Pediatric Facial Eruptions Flag Inadequate Nutrition : The typical rash associated with poor diet doesn't itch and may not respond to topical steroids.

PARK CITY, UTAH — Physicians should consider nutritional deficiencies when diagnosing facial eruptions in infants and children, according to Dr. Beth Drolet.

One of the more perplexing cases she described at a clinical dermatology seminar sponsored by Medicis was a 21/2-year-old child referred by emergency physicians for suspected Stevens-Johnson syndrome.

Dr. Drolet, medical director for dermatology at Children's Hospital of Wisconsin, Milwaukee, said the child had no history of health care or immunizations. He was brought to the hospital because of a severe rash and was found to have multiple deficiencies, including severe sensory polyneuropathy, photophobia, muscular atrophy, osteopenia, and speech and language defects.

“The child was only eating large french fries from McDonald's. He was getting enough calories, but not enough vitamins,” she said, reporting the parents said that was all he would eat. Although the boy's diet has been corrected, she reported he still has severe neuropathy and mental delay.

In another pediatric case, Dr. Drolet said that toxic epidermal necrolysis was suspected in a child with an “extremely smelly, flaky eruption.” It turned out the child had been diagnosed with a milk allergy and his diet was almost entirely Rice Dream, a nondairy beverage touted as a substitute for dairy milk.

Although Rice Dream is enriched with vitamins A, D, and B₁₂ and has comparable calcium to dairy milk, it provides little protein. Indeed, its label warns that it should not be used for infant formula or in children under 5 years of age without consulting a physician.

“This [Rice Dream] is not a bad thing if the child is getting other nutrition,” said Dr. Drolet, also of the Medical College of Wisconsin, Milwaukee.

Dr. Mark Davis of the Mayo Clinic in Rochester, Minn., described a similar case in a separate presentation on hospital dermatology at the meeting. In that case, a 2-year-old boy with rash and hair loss was diagnosed with kwashiorkor. This child also was on a Rice Dream diet, according to Dr. Davis, who emphasized the importance of history in making a diagnosis.

If a child has a nutritional deficiency, Dr. Drolet said, the facial eruption could be described by the following morphology: large plaques; large, thin scales; sharply demarcated, irregular, driplike borders; and superficial erosions.

The eruption is not itchy, she said, and it does not respond to topical steroids. The distribution is periorificial and widespread.

In addition, the child may have lackluster, hypopigmented hair with the “flag sign”—a band of lighter hair associated with nutritional deficiency.

“How does this happen in developed countries in 2006?” Dr. Drolet asked rhetorically, answering her own question with “real/perceived milk allergy, fad diets, behavioral problems, food preferences, [and] nutritional ignorance.”

Among the other nondermatologic causes of facial eruptions that could be considered when making a diagnosis, Dr. Drolet cited herpes, pediatric Horner syndrome, staphylococcus infection, juvenile idiopathic arthritis, neonatal lupus, irritable bowel disease, Crohn's disease, Henoch-Schönlein purpura, drug-induced hypersensitivity syndrome, dermoid cyst, and PHACE (posterior fossa brain malformations, hemangiomas of the face, arterial anomalies, cardiac anomalies, and eye abnormalities) syndrome.

PARK CITY, UTAH — Physicians should consider nutritional deficiencies when diagnosing facial eruptions in infants and children, according to Dr. Beth Drolet.

One of the more perplexing cases she described at a clinical dermatology seminar sponsored by Medicis was a 21/2-year-old child referred by emergency physicians for suspected Stevens-Johnson syndrome.

Dr. Drolet, medical director for dermatology at Children's Hospital of Wisconsin, Milwaukee, said the child had no history of health care or immunizations. He was brought to the hospital because of a severe rash and was found to have multiple deficiencies, including severe sensory polyneuropathy, photophobia, muscular atrophy, osteopenia, and speech and language defects.

“The child was only eating large french fries from McDonald's. He was getting enough calories, but not enough vitamins,” she said, reporting the parents said that was all he would eat. Although the boy's diet has been corrected, she reported he still has severe neuropathy and mental delay.

In another pediatric case, Dr. Drolet said that toxic epidermal necrolysis was suspected in a child with an “extremely smelly, flaky eruption.” It turned out the child had been diagnosed with a milk allergy and his diet was almost entirely Rice Dream, a nondairy beverage touted as a substitute for dairy milk.

Although Rice Dream is enriched with vitamins A, D, and B₁₂ and has comparable calcium to dairy milk, it provides little protein. Indeed, its label warns that it should not be used for infant formula or in children under 5 years of age without consulting a physician.

“This [Rice Dream] is not a bad thing if the child is getting other nutrition,” said Dr. Drolet, also of the Medical College of Wisconsin, Milwaukee.

Dr. Mark Davis of the Mayo Clinic in Rochester, Minn., described a similar case in a separate presentation on hospital dermatology at the meeting. In that case, a 2-year-old boy with rash and hair loss was diagnosed with kwashiorkor. This child also was on a Rice Dream diet, according to Dr. Davis, who emphasized the importance of history in making a diagnosis.

If a child has a nutritional deficiency, Dr. Drolet said, the facial eruption could be described by the following morphology: large plaques; large, thin scales; sharply demarcated, irregular, driplike borders; and superficial erosions.

The eruption is not itchy, she said, and it does not respond to topical steroids. The distribution is periorificial and widespread.

In addition, the child may have lackluster, hypopigmented hair with the “flag sign”—a band of lighter hair associated with nutritional deficiency.

“How does this happen in developed countries in 2006?” Dr. Drolet asked rhetorically, answering her own question with “real/perceived milk allergy, fad diets, behavioral problems, food preferences, [and] nutritional ignorance.”

Among the other nondermatologic causes of facial eruptions that could be considered when making a diagnosis, Dr. Drolet cited herpes, pediatric Horner syndrome, staphylococcus infection, juvenile idiopathic arthritis, neonatal lupus, irritable bowel disease, Crohn's disease, Henoch-Schönlein purpura, drug-induced hypersensitivity syndrome, dermoid cyst, and PHACE (posterior fossa brain malformations, hemangiomas of the face, arterial anomalies, cardiac anomalies, and eye abnormalities) syndrome.

PARK CITY, UTAH — Physicians should consider nutritional deficiencies when diagnosing facial eruptions in infants and children, according to Dr. Beth Drolet.

One of the more perplexing cases she described at a clinical dermatology seminar sponsored by Medicis was a 21/2-year-old child referred by emergency physicians for suspected Stevens-Johnson syndrome.

Dr. Drolet, medical director for dermatology at Children's Hospital of Wisconsin, Milwaukee, said the child had no history of health care or immunizations. He was brought to the hospital because of a severe rash and was found to have multiple deficiencies, including severe sensory polyneuropathy, photophobia, muscular atrophy, osteopenia, and speech and language defects.

“The child was only eating large french fries from McDonald's. He was getting enough calories, but not enough vitamins,” she said, reporting the parents said that was all he would eat. Although the boy's diet has been corrected, she reported he still has severe neuropathy and mental delay.

In another pediatric case, Dr. Drolet said that toxic epidermal necrolysis was suspected in a child with an “extremely smelly, flaky eruption.” It turned out the child had been diagnosed with a milk allergy and his diet was almost entirely Rice Dream, a nondairy beverage touted as a substitute for dairy milk.

Although Rice Dream is enriched with vitamins A, D, and B₁₂ and has comparable calcium to dairy milk, it provides little protein. Indeed, its label warns that it should not be used for infant formula or in children under 5 years of age without consulting a physician.

“This [Rice Dream] is not a bad thing if the child is getting other nutrition,” said Dr. Drolet, also of the Medical College of Wisconsin, Milwaukee.

Dr. Mark Davis of the Mayo Clinic in Rochester, Minn., described a similar case in a separate presentation on hospital dermatology at the meeting. In that case, a 2-year-old boy with rash and hair loss was diagnosed with kwashiorkor. This child also was on a Rice Dream diet, according to Dr. Davis, who emphasized the importance of history in making a diagnosis.

If a child has a nutritional deficiency, Dr. Drolet said, the facial eruption could be described by the following morphology: large plaques; large, thin scales; sharply demarcated, irregular, driplike borders; and superficial erosions.

The eruption is not itchy, she said, and it does not respond to topical steroids. The distribution is periorificial and widespread.

In addition, the child may have lackluster, hypopigmented hair with the “flag sign”—a band of lighter hair associated with nutritional deficiency.

“How does this happen in developed countries in 2006?” Dr. Drolet asked rhetorically, answering her own question with “real/perceived milk allergy, fad diets, behavioral problems, food preferences, [and] nutritional ignorance.”

Among the other nondermatologic causes of facial eruptions that could be considered when making a diagnosis, Dr. Drolet cited herpes, pediatric Horner syndrome, staphylococcus infection, juvenile idiopathic arthritis, neonatal lupus, irritable bowel disease, Crohn's disease, Henoch-Schönlein purpura, drug-induced hypersensitivity syndrome, dermoid cyst, and PHACE (posterior fossa brain malformations, hemangiomas of the face, arterial anomalies, cardiac anomalies, and eye abnormalities) syndrome.