PAPULOSQUAMOUS ERUPTIONS IN CHILDREN Dr Pearl Kwong md phd Board Certified Pediatric Dermatologist Jacksonville Fl DISCLOSURE •Nothing to disclose DIFFERENTIAL DIAGNOSIS OF PAPULOSQUAMOUS ERUPTIONS IN CHILDREN (MOST COMMON) • Tinea • Pityriasis rosea PR /lichenoides chronica PLC • Guttate psoriasis/psoriasis • Nummular eczema • Cutaneous lupus OTHER DDX TO CONSIDER • Drug induced • Lichen planus • Pityriasis rubra pilaris • Secondary lupus • CTCL • Other forms of viral exanthema TINEA . Tinea faciei • Tinea corporis • Tinea pedis • Tinea gladiatorum SUPERFICIAL TINEA: TINEA FACIEI/CORPORIS • Predilection for non hairy areas of the face the trunk extremities • Contact with other individuals • Tinea corporis gladiatorum: wrestlers • Domestic animals particularly young kittens and puppies. • Causative agents are Mcanis occasionally T menta or M audounii in younger kids; older kids T rubrum T verrucosum T menta T tonsurans • In children with T rubrum or Epidermophyton floccosum suspect parents with tinea pedis or onychomycosis TINEA CORPORIS • Tends to be asymmetrical • Usually one or more annular well circumscribed plaques with clear center • Can have popular vesicular or pustular border • Can be polycyclic • Common in children warm humid climate and in patients with systemic diseases DM or IM • DDX: herald patch of PR , nummular eczema , psoriasis , contact dermatitis, seb derm , tinea versicolor . Erythema migrans, GA , fixed drug and LE TINEA INCOGNITO /MAJOCCHI’S GRANULOMA • Tinea incognito: use of corticosteroids can alter the presenting features ( Lotrisone or Mycolog) • Majocchi’s granuloma: perifollicular granulomatous disorder mainly on shaven legs , with erythematous plaques and papules studding the surface TINEA DX • Morphology: many differential dx. ; partially treated. Masked morphology due to treatment • KOH: many false positive interpretations • Woods light: only if organism is Mcanis or M audouinii yellow green • Fungal culture : takes a long time but can identify the dermatophyte • DTM : color changes but precludes identification • Biopsy PAS: costly pain not always necessary TINEA TX Topical antifungals : butenafine ciclopirox econazole ketoconazole miconazole naftifine oxiconazole sulconazole terbinafine tolnaftate TINEA INCOGNITO /MAJOCCHI’S • Need to start oral antifungal • Griseofulvin or terbinafine TINEA PEARLS •Treat contacts : humans and animals! •Warn that it can be recurrent if not treated properly •Tinea capitis can have secondary bacterial infection too! PITYRIASIS ROSEA AND VARIANTS Pityriasis rosea Pityriasis lichenoides chronica PLEVA Pityriasis lichenoides et varioliformis acuta PITYRIASIS ROSEA • Acute self limiting disorder • Common in children and adolescents • Only 4 % occur before age 4 • Most are well • Prodrome of headaches malaise pharyngitis lymphadenopathy mild sx • Etiology still unknown. • Mostly viral HHV 6 and 7 PITYRIASIS ROSEA • Herald patch , mostly on the trunk neck thigh arms. • Scaly plaque elevated border • Often misdiagnosed as tinea • After interval of 2 to 21 days generalized eruption on trunk with xmas tree pattern • Clearance usually within 6 weeks • Morphology: oval lesions with fie collarette scales • Can have other morphologies : hemorrhagic bullous or erosive DIAGNOSIS AND TREATMENT • Clinical features • Biopsy subacute or chronic dermatitis with vascular dilatation edema superficial lymphocytic infiltrate. Mild exocytosis patchy parakeratosis. Non specific • Most patients do not need tx. Reassurance . Pruritus control. • UV light exposure hasten resolution • Erythromycin may shorten course. • Topical steroids for itching PITYRIASIS LICHENOIDES CHRONICA/PLEVA • Parapsoriasis • Acute form PLEVA Mucha Haberman disease • Chronic form PLC guttate parapsoriasis PLEVA • Polymorphous eruption 2-3 mm oval round reddish brown macules papules • Fine crust sometimes resolving with scar • Can be mistaken for chicken pox • Weeks to months • Can have asstd fever or constitutional sx • Rare variant with nodules and fever PLC • Can arise from PLEVA or denovo • Lasts weeks to months to years • Dyspigmentation no scarring • Unknown cause • Associated with preceding viral infection • Seen as a benign lymphoproliferative disorder • Rare reports of CTCL arising from PLC MANAGEMENT OF PLC • Repeated bx to confirm benign nature over the years • No response to topical CTCS • UV light : most effective • Systemic antibiotics. Erythromycin : 1-2 month tx CHILDHOOD PSORIASIS • Guttate psoriasis • Plaque type psoriasis • Inverse psoriasis /diaper psoriasis • Scalp psoriasis • Nail psoriasis • Palmoplantar psoriasis • Erythrodermic psoriasis CHILDHOOD PSORIASIS •4 % of all dermatosis in children <16 ; 2-3 % of the population •Genetic and environmental factors •Up to 70% of ped psoriasis have a positive fhx SPECIAL CONSIDERATION : GUTTATE PSORIASIS • Often first presentation of psoriasis in kids. • Round oval 2 to 3mm in diameter. • Often triggered by a gp A strep oropharynx or perianal area. • 2/3 of pts have URTI 1-3 weeks before • Suppressive tx with antibiotics do not stop the spread of the rash • Some patients with refractory psoriasis have improved following tonsillectomy SCALP PSORIASIS • Most frequent intial site of psoriatic involvement • Well demarcated silvery scales • Can have sebopsoriasis : mixture of yellow greasy scales involving the scalp eyebrows postauricular folds. • Variant of scalp psoriasis: Tinea amiantacea (not due to a dermatophyte) • Can be associated with staph infection . Do cultures and treat the staph aggessively INVERSE PSORIASIS • Diaper area (inguinal , intergluteal cleft , perianal , vulva , umbilicus , flexural surfaces axillary folds and toewebs • Rash can have crusting and oozing with tendernss and wetness. • Do bacterial culture. Staph aureus. • Treat the staph infection aggressively NAIL PSORIASIS • Nails are affected in about 25 to 50 % of pediatric psoriasis • Pitting most common presentation • May be indistinguishable from pitting of nails in Alopecia areata • May have discoloration subungual hyperkeratosis onycholysis • May have secondary bactrerial candida and dermatophyte infection TREATMENT • Preventative measures: avoid koebner phenomenon minimize friction • Maintain weight • Avoid tight garments • Avoid long nails or excessive use of nail polish • Avoid scratching and picking and removal of scales TREATMENT OF PSORIASIS : TOPICALS • Emollients • Topical steroids • Tar, anthralin , calcipotriene, tacrolimus, tazarotene combincation steroid and calcipotriene • Descaler : ceteal oil before topical steroids TREATMENT OF PSORIASIS • Phototherapy • UVB light • Narrow band UV light • PUVA seldom indicated. TREATMENT OF PSORIASIS • Biologics (FDA approved as of 2018) • Etanercept • Adalimumab • Ustekinumab . MTX or Cyclosporine or Azathioprine . Acitretin (retinoids) PEARLS IN THE TX OF CHILDHOOD PSORIASIS • Check for strep : throat and perianal • Check for staph infection • Prolonged anti strep and anti staph tx • Tonsillectomy NUMMULAR ECZEMA • Coin shaped eczema • Measuring 1 cm of more in diameter • More often seen in winter dry extremely itchy • tend to be recalcitrant to topical tx. • secondary infection common TREATMENT • More potent topical steroids • Oral antibiotics • Bleach baths • Lubrication barrier products CUTANEOUS LUPUS • subacute cutaneous lupus erythematosus (SCLE) • Discoid lupus • Other similar overlaps eg dermatomyositis CUTANEOUS LUPUS • Establish diagnosis by Hx and PE and Bx • Color is different • Scaling is different • Sun can be a trigger • R/O systemic involvement CASES • PICTURES !!! Scaly scalp Baby 1 month old with persistent cradle cap. Round scaly plaques on the scalp No sx Consulted Cardiology, consulted Rheumatology, etc MICROSPORUM CANIS • Resistance to griseofulvin; make sure use highest dosing and may need to use if for more than one course. • need to use other antifungal agents eg Lamisil . Clues DDx: Seb Derm, Neonatal lupus, Tinea, Psoriasis Test: KOH, Wood’s lamp, Bx Fluorescence Complete Hx: how many animals in the house?? Dx: Tinea by Microsporum canis Click to add title Click to add title 79 Click to add title HERALD PATCH Scaly rashes on the face 14 yo AAF with scaly rashes on face. Non pruritic Already treated with oral antifungal, not effective One side fading, another one coming on Clues Tinea or not? Tinea can come and go Black teenager: other DDx?? Psoriasis, Tinea, Lupus Test to confirm: Bx and IF Dx: Discoid Lupus Need further investigation to rule out SLE ACTIVE DISCOID LUPUS SCLE SCLE NEONATAL LUPUS SUMMARY PEARLS FOR PAPULOSQUAMOUS ERUPTIONS IN KIDS Go over the DDx of PPS conditions . Common and uncommon. Treat infections first (think of infection as a trigger ) then treat for inflammatory Don’t be afraid to bx.