Superficial peds infections abound

At the 63rd Annual Meeting of the American Academy of Dermatology (AAD) here, Tania F. Cestari, M.D., Ph.D., offered insight into the diagnosis of common pediatric cutaneous infections and infestations.

Varied manifestations While superficial cutaneous infections and infestations are among the most common pathologies affecting children, their manifestations vary from patient to patient and can sometimes mimic other skin diseases, making diagnosis sometimes challenging, according to Dr. Cestari, associate professor of dermatology, professor of the post graduation course of pediatrics at the University of Rio Grande do Sul in Porto Alegre, Brazil.

"Be aware of the so-called 'exotic diseases,' and increase the index of suspicion of superficial infections," Dr. Cestari recommends.

Increased mobility across international borders has "spread many disorders that cannot be considered rare anymore. Some take a long time to show clinical symptoms but still should be considered," according to Dr. Cestari, coordinator of the pediatric dermatology department of the Brazilian Society of Dermatology.

Leprosy Dr. Cestari considers leprosy to be "an ancient disease that is an important public health problem in many countries." Children under 12 years of age account for 12 percent of all leprosy cases, according to Dr. Cestari. Diagnosis is complicated by a long (three- to five-year) incubation period, and she says initial cases of leprosy are often misdiagnosed as pityriasis alba or hypochromic nevus.

"Remember that any skin disease with alteration in the superficial sensibility pattern - from hyper- to hyposensibility - should raise the suspicion of leprosy. The only skin disorder accompanied by neural enlargement is leprosy," she explains.

"Leprosy is a curable disorder, but a delay in diagnosis and treatment raises the chance of lifetime disabilities."

She advises a skin smear or biopsy to confirm leprosy diagnosis.

Scabies It is often possible for scabies in children to be misdiagnosed as eczema and treated as such. Dr. Cestari says such an erroneous determination and "uncontrolled use of corticosteroids leads to a chronic circle of an increasing number of parasites and a diminishing inflammatory reaction, disguising the correct etiology."

She was able to help a 3-month-old infant who had presented with crusts and erythema in the scalp and on the trunk. (See photo). After five weeks of treatment with a potent topical corticosteroid that was prescribed by the patient's primary care physician, the baby was hospitalized with very high levels of serum cortisol, and was undernourished and agitated.

Dr. Cestari treated the baby with repeated applications of permethrin, and the condition improved dramatically. She says extensive scabies cases such as this one can be difficult to treat in pediatric patients because the preferred, first-line therapy - ivermectin (Stromectol, Merck) - is an oral agent and not suitable for young children. Her usual treatment regimen includes removal of crusts and debris, administration of antiseptic baths and application of topical permethrin. She also monitors electrolyte and cortisol levels.

She notes the importance of isolating the scabies patient to prevent further contamination, and suggests treating the patient's close relatives with oral ivermectin and topical permethrin.

Awareness of other disorders Two pyodermas - impetigo and erysipelas - are particularly challenging to diagnose in children.

"Common impetigo could assume a trichophytid aspect," Dr. Cestari says, citing quick-drying crust and friction from clothing as reasons why vesicles and erythema can concentrate at the borders of aggregated lesions.