Dermatology

A 7-year-old boy was brought for evaluation of a nonpruritic, nonpainful, evolving polymorphic rash that began on the torso and spread to the extremities, face, palms, and soles over a 2-week period. He had been otherwise healthy and had no history of constitutional symptoms.

Circumscribed erythematous lesions developed on the back and abdomen of this 19-month-old boy. The rash was mildly pruritic. The parents gave the child 1 dose of diphenhydramine, and the rash resolved after an hour. About 12 hours later, new lesions developed on the face, neck, and upper back. The child was given the same treatment and the symptoms resolved. The following morning, widespread lesions were noted on the child's face, neck, trunk, and extremities.

It was hit by two hurricanes in September 2008 -- one literal and one financial -- but the Shriners Hospital for Children in Galveston will be reopening.

A 7-month-old child appears at the derm office with a blistering eruption that started six days before on her face and neck, and has spread to trunk and extremities.

The parents of this 6-year-old girl expressed concern about a yellow-brown arciform plaque on their daughter's cheek that has been present since birth. Although it has remained stable throughout her early childhood, her parents wonder whether it may become cancerous later on. Would you recommend removing the lesion?

Although it has been more than 40 years since Kawasaki disease was first described, it is still something of a medical mystery.

In his Dermclinic case in the March 2009 issue of CONSULTANT FOR PEDIATRICIANS (page 77), Dr Kirk Barber discusses juvenile plantar dermatosis (JPD). A very simple treatment for this condition is the use of a home foot spa, in which wax is melted and the foot immersed according to the directions included with the device. Following the wax immersion procedure, the patient should apply a good lotion. JPD can be remedied or at least controlled with this treatment.

A 5-month-old Asian boy was brought for evaluation of hair loss and a red, scaly rash on the scalp and body. The rash had not responded to hydrocortisone 2.5% ointment. There was a family history of asthma, food allergies, and allergic rhinitis. His mother had Hashimoto thyroiditis.

Asthma exacerbations continue to cause a significant number of emergency care visits and hospitalizations among children.1 In “Managing Asthma in Children, Part 1” (CONSULTANT FOR PEDIATRICIANS, May 2009, page 168), we reviewed the epidemiology, risk factors, and diagnosis of asthma in children. We also discussed how to make an initial assessment of asthma severity. In Part 2, we review the key components of treatment.

This white patch in the medial periorbital area of a 15-year-old girl had been present for several months. It was asymptomatic. The patient denied having had an injury to the area. Results of a potassium hydroxide preparation of a skin smear and fungus culture were negative. She had no history of other hypopigmented lesions and was otherwise healthy. There was no family history of vitiligo or autoimmune disease.

An itchy rash developed around the nose in this 8-year-old boy. At first it responded to the application of a midstrength corticosteroid cream. However, the rash returned promptly after the cream was stopped and then spread to the perioral area. It is no longer responding to treatment with the topical corticosteroid that initially was effective.

A 5-month-old girl with progressively worsening generalized rash of 3 weeks’ duration. No obvious sensitivity, fever, recent infection, medication use, or known contact with irritant.

A 14-year-old girl with systemic lupus erythematosus (SLE) was evaluated for worsening left leg pain of 1 week’s duration. A month earlier, she had presented with left knee arthritis and a vasculitic rash; the antinuclear antibody titer was positive. In addition, she had leukopenia, myositis, hypocomplementemia, and mild proteinuria.

A collection of web links about hair conditions, from a variety of dermatology resources.

A 7-month-old boy is brought in with brown warty plaques on his faces, along the lines of Blaschko.

Asthma is one of the most prevalent chronic diseases in the United States, and most medical practitioners encounter patients with asthma on a daily basis. The goal of this 2-part article is to discuss the diagnosis and management of asthma in children younger than 12 years. In part 1, we will briefly outline the epidemiology, pathophysiology, and risk factors; then we will review, in more detail, the diagnosis of asthma and the initial evaluation of asthma severity.

For 2 days, a 17-year-old boy had a widespread pruritic eruption that involved the trunk and extremities but spared most of the face. Many of the lesions were annular, and they would appear and resolve within 1 day. The patient denied shortness of breath, difficulty in swallowing, and periorbital swelling.

A toddler comes into the office with a hemorrhagic red papule.

The father of a 10-year-old boy was concerned about the asymptomatic rash on his son’s anterior thighs that had persisted for 9 months. The macular, reticular, erythematous rash hadevident hyperpigmentation bilaterally. The child had been otherwise healthy.

A 7-year-old boy with annular, asymptomatic, flesh-colored lesion onthe wrist that had developed slowly over the past month. The parents hadremoved the child from school because they were told that the lesion wasringworm. The lesion had failed to resolve after application of an antifungalcream for 10 days.

A persistent, eczematous dermatitis had developed in the perioral area during the winter months in this 10-year-old boy. Topical corticosteroid creams had been tried, and these seemed to help some, but the ondition never really cleared. Because of the failure of the corticosteroid creams, a topical antifungal cream had also been tried; however, this, too, was of limited effectiveness.

An 18-month-old white boy is brought to his well-care visit by his parents, who are concerned that for the past month he has been less social and active. He has appeared weak and has refused to walk or play with his siblings. He has also had a decreased appetite and has lost about 2 kg. He has vomited several times but with no bile or blood.

This infant was noted to have a giant melanocytic nevus at birth. Giant congenital melanocytic nevi (GCMN) can be recognized not only by their increased size (greater than 20 cm) but also by their increased cellularity and ability to affect deep dermal layers and other subcutaneous tissue. 1-4 Acquired nevi generally do not permeate the deeper dermal layers. Occasionally, GCMN may result in dysplasia of intraepidermal nevus cells, inflammatory spread of nevus cells, and proliferative dermal nodules.1

Pityriasis rosea had been diagnosed in this 10-year-old boy 3 months earlier. However, the condition had not resolved within that time as had been predicted. In addition, the patient’s parents noted that pictures of pityriasis rosea that they had found on the Internet did not resemble their child’s skin.

HISTORYBaby boy born at full term via forceps-assisted vaginal delivery to a 17-year-old primigravida was noted to have left arm and chest anomalies. Apgar scores 9 at 1 minute and 9 at 5 minutes. No pregnancy complications except for low amniotic fluid index. Second trimester ultrasonogram showed no malformations. At birth, infant was vigorous. He tolerated feeding well and passed urine and stool appropriately. Results of a hearing screen and newborn metabolic screen were normal. No family history of genetic disorders.PHYSICAL EXAMINATIONClinically, infant was asymptomatic. Vital signs normal. Weight, height, and head circumference (3.040 kg, 50.8 cm, and 33 cm, respectively) appropriate for gestational age. He had a flat left upper chest, an abnormal and caudally displaced left nipple, hypoplasia of the muscles of the upper left shoulder girdle and arm, significant shortening and bowing of the left forearm, and left hand cutaneous syndactyly. The left thumb resembled a finger and was not opposable. Heart sounds heard best to the right of midline, corresponding to dextroposition of the heart. No heart murmurs. Remaining physical findings unremarkable.WHAT’S YOUR DIAGNOSIS?(Answer and discussion on next page)ANSWER: POLAND SYNDROMEPoland syndrome, also known as Poland sequence, is a rare congenital anomaly characterized by unilateral chest wall hypoplasia and ipsilateral anomalies of the upper extremity. The condition, first described by Dr Alfred Poland in 1841, was officially named in 1962 by Dr Patrick Clarkson, who reported on 3affected children. The incidence of Poland syndrome is 1 per 20,000 to 30,000; however, it is believed to be underreported. The syndrome is 3 times more likely in males than in females; the right side is favored over the left.1ETIOLOGYDiminished blood supply to the affected side secondary to developmental defects of the subclavian artery is the suspected cause of Poland syndrome. Maternal drug abuse during pregnancy has been reported.2,3 Most cases of Poland syndrome arise sporadically. Familial cases have been described, which suggests some degree of genetic transmission. However, a case of Poland syndrome in one identical twin has been reported.4CLINICAL MANIFESTATIONSThe minimum criterion needed for diagnosis is unilateral absence or hypoplasia of the sternal portion of the pectoralis major muscle. Other classic features on the ipsilateral side include: •Hypoplasia or aplasia of the breast and nipple. •Deficiency of subcutaneous fat and axillary hair. •Abnormalities of the rib cage. •Upper extremity anomalies, such as short arm and fingers as well as syndactyly.2It is not rare for infants with Poland syndrome to have all the classic features. Intelligence is not impaired in children with this syndrome.

The most common chronic medical problem that we pediatricians treat is asthma. We do our best to manage our patients’ asthma by prescribing controller medications, providing asthma action plans, and guiding families through acute exacerbations. We often ask about possible environmental triggers, such as tobacco smoke and cockroaches, and we advise patients to reduce their exposure to those triggers.

The lesion on the left forearm of this 20-month-old girl developed shortly after birth and gradually worsened. The toddler scratched the lesion daily. It bled on occasion. The mother vigilantly kept the baby’s nails short and administered an oral antihistamine regularly. There was a family history of chronic eczema.

A review of several recent medical journal articles of interest to pediatricians.

An 11-year-old comes into the office with an asymptomatic slowly progressive eruption that began 3 years prior. The problem is finally resolved with topical and/or systemic treatment.

A 12-year-old is brought into the office for a 10-month-old generalized itchy skin eruption.