The many faces of facial cellulitis.

Practical advice for treating newborns and toddlers. Y ou have recently encountered 4 children with a very distinct, well-demarcated, flat erythro-derma of the facial area. You must determine whether this rash is due to erysipe-las, which presents with an erythematous flat, painful, cellulitis-like rash most commonly on the face or lower extremities. The differential diagnosis in each of these cases also includes allergic manifestations such as a drug hypersensitiv-ity, angioedema, or contact dermatitis; local reactions such as sunburn or other thermal burn; viral infections, such as fifth disease, etc; and bacterial infections such as cellulitis, early staphylococcal or streptococcal scalded skin, and early necrotizing fasciitis. You will also likely be tested by some children who will fail your initial " prudent " antibiotic choice, as these cases will illustrate. CASE SCENARIOS Case 1 A previously healthy white, female 6-month-old presents to your office with fussiness, a 3-day-long fever of up to 103°F, decreased appetite, rhinor-rhea, excessive drooling, and pulling at her ears. The mother has also noted occasional vomiting without diarrhea, poor sleeping, and tremendous clingi-ness. The child is fully immunized; she is receiving no medications except for ibuprofen every 8 hours. In the office, her temperature is 101°F, pulse rate 134, respiratory rate 24, and oxygen saturation 99%. When you examine her she is fairly distract-ible and cooperative for her age. Her dermatologic examination reveals the rash seen in Figure 1. Her tympanic membranes are normal, and because she has now become much less cooperative after you removed the cerumen from her ear canals, a cursory look at her posterior pharynx shows it is fairly reddened. The remainder of her examination is normal, including the lymph nodes, lungs, heart, abdomen, vaginal-rectal area, and range of motion of the extremities. Because she was so cranky and irritable, you obtain a complete blood count (CBC). While you are waiting on those results, something else bothers you about her examination. Case 2 A previously healthy white, female 8-month-old presents to your office on a September morning with abrupt 12-hour onset of irritability, fever to 102°F, no appetite, and no sleep the night before. She attends daycare, has had no gastrointestinal complaints, no tick bites, and has received no other medications except for an ibuprofen dose that Figure 1. A 6-month-old white female presents with 3 days of fever, crankiness, and a unilateral flat, non-tender, well-demarcated rash of the face only.