Home Books The Philadelphia Guide: Inpatient Pediatrics, 3e
Chapter 6: Dermatology
Kara N. Shah
Shah KN. Shah K.N. Shah, Kara N.Dermatology. In: Shah SS, Ronan JC, Catallozzi M, Frank G. Shah S.S., & Ronan J.C., & Catallozzi M, & Frank G(Eds.),Eds. Samir S. Shah, et al.eds. The Philadelphia Guide: Inpatient Pediatrics, 3e. McGraw Hill; 2022. Accessed February 02, 2023. https://accesspediatrics.mhmedical.com/content.aspx?bookid=3111&sectionid=260571692
Shah KN. Shah K.N. Shah, Kara N. (2022). Dermatology. Shah SS, Ronan JC, Catallozzi M, Frank G. Shah S.S., & Ronan J.C., & Catallozzi M, & Frank G(Eds.),Eds. Samir S. Shah, et al. The Philadelphia Guide: Inpatient Pediatrics, 3e. McGraw Hill. https://accesspediatrics.mhmedical.com/content.aspx?bookid=3111&sectionid=260571692
Shah KN. Shah K.N. Shah, Kara N. "Dermatology." The Philadelphia Guide: Inpatient Pediatrics, 3e Shah SS, Ronan JC, Catallozzi M, Frank G. Shah S.S., & Ronan J.C., & Catallozzi M, & Frank G(Eds.),Eds. Samir S. Shah, et al. McGraw Hill, 2022, https://accesspediatrics.mhmedical.com/content.aspx?bookid=3111&sectionid=260571692.
BLISTERING DISORDERS: NECROTIZING FASCIITIS
STAPHYLOCOCCAL SCALDED SKIN SYNDROME
STEVENS–JOHNSON SYNDROME (SJS) AND TOXIC EPIDERMAL NECROLYSIS (TEN)
EXANTHEMS: DRUG REACTION WITH EOSINOPHILIA AND SYSTEMIC SYMPTOMS (DRESS)/DRUG-INDUCED HYPERSENSITIVITY SYNDROME (DIHS)
ACUTE URTICARIAL HYPERSENSITIVITY
VASCULAR PHENOMENA: COMPLICATED HEMANGIOMAS
An acute, rapidly progressive, necrotizing, life-threatening infection of the subcutaneous tissues, often associated with septic shock or streptococcal toxic shock syndrome.
Can be rapidly fatal if not recognized and treated promptly and appropriately
Rare in children; estimated 500–1500 cases per year in the United States
Can be seen at any age, including neonates
Most children with invasive group A β-hemolytic Streptococcus (GABHS) infection are otherwise healthy; more than 50% of children with non-GABHS necrotizing fasciitis have at least one risk factor.
Risk factors: Antecedent varicella infection (with GABHS-related cases); recent surgery or trauma; intramuscular injection; chronic medical conditions (diabetes mellitus, malnutrition, obesity, immunosuppression). In neonates, circumcision, omphalitis, history of scalp electrode placement, necrotizing enterocolitis
Inoculation of bacteria into the subcutaneous tissues with resultant proliferation and release of destructive enzymes and exotoxins results in extensive tissue necrosis, thrombosis of blood vessels, and rapid progression along fascial planes.
Common: GABHS. Typically involves the groin or lower extremities.
Less common: Aerobic and nonaerobic organisms, including Staphylococcus aureus, anaerobic streptococci, group B Streptococcus, Proteus vulgaris, Escherichia coli, Pseudomonas aeruginosa, and Bacteroides fragilis. May be polymicrobial. Usually involves the abdominal wall, perianal or genital area, or a postoperative wound.
Cellulitis, erysipelas, pyoderma, staphylococcal scalded skin syndrome, toxic shock syndrome, burns
CLINICAL MANIFESTATIONS
Initial symptoms may be nonspecific and include localized pain, fever, chills, vomiting, pharyngitis, malaise, altered mental status, and myalgias.
Skin manifestations are toxin-mediated, are typically seen with GABHS-related necrotizing fasciitis, and present with erythematous ill-defined patch(es) or plaque(s).
Associated signs and symptoms include severe pain out of proportion to clinical findings, extreme tenderness involving both affected and clinically unaffected areas, numbness, edema, and murky dishwater-like discharge.
Rapid progression to purpuric patch(es) or plaque(s) with or without blistering, followed by the development of ulceration and gangrene. Crepitus may be appreciated in non-GABHS-related necrotizing fasciitis.
This systemic toxicity may include features of septic shock or, in the case of invasive GABHS, toxic shock syndrome with hypotension and multisystem organ failure.
Fournier's gangrene: Involvement of the genital and perianal area; typically polymicrobial
Clinical diagnosis requires high level of suspicion.
Cultures of blood, wound, and deep tissue (incisional biopsy)
Histologic examination of incisional biopsy reveals tissue necrosis.
CBC: Leukocytosis
CRP, ESR: Elevated
Metabolic panel: Hyponatremia, elevated blood urea nitrogen, metabolic acidosis, hypocalcemia, elevated serum creatine phosphokinase
Ultrasonography may show fascial thickening and fluid collections.
MRI is more sensitive than CT but may overestimate involvement; a negative MRI can exclude necrotizing fasciitis
Prompt surgical consultation and surgical exploration with wide excision of necrotic tissue; delay results in higher mortality. Surgical reexploration and repeat ...