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28 Clinical Rounds



November 2008

Other Conditions May Mimic Diaper Dermatitis


Southeast Bureau

— seemingly simple case of diaper dermati- tis, because this near-ubiquitous condition can mask something much more serious. In fact, there are at least four “zebras” whose hoofbeats may be sounding in dia- per dermatitis, Dr. Sheila Fallon Friedlan- der said at a meeting sponsored by Skin Disease Education Foundation (SDEF). That’s why diaper dermatitis should be treated. Failure to respond to treatment may be your first hint that something un- usual is happening. Zinc deficiency is the first of these ze- bras. The baby will present with dermati- tis in an acral distribution: hands, feet, face, and genitals. The parent will often men- tion that the baby has diarrhea and is not growing as well as she should. If you suspect a zinc deficiency, look at al- kaline phosphatase while you’re waiting for zinc levels to come back from the lab. A low alkaline phosphatase level should make you suspicious of zinc, said Dr. Friedlander of the University of California, San Diego. Remember to check with your lab about their procedures for zinc analysis. They’ll

Don’t ignore a



want you to use a special collection tube. Langerhans cell histiocytosis (LCH) is the next zebra. Thought by many to be a clon- al proliferative disorder, LCH has a wide variability in presentation and prognosis. Dr. Friedlander described one case in which the baby had rashes in his inter- triginous areas. Her first thought was Can- dida and, indeed, antifungals seemed to help a little bit. Adding topical steroids helped a little bit more, but the rashes nev- er fully cleared up. On top of that, the mother was noticing some small pink papules elsewhere on the baby’s body. Upon questioning, the mother noted that the baby wasn’t growing very well and also was experiencing some vomiting and diarrhea. When Dr. Friedlander did a physical exam, she noticed that the baby’s liver was enlarged. (Other babies with LCH have enlarged spleens.) And those pink papules? Those were purpuric papules of petechiae. “When you see that, you need to see Red Alert,” Dr. Friedlander said. “You have scaly papules; hemorrhagic, pur- puric, petechial lesions; and paronychial in- volvement. This is a devastating zebra sometimes.” LCH sometimes looks like seborrheic dermatitis, but the physician’s

job is to recognize it and refer the child to a pediatric oncologist. The third zebra goes by the unwieldy name “recurrent toxin-mediated perineal erythema.” Dr. Friedlander described one little girl with a recurrent red, scaly erup- tion in her groin area that never respond- ed to the typical diaper dermatitis treat- ments. The mother mentioned that the eruption often was accompanied by fever and a red tongue. “Well, certainly when we see a red tongue, we think of a toxin-mediated dis- order,” she said. “We think of strep throat, we think of staph, right? [We have to] make sure that [there’s] nothing more se- rious going on. If the patient is febrile and looks sick, you need to get blood culture; you need to get a [sedimentation] rate. And, certainly, get cultures of the pharynx, the perianal area, and lesional skin.” In a recently published case series, all 11 children had positive strep cultures, and one was positive for Staphylococcus aureus as well. Four of the children had erythe- ma and desquamation of the palms and soles, and seven had strawberry tongues (Arch. Dermatol. 2008;144:239-43). Of all the zebras, Kawasaki disease is the one you least want to miss. “If you rec-

ognize it early, you can save a life,” Dr. Friedlander said. “You can be the hero.” The first hint often is a red perianal rash. Start worrying if you learn that the child has had a high fever for 4 or 5 days, has a straw- berry tongue, and is unusually crabby. The child with Kawasaki disease will of- ten have conjunctivitis but of a specific type. The eye will not be purulent, and there won’t be an exudate. And if you look closely, you may see that the conjunctivi- tis is sparing the limbus—the area where the cornea meets the sclera. The child may have cervical lymphadenopathy, and the rash can be variable. “It’s pretty much a polymorphous eruption, but [it doesn’t] blister,” she said. Two lab values can be especially note- worthy in Kawasaki disease. The C-reactive protein level will be 3 mg/dL or higher, and the sedimentation rate will be 40 mm/hr or more. You also should order labs to rule out pyuria, meningitis, hepatitis, hypoal- buminemia, and thrombocytosis. Dr. Friedlander disclosed serving as a consultant and a researcher for Barrier Therapeutics Inc., which makes a pre- scription ointment for diaper rash. SDEF and this news organization are wholly owned subsidiaries of Elsevier.

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