Dermatology

Question 1

What are the most common areas for Eczema to arise, dependin on age?

Answer 1

Infants: face and Trunk
Older Child: Extensor Surfaces
Young Adults: Flexor surfaces (muscles that help to extend the arm)

Question 2

What is the appropriate steroid ladder for treatment of Eczema?

Answer 2

“Help Every Busy Dermatologist”
1. Hydrocortisone
2. Eumovate
3. Betnovate
4. Dermovate

Question 3

What are the main treatments for Eczema?

Answer 3

1. Emoilients
2. Steroid Treatment
3. Calcineurin inhibitors
4. Antihistamines (Sedating or Non-sedating)

Sedating: promethazine
Non-sedating: fexofenadize

Question 4

What are the classifications for Eczema and managment?

Answer 4

1. Mild: emoilients
2. Moderate: emoilients+ mild potency steroids
   3.Severe: emoilients+potent steroids +systemic therapy (phototherapy)
   4.Infected: antibiotics (Oral flucloxacillin (erythromycin if pen-allergic)- Swab and culture
   5.Eczema Herpeticum: oral aciclovir, if around the eyes then see opthalmologist the same day

Question 5

What are the different vascular malformations and when do they appear?

Answer 5

Naevus Flammeus: Port wine stain, in distribution of the trigeminal nerve

Naevus Simplex: pink or red spot, goes reader when baby cries

Question 6

What are the more malignant forms of Naevus Flammeus?
How to look out for it?

Answer 6

1.Sturge-Weber syndrome:
* Encephalotrigeminal Angiomatosis
* Flat patch that will turn bumpy
* Aetiology: GNAQ mutation  intracranial lesions
* Epilepsy, contralateral hemiplegia, intellectual disability

2. Parkes Weber syndrome
3. Kippel-Trénaunay syndrome

Examination through USS and MRI

Question 7

When do Infantile Haemangiomas develop, how long do they last for and what are some of the risk factors?

Answer 7

Develop days/weeks after birth
Last for 6-10 months and then shrink
RF’s: LBW, female, prematurity, multiple gestation

Question 8

What are the different types of Infantile Haemangiomas?

Answer 8

1.Superficial (50-60%): bright red, warm to touch appear after birth

2.Deep (15%): blue, form a lump, develops after birth

3.Mixed: bright red with a blue base, can form a lump

Question 9

What are the Syndromes associated with Infentile Haemangiomas?

Answer 9

PHACES syndrome (posterior fossa malformation, haemangiomas, Arterial abnormalities, Cardiac abnormalities, Eye abnormalities, Sternal abnormalities)

LUMBAR syndrome (Lower body or lumbosacral haemangioma,Urogenital anomalies or ulceration, Myelopathy, Bony deformities, Anorectal and arterial anomalies,Renal anomalies)

Kasabach-Merritt = kaposiform haemangioendothelioma –>thrombocytopenia–> Haemangioma with thrombocytopenia

Question 10

What are the apropriate investigations if suspecting Infantile Haemangiomas?

Answer 10

MRI or MRA is gold standard

Question 11

What are the different types of Congenital Haemangiomas?

Answer 11

1. Rapidly Involuting Congenital Haemangiomas (RICH): reach their max size at birth and then involute by 12-18 months
2. Non- Involuting Congenital Haemangiomas (NICH): increase in size as baby grows- do not shrink after birht

Question 12

What is the appropriate investigation of a Congenital Haemangioma?

Answer 12

1. USS
2. Medical photography

Question 13

What is the potential management and complications of congenital haemangiomas?

Answer 13

Management:
1. Conservative
2. Embolization, if they become too big and bleed

Complications: Heart failure (if large enough, they can generate high blood flow)

Question 14

What is a typical presentation of Erythema Toxicum?

Answer 14

• Benign maculo-papular-postular lessions
• Usually begin on the face and spread to the limbs
• Comes and goes over the first few days/weeks of life

Question 15

What should be excluded before the diagnosis of Eythema Toxicum?

Answer 15

Any congenital infection

Question 16

What is the management of Erythema Toxicum?

Answer 16

Self-limiting

Question 17

What is the appearance of Milia?

Answer 17

white pimples on nose and cheecks due to the retention of Keratin and subaceous material

Question 18

What is the managment of Milia?

Answer 18

Self-limiting

Question 19

What is the causative organism of Molluscum Contagiosum and what is the commonest age?

Answer 19

Viral Infection- pox virus
2-5 years old

Question 20

What is the appearance and presentation of Molluscum Contagiosum?

How is it transmitted?

Where is it most commonly located?

Answer 20

> white pearly or pink colored papule, ulcarated/ umbilicated
painless but may itch occasioanally

Transmitted through skin to skin contact

Commonly found on the chest, abdomen, back, armpits, groin, back of knees

Question 21

What is the management of Molluscum Contagiosum?

Answer 21

Acute: Self-limiting, 6-9 months, no need to avoid school just wear long sleeves
Chronic (>2 years)–> cryotherapy

Question 22

What is the appearance of a Mongolian Blue spot?
Which patients does it usually affect?
What is the management?

Answer 22

Blue/black macular discoloration on the base of the spine/buttocks
Asian- Afrocarribean decent
Self-limiting–> they fade slowly

Question 23

What is the presentation of Impetigo?
Which is the causative organism for Impetigo?

Answer 23

Gold-yellow crusty appearance
Staphylococcus Aureus

Question 24

What is the management plan for Imperigo?

Answer 24

1. Exclude from school until lessions are crusted of 48hrs after antibiotic

Localized- non-bollus: H202 (1%) cream or flusidic acid 2% (antibiotic) topical

Widspread, non-bollus: flusidic acid 2%-topical- or oral flucloxacillin

Widspread, bollus: oral flucloxacillin

Question 25

What is the commonest age for a nappy rash ?

Answer 25

3-15months old

Question 26

What are the different types of nappy rash and how can we distinguish them?

Answer 26

Irritant: Well demarcated, erythema, oedema, dryness, scalling !! there are no skin folds

Candida: Erythematous papules and plaques with small satellite spots or superficial pustules, sharply demarcated redness, check for oral candidiasis

Seborrheic:– cradle cap and bilateral salmon pink patches, desquamating flakes, skin folds

Question 27

What is the appropriate management for nappy rash?

Answer 27

Health education (refer to NHS choices nappy rash leaflet/website):

• Nappy type
• Leave nappy off as much as possible to help skin drying
• Clean/change every 3-4 hours / ASAP after soiling
• Use water, or fragrance-free or alcohol-free baby wipes
• Dry gently after cleaning
• Bath the child daily (do NOT use soap, bubble bath, lotions or talcum powder)

If mild erythema and the child is asymptomatic:
* Advise on the use of barrier preparation (available OTC) – applied thinly at each change
* Zinc and Castor oil ointment BP

If moderate erythema and discomfort:

• If >1-month-old = hydrocortisone 1% cream OD (max 7 days)

If rash persists and CANDIDAL INFECTION is suspected or confirmed on swab
* Advise against the use of barrier protection
* Prescribe topical imidazole cream (e.g. clotrimazole, econazole, miconazole)

If rash persists or** BACTERIAL INFECTION** is suspected or confirmed on swab
* Prescribe oral flucloxacillin (clarithromycin if pen-allergic) for 7 days
* Arrange to review the child

Question 28

How does Seborrhoeic Dermititis presents in infants?

Answer 28

Dandruff; presents in first 6 weeks, resolves over following weeks

Flaking skin on scalp (infants), erythematous, yellow, crusty, adherent layer (cradle cap) that can spread to behind ears, face, flexures → non-itchy, associated with Malassezia yeasts

Question 29

What are the appropriate investigations for Seborrhoeic Dermititis?

Answer 29

1. Clinical
2. Skin scrapings for Malassezia, culture of swabs

Pityriasis versicolor causes by malassezia furfur

Question 30

What is the appropriate management for Seborrhoeic Dermititis?

Answer 30

Spontaneous resolution (by 8m)

**1st line **if scalp affected–> regular washing with baby shampoo–> gentle brushing to remove scales

**Soaking crusts overnight **with white petroleum jelly or slightly warmed vegetable/olive oil, and shampooing in the morning / soften scales with baby oil, gentle brush, wash off with baby shampoo

**Emulsifying ointment **can be used if these measures don’t work

If other areas of skin affected, bathe infant ≥1/day using emollient as a soap substitute

2nd line if scalp affected –> topical imidazole cream (e.g. clotrimazole, econazole, miconazole)
BD or TDS (depending on preparation) until symptoms disappear
Consider specialist advice if it lasts >4 weeks

3rd line if severe –> mild topical steroids (e.g. 1% hydrocortisone)

Question 31

What is the causative organism for Tinea?

Answer 31

dermatophyte fungi invade dead keratinous structures

Trichophytum rubrum

Question 32

What is the presentation of Tinea and what are the subtypes?

Answer 32

Ringed appearance ± kerion (severe inflamed ringworm patch), red or silver rash

1. Tinea capitis – scalp
2. Tinea pedis – feet

Question 33

What is the appropriate management of Tinea and general advice?

Answer 33

Tinea Faciei, Tinea Corporis, Tinea Cruris or Tinea Pedis

• Mild –> topical antifungals (e.g. terbinafine cream, clotrimazole)
• Moderate –> hydrocortisone 1% cream
• Severe–> oral antifungals (1st line: oral terbinafine; 2nd line: oral itraconazole)

Tinea Capitis–> oral antifungal (e.g. griseofulvin or terbinafine)

Advice (very contagious so take steps to prevent spread):
* Wear loose-fitting cotton clothing
* Wash affected areas of skin daily
* Dry thoroughly after washing
* Avoid scratching
* Do not share towels
* Wash clothes and bed lined frequently
* No need for school exclusion