Dermatology Flashcards
Define Acne Vulgaris.
Skin disease affecting the pilosebaceous unit characterised by comedones, papules, pustules,
nodules, cysts and/or scarring primarily on the face and trunk
When does acne vulgaris begin?
May begin 1-2 years before onset of puberty following androgenic stimulation of the sebaceous glands and an increased sebum excretion rate.
Inflammation also present
Obstruction to the flow of sebum in the sebaceous follicle initiates the process of acne
Menstrual and emotional stress may be associated with exacerbations
Usually resolves in late teens, but may persist
What are the clinical features of acne vulgaris?
Initially open comedones (blackheads) or closed comedones (whiteheads) progressing to papules, pustules, nodules and cysts
Mainly on back, chest, face and shoulders
More cystic and nodular lesions can produce scarring
What are the ix for acne vulgaris?
Clinical diagnosis
What advice do we give for acne vulgaris?
Advice
- Avoid over-cleaning the skin (may cause dryness and irritation - twice daily washing with gentle soap is adequate)
- If make-up, emollients and cleansers are used, non-comedogenic preparations are recommended with a pH close to the skin
- Avoid picking and squeezing scars due to the risk of scarring
- Treatments are effective but may take a while to work (up to 8 weeks) and may initially irritate the skin
- Maintain a healthy diet
- Support and information:
- NHS choices leaflet on acne
- British association of dermatologists
What is the treatment for mild to moderate acne?
What is the treatment for moderate acne not responding to treatment?
- Consider adding oral antibiotics for a maximum of 3 months
- Lymecycline or Doxycycline
- Topical retinoid or benzoyl peroxide co-prescribed with antibiotic (to reduce risk of resistance)
- Change to an alternative antibiotic after 3 months if no improvement
- Oral antiandrogens e.g. cyproterone +/- spironolactone if signs of hyperandrogenism
- If not responding after 2 courses of antibiotics or if they are scarring, refer to dermatology for consideration of treatment with isotretinoin (Roaccutane)
-
COCP in combination with topical agents can be used as an alternative to systemic antibiotics in girls
- Note: progesterone only contraceptives or progestin implants with androgenic activity may worsen acne
How should we manage severe acne?
Refer to dermatologist
Oral isotretinoin
High-dose oral antibiotics for 6 months or longer
Systemic corticosteroids
When should you refer a patient with acne to a specialist?
- Severe variant (e.g. acne conglobata or acne fulminans)
- Severe acne with scarring or risk of scarring
- Multiple treatments have failed
- Significant psychological distress
- Diagnostic uncertainty
What is the follow-up routine for acne patients?
- Review each treatment step at 8-12 weeks
- If there is an adequate response, continue treatment for at least 12 weeks
- If acne has cleared or almost cleared - consider maintenance therapy with topical retinoids or azelaic acid
- If there is NO response, consider adherence to treatment, adverse effects, progression to more severe acne and discuss the next step in the management
How do we assess severity of acne?
Define Atopic eczema.
An inflammatory skin condition characterised by dry, pruritic skin with a chronic relapsing course
What is eczema caused by?
Genetic deficiency of skin barrier
How common is eczema in the UK?
20%
When is eczema onset?
Onset of atopic eczema is usually in the first year of life. It is, however, uncommon in the first 2 months, unlike infantile seborrhoeic dermatitis, which is relatively common at this age
What is eczema associated with?
There is often a family history of atopic disorders: eczema, asthma, allergic rhinitis (hay fever).
Around one-third of children with atopic eczema will develop asthma.
Exclusive breastfeeding may delay the onset of eczema in predisposed children but does not appear to have a significant impact on the prevalence of eczema during later childhood.
What are the causes of exacerbations of atopic eczema?
o Bacterial infection e.g. Staphylococcus, Streptococcus
o Viral infection e.g. HSV
o Ingestion of an allergen e.g. egg
o Contact with an irritant or allergen
o Environment: heat, humidity
o Change/reduction in medication
o Psychologicalstress
o Unexplained
How commonly does eczema resolve?
Atopic eczema is mainly a disease of childhood, being most severe and troublesome in the first year of life and resolving in 50% by 12 years of age, and in 75% by age 16 years.
What are the complications of eczema?
o Inflammation increases the avidity of skin for S aureus and reduces expression of antimicrobial peptides→S aureus thrives on atopic skin and release superantigens which can maintain and worsen eczema
o HSV can spread on eczema skin causing an extensive vesicular reaction, eczema herpeticum
o Regional lymphadenopathy is common and marked in active eczema – resolves when skin improves
What are the clinical features of eczema?
Pruritus
Dry skin
Distribution changes with age
o Infants: face and trunk
o Young children: extensor surfaces o Older children: flexor surfaces
Affected skin is erythematous, oedematous with prominent weeping and crusting
Over time, prolonged scratching can lead to lichenification (accentuation of normal skin markings)
What are the investigations of eczema?
Clinical diagnosis
If disease is severe, atypical or associated with unusual infections/faltering growth→exclude an immune deficiency disorder
How should we assess severity of eczema?
• Assessment of Eczema (Severity)
o CLEAR - normal skin with no evidence of active eczema
o MILD - areas of dry skin and infrequent itching
o MODERATE - areas of dry skin, frequent itching and redness (with/without excoriation and localised skin thickening)
o SEVERE - widespread areas of dry skin, incessant itching and redness (with/without excoriation and localised skin thickening)
o INFECTED - eczema is weeping, crusting or there are pustules with fever and malaise
o IMPORTANT: remember to assess the psychological impact of eczema on the child
▪ Consider using questionnaires such as the Children’s Dermatology Life Quality Index (CDLQI)
What are the conservative measures for eczema?
- Identify and education of triggers (e.g. food allergens, contact allergens, inhalational allergens, irritants like soaps)
- Emollients
- Cut nails short to avoid scratching especially in children
How should we treat clear eczema?
Conservative
How should we treat mild eczema?
How should moderate eczema be managed?
What is the management of severe eczema?
How should infected eczema be treated?
- Swab the affected area
- Advise about maintaining good hygiene when using emollients and other creams (e.g. using a spatula, not leaving it open)
-
1st line: Flucloxacillin (oral if extensive, topical if local)
- Penicillin allergy: erythromycin (alternative: clarithromycin)
- Use antibiotics for no longer than 2 weeks
- Recurrent infections: antiseptics (e.g. chlorhexidine) can be used to decrease bacterial load (do not use in long-term)
- Eczema Herpeticum
- Oral aciclovir
- If widespread, start aciclovir immediately and refer for same-day dermatological advice
- If around the eyes, refer for same-day ophthalmological and dermatological specialist review
- Provide parents and children advice on how to identify eczema herpeticum (rapidly worsening painful eczema, clustered blisters, punched-out erosions)
Explain the use of emollients in eczema?
Use emollients in large amounts and often
Examples: e45, cetraben, diprobase, aveeno
Emollients should be applied on the whole body
Emollients should be used as a soap substitute (also instead of shampoo or use unperfumed shampoos)
Explain the use of topical corticosteroids in eczema.
- Use once or twice daily (duration can vary from 3-14 days depending on how long the skin takes to respond)
- Only apply to areas of active eczema
- Do not use potent corticosteroids in children < 12 months without specialist advice For areas prone to flares, consider using topical corticosteroids for 2 consecutive days per week to prevent flares (review after 3-6 months)
- If a topical corticosteroid is deemed ineffective, consider using a different type of steroid of a similar potency before increasing the potency
- Mild Potency for Mild Eczema: hydrocortisone 1%
- Moderate Potency for Moderate Eczema: betamethasone valerate 0.025% or
- clobetasone butyrate 0.05%
- Potent for Severe Eczema: betamethasone valerate 0.1%, mometasone
- If very severe and extensive: consider oral steroids
Explain the use of topical calcineurin inhibitors in eczema.
- IMMUNOMODULATOR
- Topical tacrolimus may be considered as 2nd line treatment of moderate to severe eczema in children > 2 years that has not been controlled with steroids
- Alternative: pimecrolimus
- This should only be applied to areas with active eczema
- Do not use under occlusive bandages
Explain the use of bandages in eczema.
Can be used with emollients for areas of chronic lichenified skin
Can be used for short-term flares (7-14 days)
Whole-body occlusive dressings may be used by specialists
What are the indications for a specialist referral for eczema?
Eczema herpeticum (immediate referral)
Urgent referral (2 weeks) if severe atopic eczema has not responded to optimum therapy within 1 week or treatment to bacterially infected eczema has failed
Refer if diagnosis is uncertain, atopic eczema on the face is not responding, contact allergic dermatitis is suspected, causing significant social and psychological problems or severe recurrent infections
What advice should be given to parents for atopic eczema?
Explain the use of dietary elimination in eczema.
Define haemangioma.
Strawberry naevi (haemangioma): will often rapidly increase in size in first few months then slowly spontaneously resolve leaving almost no mark.
A haemangioma is a collection of small blood vessels that form a lump under the skin. They’re sometimes called ‘strawberry marks’ because the surface of a haemangioma can look like the surface of a strawberry.
What is this?
A haemangioma.
Who more commonly get haemangiomas?
They are more common in:
- girls
- premature babies
- low birth weight babies
- multiple births (twins, triplets and quadruplets).
Haemangiomas aren’t inherited, but families often say a relative had a haemangioma in childhood, because they’re very common.
How common are haemangiomas?
1 in 10
What are the clinical features of haemangiomas?
Superficial haemangiomas
- are usually a raised, bright red area of skin
- feel quite warm because the abnormal blood vessels are close to the surface
- might at first appear as a small area of pale skin on which a red spot develops
Deep haemangiomas
- might look bluish in colour because the abnormal blood vessels are deeper in the skin
- aren’t always noticeable for the first few weeks, only appearing as a lump
Haemangiomas don’t usually develop until a few days or weeks after a baby is born, but often grow rapidly in the first three months. It’s unusual for haemangiomas to grow after six to 10 months of age, when most of them tend to have a ‘rest period’ and start to shrink.
Most haemangiomas appear on the head or neck – mainly on the cheek, lips, or upper eyelids – but they can develop anywhere on the body. Some children have multiple haemangiomas, but this mostly happens in twins or other multiple birth babies.
What are the investigations for haemangiomas?
Clinical diagnosis
Might need to do ultrasound and/or MRI scans on a child who has a haemangioma that is deep, near their eye, or affecting internal organs.
How do we treat haemangiomas?
Usually are asymptomatic and undergo involution
Does not necessarily need treatment
Needs to be looked after as they can bleed when scratched
If there is functional impairment (near eyes, nose, mouth) or cosmetic disfigurement:
o Beta-blocker :PO (propranolol) o rtopical (timolol)
o Corticosteroid: PO or topical
o Until theoretical involution or 12m
o May need surgery
Cryotherapy Electrotherapy Vascular laser surgery
If it is ulcerated:
o Barrier protection and Burow’s solution for gentle debridement
o May need topical antibiotics (metronidazole)
o Beta blocker may be used if haven’t previously been treated with it
Define milia.
1-2 mm pearly white pappules which resolve spontaneously in the new born
Most often appear on a newborn’s upper cheeks, nose, chin, or forehead. They’re harmless and very common.
What is this?
milia
How do you manage milia?
Most cases eventually clear by themselves (within a few weeks in infants)
May be removed if not cosmetically pleasing
o Can do it using a fine needle
o Cryotherapy can be used
o Laser treatment
o Dermabrasion
o Chemical peeling
Define molluscum contagiosum. How is it spread?
Viral skin infection caused by pox virus
Transmission usually by direct skin contact
What are the clinical features of molluscum contagiosum?
Firm, smooth, skin coloured, pearly umbilicated papules
May be single but usually multiple
Usually 2-5mm in diameter
In children, tend to occur on trunk and extremities
What are the investigations of molluscum contagiosum?
Clinical exam
How do you manage molluscum contagiosum?
- Does not require treatment if immunocompetent (it is self-limiting), with spontaneous resolution usually occurs within 1 year
- Advise against squeezing mollusca to avoid the spread of infectious material and reducing risk of super-infections
- Avoid sharing towels, clothing and baths with uninfected people (e.g. siblings)
- If eczema or infection develops around the lesions, treat appropriately (e.g. emollients and steroids or antibiotics)
- Chemical or physical destruction may be done by a specialist and only if lesion has become symptomatic
- If anogenital lesions, can use:
- Podophyllotoxin 0.5% (usually used to treat anogenital warts but effective)
- Apply 2 x day for 3 consecutive days
- Repeat after a week if needed
- Imiquimod 5% cream
- Apply 3 x week and wash off 6-10 hours later
- Podophyllotoxin 0.5% (usually used to treat anogenital warts but effective)
Do NOT need to be excluded from school
Refer to Dermatologist if:
o Immunocompromised
o Lesions are extensive and painful (although inflamed lesions may indicate resolution) o Diagnostic uncertainty
What is this?
Molluscum contagiosum
Define Mongolian Blue Spot
Mongolian blue spots (dermal melanosis): benign but MUST be documented and pointed
out to parents, as can be mistaken for bruises and cause concern in school etc, fade to some
degree but do not necessarily totally disappear
How do we manage Mongolian blue spots?
Are harmless and usually disappear by 4yo
Do NOT need treatment and are not a sign of an underlying condition
Note: can be mistaken for bruises and thus child abuse/safeguarding issues
• So should be recorded on baby’s medical records from birth
Define nappy rash.
Inflammation of the skin in the area of the body covered by a nappy
What are the causes of nappy rashes?
- Common
- Irritant (contact) dermatitis
- Most common
- May occur if nappies are not changed frequently or if infant has diarrhoea, but can also occur even if infant is cleaned regularly
- Occurs due to the irritant effect of urine ammonia and faeces on the skin
- Urea-splitting organisms in faeces increase alkalinity and likelihood of a rash
- Infantile seborrheic dermatitis
- Candida infection
- Infections can cause or exacerbate nappy rashes
- Other pathogens: Staphylococcus aureus, enteric organs
- Atopic eczema
- Irritant (contact) dermatitis
- Rare
- Acrodermatitis enteropathica ▪
- Langerhans cell histiocytosis ▪
- Wiskott-Aldrich syndrome
What are the clinical features of nappy rashes?
• Irritant dermatitis
o Characteristic acute onset erythematous rash of convex surfaces of buttocks, perineal region, lower abdomen and tops of thighs
o Flexures (creases) are characteristically spared in irritant dermatitis
o More severe forms may involve erosions and ulcer formation
• Candida infection
o Erythematous rash including skin flexures
o May have satellite lesions
• Seborrheic dermatitis
o Erythematous rash with flakes
o May have coexistent scalp rash
• Psoriasis
o Less common cause characterised by erythematous scaly rash also present elsewhere on skin
• Atopic eczema
o Other areas will also be affected
What are the investigations for nappy rashes?
Clinical examination
How do you manage nappy rashes?
• Advise the parents/carers about self-management strategies
o Consider using a nappy with high absorbency and ensure that it fits properly
o Leave nappy off as much as possible to help skin drying of the nappy area
o Clean the skin and change the nappy every 3-4 hours or as soon as possible after wetting/soiling, to reduce skin exposure to urine and faeces
- Use water, or fragrance-free or alcohol-free baby wipes
- Dry gently after cleaning
- Bath the child daily- avoid excessive bathing (>2x a day)
- Do not use soap, bubble bath, lotions or talcum powder
• If mild erythema and the child is asymptomatic
o Advise on the use of barrier preparation to protect the skin (available OTC) and apply thinly at each nappy change
o Options: Zinc and Castor oil ointment BP, Metanium ointment, soft white paraffin BP ointment
• If the rash appears inflamed and is causing discomfort
o If > 1 month=hydrocortisone 1% cream OD (max 7 days) + barrier cream
o ADVISE:apply topical hydrocortisone first and wait a few minutes before applying barrier preparation
If the rash persists and candidal infection is suspected or confirmed on swab
o Advise against the use of barrier protection
o Prescribe topical imidazole cream (e.g.clotrimazole,econazole,miconazole)
If the rash persists or bacterial infection is suspected or confirmed on swab
o Prescribe oral flucloxacillin for 7 days
o If penicillin allergy : clarithromycin (7 days)
Arrange to review the child
Summary
- Disposable nappies are better than towel nappies
- Expose nappy area to air where possible
- Apply barrier cream (e.g. Sudocrem)
- Mild steroid cream (e.g. 1% hydrocortisone) in severe case
- Manage suspected candida nappy rash with topical imidazole (cease the use of barrier cream until candida has settled)
What is this?
Nappy rash due to candida infection
Define seborrheic dermatitis. How does it progress?
Eruption of unknown cause presenting in first 3 months of life
o Starts on the scalp as an erythematous scaly eruption
o The scales form a thick yellow adherent layer, commonly called cradle cap
o The scaly rash may spread to the face, behind the ears and then to the flexures and napkin area
What is seborrheic dermatitis associated with?
• Associated with increased risk of subsequent atopic eczema development
What are the clinical features of seborrheic dermatitis?
Cradle cap +/- extensive involvement
Rash is NOT itchy
What is this
Cradle cap - seborrheic dermatitis
What is this?
Seborrheic dermatitis with involvement of face, axillae and napkin area.
How do you manage seborrheic dermatitis?
Define tinea/ringworm infection.
Superficial fungal infection in which dermatophyte fungi invade dead keratinous structures, such as the horny layer of skin, nails and hair
Can be caused by various different types of fungi (dermatophytes)
What is the differential diagnosis for ringworm?
Discoid eczema
What are the clinical features of ringworm?
Skin lesions often have a ringed, annular appearance, gradually expanding with active edge
A severely inflamed pustular ringworm patch is called a kerion (abscess)
What are the different types of tinea infection and what are their clinical features
o Tinea pedis: athlete’s foot
o Tinea ungulum: finger and toenails
o Tinea corporis: arms, legs and trunks
o Tinea cruris: groin area
o Tinea manuum: hands and palm
o Tinea capitis: scalp - sometimes acquired from dogs and cats and causes scaling and patchy alopecia with broken hairs
o Tinea faeciei: face
o Tinea barbae: facial hair
What are the investigations for a tinea infection?
- Examination under filtered ultraviolet (Wood’s) light may show bright greenish/yellow fluorescence of the infected hairs with some fungal species
- Rapid diagnosis can be made from microscopic examination of skin scrapings for fungal hyphae
- Definitive identification of the fungus is by culture
What is the management of ringworm?
Define cellulitis/necrotising fasciitis.
This is a severe subcutaneous infection, often involving tissue planes from the skin down to fascia and muscle
The area involved may enlarge rapidly, leaving poorly perfused necrotic areas of tissue, usually at the centre
What is the pathophysiology of cellulitis/necrotising fasciitis?
The invading organism may be S aureus or a group A Streptococcus, with or without another synergistic anaerobic organism (e.g. E coli, Enterobacter)
o Bacteria are introduced into the skin and soft tissue from minor trauma, puncture wounds or surgery – but no primary site of infection is identified in ~20% cases
o Infection extends through the fascia and tracks along fascial planes extending beyond the area of overlying cellulitis
• Systemic signs of necrotising fasciitis, e.g. fever, tachycardia, hypotension, are mainly due to action of bacterial toxins
What are predisposing factors of necrotising fasciitis and cellulitis?
Predisposing risk factors include
o Diabetes mellitus
o Peripheral vascular disease
o Immunocompromising conditions
o Chickenpox or herpes zoster
o Drugs e.g. corticosteroids
What are the clinical features of necrotising fasciitis and cellulitis?
Classic features: SEVERE PAIN + SYSTEMIC ILLNESS
Severe pain or anaesthesia over site of cellulitis
Fever
Palpitations, tachycardia, tachypnoea, hypotension, lightheadedness
Nausea and vomiting
What are the investigations for cellulitis/necrotising fasciitis?
Bloods
o FBC
o Electrolytes
o U&Es
o CK
o Lactate
Blood and tissue cultures – tissue specimens obtained from surgical debridement for definitive bacterial diagnosis
What is the management of cellulitis?
- Uncomplicated cellulitis can be managed at home with oral antibiotics
- Complicated cellulitis (e.g. cellulitis with systemic illness) may require admitting, resuscitation with oxygen and fluids and IV antibiotics.
- Switch to oral when fever settles, cellulitis has regressed and CRP is reducing
- May need surgery for incision and drainage of abscess, debridement of necrotic tissue or treatment of compression syndromes
- Consider MDT approach with dermatologists, microbiology, pharmacists, surgeons (and ophthalmologists if orbital cellulitis).
- High-dose flucloxacillin for 7 days
- Or co-amoxiclav for 7 days if near the nose or eyes
- Penicillin allergy: clarithromycin
- Arrange a review in 48 hours by phone or in person
- If cellulitis occurring on top of VZV, prescribe flucloxacillin + amoxicillin
- Penicillin allergy: ciprofloxacin+ metronidazole/clarithromycin
- Rest the area – limb etc
- Advise using paracetamol or ibuprofen to relieve pain or discomfort
- Safety net: seek help if it gets worse or doesn’t improve in 24-48 hours
-
Erysipelas presents similarly but has a very clearly demarcated rash
- Treated with penicillin V
What is the management of necrotising fasciitis?
- Surgical emergency
- Surgical debridement of all infected and devitalised tissues, should go beyond visible areas of necrosis
- IV fluids
- Empirical IV antibiotics (vancomycin, linezolid, daptomycin, tedizolid phosphate, tazocin, meropenem, imipenem/cilastatin, ertapenem = 2 or 3 at the same time)
- +/- intravenous immunoglobulin (IVIG)
How do you manage periorybital cellulitis?
Periorbital cellulitis should be treated promptly with IV antibiotics (e.g. high-dose ceftriaxone)
o MRSA will require vancomycin
o May give empirical antifungal therapy
This is to prevent posterior spread of the infection which could cause orbital cellulitis
Incision, drainage and culture of peri-ocular abscess may be required
Consider ophthalmologist advice
Define psoriasis.
Chronic inflammatory skin disease characterised by erythematous, circumscribed scaly papules, and plaques
When does psoriasis present
Rarely under the age of 2 yrs
What is the most and least common type of psoriasis in paediatrics?
Guttate psoriasis is common in children and often follows a streptococcal or viral sore throat or ear infection
Chronic psoriasis: very rare
What is the pathophysiology of psoriasis?
Pathophysiology: immune response defined by T cells in the dermis, initiating release
of cytokines
What is the histology of psoriasis?
Histology: keratinocytes overproliferate so there is a thicker layer of keratin causing
scales to come off the surface
What are the clinical features of guttate and chronic psoriasis?
• Guttate psoarisis
o Lesions are small, rain-drop like, round or oval erythematous scaly patches on the trunk and upper limbs
o An attack usually resolves over 3-4 months
o Most get a recurrence within the next 3-5 years
• Chronic psoriasis (with plaques or annular lesions) is less common in children
What are the investigations for psoriasis?
Usually clinical diagnosis
May want to do throat swab and anti-streptolysin-O titre for guttate psoriasis
How should we manage guttate psoriasis?
- Reassure that it is usually a self-limiting condition that typically resolves within 3–4 months, and reassure that it is not infectious
- 1st: Phototherapy: narrow band UVB 2-3 times/week (if widespread or unresponsive to topical treatment)
- Topical preparation offered:
- Emollient to reduce scales and relieve itch (E45,Oilatum,Emulsiderm)
- Potent topical corticosteroid with vitamin D preparation +/- salicylic acid if scales are problematic
• Refer if lesions are extensive, severe or not responding to treatment
The Psoriasis Association may provide much needed support to sufferers - significant effect on QOL
What can chronic psoriasis lead to?
Occasionally, children with chronic psoriasis will develop psoriatic arthritis
What is this
Guttate psoriasis
What is hand, foot and mouth disease caused by?
Caused by Coxsackie A viruses, most commonly Coxsackie A16
What are the clinical features of hand, foot and mouth disease?
o Painful vesicular lesions on the hands, feet, mouth and tongue
▪ Should be called hand, foot, mouth and bum disease
o Systemic features are generally mild
o Disease subsides within days
What is the management of hand, foot and mouth disease?
Hand, Foot and Mouth Disease
Symptomatic treatment only (hydration and analgesia)
Keep blisters clean and apply non-adherent dressings to erosions
Reassurance there is no link to disease in cattle
Do not necessarily need exclusion from school
Will subside within days
How should you generally manage an insect bite or sting?
If stinger is visible, remove by scraping sideways with a finger nail or credit card
Clean the area with soap and water and advise on prevention
- If transient localised reaction
- Consider simple analgesia
- If swollen, can reduce with ice pack application (15min on and off regimen)
- Oral antihistamine or topical steroids (hydrocortisone 1%) may reduce itching
- Can give oral steroids for patients with moderate-severe reactions, continuing for 3-5d
- OTC agents can be used: crotamiton, topical antihistamines and topical anaesthetics
- Secondary bacterial infection can be treated as cellulitis
What precautions should be taken for:
- Bedbugs
- Fleas
- Lice
- Scabies
- Lyme disease
Specific Bites
Bedbugs – advise contacting pest control
Fleas – often associated with contact with domesticated pets (animals should be tested and treated if necessary)
Lice – check head lice management
Scabies – check scabies management
Lyme disease (Borrelia) - doxycycline, amoxicillin and cefuroxime
How should animal or human bites be managed?
Animal and Human Bite
- Check for risk of tetanus
- If unknown: tetanus/diptheria/pertussis vaccine, tetanus immunoglobulin and another tetanus/diptheria vaccine >4wks after and 6-12m later
- Check for rabies risk:
- Non-immunised: Rabies vaccine + rabies immunoglobulin
- Immunised: rabies vaccine
-
Co-amoxiclav for 7 days
- Penicillin allergy: metronidazole + doxycycline (7 days)
- Safety net about signs of infection
Define pediculosis capitis.
Pediculosis capitis (head lice infestation) is the most common form of lice infestation in children
What is the clinical presentation of pediculosis capitis?
PRESENTATION: itching of the scalp and nape of the neck
Live lice may be identified on the scalp or nits on hairs
Nits are empty egg cases that are seen on hairs
There may be secondary bacterial infection, sometimes leading to misdiagnosis of impetigo
Suboccipital lymphadenopathy is common
Widespread and troublesome in primary school children
How should you manage pediculosis capitis?
Wet combing with a fine-tooth comb to remove live lice every 3-4 days for 2 weeks is useful and safe (BUGBUSTING)
Dimeticone 4% lotion or aqueous solution of malathion 0.5% is rubbed into the hair and scalp and left on overnight and the hair is shampooed the following morning
Treatment should be repeated a week later
School exclusion NOT advised
Define scabies.
Parasitic infection caused by an infestation with the eight-legged parasitic mite Sarcoptes scabiei which burrows down the epidermis along the stratum corneum
How long after infestations do children begin itching in scabies?
Severe itching occurs 2-6 weeks after infestation and is worse in warm temperature/at night
What are the complications of scabies?
o Excoriation can lead to a secondary eczematous or urticarial reaction which masks the true diagnosis
o Secondary bacterial infection is common
What are the clinical features of scabies in younger and older children?
Severe itching
In older children, burrows, papules and vesicles involve the skin between the fingers and toes, axillae, flexor aspects of the wrists, belt line and around the nipples, penis and buttocks
In infants and young children, distribution often includes the palms, soles and trunk
What are the investigations for scabies?
- Clinical diagnosis
- Although burrows are considered pathognomonic, they may be hard to identify because of secondary infection due to scratching.
- Itching in other family members is a helpful clinical indicator.
- Confirmation can be made by microscopic examination of skin scrapings from the lesions to identify mite, eggs, and mite faeces.
What is the management of scabies?
School exclusion until treated.
What are viral warts caused by?
Caused by HPV
Where do viral warts appear?
These are COMMON and usually found on the fingers and soles (verrucae)
What is the management of viral warts?
Watchful waiting is most common in children
Daily administration of proprietary salicylic acid or lactic acid paint or glutaraldehyde lotion
can be useful
Cryotherapy with liquid nitrogen is effective but can be painful (should only be used in older
children)
Atopic eczema
Infantile seborrheic dermatitis
Candida
Scabies
Ringworm
Psoriasis
Acne vulgaris
Urticaria
Henoch Schonlein purpura
Erythema multiforme
Erythema nodosum
Erythema infectiosum / fifth disease /slapped cheek syndrome
Meningococcal septicaemia
This is a typical presentation of pityriasis versicolor, a common fungal skin infection. It often becomes more noticeable after spending time in the sun - as the healthy skin becomes darker, the white/light brown patches become more prominent.
Treatment consists of topical antifungals - NICE recommends ketoconazole shampoo. If only a very small area is affected, a topical antifungal cream may also be appropriate. In this case, both back and chest are affected, so a shampoo would be much easier to use.
Pityriasis rosea. The exact cause remains unclear, although there are links to certain viruses. It is a self-limiting disease that tends to resolve within 12 weeks with no long term complications. Most patients will not require any treatment.
If patients complain of itch we can consider emollients, topical corticosteroids or antihistamines. Steroids are unlikely to shorten the duration of the rash itself, so should only really be used if there is pruritus present and for the shortest amount of time.
You are reviewing a 5-year-old girl whose mum has been concerned about a rash. This initially started on the trunk before spreading to the rest of the body. Mum thinks she has had a temperature for 1 or 2 days prior to this.
On examination, you note a generalised, rough-textured, pin-point rash. Her tongue has a white coating through which you can see some red papillae.
She has no significant past medical history and no known allergies.
What would be the most appropriate management in this case?
This a description of scarlet fever, a bacterial infection caused by Group A Streptococci. It is highly contagious and usually treated with antibiotics. NICE recommends phenoxymethylpenicillin first line and azithromycin in true penicillin allergy, although this may be different where you work depending on local microbiology policies.
Exam questions often mention a ‘sandpaper-like rash’ or a ‘strawberry tongue’ as described in this scenario.
If you work in England, Wales or Northern Ireland you should also notify the local health protection team (in Scotland scarlet fever is no longer a notifiable disease).
