Peds Case 32- 5Y/o W Rash

Front 1

Macule:
Patch:
Papule:
Plaque:
Vesicle:
Bulla:
Pustule:
Nodule:
Wheal:
Telangectasia:
Petechiae:
Purpura:

Back 1

Macule: flat, circumscribed discoloration. Size <1cm. Example: “freckle".

Patch: larger flat lesion of color change of the skin greater than 1 cm in size.

Papule: elevated, circumscribed solid lesion. Size <1cm. Example: “mole”.

Plaque: broad, elevated lesion greater than 1 cm in size. May represent a confluence of papules.

Vesicle: Circumscribed, elevated, fluid-containing lesion less than 1 cm in size.

Bulla: Larger, circumscribed, elevated, fluid-containing lesion greater than 1 cm in size.

Pustule: circumscribed collection of leukocytes. Variables sizes.

Nodule: Circumscribed, elevated lesion that involves the dermis and may extend into the subcutaneous tissue. The majority of a nodule is below the skin.

Wheal: Elevated lesion characterized by superficial transient edema. They may be white to pale red and often appear and disappear over a period of hours.

Telangectasia: A dilation of superficial venules, arterioles, or capilaries visible on the skin.

Petechiae: Tiny, red or purple macules caused by capillary hemorrhage under the skin or mucous membrane. They do not blanch with pressure.

Purpura: Larger, purple lesion caused by bleeding under the skin. May be palpable and, again do not blanch with pressure.

Front 2

Secondary Lesions:

Back 2

Secondary Lesions:

Scale: Flakes of keratin that can be fine or coarse: loose or adherent.

Crust: Dried remains of serum, blood or pus overlying involved skin.

Fissure: Linear, often painful cleavage in the cutaneous surface of the skin.

Erosion: Slightly depressed lesion in which all or part of the epidermis has been lost. Does not extend into the underlying dermis, so healing occurs without scar formation.

Ulcer: Depressed lesion extending into the dermis or subcutaneous tissue. May lead to scar formation.

Excoriation:Traumatized, superficial loss of the skin caused by scratching or rubbing.

Front 3

Roseola

Back 3

viral exanthem
follows 3-5 days of a febrile illness.
fever resolves, patients develop a pink, maculopapular rash that starts on the trunk and may spread to the face and extremities.
human herpes virus-6 (HHV-6.)

Front 4

Papular urticaria

Back 4

caused by insect bites that can be recurrent or chronic.
Lesions are pruritic
smaller (3 mm to 10 mm) and more papular

Front 5

Streptococcal infection

Back 5

rash of scarlet fever
an erythematous, fine, sandpaper-like rash accentuated at skin creases.
know to cause urticarial rash

Front 6

Erythema multiforme

Back 6

acute hypersensitivity syndrome
symmetrical, rash that starts as a dusky red macules and evolves into sharply demarcated wheals and then into target like lesions.
Individual lesions stay fixed for one to three weeks and the condition does not come and go.
most commonly Herpes simplex infections, but may be associated with medications.

Front 7

Erythema infectiosum (Fifth Disease)

Back 7

viral exanthem that starts on the face with a "slapped" cheek appearance followed by a reticular, lacy erythematous rash on the trunk and extremities.

parvovirus B19

Front 8

Urticaria due to type 1 sensitivity

Back 8

intensely pruritic, circumscribed, raised, erythematous wheal, often with central pallor.
Individual lesions may enlarge and coalesce with other lesions. The lesions continually change with new lesions occurring as old ones resolve and are usually asymmetric.
Individual lesions tend to last only 12-24 hours as in Lauren’s case
pruritis is due to histamine release from mast cells
trigger such as a drug, food ingestion, insect sting, or infection can sometimes be identified

Front 9

Erythema migrans

Back 9

early localized Lyme disease
starts as a red papule at the site of a tick bite and expands to form a large erythematous, annular patch.

Front 10

Drug eruptions

Back 10

urticarial.
Type 1 hypersensitivity reactions or they may result from non-immunologic triggers of mast cell release, such as from opiates or NSAIDS.
rash tends to be fixed, not as fleeting as hers has been.

Front 11

less sedating antihistamines
tx for acute uticaria or hives

Back 11

loratidine or cetirizine
if doesnt work can try prednisone
heat will worsen the itching

Topical steroids don't seem to be as effective, especially since hives can occur all over the body, be transient, and cover a large area of the body.

Front 12

Seborrheic dermatitis or "cradle cap"

Back 12

is the most likely diagnosis based on the history and the photo above. This common rash consists of erythematous plaques with fine to thick, greasy yellow scale and is typically seen on the scalp, but it may spread to the ears, neck, and diaper area of infants.

older patients it is often caused by a fungus called malassezia. The treatment for infants can include baby oil and a small brush to remove the scales, medicated shampoos or a topical steroid such as hydrocortisone. We also use ketoconazole cream in older children and adults.

Front 13

Eczema or atopic dermatitis

Back 13

may involve the posterior scalp.
positive history of atopic diathesis would support this diagnosis.
pruritic, erythematous, scaling plaques on extensor surfaces as evidence of atopic dermatitis on other areas of the body.

Front 14

Candidal rash

Back 14

diaper dermatitis peaking between 7-10 months,
area of erythema in the inguinal region, as well as erythematous papules and plaques with satellite lesions.

Front 15

Psoriasis

Back 15

of the scalp may or may not be pruritic.
more erythematous with a thicker, non-waxy scale with more defined borders.
signs of psoriasis elsewhere on her body.
family history of psoriasis is present in 40% of patients.

Front 16

acne

Back 16

starts as comedones (singular 'comedo') which can be open comedones (blackheads) or closed comedones (whiteheads). Acne lesions can then become inflamed which may lead to larger, erythematous lesions called papules and pustules. The worst cases, in which acne continues to progress, is called nodulo-cystic acne.

Front 17

Staphylococcal folliculitis and furunculosis

Back 17

can be very similar to nodular or cystic acne, however it is often below the waist or in the groin area.

Front 18

Pseudofolliculitis

Back 18

papules but not pustules.
beard area, and can be distinguished from acne because the inflammation is adjacent to hair follicles. The hair grows out of the follicle and when shaved closely, often grows back in to the surrounding skin causing irritation and inflammation.

Front 19

Acne vulgaris

Back 19

Keratinous material and excess sebum (due to androgenic influence) plug the pilosebacious gland. Increased sebum provides a growth medium for superinfection with proponiobacterium acnes. Areas of the body with the greatest number of sebaceous glands usually affected including: the neck, face, chest, upper back, and upper arms.

Front 20

Erythema Nodosum

Back 20

is a hypersensitivity reaction presenting as red, tender, nodular lesions on pretibial surface of the legs. There are many possible etiologies, a few of which include infections, drugs, and inflammatory bowel disease. The primary lesions are nodules, not pustules.

Front 21

Hidradenitis suppurativa

Back 21

occlusion of the apocrine follicular units (instead of the pilosebaceous units).
superinfected with staphylococcus aureus or streptococcus pyogenes.
pustular lesions, the distribution is markedly different from acne: the axillae, groin, and inframammary regions are the most likely areas affected in women; perineal and perianal areas are more commonly affected in men.

Front 22

Rosacea

Back 22

is more often seen in adults, however there is an "early" form seen in adolescents, which is characterized by inflammatory papules and micropustules, and redness on the malar and nasal surfaces. There are NO comedones. Rosacea worsens with alcohol, spicy food, temperature extremes, and stress. It can be treated with topical metronidazole and various other medications.

Front 23

Perioral dermatitis

Back 23

can be seen around the mouth, nose or eyes. It is a variant of rosacea and is also commonly seen in adolescents, and treated the same way. Again you will see erythema, scaling and papules or pustules, but no comedones. Historically related to topical corticosteroid use.

Front 24

tx acne

Back 24

benzoyl peroxide. He used a cleanser with salicylic acid, but stopped due to worsening skin irritation

retinoids are the drugs of choice: tretinoin (retin-A, adapalene) +clindamycin (P. acne)

Front 25

diet and acne

Back 25

no convincing evidence to support a link between chocolate and acne. High glycemic index diets can lead to insulin resistance and compensatory hyperinsulinemia. These factors can, in turn, lead to increases in IGF-1 and androgen production. It has been theorized that this process may play a role in the development or exacerbation of acne. Some studies seem to support this theory but others have questioned these conclusions.

Front 26

makes acne worse

Back 26

Makeup (unless noncomeogenic), mechanical factors such as manipulation or occlusion by sports gear, and overzealous cleaning can exacerbate acne lesions. Milk and uncleanliness have not been shown to do so.

Front 27

tx mild acne

Back 27

mild acne to be comedonal acne with perhaps a few papules or pustules mixed in, and tend to start with topical treatments like the ones Lonnie has been on. Retinoids work by normalizing follicular keratinization and are considered the drugs of choice for comedonal acne. For very mild cases, many physicians use OTC benzoyl peroxide (BPO) as a good starting point. BPO is available as a gel or as a skin wash.

Front 28

stronger acne

Back 28

two treatments concurrently for anything other than mild acne. First, I like to use BPO with a topical antibiotic like clindamycin or erythromycin. I like them specifically because these come in some nice combined products and each agent addresses a different cause for the acne.

Retinoids, like tretinoin need to be used at night, because they can cause photosensitization resulting in a significant sunburn. Tretinoin is also inactivated by oxidation of BPO, so I have patients apply BPO cream in the morning. Tretinoin also must be applied to bone-dry skin or it may be significantly irritating. It is important to make sure teens know that retinoids can make acne transiently look worse

Front 29

patient has significant inflammatory lesions and I am concerned that the lesions may leave scars I consider this moderate acne

Back 29

same initial treatments as mild acne and add another product
Options for oral therapy include oral antibiotics, such as tetracycline, or oral contraceptive pills for females.

Doxycycline and minocycline are the most common oral antibiotics used to treat moderate and severe acne. Both of them have serious potential side-effect that you should be aware of before prescribing. For example, doxycycline may cause photosensitivity or esophagitis and minocycline can cause neurological side effects (like vertigo), pseudotumor cerebri, skin pigmentation (blue/gray after multiple doses), and a lupus like reaction. Oral contraceptives, especially those with a low androgenic progestin, are useful for treating moderate acne in females.

Front 30

severe acne, the nodulo-cystic type carries an even higher risk for significant scarring

Back 30

oral isotretinoin

reduces sebum secretion, thereby decreasing P. acne proliferation. It is also anti-inflammatory. However, it is associated with a number of serious adverse effects including: chance of depression, hypertriglyceridemia, hepatitis, decreased night vision (vitamin A analog), and photo sensitivity. The most serious potential risk is teratogenicity. Because there is an extremely high risk that severe birth defects will result if pregnancy occurs while taking isotretinoin, it can only be marketed under a special restricted FDA distribution program called iPledge. Prescribers and patients must be registered with this program and patients must meet all the requirements.

Front 31

contact dermatitis

Back 31

vesicles, edema, and erythema and are extremely pruritic.

delayed type IV hypersensitivity reaction. The reaction requires sensitization, so the onset is usually within 24-72 hours from the start of contact; these reactions can occur despite prior tolerance to exposure. The development of the rash also depends on whether or not the skin barrier is intact or damaged. It often resolves within days to weeks of avoidance. If it is a very difficult to control allergy, some will refer to an Allergist to consider "patch testing" to prove nickel allergy.

good emollient like petroleum jelly (Vaseline) or a quality skin lubricating cream, such as Aquaphor or Eucerin

Front 32

poison ivy

Back 32

The allergen in plants is called urushiol. It is present in the entire plant, even in the winter. It persists and is active on objects or pets (but not transferred by blister fluid). Treatment: once exposed, wash off quickly with soap and water or dish detergent (within 30 minutes). Use topical steroids and oral antihistamines, if significant rash and itching occur. If it is widespread or increasing in size still, consider using oral steroids. This course of therapy should be maintained, often in tapering doses, for 10-14 days or even longer in some cases, to prevent having the rash rebound and become severe again. Patients who are given a short burst of prednisone often get worse again when they complete it, because the dose was too low and/or administered for too short a time.

Front 33

impetigo

Back 33

most common site for impetigo is right below the nares (because of rubbing and colonization), but it can be anywhere on the body. The most common bacteria cultured from superficial skin infections are Staphylococcus aureus and Streptococcus pyogenes (Group A Strep). Mild localized impetigo can be treated effectively with topical antibiotics such as mupirocin. However, due to the widespread emergence of methicillin-resistant staph. aureus (MRSA) clinicians must be vigilant to watch for invasive complications such as abscess formation. This and other potential complications merit more aggressive therapy and systemic antibiotics.

Front 34

steroid

Back 34

class 1 agent clobetasol, 0.05%, is approximately 1000 times more potent than over-the-counter hydrocortisone, 1%! It is also important to consider the vehicle that is used in the preparation. Ointments and gels offer the most effective skin penetration, but creams and lotions are more cosmetically acceptable and are better for larger body areas.

The chemical formulation matters too. Hydrocortisone valerate is much more potent than hydrocortisone acetate.

When prescribing steroids to children it is important to keep in mind that infants will absorb significantly more medication through their skin than adults and that an occlusive dressing (like a diaper!) will cause increased absorption.

There are many potential side effects of topical steroid use, but the most important are skin atrophy, telangiectasias, hypopigmentation, and suppression of the hypothalamic-pituitary axis. Even low-potency topical steroids can cause these problems when used for long durations or over large areas of the body. Particular caution should be used when considering the use of steroids on the face or genitalia

Front 35

Pediculosis capitis

Back 35

tried over-the-counter shampoos and rinses (permethrin or pyrethrins) designed to kill lice. Unfortunately, there is increasing resistance to these agents and since they don't kill the ova (nits) they actually should be used two or three times in weekly intervals. There are a lot of myths related to treatment. I hear all the time about parents rinsing hair with vinegar or using ointments to "suffocate" the lice; both are ineffective

lindane (Ovide), which used to be the treatment of choice, is no longer effective because of resistance. Malathion 0.5% topical is currently considered the most effective drug of choice. Ovide, which actually has three active ingredients, malathion, an organo-phosphate insecticide, isopropyl alcohol, and terpineol (tea tree oil extract). It was hypothesized that with three agents, the lice and nits will not develop resistance. While not perfect at removing nits, any treatment should involve combing the wet hair with a fine-tooth comb. Furthermore, washing bedding, stuffed animals, hats, combs and brushes, and other contaminated items in hot water or drying in high heat in the dryer. Sealing unwashable items in an airtight bag also is effective as the lice cannot live off of a host for more than 26 hours and the newly born nymphs must feed immediately if there are to survive."

Front 36

Adult deer tick (Ixodes scapularis), associated with the spread of Lyme disease.

Back 36

common flea. Fleas can be vectors for Bartonella henselae (Cat Scratch Disease) and Yersenia pestis (plague).

Front 37

Sarcoptes scabiei

Back 37

is acquired by significant close physical contact. The scabies mite causes itching because it burrows into the skin and lays eggs. The most intense time of itching is often at night. The wrists, elbows, fingers, and toes are among the common distribution sites for scabies.

permethrin 5% cream to both of you and your son. You will use this cream at night before you go to bed and wash it off in the morning after around 8-12 hours. I want you to cover your body from the neck down. But on your son, you need to make sure to cover from his hair-line down, including behind his ears. Just be careful to avoid the areas around his eyes and mouth. You should wash the cream off in the morning. Do this for one night and then repeat the whole thing one more time in a week. After bathing you should wash all bed linens and clothing worn during treatment. The most common side effect is continued itching, so I will also prescribe a moderate potency topical steroid and you may use over-the-counter diphenhydramine for the itching. Don't be frustrated as the itching persists sometimes for a few weeks after the mites have been killed. If you still have any itching after four weeks, let me know. Sometimes families need to be re-treated or discover there was another hidden exposure

have an allergic response, that ivermectin orally is often effective, although currently it is not FDA approved for children under 15 kg.

Scraping the skin and looking for mites or eggs under the microscope.

Front 38

ringworm

Back 38

superficial and easy to treat fungus, especially when you tell them it is a cousin of athlete's foot or jock itch

Contact with animals
Scaling appearance with raised border
Pruritic
Otherwise well child

annular, well-circumscribed, scaly plaque with a raised border and the center becoming brown or hypopigmented. These lesions gradually enlarge and may coalesce with surrounding lesions. They may be mildly pruritic or asymptomatic. Tinea corporis can usually be diagnosed clinically, but a KOH wet-mount examination of skin scrapings can confirm the diagnosis. You can obtain the scraping with the edge of a glass slide or a #15 blade and examine it under low-power with the microscope light dimmed. You will see the classic branches and rod-shaped septated hyphae.