Pediatric emergency medicine trisk 451

CHAPTER 88 ■ DERMATOLOGIC URGENCIES
AND EMERGENCIES
ALISA McQUEEN, PETER A. LIO

GOALS OF EMERGENCY CARE
The goals in treating dermatologic conditions are to recognize signs of systemic
illness and complications such as secondary infection.
KEY POINTS
The ability to describe a rash precisely and accurately will dramatically
improve the likelihood of a correct diagnosis.
Key features of the history include duration of the rash (acute or
chronic), initial distribution, extent of spread (generalized or localized),
ill contacts (including sexual partners), and any associated systemic
symptoms, including fever.
Key features of the physical examination include a careful systematic
inspection of all mucocutaneous surfaces, with special attention paid to
involvement of the oropharynx, palms and soles, extensor or flexor
surfaces, scalp, and trunk.
RELATED CHAPTERS
Medical, Surgical, and Trauma Emergencies
Infectious Disease Emergencies: Chapter 94
Rheumatologic Emergencies: Chapter 101
Rashes and skin lesions are common presenting complaints. An accurate
diagnosis depends on a systematic approach that requires assessing the skin
carefully and knowing dermatologic terminology, morphology, and differential
diagnoses. Although not always diagnostic, morphology and distribution of
cutaneous lesions are important parts of categorizing and making a differential
diagnosis, and at the very least can help exclude worrisome conditions when
applied correctly. Terminology is an important part of this process. Descriptors
can be divided into primary and secondary. Primary descriptors include macules

(flat <10 mm), papules (raised <10 mm), patches (flat >10 mm), plaques (raised
>10 mm), nodules (solid lesion 0.5 to 2 cm), pustules (elevation with pus),
abscesses (elevated lesion >10 mm with purulent material), wheals (elevated
lesion with local transient edema), vesicles (elevated lesion <10 mm containing
fluid), and bullae (elevated lesion >10 mm containing fluid). Secondary
descriptors include crust, scale, fissuring, erosions, ulceration, umbilication,
excoriation, atrophy, lichenification, and scar. In addition to these descriptions, it
is also important to understand the distribution of the rash or lesion. Distribution
characteristics include localized, blaschkoid (following lines of embryologic
development), widespread or generalized, and photodistributed (predilection for
sun-exposed areas). Characterizing a rash or lesion using these descriptors
narrows the differential diagnosis significantly. The following sections of this
chapter will divide skin changes by their primary descriptor and then will provide
a framework for adding secondary characteristics to improve diagnosis.

PAPULES
Papules can be quite varied and the following algorithm is used to help
practitioners distinguish between some common papular lesions ( Fig. 88.1 ).

Papules With a Characteristic Appearance
Many conditions can be diagnosed on sight. For example, the experienced eye
can easily distinguish milia from molluscum contagiosum (MC) and warts from
the uncommon xanthoma. Several clues make the process of separating these
entities from one another easier such as color, distribution, and patient
characteristics.

Milia
Milia are 1- to 2-mm firm, white papules. They are produced by retention of
keratinous and sebaceous material in follicular openings. Newborns often have

milia on their face. They frequently disappear by the age of 1 month. Milia can
also arise from skin trauma, and can be seen in scars after burns and in healed
wounds in patients with blistering disorders like epidermolysis bullosa. Persistent
milia may be a manifestation of the oral–facial–digital syndrome, hereditary
hypotrichosis (Marie Unna type), and certain rare ectodermal dysplasias. Because
lesions that are not associated with syndromes often disappear spontaneously,
reassurance is generally warranted, though lesions may be easily removed by
carefully nicking the surface and expressing the keratin. This can be a
simultaneously diagnostic and therapeutic procedure.

Molluscum Contagiosum


The lesion, caused by the molluscipoxvirus , a member of the pox virus
subfamily, is a papule with a white, umbilicated center ( Fig. 88.2 ). It occurs at
any age during childhood, but is more common among swimmers and wrestlers.
Patients with atopic eczema are especially susceptible. Most lesions resolve in 6
to 9 months, but some may persist for years. Spread is by autoinoculation.

FIGURE 88.1 Approach to diagnosis of papular lesions.

Lesions can be single or numerous and favor intertriginous areas such as the
groin. They are usually 2 to 5 mm in diameter, but several can coalesce and form
larger lesions. They may become inflamed, which may herald a spontaneous
disappearance. Often when inflamed, they look “infected” but culture is usually
negative. At times, an eczematous reaction occurs around the lesions.
Since spontaneous resolution is common, treatment, if elected, should be
gentle. Application of 0.1% tretinoin cream one to two times daily may induce
enough inflammation to hasten the host’s immune response or cause extrusion of
the central core, but caution should be observed since tretinoin may exacerbate

secondary eczematization around molluscum lesions. Options for surgical
excision are available but are not appropriate emergency department procedures.


FIGURE 88.2 Child with lesion of molluscum.

Warts
Warts affect 7% to 10% of the population and are one of the most common
dermatologic problems encountered in pediatrics. The peak incidence is during
adolescence. Sixty-five percent of common warts disappear spontaneously within
2 years, and 40% of plantar warts disappear within 6 months in prepubertal
children. However, immunosuppressed patients may experience extensive spread
of the lesions.
The common wart resembles a tiny cauliflower. Lesions disrupt the natural skin
lines and may also manifest with small black dots, representing thrombosed
capillaries. The shape of the wart varies with its location on the skin. They may
be long and slender (filiform) on the face and neck or flat (verruca plana) on the
face, arms, and knees. When located on the soles, they are called plantar warts ,
and when in the anogenital area, they are referred to as condyloma acuminata.