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Home , Erythema multiforme, Exanthem, Hives, Mongolian spot

Warning! Cute Kids Ahead!

Pediatric : Not Child’s Play

Mary Ann Maurer, DO WVU School of Medicine, Charleston Campus CAMC Family Medicine Residency Are you itching to learn?! Pre-Test: What is… Common Pediatric Derm Issues

• Newborn – Milia – Dermal melanocytosis – – toxicum neonatorum • – Diaper dermatitis – Cradle cap – Viral • • Parvovirus B-19 • • Varicella Just a • Children – roadmap, – Drug eruptions • • don’t • SJS • TEN panic – – Traction alopecia – Mycoplasma pneumonia associated mucositis • Adolescents – – – –

• Newborn – Milia – Dermal melanocytosis – Hemangioma – Erythema Toxicum Neonatorum

Milia

• Tiny white bumps • Typically on face • Small follicular plugs • Often seen 3-5 days after birth • Spontaneously resolve / self-limited

http://www.dermnetnz.org/site-age- Don’t specific/neonate.html pick! Milia Dermal Melanocytosis

http://newborns. stanford.edu/Ph • Benign otoGallery/Slate • Seen in pts with darker Grey1.html – Asian – Hispanic

– Black http://www.skinsig ht.com/infant/blue – Native American - GraySpotMongolia • aka Mongolian Spot nSpot.htm • Often at sacrum • Size can vary

• Typically resolve by pre- http://www.intermix.org.uk/health school /health_bluespots.asp

http://www.whattoexpect.c om/first-year/baby- • Vascular tumors / care/baby-skin- lesions care/hemangioma.aspx • Often has a period of growth followed by period of involution • Propranolol – Till age 12-15 mos • Laser tx or excisional • Usually much improved by age 5-10 Hemangiomas

• Systematic review (2013) – n = 1264 • 74% female • 30% w other tx prior to propranolol • Mean age of intiation 6.6 mos • Mean duration of tx 6.4 mos • Mean dose 2.1 mg / kg / day • 98% response rate – *any* response to propranolol • Rebound growth in 17% • ADRs n=371 – Changes in sleep (136) – Acrocyanosis (61) – Symptomatic hypotension (6) – Hypoglycemia (4) – Symptomatic bradycardia (1)

Hemangioma

• Multiple cutaneous hemangiomas should cue imaging to look for hemangiomas in solid organs Flammeus

• Port Wine Stain

• Sturge-Weber Syndrome – V1-V2 – Seizures

• Klippel-Trénaunay Syndrome http://www.childrenshosp – Vascular malformations ital.org/az/Site2944/main pageS2944P6.html – Varicosities – Unilateral hypertrophy

Nevus Flammeus Nuchae

• Stork bite – Around 40% of kids, though may be up to 70% – Mostly Caucasian kids – Often at neck – Can also be on eyelids and between eyes /on forehead

Are you still showing baby pictures?! Srsly… Next slide, dude!! Erythema Toxicum Neonatorum http://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/articles/ image_article_collections/mcgraw_hill_skin_atlases/childhood_skin_problems/CAPD _erythema_toxicum_neonatorum.jpg • Benign • Self-limited • Small pustules with surrounding erythema • Face, trunk, buttocks, limbs – If palmar / plantar, consider other dxs • Not seen in preterm babies • Typically within 48 hrs of age but may be delayed up to two weeks • Eosinophils

http://www.skinsight.com/images/dx/webInfant/erythemaToxicumNeonatorum_17955_lg.jpg • Infants – Diaper dermatitis – Viral exanthem • Roseola • Parvovirus B-19 • Measles • Varicella

Diaper Dermatitis Ouch! • Often due to contact irritant (feces / urine) • May be related to dietary changes • Fungal a possibility

• Myriad tx based on etiology – Steroid vs antifungal vs both! – Consider thrush – Prevention w/ barrier cream – Wipes can be irritating – Spray Maalox on it!

http://dermis.net/bilder/CD050/550px/img0040.jpg Cradle Cap

• Seborrheic dermatitis • Usu in the first 3 mos • Can also see behind ears, at eyebrows • Overactive sebaceous glands http://www.cheekymaidensoap.com/_blog/Cheeky_Maiden_Blog/post/Treating_Cradle_Cap/ • Occasionally fungal • Tx with baby oil, gentle brushing to loosen • No olive / coconut oils as can worsen fungal http://upload.wikimedia.org/wikipedia/commons/5/50/Baby_With_Cradle_Cap.jpg Viral Exanthem: Roseola

• HHV-6 • aka Roseola Infantum • Typical hx is fever x 72 hrs without other etiology (eg ears, teething) • When defervesce, a appears • Self-limited Viral Exanthem: Parvovirus-B19

http://health.allrefer.com/health/fifth-disease-fifth- disease.html • aka 5th Disease or Erythema Infectiosum • “Slapped cheek rash with lacy reticular pattern on trunk” after URI symptoms • May also have arthralgias w/ rash http://www.cixip.com/index.p • Careful—can cause SAB hp/page/content/id/939 in pregnant women Viral Exanthem--Measles • Increasing #s due to poor vaccination rates • Prodrome 2-4 days – Stepwise fever to Tm http://upload.wikimedia.o 103-105 rg/wikipedia/commons/e/ e0/Measles_enanthema.j pg – 4Cs • Rash

http://www. atsu.edu/fac ulty/chambe rlain/images/ https://jdc325.files.wordpress.com/2011/04/measles_2.jpg koplik_spots 2.jpg

http://bchdmi.org/uploade d_images/measles1.jpg Viral Exanthem--Varicella

• Crops of lesions – Prodrome of fever, anorexia, malaise (1-2d) – Lesions in varying states simultaneously – Starts centrally then moves peripherally

http://s ocialhea lthboxx. com/wp - content /upload s/2014/ 04/chic http://research.fuseink.com/artifactimg/MTMxOTc5NjQ3ODMyMjFfMg.jpg ken.jpg • Children – Contact dermatitis – Drug eruptions • Urticaria • Erythema multiforme • SJS • TEN • DRESS (bit of a stretch!) – Warts – Traction alopecia – Mycoplasma pneumonia associated mucositis

Contact Dermatitis

http://blog.saintsabrinas.c om/wp- content/uploads/2011/01 • Allergic or Irritant /belt-buckle-.jpg • Remove the source – Or try to control it (!) • Mild topical http://eso- cdn.bestpractice.bmj.com may help /best- practice/images/bp/en- gb/90-3_default.jpg

http://www.skinsight.com/infa nt/irritantContactDermatitis.ht m : Urticaria

• Look for – Wheal = , and – Flare = erythema

• History is most helpful

• NB: Of course one can have urticaria for other reasons! http://allergyasthmamichigan.com/web%20site%20contents/hives.jpg Drug Eruption: Erythema Multiforme

• History is key – – Sulfa – Anti-epileptics (eg Dilantin)

• Look for well- circumscribed lesions w/ central clearing

• No oral lesions! http://www.huidziekten.nl/afbeeldingen/erythema-exsudativum-multiforme-7.jpg Drug Eruption: SJS

• History • Offending agent

• Fever, fatigue www.rightdiagnosis.com/phil/images/4650.jpg • Skin lesions and mucous membrane involvement – Including eyes! • May require ICU admission

http://www.portalesmedicos.com/imagenes/publicaciones/0803_Sindrome_Stevens_Johnson/lesiones_eritemato_papulo_bullosas.jpg

http://syndromepictures.com/wp-content/uploads/2011/10/Steven-Johnson-Syndrome-rash.jpg SJS: Treatment

• Removal of offending agent • Analgesia • Topical steroids – Eyes – Skin • No real role for systemic steroids • Occasionally IVIg • Also of interest – Cyclosporine – Tacrolimus – NAC – Biologics – Plasmapheresis • Tincture of time • Specialty consult Drug Eruption--TEN

• Occurs in response to infection or drugs • Spectrum is EMSJSthis – TEN >30% BSA • Apoptosis of leads to skin sloughing – Nikolsky sign • Admission to burn unit • Mortality 30-50% http://www.skincareguide.ca/images/glossary/toxic_epidermal_necrolysis.jpg – SCORTEN

Drug Eruption--DRESS

• Drug Reaction with Eosinophilia and Systemic Symptoms – Delayed reaction – High fever – Morbiliform (measles) rash – Rash and lymphadenopathy – Eosinophila and lymphocytosis – Elevated LFTs – Rare renal involvement – Myocarditis / pericarditis – HHV6 activation also implicated

• Offending agents – AEDs – Sulfa – Ziprasidone (Geodon) –

– Atenolol! http://archderm.jamanetwork.com/article.aspx?articleid=1733354 Warts

• Verrucae • Varied morphology • Location = anywhere!

• Tx varies http://medicalpicturesinfo.com/wp-content/uploads/2011/10/Verruca-Vulgaris-3.jpg – Cryo – TCA – Curettage – Excision

http://0.tqn.com/d/foothealth/1/0/-/2/-/-/DSC_3339.JPG Traction Alopecia

• Tension from tight braids,

ponytails, weaves / http://hairlos sgeeks.com/t raction- alopecia- extensions causes-and- treatment/ • No loss of eyebrows / body hair • Areas usually not circumferential • Can be permanent

http://dermnet nz.org/common • Treatment in peds is scalp /image.php?pat h=/hair-nails- sweat/img/trac rest tion.jpg – Occ Rogaine in adults MPAM (Mycoplasma Pneumonia Associated Mucositis) • Mucosal-only – Oral – Ocular – Urogenital • If skin involved, MASJS (Mp-associated SJS) • MPAM has better prognosis • Auto- against Mp attack mucosal cells

MPAM

Meyer Sauteur et al. (2012).

https://doi.org/10.1016/j.jtumed.2016.12.002

https://doi.org/10.1177/1203475419874444 MPAM

• Treatment – Abx – Steroids – Occasionally IVIg – Early specialist involvement if ocular involvement • Adolescents – Acne – Tinea versicolor – Tinea corporis – Keratosis pilaris

Acne

http://www.skinfoto.com/skin-facts/acne.html • Open comedones = blackheads • Closed comedones = whiteheads

• Cystic acne http://www.skinsight.com/child/acne – Oral abx Vulgaris.htm – Accutane • Must be on OCP

• Topicals http://www.dermnet.com/topics/acn – Salicylic acid e/physical-findings/ – Benzoyl peroxide – Retinoids Tinea Versicolor

• Aka Pityriasis Versicolor • Malassezia furfur • Fungal • Often see in summertime • Topical selsun blue / nizoral • Oral tx not http://www.health-writings.com/img/mi/tinea-versicolor-treatment/Tinea-Versicolor.jpg recommended currently Tinea Corporis

• Fungal • Topical anti-fungal (eg Lamisil) • Extend tx just past borders of lesion http://medicalpictures.net/wp- content/uploads/2011/10/tinea-corporis- pictures-2.jpg • Use for several days after lesion resolves

http://www.skinsight.com/images/dx/webA dult/tineaCorporisRingwormofBody_852_lg. jpg Keratosis Pilaris

• “chicken skin” • Often at upper arms, thighs • Excessive keratin • Topical exfoliant like

Ammonium lactate to http://www.dermnetnz.org/acne/img/keratosis-pilaris/source/image/3024.jpg remove keratin plugs – Retinoids can work, too, but often very drying – Need sunscreen!

http://www.atlasdermatol ogico.com.br/ListaImagens /Keratosis_Pilaris4.JPG Wrap-Up

Nevi are gone but the crazy remains!  • http://www.cdc.gov/parvovirusb19/fifth-disease.html. Accessed 08/20/13. • http://www.mayoclinic.com/health/keratosis- pilaris/DS00769/DSECTION=treatments-and-drugs. Accessed 08/20/13. • http://www.drgreene.com/articles/cradle-cap/ • Patient sheet on hemangioma https://pedsderm.net/site/assets/files/1028/12_spd_propranolol_c olor_web-final.pdf • Hemangioma and propranolol: https://doi.org/10.1111/pde.12022 • Systematic review of propranolol: https://doi.org/10.1111/pde.12089 • SJS / TENS treatments : doi: 10.4103/ijd.IJD_583_17