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Healthy Baby Practical advice for treating newborns and toddlers.

Getting Truculent with Truncal Rashes Stan L. Block, MD, FAAP

A B C All images courtesy of Stan L. Block, MD, FAAP. Figure 1. Afebrile 22-month-old white male presents to your office with this slowly spreading, somewhat generalized, and refractory truncal rash for the past 4 weeks. It initially started on the right side of his trunk (A) and later extended down his right upper thigh (B). The rash has now spread to the contralateral side on his back (C), and is most confluent and thickest over his right lateral ribs.

n a daily basis, we pediatricians would not be readily able to identify this rash initially began on the right side of his encounter a multitude of rashes relatively newly described truncal rash trunk (see Figure 1A) and then extended O of varied appearance in children shown in some of the following cases. distally down to his right upper thigh (see of all ages. Most of us gently-seasoned As is typical, certain clues are critical, Figure 1B). Although the rash is now dis- clinicians have seen nearly all versions including the child’s age, the duration tributed over most of his back (see Figure of these “typical” rashes. Yet, I venture and the distribution of the rash. Several 1C), it is most confluent and most dense to guess that many practitioners, who of these rashes notably mimic more com- over his right lateral ribs. would be in good company with some of mon etiologies, as discussed in some of From Figure 1, you could speculate my quite erudite partners (whom I asked), the following cases. Making an accurate that this is either eczema — which the diagnosis of these particularly persistent patient has never had problems with be- Stan L. Block, MD, FAAP, is Professor of Clinical truncal rashes can readily assuage the fore — or , which notori- Pediatrics, University of Louisville, and University of frustrated parent. ously has a Christmas-tree type pattern of Kentucky, Lexington, KY; President, Kentucky Pedi- distribution on the back. Both processes atric and Adult Research Inc.; and general pediatri- CASES are not associated with fever, but they are cian, Bardstown, KY. Case 1 commonly associated with pruritus. Address correspondence to Stan L. Block, MD, A previously healthy, afebrile, fully FAAP, via email: [email protected]. vaccinated 22-month-old white male Case 2 Disclosure: Dr. Block has no relevant financial presents to your office with this now gen- A previously healthy, fully immu- relationships to disclose. eralized and spreading, primarily truncal nized, afebrile two-year-old white fe- doi: 10.3928/00904481-20130723-05 rash (see Figure 1). The mildly pruritic male presents to your office with the

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Figure 2. Afebrile 2-year-old white female who pre- Figure 4. (A) Afebrile 8-month-old white female presents with a 3-week, slowly spreading, heavy crop sented with a mostly unilateral, lichenoid, pruritic of ovoid, round, and linear pruritic eczematoid lesions over mostly the right trunk and arm, but which rash on the left lateral trunk for 3 weeks. Previous is more diffuse on her back. (B) The mother recalls that the rash started with three of the more central treatment with steroid ointments for presumed round lesions on her upper back 3 weeks ago. poison ivy as diagnosed by another physician, has not ameliorated the condition at all, and in fact, the rash is now spreading. The rash also has some pe- techiae in the and in the lateral rib areas (see visits elsewhere, because she is such an Case 4 arrrows), which you presume are due to excoriation. outdoorsy girl, she was diagnosed with A healthy 8-month-old white female She has been outdoors for many days during the summer, but denies any tick bites or recent medica- poison ivy contact . She has who is fully vaccinated and afebrile pres- tions other than diphenhydramine for pruritus. been unsuccessfully treated with steroid ents with an abrupt onset rash spreading creams and diphenhydramine. You now over 2 days. It is a fairly heavy crop of observe some petechiae under her left ovoid, round and linear pruritic eczema- axilla and left mid-section, but you attri- toid-looking lesions distributed mostly on bute this to the scratching that you have her right trunk and arm regions.(see Figure witnessed in the office. She is ingesting 4A) It is also a bit more diffuse on her back, no other and has no history and her mother says that the rash started of tick bites. You are perplexed by the with three of the small round lesions seen truly unilateral nature of the rash. now on her upper back (see Figure 4B). This is her first time ever diagnosed with Case 3 “eczema.” Her previous treatments from A previously healthy afebrile 6-year- an earlier physician visit have consisted old white female presents to your office of valerate 0.2% ointment, with a primarily unilateral, non-descript emollients, and diphenhydramine. How- pruritic rash on the entire right side of ever, something peculiar about the appear- her body (see Figure 3). The mother ance and history of the rash sends alarm is quite frustrated that the child’s rash bells to your cerebral cortex. But she is too Figure 3. Afebrile 6-year-old white female who has not resolved in over 2 weeks, two young to have that type of rash? presented with a mostly unilateral rash on the lat- physician office visits, and a multitude eral abdomen, ribs, and back for 2 weeks. The rash was pruritic, non-tender and unresponsive to ste- of ointments and oral medications, in- Case 5 roid creams and two separate previous physician cluding mometasone cream, emollients, A 6-year-old white male presents to office visits. diphenhydramine, ranitidine (H2 hista- your office with low-grade fever, mild mine blocker) and oral for pharyngitis for 2 days and a 24-hour his- rash seen in Figure 2. The rash is mostly possible poison ivy . tory of the rash seen in Figure 5 (see page unilateral, quite pruritic, and has been Once again, you are perplexed by the 313). He describes the rash as not painful, distributed mostly on the left lateral nearly complete unilateral characteris- but very itchy. It is distributed over his en- trunk for 3 weeks. At previous physician tics of the rash. tire anterior trunk and even up to his axilla

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Figure 5. During August, this 6-year-old white Figure 6. (A and B) The afebrile 2-year-old white female presented this summer with these discreet very male presented with this diffuse, pruritic, fine mac- itchy maculopapular scattered lesions over her trunk and upper thighs for the last 24 hours. Although ulopapular rash over the entire anterior trunk and she has been swimming frequently, her mother usually applies DEET insect repellant to her when she is axilla. No rash was noted on the back. He has also outdoors. Note that the rash is bilaterally distributed. She is fully vaccinated for her age. complained of fever to 101°F and mild sore throat. but not on his back, legs or face. What ad- examination you notice the flushed cheeks ULE is depicted in the Hurwitz Pedi- ditional examination should be undertak- immediately, along with the reticular mor- atric Clinical textbook, 3rd en, and how should you proceed? billiform rash localized mostly on the bilat- edition3 as most commonly occurring in eral anterior trunk and upper extremities (see children between ages 1 and 5 years. The Case 6 Figure 7, page 314). Once you presume the lesions begin on the lateral trunk area and You are seeing this 2-year-old white correct diagnosis, you must warn the family then may spread centrifugally up to the female during the summer for these very that the rash may persist for a few weeks — axilla or inguinal area or posteriorly in up discreet isolated but quite pruritic macule- so that they do not get frustrated — and that to 50% of children. The lesions often dis- papules on both of her sides and a few on treatment is merely for the symptoms. They play as maculo-papules, eczematoid, li- her upper thighs for the last 24 hours. She also have a teenage daughter who has never chenified, , or even in scarla- is afebrile, fully vaccinated, and has been had this type of rash. tiniform and reticular morphologies. Half playing outside or swimming most days of children have pruritus, and desqua- this summer. When you mention the words DISCUSSION mation is common as the rash resolves. “insect bites” during this Saturday morn- Cases 1, 2 and 3 Occasionally the patient may have some ing’s visit, the mother adamantly states that Each of these three children presented low-grade constitutional symptoms, just she always sprays her children with insect with a rash history, pattern and distribution as with any other low-grade viral infec- repellant whenever they proceed outside, consistent with “unilateral latero-thoracic tion. particularly the DEET 24% family version. ” (ULE), otherwise known as In general, most experts postulate She had read about DEET in Consumer “asymmetric periflexural exanthem” of that this illness is likely caused by a Reports magazine as being the only effec- childhood. However, if you do not recog- host of multiple viral etiologies. Some tive insect repellant. What additional his- nize these terms, do not be alarmed. The have speculated that it may occasionally tory might have been important to know most recent edition of the Nelson Textbook evolve into the papular acrodermatitis of when trying to identify the etiology? of Pediatrics (19th edition)1 still does not childhood (Gianotti-Crosti syndrome, include this disorder in my search of its in- which I presented in the July 2013 Pedi- Case 7 dex. In each of these patients, the rash be- atric Annals issue), and may be caused by A 4-year-old white female has devel- gan on the lateral trunk area , and then later those same potential pathogens.4 One of oped a fever to 100.5°F, headache, and this spread distally or across the midline over a the critical features of ULE that practitio- pruritic truncal morbillifom rash for 3 days. few weeks. The first series of children with ners must be aware of and must be able to She denies recent travel, tick bites, sore ULE was described by Bodemer and de reassure frustrated parents of — the rash throat, diarrhea, or joint aches. During your Prost in 1992.2 usually resolves over 3 to 4 weeks, but it

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ULE, but only on the hands, feet and groin Although the rash here is not the typical area, not on the trunk region. A rapid anti- reticular-lacy appearance of , gen detection test of the throat for Group the clinical diagnosis is usually clinched A strep will nearly always confirm the eti- by the appearance of flushed cheeks bilat- ology, except in the rare case of “surgical erally, as seen in Figure 7. ” caused by Staphylococcus This may cause some low- aureus. Treatment is usually with beta- grade fever in 15% to 30% of patients, lactam antibiotics, such as amoxicillin. headaches and other mild constitutional symptoms. It most commonly occurs Case 6 in the spring. Once infected, immunity The rash of the afebrile 2-year-old in seems to be permanent. Importantly, Fifth Figure 6 (see page 313) upon first glance disease may cause fairly severe arthral- could easily be mistaken for multiple in- gias for days to months in more than 50% sect bites from chiggers or mosquitoes, of older adolescents, particularly females especially with her presenting in the first (so warn the sibling).4 In addition, a po- 24 hours of eruption during the swim- tential hemolytic anemia from this infec- Figure 7. The 4-year-old white female presented ming season. However, further question- tion can be quite dangerous for the fetus to your office with a fever to 100.5°F, headache, ing revealed that the child, although vac- in the first two trimesters, and for those and this pruritic generalized truncal morbillifom 4 rash for 3 days. Note the red cheeks. cinated against varicella, was exposed with chronic anemia. earlier for an extended period of time to may last as long as 8 weeks. Treatment is an aunt with known herpes zoster. About CONCLUSION symptomatic only. 20% of children who have received a sin- Clinicians should familiarize them- gle dose of varicella will develop selves with the characteristics of this Case 4 breakthrough varicella over a period of novel rash (ULE) along with the possible The 8-month-old female in Figure 4 10 years. However, these cases are often atypical presentations of these other com- has typical pityriasis rosea. Ovoid ecze- “mild and clinically modified,” according mon unique rashes, which are primarily matoid “herald” lesion(s) initiated the to the 2012 AAP Red Book,5 as in our pa- distributed on the trunk. Because many bilateral truncal rash, along with the al- tient here. of these rashes may persist for weeks, if most Christmas-tree-like bilateral pat- Over the ensuing next few days, some misdiagnosed they will become a source tern on the back. The rash can sometimes of the lesions crusted over, appeared to be of much cost, consternation and frustra- be pruritic; constitutional symptoms are in different stages, and disappeared to- tion for you and the family. uncommon and low grade when they do tally in about 5 days, instead of the usual occur. And again like ULE, the rash may 7 to 10 days in unvaccinated . REFERENCES persist for 8 to 12 weeks; its etiology is Therapy can consist of oral acyclovir, 1. Kleigman RM, Stanton B, St. Geme J, Schor unknown. or merely symptomatic treatment with NF, Behrman RE, eds. Nelson Textbook of Pediatrics. Philadelphia, PA: WB Saunders; anti-pruritics and daily oatmeal baths. 2011. Case 5 An important point to remember is the 2. Bodemer C, de Prost Y. Unilateral laterotho- Although Group A streptococcal phar- avoidance of steroid creams or oral ste- racic exanthem in children: a new disease? J Am Acad Dermatol. 1992;27(5 Pt 1):693-696. yngitis is uncommon in the summer, this roids when the diagnosis of varicella is 3. Paller AS, Mancini AJ, eds. Hurwitz Clinical young boy in Figure 5 (see page 313) pre- considered likely. Pediatric Dermatology: A Textbook of Skin sented with the classic bilateral abdominal Disorders of Childhood and Adolescence. 3rd ed. Philadelphia, PA: Elsevier/Saunders; 2006. truncal rash of scarlet fever. The rash may Case 7 4. Feigin RD, Cherry J, Demmler-Harrison GJ, be pruritic, mostly involves the anterior The truncal rash in our 4-year-old girl Kaplan SL. Feigin and Cherry’s Textbook of trunk and axilla, and most importantly from Figure 7 is distinctly different than Pediatric Infectious Diseases. 6th ed. Philadel- on physical examination, it nearly always the previous rashes displayed. It is re- phia, PA: WB Saunders; 2009. 5. AAP Committee on Infectious Diseases; Pick- starts in the groin region. Thus you must ticulated, morbilliform, and heavily dis- ering LK, Baker CJ, Kimberlin DW, Long SS, always partially pull the pants or under- tributed bilaterally over the abdomen and eds. Red Book: 2012. Report of the Committee wear down to examine the skin below the upper extremities, with none on the back on Infectious Diseases (Red Book Report of the Committee on Infectious Diseases). 29th ed. pant-line. At 7 to 10 days later, the rash or legs. This is the 2 to 3 week rash of Elk Grove Village, IL. American Academy of often desquamates in a similar manner as Fifth disease, caused by Parvovirus B19. Pediatrics; 2012.

314 | Healio.com/Pediatrics PEDIATRIC ANNALS 42:8 | AUGUST 2013 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.