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Ten derm diagnoses pediatricians should make.

Scottsdale, Ariz. -- Dr. Lawrence A. Schachner challenged physicians with a rundown of "10 cutaneous diagnoses that the pediatrician should make but usually doesn't" at a pediatric update sponsored by Phoenix Children's Hospital.

Not all the cases are difficult, according to Dr. Schachner, director of the division of pediatric dermatology at the University of Miami, but some should be referred to a specialist.

Case 1

A 13-year-old child presents with a scaly, purple lesion close to one eye. The lesion itches. Physical examination reveals mucosal involvement, flat-topped polygonal papules 3-6 mm in size on the wrist, and bandlike striations under the nails.

* Diagnosis: Lichen planus.

"The four Ps--purple, pruritic, polygonal, papule--make the diagnosis," Dr. Schachner said.

Because the condition is common in adult hepatitis C patients, he recommended screening adolescents with lichen planus for hepatitis C. If left untreated, Dr. Schachner said, lichen planus usually resolves within a year.

He warned, however, that some cases become a lifelong problem with irreversible alopecia, nail damage, and even malignant transformation.

* Treatment: Use topical steroids.

Case 2

A neonate presents with papules on the scalp and pustules on the palms and soles.

* Diagnosis: Neonatal scabies.

Dr. Schachner suggested ruling out bullous impetigo, eczema, and histiocytosis with a scabies prep that tests positive for mite eggs or stool.

"If you are thinking neonatal scabies, look at the rest of the family and see if they are itchy, too," he said. You may have to treat the whole family "and the day care center and anyone else taking care of junior."

* Treatment: The first choice is usually 5% permethrin cream (Elimite). Sulfur in petrolatum is an alternative, as are antibiotics and antihistamines. After trying permethrin, consider using topical steroids and, in persistent cases, oral ivermectin (but not for babies less than a year old), Dr. Schachner suggested.

Case 3

The parents are worried about a bunch of yellow, brown, and orange bumps 1-2 cm in diameter on their baby's skin.

The orange nodules stand out on the trunk.

* Diagnosis: Juvenile xanthogranuloma.

First, you have to rule out mastocytomas, Spitz nevus, and histiocytosis, he said.

* Treatment: This condition usually resolves spontaneously over months or years, but some large or eroded lesions must be excised, according to Dr. Schachner.

Lesions can occur in the eye and can cause hyphema and/or glaucoma. "You want an ophthalmologist to see this early and follow it up," he said.

Case 4

The child has had erupting itchy, scaly red papules 2-5 mm in size for 8 months. They heal and come back. In some instances, they are ulceronecrotic. Laboratory tests are normal.

* Diagnosis: Pityriasis lichenoides et varioliformis acuta (PLEVA, MuchaHabermann disease).

"If it looks like a mixture of healing chickenpox and acute, severe mosquito bites, I would think about PLEVA," said Dr. Schachner.

Despite being called "acuta," PLEVA can last for months or years, he said. In rare cases, it evolves into cutaneous T-cell lymphomas.

* Treatment: Mild-potency topical corticosteroids, oral erythromycin or tetracycline, ultraviolet B and tar therapy, and psoralen and ultraviolet A therapy are all options.

Methotrexate and prednisone have been used on the ulceronecrotic variant.

If the condition does not go away, Dr. Schachner suggested, refer to a pediatric dermatologist.

Case 5

The infant does not seem ill, but 1- to 3-mm papular, pustular, or crusted pustular lesions appear on the scalp, brow, and chest. These lesions dry up and come back.

Laboratory tests and a biopsy show eosinophils.

* Diagnosis: Eosinophilic pustular folliculitis (EPF) of infancy.

Dr. Schachner recommended Gram stains, potassium hydroxide testing, and Giemsa stains whenever a neonate has pustules. Otherwise, he warned, a baby with EPF can end up on unnecessary antiviral and antibacterial agents.

Treatment: Topical steroids and antibiotics such as erythromycin are options.

Older children may need antihistamines.

Case 6

The baby presents with an itchy, urticating lesion or lesions that become worse after a hot bath or rubbing.

The lesions can be red-pink or brown-yellow, and they usually have a papular surface. Sometimes flushing, diarrhea, or bone pain is a problem.

* Diagnosis: Urticaria pigmentosa.

"Any orange-brown lesion deserves a firm stroke to see if Darier's sign is present," said Dr. Schachner.

In very severe cases, he suggested, laboratory testing for elevated urinary or plasma histamine levels and x-rays for skeletal and gastrointestinal involvement may be necessary.

A Giemsa stain can document mast cells on skin biopsy.

* Treatment: Antihistamines, topical steroids, psoralen and ultraviolet A therapy (for older patients), oral cromolyn preparations, and surgical excision are options. "First, reassure the family," said Dr. Schachner.

"Most kids are perfectly fine and will outgrow the lesion."

Case 7

A child between ages 5 and 10 years has a linear lesion running down her trunk and leg.

The lesion is itchy and palpable. Her nails show plaque.

* Diagnosis: Lichen striatus.

"Linearity is the clue," said Dr. Schachner, "[but] linear things are a challenge." He urged doing a biopsy to differentiate linear epidermal nevi, linear lichen planus, linear psoriasis, and fiat warts.

* Treatment: Do not treat, or try topical steroids. "The condition will usually last 1-2 years and then spontaneously involute," he said.

Case 8

The child is not bothered by a group of 1-mm skin-colored papules that form lines when scratched. His parents are concerned.

* Diagnosis: Lichen nitidus.

"You almost always see a Koebner phenomenon," advised Dr. Schachner.

When in doubt, biopsy to differentiate from lichen planus, molluscum contagiosum, flat warts, granuloma annulare, and lichen spinulosus.

* Treatment: None is needed. Offer emollients and low-potency topical corticosteroids, which may speed resolution, if the parents demand therapy. Most cases clear in a year or less.

Case 9

A school-age child presents with an asymptomatic group of ringed papules that look like tinea and range from a few millimeters to 5 cm in size.

Neither over-the-counter medications nor topical antifungal agents have cleared the condition.

* Diagnosis: Granuloma annulare.

A common disorder, granuloma annulare often appears on elbows and ankles, said Dr. Schachner. "I think it follows trauma," he said.

A negative potassium hydroxide test can rule out tinea corporis. Biopsy may be necessary to rule out lichen nitidus, flat warts, molluscum, or sarcoidosis.

The differential diagnosis also needs to exclude rheumatoid nodules, necrobiosis lipoidica diabeticorum, and lichen planus.

* Treatment: Use midrange topical corticosteroids, intralesional steroids, or steroid tapes. Most cases will disappear without treatment within 2 years, but this condition can become resistant and disfiguring. Dr. Schachner said that oral corticosteroids, retinoids, dapsone, and cytotoxic agents can be used in tough cases.

Case 10

The scalp of a neonate has a palpable yellow-orange lesion that becomes less palpable over time. Pressing down brings out an orange color.

* Diagnosis: Nevus sebaceus of Jadassohn.

These lesions, often found on the face and neck as well, occur at a ratio of 1:300 in live births, said Dr. Schachner. Biopsy will show hyperplasia of sebaceous glands.

Most nevus sebaceus lesions are benign, he said, and the incidence of malignant transformation is reported as much less than the original estimates of 6%-15%. Very large lesions can be associated with systemic problems, including those affecting the central nervous system. They call for screening to make sure no other organ systems are involved.

Treatment: Prophylactic excision is indicated, usually at school age.

JANE SALODOF MAcNEIL

Southwest Bureau
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Author:McNeil, Jane Salodof
Publication:Pediatric News
Geographic Code:1USA
Date:May 1, 2006
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