Dermatology

Abbott's Humira (adalimumab) had been approved by the food and Drug Administration for its sixth indication, juvenile rheumatoid arthritis...

On morning rounds in the well-baby nursery, a nurse brings your attention to a 1-day-old girl who is having trouble latching onto the breast. You examine the child and note the subtle anomalies shown in Figure 1 along with a pronounced head lag and a systolic heart murmur.

As a practicing pediatrician in East Hampton, NY, where Lyme disease is endemic, I read with interest the recently published case by Riva Kamat, MD, involving a girl with Lyme meningitis who underwent a lumbar puncture.1

I always find it difficult to speak with pediatricians about diaper rashes. Pediatricians look after many more children with rashes in the diaper area than I do--and all have their own secret ways to treat these children.

For 3 weeks, a 3-year-old African American boy had a mildly pruritic rash on his buttocks, lower extremities, upper thighs, and soles. The patient was initially seen at an urgent care center, where he was given amoxicillin for suspected scarlet fever. A week later, he presented to the emergency department and was treated with griseofulvin for tinea corporis. A skin culture did not grow fungus.

During spring vacation, a previously healthy 4-year-old girl visited western Nebraska, where she and her family spent time along a river bank in a wooded area. After 4 days, her mother noticed 3 engorged ticks embedded in the child's scalp. The ticks were immediately removed and burned. The child also had a marble-sized swelling on the right side of her neck. Over the next few days, the child had temperatures that spiked to 39.4C (103F), with chills, generalized malaise, and weakness. There was no history of cough, myalgias, or headache.

Most physicians in this area of New York do not do spinal taps on patients with headaches and an erythema chronicum migrans rash unless they have meningismus. Seventh cranial nerve palsy alone is not an indication for a spinal tap.

This skin abnormality is cutis marmorata-a physiological dilatation of capillaries and venules of the trunk and extremities in infants and young children caused by exposure to cold. The discoloration fades with warming, as was the case with this baby. The condition is seen especially when subcutaneous fat is decreased.

The photos presented this month reveal disease entities I have seen that did not respond to conventional therapy and that became resistant "diaper rashes." You may have seen some of these "bottoms" in previous issues of Consultant For Pediatricians. Next to each photograph, I have given several clues to the diagnosis. See if you can match these clues with the diagnostic choices listed below. You can check to see whether your diagnostic choices are correct on page 61.

On morning rounds in the well-baby nursery, a nurse brings your attention to a 1-day-old girl who is having trouble latching onto the breast. You examine the child and note the subtle anomalies shown in Figure 1 along with a pronounced head lag and a systolic heart murmur.

The patient denied use of new skin products, detergents, or medications. He had no pets. There was no history of recent travel, and the patient was not aware of any arthropod bites. None of his family members had a similar rash. The patient was sexually active and had had 3 partners in the past 2 years; he said he always used condoms. His history was otherwise unremarkable, as were physical findings.

The child's mother recalled that the rash started as a single patch on his lower back and that the child had an upper respiratory tract infection 4 weeks earlier.

A 20-month-old is seen because of skin swelling and diffuse red eruptions that causes her to refuse to walk. Urticaria multiforme is diagnosed. Supportive treatment with oral antihistamines is prescribed. The child is walking and playing 24 hours later.

With the banning of peanut butter and jelly from some school cafeterias, peanut allergies have become a popular topic in the media and the public. Discussions often include references to an increasing prevalence of allergies, as well as to an earlier emergence of those allergies in children.

A 10-year-old boy presented with a persistent rash that began several months earlier as recurrent crops of papules and a few vesicles with crusting. Varicella was initially diagnosed, and the patient was treated unsuccessfully with over-the-counter drying lotions. The patient denied systemic symptoms and pruritus and was in his usual state of health otherwise. Review of systems, family history, and social history were unremarkable. There was no history of travel or new exposures during this period.

The National Heart, Lung, and Blood Institute and National Asthma Education and Prevention Program (NAEPP) released its Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma--Full Report, in August 2007.1 The EPR-3 is the fourth iteration of the guidelines, which were first released in 1991 (EPR-1), revised in 1997 (EPR-2), and partially revised in 2002 (Update on Selected Topics). For the first time since their inception, the guidelines include separate recommendations specific to children aged 0 to 4 years and 5 to 11 years. Table 1 highlights the key differences between the 1997 EPR-2 guidelines and the 2007 EPR-3 guidelines regarding treatment of pediatric asthma.

The mother of this school-aged girl is concerned that her child has a fungal infection in her fingernails and that the nails are destroyed forever. Your examination reveals that all 20 of her nail plates are affected similarly.

A 3-week-old boy was referred for evaluation of suspected herpes simplex virus (HSV) infection in the inguinal and pelvic regions. The rash had reportedly worsened since its appearance 2 days earlier and was associated with a foul smell.

A 3-week-old boy was referred for evaluation of suspected herpes simplex virus (HSV) infection in the inguinal and pelvic regions. The rash had reportedly worsened since its appearance 2 days earlier and was associated with a foul smell.

Infantile seborrhea has many of the features of the other papulosquamous conditions listed, but the diagnosis is most commonly clinically evident on examination alone. If you are unsure, a KOH preparation will quickly sort out the dermatophytes. Also, the lack of itch makes atopic dermatitis very unlikely.

I believe that there is an entity termed "twenty-nail dystrophy" that is a benign and idiopathic disorder. The nail plates have a distinct appearance and all 20 nails are dystrophic. The nail plates are lusterless and their surface appears to have been sandpapered in a longitudinal direction. The plates are thin and rough with accentuated longitudinal ridges and the cuticles appear to be "roughed up" and thickened. The free ends of the plates are brittle and rough. The nail plates do not appear to be growing.

With the banning of peanut butter and jelly from someschool cafeterias, peanut allergies have become a populartopic in the media and the public. Discussions ofteninclude references to an increasing prevalence ofallergies, as well as to an earlier emergence of thoseallergies in children.

Numerous scattered, mildly erythematous, brownish papules were scattered over the trunk, upper extremities, buttocks, and upper thighs. Many were slightly scaly and several had developed an eschar. The patient also had multiple areas of postinflammatory hyperpigmentation and a few varioliform scars. Other examination findings were normal.

Routine screening for eye disease at all well-child visits should begin in the newborn period. Prompt ophthalmological referral of patients with strabismus or any suspected eye disease is essential to determine the underlying cause, optimize treatment, and preserve binocular vision

Diagnosis and treatment of erythema migrans/Lyme disease