What Vaccines Does an Infant Need to Travel Abroad?

Patient Presentation

A 6 1/2-month-old male came to clinic for a health supervision visit. He is healthy but the parents want to know what they need to do before he leaves the United States in 3 months for a year long visit to China with relatives.
The pertinent physical exam shows a healthy infant with normal growth and development.

The diagnosis of a healthy infant who will be travelling internationally was made and his regular vaccines for a 6 month old were given. Additionally, a measles vaccine was given as he will be living in an endemic area.

Discussion
The world continues to globalize and more and more people are frequently travelling. Whether it is within the United States or internationally, people must be aware of the potential travel health risks. Some people say, “We’re just taking a cruise,” but they forget that the ship itself is like a small institution with its own health hazards, not to mention the ports of call that they will be going to.

There are no absolute answers as each travel situation is unique. The following is not a comprehensive list, but in general, the risks can be divided into major categories:

Diseases carried by insects including Dengue fever, Japanese Encephalitis, Malaria and Plague.

  • Pay special attention to mosquito protection between dusk and dawn. This is when the mosquito transmitting malaria is most active.
  • If visiting a malaria area, take malaria prevention medication before, during, and after travel as directed. If a fever or flu-like illness occurs either during travelling or up to 1 year after returning home (for up to 1 year), a physician should be seen and told of the travel history as part of the evaluation.
  • Wear long-sleeved shirts, long pants, and hats.
  • Use insect repellents that contain DEET (diethylmethyltoluamide). Follow the label directions closely.
  • Apply insect repellent to exposed skin, but not to broken skin.
  • With DEET, do not breathe, swallow, or get it into the eyes. If using a spray, put the DEET onto the hands and rub it carefully onto the face. The eyes, nose and mouth should be avoided.
  • DEET may be used on adults, children, and infants older than 2 months of age. Protect infants by using a carrier draped with mosquito netting with an elastic edge for a tight fit.
  • Parents should apply insect repellant to children under 10 years of age. Do not apply to young children’s hands or around eyes and mouth.
  • Use a bednet that has been sprayed with permethrin or deltamethrin, unless you are staying in an air-conditioned or well-screened house

Diseases carried in food or water (including those contaminated from animals) include Cholera, Escherichia coli, Hepatitis A, Schistomiasis, Typhoid Fever, Cryptosporidium, Giardia, Hepatitis A, and Norwalk virus.

  • Drink only bottled or boiled water, or carbonated beverages in cans or bottles. Avoid tap water, fountain drinks, and ice cubes.
  • Use this water to brush teeth and wash/prepare foods, and bathe.
  • If these types of water cannot be found, make water safer by BOTH filtering through an “absolute 1-micron or less” filter AND adding iodine tablets to the filtered water. These filters can be found in camping/outdoor supply stores.
  • Do not eat food purchased from street vendors.
  • Do not handle animals to avoid bites and serious disease. Cats, dogs and monkeys are especially risky.
  • Do not swim in fresh water (except for well-chlorinated swimming pools) in certain areas of China to avoid schistosomiasis. Salt water is usually safer. Cryptosporidium, Giardia, Hepatitis A, and Norwalk virus have moderate to very high resistance to chlorine levels commonly found in chlorinated swimming pools. Care must be taken not to drink this water. Remember children often drink water they are swimming or bathing in so even chlorinated swimming pools may not be a good option in some cases.

Diseases from person-to-person contact include Hepatitis B and HIV/AIDS

  • Do not have sexual contact (heterosexual or homosexual) with an infected person, or a person likely to be infected such as a sex worker.
  • Do not allow the use of contaminated, unsterilized syringes or needles for any injections or other skin-piercing procedures, including acupuncture, use of illicit drugs, steroid or vitamin injections, medical or dental procedures, ear or body piercing, or tattooing.
  • Do not allow the use of infected blood, blood components, or clotting factor concentrates. This mode of transmission is rare in cities or countries where donated blood products are screened.

Diseases from animals include many diseases already listed but especially rabies.

  • Care should be taken to avoid encountering all wild animals and also domesticated animals in endemic areas.
  • Most bites and stings from arthropods are unpleasant but do not cause serious disease.
  • Half of snake bite wounds contain venom but any snake bite should be evaluated by medical personnel.

Indications for appropriate travel vaccinations depend on the location, risks and patient age. Again each situation is unique. Often children under 1 year cannot receive vaccines other than the standard vaccines that would be given at their health supervision visits.
Children over the age of 7, often can receive all the indicated vaccines as would an adult. Between 1 and 7 years, the age when a child can receive the vaccine varies greatly between vaccines.

Learning Point

The evaluation of this child’s travel immunization needs included checking the Centers for Disease Control traveller’s Health website at: http://www.cdc.gov/travel/ for information on East Asia. This is a comprehensive government resource with the most current information available for health risks worldwide. He will be going to a Chinese province with known malaria risks. The general recommended vaccines include Hepatitis A, Hepatitis B, Japanese Encephalitis Virus, Typhoid, Diptheria/Tetanus, and Measles.
Because of this child’s age, he could not receive many of these vaccines. He finished the primary series for Hepatitis B and Diptheria/Tetanus and received the Measles vaccine in addition. Note that he will still need 2 measles vaccines after the age of 12 months for full immunity. General information about eating and drinking safe food and water, and decreasing risks from mosquitos and animals was discussed and written information was given to his family.
He will come to clinic before he goes to China and will be given a prescription for Azithromycin for traveller’s diarrhea and will begin his malaria prophylaxis. Liberal use of alcohol-based hand gels to help decrease risks of water contamination will also be recommended to help with hand hygiene. He will also be sent to China with a copy of his immunization records and a brief summary of his medical care to date.

Questions for Further Discussion
1. What information should be given to parents about traveller’s diarrhea?
2. What special considerations should given given to international adoptees?
3. What special considerations should be given to pregnant and nursing mothers?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for this topic: Traveling with Small Children.

American Academy of Pediatrics. Measles, In Pickering LD, ed. Red Book: 2003 Report of the Committee on Infectious Diseases. 26th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2003;426.

Centers for Disease Control. Animal-Associated Hazards. Available from the Internet at http://www.cdc.gov/travel/other/animal-hazards.htm (rev. 7/03/03, cited 4/28/05).

Centers for Disease Control. Acquired Immunodeficiency Syndrome (HIV). Available from the Internet at http://www.cdc.gov/travel/diseases/hivaids.htm (rev. 7/30/03, cited 4/28/05).

Centers for Disease Control. Rabies. Available from the Internet at http://www.cdc.gov/travel/diseases/rabies.htm (rev. 4/14/04, cited 4/28/05).

Centers for Disease Control. New Drug Approved for the Treatment of travellers’ Diarrhea. Available from the Internet at http://www.cdc.gov/travel/other/drug_for_td_approval_2004.htm(rev. 10/14/04, cited 4/28/05).

Centers for Disease Control. Health Information for travellers to East Asia. Available from the Internet at http://www.cdc.gov/travel/eastasia.htm (rev. 4/14/05, cited 4/28/05).

Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

Date
May 30, 2005

How Often Does Appendicitis Perforate?

Patient Presentation

A 3-year-old male was transferred after 24 hours of abdominal pain, diarrhea and emesis. He had at least 15 loose-watery yellow stools without blood over the past 12 hours but these seem to be decreasing more recently.
The emesis occurred 3-4 times with the last emesis about 4 hours ago. The emesis is yellow stomach contents.
The abdominal pain is described as being in the lower abdomen.
His mother also noted that in the past few hours he has had decreased urine output.
The review of systems was negative.
In the local emergency room he was noted to have a temperature of 101.9 degrees F, laboratories consistent with moderate dehydration, and air fluid levels on the abdominal radiograph. The complete blood count showed white blood cells of 13.5 x 1000/mm2 and a urinalysis with 10 white blood cells/high power field.
The pertinent physical exam shows a tired preschooler in mild pain. Temperature is 101.5 degrees F and other vital signs are normal. Lungs are clear to ausculatation and percussion. Abdominal examination shows mild distention, slightly decreased bowel sounds,
tender to minimal touch with no guarding or localization. Rectal examination showed pain and a mass in the right lower quadrant. Genitourinary examination reveals no inguinal hernia. The remainder of his examination was normal.
The repeated laboratory evaluation shows a complete blood count of 16.2 x 1000/mm2.
The radiological evaluation was a repeated abdominal radiographs demonstrating multiple dilated loops of small bowel with air fluid levels. There is also a suggestion of a soft tissue fullness in the right lower quadrant which is displacing the bowel
(see Figure 15). The patient was taken to the operating room where an exploratory laparotomy revealed the diagnosis of a ruptured appendix and pus surrounding
the appendix. An appendectomy and decontamination of the abdomen were performed. He was placed on intravenous antibiotics.
His clinical course over the next few days showed that he had a decreasing fever curve on antibiotics for 5 days. He was discharged home on day 6 off of antibiotics.


Figure 15 – Supine (left) and upright (right) radiographs of the abdomen
demonstrate multiple dilated loops of small bowel with air fluid levels. There is also a
suggestion of a soft tissue fullness in the right lower quadrant which is displacing the bowel
loops centrally.

Discussion
Appendicitis results from a closed loop obstruction of a blind-ending tubular structure arising from the cecum. It is a common cause of abdominal pain. It is the most frequent condition leading to emergent abdominal surgery in pediatrics. The combination of obstruction, edema, bacterial overgrowth, increased inflammatory process and increased intraluminal pressure leads to abdominal pain and possibly perforation.
Appendicitis occurs in all age groups but is rare in neonates. The peak age is 6-10 years old.

Classically appendicitis begins with the development of anorexia and periumbilical pain, followed by vomiting and right lower quadrant pain. However, this presentation occurs in < 60% of patients.
The periumbilical pain is often poorly defined but is often associated with anorexia that preceeds nausea and vomiting. After a few hours the pain shifts to the right lower quadrant and is generally more intense and pinpoint. Children will often be afebrile or have a low grade fever.

In contrast to appendicitis, abdominal pain with an acute onset occurs more in ischemic conditions such as torsion, volvulus, intussception, etc. Shifting of localized abdominal pain generally doesn’t occur in other abdominal conditions than appendicitis.

The physical examination often shows a child who prefers to lie still to minimize the peritoneal irritation. The exact location of the pain depends on the location of the appendix. Typically the maximal tenderness is at McBurney’s point in the right lower quadrant. Rovsing sign suggestions peritoneal irritation and is pain in the right lower quadrant when left-sided palpation occurs.
A psoas sign can be elicited by placing the child on the left side and hyperextending the right leg. The obturator sign is elicited by internal rotation of the right thigh in a flexed position. Pain with this movement is caused by an inflammed appendix or other mass overlying the psoas muscle.
A sharp pain when coughing in the right lower quadrant is also suggestive of peritoneal irritation. The rectal examination should be done last and can reveal right sided tenderness, a mass or impacted stool.

A complete blood count usually shows an elevated white blood cell count; more than 15 x 1000/mm2 WBCs may indicate a perforated appendix. Appendicitis may cause irritation of the bladder with some WBCs in the urine. More than 20 WBCs suggests a urinary tract infection. A normal urinanalysis generally is not helpful to include or exclude appendicits.
Electrolytes, renal function tests, liver function tests and human chronionic gonadotropic-beta subunit testing (beta – hCG) are often helpful for management and determining possible other abdominal pain etiologies.

Plain film radiographs generally are not helpful in the diagnosis of appendicitis. A calcified appendicolith may be seen and adds weight to the clinical diagnosis.
Ultrasound is an excellent imaging modality to diagnose appendicitis as it has an overall sensitivity of 85% and specificity of 94% and does not involve radiation. . A noncompressible dilated appendix is a strong indicator of nonperforated appendicitis. A periappendiceal phlegmom or abscess indicates performation. Ultrasound may also indicate other pathology such as mesenteric adenitis, or tubo-ovarian pathology.
Today, in many practices computed tomography is replacing ultrasound for the diagnosis of appendicitis as it is technically easier to perform, although it involves the use of ionizing radiation.

Treatment involves surgical excision (i.e. open or laproscopic), debridement, antibiotics, and supportive care. The most common organisms in appendicitis are E. coli, Bacteroids, Klebsiella, Enterococci, and Pseudomonas.
Prognosis is excellent but complications such as performation, sepsis, shock and dehiscence occur. Overall mortality is 0.1 – 1%.

Failure to diagnose appendicitis is the second most common cause of failure to diagnose pediatric malpractice claims (meningitis is the first). From 1985-2003 the overall number of closed cases for failure to diagnose was 1749. Of these, 78 were for appendicitis and 28 of these cases resulting in a claim paid. The average payment was $130,940.
Recommendations to decrease the risk of a malpractice claim are to conduct and document a through history and physical examination (especially of the abdomen and genitals), consider observing the child in the office or emergency room and performing serial examinations, and explaining to the parents why you don’t think that this is appendicitis CURRENTLY but if the patient’s condition changes that they should call or return promptly. Parents should also receive clear discharge instructions and the instructions should be documented in the medical record.
Appropriate follow-up should be arranged often within a few hours.

Children should have nausea, vomiting and diarrhea to be diagnosed with gastroenteritis. Remember that children less than 3 years will often present with diarrhea when they have appendicitis also. This current patient was 3 years old and presented with diarrhea.

Learning Point
Overall, the prognosis of appendicitis is excellent but complications such as sepsis, shock and dehiscence and perforation occur. Overall mortality is 0.1 – 1%. Overall appendicitis performation rate is between 17-40% at diagnosis for all ages. The performation rate for children < 8 years old is twice that of children > 8 years old. Perforation is as high as 50-83% in preschool children.

Questions for Further Discussion
1. What is the differential diagnosis of abdominal pain?
2. What genitourinary problems need to be considered in a sexually-active adolescent patient with acute abdominal pain?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for this topic: Appendicitis.

Reynolds SL. Failure to Diagnose Appendicitis Among Top Medical Misadventures. AAP News. 2005;April:13.

Tucker J. Pediatrics, Appendicitis. eMedicine.
Available from the Internet at http://www.emedicine.com/emerg/topic361.htm(rev. 6/4/2004, cited 4/21/2005).

Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

Date
May 23, 2005

What Evaluation Should be Done for a Child with a Single Umbilical Artery?

Patient Presentation
A newborn male was in the newborn nursery. He was born full-term to a healthy 26-year-old gravida 1 parity 0 female. There were no complications in the pregnancy or delivery.
His pertinent physical exam shows him to be an average for gestational age male. His examination is normal except that a single umbilical artery is noted.
The diagnosis of a healthy full-term infant with a single umbilical artery was made. He was discharged to home on day 2 of life. A renal ultrasound was scheduled for the following week.

Discussion
The umbilical cord usually has 2 arteries, 1 vein, the allantois, the omphalomesenteric duct remnant and Wharton’s jelly. It is spiraled (usually to the left), and is approximately 55 centimeters in a term infant. It usually detaches around 1 week of life and is entirely healed by about 2 weeks of life.
The arteries and vein still have some patentcy until ~1 month of life when they become the lateral umbilical ligaments and liamentum teres.

There are several common umbilical cord problems:

  • Congenital omphalocoele – a herniated peritoneal sac at the base of the umbilicus. It is often associated with Tristomy 13, 18, cardiac anomalies and Beckwith-Wiedemann syndrome (which also has macrosomia and hypoglycemia). Immediate treatment includes covering the omphalocoele with saline gauze or other wet protectant and a surgical consultation. A glucose and chromosomal analysis are also indicated.
  • Delayed separation of the cord – persistence of the cord more than 4-6 weeks may indicate a congenital leukocyte adherence defect (an autosomal recessive disorder of neutrophil adherence). Delayed separation is also associated with a higher risk of infection including Staphlococcus, Escherichia coli, Aspergillus and Candida. Treatment of infections and an evaluation for leukocyte adherence defect are indicated.
  • Granuloma – persistence of granulation tissue after 2 weeks. This is associated with bacterial invasion of the tissue, inadequate epithelialization and formation of granular, erythematous, seropurulent tissue. Treatment with silver nitrate cauterization and frequent alcohol applications is recommended.
  • Hemorrhage – usually due to inadequate ligation, but also due to sepsis, coagulation defects, or hemorrhagic disease of the newborn. Treatment depends on the cause.
  • Hernia – caused by incomplete closure or laxity of the umbilical ring. This is more common in dark-skinned individuals. Most resolve by 6 -12 months of age. They can spontaneously close by up to 6 years of age, but the older the child or the greater the hernia size, the less likely spontaneous closure will occur. Treatment includes observation and surgery if strangulation occurs which is rare. Surgery may also be indicated if the hernia is enlarging or the child is more than 5-6 years old.
  • Omphalitis – usually this is due to Staphlococcus aureas and Escherichia coli. The localized infection can quickly spread to the peritoneum and blood stream. Treatment includes antibiotics and possibly surgical drainage of abscesses.
  • Persistent omphalomesenteric duct – a lesion associated with an intestinal fistula and Meckel’s diverticulum. A Meckel’s scan or fistulogram may be indicated for diagnosis
  • Persistent urachus – a lesion resulting from inappropriate closure of the allantoic duct that is associated with bladder communication. Urinary fluid drainage is seen. A bladder and/or renal ultrasound often demonstrates the lesion.
  • Polyp – partial or complete present of omphalomesenteric duct or urachus. This presents as a pedunculated firm, red mass often with a mucoid secretion. This requires surgical excision.
  • Tumors – these are rare and most are benign. The differential diagnosis includes urachal cyst, omphalomesenterid duct cyst, angioma, dermoid cyst or myxosarcoma.

Learning Point
About 1% of all infants have a single umbilical artery and of those, ~15% have one or more congenital anomalies. These often involve the gastrointestinal, genitourinary, pulmonary, cardiovascular or nervous systems.
Occult renal abnormalities are common in children with single umbilical arteries and a significant proportion have Grade II or higher vesicoureteral reflux. Therefore, a renal ultrasound is a recommended screening procedure. A voiding cystourethrogram is sometimes also ordered. If other anomalies are found on careful physical examination, a chromosomal analysis should be considered.
This patient did not have a chromosomal analysis at this time as he did not have any other signs of congenital anomalies.

Questions for Further Discussion
1. What are the potential problems of a short umbilical cord?
2. What are the potential problems of a long umbilical cord?

Related Cases

    Symptom/Presentation

      Abnormal Physical Finding

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for this topic: Birth Defects.

Clemente CD. Anatomy. 2nd Edit. Urban&Schwarzenberg Baltimore. 1981.

Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:62,89-90, 1553.

Srinivasan R, Arora RS. Do well infants born with an isolated single umbilical artery need investigation? Arch Dis Child. 2005;90:100-1.

Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

Date
May 16, 2005

What is the Differential Diagnosis of an Infectious Rash on the Palms and Soles?

Patient Presentation
A 19 month-old female comes to clinic with a 24 hour history of mild runny nose, fever to 101 degrees F and general tiredness. Late last night she kept saying ‘owie’ but her mother didn’t know what was the problem. The child appeared to feel better after some acetaminophen and was okay over the night.
This morning her mother noticed a rash on her hands and feet. The rash has not spread since that time. She is otherwise healthy.
The review of systems shows her to be drinking less, not eating solid foods and she has no other rashes. She attends day care.
The pertinent physical exam shows her to have a fever of 100.5 degrees F. She appears tired and drooling slightly, but appears well hydrated. She has white/gray ulcers on her soft palate that appear punched-out and have a red halo around them. She has shoddy anterior cervical adenopathy.
On the palms and soles she has 2-4 mm dark pink macules that blanch. She has no other skin findings and the rest of her examination is normal.
The diagnosis of Hand-Foot-Mouth disease (most likely a Coxsackievirus) was made clinically. Her mother was instructed to give her acetaminophen or ibuprofen for pain and fever control. She is also to push fluids, especially cold fluids as these may feel better with the painful ulcers. She was instructed to watch for signs of dehydration and to call if she has any concerns.

Discussion
Enteroviral infections are RNA viruses including Coxsackieviruses A and B, Echoviruses and Enteroviruses. They are common and spread by respiratory secretions, fecal-oral contamination and fomites. They commonly occur in summer and fall in temperate climates but are less seasonally seen in the tropics. Hand hygiene is especially important to prevent infection.
The incubation period is usually 3-6 days. The viruses are best isolated from the throat, stool and rectal swab specimens but other infectious sites can also be used for viral isolation. Treatment is supportive but some anti-viral drugs are being developed.

Hand-Foot-Mouth disease is usually caused by Coxsackie A16 but also other Coxsackie viruses and Enterovirus 71. It is a self-limited disease with resultant acquired immunity.

Skin rashes are a common presenting problem for the clinician.
The distribution and pattern of skin rashes is especially important in identifying the etiology. The distribution refers to the location of the skin findings, while the patterns refers to the specific anatomic or physiologic arrangements. For example, the distribution may include the trunk, face, and upper arms, while the pattern could be sun-exposed, or flexural.
In addition to the distribution and pattern, the local organization of the lesions and their depth are important for diagnosis.

A differential diagnosis of some common skin rashes by distribution and pattern is presented below:

Distribution

  • Scalp

    • Contact Dermatitis
    • Hair loss
    • Folliculitis
    • Psoriasis
    • Seborrheic dermatitis
    • Pediculosis
  • Ears

    • Atopic dermatitis
    • Psoriasis
    • Seborrheic dermatitis
  • Face

    • Acne
    • Contact dermatitis
    • Dermatomyositis
    • Folliculitis
    • Herpes simplex
    • Impetigo
    • Lupus erythematosus
    • Measles
    • Parvovirus
    • Rubella
    • Seborrheic dermatitis
  • Eyelids

    • Atopic dermatitis
    • Contact dermatitis
    • Seborrheic dermatitis
  • Posterior neck

    • Acne
    • Contact dermatitis
    • Neurodermatitis (i.e. Lichen Simplex Chronicus)
    • Psoriasis
    • Measles
    • Rubella
    • Seborrheic dermatitis
  • Mouth

    • Aphthae
    • Geographic tongue
    • Herpes simplex
    • Lichen planus
  • Axillae

    • Acne
    • Acanthosis nigricans
    • Contact dermatitis
    • Erythrasma
    • Seborrheic Dermatitis
  • Chest and Back

    • Acne
    • Pityriasis rosea
    • Psoriasis
    • Tinea versicolor
    • Seborrheid dermatitis
    • Syphilis, secondary
  • Groin

    • Candidiasis
    • Granuloma inguinale
    • Intertrigo
    • Pediculosis
    • Scabies
    • Tinea
  • Penis

    • Candidiasis
    • Chancroid
    • Condyloma acuminata
    • Contact dermatitis
    • Drug eruption
    • Herpes simplex
    • Syphilis, primary and secondary
    • Tinea
  • Hands

    • Atopic dermatitis
    • Contact dermatitis
    • Erythema multiforme
    • ID reaction to fungus
    • Syphilis, secondary
    • Rocky Mountain Spotted Fever
    • Tinea
  • Cubital and Popiliteal Fossea

    • Atopic dermatitis
    • Contact dermatitis
    • Prickly heat
  • Elbows and Knees

    • Atopic dermatitis
    • Psoriasis
    • Deratomyositis
    • Granuloma annulare
  • Feet

    • Atopic eczema
    • Bacterial infections
    • Contact dermatitis
    • Erythema multiforme
    • Psoriasis
    • Rocky Mountain Spotted Fever
    • Syphilis, secondary
    • Tinea
    • Verrucea

Common Patterns

  • Flexural rashes – elbows, knees, neck, armpits, buttock/leg junction, groin, outline of breast

    • Atopic dermatitis, infantile
    • Candidiasis
    • Epidermolytic hyperkeratosis (i.e. Ichthyosis)
    • Intertrigo
    • Psoriasis, inverse
    • Seborrheic dermatitis, infantile
    • Tinea cruris
  • Sun exposed sites – legs, arms, neck, face, trunk, etc.

    • Lupus erythematosus
    • Photo-contact dermatitis
    • Porphyria
    • Sunburn
    • Viral exanthams
    • Xeroderma pigmentosum
  • Acrodermatitis – lower legs, arms, hands, feet from knees or elbows distally

    • Atopic dermatitis, infantile
    • Eczema, dishidrotic
    • Poststreptococcal desquamation
    • Tinea pedis with ID reaction
    • Viral exantham (i.e. papular acrodermatitis)
  • Pityriasis Rosea – along trunk in herringbone pattern (i.e. follows along ribs but also in similar pattern over entire trunk)

    • Pityriasis rosea
    • Atopic dermatitis
    • Drug reaction
    • Psoriasis, guttate
    • Syphilis, secondary
  • Clothing-covered sites – where clothing covers bodies

    • Contact dermatitis
    • Miliaria
    • Psoriasis
  • Acneiform rashes – face, shoulders, upper trunk

    • Acne vulgaris
    • Acne, drug-induced (i.e. prednisone, lithium isoniazid)
    • Cushing Syndrome
    • Chloracne

Learning Point

Although there are several causes of rashes that occur on the palms of hands and soles of feet, there are few which are caused by infectious agents.

Infectious causes of rashes on palms and soles

  • Enteroviral infections including Coxsackievirus and Echovirus
  • Rocky Mountain Spotted Fever
  • Scabies – atypical distribution
  • Syphilis, secondary

Other causes of rashes on palms and soles

  • Atopic dermatitis
  • Contact dermatitis
  • Drug eruption
  • Erythema multiforme
  • Palmar and Plantar Kertoderma
  • Psoriasis
  • Tinea

Questions for Further Discussion
1. What is the difference between primary and secondary skin lesions?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Hurwitz S. Clinical Pediatric Dermatology. 2nd Edit. W.B. Saunders Co. 1993.

Cohen BA. Pediatric Dermatology. Second Edit. Mosby, London, England. 2000:1-5.

Hall JC. Sauer’s Manual of Skin Diseases. 8th edit. Lippincott Williams& Wilkins. Philadelphia, PA 2000:17-24

American Academy of Pediatrics. Enterovirus (Nonpoliovirus) Infections, In Pickering LD, ed. Red Book: 2003 Report of the Committee on Infectious Diseases. 26th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2003;269-270.

Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

Date
May 9, 2005