Challenging Pediatric Rashes Richard P. Usatine, MD, FAAFP Professor, Family and Community Medicine Professor, Dermatology and Cutaneous Surgery University of Texas Health, San Antonio 1 ACTIVITY DISCLAIMER The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations. The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material 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. 2 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. 3 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. 4 2 Young boy with orange eruption What is the cause? 5 AES Question 6 3 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 7 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 8 4 Gianotti–Crosti syndrome • Infantile papular acrodermatitis • Juicy papules on the extremities & buttocks • Often follows infection • It resolves spontaneously 9 Gianotti–Crosti syndrome Infantile papular acrodermatitis 10 5 Gianotti–Crosti syndrome - Infantile papular acrodermatitis 11 AES Question 12 6 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 13 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 14 7 Hand Foot and Mouth Disease 15 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 coxsackievirus A6 - February 2012. MMWR 16 8 HFM 6 yo – A6 17 Hand Foot and Mouth Disease Coxsackievirus A16 18 9 19 Football-shaped Flat Vesicle 20 10 AES Question 21 Question 3 What is most likely diagnosis for this 4yo boy with HIV? A. eczema herpeticum B. molluscum C. chickenpox D. zoster 22 11 Question 3 What is most likely diagnosis for this 4yo boy with HIV? A. eczema herpeticum B. molluscum C. chickenpox D. zoster 23 Zoster 24 12 Otherwise healthy teen with zoster 25 AES Question 26 13 Question 4 What is most likely diagnosis for this 18-month-old? A. molluscum B. chickenpox C. eczema herpeticum D. zoster 27 Question 4 What is most likely diagnosis for this 18-month-old? A. molluscum B. chickenpox C. eczema herpeticum D. zoster 28 14 Eczema herpeticum • Severe herpes infection in patient with atopic dermatitis (AD) • May require hospitalization if systemically ill • Treat the herpes with acyclovir • Treat the AD with topical steroids 29 AES Question 30 15 Question 5 What is most likely diagnosis for this 19yo man? A. Urticaria B. Stevens-Johnson syndrome C. Measles D. Erythrodermic atopic dermatitis 31 Question 5 What is most likely diagnosis for this 19yo man? A. Urticaria B. Stevens-Johnson syndrome C. Measles D. Erythrodermic atopic dermatitis 32 16 Erythrodermic atopic dermatitis • Can require hospitalization if severe enough to cause temperature instability • Get dermatology consult ASAP for all erythroderma 33 AES Question 34 17 Question 6 What is most likely diagnosis for this 11yo girl? A. Tight jeans B. Henoch Schonlein purpura C. Ant bites D. urticarial vasculitis 35 Question 6 What is most likely diagnosis for this 11yo girl? A. Tight jeans B. Henoch Schonlein purpura C. Ant bites D. urticarial vasculitis 36 18 Henoch Schonlein Purpura with petechiae 37 38 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 39 AES Question 40 20 Question 7 What is the diagnosis of this 17yo teen? A. rosacea B. impetigo C. SLE D. erythema infectiosum (5th disease) 41 Question 7 What is the diagnosis of this 17yo teen? A. rosacea B. impetigo C. SLE D. erythema infectiosum (5th disease) 42 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 43 AES Question 44 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 45 Question 8 What is the diagnosis for this teenage girl? A. pyoderma gangrenosum B. basal cell carcinoma C. squamous cell carcinoma D. pyogenic granuloma 46 23 Pyoderma gangrenosum after years of growth and finally healing with infliximab infusions 47 Pyoderma gangrenosum • Note the gunmetal borders around this ulcer • 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 48 24 AES Question 49 Question 9 What is most likely diagnosis for this 12yo boy? A. Guttate psoriasis B. pityriasis rosea C. nummular eczema D. delusions of parasitosis 50 25 Pityriasis rosea • Herald patch (arrow) • Scale following skin lines • Don’t worry if there is no Christmas tree 51 Pityriasis rosea in darker skin 52 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 53 Phytophotodermatitis –lime juice and sun 54 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 55 AES Question 56 28 Question 11 What is the diagnosis? A. Epidermal nevus B. Nevus of Ota C. Nevus of Ito D. Flat warts 57 Question 11 What is the diagnosis? A. Epidermal nevus B. Nevus of Ota C. Nevus of Ito D. Flat warts 58 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 59 AES Question 60 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 melanoma C. Nevus sebaceous D. Geographic wart 61 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 62 31 Nevus sebaceous • Benign tumor of the epidermis, 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. 63 AES Question 64 32 Question 13 What is the diagnosis? A. lichen spinulosus B. lichen striatus C. lichen aureus D. lichen nitidus 65 Question 13 What is the diagnosis? A. lichen spinulosus B. lichen striatus C. lichen aureus D. lichen nitidus 66 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 67 68 34 69 Lichen nitidus with Koebner phenomenon small monomorphic papules 70 35 Lichen spinulosus – group of hypopigmented papules that are somewhat spiny 71 AES Question 72 36 Question 14 What is the most likely diagnosis in this 5yo? A.