Pediatric Rashes

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CHAPTER 21 Pediatric Rashes

Ronald I. Paul, MD

1 Name five bioterrorism agents that may have skin manifestations.

See Table 21-1.

TABLE 21-1 BIOTERRORISM AGENTS THAT MAY HAVE SKIN MANIFESTATIONS

Agent	Skin Findings
Smallpox	Maculopapular rash on face, forearms, and mucous membranes that becomes vesicular/pustular within 48 hours
Anthrax	Painless pruritic papule on skin that develops into a painless, ulcerated black eschar within a few days
Tularemia	Painful maculopapular lesion that ulcerates; associated with papular painful inflamed regional lymph nodes
Plague	Acutely swollen lymph nodes called buboes
Viral hemorrhagic fever	Maculopapular rash on trunk followed by mucosal bleeding

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

Chancre	Painless ulcer of skin and mucous membranes at site of inoculation
Rash	Maculopapular rash of secondary syphilis frequently involving palms and soles
Condyloma lata	Cauliflower-appearing warts on penis, labia, or rectum
Gumma	Painless pink to dusky red nodules of various sizes that may necrose or ulcerate

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.

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