PEDIATRIC SKIN AND EYE PROBLEMS
| CHILDHOOD INFECTIOUS RASHES —Kristin S. Tate, MD, MPH, Attending Physician, St. Mary’s Health Center, Jefferson
City, MO
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| Exanthems: cutaneous (enanthems mucocutaneous); scaling rare; causes—viral; bacterial; rickettsial; parasitic; drug reactions
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| Measles (rubeola): contagious; due to paramyxovirus; spread by respiratory secretions; lasts ≈10 days; prodrome—can
last for nearly entire course of disease; patients contagious; fever; chills; malaise; significant conjunctivitis and upper and
lower respiratory symptoms; enanthem—pathognomonic; small (1-3 mm) bluish-white macules on mucus membranes
(eg, hard palate, buccal mucosa) surrounded by small red ring; usually occurs on first or second day of prodrome; lasts 1
to 2 days; associated with loss of appetite, pain, and dehydration; exanthem—occurs ≈2 days after onset of enanthem;
small faintly pink macules and papules quickly coalesce and form bright purplish-red plaques and patches (>0.5 cm);
starts on scalp, face, and neck and spreads downward (resolves in same sequence); treatment—supportive care; rest; fever
reduction; hydration; appropriate nutrition; vaporizers, antitussives, and respiratory isolation often necessary; first
dose of measles, mumps, and rubella (MMR) vaccine often combined with varicella vaccine
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| German measles (rubella): 3-day measles; rash similar to that of measles, but patients do not have systemic component
of illness; prodrome mild (eg, fever, headache, lymphadenopathy); due to togavirus; exanthem—small discrete pinkish-
red macules and papules start on face, scalp, and neck and spread to trunk and extremities within 24 hr; resolves in 3 to 5
days; treatment—treat symptoms; immunization; congenital forms—fetus can be infected during pregnancy; can cause
cardiac, neurologic, and ophthalmologic anomalies and deafness
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| Erythema infectiosum (fifth disease): due to parvovirus; spread by respiratory droplets; usually occurs in late winter
and early spring; most common in children 4 to 10 yr of age; patients not contagious once rash develops; prodrome—
mild; low-grade fever; headache; sore throat; anorexia; diarrhea; can last entire course of disease; first rash—slapped-
cheek appearance; erythematous lesions start as small papules and coalesce as plaques on cheeks bilaterally and on forehead
and chin; spares periorbital and nasal areas; lasts 1 to 4 days; second rash—reticular lacy rash; subtle; common on
torso and extensor surface of extremities; explain to parents that rash can last 2 to 3 wk; can recur with exercise, secondary
febrile episode, or exposure to heat and sunlight; symptomatic treatment
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| Roseola (sixth disease): due to herpesvirus; spread by secretions; usually seen in children <18 mo of age; prodrome—
high-grade fever can last 3 to 5 days; high risk for febrile seizures; cervical lymphadenopathy; mild upper respiratory
(UR) symptoms (eg, runny nose); dehydration; exanthem—rarely occurs at same time as prodrome; rosy pink macules
with tiny white halo; can coalesce into patches; macules begin on trunk and spread to neck, face, and extremities; blanchable;
not itchy or painful; fade quickly; treatment—antipyretics; fluids; supportive care
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| Hand, foot, and mouth disease: due to enterovirus (coxsackie A16; some cases caused by enterovirus 71); occurs in
late summer and early fall; most common in children 4 to 12 yr of age; spread by oral-oral route and fecal-oral route;
prodrome—lasts 12 to 36 hr; mild; low-grade fever; malaise; anorexia; sore throat; cough; enanthem—precedes exanthem;
erythematous; macules and papules; occurs on oral cavity (eg, hard palate, tongue, buccal mucosa); lesions start
small (2-3 mm) but can coalesce into larger patches and plaques; vesicles form briefly on erythematous macules and papules
and often break down before visualized on examination (shallow, yellowish-gray ulcer with small erythematous halo
develops); resolves within 5 to 7 days; exanthem—erythematous; macules and papules 2 to 8 mm; central gray vesicle
covers nearly entire macule or papule; lesions appear elliptical and tend to occur along or parallel to skin lines; can be asymptomatic
or painful; enanthem more painful than exanthem; some lesions may occur on genital area, trunk, or face;
more often on sides of fingers than on palms; more often on dorsal surface of feet than on plantar surface; resolves in ≈10
days; treatment—hydration; topical oral rinses; analgesics; antipyretics
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| Herpangina: due to coxsackievirus and enterovirus; patients develop enanthem as seen in hand, foot, and mouth disease,
but rarely develop exanthem; occurs in late summer and early fall; seen in infants and children <5 yr of age; prodrome—
fever; malaise; headache; enanthem—papulovesicles; lesions 1 to 2 mm with erythematous rim and gray-whitish ulcer;
vesicular stage brief; occurs on tonsillar pillars, soft palate, and uvula; less common on buccal mucosa and tongue; symptomatic
and supportive care
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| Chickenpox: spread by respiratory secretions; infectious from 2 days before onset of rash through crusting of lesions;
50% of patients <5 yr of age, most patients <15 yr of age; occurs in late winter months; exanthem—papules (2-4 mm)
quickly form vesicles; fluid inside teardrop-shaped vesicle becomes cloudy, and vesicle umbilicates, ruptures, and crusts
over in 8 to 12 hr (patient usually scratches off vesicle due to itching); begins on trunk and spreads to face and extremities;
when enanthem occurs, it occurs at same time as exanthem; treatment—reduce fever; most sedating antihistamines
more effective at preventing itching than nonsedating forms; supportive care (eg, cool water soaks and colloidal oatmeal
baths); antiviral agents should be used only within 24 hr of onset of rash (American Academy of Pediatrics advises use
only in immunocompromised patients); vaccination—can be given to patients up to 18 mo of age and available with
MMR vaccine (ProQuad); in patients who received MMR vaccine but not varicella vaccine (Varivax), wait 20 to 30 days
before giving Varivax to avoid cross-reactivity; if child 19 mo to 12 yr of age and has not yet received varicella-zoster
immunization, single dose of Varivax acceptable; if child >13 yr of age, give 2 doses (4-8 wk apart); contraindications include
breast-feeding, being immunocompromised, and allergy to neomycin; warn patients to avoid pregnancy for 3 mo
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| Infectious mononucleosis: in young children, presentation usually atypical (ie, no exanthem); more common in adolescents;
prodrome—significant; high-grade fever; malaise; fatigue; myalgia; exudative pharyngitis; lymphadenopathy
(primarily cervical); splenomegaly; hepatomegaly; exanthem—occurs in ≈15% of patients; red macules and papules; occurs
on fourth day of illness; begins on trunk and upper arms and spreads to face and other areas; more common in patients
with concurrent streptococcal infection and patients taking penicillin- or ampicillin-based antibiotic
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| Unilateral laterothoracic exanthem of childhood: also known as asymmetric periflexoral exanthem of childhood;
viral etiology suspected; more common in girls than boys; prodrome rare; discrete, red, tiny (1 mm), pinpoint papules
with pale halo grow and develop into eczematous patches with scaling; appears similar to guttate psoriasis or
pityriasis, but distribution and secondary findings different; begins in axilla or groin and spreads to trunk and extremities;
bilateral after 1 to 2 wk; lasts 4 to 6 wk; treatment—antihistamines; bland emollients
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| Gianotti-Crosti syndrome: papular acrodermatitis of childhood; occurs in infants and young children; etiology unclear;
initially frequently seen with hepatitis B (can be seen with different viruses and bacteria); prodrome—high fever;
UR symptoms; exanthem—flat-topped pinkish-brown papules and plaques (1-10 mm); small overlying vesicle may
form; no pruritus; symmetric; occurs on cheeks, buttocks, and extremities (rarely on trunk); lasts 2 to 3 wk (may last up to
8 wk); lymphadenopathy; hepatomegaly; splenomegaly; treatment—supportive care; bland emollients
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| Papular purpuric gloves and socks syndrome: associated with parvovirus; occurs in late adolescence or early
adulthood; occurs in spring or summer; prodrome—fever; myalgia; arthralgia; significant anorexia, fatigue, and lymphadenopathy;
patients do not appear toxic or ill; exanthem—confluent redness and edema of hands and feet; macules,
papules, and patches can become petechial and purpuric; fine scaling; painful; pruritic; rarely extends beyond wrists and
ankles; resolves in 1 to 2 wk; enanthem—diffuse redness; petechiae on palate, pharynx, tongue, or inner lip mucosa; abscess,
ulcers, or erosions; more painful than exanthem
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| Scarlet fever: due to group A Streptococcus; spread by respiratory droplets; incubation 2 to 5 days; prodrome—red
painful pharyngitis; fever; headache; fatigue; abdominal pain; nausea; vomiting; enanthem—strawberry tongue (patchy
white exudates coat tongue and tonsils on background of bright red erythema; papillae swollen and red); exanthem—
usually occurs within 48 hr of prodrome; simultaneous to enanthem in most patients; bright red pinpoint (1-3 mm) papules;
lesions start on trunk; predominance and predilection for skin folds (eg, axilla); papules difficult to see on certain
skin tones and have sandpaper-like texture; diagnosis—physical examination; rapid streptococcal testing (if negative,
consider testing for infectious mononucleosis); throat cultures; adequate test samples prevent false-negative results;
treatment—penicillin; erythromycin; macrolides; cephalosporins; educate and talk with parents; do not use penicillin or
ampicillin if infectious mononucleosis suspected
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| PEDIATRIC OCULAR CONDITIONS —Kim Lynette Cooper, MD, Community Faculty, Department of Ophthalmology,
Lucile Packard Children’s Hospital, Palo Alto, CA
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| Possible causes of symptoms: red eye—trauma; chemicals; nonaccidental injuries; infections; allergies; systemic
conditions; itchiness—allergies; scratchiness or pain—foreign body; burning—problem associated with eyelid, conjunctiva,
or cornea; localized tenderness—styes; chalazia; insect bites; trauma; severe pain or photophobia—abrasion;
iritis; consider acute glaucoma (angle-closure glaucoma occurs in children with microophthalmia)
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| Hordeolum: treatment—promote drainage; warm compresses for 10 to 15 min, 3 times daily; if hordeolum does not
drain immediately, decrease inflammation with combination of antibiotic and steroid ointment, eg, dexamethasone and
tobramycin (TobraDex), on eyelid only (to avoid risk for infection and glaucoma, do not apply in eye); refer to ophthalmologist
for surgical removal; prevention—scrub eyelashes with baby shampoo once daily; antibiotic ointment for severe
cases
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| Conjunctivitis: pink eye; caused by bacteria, viruses, allergies, or chemicals; rarely caused by dry eye in children, unless
child underwent chemotherapy or radiation therapy to head and neck or has Riley-Day syndrome; look at pattern and timing
of pink eye; check for UR symptoms and exposure to other children in day care centers; questions to ask—1) how old is patient?
if patient <4 wk of age, examine infant to rule out neonatal conjunctivitis; obtain cultures (including viral and chlamydial
cultures) before starting empiric therapy; 2) does patient wear contact lenses? if yes, advise patient to remove contact
lenses, place in case, and take them to ophthalmologist that day to rule out corneal ulcer; 3) does patient have history of juvenile
rheumatoid arthritis? if yes, consider iritis or inflammation in front of eye; refer to ophthalmologist; 4) what does discharge
look like? if dark yellow, green, or purulent and eye sealed shut, bacterial infection likely (treat with topical antibiotic);
if stringy and white, consider allergy; if clear, consider virus, chemicals, or allergy; Neisseria infection presents as copious
amounts of purulent white pus; neonatal conjunctivitis—can be caused by gonorrhea, Staphylococcus, Streptococcus, Haemophilus
influenza, Pseudomonas, Chlamydia, herpesvirus, or adenovirus; examine and obtain cultures; obtain history (eg,
premature rupture of membranes) from mother; treat parents; wear gloves; studies conclude empiric ophthalmic antibiotic
therapy may be appropriate in children with dark green pus discharge and eyes sealed shut; question diagnosis or therapy if
child does not respond to treatment; gentamicin and tobramycin drops and aminoglycosides effective, but high doses can result
in corneal toxicity; fourth-generation fluoroquinolones 3 times daily for 5 days effective
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| Adenoviral conjunctivitis: 6-day pharyngoconjunctival fever—sore throat; earache; runny nose; cough; symptoms of
common cold; contagious for first 1 to 2 days; 25% of time, patients present with pink eye first, then develop other symptoms
within 24 hr; 6-wk epidemic keratoconjunctivitis—can lead to corneal infiltrates and photophobia (treat with steroids);
prevent transmission by hand-washing; treat foreign-body sensation with artificial tears, cool compresses, and ice
packs (eg, frozen uncooked “rice packs”)
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| Acute hemorrhagic conjunctivitis: rare; no history of trauma, nausea, or vomiting; patient bleeds from eye; usually
bacterial or viral infection; obtain culture and start fluoroquinolone; usually resolves within 2 days
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| Herpes conjunctivitis: comanage with ophthalmologist; oral acyclovir and topical antiviral agent 9 times daily; children
taking oral acyclovir must stay hydrated to avoid nephritis; recurrence in visual axis can cause scarring (children
<10 yr of age may need prophylaxis with oral acyclovir); applying steroids on herpetic ulcer can cause corneal melting in
<2 hr (do not use steroids in eye unless “you have a slit lamp and [are] very experienced”)
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| Allergic conjunctivitis: seasonal—itchy; due to allergen; self-limited; hyperemia; chemosis; eyelid edema; white
stringy discharge or clear tears; identify and remove offending allergen; educate parents and families about, eg, washing
hair at bedtime and changing pillowcases every night; use cold washcloth or rice packs; artificial tears; medications; allergy
testing; episodes of corneal melting after cataract surgery reported with generic nonsteroidal anti-inflammatory
drugs; steroids should not be used without ophthalmologic support; mast cell inhibitors effective (give once daily for 2-3
wk; if symptoms return, repeat course and consider perennial conjunctivitis); perennial—lasts all year; symptoms similar
to seasonal conjunctivitis but can be exacerbated during seasonal allergy outbreaks; patients may require mast cell inhibitors
all year long; vernal keratoconjunctivitis—long stringy discharge; severe itchiness; light sensitivity; foreign-
body sensation; mucus; photophobia; cobblestone appearance of papillae can lead to sterile shield ulcer or corneal scarring;
patients need lubrication, patching, and topical steroids
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| Corneal abrasions: symptoms—redness; tearing; pain; photophobia; decreased vision; treatment—relieve pain; prevent
infection; promote healing; keep eyelid closed; topical anesthetic drops (eg, tetracaine) effective in 20 sec and last
20 min; stain cornea and use Wood’s lamp or blue lamp to check for epithelial defect (document by drawing); because
patients develop traumatic iritis, apply cyclopentolate drop to improve light sensitivity and pain (inform parents about dilating
child’s eye); apply antibiotic ointment; patching—1) speaker patches eyes of children <6 mo of age and >6 yr of
age; consider helping child sleep, with, eg, acetaminophen with codeine (eg, Tylenol with Codeine Elixir); after 24 hr,
check for retained foreign body (remove by asking patient to look down and flip eyelid), ulcers, and “things that don’t
heal”; if no improvement, refer to ophthalmologist; 2) evidence-based studies conclude that treating corneal abrasion
with patch does not improve healing rates on first day and does not reduce pain; patches reduce binocular vision; further
research should be done on large (>10 mm) abrasions; tell patients to leave patch on and to return in 24 hr; corneal
ulcers—iris structures unclear (eg, edge of pupil obstructed); do not patch; refer to ophthalmologist for topical antibiotics
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| Strabismus: eyes not straight; child sees double and “turns off” one eye, preventing normal development of eye
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| Amblyopia: decreased vision; problem in brain; children often look normal; 1) strabismic; eyes crossed; 2) anisometropic;
one eye has different refractive error than other eye; 3) deprivation; light fails to reach back of eye; check visual
acuity in children <2 yr of age by putting finger in front of one eye, then put in front of other eye (sign of better vision in
one eye when child pushes hand away or turns head); treatment—clear media of, eg, cataract; treat hemangioma; treat
ptosis; focus image; occlude good eye to improve vision in other eye; early screening critical; vision should be normal for
age; correct refractive error first with glasses; check vision again before patching; goals—equal vision in both eyes; minimum
of 20/40 in bad eye; if cannot reach 20/40 or better, discuss monocular precautions and glasses; recurrence rate
25% with abrupt discontinuation of patching after amblyopia corrected (observe and follow children until 11 yr of age);
25% of children 11 to 17 yr of age who were never previously treated improved vision with glasses and patching; repeat
screening and refer for comprehensive examination; ask about positive family history (parental) of 1) crossed eyes; 2)
crooked eye; 3) lazy eye; 4) patching as child; 5) eye muscle surgery; 6) wearing glasses at young age; if family history
positive, child at increased risk (refer by 1 yr of age)
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Suggested Reading
Aber C et al: Fever and rash in a child: when to worry? Pediat Ann 36:30, 2007; Campos-Outcalt D: Varicella vaccination:
2 doses now the standard. J Fam Pract 57:38, 2008; Dyer JA: Childhood viral exanthems. Pediatr Ann 36:21,
2007; Guirguis-Blake J: Patching for corneal abrasions? Am Fam Physician 74:1857, 2006; Hussein MA et al: Risk
factors for treatment failure of anisometropic amblyopia. J AAPOS 8:429, 2004; Millichap JG et al: Role of viral infections
in the etiology of febrile seizures. Pediatr Neurol 35:165, 2006; Rose PW et al: Why do general practitioners prescribe
antibiotics for acute infective conjunctivitis in children? Qualitative interviews with GPs and a questionnaire survey
of parents and teachers. Fam Pract 23:226, 2006; Segura Saint-Gerons R et al: Papular purpuric gloves and socks
syndrome. Presentation of a clinical case. Med Oral Patol Oral Cir Bucal 12:E4, 2007; Swamy BN et al: Topical non-
steroidal anti-inflammatory drugs in allergic conjunctivitis: meta-analysis of randomized trial data. Ophthalmic Epidemiol
14:311, 2007; Weakley DR: The association between anisometropia, amblyopia, and binocularity in the absence of strabismus.
Trans Am Ophthalmol Soc 97:987, 1999.
Educational Objectives
| The goal of this program is to improve the management of infectious rashes and eye problems in children. After hearing
and assimilating this program, the clinician will be better able to:
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 | 1. Recognize rashes, such as German measles and erythema infectiosum, based on characteristics of the exanthem.
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| 2. Determine most effective treatment for chickenpox, such as antiviral agents or antihistamines.
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| 3. Identify bacterial or viral agents that commonly cause rash in children.
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| 4. Distinguish forms of conjunctivitis, based on clinical findings and treatment options.
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| 5. Improve prognosis of corneal abrasions and vision-threatening conditions such as amblyopia.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and planning committee
members to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of
interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and
not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Cooper is on the
Speakers’ Bureau for Alcon Laboratories, Inc. Dr. Tate and the planning committee reported nothing to disclose.
Acknowledgements
Drs. Tate and Cooper were recorded in Chicago, IL, at the 2007 Scientific Assembly, presented October 3-6, 2007, by the
American Academy of Family Physicians. The Audio-Digest Foundation thanks the speakers and the American Academy
of Family Physicians for their cooperation in the production of this program.
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