Dermatology

A healthy term infant born via normal vaginal delivery was noted at birth to have numerous small vesicles involving most of his face and upper chest. He was transferred to the neonatal ICU for suspicion of disseminated herpes simplex. On examination, the infant had small, 1- to 2-mm, superficial, clear vesicles that were confluent on the forehead, eyelids, nose, cheeks, neck, and upper back. A Tzanck test was negative for multinucleated giant cells.

After completing training in pediatrics, dermatology, and pediatric dermatology, I am convinced that the art of medicine, especially as practiced in the field of pediatric dermatology, consists largely of an ability to use pattern recognition to separate the usual from the rare.

“Drug rash” is a common pediatric complaint in both inpatient and outpatient settings. This term, however, denotes a clinical category and is not a precise diagnosis. Proper identification and classification of drug eruptions in children are important for determining the possibility of-and preventing progression to-internal involvement. Accurate identification is also important so that patients and their parents can be counseled to avoid future problematic drug exposures.

Disorders of children’s fingernails and toenails can often be difficult to diagnose or treat. Here I provide tips on identifying and treating some of the nail disorders seen in pediatric practice.

A healthy 9-year-old girl presented with pruritic, darkly colored papules and linear lesions on the left side of her face. She had recently been on a hiking trip with her family. Examination revealed erythematous papules and linear streaks with an overlying black substance that resembled black lacquer paint.

A 1-year-old boy presented with a 10-day history of a nonpruritic rash that had persisted and spread despite treatment with a topical corticosteroid. Mother reported that he was febrile at the onset of the eruption; he was given over-the-counter antipyretics. On day 3, his pediatrician evaluated his condition and prescribed amoxicillin for his fever and hydrocortisone cream for his atopic dermatitis. Over the next several days, the fever subsided; however, the rash, which had started on the child’s right hand, persisted and spread to his face and elsewhere.

Match the photographs of the rashes with the correct diagnosis.

The mother of this 7-year-old girl originally thought these peculiar scales in her daughter’s scalp and hair were nits, since there had recently been an outbreak of head lice at the child’s school. However, she was not able to find any lice, and the scales resisted removal with mineral oil and a “nit comb.”

Four hours after a 12-year-old boy was stung by a honeybee on his right middle finger, he noticed localized hand swelling, erythema, and tenderness. The following morning, his entire hand was swollen and erythematous, with contiguous erythema on the medial aspect of his forearm and arm. Although the arm was tender to palpation, he was afebrile and felt well. Because of an initial concern for cellulitis or lymphangitis, he was given intravenous antibiotics and antihistamines and was admitted overnight for observation.

During a well adolescent visit, an obese 17-year-old boy complained of left knee pain of 4 years’ duration. The pain was worse at night. He was able to ambulate. He associated the pain with a left tibial fracture he sustained after falling off a bicycle 4 years earlier; he denied recent trauma.

17-Year-old girl with a 7-month history of small, red papules on her arms and thighs. Rash is not painful or itchy. Otherwise in good health.

A hemangioma can be concerning to parents, who want to know the prognosis for the lesion as their infant grows. Here, clues to help you identify those that will rapidly involute, those that will grow for a while and then involute over a period of years, and those that without treatment will remain unchanged. Also, which hemangiomas warrant referral.

A 3-week-old baby boy is brought to the emergency depratment with swelling of hands and feet. His extremities were edematous, erythematous, and appeared painful.

An obese 16-year-old girl has been depressed about a slowly progressive skin eruption on her chest and back for a year.

A 16-year-old girl has had a left breast lump for 6 months that recently became tender. Except for several small nodules in both breasts and tenderness of the lateral left breast, physical findings are normal and the patient is otherwise healthy.

A 4-year-old boy with a history of autism presents to his pediatrician’s office with a complaint of right leg pain. He is presumed to have pulled a muscle; an elastic bandage is applied and he is given ibuprofen. Over the next few days, he begins falling and tripping and is unable to maintain his balance. At a return visit, the patient’s mother says her son’s right leg is “like Jell-O” and that he appears to be dragging the leg.

A 7-year-old African American girl presented with an asymptomatic gray lesion beneath her right eye that had appeared before her first birthday. She was a healthy child with macular gray discoloration on the right infraorbital skin. There was no abnormal pigment noted on the conjunctiva.

A 12-year-old girl presented to the emergency department with progressing generalized inflammatory symptoms (fever and malaise), visual difficulty, severe inspiratory dyspnea, and 2 painless lesions on the right upper lip that had persisted for a few days. She had been well until 2 days before presentation, when she noticed a small pimple-like lesion above the right upper lip that was followed rapidly by facial edema, erythema, and constitutional symptoms.

Baby girl born at 37 weeks’ gestation to a gravida 2 para 1, 25-year-old mother by spontaneous vaginal delivery. Apgar scores, 8 at both 1 and 5 minutes. Placenta grossly normal with a 3-vessel cord. Prenatal course uncomplicated. Mother’s blood type, A-positive. Results of prenatal testing negative for hepatitis, syphilis, rubella, group B streptococcal disease, and HIV infection. No significant maternal or family history.

Most children who present with undifferentiated rash and fever-or fever and rash and nonspecific physical findings-have a benign viral illness. However, identifying those few who have an early or atypical presentation of a more serious disease is vitally important. Here-clues that can help.

A papulosquamous rash spread from this boy’s head and neck to cover most of his body; however, areas on his trunk were spared.

A 16-year-old boy presented for evaluation of his worsening behavior at school. He was very hyperactive and had difficulty in paying attention. He had always required help with reading and language. Maternal pregnancy and birth history were unremarkable.

This 11-year-old girl has had an intensely itchy rash on her left leg for the past 10 years. It has been slowly progressing, to the point that it now extends the entire length of the leg. She has become extremely frustrated by the recurring bouts of itchiness and is desperate for relief.

Obstructive sleep apnea (OSA) has a high prevalence in the pediatric population and is associated with significant morbidity, both physical and in the realms of development, cognition, behavior, and school performance.

A 16-year-old girl presented to the emergency department (ED) with an anaphylactic reaction to a bee sting on the right side of her neck. Within 15 minutes of her arrival, swelling, numbness, and pain developed at this site. She also had headache, shortness of breath, and vague abdominal pain associated with nausea.

A 20-month-old boy brought to the emergency department with swelling on the right side of the neck and fever (temperature, 39.3°C [102.7°F]) of 1 day’s duration. The parents reported that the child had had intermittent fevers and poor weight gain for the past 3 months but no vomiting, diarrhea, rash, drooling, or difficulty in swallowing.

A 5-year-old boy has a total body, red, bumpy rash.

Children with psoriasis may be more prone to experiencing psychiatric disorders such as anxiety or depression, compared with young people who do not have the skin issue, new research indicates.

This asymptomatic swelling above a 3-month-old boy's left eyebrow had not changed since birth. The 15 × 13-mm, soft, nontender, freely mobile nodule had no punctum, hair tuft, or other skin anomaly. The infant was born at term and was otherwise healthy. At the parents' request, the nodule was excised without complications by a pediatric surgeon. Pathological findings showed lamellated keratin within the mass and surrounding pilosebaceous units opening into the mass, consistent with a dermoid cyst.

The conditions seen in these 3 photographs are easily confused. Can you match each picture with the correct diagnosis?