Pediatric emergency medicine trisk 463

chronic cases, ultraviolet light phototherapy can be an effective adjunct to
therapy.
Seborrheic Dermatitis
For more information about seborrheic dermatitis, see Chapter 69 Rash: Neonatal
. This is a red eruption with greasy scale that is seen in neonates and then in
adolescence and adulthood.
Psoriasis
Psoriasis occurs in three forms during childhood: guttate, erythrodermic, and
pustular. Any or all of these types may develop with silvery scales into the
chronic, plaque-type psoriasis. For a more detailed discussion please see Chapter
70 Rash: Papulosquamous Eruptions and Viral Exanthems .

VASCULAR LESIONS
Pyogenic Granulomas
Pyogenic granulomas ( Fig. 88.8 ) are vascular nodules that develop rapidly at the
site of an injury, such as a cut, scratch, insect bite, or burn. Clinically, the lesions
are bright red to reddish-brown or blue-black. The vascular nodules are
pedunculated, ranging from 0.5 to 2 cm in size. Their surfaces are glistening, or
raspberry-like, often becoming eroded and crusted. They bleed easily. Removal
by curettage, excision, or laser is advisable because few spontaneous resolve.
Acute bleeding may be managed by cautery, by constriction with a suture, or by
excision.

Hemangioma
Hemangiomas, including PHACE and LUMBAR syndromes, are detailed in
Chapter 69 Rash: Neonatal .

URTICARIA/WHEALS
Urticaria is often encountered in the pediatric population, occurring in 2% to 3%
of all children. In most cases, no cause is identified. A small number of cases are
caused by allergic reactions from the ingestion of drugs or foods (e.g., nuts, eggs,

shellfish). Urticaria also follows viral (e.g., Epstein–Barr virus, hepatitis),
bacterial (streptococcal), or parasitic infections. Physical factors, including
dermographism, cholinergic stimulation (induced by heat, exercise, and
emotional tension), cold (acquired and familial), and solar exposure, can induce
urticaria. Finally, urticaria may be caused by factors producing a vasculitis or
other autoimmune phenomena (particularly thyroid diseases) and substances


causing degranulation of mast cells (e.g., radiocontrast material). Episodes of
urticaria lasting less than 6 weeks are termed transient or acute. The most
common causes of urticaria are infection, insect bites, drugs, and foods. Chronic
urticaria is defined as that which lasts for more than 6 weeks. No cause is found
in 90% of children. These cases include the physical urticarias or urticarial
vasculitis. The lesion itself follows vasodilation and leakage of fluid and red
blood cells from involved vessels. The vascular damage can be caused by
mediators such as histamine complement and immune complexes. IgE can attach
to and cause degranulation of mast cells in sensitized individuals, with resulting
histamine release.

Clinical Manifestations
The typical urticarial lesions are familiar to all physicians. They can be localized
or generalized (involving the entire body). At times, the lesions are giant with
serpiginous borders. Individual wheals rarely last more than 12 to 24 hours. Most
commonly, the lesions appear in one area for 20 minutes to 3 hours, disappear,
and then reappear in another location. The total duration of an episode is usually
24 to 48 hours; however, the course can last 3 to 6 weeks. In young children,
urticaria may have an annular or polycyclic (coalescent annular) or arcuate
(partially annular) appearance and may be associated with edema of the hands or
feet. Because this is frequently confused with EM (which manifest with more
fixed, targetoid lesions), this annular urticarial hypersensitivity has sometimes

been referred to as urticaria multiforme.

Management
Acute relief can be accomplished by oral diphenhydramine 1 mg/kg (max 50 mg).
Oral antihistamines are useful for maintenance therapy for transient urticaria. H1
antihistamines for 4 to 6 weeks are usually effective for controlling urticaria.
Many recommend combinations of H1 and H2 antihistamines, but there is
currently insufficient evidence to support this as a routine practice. Shorter-acting
agents like hydroxyzine can be used for breakthrough.
Suggested Readings and Key References
General
Eichenfield LF, Esterly NB, Frieden IJ. Textbook of Neonatal Dermatology.
Philadelphia, PA: Elsevier Health Sciences, 2014.
Goldsmith L, Papier A. VisualDx: Essential Pediatric Dermatology. Visual Dx:
The Modern Library of Visual Medicine. Philadelphia, PA: Lippincott Williams


& Wilkins, 2009.
Goldsmith LA, Katz SI, Gilchrest B, et al. Fitzpatrick’s Dermatology in General
Medicine. 8th ed. New York: McGraw-Hill; 2012.
Harper J, Oranje A, Prose N. Textbook of Pediatric Dermatology. Oxford,
England: Blackwell Science; 2012.
James WD, Berger TG, Elston D. Andrews’ Diseases of the Skin. 11th ed.
Philadelphia, PA: WB Saunders; 2011.
Paller AS, Mancini AJ. Hurwitz Clinical Pediatric Dermatology. 4th ed.
Philadelphia, PA: WB Saunders; 2011.
Schachner LA, Hansen RC. Pediatric Dermatology. 4th ed. New York: Churchill
Livingstone; 2011.
Treat JR. Curbside Consultation in Pediatric Dermatology. 1st ed. Slack Inc.;
2012.

Atopic Dermatitis
Flohr C, Mann J. New insights into the epidemiology of childhood atopic
dermatitis. Allergy 2014;69(1):3–16.
Lio PA, Lee M, LeBovidge J, et al. Clinical management of atopic dermatitis:
practical highlight and updates from the atopic dermatitis practice parameter
2012. J Allergy Clin Immunol Pract 2014;2(4):361–369.
Mathes EF, Oza V, Frieden IJ, et al. “Eczema coxsackium” and unusual cutaneous
findings in an enterovirus outbreak. Pediatrics 2013;132(1):e149–e157.
Sanders JE, Garcia SE. Pediatric herpes simplex virus infections: an evidencebased approach to treatment. Pediatr Emerg Med Pract 2014;11(1):1–19.
Torti CR, Diaz L, Eichenfield LF. 2014 update on atopic dermatitis in children.
Curr Opin Pediatr 2014;25(4):466–471.
Allergic Contact Dermatitis
Adami S, Jacob SE. Allergic contact dermatitis in children: review of the past
decade. Curr Allergy Asthma Rep 2014;14(4):421.
Epstein WL. Topical prevention of poison ivy/oak dermatitis. Arch Dermatol
1989;125:499–501.
Diaper Dermatitis
Berg RW, Buckingham KW, Stewart RL. Etiologic factors in diaper dermatitis:
the role of urine. Pediatr Dermatol 1986;3:102–106.
Blume-Peytavi U, Hauser M, Lünnemann L, et al. Prevention of diaper dermatitis
in infants—a literature review. Pediatr Dermatol 2014;31(4):413–429.


Honig PJ, Gribetz B, Leyden JL, et al. Amoxicillin and diaper dermatitis. J Am
Acad Dermatol 1988;19:275–279.
Shin HL. Diagnosis and management of diaper dermatitis. Pediatr Clin North Am
2014;61(2):367–382.
Drug Reactions
Dodiuk-Gad RP, Laws PM, Shear NH. Epidemiology of severe drug
hypersensitivity. Semin Ctan Med Surg 2014;33(1):2–9.

Kirchhof MG, Miliszewski MA, Sikora S, et al. Retrospective review of StevensJohnson syndrome/toxic epidermal necrolysis treatment comparing intravenous
immunoglobulin with cyclosporine. J Am Acad Dermatol 2014;71(5):941–947.
Mathur AN, Mathes EF. Urticaria mimickers in children. Dermatol Ther
2013;25(6):467–475.
Mockenhaupt M. Stevens-Johnson syndrome and toxic epidermal necrolysis:
clinical patterns, diagnostic considerations, etiology and therapeutic
management. Semin Cutan Med Surg 2014;33(1):10–16.
Schawartz RA, McDonough PH, Lee BW. Toxic epidermal necrolysis: Part II.
Prognosis, sequelae, diagnosis, differential diagnosis, prevention and treatment.
J Am Acad Dermatol 2013;69(2):187.e1–16; quiz 203–204.
Wong S, Koh M. PD33—Drug Reaction and Eosinophilia with systemic
symptoms (DRESS): a 10-year review in a pediatric population. Clin Transl
Allergy 2014;4(suppl 3rd Pediatric Allergy and Asthma Meeting):P33.
Staphylococcal Scalded Skin Syndrome
Braunstein I, Wanat KA, Abuabara K, et al. Antibiotic sensitivity and resistance
patterns in pediatric staphylococcal scalded skin syndrome. Pediatr Dermatol
2014;31(3):305–308.
Stanley JR, Amagai M. Pemphigus, bullous impetigo and the staphylococcal
scaled skin syndrome. N Engl J Med 2006;355:1800–1810.
Bites and Infestations
Fuller LC. Epidemiology of scabies. Curr Opin Infect Dis 2013;26(2):123–126.
Howard R, Frieden IJ. Papular urticaria in children. Pediatr Dermatol
1996;13:246–249.
Jucket G. Arthropod bites. Am Fam Physician 2013;88(12):841–847.
Mounsey KE, McCarthy JS. Treatment and control of scabies. Curr Opin Infect
Dis 2013;26(2):133–139.
Paller AS. Scabies in infants and small children. Semin Dermatol 1993;12:3–8.
Shmidt E, Levitt J. Dermatologic infestations. Int J Dermatol 2012;51(2):131.