Child with a rash Flashcards
Presentation of eczema
Rash - erythema, wet weeping areas, dry scaly, thickened skin.
Commonly on flexor surface.
Intense itch
Linked to food and environmental allergens in some cases. And other atopic problems.
Onset commonly at 12m
Pattern of remitting and relapsing course
Diagnostic criteria for eczema
Must have itch plus 3 or more of the following
- History of involvement in skin creases
- PmHx of asthma or hayfever or FmHx of atopic disease in 1st degree relative if child is under 4yr
- Hx of dry skin n the last year
- onset under the age of 2 yr (not used if under 4yr)
- visible flexural eczema
Tx for eczema
Most children grow out of it by 5 yrs
Prevention - Every day treatment and avoid trigger. Trigger - heat, prickly.rough material, Dry skin. Regular moisturiser top to toe, daily cool bath with bath oil, don’t rinse. Consider Vit D oral supplements
Flare up - Topical steroids/anti inflammatory eg hydrocortisone for face and stronger for the body, tar cream for lichenifcation, Tx 2rd infections. Wet dressings eg Tubifast. Depending on severity it could be 2-3 times a day. Cool compressing to relieve itch.
Complete an eczema Tx plan
Follow up with GP or outpatient
Area of distribution of eczema rash
Infant - CHeecks, trunk, extremities - extensor areas
Child - Antecubital and popliteal foesea - flexors and neck
Older children - Neck, flexors, hands and feet
Presentation of measles
Morbilliform rash - starts at hairline and moves down then become confluence.
Fever
Cough or coryza or conjunctivitis or Koplicks spots
Onset 10-14 days after exposure
Transmission is airborne from day 1 to prodrome to 4 days post rash onset
Ix Measles
IgM at time of rash onset
PCR of viral culture of throat swab or Koplik spots
Tx of measles
Vaccination at 12m, 18m and 4yr?
Symptoms relief
Exclude from school for 5 day from the appearance of the rash.
Contacts vaccinated within 72hrs from exposure if immunised and older than 9m.
If greater then 72 HR then immunoglobulin IM within 7days
Cx of measles
Otitis media
Pneumonia
Encephalitis
Subacute sclerosing panencephalitis
Presentation of varicella zoster
Onset 14-17 days after exposure
Pattern - fever than rash (macule, vesicles, crusting) may have mucosal involvement eg mouth and genitalia
Short prodrome of fever, lethargy, anorexia
Rash 3-5 days
Crusted over by 10 days
On scalp, face, trunk, mouth and conjunctiva
Cx of varicella
Pneumonia
Secondary infection
Encephalitis
Mx of varicella
Symptom relief
Excursion Infections from 1-2 days before rash to when lesion crest over
What are the concerns with varicella and pregnancy
Cx
Mother - pneumonia,
Fetal - limb hypoplasia, microcephaly, cortical atrophy, cataracts, psychomotor retardation, convulsions, IUGR
At risk if infection 7 days prior to 7 days after birth.
Ix - Materal anti-VZV, Ig G and IgM
Tx with VZV immunoglobulin IM within 96hrs of exposure
If severe infection acyclovir every 8 HR to mum.
Infected infant needs VZIG and acyclovir.
Presentation of rubella
Onset 14-21 days after exposure
Pale morbiliform rash moves down body
Cx and Tx of Rubella
Cx - pregnancy is severe fetal anomalies if mother infected in first trimester. Congenital rubella syndrome:Cataract, deafness, heart, IUGR, thrombocytopenia, Hepatosplenomegaly and vasculitis, Renal artery stenosis.
Ix - serology prior and during pregnancy
Tx - Symptom relief,
Presentation for fifth disease
Mild illness with low grad fever
Slapped check appearance
Rash maculepapular rash: proximal extensor surfaces, flexor surfaces and trunk, then fades over next few days then central clearing then reticular pattern after 7 days.
Last up to 6 weeks.
Ix, Cx and Tx for fifth disease
PCR on blood and serology but Dx clinical
Cx - arthritis, aplastic crisis, bone marrow suppression, foetal Hydrops in newborns.
Tx - symptomatic, blood transfusion if sever haemolytic anaemia or Utero Hydrops.
No exclusion as it is non infective after rash appears.
Presentation of scabies
Intense itchy
Papular eruption several millimetres in length
Seen on palms, soles, axilla, umbillicus, frown and genitalia is common
Head is usually spared.
Onset 2-6weeks after exposure or 1-4 days after reexposure
Mx for scabies
Permethrin 5% cream - apply everywhere and leave on for 8 HR Oval ivermectin Tx all family member Wash linen, clothes etc. Itch take a few weeks to resolve. Notify contact eg school etc..
Types of nappy rash
Irritant dermatitis
Candida nappy rash
Seborrhoeic nappy rash
Psoriatic nappy rash.
Irritant dermatitis
Cause - irritation from excretions and chemical
Factors that contribute
- Excess skin hydration - water in Raine and stool, nappy change frequency
- Skin trauma - friction between nappy and skin
- Irritants - ammonia, faeces, soap and detergent reside,
- Candidiasis.
Features - erythema tours or papulovesicular lesion, fissures and erosions. Skin folds are spared.
Tx of nappy rash
Regular washing and changing, exposure to air and use of protective creams
Use disposable nappies
Frequent nappy changing
Nappy free time
seborrhoaic nappy rash
Pick greasy lesion with yellow scale Often in skin folds Non itchy Cradle cap may be present Tx with hydrocortisone 1% with nystatin or ketoconazole
Presentation of candida nappy rash
Bright red rash with clearly demarcated edge
Satellite lesion beyoud border
Inguinal folds usually involved
May or may not have oral thrush.
Tx with nystatin cream and orally if necessary
Presentation of psoriatic nappy rash
FmHx of psoriasis
Pick, greasy lesion with yellow scale other in skin folds
Similar to seborrhoea dermatitis
Other plaques commonly seen extensor surfaces, generalised small lesions.
Nail changes seen in early childhood.
Tx - Tar preparation and 1% hydrocortisone
Common transient neonatal rashes
Erythema toxic us neonatorum
Milia
Miliaria
Pigmentation disorders
Pigmented naves
Cafe au lait
Depigmentation
Vascular birthmark
Capillary haemangioma
Capillary malformation
Mongolian blue spots
Infectious causes of rash
Staph scalded skin syndrome Meningococcal Chickenpox Measles Scarlet fever Rubella Fifth disease Molluscum contagiosum Tina corporis Cold sore Common wart Impetigo Scabies head lice
Common inflammatory condition that cause rash
Atopic dermatitis/eczema Seborrhoaic dermatitis Contact dermatitis Psoriasis Acne Urticaria He notch-Schonlein purport Kawasaki diseas
Q to ask on Hx for a child with a rash
Is the child Ill or febrile?
how long has the rash or skin lesion bee present
Could it be an insect bite or allergic reaction
Is it a recurrent problem
Is it itchy
Has there been contact with anyone else with a rash
Way to describe a rash
Describe the rash in the following term
- Raised or flat
- crusty or scaly
- Colour
- Blanching on application of pressure
- Size of the lesions
- Distribution - discrete or generalised or limited to certain sites on the body
Rash of meningococcaemia
Starts as a macular papular rash that disappears after 12-24 HR then the patient worsens
Non blanching rash.
Presentation of idiopathic thrombocytopenia purpura
Acquired thrombocytopenia due to shortened PLT survival
Immune mediated
2-10 yrs
Bruising and petechiae. Oral bleeding, epistaxis, rectal bleeding, or haematuria.
Recent Hx of virus
Previously well child.
Tx of Idiopathic thrombocytopenia purpura
PLT resolve generally in 3-6m
Tx
- steroids and IVIG to increase PLT count but doesn’t change the natural history of disease.
May not Tx in milder condition.
Avoid contact sports and rough activity
Avoid aspirin and NSAIDs
Relapse occur with viral infections in the year after Dx.
Chronic refer to specialist - paediatric haematologist
Henoch-Schonlein purpura
Onset 2-8yr
Presents with 1 or more of the following
- evolving crops of palpable purpura - predominantly butt and legs
- abdominal pain (occasionally Malaena) may precede rash
- Lg joint migratory arthritis of variable duration and severity
- Nephritis
- other eg oedema dorsum of the feet and hands, acute scrotal swelling and bruising, fever and fatigue
Exclude other causes
Ix - FBC, urinalysis - Haematuria, proteinuria, U and E
Mx - Supportive with bed rest and analgesia. Corticosteroids reduces duration of abdominal pain,
Refer if renal dysfunction, hypertension or surgical complication develop.
Scarlet fever
PRodrome - sudden onset of high fever, vomiting malaise, headache and abdominal pain.
Erythema out rash - blanching, diffuse, involving torso and skin folds
Sand paper like skin
Pale around lips
Strawberry tongue, pharyngotonsillitis
Inflamed tongue, strawberry appearance.
Cx - glomerulonephritis, rheumatic heart disease, otitis media, retropharyngeal abscess, quinsy, meningitis.
Dx with throat swab
Tx - penicillin. Exclude from school until treated for 24 hrs
DDX - Kawasaki disease, strept or staph toxic shock syndrome, viral infection.
Impetigo
Group A strep or staph
Areas of ooze and honey coloured crusts on face, trunk or limbs
Can be bullous. Round and well demarcated, grouped and asymmetrical. Can be solitary and widespread.
Rapid onset
Mx
- bathe off crust
- Topical mupirocin 2% every 8 hours or flucoxacillin orally
- Isolation until lesion covered or treated.
- Treat any underlying condition
-
Kawasaki criteria
Fever for 5 days or more plus 4/5 of the following
- Polymorphous rash - macular erythema tours rash
- bilateral (non purulent) conjunctival injection
- Mucous membrane changes eg reddened or dry cracked lips, strawberry tongue, diffuse redness of oral or pharyngeal mucosa
- Peripheral changes eg erythema of palms or soles, oedema of the hands or feet, and in convalescence desquamation
- Cervical lymphadenopathy greater then 15mm, usually unilateral, single, non purulent and painful.
Need to exclude the following
- staphylococcal infection eg SSS, toxic shock syndrome
- Streptococcal eg scarlet fever, toxic shock like syndrome not just isolation from throat.
- Measles
- Other viral exam theme
- Steven’s Johnson Syndrome
- Drug reaction
- Juvenile rheumatoid arthritis
Other features
- Arthritis
- Diarrhoea
- vomiting
- coryza
- cough uveitis
- Gall bladder hydrous
Cx of Kawasaki’s
Coronary artery aneurysms
Ix for Kawasaki’s
ASOT/Anti DNAase B Echocardiography at initial presentation and at 6-8 weeks PLT count - marked thrombocytosis in 2rd week. Raised ESR and CRP Neutrophilia Mild normochromic, normalcytic anaemia Raised transaminases Hypoalbuminaemia
Tx for Kawasaki
Admit
IV Immunoglobulin over 10 hrs in the first 10 days
Aspirin 3-5mg/kg daily for 6-8 weeks
Follow up - echo at 6-8wks
DDX for nappy rash
Seborrhoaic dermatitis - Non-itchy salmon pink flaky patches may appear on the face, trains and limbs and involves skin folds
Atopic dermatitis
Psoriasis - sharply demarcated, non scaly, bright erythema tours plagues either isolated or similar lesion in other intertriginous areas such as the axilla etc.
Perinatal streptococcal cellulitis - localised well-demarcated erythema that covers a circular area 1-2 cm radius around the anus with fissuring the macerated skin. Can present with painful defecation and or constipation.
Zinc deficiency - sharply defined, red, often extensive, anogenital rash. Look for period all, perinatal and a real (hand and foot) dermatitis, alopecia, diarrhoea, and failure to thrive.
Threadworms - in older children, threadworms are common cause of itchy anogenital rash. Look for worms at night and Tx with oral mebendazole.
Langerhan’s cell histiocytosis - chronic inguinal or anogenital rash, with brownish/red scale and petechiae which is often erosive and unresponsive to Tx. A scaly Paula’s, eruption of the scalp or trunk may appear. Purpura, fever diarrhoea or Hepatosplenomegaly may be present.
malabsorption syndrome - Malabsorption from any cause eg CF can present with diarrhoea, erosive dermatitis and failure to thrive. There may be progressive intractable napkin rash contribute to both by the diarrhoea and by secondary nutritional deficiencies
Crohn’s disease
DDX for petechiae/purpura with fever
Viral infection eg enterovirus and influenza
Neisseria meningitis
Bacteremia eg strep pneumoniae and Haemophilus influenza
Henoch Schonlein purpura, ITP and Leukaemia
Illness of vomiting or coughing causing petechiae around head and neck.
All should be review by a registrar or consultant.
Indicators of meningococcal disease in a unwell child with fever and petechiae.
The unwell child
Purpura greater than 2mm unless clinical picture suggests HSP
Abnormal blood indices eg abnormal level of WCC and CRP
Signs of an unwell child
Abnormal vital signs - Tachycardia, tachypnea or desaturation, increase systolic to diastolic difference in BP
Poor peripheral perfusion - cold extremities, prolonged capillary refill
Altered conscious state - Irritability, lethargy
Purpura in well child
Greater than 2mm may be an indicator of meningococcal disease.
If clinical picture suggestive of HSP eg purpura on the lower limbs and buttocks in a well child, with or without arthritis or abdo pain.
treat as HSP
Petechiae in well children due to mechanical causes
Clear cause does not require Ix and can be discharged with review in 12-24hr
Mechanical causes
- coughing or vomiting leading to petechiae around head and neck
- Local physical pressure such as a tight tourniquet or being hel tightly for procedures. If doubt to cause manage as unknown cause.
Petechiae in well children not due to mechanical causes
If fever and petechiae with no mechanical cause need blood tests to exclude ITP and leukaemia
Children with all of the following features fave a very low risk of meningococcal disease and may be discharged after 4 hrs of observation if
- well
- WCC normal
CRP less then 8
No deterioration n clinical state or progression of the rash over 4 HR
Presentation of urticaria
Pruritic elevated skin lesion surrounded by erythema base commonly called hives.
Need t observe for dyspnoea or dysphasia for the first few hours
DDX - erythema multiforme which isn’t itchy, target legion, does not move around. Mastocytosis, flushing. Juvenile Rheumatoid arthritis, vasculitis eg HSP, Pityriasis rosea
Mx - cool compress, explanation, and reassurance. Anti histamine eg phenergan.
