1 Name five bioterrorism agents that may have skin manifestations.

See Table 21-1.

TABLE 21-1 BIOTERRORISM AGENTS THAT MAY HAVE SKIN MANIFESTATIONS

O’Brien KK, Higdon ML, Halverson JJ: Recognition and management of bioterrorism infections. Am Fam Physician 67:1927–1934, 2003.

eMedicine: Dermatologic Aspects of Bioterrorism Agents. Available at www.emedicine.com/derm/topic905.htm#section~viral_agents.

2 What are four skin findings associated with syphilis?

See Table 21-2.

TABLE 21-2 SKIN FINDINGS ASSOCIATED WITH SYPHILIS

Sexually Transmitted Disease. Syphilis pictures. Available at http://herpes-coldsores.com/std/syphilis_pictures.htm.

3 How does perianal streptococcal dermatitis manifest?

Perianal streptococcal infection usually occurs in children between 6 months and 10 years of age. It presents as sharply circumscribed superficial perianal erythema. In some patients, the rash is bright red with a wet surface, while in others it is dry and pink. Fever is generally absent, and delays in culturing, diagnosing, and initiating therapy are common.

Herbst RA: Perineal streptococcal dermatitis/disease: Recognition and management. Am J Clin Dermatol 4:555–560, 2003.

4 An atopic child with chronic eczema suddenly develops a painful, vesicular eruption in previous areas of eczema. What is the most likely diagnosis?

Eczema herpeticum, caused by the herpes simplex virus, is a vesicular eruption concentrated in areas of eczematous skin. Children with eczema herpeticum often become seriously ill with high fever because the disease can be complicated by secondary bacterial infections and viremia, leading to multiple organ involvement with meningitis and encephalitis. Treatment with IV acyclovir is necessary for children with extensive or rapidly progressing involvement.

Wollenberg A, Wetzel S, Burgdorf HC, et al: Viral infections in atopic dermatitis: Pathogenic aspects and clinical management. J Allergy Clin Immunol 112:667–674, 2003.

5 What are the clinical features of measles?

Measles, caused by an RNA virus in the paramyxovirus family, has almost been eradicated in the United States. Epidemics were seen most recently in the early 1990s, and sporadic cases still occur among travelers and immigrants. It is an acute disease characterized by fever, cough, coryza, conjunctivitis, and an erythematous maculopapular rash that begins on the forehead and behind the ears, spreading to the face, neck, torso, and extremities. Koplik spots, bright red punctae with central white flecks on the buccal mucosa near the second molars, are seen early in the disease course and are pathognomonic for measles.

American Academy of Pediatrics: Measles. In Pickering LK, Baker CJ, Long SS, et al (eds): Red Book: 2006 Report of the Committee on Infection Diseases, 27th ed. Elk Grove Village IL, American Academy of Pediatrics, 2006, pp 441–452.

6 Differentiate between erythema multiforme (EM), Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN).

EM is now thought to be a separate process from SJS and TEN. It is an erythematous maculopapular rash, characterized by target lesions that may coalesce and develop annular or serpiginous borders. The course is brief and usually resolves within 2 weeks, although recurrences are common.

SJS and TEN are now thought to represent a spectrum of the same disease. They are severe drug eruptions, and TEN has a mortality rate of around 30%. SJS is characterized by febrile erosive stomatitis, ocular involvement, and a diffuse rash of discrete dark red macules, sometimes with a necrotic center. TEN involves extensive loss of epidermis due to necrosis that leaves the skin surface looking scalded.

Bachot N, Roujeau JC: Differential diagnosis of severe cutaneous drug eruptions. Am J Clin Dermatol 4:561–572, 2003.

Roujeau JC: Stevens-Johnson syndrome and toxic epidermal necrolysis are severity variants of the same disease which differs from erythema multiforme. J Dermatol 24:726–729, 1997.

7 How does the rash of Rocky Mountain spotted fever change over time?

The rash is initially erythematous and macular, but later becomes more papular and, frequently, petechial. The rash first appears on the wrists and ankles, spreading centrally within hours to involve the proximal extremities and trunk. The palms and soles are usually involved.

8 A child helps his mother cut limes before going outside to play and then returns with inflamed hands that quickly develop hyperpigmentation. What is the name of the rash and the causative agent?

This condition is a type of toxic photoreaction called phytophotodermatitis. It is caused when the skin comes into contact with psoralen, a photosensitizing agent, and then immediately with sunlight. Psoralens can be found in some perfumes, plants, grasses, fruits, and vegetables. Limes, celery, and parsley are examples of foods that contain psoralens.

Bergeson PS, Weiss JC. Picture of the month. Phytophotodermatitis. Arch Pediatr Adolesc Med 154:201–202, 2000.

9 What are the typical features of pityriasis rosea?

Seen primarily in adolescents, pityriasis rosea begins in 80% of patients with a large, oval, solitary lesion known as a herald patch somewhere on the trunk or upper thighs. This is followed by an eruption of smaller, oval, and slightly raised papules that are pink to brown and have peripheral scales. The lesions are described as having a Christmas tree pattern on the back and involve mostly the truncal areas (Fig. 21-1), usually sparing the face, scalp, and distal extremities. Eruption is prolonged and can last 4–8 weeks.

Figure 21-1 Large herald patch of pityriasis rosea near the axilla, with numerous secondary oval lesions that follow skin lines.

10 List key features that help differentiate the purpuric rash of Henoch-Schönlein purpura from more serious infectious purpuric rashes, such as purpura fulminans.

See Table 21-3.

TABLE 21-3 HENOCH-SCHÖNLEIN PURPURA VS. PURPURA FULMINANS

Henoch-Schönlein Purpura	Purpura Fulminans
Distribution usually limited to extremities, appearing most commonly on lower legs, buttocks, and occasionally upper extremities. In infants, facial involvement may be seen. Associated features include arthralgias, abdominal pain, and hematuria. Children appear well except for painful joints and abdominal pain. Platelet count and results of other coagulation tests are normal.	Distribution of purpura is widespread. Associated features include lethargy, hypoventilation, and shock. Children appear ill, with varying degrees of toxicity. Thrombocytopenia is present, and coagulation test results are abnormal.

11 What are five skin manifestations that may be seen in Kawasaki syndrome?

Yamamoto LG: Kawasaki disease. Pediatr Emerg Care 19:422–424, 2003.

12 What are some skin findings that may be mistaken for child abuse?

See Table 21-4.

TABLE 21-4 SKIN FINDINGS THAT MAY BE MISTAKEN FOR CHILD ABUSE

Mudd SS, Findlay JS: The cutaneous manifestations and common mimickers of physical child abuse. J Pediatr Health Care 18:123–129, 2004.

13 How does scabies manifest in infants?

Scabies in infants and young toddlers may be more eczematous and less typical than in adults. In addition to the characteristic burrows on the hands and feet, young infants may present with diffuse dermatitis on the trunk, face, neck, and scalp. The axilla, diaper area, palms, and soles are frequent sites of distribution. Since infants are not able to scratch the intensely pruritic lesions, they may become irritable and sleep poorly.

Peterson CM, Eichenfield LF: Scabies. Pediatr Ann 25:97–100, 1996.

14 What are the cutaneous manifestations of disseminated gonococcemia?

The skin lesions associated with disseminated gonococcemia are often located on the extremities and may overlie the involved joints. Small macules appear initially and progress to papules. These tender lesions may develop a small vesicle and then a gray umbilicated center. A diagnosis can be established with a Gram stain or culture of the skin lesion.

15 Is poison ivy contagious?

A common misconception among families and school officials is that the rash of poison ivy is contagious. This belief occurs because of the vesicles and weepy bullae that develop in some individuals. Once the skin, clothes, and fingernails are cleaned of the sap from this treacherous plant, the rash will not spread beyond the areas already exposed. Contributing to this misconception is the fact that areas with minimal contamination can develop 5–10 days after the heavily contaminated areas appear. The bottom line is the child should go back to school!

16 Should topical agents be used to treat poison ivy?

Unfortunately, good studies have shown that topical hydrocortisone and antihistamines have no more effect on poison ivy than do bland, soothing lotions, such as calamine. Supportive care includes baths, cool compresses, and calamine lotion for mild cases. Systemic oral steroids almost always bring the acute dermatitis under control and are appropriate for moderate to severe cases. Oral antihistamines may also be helpful.

17 What is a pyogenic granuloma?

A pyogenic granuloma is a rapidly growing vascular proliferation that develops at the site of an obvious or unnoticed trauma (Fig. 21-2). Despite its name, this lesion is not infectious. Patients usually present to the emergency department with spontaneous bleeding, or after local minor trauma. Acute bleeding can be controlled with prolonged pressure or silver nitrate sticks. Ultimately, treatment consists of electrodesiccation and curettage.

Figure 21-2 Pyogenic granuloma.

From Morelli JG: Vascular neoplasms. In Fitzpatrick JE, Morelli JG [eds]: Dermatology Secrets in Color, 3rd ed. Philadelphia, Mosby, 2007, Fig. 42-7, p. 351.

18 How do the following two newborn rashes differ: transient pustular melanosis and erythema toxicum neonatorum?

Transient pustular melanosis is a benign newborn rash consisting of superficial vesiculopustular lesions that are present at birth. The lesions rupture easily with the first bath, leaving a collarette of fine, white scales and brown, hyperpigmented macules. Lesions fade within several weeks to months and are asymptomatic. Erythema toxicum neonatorum is a benign, self-limited eruption that usually appears between the first 3–4 days of life and sometimes as late as the 10th. The lesions begin as blotchy erythema that develops into pale yellow or white papules or pustules. Individual lesions last an average of 2 days, and cytologic examination, if needed to differentiate from other rashes, reveals clusters of eosinophils and neutrophils and an absence of bacteria.

Wagner A: Distinguishing vesicular and pustular disorders in the neonate. Curr Opin Pediatr 9:396–405, 1997.

19 What is the appropriate treatment for a herpetic whitlow?

Herpetic whitlow is a localized herpes simplex infection consisting of singular or multiple vesicular lesions on the distal fingers or toes. The first episode may accompany herpetic gingivostomatitis. Treatment consists of local care for mild cases, while those with severe lesions may benefit from oral acyclovir. Avoid incision and drainage, which can prolong recovery and worsen the condition.

Feder HM Jr, Long SS: Herpetic whitlow. Epidemiology, clinical characteristics, diagnosis and treatment. Am J Dis Child 137:861–863, 1983.

e-Medicine: Herpetic whitlow: www.emedicine.com/emerg/topic754.htm.

20 What condition is associated with recurrent pustules on the feet of infants?

Infantile acropustulosis consists of 7- to 10-day episodes of pruritic pustules and papulovesicles on the hands and feet of infants. The age of onset is usually between 2 and 10 months, and the condition resolves by 2 to 3 years of age. Treatment with mid- to high-potency topical corticosteroids is effective.

Dromy R, Raz A, Metzker A: Infantile acropustulosis. Pediatr Dermatol 8:284–287, 1991.

21 A diaper rash consisting of diffuse papular, scaly, and fissuring eruptions does not respond to anti-inflammatory or antifungal agents. What is a potential serious cause?

This may be one of the skin manifestations of histiocytosis X, which is a disorder characterized by proliferation of Langerhans histiocytes in the skin and other organ systems. Consider a biopsy to confirm the diagnosis or absence of histiocytosis X when a difficult-to-treat diaper rash does not improve with standard therapy.

22 What is Nikolsky’s sign?

It is a vulnerability of the skin such that apparently normal epidermis can be rubbed off with slight trauma. It may be seen in epidermal blistering diseases, such as scalded skin syndrome and pemphigus vulgaris.

23 How long do patients with erythema infectiosum (fifth disease) need isolation?

This infection is caused by parvovirus B19. For most patients with typical presentation of a “slapped cheek” and a lacelike rash on arms and legs, no isolation is needed at the time of diagnosis. By the time the rash becomes clinically obvious, these patients are unlikely to be infectious. The rash usually resolves within 3–5 days of onset.

American Academy of Pediatrics. Parvovirus B19. In: Pickering LK, Baker CJ, Long SS, et al (eds). Red Book: 2006 Report of the Committee on Infectious Diseases, 27th ed. Elk Grove Village, IL, American Academy of Pediatrics, 2006, pp 484–487.

24 What are the similarities and differences between granuloma annulare and tinea corporis?

Both are characterized by circular plaques consisting of a ring of papules around a depressed center. Granuloma annulare is a ring of nonscaling, skin-colored or red papules that are most commonly seen on the dorsal surface of the hands and feet. They are asymptomatic and resolve spontaneously after a few months to a year. Tinea corporis is a common, superficial fungal infection consisting of lesions with scaly inflammatory borders that appear anywhere on the body. There may be multiple lesions.

25 What causes roseola? What are the usual features?

Roseola infantum (exanthem subitum) is an acute febrile illness that primarily affects young children between the ages of 6 and 36 months. Most cases are now thought to be caused by human herpesvirus 6 and human herpesvirus 7. After 3 or more days of high fever, the patient abruptly defervesces, and an erythematous, morbilliform rash with discrete rose-pink macules appears. The rash begins first on the trunk and then spreads rapidly to the extremities, neck, and face. By this time, the rash is bothering the parents more than the patient.

American Academy of Pediatrics: Human herpes virus 6 (including roseola) and 7. In: Pickering LK, Baker CJ, Long SS, et al (eds). Red Book: 2006 Report of the Committee on Infectious Diseases, 27th ed. Elk Grove Village, IL, American Academy of Pediatrics, 2006, pp 441–452.

26 What are the usual findings in Gianotti-Crosti syndrome?

This self-limiting condition is characterized by symmetric erythematous papules that are primarily found on the extremities but often involve the cheeks and buttocks. Also known as papular acrodermatitis, the rash may last 2–8 weeks, and may become recurrent. Although first identified in Europe in children with hepatitis B, it is seen in the United States primarily in association with other viruses, including Epstein-Barr virus, cytomegalovirus, and coxsackie virus A16.

Weston WL, Lane AJ, Morelli JG: Viral infections. Color Textbook of Pediatric Dermatology, 2nd ed. St. Louis, Mosby, 1996, pp 97–130.

27 A toddler presents with several small, round, erythematous, and inflamed macules in a straight column down the middle of his chest and abdomen. What is the most likely etiology?

One of the most common causes of contact dermatitis in children is allergy to nickel. Infants present with skin lesions corresponding to the location of snaps on their pajamas or other garments. Avoidance of the offending object by an undershirt or nonsnap clothes, and application of a mild topical steroid, will solve the problem.

28 Which organisms cause bullous and nonbullous impetigo?

29 What are the dermal manifestations of zinc deficiency?

Dietary deficiency or inadequate absorption of zinc leads to acrodermatitis enteropathica. It is characterized by erythema, crusting, and fissuring of the perioral skin and cheeks. The diaper area may develop a diffusely erythematous rash with a sharply marginated border on the abdomen. Psoriasiform lesions may develop around the anus and on the buttocks and feet. Treatment with dietary zinc supplementation provides dramatic resolution of all dermal and systemic symptoms.

Perafan-Riveros C, Franca LF, Alves AC, et al: Acrodermatitis enteropathica: Case report and review of the literature. Pediatr Dermatol 19:426–431, 2002.

30 Contrast and compare smallpox with chickenpox.

See Table 21-5.

TABLE 21-5 SMALLPOX VS. CHICKENPOX

Koenig KL, Boatright C: Derm and doom: The common rashes of chemical and biological terrorism. Critic Decis Emerg Med 17:1–7, 2003.

31 Describe and name the skin finding associated with Lyme disease.

Erythema chronicum migrans (ECM) develops 4–20 days after a tick bite in 60–70% of patients who have contracted Lyme disease (Fig 21-3). The first sign may be a red papule at the site of the tick bite. An annular ring with a flat border slowly grows while clearing develops in the center. Some patients develop multiple secondary annular rings, days after the primary lesion appears.

Figure 21-3 Erythema chronicum migrans (ECM) developed after patient contracted Lyme disease.

Weston WL, Lane AJ, Morelli JG: Bacterial infections (pyodermas) and spirochetal infections of the skin. Color Textbook of Pediatric Dermatology, 2nd ed. St. Louis, Mosby, 1996, pp 50–69.

32 What is the typical skin finding following a bite from the brown recluse spider?

Loxosceles recluse spiders are often found in old buildings and produce a number of toxins in their venom. A hemorrhagic painful blister may initially appear. Over several days a dry gangrenous eschar will develop.

Swanson DL, Vetter RS: Bites of brown recluse spiders and suspected necrotic arachnidism. N Engl J Med 352:700–707, 2005.

Vetter R: Identifying and misidentifying the brown recluse spider. Dermatology Online Journal. Available at http://dermatology.cdlib.org/DOJvol5num2/special/recluse.html.

33 What does the term morbilliform mean?

Morbilliform literally means “measles-like.” Eruptions that are generalized, discrete red to pink macules are referred to as being morbilliform. These include rashes in association with several viral infections, including rubella, enterovirus, adenovirus, roseola, parvovirus, and Epstein-Barr virus.

34 A 7-year-old child presents with five café-au-lait spots that are 2–4 mm in diameter. Does this child have neurofibromatosis?

The diagnostic criteria for neurofibromatosis type 1 include six or more café-au-lait spots greater than 5 mm in diameter in prepubertal children and greater than 15 mm in older children.

Listernick R, Charrow J: Neurofibromatosis-1 in childhood. Adv Dermatol 20:75–115, 2004.

35 What common skin features are present in children with scarlet fever?

36 How can you distinguish irritant contact diaper rash from candidal diaper dermatitis?