Dermatology Flashcards
How to manage seborrheic dermatitis on scalp in an infant
- if doesnt work
- if sx don’t resolve after a certain time
Reassure not serious and that will resolve over a few weeks- by 8 months normally
Massage an emollient into scalp which loosens scales which can then gently brush and then wash off with shampoo
If this doesnt work then apply a topical imidazole cream
- clotrimazole 1% 2-3x up to 4 weeks
- miconazole 2x up to 4 weeks
If haven’t resolved after 4 weeks then seek specialist help
How to manage seborrheic dermatitis in areas other than the scalp
Bathe the child using an emollient instead of soap
Can consider topical imadizole for up to 4 weeks
What drug can be considered in persistent nappy rash over 4 weeks
1% hydrocortisone
Management of seborrheic dermatitis in children
Ketoconazole shampoo 2% twice a week for 4 weeks then 1-2x a week for maintenance or selenium sulphide shampoo
To remove scales can use warm olive oil or salicylic acid and cocunut oil for thicker scales
What can use in children if ketoconazole not appropriate
Shampoos containing zinc, coal tar or salicylic acid
Treatment for necrotising fasciitis
Surgical emergency
Surgical debridement of infected areas and devitalised tissues
IV fluids
Empirical abx-2 or 3 at same time
Can use IVIG
How is atopic eczema assessed (the skin itself)
Clear- normal skin
Mild- areas of dry skin, infrequent itching with or without areas of redness
Moderate- areas of dry skin, frequent itching, redness wuth or without skin thickening or excoriation
Severe- widespread areas of dry skin, incessant itching, with or without excoriation, bleeding, thickening)
How is atopic eczema assessed (QOL)
Clear- no impact
Mild- little impact on everyday activities, sleep, psychosocial wellbeing
Moderate- Moderate impact on everyday
Severe- severe limitation to every day life
Mild atopic eczema treatment
Emollients
Mild topical corticosteroid- 1% hydrocortisone used until 48 hours after flare controlled
Moderate eczema treatment
-2nd line
Emollients
Moderate topical corticosteroid- betamethasone valerate 0.025% used until 48 hours after flare controlled
1 month of non-sedating anti-histamine if severe itching/urticaria
2nd line-topical calcineurin inhbitor
Severe atopic eczema treatment
Emollient
Potent topical corticosteroid- betamethasone valerate 0.1% until 48 hours after flare controlled
Maintenance regime of topical corticosteroids
Occlusive dressing worn for 2-3 days
Wet stockinette wraps with diluted topical steorids and emollients
If severe itching 1 month non-sedating antihistamine
If sleep affected 2 weeks sedating antihistamine
Oral corticoseroids if severe psych distress or severe and extensive
Phototherapy last option
Example of sedating anti-histamine
Chlorphenamine
When are oral corticosteroids used in atopic eczema
Psych distress from severe and extensive
Second line calcineurin inhibitor
Conservative management of atopic eczema
Identify and educate about triggers
Cut nails short
Safety net about eczema herpeticum
Advice for using topical corticosteroids
Only use 1or 2 times a day only on the area
When are bandages used in eczema
Chronic lichenified skin
In short term flares 7-14 days
What is the management of infected eczema
Swab the area
1st line flucloxacillin (oral if systemic, topical if local)
Educate about emollient hygiene so using a spatula and not leaving bottle open
What determines method of administration in infected eczema
Local is topical
Systemic use oral
What to use in recurrent infections for eczema
Chlorhexidine
Treatment for eczema herpeticum
Oral aciclovir and refer for dermatological advice
Management of eczema herpeticum if around the eyes
Refer for same say opthalmological and dermatological advice
How does eczema herpeticum appear
Rapidly worsening painful eczema
Clustered blisters
Punched out erosions
What abx used for infected atopic eczema if penicillin allergic
Erithomycin
Indications for eczema referral
Herpeticum
If severe eczema hasnt responded to tx in a week
If infected hasnt responded to tx
Uncertain diagnosis- maybe contact dermatitis
How is cellulitis classified
Complicated vs uncomplicated
Complicated has systemic illness
How is uncomplicated cellulitis managed
Flucloxacillin for 7 days- can be managed at home
How is complicated cellulitis managed generally
Draw line around initial rash
Refer immediately for potential oxygen and IV fluids
IV abx which change to oral if fever going, CRP reducing or rash regressing
MDT approach
When are IV abx for cellulitis switched to oral abx
If CRP dropping , fever going, rash regressing
What is used if penicillin allergy in cellulitis treatment
Clarithomycin
What is used if cellulitis around the eyes and nose
Co-amoxiclav
Oral if mild and no signs of orbital cellulitis
What is used if cellulitis around the eyes and nose but penicillin allergy
Clarithomycin
Add metronidazole suspected
What used if cellulitis on top of chicken pox
Flucloxacillin and amoxicillin
What used if cellulitis on top of chicken pox if penicillin allergic
Ciprofloxacin and metronidazole/clarithomycin
General advice given for cellulitis
Rest the area
Paracetamol for pain
Safety net- if doesnt get better in 24-48 hours come back
Review in 48 hours
How is erysipelas treated
Penicillin V
How do infantile haemangiomas appear
Called strawberry haemangiomas
Raised red papules
Management principles of haemangiomas
Does not necessarily require treatment as will shrink naturally
If ulcerated, cosmetic disfigurement or near eyes, nose or mouth then may require treatment
When do you treat an infantile haemangioma
Ulcerated
Functional impairment near the eyes, nose or mouth
Cosmetic disfigurement
Treatment differs between ulceration and other 2
Treatment of an infantile haemangioma with ulceration
Barrier protection and burows solution for gentle debridement
Topical abx- metronidazole
Management of infantile haemangioma if cosmetic disfugurement or near to nose, eyes or mouth
If small then topical timolol
If large then oral propanolol
Where do infantile haemangiomas normally appear
On face or posterior triangle of neck
In first 5 months of life
Advice to parents for haemangiomas
Dont use shampoos or soap near to them
If bleed dab them with cotton for 5 mins
Topical beta blocker used for infantile haemangioma
Timolol
Oral beta blocker used for infantile haemangioma
Propanolol
Srugical options for infantile haemangioma
Cryotherapy
Electrotherapy
Vascular laser surgery
What causes hand foot and mouth disease
Enteroviruses- most commonly the cocksackie A16 and enterovirus 71 virus
Which pathogen causes molloscum contagiosum
Molloscum contagiosum virus
Its a pox virus
How do molloscum contagiosum lesions appear
Pearly papules with central umbilication/dimpling
Management of molloscum contagiosum
In immunocompetent people is self-limiting and doesnt require treatment necessarily excpet in certain conditions
Advise about reducing the spread
- dont squeeze them
- avoid sharing towels, clothing and baths with other people
- exclusion from pool and school not needed
When to treat molloscum contagiosum
Anogenital lesions
Immunocompromised
Lesions are symptomatic
What are treatment options for molloscum contagiousm
Podophyllotoxin 0.5%
Imiquimod 5%
Cryotherapy
What happens if eczema or infection develops around molloscum contagiosum lesions
Treat appropriately with emollients or abx
Advice for treating nappy rash
Use high absorbency nappy
Leave off as much as possible to expose to air for drying
Dont use soap
Treatment of nappy rash if mild erythema and asymptomatic
OTC barrier protection applied at every change
Zinc and castor oil ointment
Treatment of nappy rash if inflamed and causing discomfort
If infant over 1 month old 1% hydrocortisone and barrier cream
Apply barrier cream a few minutes after
Treatment of nappy rash if candidal infection suspected or confirmed
DO NOT use barrier protection
Topical imidazole cream
Treatment of nappy rash if bacterial infection suspected or confirmed
Oral flucloxacillin for 7 days
Arrrange review
Treatment of nappy rash if bacterial infection and penicillin allergic
Clarithomycin
How does candida appear
Erythematous papules and plaques
Small satellite spots and pustules
What are the satellite pustules seen in
Candida infection
What causes scabies
Sarcopetes scabiei- mite
Where does scabies tend to affect
Between fingers and toes
Palms and soles
Axilla
Lower trunk
When is scabies tiching worse
At night
In warmth
Treatment for scabies
5% permethrin cream to everyhting below chin
Decontaminate whole bedding clothing etc
Treat the family too
What is used for post-scabietic itch
Crotamiton 10%
Can use hydrocortisone 1% if know infection definetely cleared
Mangement of urticaria non symptomatic
Identify triggers using symptoms diary (UAS7)
Normally self limiting but if symptoms treat
Treatment for symptomatic urticaria
Non sedating antihistamine for 6 weeks
Treatment of very severe urticaria
Non sedating anti-histamine
Oral predinsolone 40mg for 7 days
Management of pediculosis
Wet combing with a fine-tooth comb every 3-4 days for 2 weeks
Dimeticone 4% lotion rubbed into hair and scalp then shampooed the next day
Repeat a week later
How is dimeticone used in pediculosis treatment
Applied night before and then shampooed the next day
What is difference between tinea corporis, cruris and capitis
Corporis- body
Cruris- groin and thighs
Capitis- scalp
Treatment of mild tinea cruris and corporis infections
Topical antifungals- terbinafine cream, clotrimazole
If marked inflammation 1% hydrocortisone
What is used in tinea cruris and corporis if marked inflammation
Hydrocortisone 1%
Treatment for severe tinea cruris and corporis infections
1st line- oral terbinafine
2nd line- oral itraconazole
What can be added as adjunct to treatment of tinea cruris and corporis
Aluminium acetate
What is the management of verrucas
Watchful waiting most common in children as lots of side effects to treatment
Only treat if cosmetically unappealing like on face
Treat of painful or requested treatment
Application of permethrin
Done to whole body
Must be cool and dry
Wash off after 12 hours and repeat 10-14 days later
Second line treatment for scabies
Ivermectin
What is different about application of permethrin in babies
Face and scalp included
What are milia
Small white keratin filled cysts found on the face of babies
Management of milia
Will resolve or clear by themselves
Can be removed if comsemtically displeasing
Removal options for milia
Cryo
Fine needle
Laser
If localised reaction around a sting what can do
Simple analgesia
If swollen ice pack regime
Oral antihistamine or 1% hydrocortisone can be used if itching
What can be given to people with moderate to severe reactions to a sting
Oral steroids
What to do with bite patient if tetanus status of someone unkown
Tetanus/diptheria/pertussis vaccine, another at 4wks and 12 months
Tetanus immunoglobulin
What worried about in human bite
Tetanus
What worried about in a dog and cat bite
Tetanus
Rabies
What to do post dog bite if no rabies immunisation
Rabies vaccine
Rabies human immunoglobulin
What to do post dog bite if already rabies immunised
Rabies vaccine
Treatment for all animal and human bites
Co-amoxiclav
If penicllin allergic what determines treatment of dog and human bite
Age
Under 12 co-trimoxazole
Over 12 doxycycline and metronidazole
Management of plaque psoriasis
Emollient
Topical Vitamin d and potent topical steroid
Salicylic acid if plaque problematic
What to use if plaque problematic in psoriasis
Salicylic acid
What is the nature of guttate psoriasis
Temporary lasting 3-4 months
Follows on from strep infection
Management of guttate psoriasis
Emollient
Topical Vitamin d and potent topical steroid
Salicylic acid if plaque problematic
What used if guttate psoriasis takes up over 10% of body surface
Phototherapy
How to meningococcal septicaemia lesions appear
Non-blanching purpuric lesions irregular in size with necrotic core
Management meningococcal septciaemia
Ceftriaxone
What are other words for erythema infectiosum
Fifth disease
Slapped cheek syndrome
Progression of erythema infectiosum
Initially red cheeks- becomes lacy maculopapular rash on trunk and EXTENSOR SURFACES of limbs
How are patients with erythema infectiosum
Often asymptomatic but can have myalgia, fever and headache
What are complications of erythema infectiosum
Aplastic crisis
Arthritis
Management of erythema infectiosum
Adequate fluid inake
Ibuprofen
How is erythema infectiosum spread
Resp droplets
What happens in vertical transmission of parvovirus B19
Hydrops fetalis from severe anaemia
What is itcalledifmeningococcal septciaemia widespread
Purpura fulminalis
Rfx for HSP
Boy
3-10 years
Strep infection
Tetrad of HSP
Rash over buttocks and extensor surface of arms and legs
Abdo pain
Glomerulonephritis
Arthritis
Complications of HSP
Intussusception
Pancreatitis
Acute renal impairment
Arthritis
How is HSP managed
NSAID or paracetamol and bed rest
Typically will resolve in a few weeks
Oral pred if GI bleeding, severe abdo pain or scrotal involvement
IV if nephrotic range proteinuria or declining renal function
What to do if scrotal pain, GI bleeding or severe abdo pain in HSP
Oral pred
What to do if nephrotic range protein uria or declining renal function in HSP
IV pred
Which patients are are at particular risk of PV19 infecton
HIV
SCD
On top of slapped cheek rash how else can PV19 appear dermatologically
Lace like rash on trunks and arms- normally like this adults
What causes roseola infantum
HHV6
How does roseola infantum present
High fever for a few days followed later a maculopapular rash- rose pink coloured
Can get nagayama spots- papular exanthem on uvula and soft palate
Complication of roseola infantum
Febrile convulsion
What are nagayam spots seen in
Roseola infantum
Differentials for nappy rash
Irritant dermatitis
Candida
Seborrheic dermatitis
Psoriasis
Atopic eczema
What causes irritant dermatitis
Due to effect of urinary ammonia and faeces
How does each nappy rash appear and its features
Irritant dermatitis- creases spared
Candida- erythematous rash which i- nvolves the flexures and has satellite lesions
Seborrheic dermatitis- has flakes and concomitant scalp rash
Psoriasis- scaly erythematous rash
Features of dermoid cyst
Found at sites of embryonal developmental fusion
- midline of neck
- external angle of the eye
- posterior pinna of the ear
Small cystic structure with hair/other inclusions that oten get infected
What are verruca
Warts on plantar surfaces caused by HPV 6
Treatment of verruca versus warts
Verrucas not very sensitive to cryotherapy
Use salicylic acid
Treatment difference between older versus younger children for warts/verrucas
Older- can use cryotherapy or salicyclic acid
Young- use salicylic acid
When should refer for warts/verruca and what treatment options are available
The person has a facial wart.
The diagnosis is uncertain.
The person is immunocompromised.
The person has areas of skin that are extensively affected, for example, mosaic warts of the hands and feet.
The person is bothered by persistent warts that are unresponsive to both topical salicylic acid and cryotherapy, if indicated
- podophyllotoxin
- physical ablation
- iquimiod
Presentation of hand foot and mouth disease
Mild systemic upset with sore throat and fever
Oral ulcers which then later followed by vesicles on palms and soles of the feet
Can also present with spots on abdomen and genitals
How is hand foot and mouth disease spread
Normally in outbreaks at a nursery
What is name of lyme disease rash
Erythema migrans
Progression of meningococcal septicaemia
Maculopapular then petechial/purpuric non-blanching
Complications of parvovirus
If pregnant- hydrops foetalis
If SCD- aplastic crisis
Other name for roseola infantum
Exanthema subitum
Main problem of roseola infantum
In immunocompromised especially in bone marrow transplant as affects the engraftment itself
Complications of chicken pox
Immunosuppressed- leads to severe streptococcal and staphylococcal infection affecting the joints and bones
Glomerulonephritis
Myocarditis
Pneumonitis
Bacterial superinfection
How does scarlet fever rash vary from infatum roseola
Scarlet fever normally starts on neck and trunk
Roseola starts on trunk and spreads to limbs
Management of chicken pox
Paracetamol and calamine lotion
What presents with fluid filled blisters and yellow crust
Impetigo
Management of bacterial superinfection in chicken pox
Admit to hospital
IV flucloxacillin and aciclovir
Causes of erythema nodosum
Strep infections
TB
Sarcoid
IBD
Management of impetigo
If local use fusidic acid
If more marked infection use flucloxicllin or clarithomycin if allergic
Difference between eczema herpeticum and infected eczema
Eczema herpeticum- widespread blisters and punched out lesions
Infection with strep pyogenes and s. aureus- oozing from swollen skin and yellow crust
What is labial fusion
Benign condition where labia minora fuse together
Not present at birth but can develop by 1-2 years
Will resolve by puberty typically
Management if labial fusion
If no major symptoms can reassure and review
If significant symptoms topical oestrogen for 4-6 weeks
Surgical management if thick and severe or trapped urine causing terminal dribbling and vulval inflammation
Complications of labial fusion
Local infection
Recurrent UTI
Terminal dribbling
Why are NSAIDS not recommended in chicken pox
Increased risk of necrotising fasciitis
Difference in length of treatment tinea capitis rural versus urban area
Treat for 4 weeks if urban
8 weeks if in rural area
Management of tinea captits in children
Exclude kerion
Take hair and scalp sample for culture
Commence oral terbinafine or griseofulvin
When culture comes back change antifungal accordingly
What does black dot on scalp suggest where hair stubs in follicles removed
Trichophyton tonsurans infection
What do if tinea capitis culture reveals trichophyton tonsurans infection
Continue or switch to terbinafine
What do if tinea capitis culture reveals microsporum infection
Continue or switch to griseofulvin
What is a kerion and what do if present
An abscess on scalp caused by excess reaction to tinea capitis infection
Refer immediately
How does distribution of atopic eczema vary across childhood
Infant- face and trunk
Early childhood- extensor surfaces
OLder child- typical flexural distribution
How is head lice diagnosed
Fine tooth combing
Management of branchial cyst
Antibiotics if infected
Surgical excision is needed
Neck lump full of cholesterol
Branchial cyst
Why cant use NSAIDS in chicken pox
Increases risk of secondary bacterial infections- potentially necrotising fasciitis
Complications of chicken pox
Pneumonia
Encephalitis
Secondary bacterial infections on skin- most common
Disseminated haemorrhagic chicken pox
What are 2 types of impetigo
Bullous and non-bullous
When refer someone with impetigo
Complications present
- glomerulonephritis
- deeper soft tissue injuries
- sepsis
Immunocompromised and infection is widespread
How does impetigo present
Pustular honey colour crusted lesions
When consider referral or specialist advice in impetigo
Bullous impetigo especially if under 1
Recurrent impetigo
Systemically unwell
When can return to school with impetigo
All lesions are dry and have crsuted over for 48 hours
Management of impetigo
Localised and not unwell
Hydrogen peroxide 1% cream
If unsuitable
- fusidic acid 2%
- mupirocin 2%
Widespread and not unwell
Offer oral or topical
Topical
1st fusidic acid 2%
2nd mupirocin 2%
Oral
Flucloxacillin
Clarithomycin if aged 1month-11 years erythomycin if 11-17
Bullous or unwell
1st fluclox
2nd Clarithomycin if aged 1month-11 years erythomycin if 11-17
What is acne vulgaris
Chronic inflammatory skin condition which affects the back, face and chest which is causesd by blockage and ultimate inflammation of the hair follicle and sebaceous gland
Complications of acne
Scarring
Acne fulminans
What is acne fulminans
Ulcerating and haemorrhagic form of acne
First line for acne
Mild/moderate
Combination of topical adapalene and benzol peroxide
Combination of topical tretinoin and clindamycin
Benzoyl peroxide and clindamycin
Moderate/severe
Combination of topical adapalene and benzol peroxide
Combination of topical tretinoin and clindamycin
Benzoyl peroxide and clindamycin
ALSO
Topical azelaic acid and oral doxycycline and lymecycline
ALL GIVEN FOR 12 weeks
What is management of acne fulminans
Immediately refer to on call dermatologist
When should acne vulgaris be referred to dermatologist
Mild/moderate has not respoded to 2 rounds
Moderate/severe has not responded to a round with an oral antibiotic
Acne with scarring
Acne with pigmentation changes
Acne or scarring causing significant psych distress or contributing to mental health disorder
Management of epsteins pearl
None- non serious
Safety net it notice getting larger
If have cellulitis but then develop bluish colour to limb what is diagnosis
Necrotising fasciitis
If have cellulitis on top of chicken pox- what is most likely cause
Strep pyogenes
Features of seborrheic dermatitis nappy rash
Flakes
Cradle cap
Includes the folds
Salmon pink
Most common neck lump in kids
Lymphadenitis
What is other name for wine and port rash
Naevus flammeus
Investigation for naevus flemmus
MRI
What type of haemangioma are infantile haemangiomas
Capillary
What are congenital warts
It is possible to be born with congenital viral warts on the anus or genitals transmitted from the mother to baby during birth
How long can congenital warts last for
2 years- anything after this should be investigated for sexual abuse
Rash on whole body with pustules present
Erythema toxicum
What is blueberry muffin presentation
When skin blue from bruising over body
Causes of blueberry muffin appearnace
Rubella
CMV
Strep throat then a few days later develops scaling red papules and plaques
Guttate psoriasis
Difference in presentation of scarlet fever vs guttate psoriasis
Scarlet fever- within 24 hours of sore throat
Guttate psoriasis- a few days later with scaly papules
What nail changes are alopecia areata associated with
Pitting
Onycholysis
Management of alopecia areata
If evidence of hair regrowing then can use watchful waiting
If no hair regrowth or severe distress then very potent corticosteroids- betamethasone valerate 0.1%
Boggy and pustular raised area where is hair loss
Kerion
What give if non-flare up of eczema
Emollients
Management of balanitis
Good hygiene- avoid soaps, saline washes under foreskin in general
Management of bacterial balanitis
Oral fluclox
Inflammation very bad use hydrocortisone
Management of candidal balanitis
Topical imidazole cream
Inflammation very bad use hydrocortisone
Candidal vs bacterial balanitis
Candida- white discharge
Bacterial- yellow discharge
Differentials for blisters in neonates
Burns
Drug eruptions
Epidermolysis bullosa
Infective causes
Blisters under armpits in a child with surrounding erythema
Bullous impetigo
Itchy papular rash over hair
Head lice
Gold standard for CMPA
Double blind oral food challenge
Management of periorbital cellulitis
if any signs of orbital cellulitis or are unwell then IV
If not can use oral provided able to be followed up
Differentials for small circular rashes
Discoid eczema
Tinea
How to differnetiate between tinea and discoid eczema
Tinea not very itchy
Tinea likely to be localised to a particular area, discoid can be whidespread across the body
