Challenging Pediatric

Richard P. Usatine, MD, FAAFP Professor, Family and Community Medicine Professor, Dermatology and Cutaneous Surgery University of Texas Health, San Antonio

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ACTIVITY DISCLAIMER

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2 might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP.

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1 Disclosure Statement

It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest. If conflicts are identified, they are resolved prior to confirmation of participation. Only participants who have no conflict of interest or who agree to an identified resolution process prior to their participation were involved in this CME activity.

All faculty and staff in a position to control content for this session have indicated they have no relevant financial relationships to disclose.

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Learning Objectives

1. Identify common and uncommon rashes and sources of irritation. 2. Point out the red flags that may indicate life-threatening rashes. 3. Construct appropriate evaluation, treatment and management plans for rashes based on diagnostic factors. 4. Educate patients on effective treatment methods and compliance with treatment protocol. 5. Describe the five main cutaneous findings in COVID-19. 6. Explain the relationship between “COVID-19 toes” and a better prognosis. 7. Discuss pediatric multisystem inflammatory syndrome found in children with COVID-19.

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2 Young boy with orange eruption

What is the cause?

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AES Question

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3 Question 1 What is most likely diagnosis for this in a 4yo who appears healthy and had a URI two weeks ago?

A. Flea bites B. Gianotti Crosti syndrome C.molluscum D.hand-foot-and-mouth disease

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Question 1 What is most likely diagnosis for this rash in a 4yo who appears healthy and had a URI two weeks ago?

A. Flea bites B.Gianotti Crosti syndrome C.molluscum D.hand-foot-and-mouth disease

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4 Gianotti–Crosti syndrome

• Infantile papular acrodermatitis • Juicy on the extremities & buttocks • Often follows infection • It resolves spontaneously

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Gianotti–Crosti syndrome

Infantile papular acrodermatitis

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5 Gianotti–Crosti syndrome - Infantile papular acrodermatitis

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AES Question

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6 Question 2 What is the most likely diagnosis for this 1yo child? A. B. Varicella C. Infantile papular acrodermatitis D. Hand-foot-and-mouth disease

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Question 2 What is the most likely diagnosis for this 1yo child? A. Herpes simplex B. Varicella C. Infantile papular acrodermatitis D. Hand-foot-and-mouth disease

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7 Hand Foot and Mouth Disease

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Coxsackie A6 – Atypical HFMD

• Lesions may have different morphologies including vesiculobullous or papular • Flat football shaped vesicles on palms and soles

• Atypical, severe HFMD (A6) may be associated with high fever, more extensive, denser rash in more locations, with greater malaise and likelihood of anorexia, dehydration, and pain.

– CDC, Notes from the field: severe hand, foot, and mouth disease associated with A6 - February 2012. MMWR

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8 HFM 6 yo – A6

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Hand Foot and Mouth Disease Coxsackievirus A16

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Football-shaped Flat Vesicle

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10 AES Question

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Question 3 What is most likely diagnosis for this 4yo boy with HIV?

A. eczema herpeticum B. molluscum C. D. zoster

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11 Question 3 What is most likely diagnosis for this 4yo boy with HIV?

A. eczema herpeticum B. molluscum C. chickenpox D. zoster

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Zoster

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12 Otherwise healthy teen with zoster

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AES Question

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13 Question 4 What is most likely diagnosis for this 18-month-old?

A. molluscum B. chickenpox C. eczema herpeticum D. zoster

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Question 4 What is most likely diagnosis for this 18-month-old?

A. molluscum B. chickenpox C. eczema herpeticum D. zoster

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14 Eczema herpeticum

• Severe herpes infection in patient with (AD) • May require hospitalization if systemically ill

• Treat the herpes with acyclovir • Treat the AD with topical steroids

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AES Question

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15 Question 5 What is most likely diagnosis for this 19yo man?

A. Urticaria B. Stevens-Johnson syndrome C. Measles D. Erythrodermic atopic dermatitis

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Question 5 What is most likely diagnosis for this 19yo man?

A. Urticaria B. Stevens-Johnson syndrome C. Measles D. Erythrodermic atopic dermatitis

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16 Erythrodermic atopic dermatitis

• Can require hospitalization if severe enough to cause temperature instability • Get dermatology consult ASAP for all

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AES Question

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17 Question 6 What is most likely diagnosis for this 11yo girl? A. Tight jeans B. Henoch Schonlein purpura C. Ant bites D. urticarial

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Question 6 What is most likely diagnosis for this 11yo girl? A. Tight jeans B. Henoch Schonlein purpura C. Ant bites D. urticarial vasculitis

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18 Henoch Schonlein Purpura with petechiae

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19 Henoch-Schonlein Purpura

• Often have GI symptoms with vasculitis • Check for renal involvement with UA • Unless very ill may treat as outpatient with NSAIDs and observation

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AES Question

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20 Question 7 What is the diagnosis of this 17yo teen? A. B. C. SLE D. infectiosum (5th disease)

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Question 7 What is the diagnosis of this 17yo teen? A. rosacea B. impetigo C. SLE D. erythema infectiosum (5th disease)

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21 SLE

• Note the crusting with the erythema • Needs systemic work-up with blood and urine testing • If a flare, may need hospitalization or rapid rheumatology appointment

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AES Question

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22 Question 8 What is the diagnosis for this teenage girl?

A. pyoderma gangrenosum B. basal cell carcinoma C. squamous cell carcinoma D. pyogenic granuloma

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Question 8 What is the diagnosis for this teenage girl?

A. pyoderma gangrenosum B. basal cell carcinoma C. squamous cell carcinoma D. pyogenic granuloma

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23 Pyoderma gangrenosum after years of growth and finally healing with infliximab infusions

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Pyoderma gangrenosum

• Note the gunmetal borders around this • Started in her teens and also involves her face and suprapubic area • Workup involves a biopsy on the border of the ulcer • Refer to a dermatologist as this is a difficult condition to treat

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24 AES Question

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Question 9 What is most likely diagnosis for this 12yo boy?

A. Guttate B. rosea C. nummular eczema D. delusions of parasitosis

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• Herald patch (arrow) • Scale following skin lines

• Don’t worry if there is no Christmas tree

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Pityriasis rosea in darker skin

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26 Question 10 What is the diagnosis of this teen with a new rash after eating limes in the sun? A. Acidic burn B. Lime disease C. phytophotodermatitis D. polymorphous light eruption

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Phytophotodermatitis –lime juice and sun

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27 Phytophotodermatitis –lime juice running down the trunk in the sun

Treatment:

1. Make diagnosis and warn pt to avoid limes in the sun 2. Offer topical steroid such as triamcinolone 3. Explain the pigment changes will fade over time

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AES Question

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28 Question 11 What is the diagnosis?

A. Epidermal B. Nevus of Ota C. Nevus of Ito D. Flat

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Question 11 What is the diagnosis?

A. Epidermal nevus B. Nevus of Ota C. Nevus of Ito D. Flat warts

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29 Linear epidermal nevus

• Most are benign and only cosmetic • If part of a linear epidermal nevus syndrome then there are other organ systems involved • Consider workup if there are signs of neurologic abnormalities

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AES Question

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30 Question 12 What is the most likely diagnosis of this growth on the scalp of a 14-year-old boy? A. Aplasia cutis B. Amelanotic C. Nevus sebaceous D. Geographic

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Question 12 What is the most likely diagnosis of this growth on the scalp of a 14-year-old boy? A. Aplasia cutis B. Amelanotic melanoma C. Nevus sebaceous D. Geographic wart

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31 Nevus sebaceous

• Benign tumor of the , hair follicles and sweat glands • Usually found on the scalp and appear in childhood • No action is needed unless they start changing in adulthood – undergo malignant degeneration, which is rare.

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AES Question

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32 Question 13 What is the diagnosis? A. lichen spinulosus B. C. lichen aureus D.

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Question 13 What is the diagnosis? A. lichen spinulosus B. lichen striatus C. lichen aureus D. lichen nitidus

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33 Lichen striatus

• Linear papular eruption in children that often extends down an extremity • It resolves spontaneously • It may take years to resolve

• Striations means a series of – ridges, furrows or linear marks

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Lichen nitidus with Koebner phenomenon small monomorphic papules

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35 Lichen spinulosus – group of hypopigmented papules that are somewhat spiny

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AES Question

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36 Question 14 What is the most likely diagnosis in this 5yo?

A. Henoch Schoenlein purpura B. C. Urticaria D. Gianotti Crosti syndrome

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Question 14 What is the most likely diagnosis in this 5yo?

A. Henoch Schoenlein purpura B. Erythema multiforme C. Urticaria D. Gianotti Crosti syndrome

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37 Erythema multiforme vs urticaria multiforme (targets with dusky centers with epithelial disruption vs with multiple shapes including targetoid ones)

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Urticaria multiforme

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38 Urticaria multiforme

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AES Question

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39 Question 15 What is causing these pigmentary changes in this 5yo?

A. B. C. Mosaicism D. Phytophotodermatitis

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Question 15 What is causing these pigmentary changes in this 5yo?

A. Vitiligo B. Morphea C. Mosaicism D. Phytophotodermatitis

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40 Morphea not vitiligo and hypopigmentation

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What does this 14-year-old girl have?

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41 can start with puberty

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Practice Recommendations

• Skin diseases commonly encountered in adulthood may be seen in childhood and adolescence.

• There are many skin conditions in childhood with vesicles including HFM, Gianotti Crosti syndrome, zoster, herpes and eczema herpeticum.

• Some skin conditions in childhood can be dangerous such as erythroderma, Henoch Schonlein purpura, a flareup of SLE, pyoderma gangrenosum and erythema multiforme.

• There are various benign conditions seen mostly in childhood which start with the word “lichen” and recognizing these can avoid unnecessary referrals.

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42 COVID-19 SKIN FINDINGS

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AES Question

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43 Question 16 The cutaneous findings in COVID-19 can be explained by:

A. Viral B. Vasculitis type reactions C. Adverse drug eruptions from treatment D. All of the above

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Question 16 The cutaneous findings in COVID-19 can be explained by:

A. Viral exanthems B. Vasculitis type reactions C. Adverse drug eruptions from treatment D. All of the above

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44 COVID-19

SARS-Cov-2 is a single- stranded RNA virus

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Searches June 10, 2020

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45 Cutaneous manifestations in COVID-19 2 major groups

1) clinical features similar to viral exanthems, an immune response to viral nucleotides

2) cutaneous eruptions secondary to systemic consequences caused by COVID-19, especially vasculitis and thrombotic vasculopathy.

Suchonwanit P, Leerunyakul K, Kositkuljorn C. Cutaneous manifestations in COVID-19: Lessons learned from current evidence [published online ahead of print, 2020 Apr 24]. J Am Acad Dermatol. 2020

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Increased risk of adverse

Suchonwanit P, Leerunyakul K, Kositkuljorn C. Cutaneous manifestations in COVID-19: Lessons learned from current evidence [published online ahead of print, 2020 Apr 24]. J Am Acad Dermatol. 2020

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46 375 cases in Spain

Galván Casas C, Català A, Carretero Hernández G, et al.

Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases

[published online ahead of print, 2020 Apr 29]. Br J Dermatol. 2020

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Spanish study – 5 Clinical Patterns

1. acral (hands & feet) - erythema with vesicles or pustules (19%)

2. vesicular eruptions (9%)

3. urticarial lesions (19%)

4. maculopapular eruptions (47%)

5. livedo or necrosis (6%)

Galván. Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases. Apr 29. Br J Dermatol. 2020

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47 When The Lesions Appear

• vesicular eruptions appear early • acral lesions appear late • other lesions appear during the symptomatic time

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Acral lesions

•Chilblains related to cold

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48 COVID-19 toes

•Pseudo-chilblains • affected younger patients with mild infections • appear later in the illness and lasted an average of 12 days

•Most persons with this have tested negative for COVID-19 •Some suggest these should be called “quarantine toes”

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COVID toes with COVID-19

Image copyright Jennifer Huang, MD. Used with permission from VisualDx (www.visualdx.com)

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49 Image copyright Jennifer Huang, MD. Used with permission from VisualDx (www.visualdx.com)

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Vesicular rash

• small vesicles on the abdomen or back of some patients and on the arms or legs of others • primarily affected middle-aged patients • tended to appear earlier than other symptoms of COVID-19 • often pruritic • lasted an average of 10 days

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51 Vesicular

• All of the photos from my photo collection are examples of the types of cutaneous reactions that can occur in COVID-19. • None of these photos are from real COVID-19 patients but represent the morphology that can occur.

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Urticarial rash

•usually found on the trunk but occasionally found on the palms •average duration of seven days •associated with more severe cases

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52 Urticarial

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Urticarial

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53 Maculopapular rash

• associated with more severe cases • average duration nine days • most common rash appearing in 47% of the cases

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Maculopapular

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54 Livedo (necrosis)

•purplish skin with a lacelike pattern •found in older patients with more severe illness form

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Livedo

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55 From: Petechial Skin Rash Associated With Severe Acute Respiratory Syndrome Coronavirus 2 Infection

JAMA Dermatol. Published online April 30, 2020. doi:10.1001/jamadermatol.2020.1741

Figure Legend: Copyright © 2012 American Medical Association. All rights reserved. Clinical Presentation at the Emergency Department. The consists of erythematous macules, papules, and petechiae affecting the popliteal fossae (A), buttocks (A and B), and anterior thighs (C).

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Kawasaki Disease

•Originally observed in Japan in the 1960s, Kawasaki disease is triggered by high levels of inflammation and can lead to trouble in the blood vessels and heart, among other places in the body, and occasionally prompt toxic shock syndrome and death.

•Traditional symptoms can include a persistent high fever, skin rash, conjunctivitis, swollen hands and feet, strawberry tongue and cracked lips.

•COVID-19 – Pediatric multisystem inflammatory disease

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56 Multisystem inflammatory syndrome

•A multisystem inflammatory syndrome potentially linked to COVID- 19 has been reported in children and young adults;

•clinical features include Kawasaki-like and toxic shock syndrome- like presentations.

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Multisystem inflammatory syndrome

CDC case definition (first published May 14, 2020):

An individual < 21 years of age presenting with fever*, laboratory evidence of inflammation**, and • evidence of clinically severe illness requiring hospitalization with multisystem (≥ 2) organ involvement (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic, or neurologic), AND • No alternative plausible diagnosis, AND • Positive for current or recent COVID-19 infection by reverse transcription - PCR, serology, or antigen test; or exposure to a confirmed or suspected COVID-19 case within the 4 weeks prior to onset of symptoms • *Fever > 38°C for ≥ 24 hours, or report of subjective fever lasting ≥ 24 hours.

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57 COVID-19 in child with Multisystem inflammatory syndrome

Courtesy of NIH

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Kawasaki Disease

Characterized by fever lasting at least 5 days (usually longer) plus 4 of the 5 following criteria:

1. Bilateral bulbar conjunctival injection without exudate 2. Oral mucosa changes: cracked lips, "strawberry tongue," or diffuse erythema of the mucosae 3. Changes in the extremities: erythema, induration, or periungual peeling 4. Exanthem 5. Cervical lymphadenopathy (greater than 1.5 cm diameter)

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58 Kawasaki (Courtesy Color Atlas of Family Medicine and Greg Thompson, MD)

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Kawasaki

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59 KD

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Strawberry Tongue

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Multisystem inflammatory syndrome

•Gastrointestinal — 171 patients (92%). •Cardiovascular — 149 patients (80%). •Hematologic — 142 patients (76%). •Mucocutaneous — 137 patients (74%). •Respiratory — 131 patients (70%).

•Patel MM, et al "Multisystem inflammatory syndrome in U.S. children and adolescents" N Engl J Med 2020; Published online June 29 DOI: 10.1056/NEJMoa2021680.

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61 Health-care workers skin issues with PPE

•Several dermatoses have been reported due to PPE, such as pressure injury, , pressure urticaria, and exacerbation of pre-existing skin diseases, including seborrheic dermatitis and .

•Singh M, Pawar M, Bothra A, et al. Personal protective equipment induced facial dermatoses in healthcare workers managing COVID- 19 cases [published online ahead of print, 2020 May 12]. J Eur Acad Dermatol Venereol. 2020;10.1111/jdv.16628. doi:10.1111/jdv.16628

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Just 90 minutes with N-95 mask

Used with permission by Andrea Darby, MD

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62 How to care for facial skin now that we all are wearing masks

•Use moisturizer on facial skin as dry skin is more prone to damage •Keep cloth masks clean and wash them regularly •Avoid face masks with rough fabrics •Take a break from the mask in locations where you can be distant from other humans

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Barriers to Barriers Practice

• Cutaneous manifestations of COVID-19 are relatively rare • Manifestations themselves are rarely dangerous but may give us a window into understanding some of the pathophysiology • Some presumed manifestations such as COVID toes may not be associated with the coronavirus

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63 Practice Recommendations

1. Keep an eye out for cutaneous manifestations of COVID-19 2. Consider reporting cases to the American Academy of Dermatology Registry 3. Consider Kawasaki like illness in children and its relationship to COVID-19 4. Prevent and treat PPE related skin reactions

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THE END

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64 Thank you!

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Answers

1. B 9. B 2. D 10.C 3. D 11.A 4. C 12.C 5. D 13.B 6. B 14.B 7. C 15.B 8. A 16.D

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