Even Simple Exanthems Warrant Thorough Evaluation

Exanthems in children are often benign and self-limited, but not always.

In some cases – particularly those involving purpura, blisters, mucosal involvement, a high fever, or extracutaneous organ involvement – it is important to thoroughly evaluate the child for more serious disease, Dr. Anthony J. Mancini said at the seminar, sponsored by the Skin Disease Education Foundation (SDEF).

Dr. Mancini, head of the division of dermatology at the Ann and Robert H. Lurie Children’s Hospital of Chicago and professor of pediatrics and dermatology at Northwestern University, Chicago, provided tips for assessing the child presenting with an exanthem:

• If purpura is present, consider parvovirus, enterovirus, rickettsia, Neisseria meningitidis, Henoch-Schönlein purpura, and even group A strep.

• If edema is present, consider Kawasaki disease, serum sickness-like reactions (most often distal edema), or drug hypersensitivity syndrome (notable for facial edema, especially periorbitally).

• If an associated enanthem is present, consider Kawasaki disease, drug hypersensitivity, measles, rubella, enterovirus, parvovirus, adenovirus, group A strep, and Epstein-Barr virus (EBV).

• If conjunctivitis is present, consider Kawasaki disease, drug hypersensitivity, measles, and adenovirus (the most common mimicker of Kawasaki disease in children).

Parvovirus B19 Infection

Among the exanthems that Dr. Mancini discussed were those related to parvovirus B19 infection, including erythema infectiosum (fifth disease) and papular-purpuric gloves and socks syndrome. The latter entity is notable for symmetric swelling of the hands and feet, with palmoplantar purpuric erythema and a sharp demarcation at the wrists and ankles.

Children with gloves and socks syndrome may also present with enanthem of the soft and hard palate, and importantly, children with this exanthem may still be viremic (and hence contagious), compared with those who have classic fifth disease, he said.

Parvovirus B19 can also be associated with a bathing trunk eruption with petechiae, notable for accentuation in the flexures and a prominent petechial component. The infection was found to be the culprit in 13 of 17 children who presented with generalized petechial exanthems in a study based in Wisconsin, Dr. Mancini said. These exanthems also revealed accentuation in the fold areas, as well as the acral extremities. Fever was present in 85% of patients, and many had a history of mild upper respiratory symptoms. Additionally, most of the children (83%) had leukopenia (Pediatrics 2010;125:e787).

Breakthrough Varicella

Breakthrough varicella still occurs in a significant proportion of varicella vaccinees, especially in children from countries with a one-dose vaccination schedule, such as Taiwan.

This association is important to recognize, given that many practicing clinicians may have never seen acute varicella. The "dewdrop on a rose petal" presentation is characteristic, but lesions may also develop severe crusting or ulceration when secondary bacterial infection is present. Acute varicella may also accentuate in sites of trauma or sunburn, and has been termed "occult varicella," he noted.

Herpes zoster, caused by reactivation of latent varicella zoster virus (VZV) in the dorsal sensory or cranial nerve ganglia, is not unusual in healthy children and may be caused by either the wild type or vaccine strain of VZV, he said.

The greatest risk factor for having herpes zoster during childhood is a history of acute varicella under 1 year of age. Fortunately, postherpetic neuralgia following herpes zoster is rare in children.

Hand-Foot-and-Mouth Disease

Copyright MidgleyDJ/Wikimedia Commons

In a recent nationwide epidemic of severe hand-foot-and-mouth disease (HFMD), patients presented in clusters with fevers and a more widespread HFMD eruption than is characteristic of the self-limited disease, noted Dr. Mancini. Hospitalization was common, and blistering was prominent, with frequent perioral involvement and lesions on the arms and legs in nearly half of patients.

Of note, post-HFMD nail matrix arrest, first recognized by Dr. Mancini and his colleague (Pediatr. Dermatol. 2000;17:7-11), presents on average 40 days after exanthematous illness. Deep transverse ridges with nail shedding occur, more often affecting fingers than toes, and the process is self-limited with eventual spontaneous nail regrowth.

Gianotti-Crosti Syndrome

This syndrome was classically described in association with acute hepatitis B infection, although it is becoming exceedingly uncommon in the United States, where EBV appears to be the most common cause. Patients present with upper respiratory infection prodrome and monomorphous edematous papules on the cheeks, extensor extremities, and buttocks.

While the patient should be assessed for gastrointestinal symptoms, hepatosplenomegaly, lymphadenopathy, and hepatitis risk factors, blind hepatitis blood evaluations are not warranted in this country, Dr. Mancini said. The condition typically resolves in 3-12 weeks with supportive therapy.

Unilateral Laterothoracic Exanthem

Another atypical, parainfectious exanthem, unilateral laterothoracic exanthem, also known as "asymmetric periflexural exanthem," usually presents in children 1-5 years of age. It is initially unilateral in distribution, most often starting in the axilla or on the trunk or flank. At this stage, it may be misdiagnosed as contact dermatitis. The process eventually becomes more generalized, although it tends to maintain a unilateral predominance. Sixty percent of children have associated pruritus, Dr. Mancini said.

A prodrome occurs in 60%-75% of patients, and may include rhinitis, pharyngitis, and gastrointestinal complaints. Fever occurs in roughly 50% of patients, and while the etiology is unknown, it is believed to be a viral-associated exanthem. unilateral laterothoracic exanthem resolves over a 4- to 8-week period with supportive therapy.

Dr. Mancini reported having no relevant financial disclosures. SDEF and this news organization are owned by Frontline Medical Communications.

Exanthems in children are often benign and self-limited, but not always.

In some cases – particularly those involving purpura, blisters, mucosal involvement, a high fever, or extracutaneous organ involvement – it is important to thoroughly evaluate the child for more serious disease, Dr. Anthony J. Mancini said at the seminar, sponsored by the Skin Disease Education Foundation (SDEF).

Dr. Mancini, head of the division of dermatology at the Ann and Robert H. Lurie Children’s Hospital of Chicago and professor of pediatrics and dermatology at Northwestern University, Chicago, provided tips for assessing the child presenting with an exanthem:

• If purpura is present, consider parvovirus, enterovirus, rickettsia, Neisseria meningitidis, Henoch-Schönlein purpura, and even group A strep.

• If edema is present, consider Kawasaki disease, serum sickness-like reactions (most often distal edema), or drug hypersensitivity syndrome (notable for facial edema, especially periorbitally).

• If an associated enanthem is present, consider Kawasaki disease, drug hypersensitivity, measles, rubella, enterovirus, parvovirus, adenovirus, group A strep, and Epstein-Barr virus (EBV).

• If conjunctivitis is present, consider Kawasaki disease, drug hypersensitivity, measles, and adenovirus (the most common mimicker of Kawasaki disease in children).

Parvovirus B19 Infection

Among the exanthems that Dr. Mancini discussed were those related to parvovirus B19 infection, including erythema infectiosum (fifth disease) and papular-purpuric gloves and socks syndrome. The latter entity is notable for symmetric swelling of the hands and feet, with palmoplantar purpuric erythema and a sharp demarcation at the wrists and ankles.

Children with gloves and socks syndrome may also present with enanthem of the soft and hard palate, and importantly, children with this exanthem may still be viremic (and hence contagious), compared with those who have classic fifth disease, he said.

Parvovirus B19 can also be associated with a bathing trunk eruption with petechiae, notable for accentuation in the flexures and a prominent petechial component. The infection was found to be the culprit in 13 of 17 children who presented with generalized petechial exanthems in a study based in Wisconsin, Dr. Mancini said. These exanthems also revealed accentuation in the fold areas, as well as the acral extremities. Fever was present in 85% of patients, and many had a history of mild upper respiratory symptoms. Additionally, most of the children (83%) had leukopenia (Pediatrics 2010;125:e787).

Breakthrough Varicella

Breakthrough varicella still occurs in a significant proportion of varicella vaccinees, especially in children from countries with a one-dose vaccination schedule, such as Taiwan.

This association is important to recognize, given that many practicing clinicians may have never seen acute varicella. The "dewdrop on a rose petal" presentation is characteristic, but lesions may also develop severe crusting or ulceration when secondary bacterial infection is present. Acute varicella may also accentuate in sites of trauma or sunburn, and has been termed "occult varicella," he noted.

Herpes zoster, caused by reactivation of latent varicella zoster virus (VZV) in the dorsal sensory or cranial nerve ganglia, is not unusual in healthy children and may be caused by either the wild type or vaccine strain of VZV, he said.

The greatest risk factor for having herpes zoster during childhood is a history of acute varicella under 1 year of age. Fortunately, postherpetic neuralgia following herpes zoster is rare in children.

Hand-Foot-and-Mouth Disease

Copyright MidgleyDJ/Wikimedia Commons

In a recent nationwide epidemic of severe hand-foot-and-mouth disease (HFMD), patients presented in clusters with fevers and a more widespread HFMD eruption than is characteristic of the self-limited disease, noted Dr. Mancini. Hospitalization was common, and blistering was prominent, with frequent perioral involvement and lesions on the arms and legs in nearly half of patients.

Of note, post-HFMD nail matrix arrest, first recognized by Dr. Mancini and his colleague (Pediatr. Dermatol. 2000;17:7-11), presents on average 40 days after exanthematous illness. Deep transverse ridges with nail shedding occur, more often affecting fingers than toes, and the process is self-limited with eventual spontaneous nail regrowth.

Gianotti-Crosti Syndrome

This syndrome was classically described in association with acute hepatitis B infection, although it is becoming exceedingly uncommon in the United States, where EBV appears to be the most common cause. Patients present with upper respiratory infection prodrome and monomorphous edematous papules on the cheeks, extensor extremities, and buttocks.

While the patient should be assessed for gastrointestinal symptoms, hepatosplenomegaly, lymphadenopathy, and hepatitis risk factors, blind hepatitis blood evaluations are not warranted in this country, Dr. Mancini said. The condition typically resolves in 3-12 weeks with supportive therapy.

Unilateral Laterothoracic Exanthem

Another atypical, parainfectious exanthem, unilateral laterothoracic exanthem, also known as "asymmetric periflexural exanthem," usually presents in children 1-5 years of age. It is initially unilateral in distribution, most often starting in the axilla or on the trunk or flank. At this stage, it may be misdiagnosed as contact dermatitis. The process eventually becomes more generalized, although it tends to maintain a unilateral predominance. Sixty percent of children have associated pruritus, Dr. Mancini said.

A prodrome occurs in 60%-75% of patients, and may include rhinitis, pharyngitis, and gastrointestinal complaints. Fever occurs in roughly 50% of patients, and while the etiology is unknown, it is believed to be a viral-associated exanthem. unilateral laterothoracic exanthem resolves over a 4- to 8-week period with supportive therapy.

Dr. Mancini reported having no relevant financial disclosures. SDEF and this news organization are owned by Frontline Medical Communications.

Exanthems in children are often benign and self-limited, but not always.

In some cases – particularly those involving purpura, blisters, mucosal involvement, a high fever, or extracutaneous organ involvement – it is important to thoroughly evaluate the child for more serious disease, Dr. Anthony J. Mancini said at the seminar, sponsored by the Skin Disease Education Foundation (SDEF).

Dr. Mancini, head of the division of dermatology at the Ann and Robert H. Lurie Children’s Hospital of Chicago and professor of pediatrics and dermatology at Northwestern University, Chicago, provided tips for assessing the child presenting with an exanthem:

• If purpura is present, consider parvovirus, enterovirus, rickettsia, Neisseria meningitidis, Henoch-Schönlein purpura, and even group A strep.

• If edema is present, consider Kawasaki disease, serum sickness-like reactions (most often distal edema), or drug hypersensitivity syndrome (notable for facial edema, especially periorbitally).

• If an associated enanthem is present, consider Kawasaki disease, drug hypersensitivity, measles, rubella, enterovirus, parvovirus, adenovirus, group A strep, and Epstein-Barr virus (EBV).

• If conjunctivitis is present, consider Kawasaki disease, drug hypersensitivity, measles, and adenovirus (the most common mimicker of Kawasaki disease in children).

Parvovirus B19 Infection

Among the exanthems that Dr. Mancini discussed were those related to parvovirus B19 infection, including erythema infectiosum (fifth disease) and papular-purpuric gloves and socks syndrome. The latter entity is notable for symmetric swelling of the hands and feet, with palmoplantar purpuric erythema and a sharp demarcation at the wrists and ankles.

Children with gloves and socks syndrome may also present with enanthem of the soft and hard palate, and importantly, children with this exanthem may still be viremic (and hence contagious), compared with those who have classic fifth disease, he said.

Parvovirus B19 can also be associated with a bathing trunk eruption with petechiae, notable for accentuation in the flexures and a prominent petechial component. The infection was found to be the culprit in 13 of 17 children who presented with generalized petechial exanthems in a study based in Wisconsin, Dr. Mancini said. These exanthems also revealed accentuation in the fold areas, as well as the acral extremities. Fever was present in 85% of patients, and many had a history of mild upper respiratory symptoms. Additionally, most of the children (83%) had leukopenia (Pediatrics 2010;125:e787).

Breakthrough Varicella

Breakthrough varicella still occurs in a significant proportion of varicella vaccinees, especially in children from countries with a one-dose vaccination schedule, such as Taiwan.

This association is important to recognize, given that many practicing clinicians may have never seen acute varicella. The "dewdrop on a rose petal" presentation is characteristic, but lesions may also develop severe crusting or ulceration when secondary bacterial infection is present. Acute varicella may also accentuate in sites of trauma or sunburn, and has been termed "occult varicella," he noted.

Herpes zoster, caused by reactivation of latent varicella zoster virus (VZV) in the dorsal sensory or cranial nerve ganglia, is not unusual in healthy children and may be caused by either the wild type or vaccine strain of VZV, he said.

The greatest risk factor for having herpes zoster during childhood is a history of acute varicella under 1 year of age. Fortunately, postherpetic neuralgia following herpes zoster is rare in children.

Hand-Foot-and-Mouth Disease

Copyright MidgleyDJ/Wikimedia Commons

In a recent nationwide epidemic of severe hand-foot-and-mouth disease (HFMD), patients presented in clusters with fevers and a more widespread HFMD eruption than is characteristic of the self-limited disease, noted Dr. Mancini. Hospitalization was common, and blistering was prominent, with frequent perioral involvement and lesions on the arms and legs in nearly half of patients.

Of note, post-HFMD nail matrix arrest, first recognized by Dr. Mancini and his colleague (Pediatr. Dermatol. 2000;17:7-11), presents on average 40 days after exanthematous illness. Deep transverse ridges with nail shedding occur, more often affecting fingers than toes, and the process is self-limited with eventual spontaneous nail regrowth.

Gianotti-Crosti Syndrome

This syndrome was classically described in association with acute hepatitis B infection, although it is becoming exceedingly uncommon in the United States, where EBV appears to be the most common cause. Patients present with upper respiratory infection prodrome and monomorphous edematous papules on the cheeks, extensor extremities, and buttocks.

While the patient should be assessed for gastrointestinal symptoms, hepatosplenomegaly, lymphadenopathy, and hepatitis risk factors, blind hepatitis blood evaluations are not warranted in this country, Dr. Mancini said. The condition typically resolves in 3-12 weeks with supportive therapy.

Unilateral Laterothoracic Exanthem

Another atypical, parainfectious exanthem, unilateral laterothoracic exanthem, also known as "asymmetric periflexural exanthem," usually presents in children 1-5 years of age. It is initially unilateral in distribution, most often starting in the axilla or on the trunk or flank. At this stage, it may be misdiagnosed as contact dermatitis. The process eventually becomes more generalized, although it tends to maintain a unilateral predominance. Sixty percent of children have associated pruritus, Dr. Mancini said.

A prodrome occurs in 60%-75% of patients, and may include rhinitis, pharyngitis, and gastrointestinal complaints. Fever occurs in roughly 50% of patients, and while the etiology is unknown, it is believed to be a viral-associated exanthem. unilateral laterothoracic exanthem resolves over a 4- to 8-week period with supportive therapy.

Dr. Mancini reported having no relevant financial disclosures. SDEF and this news organization are owned by Frontline Medical Communications.