Dermatological Emergencies

46
M Ramam and l K Gupta

A significant propor1io11 of children sc ·king
emerge ncy care present with e11ta11cous lesions as
the major or sole complaint . Skin nrnnifcstalions may
be primary in nature ur a n1a11il'cslation of an
u111Jerlying systemic disorder. Ol'tcn. a dcrn1atologist
is not available for consultatio11 a11d the 111anagc n1enl
of these patients becomes the responsibility of the
family physician or pcdiatri cia11 . Wc have attc111pted
here to provide a practical approach for the
assessment and initial manage ment of the con1111011
derm atological e111ergencies . The emphasis has
been laid on the dia g nosis and therapy in the
emergency situation . Details of the individual
di sease s have been deliberately omitted: these can
be studied from standard textbooks on the subject.
A di sc us s ion of the general approach to
derm atological emergencies is followed by a fuller
desc ription of the individual conditions arranged
into groups which share a common management
plan. Clinical signs that point towards a particular
dermatologic emergency arc listed in Table 46.1.
Table 46.l Common correlates of dermatological
emergencies
C linical parann·ter l'o ~ ~ihlc di!rma t oscs
'o n ~ tilulion :i l TEN. SJS. purpura fulminan s.
~rkrcma 111.:on alorum
s ympwm
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I. ()o 's th e ·rurtio11 involve large arL'as of th e
skin?
2. Docs th e c hild have bli sters or eros ions?
J. Drn..: s the child appear ill?
Most of th· conditions that require in1111edia1c
intervention involv e large areas of lhc skin. If a
child pre se nt s c;1rly in th e di sease process. only a
few a11a1on1i c areas may be allec lcd . However. if
th e hislory re ve als that the les io ns ha ve spread
rapidly. the eruption is expected lo in vo lve large
areas of the skin and would need urge nt treatment.
The most serious emergencies arc lhose
associated with raw IL:sions and blisters involving
large areas of the skin . These children require
immediate hospitalization and intens ive care. In
newborn babies. sckrc111a nconatnrum (hidl!-hound
skin), subcutaneous fat nec rosis (due lo cold injury)
and purpura ful111ina11s (sepsis) arc sugges ti ve of
lifo-thrcatcning disorders with ominous out come.
Another clue to the severity of a child's
discasc de pends upon how ill the child arpcars.
Though this aspect generally correlate ~ well with
the extent or thc e~·uption-and th e.: pre sence of
blisters and raw areas. it can be a u:-.el'u l elm: in
situations where the skin lesions arc lim ited in cx1cnl
but arc associated with complications_ e.g. Hcnrn:h-

Purpura/ ~ ki n SJS . TEN . purpura l'ulminans. Schonlcin purpura . Conversely. ~1 child with an
nccrmi n i:c.:ro li ~i n g ra~riili'
extcnsive eruption ma y be quite d1 cc rful as in
Widespre ad hullac/ Pc.:mphi gus vulgari~. TEN. SJS , pityriasis rosca or son{c viral cxa111 hcms. These
cro ion s cp id c rnwt y ~ i s
hullo,a children do not usually need emerge ncy i111L· n·c11tion.
Muco ~ at erosions l'cmphi ·u~ vul ga ri . . TEN. SJS However, in the latter situation . 11 11 • 111 11 st ht:
Gcncrali 5cd e;o; foliation SSSS, cry1hrndern1a
cautious in rulin!.! out a severe di sca,l· bec ause
co~1stitutional syn~ptoms may sci in l.1tcr 1h:1n _ii~~
TEN ::: Toxic.: cpidt: rn1:ol 11 cc roly ~ i ~; SJS ::o S1cvl' ns-Johnson skin lesions in some conditions. When ind ni ht. 111 ~
=
'<yndro mc; SSSS S1aphylm:m:r:il 'caldt!d skin sy ndrome
preferable to ke e p the child under n b ~cr l.' :1ti o n.

Al'PHO,\ C H TO TllE 'lllLD WITll A On the basis of this initi al :· - 0 · ~:- m.ent
dermatological emcrp.cncies can be cl a-.· d icd 1111 l
1
DE n MATOL0<;1c EMfm<;ENCY
3 brnad groups:
A qui ck a ~~e s ~ menl of the child 's condi1ion can (.a ) (.) 1seases
. . · · 11d ~ ~in
be made hy ask111g three.: question s: with extensive bl1 s1 c ri n:-- "
erosions.

:f· Diseases with extensiv · skin i11volve111 ·111
-i (b)
·1 without blisters.
-I
(c) Diseases with localized skin k:sio11s.
I target lesions (SJ sy ndrome) , necrotic brown
These categories are ensily recog11i1.ed and
do not require l'allliliarity with the minutiae of
dcrnwtological 1H1rnenclature. The general approad1
to diseases within each category is substantially
similar and will faciliLatc initial nianag1.;1111.;111 till a
more specific diagnosis is r1.;adwd. Each or the
following sections begins with the gcnl!ral pri nci pies
of diagnosis and managl!ment of' thl! 1.;mergency and
is followed by an account of' individual condit.ions,
with special focus on specific 111anifl!s1a1ions.
There is a fourth category of' perceived
emergencies that arc not dealt with in this chapter.
In thi s sub-group. a benign skin disease provokes
anxiety in .the child or parents prompting them to
seek immediate medical <lllention. The ran ge of
conditions that can precipitate this behaviour is 100
larne to dea l with but most often the concern is
0
that the chi Id has developed a reaction to a drug or
an allergy to a food. If a specific diagnosis of the
child's eruption is made, then specific treatment and/
or reassurance is easy. Howev1.;r. if the condition
cannot be diagnosed confidently, a quick review of
the questions listed at the beginning of this se~tion
is a helpful starting point. tr the lesions arc neither
extensive nor troublesome, reassurance may be all
that is necessary. However, parents must be asked
to report back if they feel the eruption is worsening
or if the chi Id appears i11.
EXThNS JVE E R UPTIONS WITH
BLISTERING AN D RAW AREAS
Diseases with extensive blistering and erosit~ns
arc characterized by large raw areas of the skrn.
The development of blisters is followed by rupture
and ex tensio n to form raw areas. The oral and
gen ital rnucosac and the conjunctivae ma~ al~o be
in volved. In some patients, severe const1tut10nal
symptoms may accompany the eruption.
. The prototype of diseases with cxte.nsive ~~i. 1~
eros ion s is burn. Though, by conve11t101~ .~lus I.
<.: onsiclt:rcd a surgical emergency, it ~xen.1plt.I 1.es th~·
proh lcms that occur when the barrier l11nc11on
-;k in is scv1.;re ly damaged viz. fluid and cl~c~r~1 lytl!
loss1.:s occur and there is increased susccpttbtlity 10
~ upcrad d cd infections.
. Seve ral different conditions, infective and m~n ­
lllkctivc 1nay h.:ad 10 thi s presentation. Some usl'lul
cha 'nostic clues which help differentiate betwc ' 11.
tl1 ':-· l·· cone
• 1·1t1ons
· .
1ncludc the rap1'd 111vo
· I'' c· 111cnt
"ll<: n-;ive areas over a few hours with :isscH.: tated
11-.'
ill.
toxemia (toxic epidermal necrolysis (TEN) and
Stevens-Johnson (SJ) syndrome), accompan ying
lesions (1 EN) or large pustules (hullous impetigo),
preceding oral mucosa! lesions (pemphigus) and
history of drug intake (TEN and SJ syndrome).
The treatment of patients with extensive
erosions requires illlmediate hospitalization and
excellent nursing and supportive care. The eroded
ur1.; as need to he cleansed regularl y with soap and
water followed by application of an antiseptic lotion
or cream such as povidone iod ine or s ilv er
sulfadiazine. In most instances, eros ions do not
rl!quire to be bandaged and can be le ft open.
Paraffin gauze or sof'ra tull e can be applied on
erosions in contact with bed c lothes to prevent
stickinl.!. Frequent changing of position in bed helps
in the healino of erosions on pressure sites. The
1111H.:osal lesi~ns in the oral cavity and genitalia
should he cleansed by repeated washes with normal
saline and antiseptic solutions (pov ido ne iodine
mouth wash. diluted Condy's solution). Conjunctiva[
lesions can be cleansed with antibiotic eye drops
several times during the clay and antibiotic ointment
applied at night.
Fluid and e lectrolyt e loss from exuding
erosions is a major proble;n in these patients which
may be aggra vated by reduced intake due to painful
oral lesions. A close record of intake and output
should be maintained and patients encouraged to
take fluids and semisolids orally. Intravenous fluid s
should be infused if oral intake is inadequate.
Systemic antibiotics should be instituted if
there are signs of cutaneous infection such as
pustulation ~r purulent di~charg~ from. the sk in
lesions or if patients show signs ol 1oxc1111a such as
fever. tach ycardia and tachypnca . The organisms
responsible for most of the secondary infections
arc Sraphylococ ·11 .1· a11rc11s and Srreprococc11s
pyogencs. Antibi otics eff.ec.ti ve again st. these
orl.!anisms such as c:l ox ac illin. cephalex1n and
erythromyc in should be administered .
The use ur systemic corticosteroids in large
doses ( 1-2 mg/kg of prednisolone eq ui va lcnt~day)
is required in some co11dit.in11s such as pemph1gus.
° toxic epidermal lll.!l'l'Olys1s and Stevens-Johnson
syndrome.
Toxic E pidermal Nraolys is (T EN l 1 ·~
T EN is a sc\'crc ;icute blistering disea. e th'.1t
. ~ ,1 high mortalit y rat, without treatment. I~ is
I1.1s • - · 't " "t1on
gcnc1.1 .. 11 , ''C)l\Sidcn:d-to be a hvperscns111v1 y rca-.
. nl ) "' · · t 'd ·
to <.I rugs. S\ll;. ·11 •·1s· thine •tazcine. sulp 10narn1 C!>,
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 i\·h die.ii [11wr~~encie i11 Childn.:11·
I h ·ny1 in. l arbituratcs. penicillin, non-stcmidal a11ti -
i n fla mmat ory <igenu. am o ng the others. The
I ' :l · ti I\ ge n~rally develops within 2-3 W Cl.:b of
:'tarting the dnig in a non- sen. itizcd person hut may
Ut'\' elop within hours if the pati1.:nt is already
sen ·itizcd to the drug. T EN can occur at all ages
thou):!h mo t patients arc youn g adults.
The eruption begin s abruptl y a s tend e r,
erythematous rnaculcs accompained by vc'.'. ic.:ulation
and bullae . Large area. of the crythematuus skin
develop a characteri stic brown hlac.:k di sc.:ol oration
(Figure -l6. I ) . The nec rotic skin pee h off eas i Iy
Nikol y ky ign ) to lea e large raw areas. Mu cou'>
membrane involvement is invariable and is generally
se vere. Mu co ac of oral cavity, eyes, genitalia ,
e ophagus and bronchial tree may be in vol ved.
0 ular 1e. ions carry a high ri sk of seyuelae such
a corn eal . earring and blindness. There is marked
~ periphery of lesio n'> . l•.ry1lre11J:i 1111 rite p:dw ·. ,u,•l
c '
-·
0
u ·
~~
· 4(..1 I n c· cro l y ~ i , C h
'l m . 1 · l' (Htl.c: t m .
wiJc-~pr d b111w11 hlui.: k nn r•J'f J11d rr11 <.1t11
toxemia a11d hi •II gra<k k v1:1. ( '01npl k:11 irni:>i11•;J111t1-
supc rndded inf' ·1.:1io11:-i ;111d ~.1.:p1i 1 : 1 ~ 111 i:1 , ll yp11v11k'.111i:
shoc k, acute tuhul:tr 11cc rns11,, 1'. l11111 1:111 lo111:pl11 11h,
1>ronchop11 c 11111011ia , pulllll/l lH J'/ nk 11w 11 11d
gastroi 111 csli na I I> Iced iIlg. I
M a na~cmc11t
The im11H.:di:tl t~ <i loppagc 111 :dl tll•t dJll t' '' lfJ;il
th e patient llas hcc11 t:1 ki111•. i:; tl1c: 11 ~0» 1 i1111><11l:i111
p;irt nf the 111anagc1111.:111 '." If : J. It Jr-. (!1.11 pfl:1·,1·: :d 1
tll at suspec tin g and .,1o ppJ11;'. 011f y 1111 ' 111 th<: d11 •i'.'t
be in g ta ke n is cx trc 1nc fy d :11w ·rn 11 'l I t:c:1 11 s1: :1
mi stake in itk111if'yi11 g 1111.: d1uµ c:i11 k :1d111 m:ub:d
worse nin g of th l'. co ndi1i1111. JI' :i dr1J i' 11. 1.:'>'o .;111i al, :J
1
che mi call y 11nrc la1cd .,1111..,1i1111 • :ilH11 dd lie t1 ~.1:d .
Nurs ing and ... 11ppor1 iv · c:Jrc; i· pr11 vi d1;d ·1~
outlined in the <.ecti on on j!Clleral prim: ipf1:·1. f1:1fl(.:11t:)
who re port earl y Jurin ~'. 1111.; c cJJHM.: 111 Ill•! dh1.:;1 ·.~:
(as manifes ted by th e pn.:i..,enc.:c nf' 1.:rytli 1: 111a an Hwd
skin les ions) be ne fit frn111 t:l)1l i ·11»1u1iid tlJ ·rar1-
Thosc who arc s1.:en ;1 few d;J} '' ;lft 1:r ow.I:! (JI
di sease, sho w mil d CJr 111i · 1 yth -111:; ;11 111Hld ~ 111
lesions and/or sh<J w pc ·Jing o f 11v..:r11tii..: sbn 'Jtllh
underlyin g re-c pithc li :.tl ha tw11 dLJ 11111 f q11i1 c
c:orticostcroich. Prcd11 hlJ l<1n · ;.., ad111111i ·.1cr ~d 111 :111
initial dn'> c of' 1.5-2 r11 g/kg cbily. ·1h1~ c.:1111di1u111 ol
the patient i'> do<.,c.: ly 1111i11 i1on;d ov1;1 ;J p ·1i11d of
24-48 hour:-, for tll ' :lf>JlC:tfalJC:C Of l fl'.W h: '1 JIHJ'1 ifr~IJ
pcrs ii; tcnc1.: or arr ·a ra ncc or -r yr tw u1;1 ;11 du:
soli;s pcr:-i i'> l:-i rnu c: h 10 11 )! ·r 111:111 d -i•"J I ·w .11111
'> hould not he U'> ed to 1itr:1t · tll1;1;1py. JI 111 • · l!'ll
of acti vity ari; pre'> ·n t, a11 i111.:1 •w·, • 111 1tw d.idy
doi,e hy 0.5- I mµ)kg o f prc:dn i·.11)11111' ''!1w1a k 11
i<. made and tli c 11a111c d11 • i.., 11J;i111ta11 wd Ji,, -~ ~
day-; till th c di •,c;p,c ;., c rJ11 l11Jl lcd . 'I lie ifr, : J 11,1·:1
ahruptl y halved ·ve ry 2- .S day -. ;u1d ·.i..rtllllr •.. 11
c.: 1J111plclc ly over a p ·ri11d 111 l IJ I· if,1
So1111.: wor e r'> ;11h 1J1..<1 1 • 11l :1t lllff"-'' t•, · 11 ·J
'> hould h e a vo id e r!. i11 1lt 1: 11 .·a1111•;lll 1,I f I• : .
II ow• c vc r, •w 1.: Ii ;1v • 1,., d 1.",, ,HJ 11: ·, u l r . • It
cwt JCO'> ll: I0 111 th · 1 apy and :w ild ::1f\1tK,.1f!' • "
d11<, ·• r-.hon d111 ;1ti1111 1ci• i1111: 10 r;ipidl) u11111
di '> "' "C i11 l ho 'it' with ;w 11 ve b i11 k -,1 <111 . ' ·
ai· 1~ 11f 'i rlwt llave h ·i: 11 d e~ ·r 11> ·d 111 tw ·f11·1 11
M ime wor~. e 1 i, i11d 11d • t:yd11·, 1 1Jrtrlc ;11J1J 11111
111111111nog loh11f1n., 11 \l lC i).
~t ·vc11:-i-Jol111 ..,1111 '• •11dr11111 • 1· :J 1 111: 1 111
1 ·:it:ti n11 pa ll · rn tl 1t11 i'> ll '> ll iJll y t ri~'l'' r •l !,: '
r,it' I P fl\ 1 ~. ( 11 •, tetl l'/1fr ,\ltfJr o 111 tl1 c 1~ 1101 1111 'J J·
l n fr t: l i1111 1; Cp l1;11 11 g 111 :-. . p;11: 1i J1JoHit1 •J·1 1
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111 .,.co11/asmt1 1n~ c 11111011ine ,

herpes lab hi·1 .
hcpatiti . ). The .·lmi~al picture closely res 'n~bl ;~
·- 677

TEN. Target lesions 1.e. c1:yt~1ematous lesions with

a bluc-hl:1ck c 'Iller arc a d1st_rncti\ e feature (Figure
.+b.2). In the absence ot target lesions, the
liffcrc~c' h_etwccn SJ syndrome and TEN is large! ,
:;nbjcctl\:c. !he mana?~ment is essentially sin;il~;..
to that ot TEN. ln add1_t1on. a thorough search must
be ma le to look for a tocu~ or infection which may
be the ~ausc of the . reaction and must be treated
:1ppropnarely. In ~at1ents who have herpes simplex
1nkctton. acy~\ov1~ 5 mg/kg 8 hourly. intravenously
or 200 mg tive t11nes a day. orally should be
ad mini tered.

Figure 46.3 Pcmphi gus Yul gnris with c. tcn s in~ crnsi\)llS :rnJ
crusting

Figurt ~6.2 Sle\cn s-Johnson syndrome
Ptmphigus 3 • 6 -
Pc mphi g us is an auto-immune blistering
disorder that manifc. Ls as flaccid bullae which
U<;uall y occur on apparently normal skin. The bullae
rupturl! C't~ ily leaving large. raw areas which have
a. lendi.;ncy ro extend peripherally (Figure .+6.3,>.
Spontaneous healing is very !-.low. The normal skrn
ca~ he: peeled off easily with gcutlc prc~sun:
<1 ik!o-,ky ' s sign). In over half or rhc pat1cnts •.
ulcer~ in rhc mouth precede the <.1ppcara11cc ol
<~ it.menu , le~ ion s and eventually almost all patienls.
develop .Oral muco<.;al lesions. Gicmsa staining 01
tltl: crape I inmcrial ohwinc<l from the base of the
r~::ht y ruptured hullnc whc11 cxalllitlcd under the
1
'HCnJ'iCope (Tzanck s111ci.1r) reveals the pn.:scnci.;
01
. ·har~t(.; t ·ri~tic ucantholytic cclb i..c. large round.
piucrniuJ cells \\;ith prnr11i11cn1 nuc.:lcw; and loss 01
~::~:'.1 c1_ \vith !>Urru~1rHiing cells. The diagnosis is
. i •rmcu hy ~kin biop:.y.
Management
The general principles or tn:at 111c 111 or diseases
with extensive erosions appl y t 1 JKtticnts with
pemphigus. Corti co. tcroids arc.: the main, iay l'f
therapy. We use clexa1m:thaw nc 50 m~ intust•d in
5% dextro ·eon 3 consccut i ve days. cvi..:ry .+ weeks.
Jn th e initial few week-;. mos1 p:tticnts \\'ill also
require a daily closl' of ora l cortic\1stcniids such as
prednisolone 0.5- l mg/kg. As the disl':ISl' becomes
inactive. the dail r dos. t::\11 b' r ·du '1.'d and stopp d
hut th' pulse:-. nf ck,\ tllll •thason1.: art: 1.·n11ti11ucd for
a p1..1riml or 6-9 111011ths :1rt ·r (' 11111~ krc dinkal
remission. 111 ourt'X1wril'11 ·i.: . this rcgimL' ~ivC's I n~
lasting remi~sions L'Vl.'tl after th1.~ rapy b sll'(lJl1.'tl.
/\n al1ernatin: schcd uk e1 nsists nf usin' I -_
mg/kg/day or higher dose '.if pre dni sl l <1nl' or
cquivaknt steroid. The. d:~r.ly do.sc 1.·n~ . 11~
im:r<.:il'-l'd b , I mg/kc. datly ti th •r · 1s m1 dtni ·al
respouse as indicatt:d hy t:n11ti11.ucd 11p1 r:1r.an ·c
of new I 'sinus. and 1:xrenl>tllll of ~h ·~>Id t ~~ mn~.
The dos1• of :-rcr(lid shuuld I e 11~1.1111ta1ncd .1111 111
lct< iun.c. have h •akcl cp111pktdy. I ltc· di1Su 1. . 1hcn

·'

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·.-:.
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/'v1ed icJI Emergencies in Children

gradually tapered and the patient maintained on the

minimal required dose.
Most patient. also require the use or an
additional immunos uppre ss ive agent such a_s
azathioprine. methotrexate or mycophenolate mof~til
in order to reduce the requirement of corticosteroids
and to maintain a remission . This di sease is best
managed in association with a dermatologist.
9
St.1phylococcal Scalded Skin Syndrome (SSSS)
SSSS is an uncommon but serious condition
caused by the epidermolytic toxin liberated by some
strain s of St(lp/tylococcus {ll/re11s . It is
characterized by tenderness, erythema and peeling
of skin. The condition occurs almost exclusively in
infants and young children. It usuall y begins from
perioral areas and flexure s and may spread to
invol ve the entire skin (Figure 46.4) . Mucosae are
not usually affected. The child is usually toxic. The
underlying staphylococcal infection is usually occult
(conjunctivitis, pharyn g iti s, otitis media) or
sometimes obvious as boils or umbilical sepsis.

M anagement
The condition is treated by administration of
appropriate antibiotic s effective against
staphylococci, including the penicillinase producing
strains. Cloxacillin ( I 00 mg/kg/day) and amoxicillin-
clav ulanic acid (50-100 mg/kg/day of amoxycillin
base) intravenously q 6-8 hours is generally the
preferred choice. The use of corticosteroids is
contraindicated.

Bullous lmpetigo 10
Bullou s impetigo is a contagious, superficial
b acterial infection of s kin caused by
Staphl;Yloc:occ11s our(:11s , ~trcp1o cocc11s pyogenes
0

a
~>r mi xture o'. both. 1 he disease commonly affects
111fant<> a~ d children. Lesions begin as clear vesicles
and fl accid bullac whic.:h <>0011 turn into pustules and
rupture to form ye llow brown crusts (Fiour' 4f 5)
F . II t c c >• •
ace , cspccw. ~ t ic area around the nose and mouth
a nd cxtrem111cs are cu111111011 s 1't•" .11·1· t J
E · . · "" · ec.: e(
·xtcns1ve _arcas of the skin may be involv. 1 •1,1 ·
· · d. C( . lC
Ic <, HH1
_ S rema111 .iscrcte and even wl·1c·1·1 numerous
generally c.:ausc llltlc systemic.: disllirl1•111 ,.c M _ · '
. ,· . · ' '- · ucosal
I_1.:•m_>ns <lo not occur. A Gram stained s " 1·
th e .bl .· ~ 1··a fl u1·c1 s·Jmws the pn.:scnc.:e of ·t·· mc.ir rom.
1 I1 I
:md/or ~trepto<.:occ i. s • P Y 1J<.:ncc1

.Management
· Systemic antibintin sho 111
- :! period or-S-7 duy s 'c10t'.l ·1)c1·· ad111inistcrcd for Fi~ure 4<, ·4 1-Y111cal
.
. . .· · ··11
x .tc 1 111 ,- ainox IC.: ·
I 111- I appearances or ~c;d clt:d
l UC 10 staphyln1.:11ccal infection

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De rrnat.ol.ogk al Emergencies
.·:·1
. .

'
,. -679 ' ··

Figure -l6.5 B~1llou s impetigo. Ruptured and intact bli sters

with turbid llu1d on erythematous skin

cl~rnl_anic ac~d.cephalexin and erythromycin are

eftecttYe ch~1ces. The crusts should be removed
tho:oughly with the h_e lp of soap and water. A proper
nmntenance of hygiene and cleanliness must be
emphasised .
Figure 46.6 Epidermolysis bullosa simplex
Epidermolysis Bullosa 11
Multiple clear and/or hemorrhagic blisters on c_ontagiosa or infective dermatitis at presentation
ti.II a fr_esh er.op of tense vesicles suggests the
the hands and feet and the knees and elbows are
dwgn~s1s. A_ biopsy reveals a subepidermal blister
suggesti ve of epidermolysis bullosa. Blisters are
a_nd direct 1mmunofluorescence demonstrates a
present at or soon after birth in severe varieties of
lmear band of lgA along the basement membrane
th~ disease and are often accompanied by erosions
zone.
(Figure 46.6). Extensive erosions of the skin may
lead to overwhelming super added infection. In
Management
some neonates, epidermolysis bullosa may be
accompanied by other anomalies such as pyloric Treatn~ent \~ith dapsone 25-50 mg daily and a
atresia. low dose ot corticosteroids (0.5-1 mg/kg) control s
the blisters. The corticosteroids may be tapered over
Management 2-4 weeks. Dapsone should be continued for 3-6
months. Recurrences may de velop and should be
. Supportive care as detailed in the introductory treated similarly. The disease remits spontaneously
~ectio n is necessary. Associated anomalies should by puberty in most children .
e managed appropriately.
3 6 12 EXTENSIVE ERUPTIONS WJTHOUT
Chronic Hullous Dermatosis of Childhood • •
BLISTERS/ RAW AREAS
ch This auto-immune bullous disorder is ln this group of disorders. patients present with
th·,<irac teriscd by tense. clear vesicles and bullae erythema, edema, warmth, tenderness and itching
pre.it ,.may'. . .de ve Jop anywhere on the skt0
· but liave a
of varying severity. Fever and other constitutional
1
. ~· ccuo.n for the peri-oral and !!en ital skin. The
1
symptoms may .accompany the eruption . If lesions
·bllsters 0 f . . ~ .
central . . ~en develop m .~ rmg a~r~nged around a persist, s.econdary changes such as scaling, crusting,
'· . '\trino acttvc or healed blister; this 1s known as the thickening, pigmentation anu excoriations may .
impet~ ~f pearls" appearance. The blisters are often appear. Secondary pyogenic infection and ·
· . iginized and may be mistaken for impetigo
·: ....

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• ~ . J I ,, I 111•·r
ffll'CJI,,
p n..:1, 1i1e \ I) 111plu k1h'p.1t h mny ll:c ur. follll\ving
I.' \ ·,~:t .~! t \\I '-,
S \)I\ lt, c:lul d i:t!,!110'\ic l·luc:' Ill diffi.: n: ntiat ~
l h~ \ ·1111:\ll ~ ':\ in thi ' !!I lll p it1cl lldC duratillll Of
indt \' i,lu:JI J •:-i<Hh tfC\\ miHlll '" I() ft'\\' hours in
un i .1ri .l). h 1 ::a~1r) uf dnJ1• intnl-.l' prior lll 1hc
I·' ·!l-'pm · n t ~i r ' " 'II ( l''anthl·ma tntt s dru g
' Ill{ ti )11' , f ru~l . , ~j,-,. 'Pr ',Id nr erupt i1111 fru lll Oll C
.1r""' ,f , !._ in 111 .llH th ·r :rnd th e oc currence <i f
J i, ·:t~.: :ttn i'!l~ ' 1.)Htn ' h 1,·i1;1! n anthem) ancl th e
pr ·,;.:n·..: • 1'i ( r ,_, i .· ti n ~ sl.. i11 k il 1i-. (cxfo li ati,·c
1.kr m ,1\m ' l.
l n.m-:-J i;H 1111 •n cnti tm in th c . c patient
n :i i ' of 1' • r.ipiJ ('on1rol of innamma1ion and
·lt " tif : ymi 1 n m ~ . \l any pa tient ~ have severe
it d~rn~ ' hi ·h l·an he ·o ntrol led w ith o ral or
r ": , I Jnlihi· taminc-, lc .g. phcniraminc makate.
· •lin;r • c di h ~dn c hlnridc. cyp ro heptadine
;Jr< -hi• nJi.:. h: drcn: zinc hvd rochl oride). It mu · t
_ r' '\)p1 i?cd t ha t :rnt ihi -t J. minc. are highly
d -me . n d1!ldr{' n v. i h urticaria but; they provide
l: p;:i 11:.d ymp nmatic rel ic in other condi ti ons.
l
C~l~ er.l!Pll:JJ ant1hi. taminC'<; are preferred because
th ' Ir "l·Jat1' e cf fee t cnntri hute'> lo the control
f 1 d11ng • l (•thllll! local :ipplication uch a ·
.::l Ct nut oal 11r co ld \\ at cr . oa k ~ ma,· rclie\'e
·~mptc m ,\ .,,n1d thl· u-.c of ca lamine- lo ti on in
1Jtr1111 nl r, 'h.:' tw ·au,c th e pink caq o f the
!1 1,,n n 1..ll1l·' the c ut an.:nu '> i):'.n' .ind make<> it
lt to c•. luJ lt: J tl~ ub cquc nt ch:rnge' in the
!r1 11 .1 tlrui• h "' 'Jll'.l· te tl l l l b e the ·a u c o f
cr , . '11 I t1 h ·r drni.: 1111a · mu 1 b 1nr pet!. Effo rt:,
., .i'J I • 111.,1.k h• l1>o l. !Pr ;111~ in fcl·ti\l: foc u
·· :d, ~ ••Ul ! h.: Jj•p111pn.11 e l~ 1ri.::1ted. "tero id in
--;- .. ii .j, i::- 11 1 II ~ - I mg/ ~ u i pred n i o lo nt:
.1.:.rl .• r.· 1nd1..-JtcJ Ill '-Ollle ·lmdill!IO"
1! ru 111•11 . .:nJ l' n l rn ti~<.· J rm tll i .
l •
·,;;.,1cJ<· i1°) c·Jiildren
' r+ ·
11r1ic;1ria and ~y n <.:o pc. Thi.: c o11ditio 11 i-; poll:11fiall y
fatal Ullli.: SS llHlllH gi.;d rrornpll y. /\napltylat.:lic..: shock
usual Iy develops f'ol lo win g ~Ill i nje<.:1io n or ;111 i ni,cc.: t
bitt.:.
l\l a nag cmcnt
In a11 ~1plt y la ctic s hock ;1s soon as pu\s ihlc , the
patient 11111st be give n oxygen inhalat ion and inji.:c1io11
adn.: n:ilin (I : I 000). 0.0 I ml/kg intramusc ularl y. J\n
int rave nou<> lin e s ho11ld he se t up. a cut clow n may
be required. The patient s hould he observed over
1hc next fifteen minure~ and an inji.:c..:tion of adre nalin
0.0 I ml/kg repea ted if rh crc i ~ no impro veme nt.
Inj ection pheniramine rnal c atc 25 mg
intr:rnwscu larl y s hould a ls o be g iven a long with
inj ect ion hydrocnrti so ne 2 mg/k g irn or iv.
c ute urti caria is man aged by admini stratic n
of adequate doses of an tihi sta mine .... Thi s 11<i uall y
cons i. ts of 1wo di fferen t dru gs e .g . phi.:n iramine
ma lea te and cctiri.dne dihydruchloridc. g ivt: n three
Lo fo ur tim es dail y and one co two ti me' d ai lv
re s pectively. Tht:rc is little 10 <.: li oo 'c a m n n ~
different antihistamim.:s as all work. equall y we l ~
Parenteral therapy is not usuall y requ ired . Tht: dnrc'
beg!n to act within half an lu >ur and peak •1c tiv ityi ...
achie ved al 3-4 ho urs. It is e .xpe c tcd tlt~1 r acute
urti cari a wi ll be ~ub~tantiall y co111 rolled wirhin --~
hou rs. If 1hi' u ol!s no l hap pen. the J u ., l! pf
a nt i hi stami n e~ ca n be i1H.: rt.: a\e d . l H a not her
anti hi starnint: added to con 1ro l tht.: :-.y111 pt o111'.
i\lo '> t o f~cn. an 1ihi:-.ta 111i11t.:s a rl· :1dcqu ,1t ~· en
co ntro l the J 1..,ca ... c. S y~ t t:n1i c c1Jn ic<>:-.tt.:rnid' Jr ...·
oft en pre'>c ribcd in ac ut e urti ca ria hut .1r · u-.1i.dl\
not n ~n: \ C1ry. Adri.:: na line :-. l1u11ld h1.· u ... ·d 1111h 1.r
the re l '\ l;iryngc:al Cdl.: 111:1 and re-. pi r:ttor. ui-,tr~''
Once'>) mpt u m ~ an: cn111 ro ll ·d , :mt ihi t.11111n ·
h uld tx <..:0111 inu t:tl for 7- 10 d a\' t•ct on.; ,1,1pp11:
t h~rap} . It r:-. i111 pn r1 a nt tu ! l'~o •11 i-.. 1l .1t II' "
C: p hO<l t:\ o f CJ 'Uk ll!'l il ' '1ft:1 ;(f l" :. ·ll -l11ui1 ·d. l:t ! (
..i O U! J \\t:d, ·111 ·' cl
\ \" • u 11 110 I fl'·'-! llltl'
' 11 · 1\ l'' fl !'.llH'l'
hl'n l'phode• l1f u111 ·:1n.1 p ·1 ' 1'1 b c:.l•!1tl l 1 111.·,·l
1l ' ' l.1hc kd :1\ ..:h1P111i: un il: ar i.i :m I i. b~·vl'lld t
~ · 1 • ol t ilt d1;1pt -r. ·
l·'. x 111 lh 1· ni .1 lo u<; P rug E uptlou 11 1•
'I Ill I'> ttw ·0 111111 L•t1l' 11 .1111.'rtt >I d111. l'ntf'!" •; ·
.u1d '.111 I" '"111wJ I>) :i r111111 h1,·1· •I drn. d11>•1 l
lllphi• 11 •1111111 ··"· r · 111 ·111 111, , a1111,. .... , ul :111h , 11 1
.inrnult,·r"' ul 11 ·'"'
". I 11 ' l II ' ~lj j'l".ll :lfh.'1.• 1•1 Ill(· t,t- 11
1l·
j .,·~·~ i1Pl f llt1\. 1.d I I' ·' l ·I UC'\ lit I Il ' '•1111',\tl \ ' ' dl!I )'
tl' l1 •f1 r;llh . II' > 1111 11 •tri «al 11,; fl\ I ll[\ 111.u ,ll . I
. i .11.11,
p 1p11l.1r c t11(1t 1< •11 n phlh ' l' .,,,1, tu i 11 ' ;.1, i · ti!. ~·nt11\.'
ot:i111« ·11 ~ ~111 l.11.t: llt. '!udin1 Ill\· I ·t_ln l\ " " ' ·' . l I.:'
lfHI Hl(I\ 1!11.• k 1111 . Ht1· 1h•1t I ' IC' t• lll llH\ ~· 11:.f~·,,·,
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" . ::: .:-·
int b rgl.' p:11chl's lPigurl.' ·Ui .7 ). Th e niucusal
surfa ·cs may b ' in\'nl\'ed . Fl'\'1.'r may Sllllll'lillles
<K\.'.l)mpany !hi.' rash. The rash usually 1..· on1inucs lu
spread if 1he d ru~ is not stoppl.'d . C11fl\'l.'rs1..•l y, ii
be omes static or bq!ins 10 rcg1\'.ss within _.1 h;iurs
of slopping the drug . lf kft unlrl.'atcd. 1hc rash cui
prl ceed to ex f liati,·c dl'rmatitis lSl'c bclmv).
Figure ~6.7 Exanthcmat o us drug auplions. Uniform.
erythem:nous. coalescing papules
The de velopment of a generalised.
symmetrical. rapidly progressive. erylhemalous
eruption should prompt a detailed inlerrogalion for
dru g intake and the timing of the intake in relation
to ~he ra s h . A system- wise qu es tioning for
y mpt o ms and the treatment taken is often
rewarding as most patients omit to mention over-
th e-cou;ter preparations and self-prescribed
medications unless specifically questioned.
Mana gement
All drugs being taken when the rash developed
must be stop-ped. It is risky to try to guess and stop
o nl y o ne drug becau se an error may lead t_o
wo rsening of disease. If a particular drug 1s
e. sential , a chemically unrelated substitute may be
used.
Mos t patients will require systemic
corticosteroid therapy in a dose of 0.5-1 mg/kg
prednisolone equivalent daily. The rash_ c'.111 be_
controlled in 24-48 hours as evidenced by lad mg of
erythema and lack of new lesions. The dose. of
prednisolone can be tapered gradually over a period
of 4 weeks; rapid withdrawal may lead to n
recurrence of the eruption (even if the dru~ h:1s
been-stopped). Antihistamines are not cffcct1ve 111
treating cxanthematous drug eruptions. They only
provide symptomatic relief of itching.
•• ·: •!.
(_. ·:·. . ,.,...
JW. .' '.:.'
Se ve ral virnl i11f'n·1io11s ;11·1· 11 s~H 1\:i :i1 cd with ii
s ki.11 ra s h. M11r11l a r 1111<1 p11 p11l nr ~ ry 1ll e rn a 1ou s
k s1n11s drvt·lup ov ·r n11 l· part 11f' 1l1l' ski11 ~ 11rf'ai:c
alld grad1111ll y sprcud f(1 i11 v11lv1· n1hn parl s of 1lw
l>nd y O \' ('I' - · -'days. l11ilial k sinns 11 111y fade whill.!
11cw lesion /\ co111i11m· lo ck vrl11p . Mt1 cnsal lesions
111ay he .sl'l'l1 :111d ocr as io1111ll y pr1·cede lhc skin
c nip1io11. C(l11s1i111lio111ll sy111plo1i1s s11d1 as k ver.
111 y11l 1:: i11 a11d 111 :ilai sl' 11 .s1111ll y :i cc n111p11n y !he
l'l'llplinn, hut 11111y so111c1i111cs pn.:cl'de 1h1· rash.
<krnsio11:illy. ii 111ay hL: v1~ ry diffii:ult lo
diff"re 111iat e a viral l' X1111lh c 111 fro111 1111
cxa111h ·111al<lll.'\ drng cnip1i11111·.spcci11lly if th· pa1ic111
wa s lakirit! dru g(s) hcf'orc lhc onse t of' lh c rash .
flow ·ver, spn.::ul of !he rash in a scquc111ial 111a1111cr
(Fi g ure 4 (>.8) a11d 1hc d1.:ve lop111 1.: 111 of' sirnilar
cruplion s in olhe r f'a111il y 111 c 111hers or in !h e
rn1111nu11i1y 111ay provide a cl11c 10 !he cause. lJs11ally,
111osl viral e xa11therns suhsid · i11 about 2 wee ks wilh
fin e scali11 g a11d some pu s l- i11fla111111a1or y
pig111e111at io11.
Managcmcnl
J\111ipyre1ics a11d a11algcsks 111ay lie prescribed
for the fever and 111yal gias. If a dnig erupt ion cannot
he reliabl y excluded, and !he pa1ie111 has already
been taking thes e dru gs . ch c111i eall y unn.: la!ed
substitutes should be advi sed .
Exfolintivc DcrmatHis (Erythrodl'rma ) 17 • 1M
This potentially serious condition can be caused
by several diseases including psorias is , at opi c
dermatitis. drug eruptions. scborrheic dcm1a1 iti s and
Fi1111rc 46.8 Viral cxa11lht•111. l'apulcs have t·nafc, n •d anll ~ l 1l•IV
subsiding crylhcma 011 hack while th crC' nrt• ftt' sh. ilis\'frtc,
brighl red papulcs 011 the arm
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 f if • t I ,,) f ,,,, f ,'1 1 II' lf1 I l1 1•1 •.f

1 11 ,1 , 111' 11 fl• ' l 1I /11 "1 1111 ,, .ill1.

ic.:hl II yo .c:, ;m101w "' h1;r,..,. lrrw.1,1· ·11 •11: 1,I If,•: '-i 11·:1 ' ,
,11J•·1 11;11 11 1 II• .. , I I 11 t1.•ltf , ,,, 1111/.1 ' 1dl {11,1 / I I
th<: ;ippctirancc nf Lilt: .. • p:111 1: 11h 1. •' l'J '-111111,u.
1lwti1J1/ 11111i. '/ f1 "' • 11 f1iid 111 1
di ,~, I f1
1 11f <1
Th1.: c li11 k al p ie ur · i ~ d1:11 ;1 1, f1:11 -;c d · 'j ftqi f . II J1f l' tftt1 , l1Jf,p,I 11 If 11 11 t / d11d/ f1q •I / fi
crythema ;JJ1d ...e:ili111~ i11w1l 'l1111: 11•:;1tf'l Iii•: 1· 1111ir :-;l--111 ;i1;:d11;:f l •; 1, 1U 1 ~ I l 11l11 1, . l11trltf , J1 ,qjlf
l I, 111>'
i.url·ac •. ltd1i11g i·) cr.tn: 1111;f1 1:· 1:11: r1wl rlw n:11I l;1• .1 •11i1 1k1I ,,, I I ;d1 11 . l1 111' ' '" 11 . I• .11 1, . I . / I I
1

pl a tc1i may :.ip fH:a r -, hill'.! b1:1.;111 ..,1: tl11; / ;111: p :lfl"ld .., 1 :111 1, •. IU·if d 1tlr111;rl1 •rdlt
repeated ly po l i ~h i.:J duri11/'. ..u:1tdli11; 1 • ';1_;ili111~ 1. 11 1• ' Jl11,111· 1 , 11 11 ~I • 111•// l!I 1rd
often profo 'lc lc:idin;~ ro ' i f~11i li 1,;01f 1111,11:i111 1 1 ·.·•• ' 1111:
patient 1 11~y h1.: lc hril • '" ll/11<11111:11111 1_ ;ii1d IJ;1
J f;irfl' tjlJ II 1 t· llJ . ( 111f11fl fl/I H 1l1t ''"' {Jj ,, '
difficu lt y in 111ai11titi t1i11 ;'. ;i 1, 1Jw., 1:11 I 1>1,d ·;
( '. 0 1 1: ~1 · 1 I : I 11 tJllt 11 ': 1' ,
tcmpcr:.t turc. Gr.:11cr;:1l hi.:d l/111pll11tl1:111111alf1'J , ..,
LJ'>trnll y prc1ienl. 'l /t1d ·~ 1 ; f1 •. /111 • ( lffl' l' flfl( I 1111 I 11

l1;tl/ll fl ' fl A I/. l f'1 d/lf l llf , /lfll/' {I llf1/ll ' flfl (/1 I'.;
M :rn a ~ ·ment ' 11 11 ' 1fi:1'. 11·1: 1, f .1 ;1 l11w ;1r1 rJ 11,, tl1· / 1111111l 'J 11111 . '"''"
1; u11dlflt1l l It 1 11111l1fl11l1 '1111 ' fl/IJ :f .t 'll' fl ' 1·; r. 11 f l
Anti h i :-. t<Jrni 111.: ~ arc 1c.:c11w c:tf 111r1:li 11: 11d11111
1: 1 1
•
l ' /il11Jj 1flfl l:tf l1j l liitf ' lj l ll t l ff' fll ' Ill 11f11111
flW fl 1 l.f1 ,fl f•
Scdati11 11 coJJ vc n1i11n:il ;11J1il1 hf:iH1 1111;•, :i11: r1r1 f1:11 1·il ,
I"> 1:111.a·.1·11 Ill ;1 11111;d1 .f,1·; 111 I f .1 .;d r ': ( l'r ;~ ,,, ·If, 11 I
\fo.,.,agc 11ith hland c111nllk11h ·,1H..f1 :1 .., p1:f 111!1: 11 111
j ell y, col d cream or coc.:1111111 11il 'lt dl v1111 111I 111•:
11u111111 1•: 111 l1 . . 11w. ,,,, ,, ,,,,, ,,..,,1,,.,.,,
111 1• ..1 ,iJ1•; I lw
":lrdt.11 f•f•1tflf! 1·il 111 1111 · .1 ,di., li-:al, tu 1·1 ll t 1p11111
'lcal ing and rc lic•1c hi.; '1l1dd1111; 1 , ,, 111•: ·J 111. 'J111111. ;d
corLicO'>tcmid'I nrny be ;idcl ·d 111 rf11: · 111111111:111 111 1·1,. f;if1ll1ll :111ff l .(IJlll(illlf!' l1f ffl 1' /'1lf ( l 11f1 1dlt>/1 l1;1f1j
brin 1 :.i.b1,u1 a mnrc rapid r1.:-.ol111i1111 . 'J11 •: 11Jb1: Ill 111111 l.11f11,11 .1111d L11lf1111, 11 bll1'Jli . dl1fll111;ll1t11d 1•1111 ,r

b c1amc 1ha \ CJ IH: vakrnt · <I) µ111) 111 1! p11111111: 111 :11i'I l;11111; f1;111111111 ff • .I'. .h1 1It i i-.1111il:1t 1.111111.;d (> If lt1r 1·
~ t cro i d c.: rcam c;w he ad<kd 111 I CJ J ""' "' 1w. •ffll 1: 'llif lJ flllllfl( 1. fflll ;,f 'l i ll lilfll 1fl , ir1 If I' !f 1:!)1•1• /,f
or c.:old t:rc:im and appli ·d :di 11•11:r 1li1; IJ1>d/ 2-· 1: rj'll1 1: r11;i , •.1 11 · td1111}· r,I 1lw .. ~ 111 ;111tl tf1•: p fl " .1r111
timc'I a Jay. Tile raLicnl '> lilJIJld 111; ·11dl Cll' ';11;d fll llf ;,f •.1:1 '-1: IJf f1f I , fl.f'.
a oid hc:it l<i'>'>tJll(I hyp1ith · 1111i;1 , I-. hwll r11 1i11:ir1 di1;1
i'> advi'>cd to C()Untcr;ict 1h • l i".'>,,f pr11 :i ll', i11 ·~c1 k .
1

. ; "t ·rd/ ~dk1. 1 1;d 11 1:1,1 i;1 1 1~ . ,,,,=1t' .11;ill y •w1;

tll ::11d 111:_iy 11 : di:! 1
y dt:1f :d 1111tl ltyf1!1fl1t: 111 I(. . Irr .j1lf1•
'.'' 11111: r1:. 1•11: t1111 i. 111~~ 1.111 1:, lf1:111y ,f ll1 w.1· fi:d1w '. dw
Ill llJ•; . f 11 .I I :w 11 :1'1 , 111 1111:, 111 tl.11 .1; 1f11 1 .11r •11 '1('.,
·r~ltllfr1~11J • ' .llc f, It'; U1'.flllllf (il l 11( ; ff(,11; 11111 j1·llj r
111' 1Y hi, 11 .i:il ''' •f f!:!/ 1! rl1 1; .tr : tdli11;~ r,f rll1: '.hlf f 1,
r ·1: ·111 y1: :1r ' ur;d 11:ti1111id·. . 11 ·It :1 r11: 1lrt:ti11 , (1 ';
111;1¥.
• . ' : l1:1 v • lw• . 11 11•..1.1
11
• I ·rr1 I I 11:•. ; ·fmtl111<111
.. '. •111111 :1
' l 1 1f1 c.:·11t 1 ·1f .,
11 .
.!· , , , .. LJ . ,, ,,, '' i1:;rlnw :1r1d 1 1~ 1 : rl1 1: 1 ~i1 ' " ' '·
• fll <.: ' tlJ1; l lllftr(l '1 · rt • I
• • • "· " rt: ven. • • 11 V1: r 11111 1: 11 fl' 1·
rt:
• flrll
J , .1HI·. 111 "·d . rl ,,_. , l nw111;·fl-.f11l1· :t1flllf11wil
• ~1n·. 1•,, , Ir
llH . 1r111i;l
1. .
y 111 ''JJ
.
l 11 1i1 . I' .
II .I :1 ;1 l lll ('. rtfll fJ1 :11tfy Vtlt1 :1it"1I·(
I1y p ·rr.<.:r:110 1-i 11 r. .. 1
· ff f· f J l ff , I \ ffr l11Jvlf f lf ~ dlll " I.
t h .~
''
· ,,f , ' . • f t1• r'IC: ll l ·I•. 11 tll:<m:rl • ( 1r i1if' /i1d
" " ' 1 > i; wfw,, tf 11·

c '" ' • 1 <.:ti .I :111d 111 11111·11

• ••111 •·11
' I;i f ''' I'11y , ,,, 1r1·1 't1 11 11·
•
Hl ""I ' y I
i11cr'"1'1·· ' .,, r ,: 111 •.
.
:1 "l. '" . -1ir l:i "(: ~" ·:1 ,,f th1: IH1dr
. • ,, . •
... , . . .. i.11 n·t1rrrn11 .1 r ., 11. .I I ,
•,l v·,,1·1:1'11. :md i,, · T .• ' I " 1' 1 I 1111 1·. rr11m·. wirJ111
fo1111d '" lw .. i:,n• "-:H•f y l<:'i . ·r. p ·rr .•i v1~ f, :,._ 11•, r1
• ' 1 ' 1· l cc: t i vt- w. ~1r.:if r : tir1 .

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 Dermat()logica l Emergencies
of the insult and the accompanying systemic
symptom .
The rapy of localized skin lesions consists
111 ainly of measures to control inflammation and
prc,·e nt seco ndar~ in.fection. The as soc iated/
underlying systemic di sorder should be treated .
Appl ication of irrit<~nt substance~ should be stopped
and the affected skin washed with soap and water.
Topical s teroi~ s. and antibiotic therapy is required
in the dermat1t1s group. Systemic therapy with
antihistamines, steroids and antibiotics may be
required if inflammation and infection is severe.

Purpura (syn. petechiae, ecchymosis)io Figure 46.10 Typical vasculitis purpura du e to Hen uc h-
Schonlein syndrome (" palpable purpura")
Purpuras represent small bleeds into the skin .
Clinically, the lesions are non-blanchable, pink to
red pot s that fade over 5-7 days with s light
hyperpigmentation. They may be caused by a
bleeding diathesis or a vasculitis.
Purpura due to a bleeding disorder is
recognised by the random distribution of skin lesions
determined by the site of skin injury. The purpura
itself is bland and unaccompanied by erythema or Figure 46.11 Typical irregular purpuric and gangrenous sk in
edema. Mucosa! bleeds may also be seen. Large rash over th e legs in a child with fulminant meningococ:c:em ia
purpuras may be noticed at the sites of injections
or venipuncture. The presence of a hematoma at a In purpura fu lminans. several, large ecc hy-
site of injury or a hemarthrosis provides additi~nal moses develop which progress to hemorrhagic bullae
clues. The child may have bleeds from other sites and full thickness necrosis of the skin. Similar lesions
such as the nose or the gut. may affect the hands, feet and nose (Figure 46.12).
Purpura due to a hypersensitivity vasculit!s is There may be bleeds from multipl e sites. The
characterised by the development of lesions mainly condition is usually accompanied by shock which is
on the legs. Lesions also develop on the buttocks an extremely grave prog nostic sign. The commonest
and forearms. The trunk, head and face are usually cause is septicemia.
spared. The purpura is bright red, has a blanchabl~
component, and is accompanied by edema .an Management
infiltration, which leads to the lesions being, r~i_sed If purpura is due to a blce.cling disorder. urge1_11
i.e. "palpable purpura" (Figure 46.10). In ad~tt.ion, eva luati o n and approp.ri :1tt' t hS)r:i~y ate
the child may have pain and swelling of the JOllltS, . on1111 e ncl ed ( Rcfrr to C h:ipt~r 1 . t~r p ura
abdominal pain hematemesis and mclena and i ec . . ·l1 tiu ld be treated with fresh lrozen
ful1111nan s s · · I
~cmaturia. A his~ory of an upper respiratory tract hsnia I 0 n11/ kt-" · rc nea t
tcd as required . Plate ct
I .
P • · _ .· . tin v be necessary. The under y1ng
infect ion or drug intake should be sought. translus1ons • , · ·I
·. . _ be treated. In patients wit l
When purpura is accompamed · b Y f cv
. er• the
., co nd It inn s1l o u 11 t . . I ()0 ') 00 "I
. . . . 1·. ·cft riaxo nc or cdotax11rn.: -- m"'
PO:-..sibility of a septic vasculitis or a hcmor~h·a.gi~ sept tcclll.
. •1. c
1n vcnous ·I)' s·li tnild be started wh1. k
· . .
fever must be considered. In septic vas~ul~l!s, ' kg 11<. ·~ Y
1 111
'J ·ultun: reports. The antibiollL' regime
few lesions are scattered over the skin in no H\V;\lllll g hl(lll .. l . I . r ·•CSS 'lf\' \Vht!Jl thC CUiture
can he mod JI i c u. i. 111.: .i;; •• , • •
P<t~icl1lar pattern. The skin lesions may hav~ b~c~ . ts beccJJ11c a va tluhk .
no~iccd by the parents but should be looked for 10 ' 1 repor
ch1Jc] .w·tl· . . . . du e to IivpL.·r<>L'll-<itivitv
. , - vasc ulitis . .,.,
1 . 1 sign:-. ol. menmgeal
. . . .
1rntat1on. The common
·. .1 Purpur.1 . . 1 : ·kin lesions arc severe. .1
. ·:1, cau~e<; 0 f h' . . . coccemHl anu. . . . ttncnt ' 1 s . .
1 · · l 1s syndrome arc menmgo rec1nircs 11c.1 . t ic
. .• or severe .n1.t1cu I .u ; .
~. engue heinorrhagic fever (Figure 46. I I). l~f ''. . I 111 vo l \' t t1l 11 1
·' there · Js rena . , · ., d11sc ot 0.5-1 mg ~gI
• •/'-
· .~ : c1·0 lll 111 unity expcric11cing an epidemic, ~~cc• _.•c syinptoms.
' ·ptcd111 sDIOl1 t lit.
. 1 . . " ·4 weL· k·' ·
' '.
'• · feat · · ung tor .Jay is nd~1i'i ni stc~ct f 1H - «
··' .... lah(J~ent !:.hould he instituted ~ithont. wm .
· ::1 ·~.; . .. · . .· atory confirmation of the diagnosis.
;;.:<:L ., > :~· · , ..::·- . .
·... J
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 ,\ \ •Ji ._,f rn1t."r. Pn ·· ~ in Chifdr

. . f tht: au~ . chi? dirucal pktm

I rre - II' o . • .. . . 1· J .,
. . . di d~t rmrned by the C\t'rt ~ i1 t •
is un1 fo:mE:.1'.1 d ti on t!de111;:i and
Pr c e. :>. x u J
bli~11:nng
;ire
. J • · -1· .. j
. . th ~ a c ute phL!. e. :if U 0 \C ICC ' c.V
prom111e~1 rnh I I ' r p ha:-e. . - There• j,• :J rtem!er
WI pu I(.' s In I e a I. • J·:
. . _ 1, . - n tod i -.eminJtc ror,11 ,1:
ro:
t·
derm~tltlC de. ·~ail · r a ·ht:
.

primary . lle an . .·
ma: I e fou nd
s :111aed over the re. t f th e _kill.

l\ Jnnagem e nt

. . cm a nt inlef\ e 11i11 Ji w " a~h i.i:

Th e mo t unp . • . d · j>J ·
·· 111 so·1p :rnd " a ter "t'' eral umc . .a a . . <JJn
are n " 1 • • • • J .,
corti. cn tero1u ··rn (e · eo · ~ a.metha1..o
· . 1 crt:· u . e . <.i t-s ..., c.
nu in loncaceto nide ) houldb-.!<ip liedtV.J .c/<l(!J;f
\II o ther lo a l appl i <ition ho uld be a\ u Jt..r: .
r
derrna1111:- . w1"d e prea d and e·:ere . <3 . h <) .(. ()' Y:.
. . I. > •

o fs\' . tem1. k ro 1·d 1· re ·o mm ·nded. P red 1 J! 11: t'

0 .5 -m !!lkg daily u ually -.uffj~·e an? ·~ ~ t:d m
afte r J-4 dav . If . e ondary rn e H o I
o ur. c of y. tem i a nt ibiotic · _h o uld e

Photodermatiti.

Sy te mi c lupu .

Fii:un· -t6.12 G:rngr<"lhHIS lt•s i on~ nva 1h,· .::1.1r<"m i 1i~s :ind
nn ~.: duo: 111 purpura fuln1in a11s

In dcrl!!llc and other haemorrhagic feyer..

inlravcnous l ·tuids and other s upponiw me:.Jsures
form 1he mainslny of therapy. For detail.. please
rl!fcr 10 Chaprcr 29.

Eczcma/J>crmatitis~•

Exudative skin lesions accompanied by edem:.J.

bli ster. , papules and papulovc. icles are a common
reason for seeking urgent medical advice.
Commonly, lhese follow !he application of an irritant
substance for a banal skin problem. The range of
substances applied is large and includes undiluted
nnti cptks (dcllol. savlon), indigenous lotions (zalim
lotion, sapal lorion. bcetcx ), acid s, plant extracts.
and some propric1ary preparation s (Derobin). An
irritant dermatitis occurring in a linear. s treak y
paltcrn on exposed skin caused hy the vesicating
hody nu id of insec1s is seen commonly in the rainy
season. Dermatitis may also develop following
contact allergy to local medicament s u sed for
drcs,;i ng ;ind antifungal ointments. Occasionall y.
dermatiti s may develop at the site or a pyogenic
infection when purul.c nt discharge and cru. ting arc
rnorc prc1minent.
sympto m atic m a nageme n .
Ervthem a and bum in£ of
of kin· inYol\'ing th e fa ~ ( p odu i '.lL' 1:.-
pattern ). neck (C a ar ~ neckl·ce ). dor~-aJ <-. :::'.::.
of hand . forea rm s and feet are ·Ia '> <:-i v ft<::.' - ·
of nicotini c acid def1c i e cy_ P e ll <:.g L
characterized by a tria d o a .. ode ,. a~ti s. 6 ·- ·.
and dementia th a t u uallv oc ur in ·o. -=-·.::
earjng solely a corn bas~d di ei v.·bi::-.b i.s <i - • •
source of try ptophan. H a n: up d i e<:.. e ;_ ;:. · :
autosomal re essiYe di order due to j_
of meta bo lism with inability to a !>Or tr:·p~u;::: <
leading to deficient vmhe i o f ni .oi · · r · ::-i • ·,
pellagra-like . ynd;ome. T here i1, z _-r~·; ~: _:
response to admini tra tjon o f nicori ic aC':d t . f. -_ ;
mg daily) along with intaJ e o f ba12J~c
s upplement of other B comple · Yi t<: ·

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th C11:1r:...r ·,.·~- 7r · t: .!..... ..z:Tl~.J. i~·..-:-r.1j ,.,; .. .,
mJlar ..1rcJ' :i~J .:;u:: dtn.;: U' .:r th~ nJ!!c: of rbc: no~..: 1n J~
0

.i<lnk,c~n t ;::irl ""ith sy, t::-~i .: l:.rpti> c:r;.rh~mJm'lu,. There t.1

J.
int<.:n t! cr~!.h c: m;i. '>>1th r;ipufO-\ .;.'. j ul:ir ~1..in ft:Sll1 fl> h: vin ·•
! !1 . - ·'
-. -... ·..
1rrt::;ubr 1 .JI~-i~ I

:.
+.
mull:r.irn l:. !il.:."'·~1·- _·,,l~ "'· ... : . r~ .n:: ..~ . t. _,. ,_......,
CeUuliti -/'.."\ec ro li zin o FasciiHs 2! ~
; 01dl:.:7Tl<!! ·l t:'- :-:11:· , ... rr -.:llit~ .:... r-.· ,\ p ' ..,.
Inf ctioo c f th· Jeep d-rmi . a nd s uhcuwneous _._;_:~r-...· .::::n:--e.:u:__. ::.f-!;,., • •"t,;;~-,...... .:-.i. •.-. ::._:=.. . ..r ~ -

ti . ue by wphylococcus aureus :ind 5 Cha" " T -:~. . !1.rr::m::;-- . ~. ~.; :! ·.. . ..:.~. : 11u .. !lt. ... . ~L
S re1 :-ucvcc:uY p_·o:.,enes leads to celluliti<; . . ~ais FE.T·1::.1: z:nll l~L._; It :~ - . j ·· '=-. -'J f':""",-.:.."'."t\'.: • t . :-...~ :~...... .
may J ·velo p de rwrn or around a pre-e '\L ung l"'T' L.: :t..-:tl fTI_';!ffi~O~T: t!:IT -I1 ::_ l !~f'=: .: !C":" ..... i\,,l', _!

ksioo. Redne- ·- warm h. tenderness and swelling Dt~ 171Ull11J .:!l•J: _:.::· ~ - ~...
of a loc~li e 1 are~'. usuallv over the lo wer limb Ii.
d v top - rather rapidly .· T he area is u su al ~y
t.:on ·}uern.bly _\\ ollen and hm. The overlying skin .!lllG: f --, - •
is red and ma . h t\ bti ter ·. The draining: lymph
... ..
node are l- nder and enlar~ed. Ot:~.:: me. !IL.!. Htt:'"'-..t-2 ntu"'~ !l_mll."';: '"'a ~~ !h:.'::·J"\ ,-,
S me patientS. d~vclop more seve re damage enrrin g11~. ,·ur r ;: e~n:i q :-,. :-7· :-. . :-..~'2
with necn.b-is of .- kin -urrounded by infla mmatory
zone of ervth~m:i ahd blisterin!?. Lesions progr · 5 -
with ext~n~ion of necrosis.. Co n ':"um1iona1 symptom.
may bi! 'le•;ere in th~se patie nts. CJ. L:_11:f! 1~ ·.i:.zpn ~..!11-:1 ·::.::i ,~ · :.-..rt ~:n .. ·.1 . ~: n~, 't·
hi~tnrL'..ti ~!!. .- - :-. -=-:f>:--=:: .-:::ri.t=~~~~· .tf f;:::~'l :': rr~1.:. --t.:; ::1J.t}..
11f S'liip11."Jr:c·., c~::lJ,: Ju.r~'".l:... ..lmf . · 1~! -..."':" · 1 (. rtl.•.'
Management cp1dc~u t.~~c ·or.: rr. ~ ~":'t!" ...i : ... ·-~~ ! :t' ' U 1
1
"':r .. 1
.. ~."JJ ...1l-':J.ll [),.!.'7fkll':J t"' :~!>·~- ·-r- _. -
.... , lh~n:e-:utv, cetlutitl.s L'J O be managed f:ry ;re t
and i!le\-.d( on o f the p:m
and· '>y~re-mi:.: anti.oi~ti .. TfL Tcinnr.:::·:.:n ~ ' !r: :!tr.'!.."!' -;.~ .;:: - .Hi _1..·1.-·r~:. ~'i..11.
tne ra-p~ . Bed ~ st i·s advi ·ed. Thi! aff~cted - f.u:nl'J i llfd'""rHJnJ ~Tr -~i.U_rr""J~ {1'~iliJ:r ~t; r4.c::u ·' I ~ 1 _:~:
-~hould_ he c-1.e'lat~d on a piUOVt and k.!pt: ir:n:mohik - :i:~

. .· ... . . ..
.. .. · ~~
;" { ·-.~ '

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