Don’t Make A Rash Decision About Infant Vesicles or Pustules
September 11, 2024
Please don’t skip this 😬…
Tell us what you think about a potential new JF summary that incorporates AI, and see if you can tell which post was written by AI vs written by me. We will share these findings with the whole audience, but we need a bunch more responses to make sure these data are meaningful.
Many thanks,
Clay
Written by Joshua Belfer
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In a cohort of afebrile infants with pustular or vesicular rashes, none were diagnosed with serious bacterial infection attributable to a skin source, though some were ultimately diagnosed with herpes simplex virus (HSV).
Many workups, (fortunately) not many serious infections
A retrospective cohort of 183 afebrile infants ≤60 days old who received pediatric dermatology consultation assessed the variable management of rashes. Of the 183 infants included, 124 had pustules and 57 had vesicles. 39% of the rashes were attributed to infectious etiologies, with 67% attributed to noninfectious sources. There were no positive CSF or pathogenic blood cultures.
Blood cultures were obtained in 57% of the patients, urine cultures in 39%, and lumbar punctures in 33%. 53% received IV antibiotics, and 44% received IV acyclovir. Out of 127 infants were evaluated for HSV infection, 9 (7.1%) were diagnosed with such. All cases of skin, eye, and mouth (SEM) HSV occurred in full-term infants, while both cases of disseminated HSV were in preterm infants. Of note, preterm infants born earlier than 32 weeks gestational age had greater rates of life-threatening infections.
The authors propose a management algorithm:
This study only included infants who received pediatric dermatology consults; as such, the results should not be generalized to the outpatient setting or children for whom diagnoses were made without the assistance of dermatologists. Additionally, the small sample size and the rare incidence of serious infections limit the utility of the findings.
How will this change my practice?
Echoing the discussion on febrile infants and bacterial infection: How much risk are you willing to tolerate? In this study, how much risk in afebrile infants with rash, considering the invasiveness of extensive workups? I tend to be very cautious in this group of infants, as HSV rashes may not look exactly as they do in the textbook. While the proposed management algorithm suggests that pustular rashes in an otherwise well appearing infant may be discharged with strict return precautions, I hesitate to lean too heavily on these findings, given the limitations of this study. What this does reinforce, though, is to be very concerned when preterm infants present with a rash, given their increased risk of serious infection.
Source
Management of Pustules and Vesicles in Afebrile Infants ≤60 Days Evaluated by Dermatology. Pediatrics. 2024 Jul 1;154(1):e2023064364. doi: 10.1542/peds.2023-064364. PMID: 38910522.