Not All Rash is Caused by Allergy

KOMANG AYU WITARINI

ASIA PACIFIC ACADEMY OF PEDIATRIC

ALLERGY, RESPIROLOGY AND IMMUNOLOGY (APAPARI) CONGRESS
THE STONES HOTEL, BALI, INDONESIA
9-12 October 2019
 Introduction

• Skin problems contribute about one-third of all consultation in

pediatric and dermatologist outpatient clinic
• Developing country: infections (bacterial, fungal, viral) and
infestation (scabies) are the most common skin problem,
followed by eczema

Ramos JM, et al. Asian Pac J Trop Biomed. 2016;6(7);625-9

Sethuraman G, et al. Indian J Pediatr. 2014;81(4):381-90
WHO. Epidemiology and management of common skin diseases in children in developing countri. 2005.

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 What is Rash?

Eruption of the body

Primary Skin Lesion Secondary Skin Lesion

2
 Primary Skin Lesion
Morphology
Macule Flat circumcribed, non palpable lesion with color change (hyper or
hypopigmented, erythematous) <1 cm diameter
Patch Macule with ≥1 cm diameter
Papule Raised lesion <0,5 cm diameter
Plague A flat topped, elevated area of the skin ≥0,5 cm diameter, may formed from
coalescence of Papules
Nodule A solid lesion (>0,5 cm) with deep (dermal and/or subcutaneous) component
Vesicle Well circumscribed fluid-filled lesion <0,5 cm diameter
Bulla Vesicle with ≥0,5 cm diameter
Pustule Circumscribed lesion filled with purulent exudate
Wheal A localized edematous plaque-like lesion, somewhat irregular and transient
Cyst A circumscribed, usually slightly compressible, round, walled lesion, below the
epidermis, may filled with fluid or semi-solid material

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 What Skin Lesion?
A B

• Flat • Flat
• Hyperpigmentation • Hyperpigmentation
• <1 cm diameter • >1 cm diameter

4
 What Skin Lesion?
C D E

• Raised • Raised • Palpable solid

• <0,5 cm • > 0,5 cm • Deep component
• > 0,5 cm

5
 What Skin Lesion?
F G H

• Well circumscribed • Well circumscribed • Circumcribed

• Fluid fill • Fluid fill • Fill purulent
• <0,5 cm • > 0,5 cm exudate

6
 What Skin Lesion?
I J

• localized • Circumscribed, round

edematous plaque- • Walled lesion
like lesion • Below epidermis
• Irregular, transient

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 Secondary Skin Lesion
Morphology
Scale Surface alteration resulting in a “flaky” surface, due to hyper-
proliferation stratum corneum, being thick and greasy, or loose
of adherent
Crust Dried residue of serum, blood or pus
Excoriation Linier erosion cause by mechanical means
Fissure Vertical cleft extending into the dermis
Erosion Loss portion of the epidermis, superficial and non-scarring
Ulcer Loss of skin extending into the dermis, scarring
LIchenification Hyperplasia of epidermis
Athropy Thining of epidermis and/or dermis

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 What Skin Lesion?
A B

• Thick and greasy • Dried residue of

stratum corneum serum and pus
• Loose of adherent

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 What Skin Lesion?
C D

• Linier erosion • Vertical cleft into

dermis

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 What Skin Lesion?
E C
F

• Loss portion of the • Loss of skin extending

epidermis into dermis
• Superficial

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 What Skin Lesion?
G H

• Hyperplasia of • Thining of epidermis

epidermis

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 What the diagnosis?
CASE 1
11 years old girl with chief complaint of intense body itchiness between
the fingers, wrist, palm, and armpit, especially at night. She reports that
her friends have the same itchy.
The general examination was within
normal limits with optimal vital
measures.
On examination found
maculopapules, round shaped with a
well defined border, discrete
presentation and distributed
bilaterally
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 Diagnosis of The Maculopapular Rash

Central Distribution Peripheral Distribution

Fever/ill Fever/ill
Yes No Yes No

• Viral Exanthem • Drug Reaction Target Lesions Lesi Distribution

• Lymp Ds. • Pityriasis
(Erythema (Herald Patch) Yes No
Migrans) Flexor Extensor

• Erythema • Meningoco • Scabies • Psoriasis

Multiforme ccemia • Ecxema
• SJS/TEN • RMSF
• Syphilis
Murphy-Lavoie, et al. Emedmag. 2010:6-16
• Lymp Ds.
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 Diagnosis of The Maculopapular Rash

Central Distribution Peripheral Distribution

Fever/ill Fever/ill
Yes No Yes No

• Viral Exanthem • Drug Reaction Target Lesions Lesi Distribution

• Lymp Ds. • Pityriasis
(Erythema (Herald Patch) Yes No
Migrans) Flexor Extensor

• Erythema • Meningoco • Scabies • Psoriasis

Multiforme ccemia • Ecxema
• SJS/TEN • RMSF
• Syphilis
Murphy-Lavoie, et al. Emedmag. 2010:6-16
• Lymp Ds.
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There are four cardinal signs to diagnose scabies:
1. Nocturnal pruritus
2. Affecting group
3. Burrow; a short, wavy, scaly, grey line on the skin surface appearance
4. Sarcoptes scabiei (mite) on witness

The diagnosis can be made as long as the patient met two over four of
the cardinal signs

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 What the diagnosis?
CASE 2
Four years and six months boy was admitted to the Paediatrics Clinic caused
by generalized skin rash associated with fever. Clinical progress of a boy with
macular erythema followed by diffuse epidermal exfoliation from the face
and back is described

On examination: nikolsky
sign was positive

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 Diagnosis of The Erythematous Rash

Nikolsky Sign
Yes No

Febrile Afebrile Febrile Afebrile

• SSSS (child) • SJS/TEN • TSS (mucous • Anaphylaxis

• SJS/TEN membrane) • Scombroid
(adult) • Kawasaki Ds. poisoning
(swollen hand) • Alcohol Flush
• Scarlet fever
(sandpaper
rash)
Murphy-Lavoie, et al. Emedmag. 2010:6-16
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 Diagnosis of The Erythematous Rash

Nikolsky Sign
Yes No

Febrile Afebrile Febrile Afebrile

• SSSS (child) • SJS/TEN • TSS (mucous • Anaphylaxis

• SJS/TEN membrane) • Scombroid
(adult) • Kawasaki Ds. poisoning
(swollen hand) • Alcohol Flush
• Scarlet fever
(sandpaper
rash)
Murphy-Lavoie, et al. Emedmag. 2010:6-16
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 Comparing SSSS and SJS
SSSS SJS
Infection: staphylococcus Drug causes
Commonly occur in Infants Uncommon in infant
Krusta lesion Macular dusty lesions
No mucosal involvement 90% mucosal involvement and many on
more than one sites
Skin biopsy: intradermal cleavage with Skin biopsy: full- thickness epidermal
acantholysis in the subgranular layer necrosis and dermal-epidermal separation

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 What the diagnosis?
CASE 3
This 5-year-old girl presented with sudden onset of diffuse purpuric and
petechial skin lesions, subfebrile. She had swelling and pain of her knees. She
suffer from “cold” a week before.
On examination found diffuse palpable
purpuric and petechial skin lesions

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Diagnosis of The Petechial/Purpuric Rash

Murphy-Lavoie, et al. Emedmag. 2010:6-16

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Diagnosis of The Petechial/Purpuric Rash

Murphy-Lavoie, et al. Emedmag. 2010:6-16

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EULAR criteria for HSP:
Mandatory criteria:
• Palpable purpura
Plus one of the following criteria:
• Diffuse abdominal pain
• IgA deposition in any biopsy
• Arthritis/Arthralgia
• Renal involvement (hematuria and/or proteinuria)

Tizard EJ, et al. Archives of Disease in Childhood: Education and Practice. 2008;93:1-8

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 What the diagnosis?
CASE 4
A 6-year-old boy presents with fever, headache and a diffuse, pruritic,
vesicular rash, which is most prominent on the face and chest. He has had
generalized malaise and low-grade fever for a few days prior to presentation.
He developed high fever and a rash in the last 48 hours.
On examination: few scattered vesicular
lesions prominent on the face and chest,
but all extremities are also involved. In
some areas the lesions are crusted, while
in others they appear newly formed.
Classmate had the symptom a few days
ago
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Diagnosis of The Vesiculobulous Rash

Murphy-Lavoie, et al. Emedmag. 2010:6-16

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Diagnosis of The Vesiculobulous Rash

Murphy-Lavoie, et al. Emedmag. 2010:6-16

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DIAGNOSIS
•Typical vesicular rash at different stages, with pruritus, fever, malaise,
frequently a history of exposure
•Classically, lesions are described as "dew drops on a rose petal,"
vesicular lesions filled with clear fluid and surrounded by erythema.

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 What the diagnosis?
CASE 5
A 2-month-old boy developed scaly yellowish eruption on the face skin.
History: scaly patches had appeared in the previous week. The baby was
otherwise well and thriving

On examination, there were greasy

yellow scaly patches on the skin of the
face

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 • Seborrheic dermatitis is a clinical diagnosis based on the location
and appearance of lesions
• In infants, it is usually benign and resolves spontaneously
Most Common. Red-yellow plaques coated by thick, greasy scales on
Scalp vertex, appearing within 3 months of age.

Erythematous, flaky, salmon-colored plaques on forehead, eyebrows,

Face/Retro-auricular area eyelids, nasolabial folds, or retro-auricular areas.
efflorescence
Lesions have moist, shiny, non-scaly aspects that tend to coalesce on
Body folds neck, axillae or inguinal area.

More extensive form: Sharply limited plaques of erythema and scaling

Trunk
that cover lower abdomen.

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 What the diagnosis?
CASE 6
A 10 year old male, come to pediatrician accompanied by his mother.
During the visit, he is noted to frequently scratch the flexural areas of his
arms.
History: He has complained of dry, itchy skin on his arms for many years
that worsened over the past 2 years. Symptoms getting worse in cold
weather. Mother had asthma and he also has asthma since 4 years of age

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On examination, he has dry skin,
erythema, dryness, lichenification
noted in flexural areas of both arms.
Hyperlinear palms and increased
scaling on legs

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 Hanifin and Rajka Diagnostic Criteria for Atopic Dermatitis
Major Criteria: must have 3 or more of:
• Pruritus
• Typical morphology and distribution
• Flexural lichenification or linearity in
adults
• Facial and extensor involvement in
infants and children
• Chronic or chronical-relapsing dermatitis
• Personal or family history of atopy
Minor criteria: should have three or more of:
• Xerosis
• Ichtyosis, palmar hyperlinearity, or keratosis pilaris
• Immediate (type 1) skin test reactivity
• Raised serum IgE
• Early age of onset
• Tendency toward cutaneous infection or impaired cell-
mediated immunity
• Tendency toward non specific hand or foot dermatitis
• Nipple eczema
• Cheilitis
• Recurrent conjunctivitis
• Dennis-morgan infraorbital fold
• Keratoconus
• Anterior subcapsular cataracts
• Orbital darkening
• Facial pallor or facial erythema
• Pityriasis alba
• Anterior neck folds
• Itch when sweating
• Intolerance to wool and lipid solvent
• Perifollicular accentuatum
• Food intolerance
• Course influence by environmental or emotional factor
• White dermographism or delayed blanch

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 Skin Rash: When to consider allergy?

Clinical history:
• Itch and impact on daily activity
• Diseases persistence  symptom chronically and fluctuated with
remission and relapse
• Triggers factor
• Risk factor  personal or family history of atopy

Yes No

Allergy Non Allergy

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 Conclusions

• Rashes may be difficult to differentiate by appearance alone, it is

important to consider the entire clinical presentation, include the
appearance and location of the rash, the clinical course, and associated
symptoms, such as pruritus or fever
• Allergic rashes  pruritus, disease persistence, triggers factor, risk
factor (family history of atopy)

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