Daniel Tawfik, MD, PGY-3 6 November 2013

8yo boy with 4 weeks of rash

4 weeks ago:
Erythematous, pruritic rash began over right shin. One day later, also noted similar rash on left shin. Slowly worsening pruritis.

2 weeks ago:
Noted rash spreading to trunk, extremities, groin, and buttocks. Saw PCP, started on Triamcinolone cream and Cetirizine. Mild benefit noted, but stopped after 2 days. Continued worsening pruritis and spread of rash.

PMH: Epidural hematoma 4 years ago after falling down stairs Meds: none FHx: Brother with eczema SHx: Lives with parents and 3 siblings Imms: up to date except influenza Allergies: NKDA

VITALS: Temperature 36.5, HR 92, RR 16, weight of 23.1 kg. GENERAL: awake, alert, attentive, well-appearing. HEENT: Tympanic membranes normal. Oropharynx normal. No lesions noted in the mouth, nares, or the conjunctival region. No conjunctival injection. NECK: No lymphadenopathy of the neck. CARDIOVASCULAR: S1 and S2 are normal without murmur, gallop, click, or rub. RESPIRATORY: Lungs are clear to auscultation throughout without rhonchi, wheezes, grunting, retractions, or nasal flaring. GASTROINTESTINAL: Abdomen is soft and nontender without rebound, guarding, or masses. Bowel sounds are normal. There is no organomegaly. EXTREMITIES: Warm and well perfused. DERM: Well-demarcated erythematous scaly plaques on the bilateral shins with overlying yellow-colored crusting. Numerous pink scaly papules and plaques scattered on the neck, chest, abdomen, back, and bilateral upper and lower extremities, many with overlying hemorrhagic crusts.

Derm
Allergic contact

ID

dermatitis Irritant contact dermatitis Atopic dermatitis Nummular dermatitis Bullous pemphigoid Heme/Onc Photosensitivity Cutaneous T-cell Lymphoma Stasis dermatitis Other Linear IgA Dermatosis Drug eruption Dermatitis Herpetiformis Granuloma annulare

Mycosis fungoides Scabies Cutaneous tuberculosis Viral exanthem Gianotti-Crosti Syndrome

Overview
Response to an exogenous agent
Nickel, ammonium, gold, thimerosal, p-toluenediamine (hair dyes), poison ivy, poison oak, poison sumac

T-cell mediated delayed-type hypersensitivity

reaction
Common association with atopic dermatitis

Erythematous plaques and pruritis most prominent

Also edema, vesiculation, bullae

Usually confined to area of contact with allergen

May spread by secondary transfer

Acute, pruritic dermatitis Distant from initial focus Pathogenesis not fully understood
May be due to cytokine effect
May be due to dissemination of antigen

Treatment similar to ACD

Avoidance of offending agent! Topical corticosteroids

First line treatment Treat similar to atopic dermatitis Example: Triamcinolone 0.1% ointment BID For failure of topical steroids or if on face/intertriginous areas Slower onset than steroids, and may cause burning/stinging Example: Tacrolimus 0.1% ointment BID May reduce itching and discomfort Examples: calamine lotion, oatmeal compresses, oatmeal baths

Topical calcineurin inhibitors

Topical symptomatic relief

Topical emollients

Systemic corticosteroids
Systemic antibiotics
If involving >20% of body surface area If quick relief is needed (face/hands/feet/genitalia involvement) If evidence of secondary bacterial infection Primarily target pruritis Examples: Cetirizine, Diphenhydramine Rarely needed May be needed if allergen avoidance is impossible (aeroallergens or

Systemic symptomatic relief

Systemic immunosuppression

Phototherapy

photodermatitis) Examples: Azathioprine, Mycophenolate mofetil, Cyclosporine

Psoralen+UVA (PUVA) or narrow-band UVB If chronic dermatitis unresponsive to topical/oral steroids

Acute treatment
Avoid shin guards responsible for rash Triamcinolone 0.1% ointment BID to trunk and

extremities Cetirizine 5mg PO daily Diphenhydramine 25mg PO qHS Cephalexin 30 mg/kg/day PO divided TID for 10 days Bathe in lukewarm water, pat skin dry, and immediately moisturize with Eucerin cream, 1-2 times per day Bleach baths 2x/week (1/4 cup to half bath or 1/2 cup to a full bath)

1 week later
Had not taken full course of topical steroid or

antibiotics Still with diffuse rash Started Prednisolone 24mg PO daily x 7 days Restarted Cephalexin x 10 days Restarted Triamcinolone ointment Continued Cetirizine Continued Diphenhydramine