Paediatric dermatology Flashcards
What is eczema?
Chronic atopic condition caused by defects in the normal continuity of the skin barrier, leading to inflammation in the skin
When does eczema usually present?
Infancy with dry, red, itchy and sore patches of skin covering the flexor surfaces
What is the management of eczema?
Emollients
What is the management of eczema flares?
Emollients and topical steroids and treating any complications such as bacterial or viral infections
What thin emollients are available?
E45
Diprobase cream
Oliatum cream
Aveeno cream
Cetraben cream
Epaderm cream
What thick, greasy emollients are available?
50:50 ointment
Hydromol ointment
Diprobase ointment
Cetraben ointment
Epaderm ointment
What are the side effects of topical steroids?
They can thin the skin- more prone to flares, bruising, tearing, stretch marks and telangiectasia
What is on the steroid ladder for eczema?
Mild: Hydrocortisone 0.5%,1% and 2.5%
Moderate: Eumovate (clobetasone butyrate 0,05%)
Potent: Betnovate (betamethasone 0.1%)
Very potent: Dermovate (clobetasol propionate 0.05%)
What is the most common organism to infect the skin in eczema?
Staphylococcus aureus
How do you usually treat staphylococcus aureus infection of the skin?
Flucloxacillin
What is eczema herpeticum?
Viral skin infection in patients with eczema caused by herpes simplex virus or varicella zoster virus
What was eczema herpeticum previously known as?
Kaposi varicelliform eruption
What is the typical presentation of eczema herpeticum?
Patient who has eczema, develops a widespread, painful, vesicular rash with systemic symptoms such as fever, lethargy, irritability and reduced oral intake. Usually have lymphadenopathy
What is the management for eczema herpeticum?
Aciclovir- oral or IV if severe
What are the complications of eczema herpeticum?
Can be life threatening and leave patients immunocompromised.
Bacterial superinfection
What is psoriasis?
A chronic autoimmune condition that causes recurrent symptoms of psoriatic skin lesions
What is the genetic component of psoriasis?
A 1/3 of patients have a first degree relative with psoriasis
What does psoriasis look like?
Patches of dry, flaky, scaly, faintly erythematous skin lesions that appear in raised and rough plaques, commonly on extensor surfaces
What are the 4 types of psoriasis?
Plaque psoriasis
Guttate psoriasis
Pustular psoriasis
Erythrodermic psoriasis
What is plaque psoriasis?
Thickened erythematous plaques with silver scales on scalp and extensor surfaces, 1-10 cm in diameter, most common type
What is guttate psoriasis?
Second most common and common in children. Raised papules across trunks and limbs, over time they can turn into plaques. Usually resolves spontaneously within 3-4 months
What is guttate psoriasis often triggered by?
Streptococcal throat infection, stress or medications
What is pustular psoriasis?
Rare and severe with pustules under areas of erythematous skin, pus is not infectious. Patients can be systemically unwell and usually require admission to hospital
What is erythrodermic psoriasis?
Rare, severe form with extensive erythematous inflamed areas covering most of the surface of the skin. Skin comes away in large patches and should be treated as a medical emergency
Which type of psoriasis is more common in children?
Guttate psoriasis
What specific signs are suggestive of psoriasis?
Auspitz sign- small points of bleeding when plaques are scraped off
Koebner phenomenon- development of psoriatic lesions to areas of skin affected by trauma
Residual pigmentation of the skin after the lesions resolve
What treatment options are there for psoriasis?
Topical steroids
Topical vitamin D analogues
Topical dithranol
Topical calcineurin inhibitors (tacrolims) usually only in adults
Phototherapy with narrow band ultraviolet B light - particualryl useful in extensive guttate psoriasis
What medications may be presrcibed for children with psoriasis that are unlicensed?
Dovobet
Enstilar
What else is associated with psoriasis?
Nail psoriasis, psoriatic arthritis and cardiovascular disease associated with psoriasis
What is acne caused by?
Chronic inflammation with or without localised infection, in pockets within the skin known as pilosebaceous unit
Why is acne exacerbated by puberty?
Androgenic hormones increase production of sebum
What bacteria plays an important role in acne?
Propionibacterium
What are macules?
Flat marks on the skin
What are papules?
Small lumps on the skin
What are pustules?
Small lumps containing yellow pus
What are blackheads?
Open comedomes with black pigmentation in the centre
What are comedomes?
Skin coloured papules representing blocked pilosebaceous units
What are ice pick scars?
Small indentations in the skin that remain after acne lesions heal
What are hypertrophic scars?
Small lumps in the skin that remain after acne lesions heal
What are rolling scars?
Irregular wave-like irregularities of the akin that remain after acne lesions heal
What is the most effective combined contraceptive pill for acne?
Co-cyprindiol because of its anti-androgen effecrs but has a higher risk of thromboembolism
What are the side effects of isotreintoin?
Dry skin and lips
Photosensitvity of the skin
Depression
Rarely Stevens-Johnson syndrome and toxic epidermal necrolysis
What is exanthem?
Eruptive widespread rash
What are the six exanthems?
First: Measles
Second: Scarlet fever
Thrid: Rubella
Fourth: Dukes’ disease
Fifth: Parvovirus B19
Sicth: Roseola infantum
What is measles and how does it present?
Highly contagious via respiratory droplets, symptoms start 10-12 days after exposure with fever, coryzal and conjunctivitis
What is another sign of measles that is pathognomonic?
Koplik spots are greyish white spots on the buccal mucosa which appear 2 days after fever
What is the rash like in measles?
Starts on the face, classcially behind the ears, 3-5 days after the fever and then spreads to the rest of the body. It is erythematous, macular with flat lesions
What is the management of measles?
Self-resolving after 7-10 days of symptoms. Children should isolate until 4 days after their symptoms resolve
What are the complications of measles?
Pneumonia
Diarrhoea
Dehydration
Encephalitis
Meningitis
Hearing loss
Vision loss
Death
What pathogen is scarlet fever associated with?
Group A streptococcus, usually tonsilitis but it is not caused by a virus
What is scarlet fever caused by?
Exotoxin produced by streptococcus pyogenes
What are the features of scarlet fever?
Red-pink, blotchy, macular rash with rough sandpaper skin that starts on the trunk and spreads outwards. may have red flushed cheeks
Fever
Lethargy
Flushed face
Sore throat
Strawberry tongue
Cervical lymphadenopathy
What is the treatment of scarlet fever?
Phenoxymethylpenicillin for 10 days
What are the notifiable dermatological conditions?
What conditions are associated with group A strep infection?
Post-streptococcal glomerulonephritis
Acute rheumatic fever
What is rubella caused by?
Caused by rubella virus, highly contagious and spread by respiratory droplets
how does rubella present?
2 weeks after exposure
erythematous macular rash milder than measles that starts on the face and spreads to the rest of the body. Rash classically lasts 3 days
What can rubella be associated with?
mild fever, joint pain and a sore throat.
Patients often have enlarged lymph nodes
What are the complications of rubella?
Thrombocytopenia and encephalitis
What can rubella in pregnancy lead to?
Congenital rubella syndrome; deafness, blindness and congenital heart disease
What is parvovirus B19 also known as?
fifth disease, slapped cheek syndrome and erythema infectiosum
What does parvovirus infection start with?
Fever, coryza and muscle aches and lethargy
When does the rahs in parvovirus B19 usually occur?
after 2-5 days of non-specific symptoms
Where is the rash in parvovirus B19?
On both cheeks as though they have slapped cheeks and then a few days later a reticular mildly erythematous rash affects the trunk and limbs that appears raised and itchy
What is the management of parvovirus B19?
Usually self-limiting and rash and symptoms fade over 1-2 weeks
Which patients are at risk of complications with parvovirus B19?
Immunocompromised patients, pregnant women and patients with haematological conditions such as sickle cell anaemia, thalassaemia, hereditary spherocytosis and haemolytic anaemia
What do patients at risk of complications of parvovirus B19 require?
FBC and reticulocyte count for aplastic anaemia and serology testing
What are the complications of parvovirus B19?
Aplastic anaemia
Encephalitis or meningitis
Pregnancy complications including fetal death
Rarely hepatitis, myocarditis or nephritis
What is sixth disease?
Roseola infantum
What is roseola infantum caused by?
Human herpesvirus 6 or less frequently human herpesvirus 7
What is the typical pattern of illness in roseola?
presnets 1-2 weeks after infection with sudden high fever that lasts for 3-5 days then disappears suddenly. When fever settles, rash appears for 1-2 days- mild erythematous mcular rash across the arms, legs, trunk, face and is not itchy
What is the main complication of roseola infantum?
Febrile convulsions
What are the complications of roseola infantum in immunocompromised patients?
Myocarditis
Thrombocytopenia
Guillain-Barre syndrome
What is erythema multiforme?
Erythematous rash caused by a hypersensitivity reaction
What are the most common causes of erythema multiforme?
Viral infections and medications
What is erythema multiforme associated with?
Herpes simplex virus and mycoplasma pneumonia
What is the rash in erythema multiforme like?
widespread, itchy, erythematous rash. It has characteristic target lesions which are red rings within larger red rings similar to a bulls eye target, redder in the middle
What symptoms can accompany erythema multiforme rash?
stomitis
mild fever
muscle and joint aches
headaches
general flu-like symptoms
When might you do a chest xray in erythema multiforme?
When looking for the cause being mycoplasma pneumonia
What are the most common medications that cause erythema multiforme?
aminopenicillins , sulfonamides, carbamazepine, allopurinol, NSAIDs and the oral contraceptive pill
What is the pathophysiology of urticaria?
Caused by the release of histamine by mast cells in the skin. May be allergic in acute or autoimmune in chronic idiopathic urticaria
What typically triggers acute urticaria?
Allergies to food, medications or animals
Medications
Viral infections
Insect bites
Dermatographism
What are the three types of chronic urticaria?
Chronic idiopathic erticaria
Chronic inducible urticaria
autoimmune urticaria
What is chronic idiopathic urticaria?
recurrent episodes of chronic urticaria without clear underlying cause or trigger
What is chronic inducible urticaria?
describes episodes of chronic urticaria that can be induced by
sunlight
temperature change
exercise
strong emotions
hot or cold weather
pressure
What can autoimmune urticaria be associated with?
systemic lupus erythematous
What is the usual antihistamine for urticaria?
Fexofenadine
What are the treatments for very problematic urticaria?
Anti-leukotrienes such as montelukast
Omalizumab which targets IgE
Cyclosporin
What is chickenpox caused by?
varicella zoster virus
What is the rash like in chicken pox?
Widespread, erythematous, raised, vesicular blistering lesions. Usually starts on the trunk or face and spreads outwards affecting the whole body over 2-5 days. When scabbed they stop being contagious
What are the other symptoms of chicken pox apart from the rash?
Fever often first symptom
Itch
general fatigue and malaise
What is the infectivity like in chicken pox?
Highly contagious and patients can become symptomtic from 10 days to 3 weeks after exposure
What are the complications of chicken pox?
Bacterial superinfection
Dehydration
Conjunctival lesions
Pneumonia
Encephalitis
Where does the chickenpox virus lie dormant and what can it becomes when it reactivates later in life?
Sensory dorsal root ganglion cells and cranial nerves, becomes shingles or Ramsay Hunt syndrome
What can be given to pregnant women who are at risk of chicken pox?
varicella zoster immunoglobulins
What can chicken pox cause in pregnancy before 28 weeks gestation?
Congenital varicella syndrome
What can chicken pox in a pregnant women at time of delivery lead to and what is it treated with?
Life threatening neonatal infection which is treated with varicella zoster immunoglobulins and aciclovir
When might treatment be administered to children with chicken pox and what is this treatment?
Aciclovir in immunocompromised patients or adolescents over 14 years presenting within 24 hours, neonates or those at risk of complications
What are the complications of chicken pox?
Encephalitis
What can the itching from chicken pox be treated with?
Calamine lotion and chlorphenamine
How long do chicken pox lesions usually take to scab over?
around 5 days
What is hand, foot and mouth disease caused by?
Coxsackie A virus
What is the incubation period for hand, foot and mouth disease?
3-5 days
What does hand, foot and mouth disease normally start with?
Viral upper respiratory tract symptoms such as tiredness, sore throat, dry cough and raised temperature
When does the rash appear in hand, foot and mouth disease?
after 1-2 days of symptoms, small mouth ulcers, particularly on the tongue and then blistering red spots spread across the body
How is hand, foot and mouth disease treated?
There is no treatment but symptoms resolve within a week to 10 years
What are the complications of hand, foot and mouth disease/
Dehydration
Bacterial superinfection
Encephalitis
What is molluscum contagiosum?
viral skin infection caused by molluscum contagiosum virus
How is molluscum contagiosum characterised by?
Small, flesh coloured papules that characteristically have a central dimple, typically appear in crops of multiple lesions in a local area
How long can it take molluscum contagiosum papules to resolve?
up to 18 months
What is pityriasis rosea?
A generalised, self-limiting rash that has an unknown cause
What symptoms may be present with pityriasis rosea, and can be prodromal?
headache
tiredness
loss of apetite
flu-like symptoms
What does the pityriasis rash begin with?
herald patch which is a faint red, or pink, scaly, oval shaped lesion that is 2cm or more in diameter usually on the torso
What is the rash like in pityriasis rosea?
widespread faint red or pink, slightly scaly, oval shaped lesions usually less than 2cm in diameter. On the torso they can be arrnage din a characteristic christmas tree fashion along the ribs
What are the pityriasis rosea symptoms like in dark skinned people?
Patches can be grey coloured, lighter or darker than their skin colour
What is the disease course of pityriasis rosea?
Rash resolves within 3 months without treatment
What is seborrhoeic dermatitis?
inflammatory skin condition that affects the sebaceous glands
What plays a role in seborrhoeic dermatitis that improves with anti-fungal treatment?
Malassezia yeast
What is infantile seborrhoeic dermatities also known as and what does it cause?
Cradle cap and causes a crusted flaky scalp
What is first and second line and third line for infantile seborrhoeic dermatitis?
baby oil
White petroleum jelly
Anti-fungal cream (clotrimazole or miconazole) for 4 weeks
What is first line treatment for seborrhoeic dermatitis of the scalp (dandruff)?
Ketoconazole shampoo
What is seborrhoeic dermatitis of the face and body treated with first line?
Anti-fungal cream- clotrimazole or miconazole used for up to 4 weeks
Where does seborrhoeic dermatitis of the face and body tend to affect?
eyelids, nasolabial folds, ears, upper chest and back
What is ringworm and what is it also known as?
Fungal infection of the skin and also known as tinea or dermatophytosis
What is ringworm affecting the scalp called?
Tinea capitis
What is ringworm affecting the feet called?
Tinea pedis
What is ringworm affecting the groin called?
Tinea cruris
What is ringworm affecting the body called?
Tinea corporis
What is a fungal nail infection called?
Onychomycosis
What is the most common type of fungus that causes ringworm?
Trichophyton
How does ringworm present?
Itchy rash that us erythematous, scaly and well demarcated, one or several rings or circular shaped areas that spread outwards, edge is more prominent
What are the anti-fungal creams?
Clotrimazole and miconazole
What is the fungal shampoo for tinea capitis?
Ketoconazole
What oral anti-fungal medications are there?
Fluconazole, griseofulvin and itraconazole
What medication can be used for fungal nail infections?
Oral terbinafine
What is tinea incognito?
Extensive and less well recognised fungal skin infection resulting from the use of steroids to treat initial fungal infection when it was misdiagnosed as dermatitis as a topical steroid was prescribed, it dampens immune response
Why is tinea incognito less reocgnisable as ringworm?
less well-demarcated border and fewer scales
What is nappy rash?
contact dermatitis in the nappy area caused by friction between skin and nappy and contact with urine and faeces
What are the RFs for nappy rash?
Delayed changing of nappies
irritant soap products and vigorous cleaning
Certain types of nappies
Diarrhoea
Oral antibiotics predispose to candida infection
Pre-term infants
How does nappy rash present?
sore, red, inflamed skin in the nappy area in individual oatches and tends to spare skin creases
What signs point to candidal infection rather nappy rash?
Rash extending into the skin folds
larger red macules
Well demarcated scaly border
Similar rash to ringworm
Satellite lesions which are small similar patches of rash near the main rahs
How can you check for candidal infection rather than nappy rash?
Check for oral thrush
How do you manage nappy rash?
More absorbant nappies
Change nappy as soon as possible after soiling
Use water or alcohol free products to clean nappy area and make sure it is dry
Maximise time not wearing a nappy
How do you treat candida infection in babies?
Anti-fungal creams (clotrimazole or miconazole) or antibiotic (fusidic acid cream or oral flucloxacillin)
What are the complications of nappy rash?
Candida infection
Cellulitis
Jacquet’s erosive diaper dermatitis
Perianal pseudoverrucous papules and nodules
What are scabies?
Tiny mites called sarcoptes scabei that burrow under the skin causing infection and intense itching, it can take up to 8 weeks for symptoms to appear after the initial infection
How does scabies present?
Incredibly itchy small red spots, possibly with trakc marks where the mites have burrowed classiclaly in the finger webs
What is the treatment for scabies?
Permethrin cream left on for 8-12 hours
What can be given a week after permethrin cream for difficult to treat or crusted scabies?
oral ivermectin
What is crusted scabies?
Also known as norwegian scabies. Serious infestation with scabies in people that are immunocompromised and can be misdiagnosed as psoriasis
What is the headlice parasite?
Pediculus humanus capitis parasite
What is the management of nits?
Dimeticone 4% lotion which is repeated after 7 days
What are petechiae?
small < 3 mm, non blanching red spots on the skin caused by burst capillaries
What are purpura?
larger 3-10 mm non-blanching, red-purple, macules or papules created by leaking blood from vessels under the skin
What is the most concerning differential of a non-blanching rash?
Meningococcal septicaemia
What are the differential diagnosis for non-blanching rash and how are they distinguished?
Meningiococcal septicaemia- feverish child
HSP- purpuric rash on the legs and buttocks and may have associated abdominal or joint pain
ITP- over several days in a well child
Acute leukaemias- gradual petechiae, anaemia, lymphadenopathy and hepatosplenomegaly
Haemolytic uraemic syndrome- associated with oliguria and anaemia and often recent diarrhoea
Mechanical- above neck and around eyes
Traumatic- tight pressure on the skin
Viral illness- influenza and enterovirus
What are the investigations for a non-blanching rash?
FBC- anaemia could be HUS or leukaemia, Low whute cells could be neutropenic sepsis or leukaemia, low platelets can suggest ITP or HUS
Urea and electrolytes- high urea and creatinine can indivate HUS or HSP with renal involvement
CRP- indicate inflammation or infection
ESR- non specific for HSP or infection
Coagulation screen- PTT, APTT, INR and fibrinogen can diagnose clotting abnormalities
Blood culture
Meningiococcal PCR- can confirm meningiococcal disease
Lumbar puncture- meningitis or encephalitis
BP- HTN can show HSP and HUS or septic shock
Urine dipstick- proteinuria and haematuria can suggest HSP or HUS
What is erythema nodosum?
red lumps appear across patient’s shins
What is erythema nodosum caused by?
inflammation of the subcutaneous fat on the shins (panniculitis) caused by a hypersensitivity reaction
What can be the causes of erythema nodosum?
Streptococcal throat infections
Gastroenteritis
Mycoplasma pneumoniae
TB
Pregnancy
Medciations e.g. OCP and NSAIDs
Chronic disease: IBS, Sarcoidosis, lymphoma and leukaemia
In exams whar does erythema nodosum often indicate?
IBS or sarcoidosis
How does erythema nodosum present?
red, inflamed, subcutaneous nodules across both shins
What investigations are useful in erythema nodosum?
Inflammatory markers
Throat swab for streptococcal infection
Chest xray for mycoplasma, TB, sarcoidosis and lymphoma
Stool microscopy an culture for campylobacter and salmonella
Faecal calprotein- IBS
What is impetigo?
Superficial bacterial skin infection usually caused by staphylococcus aureus or less commonly strep pyogenes
What is characteristic of impetigo?
golden crust
What are the two types of impetigo?
Bullous or non-bullous
Where does non-bullous impetigo typically occur?
Around the nose and mouth
What can be used to treat localised non-bullous impetigo?
Topical fusidic acid
What can be used to treat widespread non-bullous impetigo and is the antibiotic of choice for staphylococcal infections?
Oral flucloxacillin
What is bullous impetigo caused by?
Staphylococcus aureus bacteria that can produce epidermolytic toxins that break down the proteins that hold skin cells together
Which type of impetigo is more common in neonates and children under 2 years?
Bullous
Which type of impetigo do patients have more systemic symptoms?
Bullous
What is severe bullous impetigo with widespread lesions called?
Staphylococcus scalded skin syndrome
What is the treatment for bullous impetigo?
Oral flucloxacillin
What are the complications of impetigo?
Cellulitis
Sepsis
Scarring
Post streptococcal glomerulonephritis
Staphylococcus scalded skin syndrome
scarlet fever
Why is staphylococcal scalded skin syndrome usually only affecting children under 5 years?
Older children and adults usually develop immunity to the epidermolytic toxins produced by staphylococcal aureus bacteria
What sign is positive in Staphylococcal scalded skin syndrome? (SSSS)
Nikolsky sign which is where very gentle rubbing of the skin causes it to peel away
What is the management of SSSS?
Admission and IV antibiotics and management of dehydration
What is the presentation of SSSS?
generalsied erythema patches and then the skin looks thin and wrinkled followed by formation of fluid filled blisters called bulbae which burst and leave sore red skin behind. Also have systemic symptoms
What are Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN)?
Spectrum of same pathology, where a disproportionate immune response causes epidermal necoriss resulting in blistering and shedding of the top layer of skin
What is the difference between SJS and TEN?
SJS affects less than 10% of body surface area whereas TEN affects more than 10%
What can cause a higher risk of SJS and TEN?
HLA genetic types
What are the causes of SJS and TEN?
Medications: Anti-epileptics, Antibiotics, Allopurinol and NSAIDs
Infections: Herpes simplex, Mycoplasma pneumonia, Cytomegalovirus and HIV
What is the presentation of SJS and TEN?
Usually starts with fever, cough, sore throat, sore mouth, sore eyes and itchy skin. Then they develop a purple or red rash that spreads and starts to blister. A few days after blisters burst leaving red skin beneath it. Pain, erythema, blistering and shedding can also happen on lips and mucous membranes. Eyes can become inflamed and ulcerated and can also affect urinary tract, lungs and internal organs
What is the management for SJS and TEN?
Medical emergency and should be admitted to dermatology or burns unit. may need steroids, immunoglobulins and immunsuppressant medication
What are the complications of SJS and TEN?
Secondary infection such as cellulitis and sepsis
Permanent skin damage
Visual complications
