Disclosures Name That Rash or Lesion: Dermatology Across Lifespan ►►Grants: Novartis, DaiichiDaiichi--SankyoSankyo ►►Speaker Bureau: OrthoOrtho--McNeil,McNeil, Wendy L. Wright, MS, RN, ARNP, FNP, FAANP Abbott, Novartis, GSK, SanofiSanofi--Pasteur,Pasteur, DSI, Takeda, Merck Adult/Family Nurse Practitioner Owner ––WrightWright & Associates Family Healthcare Owner ––AndersonAnderson Family Healthcare Partner ––PartnersPartners in Healthcare Education Wright, 2012 Wright, 2012 Fifth’s Disease Objectives (Erythema Infectiosum) Upon completion of this lecture, the Human Parvovirus B19 participant will: ––OccursOccurs in epidemics 1. Identify various pediatric dermatology ––OccursOccurs year round: Peak incidence is late winter and conditions early spring 2. Discuss those dermatology conditions Most common in individuals between 55--15years15years of age that require an immediate referral ––PeriodPeriod of communicability believed to be from exposurexposuree 3. Develop an appropriate plan for to outbreak of rash evaluation, treatment, and followfollow--upup of the ––IncubationIncubation period: 55--1010 days ––CanCan cause harm to pregnant women and individuals who various lesions Wright, 2012 Wright, 2012 are immunocompromised Fifth’s Disease Fifth’s Disease (Erythema Infectiosum) (Erythema Infectiosum) Low grade temp, malaise, sore throat Physical Examination Findings ––MayMay occur but are less common ––LowLow grade temperature 3 distinct phases ––FacialFacial redness for up to 4 days ––ErythematousErythematous cheeks ––FishnetFishnet like rash within 2 days after facial redness Nontender and wellwell--defineddefined borders ––Fever,Fever, itching, and petecchiae ––NetlikeNetlike rash Petecchiae stop abruptly at the wrists and ankles Erythematous lesions with peripheral white rims ––HandsHands and feet only RashRash--remitsremits and recurs over 2 week period Wright, 2012 ––PetecchiaePetecchiae on handsWright, and2012 feet Wright, 2012 1 Fifth’s Disease Fifth’s Disease Wright, 2012 Wright, 2012 Fifth’s Disease Fifth’s Disease (Erythema (Erythema Infectiosum) Infectiosum) Diagnosis/Plan Diagnosis/Plan ––WasWas contagious before rash appeared therefore, no ––ParvovirusParvovirus IgM and IgG isolation needed ––IgM=MiserableIgM=Miserable and is present in the blood Spread via respiratory droplets from the onset up to 6 months ––SymptomaticSymptomatic treatment ––PatientPatient educationeducation--I.e.I.e. contagion, handwashing ––IgG=GoneIgG=Gone and is present beginning at day ––CanCan cause aplastic crisis in individuals with hemolytic 8 of infection and lasts for a lifetime anemias ––CBCCBC--MayMay show a decreased wbc count ––ConcernConcern regarding: miscarriage, fetal hydrops ––Adults:Adults: arthralgias Wright, 2012 Wright, 2012 Hand, Foot, and Mouth Disease cdc.gov (Coxsackie Virus) From November 7, 2011, to February 29, 2012, CDC received reports of 63 persons with signs and symptoms of HFMD or with fever and atypical rash in Caused by the coxsackie virus A16 Alabama (38 cases), California (seven), Connecticut (one), and Nevada (17). Most common in children Coxsackievirus A6 (CVA6) was detected in 25 (74%) of those 34 patientspatients Rash and fever were more severe, and hospitalization was more common 22--66 day incubation period than with typical HFMD. Occurs most often in late summersummer--earlyearly fall Signs of HFMD included fever (48 patients [76%]); rash on the hands or feet, or in the mouth (42 [67%]); and rash on the arms or legs (29 [46%]), face (26 Symptoms [41%]), buttocks (22 [35%]), and trunk (12 [19%]) Of 46 patients with rash variables reported, the rash typically was ––LowLow grade fever, sore throat, and generalized maculopapularmaculopapular;; vesicles were reported in 32 (70%) ppatientsatients malaise Of the 63 patients, 51 (81%) sought care from a clinician, and 12 (19%) were hospitalized. Reasons for hospitalization varied and included dehydration ––LastLast for 11--22 days and precede the skin lesions and/or severe pain ––20%20% of children will experienceWright, 2012 lymphadenopathy No deaths were reported Wright, 2012 Wright, 2012 2 Hand, Foot, and Mouth Disease Hand, Foot, and Mouth Disease (Coxsackie Virus) (Coxsackie Virus) Physical Examination Findings Physical Examination Findings ––OralOral lesions are usually the first to appear ––Hand/feetHand/feet lesions 90% will have As they evolve ––maymay evolve to form small thick ––LookLook like canker sores; yellow ulcers with red halos gray vesicles on a red base ––SmallSmall and not too painful May feel like slivers or be itchy ––WithinWithin 24 hours, lesions appear on the hands and feet 33--77 mm, red, flat, macular lesions that rapidly becombecomee pale, white and oval with a surrounding red halo Resolve within 7 days Wright, 2012 Wright, 2012 Hand Foot and Mouth Hand Foot and Mouth Disease Disease Wright, 2012 Wright, 2012 Hand, Foot, and Mouth Disease Hand, Foot, and Mouth Disease (Coxsackie Virus) (Coxsackie Virus) Plan Plan ––Diagnostic:Diagnostic: None ––EducationalEducational ––TherapeuticTherapeutic Very contagious (2d before --22 days after eruption begins) Tylenol Entire illness usually lasts from 2 days ––11 week Warm baths Reassurance Oragel or Benadryl/Maalox No scarring Wright, 2012 Wright, 2012 Wright, 2012 3 Pityriasis Rosea Pityriasis Rosea Etiology Symptoms ––Common,Common, benign skin eruption ––RashRash initially begins as a herald patch ––OftenOften mistaken for ringworm ––EtiologyEtiology unknown but believed to be viral ––29%29% have a recent history of a viral infection ––SmallSmall epidemics occur at frat houses and military ––Asymptomatic,Asymptomatic, salmon colored, slightly itchy rash bases Signs ––FemalesFemales more frequently affected ––ProdromeProdrome of malaise, sore throat, and fever may preceprecedede ––75%75% occur in individuals between 10 and 35; ––HeraldHerald patch: 22--10cm10cm ovaloval--roundround lesion appears first higheset incidence: adolescents ––MostMost common location is the trunk or proximal extremiextremititieses ––2%2% have a recurrence ––MostMost common during winterWright, 2012 months Wright, 2012 Pityriasis Rosea Pityriasis Rosea Wright, 2012 Wright, 2012 Pityriasis Rosea Pityriasis Rosea Signs ––EruptiveEruptive phase Signs (continued) Small lesions appear over a period of 11--22 ––77--1414 days after the herald patch weeks ––LesionsLesions are on the trunk and proximal ––Fine,Fine, wrinkled scale extremities ––SymmetricSymmetric ––CanCan also be on the face ––AlongAlong skin lines ––LooksLooks like a drooping pine tree ––FewFew lesionslesions--hundredshundreds ––LesionsLesions are longest in horizontal dimension Wright, 2012 Wright, 2012 Wright, 2012 4 Pityriasis Rosea Pityriasis Rosea Plan Diagnosis ––TherapeuticTherapeutic ––HistoryHistory and physical examination Antihistamine Topical steroids Plan Short course of steroids although, may not respond ––DiagnosticDiagnostic Sun exposure Can do a punch biopsy if etiology uncertain Moisturize ––EducationalEducational ––PathologyPathology is often nondiagnostic Benign condition that will resolve on own ––Report:Report: spongiosis and perivascular round ––MayMay take 3 months to completely resolve cell infiltrate No known effects on the pregnant woman Consider an RPR to rulerule--outout syphilis Reassurance Wright, 2012 Wright, 2012 Impetigo Impetigo Contagious, superficial skin infection Symptoms: Caused by staphylococci or streptococci ––RashRash that will not go away ––StaphStaph is the most common cause ––BeginsBegins as a small area and then increases in size ––MakesMakes entrance through small cut or abrasion ––Yellow,Yellow, crusted draining lesions ––ResidesResides frequently in the nasopharynx Physical Examination Findings Spread by contact ––SmallSmall vesicle that erupts and becomes yellowyellow-- More common in children, particularly on the brown nose, mouth, limbs ––Initially,Initially, looks like an inner tube ––SelfSelf--limitinglimiting but if untreated may last weeks to ––CrustCrust appears and if removed, is bright red and Wright, 2012 Wright, 2012 months inflamed Impetigo Impetigo Wright, 2012 Wright, 2012 Wright, 2012 5 Impetigo Impetigo Physical Examination Findings ––22--88 cm in size Diagnosis ––Diagnostic:Diagnostic: Culture ––MustMust absolutely consider MRSA ––Therapeutic:Therapeutic: Bactroban vs. Altabax 11stst generation cephalopsporin vs. TMP/SMX Let’s discuss MRSA Wright, 2012 Wright, 2012 Impetigo Educational CA --MRSAMRSA ––GoodGood handwashing and hygiene ––NoNo school/daycare for 2424--4848 hours ––WashWash sheets and pillowcases ––MonitorMonitor for serious sequelae Wright, 2012 Wright, 2012 CACA--MRSAMRSA CACA--MRSAMRSA First identified in the 1940’s; first US case -- 1968 ––CACA--MRSAMRSA is distinctly different than the MRSA First domestic cluster of cases identified in hospitals identified in 1982 in Detroit, Michigan ––MostMost CACA--MRSAMRSA are known as USA300 or USA400 ––IVIV drug users whereas hospital infections are USA100, USA500 1992, 2 ndnd cluster among IV drug users Since 1990, the burden on society has increased substantially Most infections are located in the soft tissue and present as carbuncles, furuncles or abscessesWright, 2012 Wright, 2012 Wright, 2012 6 CACA--MRSAMRSA CACA--MRSAMRSA Males are affected more often than females Affects the very young and old disproportionately Blacks are also affected at greater rates than whites Recurrent antimicrobial usage may be a risk factor Exposure to farm