CHICAGO Many childrens dermatologic diseases are
look-alikes, and careful differential diagnosis is necessary to find the
culprit behind pediatric lesions.
Speaking here at the American Academy of Pediatrics, Anthony J.
Mancini, MD, of Childrens Memorial Hospital, Northwestern University
Medical School, reviewed pediatric cutaneous presentations that could represent
several diseases and discussed methods of differentiating them from one
in a 5-year-old boy.
granuloma, or lobular capillary hemangioma, is an acquired, benign
vascular tumor fairly common in children, Mancini said. He said it may
develop within a port wine stain or other vascular malformation. The name is
misleading, he said, as a biopsy shows these lesions to be neither pyogenic or
granulomatous. The often dome-shaped, red papules bleed easily and sometimes
have a collarette at the base, which helps you if theres a question
about the diagnosis. The surface is often moist and friable. These
lesions are often treated by excision with electrocautery.
Pyogenic granuloma can resemble spitz nevi and juvenile
xanthogranuloma (JXG), Mancini said. Spitz nevi are typical melanocytic lesions
in children that are red but are flatter and not as friable. Unfortunately,
spitz nevi are often confused with melanoma, Mancini said.
JXG is red in young children, but the lesions normally become
lipidized, picking up a yellow-orange hue that can help differentiate them.
However, there is no association with any systemic hypercholesterolemia
or hyperlipidemia, he said. They are benign neoplasms more common in
younger children. If multiple JXG lesions are present, he recommended that
patients have an eye exam as the lesions can grow in the eye and cause anterior
Granuloma annulare (GA) is often mistaken for tinea corporis,
Mancini said. GA lesions are grouped papules in ringed or annular arrangement,
helping differentiate them from tinea, because they do not have scaling, he
said. The cause is unknown, although trauma is suspected. Occasionally the
lesions can be widely disseminated. The asymptomatic lesions are common over
bony prominences. A subcutaneous version is common in children, however.
GA can be treated with topical corticosteroids but often resolves
on its own. So really, just watchful waiting and reassurance,
Mancini said. While it can be confused for tinea corporis, the lesions of t.
corporis are more inflamed and often have scaling.
---Vitiligo in a 10-year-old
Vitiligo is acquired depigmentation in a specific
spot, particularly in places such as the inguinal creases and bony prominences.
Vitiligo is common, occurring in about 1% of the population. It can be
generalized or localized, and about one-half of patients have pediatric onset.
Vitiligo is true depigmentation in macules and patches, and not just
hypopigmentation such as with pityriasis alba or tinea versicolor. Because it
is an autoimmune response against melanocytes, vitiligo may have associated
halo nevi or poliosis.
Segmental vitiligo is common in children, and it is a dermatomal
distribution of pigment loss that is localized. The disease can be associated
with thyroid disease and pernicious anemia. Treatment of vitiligo is
difficult, Mancini said, and may include topical steroids, psoralen and
light therapy or cover-up cosmetics. Ive been underwhelmed by
everything. Nothing consistently works in every patient. He said he
weighs risks carefully in children, tending to stick to more benign therapies.
Transient neonatal pustular melanosis presents as juicy pustules
in the first few days of life on the chin, neck, forehead, palms, soles and
buttocks, and 1% to 5% of all black infants have these lesions. The pustules
resolve in a few days, although hyperpigmentation may last for a few months.
Diagnosis can be assisted by looking for collarettes around the pustules. The
child is otherwise well, and the pustules resolve on their own.
This is distinguished from congenital candidiasis, Mancini said,
by its lack of inflammation and the fewer number of smaller pustules with
neonatal melanosis. Vesicular newborn disease is often problematic to diagnose.
You really have to work these up systematically, and it can be difficult
just from skin exam, although there can be some cues. Also, miliaria or
prickly heat, two other lesions that can be confused with melanosis, will both
be dispersed in clothing-covered areas and resolve in a few days if the child
is kept cool.
H. BRIEN, DO
Congenital cytomegalovirus (CMV) is one of several
etiologies for blueberry muffin rash, but babies with CMV often
have numerous complications including hepatomegaly, splenomegaly, jaundice and
hematologic complications. The virus can be isolated from urine or another
sterile site, and while ganciclovir (Cytovene, Roche) can be given in extreme
cases, traditionally there is no therapy.
CMV can resemble other dermal hematopoiesis disorders, such as
rubella, red blood cell deficiencies and parvovirus B19. Also, neoplastic
infiltrates can cause further problems, especially congenital leukemia and
Nevus sebaceous is a hamartoma of primarily the sebaceous glands
and affects 3:1,000 infants. The lesions manifest in a well-demarcated pink,
yellow-orange or tan plaque on the nasal bridge, and they are often devoid of
hair. The color fades and flattens after infancy, although they change at
adolescence, becoming more prominent and greasy.
There is a risk of secondary neoplasm with nevus sebaceous,
including a 6% to 15% chance of basal cell carcinoma later in life. The lesions
can be excised. While they could be confused with JXG, Mancini said, nevus
sebaceous is far more common than JXG.
For more information:
- Mancini A. Look-alikes and controversies in pediatric
dermatology. Session E403. Presented at the American Academy of Pediatrics.
February 4-8. Chicago.