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Case 32
5-YEAR OLD WITH RASH - LAUREN
Author: Ashley Brunelle, M.D, Dartmouth Medical School & Mark Fergeson, M.D.,
The University of Oklahoma College of Medicine

Learning Objectives
1. Describe both primary dermatological lesions and secondary changes
commonly seen in pediatric patients in a systematic manner using
appropriate medical terminology.
2. Outline the key history and physical findings associated with the following
common pediatric dermatologic conditions: Urticaria, seborrheic dermatitis,
contact dermatitis, acne, superficial fungal infections, and scabies.
3. List a prioritized differential diagnoses for an urticarial rash.
4. Discuss the diagnosis and management of acne.
5. Discuss the general approach to choosing a topical steroid and the common
side effects associated with their use.
6. Discuss treatment options for common warts.
7. List at least three conditions in the differential diagnosis of diaper rash.

Summary of clinical scenario: This case takes place in a busy pediatric

dermatology clinic, and students are exposed to a series of clinical scenarios.
Seven patients are evaluated and diagnosed with, respectively, acute urticaria,
seborrheic dermatitis, acne, chronic contact dermatitis, pediculosis capitis,
scabies, and tinea corporis.

1. Lauren is a 5-year-old girl with a family history of atopy who presents with
an evanescent rash on her arms, legs, and trunk that is sometimes pruritic.
On physical examination, the rash is erythematous and slightly edematous.
There are multiple plaques with surrounding clearing and some wheals.
After considering the differential, she is diagnosed with acute urticaria,
advised to avoid potential allergens, and given antihistamine for
symptomatic relief.
2. Three-month-old Clara is brought to the physician for evaluation of a scalp
lesion. Physical examination reveals a waxy yellow scale and mild erythema.

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She is diagnosed with seborrheic dermatitis and counseled regarding

suitable treatment.
3. Lonnie is a 16-year-old male who has been followed for acne. Despite trying
over-the-counter benzoyl peroxide and prescription tretinoin and
clindamycin, he still has open and closed comedones, papules, and pustules.
The classification and stepwise treatment of acne is considered, and Lonnie
is given a prescription for a three-month trial of doxycycline.
4. Kevin is a 13-year-old male with a three-week history of a rash below his
belly button. On physical exam, a raised, erythematous, scaly plaque, about
4 cm in length, and 23 cm in width is noted in the periumbilical region. It
appears that Kevin is allergic to the nickel in the buttons of his new jeans.
He is given a diagnosis of chronic contact dermatitis and appropriate
counseling.
5. The dermatologist receives a phone call regarding a girl who has a history of
severe eczema and has recently been exposed to lice. The mother wants to
know if she should pick up her daughter from school and bring her in for
treatment right away. The student and preceptor review suitable counseling
regarding the etiology and treatment of lice.
6. Johnny is a 13-month-old male who developed a rash over the past week.
Physical exam reveals a pustular eruption on his trunk, palms, and soles.
Further questioning reveals that Johnny and both of his parents have been
itchy. Examination of the Olsons reveals linear lesions between the mother's
fingers and along the father's abdomen. The family is diagnosed with
scabies and given permethrin.
7. A young mother has been told that her children have ringworm. This worries
her because her horse recently had worms, too. Etiology and treatment of
ringworm is discussed, and the student learns about the other forms of
tinea as well.

Case highlights: This case reviews the accurate description of primary and
secondary skin lesions. In addition to the above clinical scenarios, the student
completing this case learns about the differential diagnoses and treatment of
warts and diaper rash. The case is replete with photographs demonstrating classic
presentations of many common pediatric dermatology conditions.

Key Teaching Points

Knowledge
Acne classification:

Severity of acne Types of lesions

Comedonal acne with perhaps a few papules

Mild
or pustules

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Significant inflammatory lesions that may

Moderate
leave scars

Nodulo-cystic type carries an even higher

Severe
risk for significant scarring

Pediculosis capitis (lice):

Commonly seen among school children because of close personal contact

and shared belongings
Not related to personal hygiene habits
Nits are the egg cases of lice. They are firmly attached to the hair shaft 12
mm from the scalp and difficult to remove.

Scabies:

Classic lesion: 510mm linear thread-like lesion (the burrow, or molting

pouch).
Often difficult to diagnose in infants because of its atypical appearance.
Common. Infection has nothing to do with cleanliness.
Caused by a mite called Sarcoptes scabiei.
Acquired by significant close physical contact or through fomites (bedding,
clothes).
Pruritis caused by mite burrowing into the skin to lay eggs
Most intense time of itching is at night.
Common distribution sites: Wrists, elbows, fingers, and toes
Definitive diagnosis relies on the identification of mites, eggs, eggshell
fragments, or fecal pellets:
Superficial skin samples should be obtained from characteristic lesions
by scraping laterally across the skin with a blade
Specimens can be examined with a light microscope under low power
with mineral oil.

Tineas:

Tinea corporis (ringworm). (See Case 7 below.)

Tinea pedis (athletes foot)

More common in young adults than children

Usually appears scaly, with cracks and fissures between the toes

Tinea versicolor

Infection with the yeast form of a fungus (Malassezia globosa), part of

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normal skin flora

May be contagious
Excess heat and humidity predispose to infection
Pink, brown, or white lesions with fine scale
Changes color
Recurrences common, may take months for pigment changes to return to
normal

Tinea capitis (ringworm of the scalp)

Slow-growing fungus in hair follicles

Kerion: An inflamed, weeping boggy lesion caused by a significant allergic
response to the fungus

Warts (verrucae):

Caused by human papillomavirus (HPV)

Mulloscum contagiosum:

Caused by mulloscum contagiosum virus

Lesions are small, smoother than common warts, and may have a central
dimple ("umbilicated").

Diaper rash:

Irritant dermatitis

Most common
Due to prolonged exposure to moisture, friction, and/or digestive enzymes
(worse with diarrhea)
Irregular areas of erythema with skin maceration on convex surfaces of the
skin
Typically spares the intertriginous creases

Diaper candidiasis

Erythematous papules that become confluent, bright red plaques

surrounded by more erythematous papules (satellite lesions)

Bacterial infection

Less common
Usually in perianal area
Often caused by Group A Strep (Streptococcus pyogenes)
Potentially serious, leading to cellulitis and even dissemination via
bacteremia
Infant may be irritable
May see streaks of blood on stools

Zinc deficiency

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Infrequent cause of significant diaper rash

May result from either nutritional deficiency (acrodermatitis enteropathica)
or malabsorption (cystic fibrosis).

Langerhans cell histiocytosis

Crusty, weepy lesions that may bleed

Biopsy required for diagnosis

Skills
History:

Duration
Rate of onset
Location
Associated symptoms
Family history of similar symptoms
Patients allergies
New exposures
Previous treatments

Physical exam:

Skin exam:

Have patient disrobe completely (even if she/he says it looks the same
everywhere!)
Thoroughly examine every part of the skin, including mucous membranes.

Describing primary and secondary lesions:

Characterize by:
Size
Shape (flat, raised, domed, umbilicated)
Surface changes
Overall distribution

Primary lesions:

Description Size

Flat, circumscribed discoloration

Macule < 1 cm
(e.g., freckle)

Larger, flat lesion of color change of

Patch > 1 cm
the skin

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Elevated, circumscribed solid lesion

Papule < 1 cm
(e.g., mole)

Broad, elevated lesion; may

Plaque > 1 cm
represent a confluence of papules.

Circumscribed, elevated, fluid-

Vesicle < 1 cm
containing lesion

Larger, circumscribed, elevated,

Bulla > 1 cm
fluid-containing lesion.

Circumscribed collection of Variably

Pustule
leukocytes. sized

Circumscribed, elevated lesion that

involves the dermis and extends
Nodule into subcutaneous tissue. The
majority of a nodule is below the
skin.

Elevated lesion characterized by

superficial transient edema. May be
Wheal white to pale red and often appear
and disappear over a period of
hours.

A dilation of superficial venules,

Telangectasia arterioles, or capillaries visible on
the skin

Tiny, red or purple macules caused

by capillary hemorrhage under the
Petechiae
skin or mucous membrane. Do not
blanch with pressure.

Larger, purple lesion caused by

bleeding under the skin. May be
Purpura
palpable. Does not blanch with
pressure.

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Secondary lesions (changes that occur later in the course of a lesion or

rash):

Flakes of keratin that can be fine or coarse, loose

Scale
or adherent

Dried remains of serum, blood, or pus overlying

Crust
involved skin

Linear, often painful cleavage in the cutaneous

Fissure
surface of the skin

Slightly depressed lesion in which all or part of

the epidermis has been lost. Does not extend into
Erosion
the underlying dermis, so healing occurs without
scar formation

Depressed lesion extending into the dermis or

Ulcer
subcutaneous tissue. May lead to scar formation.

Traumatized, superficial loss of the skin caused

Excoriation
by scratching or rubbing

Differential diagnosis:
CASE 1 (Lauren)

1. Acute urticaria (hives)

Due to type 1 hypersensitivity
Affects up to 15% of the population at some point in their lives.
Classic lesion is an intensely pruritic, circumscribed, raised,
erythematous wheal, often with central pallor.
Usually asymmetric
Individual lesions may enlarge and coalesce with other lesions.
Lesions continually change with new lesions occurring as old
ones resolve.
Individual lesions last 1224 hours.
Pruritis:
Due to histamine release from mast cells during allergic
inflammation.
Generally rules out diagnoses such as viral exanthems.
If an antihistamine alleviates the symptoms, this supports a
theory of an allergic reaction.

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Triggers:
Drug
Food ingestion
Insect sting
Infection
Dog saliva (a more significant allergen than dander)

Family history of atopic triad (asthma, eczema, and allergies)

suggests possibility of allergic reaction.
2. Papular urticaria:
Common pediatric condition caused by insect bites (may appear after
a child has been outside).
Lesions are pruritic, but smaller than in acute urticaria (310 mm),
more papular, and may be, recurrent or chronic (tending to last one to
two weeks).
3. Streptococcal infection:
Most commonly associated with the rash of scarlet fever.
Erythematous, fine, sandpaper-like rash accentuated at skin creases.
Uncommonly causes an urticarial rash, similar in appearance to acute
urticaria, but associated systemic symptoms would also be present.
4. Erythema multiforme:
Acute hypersensitivity syndrome associated with a symmetrical rash
that starts as dusky red macules and evolves into sharply demarcated
wheals and then into target-like lesions.
Individual lesions stay fixed for one to three weeks.
Most commonly caused by Herpes simplex infections, but may be
associated with medications.
5. Drug eruption:
Commonly urticarial
Type 1 hypersensitivity reactions or may result from non-immunologic
triggers of mast cell release, such as from opiates or non-steroidal
anti-inflammatories.

Less likely diagnoses:

Erythema infectiosum (Fifth disease):

Viral exanthem
Starts on the face with a "slapped-cheek appearance followed by a
reticular, lacy erythematous rash on trunk and extremities.
Caused by parvovirus B19.

Erythema migrans:

Lesion associated with early localized Lyme disease

Starts as red papule at the site of the tick bite and expands to form a large,
erythematous, annular patch.

Roseola:

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Viral exanthem that classically follows three to five days of a febrile illness.
Pink, maculopapular rash that starts on the trunk and may spread to the
face and extremities.
Caused by human herpes virus-6 (HHV-6)

CASE 2 (Clara)

1. Seborrheic dermatitis ("cradle cap"):

Common rash
Erythematous plaques with fine to thick greasy yellow scale
Typically seen on the scalp, but may spread to the ears, neck, and
diaper area of infants.
In older patients, often caused by a fungus called malassezia.
2. Eczema (atopic dermatitis):
May involve posterior scalp
Positive history of atopic diathesis would support this diagnosis.
May find pruritic, erythematous, scaling plaques on extensor surfaces
as evidence of atopic dermatitis on other areas of the body.
3. Candidal rash:
Commonly manifests as a diaper dermatitis peaking between ages
seven and ten months
Area of erythema in the inguinal region, as well as erythematous
papules and plaques with satellite lesions.
4. Psoriasis:
May or may not be pruritic.
Erythematous with a thick, non-waxy scale and defined borders.
Look for signs of psoriasis elsewhere on the patients body.
Family history of psoriasis is present in 40% of patients.

CASE 3 (Lonnie)

1. Acne Vulgaris:
Reason for > 4.5 million doctors visits a year
85% of patients are age 1224 years
Caused by keratinous material and excess sebum (due to
androgens) plugging pilosebaceous glands
Increased sebum provides growth medium for superinfection with
proponiobacterium acnes
Located in neck, face, chest, upper back, and upper arms (areas with
greatest number of sebaceous glands)
Course of disease:
1. Starts as open comedones (blackheads) or closed comedones
(whiteheads)
2. Lesions can then become inflamed, which may lead to larger,
erythematous lesions called papules or pustules.
3. If lesions continue to progress, may lead to nodulo-cystic acne
2. Staphylococcal folliculitis and furunculosis:
May look similar to nodular or cystic acne

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Often located below the waist or in groin area

3. Pseudofolliculitis:
Papules (not pustules)
Often located in the beard area
Inflammation is adjacent to hair follicles
Caused by shaved hairs regrowing into surrounding skin, causing
irritation and inflammation
4. Erythema nodosum:
Hypersensitivity reaction
Red, tender, nodular lesions on pretibial surface of the legs
Etiologies include infections, drugs, and inflammatory bowel disease.
5. Hidradenitis suppurativa:
Occlusion of the apocrine follicular units
Often superinfected with staphylococcus aureus or streptococcus
pyogenes
Pustular lesions, but distribution markedly different from acne:
Women: Axillae, groin, and inframammary regions
Men: Perineal and perianal areas
6. Rosacea:
More often seen in adults
Early" form seen in adolescents
Inflammatory papules and micropustules
Redness on malar and nasal surfaces
No comedones
Exacerbated by alcohol, spicy food, temperature extremes, stress
7. Perioral dermatitis
Located around the mouth, nose, or eyes
Variant of rosacea
Commonly seen in adolescents
Erythema, scaling, and papules or pustules
No comedones
Historically related to topical corticosteroid use

CASE 4 (Kevin)

1. Contact dermatitis:
Common delayed type IV hypersensitivity reaction
Onset within 2472 hours from start of contact
Can occur despite prior tolerance to exposure
Resolves within days to weeks of avoidance
Causes:
Wide variety
Topical antibiotics such as the common generic "triple antibiotic
ointment" or bacitracin
Plants in the toxicodendrons (or Rhus) genus (poison ivy, oak,
and sumac)
Nickel

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Chronic contact dermatitis may appear as erythematous, scaly plaque.

Acute contact dermatitis is erythematous, vesicular, edematous and is
extremely pruritic.
2. Impetigo:
Weepy with honey-colored crusts
Below the nares is most common site (because of rubbing and
colonization), but can be anywhere on the body.
Most common bacteria: Staphylococcus aureus and Streptococcus
pyogenes (Group A strep)
Treatment:
Topical antibiotics (e.g., mupirocin)
Due to widespread emergence of methicillin-resistant
Staphylococcus aureus (MRSA), watch for invasive complications
such as abscess formation.
Complications merit systemic antibiotics.

CASE 5 (Johnny and parents): See Scabies in Knowledge section.

CASE 6 (Patient on phone): See Pediculosis capitis in Knowledge section.

CASE 7

1. Tinea corporis (ringworm):

Superficial fungus
History of contact with animals
Classic lesion:
Annular, well-circumscribed, scaly plaque with a raised border
and the center becoming brown or hypopigmented
Gradually enlarges and may coalesce with surrounding lesions
Mildly pruritic or asymptomatic
Diagnosis usually clinical, but a potassium hydroxide (KOH)
wet-mount examination of skin scrapings can confirm the diagnosis.
Obtain scrapings with the edge of a glass slide or a #15 blade
and examine them under low power with the microscope light
dimmed.
Observe classic branches and rod-shaped septated hyphae
2. Nummular eczema:
Coin-shaped lesions commonly found on legs and buttocks
Annular configuration and scaly appearance
3. Psoriasis:
Erythematous papules and plaques with a thick silver scale.
May have an annular configuration
Chronic disease (unlike tinea)
4. Pityriasis alba:
Patches of hypopigmentation on the face, neck, upper trunk, and
proximal extremities
Lesions range from 0.5 to 5 cm in diameter and have well defined,
irregular borders and fine scale.

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Associated with sun exposure

Can be mistaken for tinea versicolor
5. Pityriasis rosea:
Scaly papules and plaques in "Christmas tree" distribution on back
and trunk, following the lines of skin cleavage
Lesions may also be found in the upper thighs and groin area.
Initial lesion, called the herald patch, is usually the largest scaly
plaque with a raised border

Management
Topical steroids

Powerful and effective treatment for many dermatologic conditions

Four potency groups, corresponding to seven potency classes:

Potency Group Potency Class Example

Mild Class 6 & 7 hydrocortisone acetate, 1% (OTC)
Intermediate Class 4 & 5 triamcinolone acetonide, 0.1%
Potent Class 2 & 3 betamethasonedipropionate, 0.05%
Super Potent Class 1 clobetasol propionate, 0.05%

Acute urticaria:

Avoid suspected allergens.

Cool, soothing baths
Treat symptoms:
Over-the-counter antihistamines (loratidine, cetirizine)
If these are ineffective, add prednisone.
Topical steroids not effective, since hives can be transient and cover a
large area of the body.
If still no improvement, can do allergen antibody blood testing in the
office or refer to allergist for skin scratch testing.

Seborrheic dermatitis:

Infants: Use baby oil and a small brush to remove the scales.
May try medicated shampoos or a topical steroid, such as hydrocortisone
Older children and adults: Ketoconazole cream.
Most children grow out of it whether treated or not.

Acne:

Avoid exacerbating factors:

Makeup (unless noncomedogenic)
Manipulation or occlusion by sports gear

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Overzealous cleaning
Important to consider how much acne affects teenager's quality of life when
deciding on a treatment.

Severity of acne Treatment

Start with over-the-counter benzoyl

peroxide (BPO) gel or skin wash

Retinoids (Tretinoin [e.g., Retin-A] or

adapalene [Differin]) are considered the
Mild drugs of choice for comedonal acne.
Retinoids work by normalizing follicular
keratinization.

For more severe acne, BPO with a topical

antibiotic like clindamycin or erythromycin

Step-wise approach: Same initial

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

Refer to a dermatologist. If all other

treatments have failed or have not been
tolerated, many dermatologists will then
use oral isotretinoin
Severe
This medication carries significant risks
and is regulated strictly by the federal
government

Side effects:
Retinoids
Can cause photosensitization resulting in significant sunburn.
Direct patients to use this at night.
Inactivated by oxidation of BPO. Direct patients apply BPO
cream in the morning.
Must be applied to bone-dry skin or it may be significantly
irritating.
Can make acne transiently look worse.
Doxycycline:

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Photosensitivity
Dental staining in children under age nine
Teratogenicity
Pseudotumor cerebri

Chronic contact dermatitis:

Avoid the allergen.

Use an emollient like petroleum jelly (Vaseline) or a skin-lubricating cream,
such as Aquaphor or Eucerin.
Use a medium potency topical steroid ointment twice a day for two weeks.
Topical steroids come in a variety of potencies and delivery vehicles.
Potency varies from Class 1 or super potent to Class 6 and 7 which
are mild potency.
Ointments and gels provide more skin penetration than creams and
lotions.
Occlusion, such as by a diaper, increases skin penetration and
systemic absorption.
Important side effects include skin atrophy, telangectasias,
hypopigmentation and suppression of the hypothalamic-pituitary axis.
If difficult to control the allergy, refer to an allergist to consider "patch
testing."

Pediculosis capitis:

No need to treat lice unless they are actually found on the patient.
Reassure families that lice infestation is not a reflection of poor hygiene.
Prevent lice by discouraging school-aged children from sharing belongings
such as hats, coats, combs, and barrettes.
Managing lice infestation:
Rinsing hair with vinegar or using ointments to "suffocate" the lice are
ineffective.
Comb wet hair with a fine-toothed comb.
Wash bedding, stuffed animals, hats, combs and brushes, and other
contaminated items in hot water or dry in high heat in the dryer.
Seal unwashable items in an airtight bag
Over-the-counter shampoos and rinses (permethrin or pyrethrins):
Increasing resistance to these agents.
Do not kill the ova (nits), so should use two or three times in weekly
intervals.
Prescription:
Malathion 0.5% topical is currently considered the most effective
drug.
Lindane used to be the treatment of choice, but is no longer effective
because of resistance.

Scabies:

Cover body from the hairline down with permethrin 5% cream at night

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before bed
Wash it off in the morning after 812 hours.
Repeat once more in a week.
After bathing, wash all bed linens and clothing worn during treatment.
Itching may persist for a few weeks.
May use a moderate potency topical steroid
Over-the-counter diphenhydramine
If itch persists > four weeks, may need to retreat
If patient does not respond well to permethrin or has an allergic response,
may give ivermectin orally (Food and Drug Administration [FDA] approved
for children greater than 15 kg).

Warts:

Aggressiveness of therapy depends on location, severity, and patient

cooperation.
Two-thirds of warts spontaneously resolve within two years, so observation
is always an option. However, it is easier to treat smaller warts early than
wait until they expand.
Over-the-counter salicyclic acid
Useful for most warts
Can be used in children
Disadvantages: Must apply daily; works slowly
Duct tape
Unclear if better than placebo
Liquid nitrogen
Not as effective as salicylic acid, but treatment is faster
May be useful in older children and adults; too painful for younger
children
Cantharidin
Causes blistering at site of wart
Applied in physicians office
Paucity of data documenting effectiveness
Approved by the Food and Drug Administration (FDA) for use only in
combination with other products
Candidal antigen therapy
Immunotherapy
Limited evidence
Curettage
May leave a significant wound or scar
Recurrence is common

Tinea capitis:

Requires systemic antifungal therapy

Griseofulvin is treatment of choice.
Because the fungus grows slowly and is killed in replication phase, requires
extended treatment period, usually six to eight weeks.

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Treatment should continue after it appears better, or it will again recur.

For resistant strains or a child who does not tolerate griseofulvin, alternative
therapies include terbinafine and itraconazole.
Kerions often require treatment with oral steroids (although once the fungal
infection is controlled, this reaction goes away).

Diaper rash:

Irritant dermatitis

Keep diaper area as clean and dry as possible

Use zinc oxidecontaining creams or ointments to limit contact of urine and
feces with the skin

Diaper candidiasis

The anti-fungal medication nystatin is effective against Candida and is

approved for all ages by the FDA.
Imidazole antifungals (such as miconazole and ketoconazole) can also be
effective, but some of these products are not approved for infants.

Bacterial infection (perianal Group A streptococcus)

Standard treatment with oral antibiotics

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