Dermatology / CV (April 2017)
Allmon et al. “Common Skin Rashes in Children”. AAFP. 2015.
AIR: Cardiovascular
For a Review Article
- How has reading the article changed your practice?
- What information had you believed in previously that were debunked by reading this article?
- What new information did you learn from reading this article?
- What are current areas of uncertainty on this topic that can be potential areas for research?
For an Original Research Article
- What are some strengths of the study?
- What are the limitations?
- What are the main outcomes of the study?
- Does reading this article change your practice? If so, how?
10 comments
Pallin et al.
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I have to say, this is the first study to tell people to stop abx before completing course if symptoms are resolved, though they did tell them to take it for at least 1 week
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It seems to me the that I’ve been underdosing my Keflex according to this paper, though 1g tid or 1g qid seems like a lot.
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I wish they were powered to do more than detect 13% diff, esp when rates of purulent cellulitis is low (8%).
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Nevertheless, I will continuing using keflex alone for uncomplicated cellulitis.
Allmon et al.
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Nice concise review. I saw molluscum the other day in pedi. Though I’m surprised to find that the duration of some of these rashes.
For instance, scarlet fever rash could last for weeks, molluscum for months to years!
Allmon- My practice will change by starting to use potassium hydroxide to differential pityriasis from tinea. I didn’t realize that the palms and soles desquamated with scarlet fever. I learned how to diagnose roseola. Future research could look at etiology of pityriasis.
Pallin- Strength was focusing on very clear population- cellulitis without abscess. The study might have been limited in terms of power with only 70 in each group. They also used higher doses of keflex than standard use, so they might have had better outcomes than would have been seen with standard dosing. They found no difference to adding bactrim to keflex for cellulitis without abscess, indicating that these infections are likely not MRSA. The patients in this study had very low MRSA colonization rates, around 5%. I wonder if these results would be different in populations with higher MRSA carriage. For my practice, I will use keflex for non-purulent cellulitis.
Pallin et al.
1. What are some strengths of the study? Clinically useful question.
2. What are the limitations? As said by Alex and Grace, could have been powered to detect smaller differences.
3. What are the main outcomes of the study? The main outcome is “the risk difference for treatment success, determined in person at 2 weeks, with telephone and medical record confirmation at 1 month.” I liked the secondary outcome of looking at if MRSA nasal swabs correlate to treatment success.
4. Does reading this article change your practice? If so, how? No.
Allmon et al.
1. How has reading the article changed your practice? Provides more background information for counseling parents.
2. What information had you believed in previously that were debunked by reading this article? N/A.
3. What new information did you learn from reading this article? Great review. Specifically I learned more details about roseola. I also learned that there are two types of strawberry tongue in scarlet fever.
4. What are current areas of uncertainty on this topic that can be potential areas for research? Vaccine for parvovirus B19 for patients with sickle cell disease.
Seems like I am under dosing keflex as well. Again 4 grams a day seems a lot. Although that is a max dose for bacterial infection but with systemic symptoms.
It does vary regionally I think, depending of sensitivity of medication to organisms. If someone has to pick keflex vs Bactrim.
#rashes
It’s always good to have a derm refresher on rashes. In practice, I like to start off by asking myself, “is this a serious rash (or not)” – shout out to Morasal for intern pearls. This article is largely about the less lethal but more common rashes we see. It does a decent job of summarizing common rashes particularly seen in kids. One thing I don’t do often enough is ask about the rash’s evolution which might elucidate the etiology. Some new info that was cemented here was the bullous vs nonbullous types of impetigo. I had a case at Children’s where there was a slight concern for TEN/SJS (at least it was on the differential) but the kid had bullous impetigo and it served as a good learning case. Another piece of new information gleaned from the article was the prevalence of arthralgias in erythema infectiosum. Not too much debunked info here (given the million ways these rashes can present, I don’t hold too many absolute truths). In terms of research, would be great to see the development/implementation of some sort of peds rash educational intervention for parents with the goal of decreasing ED visits.
#abx #cellulitis #abscess
-Strengths? Randomized, multicenter, double blinded, placebo controlled trial; objective was straightforward, practical, and useful particularly on a subject with significant practice differences; nasal swabs taken to assess for MRSA
-Limitations? Limited to outpatients, diabetic and immunocompromised excluded; total duration of tx not recorded and subjective to bias;
-Outcomes? Outpatients dx with cellulitis w/o abscess did not benefit from adding bactrim (MRSA coverage)
-Change in practice? Not really. I typically give keflex for outpt abx and only bactrim if there’s an abscess with surrounding cellulitis. I guess the logical next step after reading this is determining if you indeed need MRSA coverage in the case of abscess with surrounding cellulitis? The paper notes that there’s only some indirect evidence (and speculation) that MRSA is a/w abscesses.
Cephalexin plus/minus Bactrim
1. It’s randomized, multicenter, double-blind, and placebo controlled – the methodology was very strong. Also, it attempts to improve upon our antibiotic prescribing.
2. They excluded diabetic patients, even though they did not find any evidence to suggest higher rates of CA-MRSA in diabetic patients. Why did they exclude diabetics? Also, how did they determine presence/absence of abscess?
3. There was no observed benefit from adding Bactrim to cephalexin for outpatient cellulitis treatment.
4. No, I don’t regularly add Bactrim to cephalexin for uncomplicated cellulitis. What I wonder is whether this practice is okay for diabetics (not answered by this study) and if we need to ultrasound for abscesses if they are not clinically apparent before making our antibiotic choice. What I did find interesting was that response was not associated with nasal MRSA colonization (although they only had 7 patients who were colonized so maybe sample was too small).
Skin rashes in children
1. I’m bad at rashes to begin with, particularly pediatric rashes, so this article is very helpful.
2. I don’t think this article debunked anything that I previously believed, instead it refreshed my memory on identifying characteristics of pediatric rashes.
3. No new information, but I found the pictures very helpful.
4. All of the “key recommendations for practice” have an evidence rating of “C”, so it seems that there really isn’t any good evidence on pediatric rashes!