Bullous Impetigo Rapid Diagnostic and Therapeutic Quiz: A Model for Assessing Basic Dermatology Knowledge of Primary Care Providers

Dermatological opinions are imperative in ambulatory and acute care settings for pediatric skin disorders - HL-SkinPed

BACKGROUND

Children with skin disorders usually receive care from a pediatrician, despite their limited training in this discipline. The advice of a dermatologist is frequently requested.

OBJECTIVES

To estimate the degree of concordance in the diagnosis, treatment, advice, and recommended follow-up of skin disorders between pediatricians (in private practice or a pediatric emergency department [PED]) and a dermatologist.

METHODS

This prospective study was carried out between June 25 and September 13, 2018. All patients younger than 18 years consulting at the PED of the University Children's Hospital or a pediatric private practice in Nancy, France, for a dermatological disorder (primary complaint) were included. Photographs, medical data, diagnosis, treatment, advice and follow-up recommended by the pediatricians were recorded in a dedicated anonymous medical file. Clinical data and photographs were subsequently reviewed by a dermatologist who provided a diagnosis.

RESULTS

A total of 103 patients were included and 99 were analyzed: 53 from the PED and 46 from private practice (three patients were excluded because of unclear photographs and one was referred for maxillofacial advice). The median age was 4 years and there was a slight predominance of females (53.5%). The seven main diagnoses were: atopic dermatitis, insect bites, nonspecific viral rash, viral urticaria, hand-foot-and-mouth disease, impetigo, and contact dermatitis. The rate of agreement between the pediatricians and the dermatologist was 55% for diagnosis (73% for atopic dermatitis, 53% for insect bites, 33% for nonspecific viral rash), 40% for treatment, 54% for advice, and 58% for recommended follow-up. Reinterpretation by the dermatologist changed patient management in 15% of cases.

CONCLUSIONS

The significant discordance between the pediatricians and the dermatologist suggests the need for a greater emphasis on dermatological disorders in medical training programs and for closer collaboration between disciplines for the benefit of younger patients.

Disseminated bullous impetigo and atopic dermatitis: Case series and literature review

BACKGROUND

Bullous impetigo (BI) is a common skin infection of early childhood, resulting from desmoglein-1 cleavage by Staphylococcus aureus exfoliative toxins. Due to compromised barrier function and immune dysregulation, children with atopic dermatitis (AD) are at increased risk of cutaneous infections, yet no literature has been published on disseminated bullous impetigo (DBI) in children with atopic dermatitis (AD). We sought to explore the atopic phenotypes, antibiotic sensitivities, and treatment courses of children diagnosed with disseminated bullous impetigo at our institution.

METHODS

We conducted a retrospective case series of 12 children diagnosed with disseminated bullous impetigo at Johns Hopkins from 12/2016 to 5/2017.

RESULTS

Eleven children (92%) had severe AD. All children were initially misdiagnosed; the majority (67%) were misdiagnosed with AD flares, and other misdiagnoses included scabies, eczema herpeticum, ecthyma, varicella, and eczema coxsackium. All cultures were positive for methicillin-sensitive Staphylococcus aureus (MSSA). Three children (25%) had clindamycin-resistant strains of MSSA, and only one child was positive for both MSSA and methicillin-resistant S aureus. All children were treated with systemic antibiotics and experienced resolution of symptoms within 24-48 hours.

CONCLUSIONS

This case series is the first of its kind exploring children with DBI with the atopic diathesis. Our results indicate that DBI is often misdiagnosed, and increased training is likely needed for pediatricians, emergency room physicians, and dermatologists. Earlier diagnosis of bullous impetigo may prevent dissemination and spare a patient treatment with systemic antibiotics. Given the high rate of clindamycin resistance observed in this series, we recommend cephalosporins to treat uncomplicated cases of DBI.