 days, and a red pharynx and hospital ED. tender 1.5-cm swollen anterior cervical Should you proceed with a different nodes. He had been treated with 5 days empiric oral therapy? Is this a bacterial, of azithromycin for pharyngitis that was viral, fungal, or irritant rash? Should you diagnosed last week by an urgent care perform a specific culture?

Figure 4. A 4-year-old white female with almost center. No strep testing was performed. perfectly circumscribed peri-labial lesion of the You also noticed the recent development CASE DISCUSSIONS mouth. The child was otherwise asymptomatic, of this large crop of circular and irregu- but upon questioning, her mother said that the Case 1 child was quite nervous about school. lar small crusted lesions on the anterior The annular lesion, with its classic nares, lips, and chin region (see Figure “honey-crusted” scaliness on the upper Should you proceed with a topical oint- 5, page 446). The rash has also been un- philtrum of this 6-month-old infant is typi- ment or an empiric oral therapy? Is this a responsive to over-the-counter topical cal of impetigo. Impetigo is a superficial bacterial, viral, fungal, or irritant rash? antibiotics. skin infection nearly always caused by Should you proceed with a topical oint- Staphylococcus aureus (75%-90%) and CASE 3 ment or an empiric oral therapy? Is this by group A streptococcus (GAS) (10%), The 6-year-old afebrile and otherwise a bacterial, viral, fungal, or irritant rash? and sometimes by a mixed infection with healthy white male developed an almost Should you perform a specific culture? these two same organisms. Although topi- annular maculo-papular raised rash that cal therapy with mupirocin or retapamulin extended to the tip of the nose and up- CASE 6 might alleviate the infection, my impres- per vermillion border (See Figure 3). You The 6-year-old white female has been sion is that oral therapy is much more also note several large crops of tiny ves- feeling poorly for about a week with in- likely to eradicate infection in this locale,

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which probably involves the anterior nasal mucosa and septum as well. In the past, S. aureus impetigo had typically been treated with a beta-lactam antibiotic, usually either an oral cepha- losporin (not cefixime or ceftibuten) or amoxicillin-clavulanate (AMC). How- ever, due to the increasingly high rates (60%-75%) of MRSA among outpatient S. aureus isolates being observed in A most sites throughout the US, I prefer to initiate empiric oral therapy with ei- Figure 5. A 7-year-old white male who presented with pharyngitis, fever, and mild lymphadenitis ther clindamycin or trimethoprim-sul- treated with azithromycin. His pharyngitis symp- famethoxazole (TMP-SMX) for MRSA toms only abated partially, and he subsequently strains. Nonetheless, because of the sig- developed crusted, red peri-oral lesions concom- itantly a few days after therapy. nificant likelihood of GAS in any case of impetigo, practitioners should only use being blunted by the prior treatment with oral (TMP-SMX) if a pre-therapy cul- topical steroids. This somewhat more ture is obtained, or when careful follow- atypical and non-descript rim of rash as up can be obtained within the next 48 seen in Case 3 is commonly termed tinea hours to ensure improvement. incognito. Thus for impetigo simplex, my initial Also, note the difference in the central choice is usually oral clindamycin, unless area of the rash in both children. Typi- taste issues (even with FLAVORx [Co- cal of tinea infections, Case 2 has some B lumbia, MD] ) are problematic. I would residual slightly reddened scaliness. By still avoid macrolides if at all possible due contrast, Case 3 has more than 40 tiny Figure 6. A 6-year-old white female with an 1 abrupt onset of (A) peri-oral and (B) generalized to their notable rates of GAS resistance vesicles in the middle of the semi-annular vesicular lesions that were also honey crusted, and MRSA resistance. If clindamy- rim of the lesion. Is this more typical of somewhat painful and pruritic. Her rash has been unresponsive to oral cephalosporins and steroid cin cannot be used for impetigo, then another type of infection? Any guesses? cream over the last week. be highly cognizant of the high rates of According to Paller and Mancini,2 MRSA when using oral beta-lactams and similar to tinea capitis, tinea faciei often recurrent cold sores. The herpetic lesions of GAS when using TMP-SMX. requires systemic oral antifungal therapy abated promptly as well, most likely due due to its location. In the two cases pre- to the early initiation of antiviral therapy. Cases 2 and 3 sented here, you were able to prescribe These two children presented with topical ketoconazole twice daily with an Case 4 similarly symmetrical annular scaly-bor- excellent response for the fungal portion You are concerned that the symmetri- dered rashes on the naso-labial/philtrum of the infection. You also told the parents cal annular rash seen on the peri-oral area region extending onto the nose (see Fig- to follow up by phone within the next few of the otherwise healthy 4-year-old girl in ures 2 and 3 page 445). This particular days, in case an oral systemic antifungal Figure 4 (see page 445) may have been rash location is known as tinea faciei, like griseofulvin might be needed if the caused by an impetiginous infection. De- (a “cousin” to tinea capitis), and is due fungal portion of the rash did not respond. spite the somewhat crusted appearance of to a superficial fungal infection of the However, in Case 3, you also recom- the dermatitis rim, in your career you have facial skin. It is most commonly caused mended that the family initiate antiviral previously seen several children with this by Trichophyton tonsurans (> 90%),2 therapy with oral acyclovir for this child, type of dermatitis, most of whom were and illuminating the rash with a Wood’s because of the high probability that a sec- noted to be quite chronically anxious or lamp in a dark room is typically fruitless, ondary herpes simplex infection had also recently stressed. In this case, you have as only Microsporum species fluoresce. erupted in the center of the fungal tinea in- uncovered a tremendous amount of sepa- Note that the annular area of the lesion in fection. The child had no history of prior ration anxiety, school phobia, and some Figure 3 (see page 445) is not as scaly — cold sores or herpes simplex infections, other milder nervous habit tics as well. an inflammatory response that has been although both parents had a history of She had no history of eczema.

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This child has developed “lip-licker’s petigo simplex, especially in view of the dermatitis” from her constant chronic crusty sore on the anterior nares. tongue licking of her peri-oral skin.2 Azithromycin-resistant GAS has been Saliva is a notable skin irritant, causing noted to be as high as ~50% in some ar- inflammation and irritation of the skin, eas of the US.1 Even before these reports particularly among those with atopic der- of resistance, azithromycin treatment matitis or infants with chronic pacifier failures among children with GAS phar- use. Occasionally, the contact dermatitis yngitis have been observed to be as high can result from certain foods, notorious- as 42% to 62% as well.3,4 Thus you are ly citrus, carrots, shrimp, spinach, and in not surprised by the antibiotic failure my experience “ketchup” condiments. with azithromycin for both the pharyn- This child was treated with hydrocor- gitis and the new-onset impetigo. You tisone valerate 0.2%, a mild steroid oint- prescribe oral cephalexin twice daily for Figure 7. A 2-year-old white female with fever to ment, along with a bland emollient sev- 10 days (to cover for the possible S. au- 102°F, dysphagia, drooling, a few honey-crusted peri-oral lesions, and a few blisters on the tongue eral times a day, resulting in only a partial reus co-pathogen) with good resolution but none on the posterior pharynx. resolution. Although anti-anxiety drugs of both infection sites. The child obvi- like SSRIs may be appropriate in older ously did not have MRSA causing the is a fissuring and inflammation of the children with moderate to severe anxiety, impetigo. corners of the mouth (see Figure 7). they should probably not be prescribed Cheilitis usually appears to be related to by pediatricians to this age group. After Case 6 moisture collecting at the mouth angles, 4 weeks of only partial amelioration, and This previously healthy 6-year-old although it can be occasionally second- the persistent lip licking, you prescribed girl developed extensive crops of herpet- ary to candida or impetigo in refractory a low dose of an antihistamine drug, oral ic and severe crusted lesions, particularly cases. Saliva is considered to be quite an hydroxyzine, and a much weaker anti- in the peri-oral region over several days irritant of the skin. However, this child’s anxiety drug three times a day. She had (see Figure 6A, page 446). To determine cheilitis is most likely related to the viral a much improved response for both the the etiology of her severe dermatitis, you herpangina infection and her concomi- dermatitis and the separation anxiety. thought that she required cultures for tant constant drooling. As the fevers and Sedation from the hydroxyzine was tran- both herpes and for bacterial coinfec- blisters on the tongue resolved, so did sient and not much of a problem, due to tion. In light of her history of mild atop- the cheilitis sores. Herpangina requires the low dose employed. ic dermatitis, you surmised that she had no specific treatment except for non- been afflicted with a disseminated gen- specific therapies such as ibuprofen, Case 5 eralized herpes rash, known as eczema extra oral fluids, and emollients for the The 7-year-old boy in Figure 5 (see herpeticum (see Figure 6B, page 446).2 cheilitis. Thus, you discontinued her oral page 446) initially presented with classic Her cultures also grew MRSA, a second- antibiotic. signs and symptoms of GAS pharyngitis, ary bacterial super-infection, along with including sore throat, low-grade fever, her positive PCR lesion test for herpes REFERENCES and anterior cervical lymphadenitis 7 simplex type 1. Despite numerous oral 1. Martin M, Green M, Barbadora KA, Wald ER. days prior to today’s visit. His symptoms courses of clindamycin and oral acy- Erythromycin-resistant group A streptococci in schoolchildren in Pittsburgh. N Engl J Med. and signs, which were milder, persisted clovir with some initial partial amelio- 2002;346(15):1200-1206. despite treatment with 5 days of standard ration over the next several weeks, she 2. Paller AS, Mancini AJ, eds. Hurwitz Clinical dose azithromycin. However, in light of eventually required IV vancomycin and Pediatric Dermatology: A Textbook of Skin Dis- orders of Childhood and Adolescence. 3rd ed. the development of this new-onset peri- IV acyclovir for several days due to her Philadelphia, PA: Elsevier/Saunders; 2006. oral crusted rash, you wondered if this worsening rash and intermittent fevers. 3. Cohen R, Reinert P, De La Rocque F, et al. Com- also could have been a herpetic pharyn- She did not develop a commonly asso- parison of two dosages of azithromycin for three gitis initially and that your azithromycin ciated secondary keratoconjunctivitis as days versus penicillin V for ten days in acute group A streptococcal tonsillopharyngitis. Pedi- treatment was irrelevant anyway. well. atr Infect Dis J. 2002;21(4):297-303. You decide to test for GAS with a rap- 4. Schaad UB, Kellerhals P, Altwegg M; Swiss id antigen detection test — which turns Case 7 Pharyngitis Study Group. Azithromycin versus penicillin V for treatment of acute group A up positive. Now, the more you examine This 2-year-old girl had developed an streptococcal pharyngitis. Pediatr Infect Dis J. the rash, the more it appears to be im- “angular cheilitis,” or perleche, which 2002;21(4):304-308.

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