William L Weston

By Joanna M. Burch, MD, and William L. Weston, MD 

 Lumps in children that cause pain have six basic   causes. Here's how to differentiate among them and determine which require further   investigation.  

 Many conditions can cause a lump or mass in a child's skin. Most masses are   asymptomatic. A few are characteristically or frequently tender, however. When   confronted with a painful lump in a child's skin, careful palpation with the   thumb and forefinger can determine whether the lesion is soft or firm, mobile   or bound down, and multilocular or not (Figure 1). These characteristics, along   with the color of the lesion, can help you distinguish the cause of the lump   and decide what, if anything, to do about it. 

 Six most common causes of painful lumps 

Six entities account for most painful lumps in children:

 calcifying epithelioma of Malherbe (pilomatricoma) 

eccrine spiradenoma (less common than the others) 

 An easy way to remember these lumps is the mnemonic CANDLE (see the 

).   A few other masses, such as neuromas, glomus tumors, and leiomyomas, are also   painful, but they are rarely seen in children. Keep in mind that any lump may   be tender occasionally. 

Calcifying epitheliomas of Malherbe (pilomatricomas)

 are  benign tumors of hair germ cells. They appear most often as solitary, tender nodules on the head, neck, and proximal extremities, although multiple lesions have been reported. Despite their origin in the hair matrix, very few are found on the scalp. It has been suggested that hair follicle density is a factor in their formationthe greater the density, the more likely the tumors are to developand the follicle density of the scalp is half that of the face even though the scalp has more hair follicles.

   Calcifying epitheliomas typically occur in the first 15 years of life. They vary in diameter from 0.5 cm to as large as 15 cm; most are between 0.5 and 1.5 cm. In rare cases, occurrence follows a familial pattern.

 Calcifying epitheliomas are dermal tumors, usually covered by normal or translucent,   bluish skin. They calcify with time and tend, on physical examination, to be   mobile, multiloculated, and rock-like (Figure 2). Malignant transformation is   rare but has been reported in adults.

 Because the lesions do not   regress spontaneously,

 are benign fat cell tumors with proliferating blood vessels. They appear as tender, compressible, subcutaneous masses, most commonly on the upper outer arms of adolescent girls. The initial large study of angiolipomas found that most patients were 16 years of age or older and that the lesions appeared most often on the extremities and trunk.

 Masses are often 2 to 8 cm in diameter. The innervated vasculature of the tumors is believed to cause the pain. Treatment is surgical excision.

 are soft, fleshy papules ranging from skin-colored   to dusky brown (Figure 3). On direct palpation perpendicular to the skin, they   often display the so-called buttonhole sign; that is, the examiner can feel   an opening just below the lesion into which the lesion can be indented. 

 Neurofibromas originate from cells of the nerve sheath. They can occur anywhere   on the skin and can be solitary or multiple. Plexiform neurofibromas are larger,   pendulous lesions with numerous thickened nervessometimes described as   feeling like a "bag of worms" on palpationand, often, marked by overlying   hyperpigmentation (Figure 4). Because neurofibromas can be the presenting sign   of neurofibromatosis, children with a family history of neurofibromas should   be followed every six to 12 months to monitor for the appearance of café-au-lait   macules or other signs and symptoms of this autosomal dominant disorder.

   Pain may accompany neurofibromas of any size, although the larger plexiform   lesions are more likely to be painful. 

Neurofibromas that are solitary or few in number can be monitored clinically and do not require intervention. Patients with neurofibromatosis who have many or large neurofibromas may be referred for surgical excision for cosmetic reasons or if the lesions are bothersome (because they catch on clothing, for example).

are fibrous intradermal tumors that appear as   firm, brown papules in areas where there are hair follicles (Figure 5), typically   on the arms and legs. They are thought to occur after trauma or an insect bite.   Dermatofibromas can be painful, especially when located in an area exposed to   frequent pressure, such as the back of the torso or extensor aspect of the leg. 

Dermatofibromas move with the skin upon palpation and "dimple" when lateral pressure is applied. Although sometimes mistaken for nevi, they are much firmer than nevi and, unlike nevi, often exhibit the so-called dimple sign. 

  Growth of a dermatofibroma beyond a diameter of 2 or 3 cm suggests that the lesion may be a dermatofibrosarcoma protuberans, a very aggressive and locally recurrent tumor that requires Mohs' technique (controlled serial excision) micrographic surgery or wide local excision.

 Refer patients with these larger lesions to a dermatologist for biopsy.

may become tender when enlarged by the immune response to an infection or to development of microabscesses within the node (lymphadenitis). Proliferation of neoplastic lymphocytes (lymphoma), or buildup of large macrophages (storage diseases) can also cause enlarged lymph nodes. 

Lymph node enlargement is generally more striking in children than in adults; normal nodes do not exceed 2.5 cm in diameter. They are not warm or fluctuant and do not have overlying erythema or show a tendency to mat together. 

 Viral infection is the most common cause of generalized lymphadenopathy (involving   two or more noncontiguous lymph node regions) in children. Lymph nodes enlarged   by malignant disease usually are nontender, rubbery in consistency, matted together,   and more bound down than other nodes.

Palpation of a normal reactive   lymph node enlarged by causes other than malignancyeven when it is slightly   tenderwould reveal a mobile subcutaneous mass with a smooth capsule. Location   along well-recognized lymphatic chains such as the cervical, submandibular,   axillary, or inguinal chain is helpful in establishing a lymph node as the cause   of a painful lump. Occipital or posterior cervical lymphadenopathy in children   should prompt the clinician to consider tinea capitis (Figure 6). 

 are dermal tumors that originate from eccrine   sweat glands. They are much less common than other types of painful lumps. The   classic clinical presentation is a solitary, tender, dermal nodule often with   a reddish or bluish hue (Figure 7). They tend to occur on the ventral surface   of the upper half of the body. Eccrine spiradenomas usually occur in patients   between 15 and 35 years of age and have a generally benign course.

   Malignant degeneration is very rare and usually occurs within pre-existing eccrine   spiradenomas. Most eccrine spiradenocarcinomas occur in elderly patients, although   they have been reported in patients as young as 12 years old.

 A quick way to sort out common painful lumps 

The following questions can help you differentiate quickly between the various types of painful lumps:

 If the lump moves with the skin, it is intradermal; if the skin moves over it freely, it is subdermal. If the lump is subdermal, it is likely to be an enlarged lymph node or an angiolipoma.

A lymph node is almost the most likely diagnosis if the lump is located in the recognized suboccipital, cervical, axillary, or inguinal chain. As mentioned, angiolipomas tend to appear on the upper outer arms. 

If the lump is intradermal, the differential includes dermatofibroma, neurofibroma, or calcifying epithelioma (pilomatricoma). These can be distinguished based on their specific clinical characteristics as described above.

 Color may help distinguish among intradermal lumps. Neurofibromas are skin colored to dusky brown with an indistinct border. Dermatofibromas are brown, eccrine spiradenomas tend to have a bluish hue, and the others are skin colored.

 If firm, consider a calcifying epithelioma, dermatofibroma, or lymph node. In contrast, neurofibromas and angiolipomas are soft and compressible on palpation.

 If it has multiple compartments, it is likely a calcifying epithelioma.

Are there any features specific to a particular type of lesion?

 Look for the buttonhole sign to help confirm the diagnosis of neurofibroma; the dimple sign for dermatofibromas; the "rock-like" consistency of calcifying epithelioma; or the firm, smooth, very mobile nature of a lymph node that slides back and forth under the epidermis. Location is often helpful as well. 

It is not always possible to distinguish between lesions based on the clinical examination. When that happens, biopsy is required.

 An enlarged lymph node should prompt the clinician to seek an infectious cause.   The skin in the region of the node should be carefully examined for pustules,   crusts, or other signs of infection. If the node is very tender, or associated   with a fever, consider aspirating the node for culture. If the node is rubbery,   nontender, or matted, referral for biopsy to rule out malignancy is warranted.   As noted previously, surgical excision is the treatment for painful calcifying   epitheliomas, angiolipomas, some neurofibromas, dermatofibromas, and eccrine   spiradenomas. 

 Lumps that are located at midline or show rapid progressive growth are cause   for concern. Midline lumps often have a connection to the CNS. Any mass that   grows quickly and progressively should be evaluated for possible malignancy.   Fortunately, fewer than 1% of all skin growths in children are malignant. 

 	1.	Noguchi H, Hayashibana T, Ono T: A statistical   study of calcifying epithelioma, focusing on the site of origin. 

 	2.	Demircan M, Balik E: Pilomatricoma in children:   A prospective study. 

 	3.	Julian CG, Bowers PW: A clinical review of 209   pilomatricomas. 

 	4.	Duflo S, Nicollas R, Roman S, et al: Pilomatrixoma   of the head and neck in children. 

 	5.	Green E, Sanusi D, Fowler M: Pilomatrix carcinoma.   

Color Textbook   of Pediatric Dermatology

 	8.	Gloster Jr HM, Harris KR, Roenigk RK: A comparison   between Mohs' micrographic surgery and wide surgical excision for the treatment   of dermatofibrosarcoma protuberans. 

 	9.	 Oski FA, DeAngelis CD, Feigin RD, et al (eds):   

, ed 2. Philadelphia, JB Lippincott   Co, 1994, p 1681 

 	10.	Kersting DW, Helwig EB: Eccrine spiradenoma.   

 	11.	Granter SR, Seeger K, Calonje E, et al: Malignant   eccrine spiradenoma (spiradenocarcinoma): A clinicopathologic study of 12 cases.   

DR. BURCH is a dermatology resident at the University of Colorado School of   Medicine, Denver. 

 DR. WESTON is professor and chairman, department of dermatology, and professor   of pediatrics at the University of Colorado School of Medicine. 

A mnemonic for remembering painful lumps in children 

	Calcifying epithelioma of Malherbe (pilomatricoma) 

 

Joanna Burch, Wiulliam Weston. Painful lumps: Cause for concern?. 

Articles

Lumps in children that cause pain have six basic causes. Here's how to differentiate among them and determine which require further investigation.

Painful lumps: Cause for concern?

 Atypical viral exanthems: 
  New rashes and variations on old themes 

By K. Robin Carder, MD, and William L. Weston, MD 

A viral skin eruption that doesn't follow a familiar   or classic pattern can confuse the diagnosis, leading to unnecessary tests when   only reassurance is needed. This practical guide to recently identified, less   known, and atypical viral rashes of childhood takes the mystery out of your   evaluation. 

 Viral skin eruptions are familiar to pediatricians and dermatologists alike.   Yet such eruptions can be a source of great confusion. 

 Consider the child who is brought to you with a "rash." She (or he) may have   a concurrent fever or other nonspecific symptoms such as an upper respiratory   infection, sore throat, malaise, or lymphadenopathy. Or she may have only the   rash without a history of associated illness. As clinicians, we are accustomed   to and comfortable with certain patterns. We easily recognize an eruptive, pink,   papular rash following a high fever as roseola or exanthem subitum. Red, "slapped"   cheeks followed by a reticulate erythema on the extremities suggest erythema   infectiosum (fifth disease). We would still recognize red macules and distinct   pink-red papules in a child with high fever, coryza, and conjunctivitis as measles,   even though effective vaccination has made measles uncommon. 

 But it is the eruption that does not follow a recognized or classic pattern   that makes us uncomfortable. Sometimes an eruption follows a classic patternbut   the child is the wrong age. At other times, the lesions look familiar, but their   distribution is unusualthey appear on only one side of the body, for example. 

 We examine the child with the unfamiliar eruption and try to assemble the   pieces of the puzzle, aware that the parents are concerned and looking to us   for help, reassurance, and a diagnosis. We think through a differential diagnosis,   but it raises more questions than answers. Should we order laboratory studies?   Perform a skin biopsy? Prescribe antibiotics or a topical steroid? 

 The goal of this review is to remove some of the mystery from the evaluation   of viral eruptions. Realizing that most diagnostic dilemmas do not involve more   common eruptions, we focus on recently identified and less-known viral skin   conditions (Table 1). We also consider unusual or atypical presentations of   more familiar viral eruptions. We describe the clinical signs and symptoms of   each condition, review helpful laboratory or histologic studies, and, most important,   offer a differential diagnosis to help distinguish between similar eruptions. 

Asymmetric periflexural exanthem of childhood (APEC)       

 Papular-purpuric gloves-and-socks syndrome       

 Atypical pityriasis rosea 
          Inverse 
          Vesicular 
          Purpuric, erythema multiforme-like, urticarial       

 Infectious mononucleosis in toddlers    

 Asymmetric periflexural exanthem of childhood 

 Taïeb and colleagues first described asymmetric periflexural exanthem   of childhood (APEC), also called unilateral laterothoracic exanthem, in 1986   (Table 2).

 Two published case series have evaluated the characteristics   of this eruption.

 Both found a female predominance. The condition   also appears to be seasonal, with peak occurrence in the spring. As the name   implies, the exanthem affects young children, between 1 and 4 years of age,   with a mean age of onset of 2 years. Interestingly, two familial cases have   been described.

Asymmetric periflexural exanthem of childhood 

 Progression of skin lesions is typical 


 Unilateral erythematous papular eruptions near         the axilla 

 Centrifugal spread, morbilliform or eczematous,         asymmetric 

 Variable constitutional symptoms 
          Regional lymphadenopathy 
          Pruritus 
          Fever 
          Rhinopharyngitis, diarrhea, vomiting, otitis       

 Spontaneous resolution in 3­6 wk       

 No treatment available; antibiotics and topical steroids are not helpful       

 The initial eruption is strikingly unilateral. Classically, a pink-red papular   eruption appears first in the area of the axilla, on one side of the body only   (Figure 1); the left side was affected more often in one series.

   Less often, the lesions appear first on the thigh, flank, or inguinal fold.   The palms, soles, and face are always spared. Occasionally, the lesions are   serpiginous (circinate) with central blue-gray coloration. 

 By the end of the first week, the eruption spreads centrifugally, away from   the axilla, and may become bilateral or generalized. Despite the spread, the   papules remain asymmetric with greater involvement of the originally affected   side. After the first week, the lesions may appear more scarlatiniform, morbilliform,   or eczematous. By the third week, the pink-red lesions resolve, leaving only   residual dry skin at week four. The eruption resolves spontaneously in three   to six weeks in most cases, although one case was reported to have persisted   for four months.

 No lasting sequelae have been reported after the   lesions resolve. 

 Most children are otherwise asymptomatic, although half may experience mild   or moderate itching. Localized lymphadenopathy may develop in the area where   the eruption began. Some children have fever, sore throat, otitis, vomiting,   or diarrhea at or near the time of the eruption. 

 The cause of APEC remains unknown. A viral etiology has been suggested because   of the young age group, seasonal occurrence, reports of familial involvement,   and occasional lymphadenopathy and fever.

In the two case series,   laboratory tests did not show evidence of infection. Tests performed included   complete blood cell count, liver function tests, throat cultures, and tests   for Epstein-Barr virus (EBV), cytomegalovirus (CMV), parvovirus B19, hepatitis,   coxsackievirus, 

   (one case tested positive with a low titer

 Skin biopsy findings are nonspecific. Histology reveals only epidermal spongiosis,   exocytosis of mononuclear cells, and perivascular and periappendageal inflammation.

   Because laboratory and histologic studies are nonspecific, diagnosis is based   on clinical findings alone. 

 Although oral antibiotics and topical steroids have been given to treat APEC,   they do not appear to alter the course of the illness.

 In both   case series mentioned, the time to resolution of lesions in treated and untreated   children did not vary. Therefore, no treatment is indicated other than, perhaps,   an oral antihistamine to relieve itching. 

 The unilateral onset of this eruption is unique. Eczematous conditions, such   as allergic contact dermatitis or atopic dermatitis, can be unilateral, but   they are much more pruritic, often weep or crust, and respond well to topical   steroid therapy. The more morbilliform lesions of APEC may mimic miliaria, Gianotti-   Crosti syndrome, or roseola, but differ in their unilateral distribution. Also,   miliaria typically occurs on the face, an area spared by APEC. Gianotti-Crosti   syndrome is localized to the face and extremities, whereas roseola is more generalized   and transient (often fading within 24 hours). APEC also may mimic pityriasis   rosea, but pityriasis rosea occurs more often in older children, is often preceded   by a "herald" patch, and has larger, symmetrically distributed lesions that   follow skin folds. 

 The self-resolving eruption of Gianotti-Crosti syndrome (Table 3) was first   described by Gianotti in Italy in 1955. Soon thereafter, he described an association   between the syndrome and hepatitis B infection. Gianotti defined the association   of the classic skin eruption with hepatitis B infection as true Gianotti- Crosti   syndrome or papular acrodermatitis of childhood.

Etiology is a viral infection (see Table 4) or sequela of vaccination       

 More common in spring, early summer       

 Skin eruptions 
          Flat-topped, red-to-purpuric papules and papulovesicles 
          Symmetric on face, buttocks, extensors (elbows and knees)       

 Variable constitutional symptoms 
          Lymphadenopathy (axillary, inguinal) 
          Low-grade fever 
          Pruritus (uncommon)       

 Spontaneous resolution in 3 or 4 wk       

 Laboratory findings 
          Transient elevation of hepatic enzymes (if patient is hepatitis         B­positive) 
          Evaluation to determine infectious cause       

 Treatment is symptomatic (oral antihistamine for pruritus)       

 Similar cases were later described after infection with nonhepatitis viruses   and were termed papulovesicular acrolocated syndrome because they were thought   to differ clinically from classic Gianotti- Crosti. The clinical findings associated   with hepatitis B infection have since been shown not to differ significantly   from those that follow infection with other viruses.

 Most people   now believe that all such cases should be designated as Gianotti-Crosti syndrome.

 Gianotti-Crosti syndrome is typically a disease of young children. Caputo   and colleagues reviewed more than 300 cases and found the mean age of onset   to be 2 years (range, 6 months to 14 years).

 They also found that   the condition was somewhat more common in boys and during the spring and early   summer. 

 Onset is characterized by the appearance of monomorphous, 2- to 5-mm, red   to red-brown, flat-topped papules (Figure 2). Lesions may also be flesh-colored   or papulovesicular (blister-like papules). Occasionally, they appear purpuric   on the lower extremities or edematous. The papules are distributed symmetrically   on the face, buttocks, and extensor extremities (especially the cheeks, ears,   elbows, and knees). The eruption typically begins on the legs and buttocks,   then spreads upward toward the face within the first week. The flexor surfaces   of the extremities and trunk are usually spared. Occasionally, the lesions are   more widespread but remain dense on the extensor surfaces. Some lesions may   demonstrate the Koebner phenomenon (accentuation in areas of trauma) early in   the course of the eruption. 

 The eruption resolves spontaneously over three to four weeks with residual   desquamation, but may persist for as long as two months.

 Variable constitutional symptoms may accompany Gianotti-Crosti syndrome. In   one series, nonspecific viral symptoms such as fever, cough, rhinitis, and other   upper respiratory tract symptoms preceded the eruption in six of seven cases.

   Lymphadenopathy, especially axillary and inguinal, occurred in approximately   half of the children, and splenomegaly was noted in two (one of whom was the   child who did not have viral symptoms). Each of the seven children had at least   one associated sign or symptom. Hepatomegaly is noted more often in hepatitis   B­associated cases, but more serious hepatitis-related sequelae seldom   occur.

 The association of Gianotti- Crosti syndrome with hepatitis B virus is strongest   in Italy and Japan and most often involves the 

 subtype of the virus;   less often, the 

 Hofmann   and colleagues detected hepatitis B virus in none of seven affected patients   in Germany, but found evidence of EBV virus in five of them.

 No   clear viral etiology was found in the remaining two patients, but both had received   immunizations (polio and DTP plus polio) two to three weeks before onset of   the eruption. Several viral and bacterial infections and several immunizations   have been implicated in the etiology of Gianotti-Crosti syndrome (Table 4).   In Europe and North America, EBV appears to be most often associated with Gianotti-   Crosti.

 Associations with Gianotti-Crosti syndrome 

 Adenovirus 
        Coxsackievirus 
        Cytomegalovirus 
        Echovirus 
        Enterovirus 
        Epstein-Barr virus (most common) 
        Hepatitis A, B, and C 
        Human immunodeficiency virus 
        Parainfluenza virus 
        Parvovirus B19 
        Poliovirus 
        Respiratory syncytial virus 
        Rotavirus 
        Rubella       


        Mycobacterium avium-intracellulare

Diphtheria 
        Influenza 
        Pertussis 
        Polio 
        Tetanus 
        Vaccinia       

 Laboratory findings are not characteristic, with the exception of transiently   elevated levels of hepatic enzymes in cases associated with hepatitis B virus.   Because hepatitis B­ induced cases are rare outside Italy and Japan, possibly   as a result of early vaccination, evaluation for hepatitis B is often unnecessary.   Reserve testing of the hepatitis B surface antigen level for patients with a   history of hepatitis B exposure, systemic symptoms (hepatomegaly, splenomegaly,   diarrhea), elevated hepatic enzyme levels, or Italian or Japanese heritage.   If lymphadenopathy, fever, or sore throat is present, testing for EBV, which   is more likely to be the causative agent in Europe and North America, is recommended. 

 Biopsy is unwarranted because the histopathology of Gianotti-Crosti syndrome   is nonspecific. Findings include hyperkeratosis, acanthosis, and focal parakeratosis   of the epidermis. Perivascular inflammation can be seen in the superficial dermis.

 The distribution and appearance of lesions in Gianotti-Crosti syndrome are   characteristic, and the diagnosis is largely clinical. The lesions, when purpuric,   may occasionally be confused with those of Henoch-Schönlein purpura. In   Henoch-Schönlein purpura, however, the lesions typically do not involve   the face and arms, and gastrointestinal, renal, and joint symptoms are often   present. 

 Lichenoid eruptions also may resemble those of Gianotti-Crosti syndrome. The   lesions of lichenoid drug eruptions tend to occur on areas exposed to the sun,   however, and are uncommon on the buttocks. They also persist until the offending   medication is discontinued (see "

".).   Pityriasis lichenoides et varioliformis acuta (PLEVA) is characterized by recurrent   crops of crusted lesions over weeks to monthsunlike Gianotti-Crosti, in   which lesions are not crusted and resolve within one month without recurrence. 

 As with asymmetric periflexural exanthem, treatment of Gianotti- Crosti syndrome   is indicated only if the child is symptomatic. Oral antihistamines relieve itching;   topical steroids also have been used to control itching but do not usually improve   the appearance of the skin or shorten the duration of the skin lesions.

   In fact, topical steroids occasionally exacerbate the eruption, causing an abrupt   increase in the number of skin lesions.

 For this reason, steroids   are generally discouraged. 

 If hepatitis B virus or EBV is present, precautions should be taken to prevent   spread of infection. Obtain a history of the patient's contacts, and, if indicated,   evaluate them for evidence of infection. 

 Papular-purpuric gloves- and-socks syndrome 

 Also known as petechial glove-and-sock syndrome, papular-purpuric gloves-and-socks   syndrome (Table 5) was first described by Harms and colleagues in 1990.

   They reported a distinct pruritic, erythematous, petechial eruption of the hands   and feet that appeared suddenly, then spontaneously regressed within days of   onset. Since then, many more cases have been reported. 

Papular-purpuric gloves-and-socks syndrome 

Etiology is a viral infection (parvovirus B19)       

 Most often affects Caucasian children and young adults (9­45 yr),         male and female       

 Skin eruption 
          Pruritic or tender erythema and edema of hands and feet 
          Progression to confluent petechiae (palmoplantar and dorsal         surfaces) 
          Sharp demarcation at wrists and ankles 
          Enanthem (petechiae, aphthae, erosions, edema, vesicles) 
          Occasional lesions of face, buttocks, extremities, groin,         trunk       

 Variable constitutional symptoms 
          Lymphadenopathy 
          Transient fever (to 39° C) 
          Arthritis, arthralgia
          Anorexia or myalgia 
          Respiratory or gastrointestinal symptoms       

 Spontaneous resolution in 1­2 wk       

 Laboratory results 
          Anemia, leukopenia, or thrombocytopenia 
          Elevated AST 
          Determine viral cause 
            Presence of parvovirus B19 IgM or IgG antibodies         
            Polymerase chain reaction of skin or serum for         parvovirus B19 DNA       

 Children and young adults (9 to 45 years of age) are affected most often,

   although the eruption has been reported in children as young as 22 months.

   Most cases involve Caucasians, males and females, and tend to occur in the spring   and summer.

 The typical presentation begins with a progressive redness and swelling of   the hands and feet,

 often accompanied by itching or tenderness.   Onset is sudden and redness is strikingly symmetric. The eruption progresses   to numerous, confluent petechiae on the palmoplantar and dorsal surfaces of   the hands and feet over the first few days (Figure 3). A characteristically   sharp demarcation at the ankles and wrists can be noted. Often, petechial or   purpuric lesions appear on the trunk, extremities (especially the inner aspect   of the thighs), groin, genitalia, and face. A characteristic enanthemerosions,   vesicles, petechiae, diffuse redness, edema, or aphthaemay occur on the   oral mucosa, including the tongue, lips, and palate. The cutaneous lesions resolve   spontaneously in one or two weeks with only residual fine desquamation on affected   areas. 

This practical guide to recently identified, less known, and atypical viral rashes of childhood takes the mystery out of your evaluation.

William L Weston

Articles

Painful lumps: Cause for concern?

Atypical viral exanthems: New rashes and variations on old themes