Pediatric dermatology emergencies.

Many pediatric skin conditions can be safely monitored with minimal intervention, but certain skin conditions are emergent and require immediate attention and proper assessment of the neonate, infant, or child. We review the following pediatric dermatology emergencies so that clinicians can detect and accurately diagnose these conditions to avoid delayed treatment and considerable morbidity and mortality if missed: staphylococcal scalded skin syndrome (SSSS), impetigo, eczema herpeticum (EH), Langerhans cell histiocytosis (LCH), infantile hemangioma (IH), and IgA vasculitis.

Epidemiology of Eczema Herpeticum in Hospitalized U.S. Children: Analysis of a Nationwide Cohort.

Eczema herpeticum (EH) is characterized by viral infection of a preexisting inflammatory dermatosis and is associated with considerable morbidity. In this cross-sectional study, we sought to determine the incidence, risk factors, comorbidities, costs of care, length of stay, and mortality in hospitalized U.S. children with EH. The Nationwide Inpatient Sample 2002-2012, containing a 20% sample of all U.S. hospitalizations, was analyzed. We used a validated approach involving InternationalClassification of Diseases, Ninth Revision-Clinical Modification codes to identify patients primarily admitted for EH (n = 4,655 weighted). The mean annual incidence of hospitalization for EH per million children ranged from 4.03 to 7.30, increasing significantly from 2008 to 2012. EH was associated with younger age (odds ratio [95% confidence interval] for 3-4 years = 1.29 [1.02-1.64]) and nonwhite race/ethnicity (black = 2.93 [2.35-3.66], Asian= 4.41 [3.34-5.83], Native American = 2.96 [1.51-5.78]) but was less likely to occur in areas with lower income quartiles (quartile 1, 0.66 [0.53-0.84]; quartile 2, = 0.68 [0.54-0.87]; quartile 3, 0.70 [0.56-0.88]). EH was associated with atopic dermatitis (11.72 [9.48-14.49]). Increased length of stay and costs of care were associated with Asian race. Mean length of stay was 3.86 ± 0.09 days, and mean cost of care was $5,237.6 ± 160.6. Overall mortality was 0.1%. EH in hospitalized children poses a substantial burden to the health care system.

IL-1R Type 1-Deficient Mice Demonstrate an Impaired Host Immune Response against Cutaneous Vaccinia Virus Infection.

The IL-1 superfamily of cytokines and receptors has been studied extensively. However, the specific roles of IL-1 elements in host immunity to cutaneous viral infection remain elusive. In this study, we applied vaccinia virus (VACV) by scarification to IL-1R1 knockout mice (IL-1R1-/-) and found that these mice developed markedly larger lesions with higher viral genome copies in skin than did wild-type mice. The phenotype of infected IL-1R1-/- mice was similar to eczema vaccinatum, a severe side effect of VACV vaccination that may develop in humans with atopic dermatitis. Interestingly, the impaired cutaneous response of IL-1R1-/- mice did not reflect a systemic immune deficiency, because immunized IL-1R1-/- mice survived subsequent lethal VACV intranasal challenge, or defects of T cell activation or T cell homing to the site of inoculation. Histologic evaluation revealed that VACV infection and replication after scarification were limited to the epidermal layer of wild-type mice, whereas lack of IL-1R1 permitted extension of VACV infection into dermal layers of the skin. We explored the etiology of this discrepancy and determined that IL-1R1-/- mice contained significantly more macrophages and monocyte-derived dendritic cells in the dermis after VACV scarification. These cells were vulnerable to VACV infection and may augment the transmission of virus to adjacent skin, thus leading to larger skin lesions and satellite lesions in IL-1R1-/- mice. These results suggest new therapeutic strategies for treatment of eczema vaccinatum and inform assessment of risks in patients receiving IL-1 blocking Abs for treatment of chronic inflammatory disorders.

Management of eczema herpeticum in a Burn Unit.

OBJECTIVE: To study the clinical features, course and outcome of eczema herpeticum in burn patients. METHODS: This prospective study was conducted at the King Edward Medical University / Mayo Hospital, Lahore, Pakistan, from November 2012 to October 2015, and comprised eczema herpeticum patients. Demographic and clinical features of the patients, treatment protocols and outcomes were noted. SPSS 18 was used for data analysis. RESULTS: Of the 18 patients, 10(56%) were females and 8(44%) were males. The overall mean age was 29.17±8.36 years. The mean total body surface area burnt was 30.83±8.58%. Besides, 7(39%) patients had 2nd degree burns and 11(61%) had both 2nd and 3rd degree burns. There was no history of previous skin disease. Moreover, 4(22%) patients had diabetes and 6(33%) were smokers. The mean difference between the occurrence of fever and the appearance of skin lesions was 4.44±1.46 days. The overall mean temperature was 102.22±1.06 oF. The mean duration between the eruption of skin lesions and crusting of lesions was 4.38±1.26 days. Areas involved with skin lesions were trunk in 13(72%) patients, arms 12(67%), thigh 10(56%) and face in 4(22%) patients. Also, 2(11.1%) patients developed acute respiratory distress syndrome. Tzanck test showed multi-nucleated giant cell in all patients. The mean number of days since the eruption of lesions and the settling of fever was 5.56±0.73 days. The mean duration for complete healing, which occurred in 16(89%) patients, was 3.81±0.75 weeks. The overall mean follow-up period was 15±2.03 months. CONCLUSIONS: Eczema herpeticum may occur in a burn patient and should never be missed as early diagnosis will lead to a better outcome.

Eczema herpeticum in children: clinical features and factors predictive of hospitalization.

OBJECTIVE: To describe the clinical characteristics of pediatric patients with eczema herpeticum and to determine the predictors of hospitalization, and recurrence and repeat episodes. STUDY DESIGN: A retrospective cohort study of patients 0-18 years of age diagnosed with eczema herpeticum between May 2000 and April 2009 was carried out at a tertiary pediatric care center in Canada. Seventy-nine patients were included. The primary outcome was hospitalization; secondary outcomes were recurrent and repeat episodes of eczema herpeticum. RESULTS: At presentation, 76% of 79 patients with eczema herpeticum had a generalized eruption, 56% had fever, 37% had systemic symptoms, and 10% had eye involvement (keratoconjunctivitis). Forty-five patients (57%) were hospitalized. Predictors for hospitalization included male sex (OR = 3.09; 95% CI, 1.20-7.95, P = .017), fever (OR = 5.75; 95% CI, 2.17-15.26, P < .001), systemic symptoms (OR = 2.84; 95% CI, 1.06-7.62, P = .035), and age <1 year (OR = 7.17; 95% CI, 2.17-23.72, P = .001). Recurrence rate (<1 month) was 8.9% and rate of repeat episodes (>1 month) was 16%. Hospitalized patients were more likely to have a repeat episode (OR = 8.25; 95% CI, 0.99-68.69, P = .05). Patients with a previous history of eczema herpeticum had increased likelihood of early recurrence (OR = 6.80; 95% CI, 0.99-46.62, P = .05) and repeat episodes (OR = 9.43; 95% CI, 1.52-55.9, P = .01). CONCLUSIONS: Predictors of hospitalization in this cohort included male sex, age <1 year, fever, and systemic symptoms at presentation. Hospitalized patients may be at risk for repeat episodes of eczema herpeticum.

Vaccinia virus inoculation in sites of allergic skin inflammation elicits a vigorous cutaneous IL-17 response.

Eczema vaccinatum (EV) is a complication of smallpox vaccination occurring in patients with atopic dermatitis. In affected individuals, vaccinia virus (VV) spreads through the skin, resulting in large primary lesions and satellite lesions, and infects internal organs. BALB/c mice inoculated with VV at sites of Th2-biased allergic skin inflammation elicited by epicutaneous ovalbumin (OVA) sensitization exhibited larger primary lesions that were erosive, more satellite lesions, and higher viral loads in skin and internal organs than mice inoculated in saline-exposed skin, unsensitized skin, or skin sites with Th1-dominant inflammation. VV inoculation in OVA-sensitized skin induced marked local expression of IL-17 transcripts and massive neutrophil infiltration compared to VV inoculation in saline-exposed skin. Treatment with anti-IL-17 decreased the size of primary lesions, numbers of satellite lesions, and viral loads. Addition of IL-17 promoted VV replication in skin explants. These results suggest that IL-17 may be a potential therapeutic target in EV.

[Eczema herpeticum: Pathogenesis and therapy]. / Eczema herpeticatum: Pathogenese und Therapie.

Eczema herpeticum is an acute, disseminated herpes simplex virus infection which remains a feared complication of eczematous skin diseases, especially atopic dermatitis. The vesicular and erosive clinical picture is often accompanied by systemic signs and symptoms. Why some atopic patients experience multiple attacks of eczema herpeticum and others never have the disorder remains a mystery. Patients with severe or untreated atopic dermatitis are more likely to be affected. The pathogenesis appears to involve a complex interplay of factors, including demasking of binding sites for the virus through the dermatitis, failure to up-regulate antiviral proteins and a lack of plasmacytoid dendritic cells. Treatment of choice is systemic acyclovir therapy.

Viral infections in atopic dermatitis: pathogenic aspects and clinical management.

A number of different widespread and disseminated viral infections can occur in patients with atopic dermatitis. Eczema molluscatum is troublesome but not dangerous. Although eczema vaccinatum is rare, it is life-threatening and of increased concern as smallpox vaccinations are reintroduced as a response to possible bioterrorism. There is little information on the course of smallpox itself in atopic dermatitis. Eczema herpeticum is the most common member of this group; recent advances in understanding its pathogenesis might contribute to a more successful management of this serious complication.

Adverse events occurring after smallpox vaccination.

We reviewed the literature on adverse events reported to occur after smallpox vaccination. Nearly one-half of the United States population is vaccinia-naïve and may be at risk for development of serious adverse events. We describe the clinical features of postvaccinial central nervous system disease, progressive vaccinia, eczema vaccinatum, accidental implantations, "generalized vaccinia," and the common erythematous and/or urticarial rashes. In the 1960s, death occurred approximately once in every million primary vaccinations, with fatalities resulting from progressive vaccinia, postvaccinial encephalitis, and eczema vaccinatum. Death in revaccinees occurred less commonly and almost entirely from progressive vaccinia. In today's population, death rates might be higher because of the increased prevalence of immune deficiency and atopic dermatitis.

[Eczema herpeticum in children: clinical picture and therapy]. / Eczema herpeticatum u detí: klinický obraz a terapie.

The authors submit information on the course and therapeutic experience with acyclovir (Zovirax Wellcome Co. and Herpesin Lachema Co.) in 67 children with eczema herpeticatum (EH) who were hospitalized at the Clinic of Infectious Child Diseases in Brno from January 1983 to January 1991. In all instances treatment led to rapid drying of the herpetis eruptions, a shorter period of new eruption and rapid improvement of the serious clinical condition. In none of the children visceral dissemination of the virus of herpes simplex (HSV) were occurred and in none of the children toxic side-effects were found. The authors confirmed the assumed identical course of EH after i. v. administration of acyclovir of foreign or local origin. After i.v. administration frequently dramatic improvement of the general and local finding was recorded, as compared with oral administration. There were no therapeutic differences in the clinical effects of tablets and suspension, the clinical effect being comparable.