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LIVE BLOG: Pediatric Look Alikes and Controversies

In this live blog from the Fall SDPA Conference in Atlanta, Leslie Lawley, MD, lectures about Pediatric Look Alikes and Controversies. Her objections were to compare and contrast papulosquamous eruptions in pediatric dermatology, differentiate acute cutaneous eruptions due to infections or drugs, and to propose a differential diagnosis for a red facial birthmark and distinguish these diagnoses. Here are some highlights of the cases she covered.


Six year old with an asymptomatic lesion for one month:

a. Tinea Corporis
b. Pityriasis Rosea
c. Granuloma Annulare
d. Psoriasis

a. Tinea Corporis:

• Usually solitary; may be multiple and polycyclic
• Pruritic
• Expands outward
• More inflamed at the edge
• Dx: KOH, fungal culture
• Tx: topical antifungal
• Complications: tinea incognito and Majocchi’s granuloma

b. Pityriasis Rosea:

• Herald patch
• Christmas tree distribution of smaller lesions in 2-21 days
• Preceding viral illness
• Usually not pruritic (75%)
• Clearance 6wk (up to 5 mo)
• Palms and soles involved- check RPR
• Dx-clinical, Tx-supportive

c. Granuloma Annulare

• NEVER scaly
• NEVER itchy
• Usually over joints
• Bee-bee sized papules along the rim in the dermis
• Subcutaneous GA most common in kids
• ROS and family hx and consider glc test
• Dx clinical and/or path
• Spontaneous resolution

Common Locations of dermal Granuloma Annulare:

• Dorsal hands/feet
• Wrists/ankles
• Knees
• Common Locations SQ GA:
• Scalp
• Anteriortibia
• Hands, fingers
• Feet

d. Psoriasis

• Thick white adherent scale • Guttate form eruptive in childhood
– Strep may be precursor (66% recent URI)
• Non-pruritic
• Family hx (up to 70%)
• Involves elbows, knees, scalp, ears, periumbilical, +/- nails


Four day old newborn with a new rash on the trunk and extremities:

a. Erythematoxicum
b. Transientneonatal pustular melanosis
c. Congenital candidiasis
d. Miliaria rubra
e. Incontinentia Pigmenti

a. Erythema Toxicum

• Onset birth-10 days
• Healthy infant
• Urticarial papules and plaques predominate, may be >2cm
• May see pustules
• Widespread
• Dx: eosinophils on gram stain; +/- peripheral eosinophilia
• No tx, self limiting

b. Transient Neonatal Pustular Melanosis

• Present at birth
• More common in Fitzpatrick V-VI skin
• Soupy, baggy pustules, rupture easily with collarette of scale
• Hyperpigmented macules
• Minimal inflammation and no urticarial papules
• Dx: PMNs on gram stain
• Resolves 24-48 hrs; fades over wks-mos

c. Congenital Candidiasis

• Terminfant-healthy; birth to 6 days life
• Diffuse pustules with predilection for palms and soles
• Inflammatorypapules,intactpustulesonback, extremities, skin folds (spares diaper area)
• Diffusedermatitis
• History maternal candida
• Organisms on KOH
• Txtopicalantifungal 

d. Miliaria Rubra

• Discrete erythematous papulovesicles; no urticarial plaques
• Prominent at occluded and intertriginous sites
• No involvement of palms and soles
• Immature sweat ducts develop keratin plugs and sweat retention
• Eosinophils on gram stain
• Tx: cooling, avoid excess heat; light cotton clothing

e. Incontinentia Pigmenti

• Diffuse erythematous linear papules and pustules in lines of Blaschko
• Usually well infant
• May have ophthalmologic, neurologic, or dental abnormalities
• Four stages: inflammatory, verrucous, hyperpigmented, hypopigmented
• Dx: Path, peripheral eosinophilia (74%)


Four year old with a rash around the mouth for 2 months:

a. Herpes simplex
b. Candidiasis
c. Periorificial dermatitis
d. Lip lickers dermatitis
e. Atopic dermatitis with infection

a. Herpes Simplex Infection

• Abrupt onset of tingling vesicles that rapidly crust on the lips
• Localized to single area in most patients
• Can spread to glabrous skin around lips
• Dx:DFA, viral culture
• Resolution over 10-12 days

b. Candidiasis

• Maceration and fissuring mouth commissures with inflammation
• Associated with dental malocclusion, orthodontics, lip-licking
• Responds best to topical antifungal alternating with low potency steroid

c. Periorificial Dermatitis

• Inflammatory papules and pustules around mouth, nose, eyes
• Slow spread over weeks to months
• Topical steroids decrease erythema but can worsen rash
• Fluorinated corticosteroids may produce dermatitis
• Maybe granulomatous – discrete edematous papules
• Treatmentoral erythromycin or azithromycin for 1-2 months; must stop topical corticosteroids

d. Lip Lickers Dermatitis

• Irritant dermatitis on perioral skin from lip licking
• May be upper and lower lip
• Dermatitis not inflammatory papules
• Tx:low potency topical CS

e. Atopic Dermatitis with Infection

• Frequent in infants with pacifiers around the mouth
• Dermatitis not papules and pustules
• Evidence of eczema elsewhere
• Tx:low potency topical CS and antibiotics if indicated


A one-week newborn presents for the first well child check with a red facial birthmark:

a. Nevus simplex (“angel kiss”)
b. Aterio-venous malformation
c. Capillary vascular malformation (PWS)
d. Infantile hemangioma (IH)

a. Nevus Simplex “angel kiss” or “stork bite”

• Up to 40% of newborns – 81% nape of neck – 45% eyelids – 33% glabella
• Ectatic capillaries represent persistent fetal circulatory patterns in skin
• Central face, symmetric
– Arterio-venous malformation
• Rare
• Fast flow dysmorphic arterial and venous connection
• Stage I- quiescent
• Stage II/III- progressive
• Stage IV- cardiac compromise

Capillary vascular malfomation “port wine stain”

• Present at birth
• 3/1000 infants
• Face/neck
– With time darken, more violaceous, thicken, blebs, hyperkeratotic surface
• Limb/trunk
– Occasionally fade over time

Sturge-Weber Syndrome

• CM in VI distribution – Eyelid V1/V2 watershed – 8% incidence – 24% if multiple dermatomes or bilateral
• Vascular malformations of leptomeninges and the eye
– Seizures (55-90%) – Hemiplegia (30%) – Mental retardation (50-65%)
– Ocular (60%): Glaucoma, nevus of Ota, buphthalmos, blindness

Infantile hemangioma (IH)

• Most common benign soft tissue tumor – 1-2% incidence – 10% Caucasians
• Appear birth to 6 wks
• Proliferate 6-12 mo – Most dramatic growth 5-7 weeks of age
• Focal or segmental

Syndromes with segmental IH

– Posterior fossa malformations
– Hemangioma
– Arterial anomalies
– Cardiac anomalies and aortic coarctation
– Eye abnormalities
– Sternal clefting and supraumbilical abdominal raphe

Haggstrom AN et al. Pediatrics 2006;117:698-703. Metry, Heyer, Hess, et al: Pediatrics 2009;124:1447-1456.

Facial segmental IH

• 31% have PHACES, majority >1 extracutaneous finding
• 91% cerebral arterial anomalies, 67% cardiac anomalies
• S1 with or without other segments most common

Haggstrom AN, Garzon MC, Baselga E, et al Pediatrics 2010; 126:e418.

Take home message vascular birthmarks

• Monitor over the first 1-2 months for changes indicative of an IH
• Most dramatic growth occurs at 5-7 wks of age
• Counsel parents regarding both IH and PWS since both have important syndromes to consider


Image: Ophelia Photos

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