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- Presentation
Three Challenging Inpatient Pediatric Dermatology Consult Cases: Bullous Pemphigoid, Neutrophilic Eccrine Hidradenitis, and SCORCH/DRESS
Description
The talk reviewed three challenging inpatient pediatric dermatology consults and emphasized pattern recognition, biopsy, and not assuming every febrile rash is infection. The first case was a 3-month-old infant with recurrent acral vesicles and tense blisters initially associated with COVID infection; biopsy, BP-180 antibodies, and direct immunofluorescence confirmed infantile bullous pemphigoid, which was treated successfully with high-potency topical steroids and has a generally self-limited course though relapses can occur. The second case involved a 10-year-old boy with AML, fever, and painful erythematous plaques on the trunk, extremities, palms, and soles after chemotherapy; negative cultures and biopsy showing neutrophils around eccrine glands led to neutrophilic eccrine hidradenitis, a chemo-associated neutrophilic dermatosis managed supportively without stopping chemotherapy, with dapsone as an option for recurrences. The final case was a 16-year-old girl who developed shock, fever, conjunctivitis, facial edema, and a diffuse morbilliform rash about 10 days after starting TMP-SMX; negative infectious workup and the clinical picture supported SCORCH, a severe delayed drug hypersensitivity reaction that can mimic sepsis or DRESS. Management required stopping the drug and using systemic steroids and cyclosporine. The speaker closed by contrasting DRESS, SCORCH, and SJS/TEN by timing, morphology, systemic findings, and severity, and highlighted key pearls: acral vesicles suggest bullous pemphigoid, painful plaques with fever on chemotherapy may be neutrophilic eccrine hidradenitis, and sepsis-like rash after new medication should raise concern for SCORCH or DRESS.
View moreConclusions
- In infantile vesicular eruptions with acral blisters, infantile bullous pemphigoid should be considered and confirmed with biopsy and immunofluorescence rather than assuming infection.
- Infantile bullous pemphigoid often responds to high-potency topical steroids, is usually self-limited, and may relapse, with dupilumab emerging as a useful option for refractory cases.
- In febrile oncology patients with tender plaques, neutrophilic eccrine hidradenitis is an important noninfectious diagnosis that can mimic infection, sweet syndrome, or vasculitis.
- Neutrophilic eccrine hidradenitis is typically associated with chemotherapy in AML, shows neutrophils around eccrine structures on biopsy, and is usually self-limited without needing to stop chemotherapy.
- Sepsis-like presentations with rash after recent TMP-SMX exposure may represent SCORCH or another severe drug reaction rather than infection.
- SCORCH appears to be an early hypersensitivity reaction characterized by sunburn-like erythema, conjunctivitis, facial or acral edema, lymphopenia, and hemodynamic instability after drug exposure.
- Across these pediatric consults, early biopsy and focused dermatologic pattern recognition were emphasized as key to avoiding diagnostic delay.
- A major recurring lesson is not to default to infection when fever, rash, and systemic illness occur in hospitalized children, because several important dermatologic mimickers exist.
- Timely dermatology consultation can change management and improve outcomes in complex inpatient pediatric eruptions.
- Remie Chrabieh, MD. F056 Treating the “Outsides” of the Inpatient: Pediatric Consults for the General Dermatologist. American Academy of Dermatology Annual Meeting, March 27–31, 2026, Denver, Colorado.
- Infantile Bullous Pemphigoid.#10.1684/ejd.2022.4229
- Neutrophilic Eccrine Hidradenitis.#10.32388/fjj5lq
- Sudden conjunctivitis, lymphopenia, and rash combined with hemodynamic changes (SCoRCH)