Diagnostic and Therapeutic Procedures

Jane Sanders Bellet

Introduction

Diagnostic and therapeutic procedures are a standard part of the evaluation and management of dermatologic conditions in neonates and infants. Performing procedures on younger children can be technically challenging, and requires knowledge of differences in approach and other special considerations due to the child’s young age. This chapter discusses the most common of these diagnostic and therapeutic procedures.

Diagnostic procedures

Bacterial culture

Bacterial culture is a frequently performed diagnostic test. Purulent material draining from a pustule or nodule can easily be obtained with a bacterial swab. If the material is dry or crusted, wetting the swab with water prior to rubbing the area increases the likelihood of obtaining material to grow an organism. The results of a Gram stain performed by the microbiology laboratory are usually available within a few hours, while the final bacterial culture result with drug susceptibilities may not be known for 48–72 h. The laboratory should be notified when Gram-negative or anaerobic bacterial infections are suspected, so that specific culture media may be used.

Bacteria causing certain infections such as necrotizing fasciitis may not be easily cultured from superficial skin samples, so that a skin biopsy for frozen section may be necessary for a rapid diagnosis (see ‘Skin biopsy’, below). A bacterial stain such as Brown–Brenn performed on the histologic sections can differentiate Gram-positive from Gram-negative organisms.

KOH preparation

Potassium hydroxide (KOH) preparations are useful to identify the presence of fungi and yeast. They can be performed on samples of skin, hair, and nails. The skin should be scraped such that adequate material is available for microscopic examination (Box 6.1). If the KOH preparation is negative or equivocal, the skin scales may be placed onto fungal culture plates or sent for culture in an appropriate container, such as a sterile urine cup or wax paper envelope (see ‘Fungal culture’, below).

Box 6.1

Technique

KOH preparation

1. Scrape the skin with the edge of a glass microscopic slide, a #15 blade, or a double-edged knife (Joseph or Fomon blade).

2. Spread the skin scales on a glass microscopic slide.

3. Apply 1–2 drops of 10–20% KOH solution prior to placement of the coverslip or place the coverslip first and apply 1–2 drops at the edge, allowing the liquid to flow beneath the coverslip. A KOH solution that also contains DMSO (dimethyl sulfoxide) dissolves the keratin more rapidly, leaving fungal elements undisturbed.

4. Press the coverslip to disrupt the keratinocytes and wait 10–20 min to allow the KOH to dissolve the keratin, leaving the hyphae behind.

A scalp sample may be obtained by wetting a cotton-tipped applicator with water and rubbing the suspected area of involvement.¹ Another technique is to use a toothbrush² or gynecologic viral collection brush.³ The material from the swab is plated directly onto the fungal culture plate. Hairs can be plucked for culture, but this is not usually recommended in infants because of the pain caused by pulling hairs. Usually enough hairs can be gathered by scraping the scalp with a glass slide or #15 blade.

For nail samples, a sharp instrument, such as a Skeele curette, is used to collect debris from underneath the nail plate and this material can be stabbed directly onto the fungal plate. Nail clippings can be obtained by using a nail nipper. In young infants with soft nails, a cuticle nipper is sometimes sharp enough. The clippings can either be placed directly on the culture medium or in a sterile cup for the laboratory to plate. In addition, nail clippings can be placed in formalin and sent directly to pathology so that a periodic acid Schiff (PAS) stain⁴ can be performed; the results are usually known within 2–3 days compared with 30 days, which is the standard for fungal cultures in a microbiology laboratory. This method has been shown to be more reliable than KOH preparation and fungal culture in detecting the presence of organisms; however, fungal culture remains the gold standard for identifying the organism and determining drug susceptibilities.⁴

Fungal culture

Mycosel™ agar and mycobiotic agar are two types of fungal culture media that are frequently used. They contain Sabouraud dextrose agar with chloramphenicol and cycloheximide to decrease bacterial overgrowth.

For deep fungal infections of the skin, a skin biopsy is necessary so that material from the dermis, and sometimes the subcutaneous fat, can be cultured, since the organism is not present in the superficial epidermal scales (see ‘Skin biopsy’, below).

Direct fluorescent antibody test for diagnosis of herpes virus infection

Direct fluorescent antibody (DFA) testing uses mouse monoclonal antibodies to detect herpes viruses such as herpes simplex virus (HSV) 1 and 2 and varicella-zoster virus (VZV).⁵ Specimens are best obtained from the base of a ruptured vesicle, erosion, or ulcer. The likelihood of a positive result is much lower if the lesions are crusted or already healing. A Dacron® swab with a plastic shaft is used to rub the lesion and the swab is placed in viral transport medium. A calcium alginate swab should not be used because the chemicals are toxic to the virus. The laboratory can prepare the slide after cytospin preparation; however, a slide can also be prepared at the bedside by careful rubbing of the swab onto the slide, which is allowed to air dry prior to transport to the laboratory.

Viral culture

Using a Dacron® tipped swab, the fluid from an intact vesicle is absorbed and the swab is rubbed over the base of the lesion prior to placement in viral transport medium (buffered isotonic saline solution, often with antibiotics added to prevent bacterial contamination). The results are usually available in 2–3 days for herpes simplex viruses and 7–14 days for varicella-zoster virus.

Viral culture has historically been the gold standard for isolating viral pathogens, such as herpes viruses; however, this is likely to change with improved polymerase chain reaction (PCR) techniques.⁶

Polymerase chain reaction (PCR) test for diagnosis of herpes virus infection

Polymerase chain reaction (PCR) is now used by many laboratories to definitively identify herpes virus infections as well as other viral infections. Compared with viral culture, this test is more sensitive and the result is available more rapidly.⁷ The swab obtained for viral culture that has been placed in viral transport medium can be used for PCR.⁸

Scabies preparation

Scabies infestation is frequently seen in young infants. Sensitization after primary infestation takes 3–4 weeks before symptoms occur. With recurrent infestation, symptoms appear immediately. Performing a scabies preparation can confirm the diagnosis. Detection of evidence of scabies infestation is most likely by scraping linear burrows, vesicles, or papules that have not been excoriated. Interdigital spaces of the hands and feet, wrists, and axillae are often high-yield locations. Sometimes parents or other caregivers have papules or burrows that can be scraped as well.

The finding of mites, eggs, or feces on a scabies preparation using a microscope with a 10× objective confirms the diagnosis (Box 6.2). Mites have eight legs (Fig. 6.1); eggs are oval in shape and ten times smaller than mites; and feces, which are even smaller, appear as golden-brown clumps (Fig. 6.2). Air bubbles are round, which helps distinguish them from eggs or feces. Dermoscopy can also be useful in the diagnosis of scabies infestation (see below).

Box 6.2

Technique

Scabies preparation

1. Scrape the suspected lesion vigorously with the edge of a glass microscopic slide or a #15 blade. A drop of mineral oil can be placed on the lesion first, prior to scraping. The appearance of punctate bleeding signifies the proper depth.

2. Smear the scrapings onto a glass microscopic slide.

3. Apply 1 drop of mineral oil to the slide.

4. Place coverslip and gently press to remove any air bubbles.

Dermoscopy

Dermoscopy (dermatoscopy or epiluminescence microscopy) is the examination of skin lesions with a handheld dermatoscope. Most dermatoscopes utilize polarized light to eliminate skin surface reflection. Specific patterns can be seen that help confirm a suspected diagnosis. Dermoscopy can be useful in the identification of a broad set of conditions and lesions such as scabies mites or burrows; congenital and acquired melanocytic nevi including Spitz and blue nevi; and juvenile xanthogranuloma. The ‘triangle’ sign is the pigmented anterior portion of the scabies mite, which includes the head and first two pairs of legs,⁹ while ‘the jetliner with contrail’ sign represents the head of the mite along with the trailing burrow (Fig. 6.3).¹⁰^,¹¹ Typical Spitz nevi have four distinct dermoscopic patterns: starburst, globular, negative network, and homogeneous (Fig. 6.4).¹²^,¹³ Histiocytes laden with lipid give juvenile xanthogranulomas their characteristic yellow-orange color. Dermoscopy can show this orange-yellow background with an erythematous border, the ‘setting sun’ sign.¹⁴ Pale yellow ‘clouds’ can also be seen, which are thought to be lipid-laden histiocytes in the superficial dermis.¹⁴ Blue nevi have homogeneous, structureless pigment patterns of different colors (white or blue most commonly) or a combination of colors (Fig. 6.5).

Figure 6.5 Blue nevus dermoscopy. Homogenous structureless pattern. (Courtesy of Ashfaq Marghoob, MD.)

Microscopic hair examination

A number of hair shaft abnormalities can be detected by microscopic hair examination using a standard light microscope with and without a polarizing lens. Sharp iris scissors can be used to obtain hairs without the need to pluck them. A mounting medium such as Permount™, or immersion oil, and a cover slip may be used to mount the hairs on a glass slide. Only rarely is the hair bulb needed for diagnosis, such as with suspected loose anagen syndrome, in which case the hairs need to be gently pulled. Usually, an examination of scalp hair demonstrates the findings necessary for diagnosis; however, Netherton syndrome can be an exception, in which only eyebrow or eyelash hairs may have the characteristic findings. See Chapter 31 for a discussion of hair disorders.

Wood’s light examination

A Wood’s lamp is a handheld device fitted with a mercury lamp and a filter made of nickel oxide and silica. The light emitted from the device has wavelengths from 320 to 400 nm, which is the range in which melanin absorbs ultraviolet radiation. The lamp should be used in a dark room, so that ambient light does not interfere with the examination. Loss of melanin (depigmentation) appears as a ‘bright white’ area compared with surrounding normal skin. A Wood’s lamp can be useful in the identification of vitiligo, tuberous sclerosis (ash leaf macules), and incontinentia pigmenti. Also, infected hairs fluoresce bright yellow-green in tinea capitis caused by Microsporum canis. The urine of neonates with congenital erythropoietic porphyria fluoresces coral red.¹⁵

Skin biopsy

A skin biopsy can be very useful in determining a diagnosis. The tissue can be examined microscopically and it can also be cultured (bacterial, viral, fungal, mycobacterial). When the lesion is <6 mm in diameter, the entire skin lesion can be removed using a punch technique for both diagnostic and therapeutic purposes. The depth of the pathologic process determines how deep the skin specimen needs to be. Usually, a punch biopsy can be performed, since epidermis and dermis will be obtained, as well as the top layer of fat in some body locations (Box 6.3).

Box 6.3

Technique

Skin punch biopsy