Pediatric Dermatology

Overview

• Pediatric Dermatology focuses on differentiating between benign skin disorders and life-threatening diseases in children.

• This guide reflects essential concepts in the assessment and treatment of pediatric dermatological conditions.

Key Details from the Presentation

Speaker Introduction

• Speaker: Sarah B. Wren, RN, MS, CPNP

• No disclosures regarding potential conflicts of interest.

Learning Objectives

• Evaluate skin lesions to assess for dangerous dermatologic disorders.

• Differentiate skin disorders requiring immediate treatment from benign conditions.

• Analyze pediatric skin diseases for evidence-based treatment plans.

• Use accurate terminology for diagnosing and treating dermatological disorders.

• Assess treatment modalities, particularly considering ethnically diverse populations.

Describing Rashes – Key Points

• Importance of evaluating skin of color due to underrepresentation in medical education.

• Major differences in presentation:

  • Erythema

  • Eczema and dry skin dermatitis

  • Recognition of petechiae and purpura

  • Hypo- and hyperpigmentation

Common Pediatric Dermatological Conditions

Eczema Herpeticum

• Lesions appear as punched-out and spread rapidly, often on the head and neck.

• Concomitant infection can complicate presentation; febrile illness may be observed.

• Hospital admission should be considered.

Atypical Coxsackie Infection

• Caused by a new strain (Coxsackie A6) characterized by high fever and extensive vesiculobullous rash.

• More severe than typical hand, foot, and mouth disease (HFMD).

Eczema Coxsackium

• Infants with eczema may be at risk for severe disease with Atypical Coxsackie.

• Lesions often appear in areas affected by atopic dermatitis.

• Appear similar to eczema herpeticum, requiring careful differential diagnosis.

Varicella (Chickenpox)

• Caused by the Varicella Zoster Virus; characterized by pruritic erythematous macules, papules, vesicles, and crusts.

• Extremely contagious via airborne transmission.

Meningococcemia

• Caused by Neisseria meningitidis.

• Initial symptoms include a URI, sore throat, malaise, with a rash as the common manifestation.

• Rapid rash progression can lead to purpura, with a mortality rate of 10-15% despite treatment.

Neonatal Herpes Simplex Virus (HSV) Infection

• Lesions typically present within the first weeks of life and can present with nonspecific sepsis-like symptoms.

• Requires immediate medical attention and management.

Urticaria

• Usually benign but can be mistaken for anaphylaxis; often has a variable etiology.

• Self-limiting, but differentiation is key with the involvement of multiple organ systems in anaphylaxis.

Erythema Multiforme

• An immune-mediated condition characterized by target lesions, commonly triggered by infections, particularly viral.

• Skin lesions have a characteristic appearance and are usually asymptomatic aside from pruritus.

Staphylococcal Scalded Skin Syndrome (SSSS)

• Caused by exotoxins from staph bacteria, presenting with fever, skin tenderness, and rash.

• Rapid spread leading to exfoliation must be monitored closely in young children or immunocompromised individuals.

Scarlet Fever

• Caused by toxins from Group A Streptococcus; recognizable and treatable condition.

• Characterized by a red rash often resembling sandpaper, typically starting in the groin region.

Necrotizing Fasciitis

• Emergency condition, usually due to Group A Streptococcus, starting with vague muscle soreness but progressing rapidly.

• Requires immediate medical intervention, including surgical debridement.

Atopic Dermatitis

• Chronic inflammatory condition characterized by pruritus and dry skin, often starting in infancy.

• Changes in distribution with age; common associated comorbidities include asthma and food allergies.

Dupilumab (Dupixent)

• A newer treatment targeting specific interleukin receptors in atopic dermatitis.

• Administered via subcutaneous injection; eligible for children over 6 months. Side effects may include injection site reactions.

HSV Labialis

• High prevalence condition primarily caused by HSV Type 1; significant recurrent episodes.

• Treatment options include Valacyclovir, particularly effective if started at prodromal symptom onset.

Reactive Infectious Mucocutaneous Eruption (RIME)

• Severe mucocutaneous reactions triggered by viral or bacterial infections, most commonly Mycoplasma pneumonia-related.

• Diagnosis is critical, often necessitating consultation with dermatology and supportive care.

Lecture Voice recorded (late)

Resurgence of Scarlet Fever

• Scarlet fever is experiencing a resurgence worldwide.

• Increased literature exploring the reasons behind the rise in cases.

Historical Context

• In the past, cases of scarlet fever were rare, and health professionals would bring awareness to each case as significant.

• Currently, health professionals encounter scarlet fever cases on a daily basis.

Reasons for the Increase in Cases

1. Impact of COVID-19

• The COVID-19 pandemic has had widespread effects on health.

• Children were not exposed to various infections during lockdowns and restrictions, affecting their immunity.

2. Concurrent Respiratory Infections

• Increased prevalence of multiple respiratory viruses leading to lower immunity among children.

• This situation contributes to a higher susceptibility to infections like scarlet fever.

3. Emergence of New Strain of Group A Strep

• A new strain known as MIUK has been identified in England.

• This strain is associated with higher susceptibility to both scarlet fever and invasive group strep infections.

• Patients infected with the MIUK strain may present with characteristic rashes.

Necrotizing Fasciitis

• Sudden onset of blister and significant pain, erythema around the ankle or calf.

• Medical emergency, colloquially known as flesh-eating disease.

• Mostly caused by Group A Streptococcus (GAS), an invasive bacterial infection.

• Symptoms include:

  • Extreme tenderness, often disproportionate to appearance.

  • Rapid spread of redness and pain over hours.

• Requires immediate antibiotics and surgical debridement; high morbidity and mortality.

Atopic Dermatitis

• Also known as eczema; a common chronic skin condition, especially in children.

• Key features include:

  • Dry, itchy skin; papules and plaques; most prevalent skin disease in children.

  • 50% of cases persist into adulthood.

• Presentation varies by age group:

  • Infants: extensor surfaces (face, chest).

  • Children: flexor surfaces (elbow, knee).

  • Adolescents & adults: similar to children, possible hand and foot involvement.

• Headlight sign: classic indicator where skin around eyes and nose is spared even when affected by atopic dermatitis.

• Associated comorbidities include asthma, allergies, sleep issues, anxiety, and learning disabilities.

• Treatment considerations:

  • Patients often on multiple medications including steroids.

  • Importance of knowledge of topical steroids - mild (2.5% hydrocortisone), moderate (mometasone), and high potency.

  • Educate patients to use more potent treatments initially to control severe dermatitis.

  • Emphasize emollient therapy using creams and ointments to maintain skin moisture.

  • Advise against short baths, advocate for bleach baths for antimicrobial and anti-inflammatory effects.

  • Discuss the necessity of timely treatment initiation to prevent chronic exacerbations.

RIME (Reactive Infectious Mucocutaneous Disorder)

• Immune-mediated mucocutaneous disorder triggered post-viral infection, often mycoplasma pneumonia related.

• Symptoms include severe mucositis mainly in the mouth; may involve other mucous membranes.

• Usually self-limiting, good prognosis, may see some skin lesions.

• Treatment is primarily supportive; become aware of potential for misdiagnosis with other serious conditions (e.g., Stevens Johnson syndrome).

Common Skin Emergencies

• Importance of detailed history and examination in febrile rash patients.

• Pay attention to blisters, denuding skin as possible indicators of serious conditions.

• In immunocompromised patients, rashes should always raise concern.

Patient Case Highlights

• Case of a teenage girl with swollen, crusted lips due to an irritant (garlic).

• Unique presentation of atypical dermatitis mistaken for burns (burns hurt these don’t) as showcasing the therapeutic role of patient education regarding traditional remedies.

• Importance of recognizing the emotional impact of skin diseases on adolescents in social contexts.