What Caused This Summer Birthday Party Rash?

Patient Presentation
A 2-year-old female came to clinic with a “rash” on their cheeks and chin. This appeared after attending a birthday party the day before. The mother said she had no new foods, nor was exposed to any new sunscreen, insect spray, soaps, detergents, etc. She also was unaware of any lawncare being done in the area such as pesticides, or plant exposures such as poison ivy, and denied that the child “… got into anything else” at the party. “I really didn’t notice anything until the end of the party when her cheeks were red and she was complaining that her mouth hurt. I saw that her mouth and face were red but she had been eating lots of popsicles and birthday cake and I thought it was the food dye but it didn’t go away. There’s even one area that is a little purple now,” the mother pointed out. The mother reported that she was just a bit fussier and didn’t eat as much for breakfast. She had given the child some acetaminophen for pain.

The past medical history showed no relevant dental history. The review of systems was negative including any problems with oral intake, drooling, respiratory distress or pruritis or urticaria.

The pertinent physical exam showed a smiley toddler, who was cooperative except for the oral examination. Her skin showed redness and some swelling of the cheeks and chin particularly around the mouth. There was a 5 mm area with a purplish hue on the left side that also was more tender and harder on palpitation. Her oral examination showed good dentitia and some mild erythema of the tissues matching the red and purple areas of the cheeks.

The diagnosis of popsicle panniculitis was made. The pediatrician educated the parent about the problem and recommended to continue the acetaminophen for the discomfort. The pediatrician also counseled the parent about the risks of popsicle sticks and similar items being used by young children.

Discussion
Panniculitides are a diverse group of problems involving inflammation of subcutaneous fat. Subcutaneous fat has limited ability to show different patterns of disease and therefore the clinical appearance is the same but has different etiologies. The skin appears red or purple, swollen, may have discrete nodule(s) or plaque(s) and the affected area can be painful or pruritic. If necessary skin biopsy can help determine the etiology. Overall panniculitides are not very common but some presentations are expected because of particular exposure (i.e. cold) or inflammatory disease processes.

Types of panniculitides include:

• Pediatric specific
  • Cold panniculitis – see below
  • Poststeroid pannicuitis – very rare and occurs with infants and children on prolonged systemic corticosteroid treatment after abrupt withdrawal.
  • Subcutaneous fat necrosis of the newborn – occurs in well newborns with an unknown etiology which usually resolves without problems
  • Sclerema neonatorum – rare and occurs in very ill newborns. Many die within a few days and etiology is unknown.
• Adult-type appearing in children
  • Erythema nodosum – overall the most common panniculitis in children. Seen in boys and children, generally over the age of 2. Causes are the same as adults with Streptococcus and gastrointestinal infections as main causes. Up to 40% may be idiopathic.
  • Connective tissue disorders – Lupus erythematosus, dermatomyositis, polyarteritis nodosa and other similar etiologies
  • Enzymatic panniculitis – rare, associated with alpha-1 antitrypsin deficiency or pancreatic disease
  • Infectious – may be due to bacteria, fungi and Mycobacterium species
  • Malignancy – rare, associated with T-cell lymphomas and other malignancies
  • Physical panniculitis – due to trauma such as blunt trauma, injections, extravasation
  • Idiopathic lipoatrophic panniculitis in childhood – rare, presents clinically with childhood onset of fever and lipoatrophy that progresses over time with inflammation as an end process.

Learning Point
Cold panniculitis (CP) is relatively common in cold environments and in the right setting. It is sometimes called Haxthausen’s disease, adiposecrosis e frigore, popsicle panniculitis or equestrian cold panniculitis. CP is more common in infants and children than adults likely due to the difference in fat composition. Infants and young children have more saturated fat oils which have a higher solidification point. Therefore when they are subjected to cold, the fat oils can crystalize within the subcutaneous fat. As the child ages, there is less saturated fat. A 1928 study found 100% of newborns, 40% of 6 month olds and few 9 month olds to have subcutaneous nodule induction by holding an ice cube on the skin for 50 seconds. Body areas commonly affected are face and chin. In youth and adults it is associated with females, obesity and activities such as horseback riding, cycling or motorcycling. Areas affected especially are the thighs which may be subjected to wind and humidity with little protective clothing.

The differential diagnosis of CP includes chilblains and frostbite in addition to the other panniculitides above. The diagnosis can be made easily if the history of cold exposure is given which may include eating popsicles, sucking on ice cubes, using ice packs after trauma or for treatment of supraventricular tachycardia. Treatment is practical with rewarming the area and decreasing exposures. Most cases resolve in a couple of weeks without treatment.

Questions for Further Discussion
1. How is chilblains different from cold panniculitis? A review can be found here
2. How is frostbite different from cold panniculitis? A review can be found here
3. What anticipatory guidance do you provide to families about summer safety?

Related Cases

Disease: Panniculitis | Skin Diseases

Symptom/Presentation: Rash

Specialty: Dermatology | General Pediatrics

Age: Toddler

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

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Rashes

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Torrelo A, Hernandez A. Panniculitis in children. Dermatol Clin. 2008;26(4):491-500, vii. doi:10.1016/j.det.2008.05.010

Quesada-Cortes A, Campos-Munoz L, Diaz-Diaz RM, Casado-Jimenez M. Cold Panniculitis. Dermatologic Clinics. 2008;26(4):485-489. doi:10.1016/j.det.2008.05.015

Delgado-Jimenez Y, Fraga J, García-Diez A. Infective Panniculitis. Dermatologic Clinics. 2008;26(4):471-480. doi:10.1016/j.det.2008.05.005

Aguirre-Martinez IL, Torrelo A. Lipoatrophic panniculitis of children. Clinics in Dermatology. 2021;39(2):220-228. doi:10.1016/j.clindermatol.2020.10.010

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa