Pediatric Boards Dermatology

Front 1

At what age do most cases of eczema began?

Back 1

<5 years old (90%), < 1 year old 60-70%

Front 2

What clinical characteristics define eczema?

Back 2

pruritis, chronic/relapsing dz, personal/family hx of atopy, typical distribution (face/extensor in infants, flexor in older children)

Front 3

Typical locations of eczematous lesions

Back 3

- location of lesions in infants: face and cheeks (sparing of nasolabial folds), extensor extremities (knees, ankles, tops of hands and feet), also sparing of diaper area

- location of lesions in childhood: flexoral extremities, still hands and ankles, but also popliteal fossa, neck, antecubital fossa

Front 4

How do you diagnose/treat tinea capitis

Back 4

-Clinical diagnosis. If needed, fungal culture is gold standard (KOH prep also available)
-Treat with systemic antifungal therapy with griseofulvin (eat with fatty meal) for 6-8 weeks-do not need to get routine lab work in healthy children, fluconazole, itraconazole

Front 5

Alopecia and nail pits?

Back 5

Think alopecia areata, treatment with steroids (intralesional and systemic)

Front 6

What is telogen effluvium?

Back 6

Diffuse hair loss/thinning secondary to stress/infection/surgery, self limited condition, complete hair growth over time

Front 7

Pustules in young infant (<7 days of age)

Back 7

Most likely infectious (bullous impetigo), dx with gram stain/bacterial culture. In pustular melanosis pustules are only present right after birth and are quickly washed off.

Bollous impetigo-multiple pustules most common in diaper region and lower abdomen

(picture staph diaper dermatits

Front 8

How do you diagnose transient neonatal pustular melanosis?

Back 8

Clinical. But can also do Wright stain (neutrophils but no bacteria). The first stage (the papules) do not last very long. The third stage is hyperpigmented macules.

Front 9

What is this?

Back 9

Erythema Multiforme Minor-fixed targetoid lesions +/- mucous membrane involvement. Self limited. Most common cause is HSV. DDx = annular urticaria (edema but not necrosis-will have central clearing vs central duskiness as in erythema multiforme)

Front 10

What diagnosis is this? You see thick hemorrhagic crusting of lips and targetoid lesions on skin followed by 7 day course of bactrim?

Back 10

SJS/erythema multiforme major: acutely ill, prodromal symptoms of fever and malaise. Mucuous membrane invovlement occurs first followed by skin involvement. Must have 2 mucous membranes involved. if >10% of skin denuded then diagnosis is TEN.

Common drugs: Sulfa drugs, doxycycline, lamotrigine, phenytoin, phenobarbital, PCN/cephalosporins, allopurinol and infections (mycoplasma PNA)

Front 11

Rash that begins with scaly herald patch (resembles tinea corporis) then gradually spread in a Christmas tree distribution?

Back 11

Pityriasis Rosea.

Is a self limited condition, no treatment necessary, but UV light can be helpful. DDX is secondary syphilis.

Front 12

What are you at risk for if you have a large (>20 cm) congenital melanocytic nevi?

Back 12

Neurocutaneous melanosis, pre pubertal melanoma, dandy-walker syndrome

Front 13

Myopathy, Heliotrope rash, Gottron's papules over knuckles, joint involvement, dilated capillary nailbed vessels

Back 13

Juvenile dermatomyositis

Front 14

What is this?

Back 14

Papular urticaria (multiple urticarial papules, frequently clustered, very pruritic, can get secondary infection). Think of bug bite.

Front 15

Waxy hamartoma of appendageal structures (type of epidermal nevus).

Back 15

Nevus sebaceous.
Seen most prominently on scalp.
waxy plaque
Can present as alopecia

Front 16

What is this?

Back 16

Dermoid cyst (These cysts present as smooth, painless, mobile, subcutaneous, round or oval masses. Dermoid cysts are most frequently located in the lateral brow area adjacent to the zygomaticofrontal suture.)

CNS extension is more common when occurs on midline scalp or a cutaneous nasal lesions or when associated with a cutaneous dimple or sinus

Front 17

Treatment of tinea corporis

Back 17

Annular plaque (ddx includes nummular eczema, granulmoa annulare)
DX: fungal culture or KOH scraping
Tx: topical treatment for 2-4 weeks, can use oral/systemic therapy if hair involvement, diffuse rash, immunocompromised. Includes griseofulvin.

Front 18

What is this?

Back 18

Diaper psoriasis. See rash in skin folds. think of it if doesn't respond to candidal therapy.

Front 19

Perianal erythema

Back 19

Streptococcal infection vs zinc deficiency (triad of acral/around the mouth dermatitis, alopecia, diarrhea and irritability) vs child abuse.

Front 20

Neonatal (cephallic pustulosis) vs infantile acne

(Above is neonatal)

Back 20

Neonatal acne occurs in first three weeks of life (no comedones) and usually resolves spontaneously

Infantile acne occurs at 3-4 months and sometimes does require treatment with benzoyl peroxide (see open and closed comedones)

Front 21

Small pustules filled with eosinophils

Back 21

Erythema toxicum

Front 22

What locations of infantile hemangiomas warrant referral or further investigation?

Back 22

Periorbital lesions (occular complications), beard lesions (concern for airway issues including subglottic hemangiomas), tip of nose/ear/lip (greater tendecy to ulcerate), midline lumbosacral region (increased risk for spinal involvement, MRI is best diagnostic tool).

Start involuting by age 2, 50% gone by 5 years, 90% by 9 years

Front 23

What is PHACES syndrome?

Back 23

Large segmental facial hemangioma puts child at risk for this syndrome.
Posterior fossa abnormalities (dandy walker syndrome)
Hemangioma
Arterial anomalies (usually intracerebral)
Cardiac defects, esp coarctation
Eye abnormalities

Front 24

In Sturge Weber syndrome what eye condition are they at risk for?

Back 24

Glaucoma-first screen these kids with a full ophthalmologic evaluation (Buphthalmos is pictured above)

Other associations include
-Facial port wine stains in V1 distribution (more common if bilateral facial lesions)
-Neuro complications include seizures, MR, hemiplegia (in Sturge Weber syndrome seizures and MR are common unlike in NF). MRI is best diagnostic tool.

Front 25

Tuberous Sclerosis skin findings

Back 25

AD, disease characterized by hamartomas of skin, brain, eye, kidneys, heart, lungs and bone.

Hypopigmented macules (ash leaf, one of earliest skin findings) and Facial angiofibromas (sparing of forehead, cheeks and nasolabial folds) are most commonly seen. Can also see fibromas (later finding) and collagenomas (shagreen patch if in lumbosacral area).

WITH TS have high likelihood of seizure, MR and brain calcifications

Front 26

What is this and what is it associated with?

Back 26

Shagreen patch. Tuberous Sclerosis.

Front 27

Several tan to light brown patches/macules over trunk are observed -what is your next step?

Back 27

These are cafe au lait spots. IF you see a large (>3 cm) or multiple lesions (>6) then you may suspect Neurofibromatosis

Other characteristics include positive family hx, possible eye complications including optic glioma (and Lisch nodules shown above), macrocephaly, skin findings/Crowe's sign (freckling of axillary/inguinal skin, fibromas).

In this disease your main concern is neurofibromas.

Front 28

Orange/brown macules/patches, some edematous and erythematous, worse after hot bath

Back 28

Solitary mastocytomas (5 or less lesions)

Usually present at birth, and appear by 2 years of age, yellow/brown, oval, slightly raised. Surface may have orange peel texture. Hx of intermittent urtication.

When rub lesions, see wheal/urtication from histamine release (darier sign)

Front 29

Diagnosis of this rash?

Back 29

Urticaria pigmentosa (most common presentation of mast cell disease). Multiple macules/plaques. Urticarial flares are also common.

Front 30

What do you suspect with segmental cafe au lait macules, precious puberty, hyperthyroidism, polyostotic fibrous dysplasia? McCune Albright syndrome

Back 30

McCune Albright syndrome

Front 31

What is this?

Back 31

Psoriasis. Red, well-demarcated plaques covered with dry, thick, silvery scales. Lesions of psoriasis are often induced at sites of local injury such as scratches, surgical scars, or sunburn, a response termed the Koebner phenomenon

Front 32

What is this? Distribution is unilateral. Rash is asymptomatic.

Back 32

Lichen striatus: linear band of coalescing skin colored papules, usually unilateral. It is asymptomatic and self resolves.

Front 33

What is this?

Back 33

Keratosis pylaris. Common, asymptomaic. papules on cheeks, extensors and buttocks. Has a very rough texture.

Front 34

What is this?

Back 34

Infantile scabies.

Pruritis and red papules, vesicles, pustules, nodules, crusted papules and possible burrows. Involves trunk, hands, feet, web spaces, axilla and genitalia.

Tx with 5% permetrhin cream, repeat in one week, treat all family members

Front 35

Rash. Improves with warm, humid weather. Flexural sparing.

Back 35

ichthyosis vulgaris. Retention hyperkeratosis. Similar genetic mutation as eczema. Diffuse scaling with flexural sparing. Hyperlinearity of palms and soles. Improved with warm, humid weather.

Front 36

Pityriasis Alba

Back 36

Hypopigmented (not de pigmented lesions). Usually seen with patients with atopic dermatitis or xerosis. More obvious in sunlight.

Front 37

Patient with a eczema presents with this rash?

Back 37

Eczema herpeticum.
Frequently have associated systemic symptoms. Clustered blisters, pustules or punches out erosion. If suspect, treat empirically. Often with antibacterials and antivirals at the same time.

Front 38

Treatment of acne

Back 38

-Topical therapy: benzoyl peroxide (useful in all stages of acne), topical retinoids (usually most consider to be first line therapy as well since it works to prevent formation of new comedones), topical antibiotics
-systemic: oral abx, oral retinoids and finally OCPS
Use oral abx if failed topical therapy or with moderate to severe inflammatory acne.