Photo Quiz

A Vietnamese Child with a Rash on the Back

 

Am Fam Physician. 2016 Jan 15;93(2):131-132.

A nine-year-old Vietnamese girl presented with an erythematous rash on her back that appeared suddenly one day prior. She also had upper respiratory tract symptoms, including nasal congestion, sore throat, nonproductive cough, and a fever of 102°F (38.9°C) for three days. Her history was otherwise unremarkable.

On physical examination, the patient appeared acutely ill. She had erythematous nasal turbinates and bilateral anterior cervical lymphadenopathy. The lungs were clear to auscultation. There were linear erythematous lesions located on her posterior thorax (Figure 1). The lesions included petechiae and were nontender to palpation. She had no other skin lesions.


Figure 1.

Question

Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

A. Atopic dermatitis.

B. Child abuse.

C. Coining therapy.

D. Contact dermatitis.

E. Viral exanthem.

Discussion

The answer is C: coining therapy. Coining therapy, or cao gio, is a traditional practice used by many Vietnamese, Cambodian, and Laotian persons.1 Mentholated oils are applied to various parts of the body, including the back, and then a coin is rubbed on the skin in a fishbone pattern. This can result in ecchymosis, petechiae, and mild skin burns.2 Coining is used to treat symptoms such as cough, nausea and vomiting, and viral illnesses.3 The diagnosis is clinical, through identification of the characteristic pattern of petechial, ecchymotic streaking lesions along the spine and ribcage.4 A thorough history is important to rule out other diagnoses, such as child abuse.

Atopic dermatitis is characterized by dry skin and pruritus. It is common in infancy, but the incidence is only 10% between six and 20 years of age. Its distribution is mostly on the flexor surfaces.2

Child abuse should be suspected if the history provided by the caregiver does not explain the child's injuries, the history changes over time, there is history of self-inflicted trauma that does not correlate with development, or there is an inappropriate delay in seeking care.5 The possibility of abuse should also be pursued if there are injuries to multiple areas of the body, injuries in various stages of healing, or suspicious injury patterns.5

Contact dermatitis can occur after exposure to many agents, including soaps, detergents, other cleaners, industrial solvents, acids and alkali materials, fiberglass, and mold. Subjective symptoms occur within seconds of exposure or can be delayed up to eight to 24 hours. Lesions are localized to the area of exposure and include erythema and edema. The lesions evolve from erythema to vesicles, erosion, and then crusting. More severe contact dermatitis may result in necrosis.2

Many viruses can cause rashes in children, but the distribution of this child's rash is not typical of an exanthem. Viral rashes are initially discrete and usually appear as pink papules and macules. They often start centrally and progress centrifugally, becoming confluent.2

View/Print Table

Summary Table

ConditionCharacteristicsExposure

Atopic dermatitis

Dry skin and pruritus; most commonly on flexor surfaces

Dry environment

Child abuse

Lesions in multiple areas at various stages of healing; suspicious injury pattern

Bruises, bites, burns, fractures, abdominal and head trauma

Coining therapy

Petechial to ecchymotic lesions; fishbone pattern on the back

Medicated oil and coin rubbing

Contact dermatitis

Sharply demarcated; erythema and superficial edema over area of exposure

Exposure to an agent, such as soaps, detergents, other cleaners, industrial solvents, acids or alkaline materials, fiberglass, mold

Viral exanthem

Maculopapular; starts centrally and progresses centrifugally

Viral illnesses

Summary Table

ConditionCharacteristicsExposure

Atopic dermatitis

Dry skin and pruritus; most commonly on flexor surfaces

Dry environment

Child abuse

Lesions in multiple areas at various stages of healing; suspicious injury pattern

Bruises, bites, burns, fractures, abdominal and head trauma

Coining therapy

Petechial to ecchymotic lesions; fishbone pattern on the back

Medicated oil and coin rubbing

Contact dermatitis

Sharply demarcated; erythema and superficial edema over area of exposure

Exposure to an agent, such as soaps, detergents, other cleaners, industrial solvents, acids or alkaline materials, fiberglass, mold

Viral exanthem

Maculopapular; starts centrally and progresses centrifugally

Viral illnesses

Address correspondence to Nguyetcam V. Lam, MD, at nguyet-cam.lam@sluhn.org. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. Davis RE. Cultural health care or child abuse? The Southeast Asian practice of cao gio. J Am Acad Nurse Pract. 2000;12(3):89–95....

2. Wolff K, Johnson R, Saavedra A, Fitzpatrick TB, eds. Fitzpatrick's Color Atlas and Synopsis of Clinical Dermatology. 7th ed. New York, NY: McGraw-Hill; 2013.

3. Shukla R. Dermatology's changing face…and body. Practices adapt to demographic and racial shifts. American Adademy of Dermatology. Young Physician Focus. Fall 2012. https://www.aad.org/file%20library/global%20navigation/member%20tools%20and%20benefits/publications/ypf/fall-2012-ypf.pdf. Accessed October 22, 2015.

4. Greenberg M. Greenberg's Text-Atlas of Emergency Medicine. Philadelphia, Pa.: Lippincott Williams & Wilkins; 2005:938.

5. McDonald KC. Child abuse: approach and management. Am Fam Physician. 2007;75(2):221–228.

This series is coordinated by John E. Delzell, Jr., MD, MSPH, Assistant Medical Editor.

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