Common pediatric rashes JFK pediatric core curriculum

1. Common pediatric rashesJFK pediatric core curriculum MGH Center for Global Health Pediatric Global Health Leadership Fellowship Credits: Brett Nelson, MD, MPH Sohil Patel, MD

2. Discussion outline • Dermatology terminology • Common benign newborn rashes • Common infectious newborn rashes • Newborn vascular lesions • Various other pediatric rashes

3. Common dermatology terms • Macule: circumscribed change in skin color without elevation or depression • Papule: solid elevated lesion usually <0.5 cm in diameter • Plaque: raised lesion >0.5cm in diameter • Wheal (hive): rounded or flat-topped elevated lesion formed by local dermal edema • Purpura: non-blanching erythema or violaceous color due to extravasation of blood • Nodule: palpable solid lesion of varying size • Vesicle: circumscribed elevated lesion which contains free fluid and is <0.5 cm in diameter • Bulla (blister): same as vesicle but with diameter >0.5 cm • Cyst: sac containing liquid or semisolid material usually in the dermis • Pustule: circumscribed elevated lesion which contains pus • Abscess: collection of pus in the dermis or subcutis

4. Benign newborn rashes • Erythema toxicum neonatorum • Miliaria • Neonatal acne • Milia • Seborrheic dermatitis • Benign pustular melanosis of the newborn • Sucking blisters Presented in random order….

6. Miliaria • Due to obstruction and rupture of exocrine sweat duct • Commonly seen secondary to thermal stress, particularly with crops of lesions over face, scalp, and trunk • Important to ensure infant is not over-wrapped • Once heat stress is removed, lesions usually resolve quickly

8. Neonatal acne • Can be present at birth or develop in first 2-4 weeks of life • Consists of pustules over the cheeks primarily, but also involves other areas of face and scalp • No comedones in neonatal form • Resolves spontaneously and without scarring

11. Benign pustular melanosis of the newborn • Lesions present at birth • Superficial pustules which rupture easily without pus content, leaving spot of hyperpigmentation • Pustules last 1-2 days but pigmented spots may persist for a while • Any area of the body may be involved • Smears from pustules reveal polymorphonuclear leukocytes with absence of organisms

13. Seborrheic dermatitis • Primarily affects scalp and intertriginous areas • Involvement of scalp is frequently termed "cradle cap“ and manifests as greasy, yellow plaques on scalp • Most common in first 6 weeks of life, but can occur in children up to 12 months of age • Usually clears up without treatment in 3-4 weeks • If needed, treatment can include mild tar shampoo, oatmeal baths, avoidance of soaps, and occasional use of mild topical steroid • Involvement of skin creases can lead to secondary candidal infections • Etiology unknown

15. Erythema toxicum neonatorum • Onset on day 2-3 of life, mostly in term babies • Lesions wax and wane over ensuing 3-6 days • Lesions may intensify or coalesce particularly in response to local heat • Central white-yellow papule surrounded by a halo of erythema, mainly over trunk (but also on limbs and face) • Scrapings of lesions would reveal eosinophils • Etiology unknown

18. Milia • Tiny, white, usually discrete papules • Inclusion cysts that contain trapped keratinised stratum corneum • Commonly occur on face and scalp • Usually resolve within a few months without treatment • Rarely associated with dermatologic syndromes • Epidermolysis bullosa, oro-facial-digital syndrome (type 1) • Similar lesions may occasionally be seen in mouth • When on hard palate, called Epstein's pearls • When on alveolar ridges, called alveolar cysts or Bohn's nodules

20. Sucking blisters • Present at birth, most often over dorsal and lateral aspect of wrist • Either bilateral or unilateral • May appear like well-demarcated bruises or vesicles • Infant is noted to exhibit excessive sucking activity

21. Infectious newborn lesions • Staphylococcal pustules • Herpes simplex • Generalized in utero infection • Paronychia • Bullous impetigo • Omphalitis • Congenital syphilis • Candida Dermatitis Presented in random order….

23. Paronychia • Localized inflammation with infection of nail fold • Relatively common in infants • Treat most infections with oral antibiotics and severe cases with IV antibiotics • First line treatment is usually flucloxacillin/floxacillin for Staphylococcus aureus or Streptococcus pyogenes • For chronic lesions, consider Gram-negative organisms or Candida as potential causes

25. Bullous impetigo • Skin infection typically caused by Staphylococcus aureus • Lesions tend to appear DOL 5-10 • Any body site may be involved, with predilection to diaper area • Bullae are flaccid, containing straw colored or turbid fluid • Rupture easily leaving moist denuded area (“honey-crusted lesions”) • Treatment with systemic antibiotics, particularly for lesions around umbilicus

27. Staphylococcal pustule • Typically seen first few days of life • Predilection to neck, axilla, and inguinal areas • Nearly always caused by Staphylococcus aureus • If one lesion, may be treated "expectantly" with application of chlorhexidine (mainly to prevent spread) • However, if more than one lesion, oral antibiotics are indicated after culture is taken • For pustules in periumbilical area, consider systemic antibiotics

30. Herpes simplex • May involve skin, mouth, or eye • Lesions typically develop DOL 5-10 • Grouped vesicles may be seen, often in linear distribution if affecting limbs (1st slide) • If vesicle eroded, shallow ulcer with erythematous base may be seen (2nd slide) • May have associated lesions on lips -- similar to those of "cold sore" in an adult

31. Herpes Simplex: SEM • HSV infection develops in one of three patterns, with roughly equal frequency • Localized to the skin, eyes, and mouth (SEM) • Localized CNS disease • Disseminated disease involving multiple organs • Can develop anytime between birth and four weeks • Patients with disseminated disease present earliest, often within the first week after delivery, although CNS symptoms usually occur during the second or third week

32. Discussion point:How do you differentiate HSV from impetigo from staph from millia?

34. Omphalitis • Infection of umbilical stump • Erythematous, edematous, +/- exudative • Most commonly occurs after day 3 • Infective organisms are variable, but S.aureus, S.pyogenes, and Gram-negative organisms are common • If cultures available, swab affected area for Gram-stain and culture to guide treatment • Initiate IV antibiotics

36. Congenital syphilis • Dermatological findings quite variable • Classically involve palmar/plantar, perioral, and anogenital regions • Early lesions include petechiae, hemorrhagic vesicles, and bullae • Lesions extremely infectious • May have extracutaneous findings • Hepatomegaly, low birth weight, thrombocytopenia, anaemia, jaundice, respiratory distress, osteochondritis, hydrops fetalis, meningitis, chorioretinitis, and pseudoparalysis • Older infants may present with "snuffles" (syphylitic rhinitis) which, in early stages, may be mistaken for URI

37. Candida Dermatitis • A common condition of young infants • Most commonly caused by C. albicans • Characteristically appears as an erythematous rash in the inguinal region • Classically has areas of confluent erythema with discrete erythematous papules and plaques with superficial scales • Satellite lesions are typically noted

38. Candida Dermatitis

39. Newborn vascular lesions • Harlequin phenomenon • Cutis marmorata

41. Cutis marmorata • Reticulated pattern of constricted capillaries and venules • Often called "mottling“ • Due to vasomotor instability in immature infants • Generally resolves with increasing age and for most infants is of no significance • However, may reflect underlying poor perfusion • Infants who develop mottling and are unwell need to be clinically evaluated for sepsis and other illnesses

43. Harlequin phenomenon • Striking reddening of one side of body and blanching of other half • Each episode may last from seconds to minutes • Episodes occur most often during first few days of life • Thought to be vascular manifestation of changes occurring in newborn’s autonomic system

44. Various other pediatric rashes Adapted from: Paul Geltman, MD, MPH and Johns Hopkins DermAtlas The following are ~80 slides to be used as time permits – possibly during a second lecture session. Some photos may contain nude anatomy and would not be appropriate for openly public display.

45. Description: Measles red confluent papular eruption Comments: A 5 year old boy developed fever, headache, and sore throat followed several days later by a red papular rash on the face. Five days later the rash was confluent on his face and disseminated over the trunk and extremities including the palms and soles.

46. [The remainder of these ~80 slides have been temporarily removed from this lecture due to space limitations. The full lecture (25MB) is available from brett.d.nelson@gmail.com.]