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Paediatrics > Paediatrics Dermatology > Flashcards

Paediatrics Dermatology Flashcards

1
Q

What is eczema?

A

Chronic atopic condition

Defects in continuity of skin barrier causing inflammation

Runs in families

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2
Q

When does eczema present?

A

Infancy with dry, red, itchy and sore patches on flexor surfaces

Comes in flares

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3
Q

What is the management of eczema?

A

Maintenance = emollients (thick and greasy - artificial barrier) after washing + before bed soap substitutes

Flares = thicker emollients, topical steroids (sometimes tacrolimus)

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4
Q

What are some specialist treatments in severe eczema?

A

Zinc impregnated bandages

Topical tacrolimus

Phototherapy

Systemic immunosuppressants (oral corticosteroids, methotrexate and azathioprine)

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5
Q

What are the thin creams and thick creams used in eczema?

A

Thin = E45, diprobase cream, oilatum cream, aveeno cream, cetraben cream, epaderm cream

Thick = 50:50 ointment (50% liquid parafen), hydromol ointment, diprobase ointment, cetraben ointment, epaderm ointment

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6
Q

What are the side effects of topical steroids?

A

Thinning of the skin = flares, bruising, tearing, stretch marks, enlarged blood vessels (telangiectasia)

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7
Q

What is the steroid ladder for steroid cream?

A

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%)

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8
Q

What can treat bacterial infection of the skin in eczema? Which bacteria is most common?

A

Oral abx (flucloxacillin - if severe then IV)

Staphylococcus aureus

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9
Q

What is eczema herpeticum?

A

Viral skin infection caused by herpes simplex virus (HSV) ot varicella zoster virus (VZV)

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10
Q

What was eczema herpeticum previously known as?

A

Kaposi varicelliform eruption (don’t confuse with Kaposi’s sarcoma)

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11
Q

What is the most common organism in eczema herpeticum?

A

Herpes simplex virus 1 (coldsore)

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12
Q

Who does eczema herpeticum usually occur in?

A

Patients with pre-existing condition e.g. atopic eczema or dermatitis

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13
Q

How does eczema herpeticum present?

A

Widespread, painful vesicular rash

Fever, lethargy, irritability

Lymphadenopathy

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14
Q

Describe the rash in eczema herpeticum?

A

Widespreak, erythematous, painful, itchy, vesicles containing pus (burst and leave punched out lesions)

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15
Q

What is the management of eczema herpeticum?

A

Viral swabs of the vesicles to confirm diagnosis

Aciclovir (mild = oral, severe = IV aciclovir)

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16
Q

What are some complications of eczema herpeticum?

A

Can be life-threatening if not treated properly (in immunocompromised)

Bacterial superinfection

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17
Q

What is psoriasis?

A

Chronic autoimmune conditon causing psoriatic skin lesions

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18
Q

What causes psoriasis?

A

Genetic component (but not clear)

1/3 patients have first degree relative with psoriasis

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19
Q

Describe the patches of psoriasis?

A

Dry

Flaky

Scaly

Faintly erythematous

Raised

Rough plaques

EXTENSOR SURFACES

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20
Q

Why do psoriatic plaques occur?

A

Rapid generation of new skin cells causing

abnormal buildup and thickening of the skin

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21
Q

Name 4 types of psoriasis?

A

Plaque psoriasis

Guttate psoriasis

Pustular psoriasis

Erythrodermic psoriasis

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22
Q

Describe plaque psoriasis?

A

Thickened erythematous plaques

Silver scales

Exensor surfaces

Most common form of psoriasis

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23
Q

Describe guttate psoriasis?

A

Common in children

Many small raised papules across trunk and limbs

Mildly erythematous and slightly scaly

Triggered by streptococcal throat infection, stress or medications

Resolves spontaneously in 3-4 months

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24
Q

What is pustular psoriasis?

A

Rare severe form of psoriasis where pustules form under areas of erythematous skin

Pus is not infective

Systemically unwell - medical emergency

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25
Q

Describe erythrodermic psoriasis?

A

Rare and severe psoriasis

Erythematous inflamed areas on most of the surface of the skin

Skin comes away in large patches = raw exposed areas - medical emergency and requires admission

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26
Q

Which specific signs are suggestive of psoriasis?

A

Auspitz sign = small points of bleeding where plaques are scraped off

Koebner phenomenon = development of psoriatic lesions to areas of skin affected by trauma

Residual pigmentation = after lesions resolve

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27
Q

How is psoriasis diagnosed?

A

Clinical appearance of the lesions

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28
Q

What are the treatment options for psoriasis?

A

Topical steroids

Topical vitamin D analogues (calcipotriol)

Topical dithranol

Topical calcineurin inhibitors (tacrolimus) usually only used in adults

Phototherapy with narrow band ultraviolet B light for guttate psoriasis

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29
Q

Which unlicensed treatments can be used for difficult to control psoriasis?

A

Methotrexate

Cyclosporine

Retinoids

Biologic medication

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30
Q

Which products contain both a potent steroid and vitamin D analogue?

A

Dovobet

Enstilar

(not licensed in children)

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31
Q

What conditions are associated with psoriasis?

A

Nail psoriasis - pitting, thickening, discolouration, ridging and onycholysis (separation of the nail from nail bed)

Psoriatic arthritis - (10% of patients with psoriasis) within 10 years of developing skin changes

Psychological - depression and anxiety

Obesity, hyperlipidaemia, hypertension and type 2 diabetes

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32
Q

What causes acne?

A

Blocking of the pilesebaceous unit by increased production of sebum trapping keratin

Causing chronic inflammation with / without localised infection

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33
Q

What are the pilosebaceous unit?

A

Tiny dimples in skin containing hair follicles and sebaceous glands (produce natural skin oils and sebum)

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34
Q

Why is acne exacerbated by puberty / improving with anti-androgenic hormonal contraception?

A

Androgenic hormones increase the production of sebum

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35
Q

What are swollen and inflamed pilosebaceous units known as?

A

Comedones

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36
Q

What bacteria is thought to overgrow in acne?

A

Propionibacterium acnes (usually colonises the skin)

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37
Q

Define the following terms:

Macules

Papules

Pustules

Comedomes

Blackheads

Ice pick scars

Hypertrophic scars

Rolling scars

A

Macules = flat marks on the skin

Papules = small lumps on the skin

Pustules = small lumps containing yellow pus

Comedomes = skin coloured papules representing blocked pilosebaceous units

Blackheads = open comedones with black pigmentation in the centre

Ice pick scars = small indentations in the skin that remain after acne lesions heal

Hypertrophic scars = small lumps in the skin that remain after acne lesions heal

Rolling scars = irregular wave-like irregularities of the skin that remain after acne lesions heal

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38
Q

What is the management of acne?

A

Reduce symptoms / scarring / psychosocial impact

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39
Q

What medications can be used for acne?

A

No treatment if mild

Topical benzoyl peroxide to reduce inflammation​ (toxic to P. acnes bacteria)

Topical retinoids (chemical related to vit A) slow production of sebum

Topical abx e.g. clindamycin (prescribed with benzoyl peroxide to reduce bacterial resistance)

Oral abx e.g. lymecycline

Oral contraceptive pill to stabalised hormones and slow production of sebum

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40
Q

What is the last-line option for treating acne?

A

Oral retinoids i.e. isotretinoin (specialist prescribes) - careful follow up and monitoring

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41
Q

What is the most effective COCP for treating acne?

A

Co-cypindiol (Dianette) due to anti-androgen effects

Higher risk of thromboembolism so treatment is discontinued once acne is controlled

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42
Q

What is the oral isotretinoin called?

A

Roaccutane (retinoid)

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43
Q

How does roaccutane work?

A

Reduce production of sebum

Reduce inflammation

Reduce bacterial growth

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44
Q

What is the risk of roaccutane in women?

A

Teratogenic (harmful to foetus) patients must have effective and reliable contraception - must stop medication a month before becoming pregnant

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45
Q

What are some side effects of isotretinoin?

A

Dry skin and lips

Photosensitivity of the skin to sunlight

Depression and suicidal ideation (must be screened for mental health issues before starting treatment)

Rarely stevens-Johnson syndrome and toxic epidermal necrolysis

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46
Q

What is an exanthem?

A

Eruptive widespread rash

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47
Q

Name the original six “viral exanthemas”

A

First disease: Measles

Second disease: Scarlet Fever

Third disease: Rubella (AKA German Measles)

Fourth disease: Dukes’ Disease

Fifth disease: Parvovirus B19

Sixth disease: Roseola Infantum

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48
Q

What is measles caused by?

A

Measles virus - highly contagious via respiratory droplets

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49
Q

How and when do symptoms of measles start?

A

10 - 12 days after exposure

Fever, coryzal symptoms and conjunctivitis

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50
Q

What are Koplik spots?

A

Greyish-white spots on the buccal mucosa - pathognomic for measles

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51
Q

Describe the rash in measles?

A

Starts on the face behind the ears

3-5 days after the fever

Spreads to rest of body

Erythmatous, macular rash with flat lesions

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52
Q

What is the management of measles?

A

Self-resolves after 7-10 days of symptoms

Isolate until 4 days after symptoms resolve

Notifiable disease

30% develop complications

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53
Q

What are the complications of measles?

A

Pneumonia (most common cause of death)

Diarrhoea

Dehydration

Encephalitis

Meningitis

Hearing loss

Vision loss

Death

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54
Q

What is scarlet fever associated with?

A

Group A streptococcus infection, usually tonsillitis (not caused by a virus)

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55
Q

What is scarlet fever caused by?

A

Exotoxin produced by the strep pyogenes (group A strep) bacteria

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56
Q

Describe the rash in scarlet fever?

A

Red-pink, blotchy, macular rash with rough “sandpaper” skin - starts on the trunk and spreads outwards

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57
Q

What are the other features of scarlet fever?

A

Fever

Lethargy

Flushed face

Sore throat

Strawberry tongue

Cervical lymphadenopathy

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58
Q

What is the treatment of scarlet fever?

A

Abx for the underlying strep bacterial infection

Phenoxymethylpenicillin (penicillin V) for 10 days

Notifiable disease

Kept off school for 24 hours after starting abx

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59
Q

Which other conditions are associated with group A strep infection?

A

Post-streptococcal glomerulonephritis

Acute rheumatic fever

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60
Q

What is Rubella caused by? When do symptoms appear?

A

Rubella virus

2 weeks after exposure

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61
Q

Describe the rash in rubella?

A

Milder erythematous macular rash starting on face and spreading to rest of the body

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62
Q

How long does the rash last in rubella?

What are the associated symptoms?

A

3 dyas

Mild fever

Joint pain

Sore throat

Lymphadenopathy

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63
Q

What is the management of rubella?

A

Self-limiting

Notifiable disease

Stay off school for 5 days after rash disappears

Avoid pregnant women

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64
Q

What are the complications of rubella?

A

Thrombocytopenia

Encephalitis

Pregnancy = congenital rubella syndrome (deafness, blindness, congenital heart disease)

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65
Q

What is the fourth disease?

A

Dukes disease- mostly forgotten in clinical practice (no organism found to explain it)

Non-specific viral rash

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66
Q

What is the fifth disease also known as?

A

Parvovirus B19

Slapped cheek syndrome

Erythema infectiosum

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67
Q

What are the features of parvovirus infection?

A

Mild fever, coryza, non-specific viral symptoms e.g. muscle aches and lethargy

2-5 days after the rash appears (bright red, both cheeks, “slapped cheeks”

A few days after the reticular (net-like) erythematous rash appears which affects the trunks and limbs (raised and itchy)

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68
Q

How is parvovirus B19 managed?

A

Self-limiting

Rash / symptoms fade over 1-2 weeks

Supportive with fluids / analgesia

Infectious prior to rash but once formed, no longer infectious and can return

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69
Q

Who is at risk of complications to parvovirus?

A

Immunocompromised

Pregnant women

Haematological conditions (sickle cell anaemia, thalassaemia, hereditary spherocytosis and haemolytic anaemia)

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70
Q

How to manage patients with parvovirus and at risk of complications?

A

Serology testing to confirm diagnosis

FBC and reticulocyte count for aplastic anaemia

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71
Q

What are some complications of parvovirus infection?

A

Aplastic anaemia

Encephalitis or meningitis

Pregnancy complications including fetal death

Hepatitis, myocarditis or nephritis

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72
Q

What is the sixth disease? What causes it?

A

Roseola infantum

Human herpes virus 6 (HHV-6)

Human herpes virus 7 (HHV-7)

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73
Q

How does roseola progress?

A

1-2 weeks after infection with high fever (up to 40) suddenly lasting 3-5 days then disappearing

Coryzal symptoms, sore throat, lymphadenopathy

Fever settles and rash appears for 1-2 days

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74
Q

How does the rash appear in roseola?

A

Mild erythematous macular across arms, legs, trunk and face - is not itchy

Full recovery in a week- don’t generally need to be kept of nursery

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75
Q

What is the main complication of roseola?

A

Febrile convulsions due to high temperature

Immunocompromised = myocarditis, thrombocytopenia, Guillain-Barre syndrome

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76
Q

What is erythema multiforme?

A

Erythematous rash caused by hypersensitivity reaction

Caused by viral infections and medncations

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77
Q

Which infections are associated with erythema multiforme?

A

Herpes simplex virus

Mycoplasma pneumonia

78
Q

How does erythema multiforme present?

A

Widespread, itchy, erythematous rash

Characteristic “target lesions” = red rings withing larger red rings - darkest red at centre

Stomatitis

Mild fever

Muscle

Joint aches

Headaches

Flu-like symptoms

79
Q

What is the management of erythema multiforme?

A

Clinically diagnosed - on appearance of rash

Establish cause (e.g. coldsore or treatment with penicillin) CXR to look for mycoplasma pneumonia

If mild usually self-resolves within one to four weeks

Cases may be recurrent

80
Q

How are severe cases of erythema multiforme managed?

A

Admit (especially where oral mucosa affected)

IV fluids

Analgesia

Steroids (systemic - use is contoversial / topical)

Abx / antivirals where infection is present

81
Q

What are urticaria?

A

AKA hives

Small itchy lumps which appear on the skin

May be patchy erythematous rash (localised / widespread)

Associated angioedema and flushing

Can be acute or chronic

82
Q

What is the pathophysiology of urticaria?

A

Release of histamine and other pro-inflammatory chemicals by mast cells in the skin

83
Q

When is urticaria seen?

A

Allergic reaction

Acute urticaria

Autoimmune reaction

Chronic idopathic urticaria

84
Q

What causes urticaria?

A

Something that stimulates the mast cells to release histamine e.g:

  • Allergies to food, medication or animals
  • Contact with chemicals, latex or stinging nettles
  • Medications
  • Viral infections
  • Insect bites
  • Dermatographism (rubbing of the skin)
85
Q

What causes chronic urticaria?

A

Autoantibodies targetting mast cells, triggering them to release histamines

86
Q

What are the sub categories of chronic urticaria?

A

Chronic idiopathic urticaria

Chronic inducible urticaria

Chronic autoimmune urticaria

87
Q

What is chronic idiopathic urticaria?

A

Recurrent episodes of chronic urticaria without a clear underlying cause

88
Q

What causes chronic inducible urticaria?

A

Chronic urticaria, triggered by:

  • Sunlight
  • Temperature change
  • Strong emotions
  • Hot or cold weather
  • Pressure (dermatographism)
89
Q

What is autoimmune urticaria?

A

Chronic uritcaria associated with an underlying autoimmune condition e.g. SLE

90
Q

What is the treatment of urticaria?

A

Antihistamines: fexofenadine

Oral steroids for severe flares

If severe:

  • Anti-leukotrienes e.g. montelukast
  • Omalizumab which targets IgE
  • Cyclosporin
91
Q

What is chickenpox caused by?

A

Varicella zoster virus - highly contagious generalised vesicular rash

92
Q

How does chickenpox present?

A

Widespread, erythematous, raised, vesicular (fluid filled), blistering lesions

Starts on trunk and spreads outwards affecting the whole body over 2-5 days

93
Q

What are the other symtoms of chickenpox?

A

Fever

Itch

General fatigue and malaise

94
Q

When is chickenpox contagious?

A

Highly contagious initially - spread through direct contact with lesions or through infected droplets (cough or sneeze)

Symptomatic 10 days - 3 weeks after exposure

Stop being contagious when all lesions have crusted over

95
Q

What are some complications of chickenpox?

A

Bacterial superinfection

Dehydration

Conjunctival lesions

Penumonia

Encephalitis (presenting as ataxia)

96
Q

Where does varicella zoster virus lie dormant? What can it reactivate as?

A

Sensory dorsal root ganglion cells

Shingles / Ramsay Hunt syndrome

97
Q

What can be given to pregnant women who are not immune to VZV after exposure?

A

Varicella zoster immunoglobulins

98
Q

What can chickenpox in pregnancy, before 28 weeks gestation cause?

A

Developmental problems in the foetus (congenital varicalle syndrome)

99
Q

What can chickenpox in the mother around time of delivery cause?

A

Life threatening neonatal infection

Treated with varicella zoster immunoglobulins and aciclovir

100
Q

When is medication considered for chickenpox? What is given?

A

Immunocompromised, adults, adolescents over 14 years presenting within 24 hours, neonates

Aciclovir

101
Q

What can treat the itching in chickenpox?

A

Calamine lotion and chlorphenamine (antihistamine)

102
Q

How long do lesions take to scab over in chickenpox?

A

5 days after rash appears

103
Q

What causes hand, foot and mouth disease?

What is the incubation period?

A

Coxsackie A virus

Incubation is 3-5 days

104
Q

How does hand, foot and mouth disease present?

A

Fever, anorexia, cough, sore throat, abdo pain

After 1-2 days small mouth ulcers appear followed by blistering red spotsacross the body (most notable on thehands,feet and mouth (also buttock, genitals and legs)

Rash may be itchy

105
Q

How is hand, foot and mouth disease diagnosed?

A

Clinical appearance

106
Q

What is the management of hand, foot and mouth?

A

Supportive - fluid and simple analgesia e.g. paracetamol

Resolves spontaneously after 7-10 days

Highly contagious - avoid sharing towels and bedding, careful handling of dirty nappies

107
Q

What are the complications of hand, foot and mouth?

A

Dehydration

Bacterial superinfection

Encephalitis

108
Q

What is molluscum contagiosum?

A

Viral skin infection caused by molluscum contagiosum virus - type of poxvirus

109
Q

What are the features of molluscum contagiosum?

A

Small, flesh coloured papules with a characteristic central dimple

Appear in crops

110
Q

How is molluscum contagiosum spread?

A

Direct contact or sharing items like bed towels or bed sheets

111
Q

What is the treatment of the papules in molluscum contagiosum?

A

Resolve by themselves - without treatment - takes up to 18 months

Scratching should be avoided = spreading, scarring and infection

112
Q

What is the management of molluscum contagiosum?

A

No change in lifestyle required - avoid sharing towels or close contact with lesions

113
Q

What is the treatment if bacterial superinfection occurs in molluscum contagiosum?

A

Topical fuscidic acid

Oral flucloxacillin

114
Q

When will specialist treatment be considered for molluscum contagiosum?

A

Immunocompromised

Lesions on eyelids / anogenital area

115
Q

What are some specialist treatment options for molluscum contagiosum?

A

Topical potassium hydroxide, benzoyl peroxide, podophyllotoxin, imiquimod or tretinoin

Surgical removal and cyrotherapy (freezing with liquid nitrogen) - can lead to scarring

116
Q

What is pityriasis rosea?

A

Generalised, self limiting rash of unknown cause occuring in adolescents and young adults (possibly caused by HHV-6 or HHV-7)

117
Q

How does pityriasis rosea present?

A

Pro-drome before rash = headache, tiredness, loss of appetite and flu-like symptoms

Rash = herald patch (faint red, scaly, oval lesion - 2cm/ more diameter on torso) then 2 days after widespread pink, scaly, oval lesions 2cm/less - follows chrismas tree fashion, following lines of the ribs

(dark skinned = grey / lighter than skin lesions)

Other symptoms = generalised itch, low grade pyrexia, headache, lethargy

118
Q

What is the disease course of pityriasis rosea?

A

Resolves without treatment within 3 months - can leave discolouration of skin where lesions were

119
Q

What is the treatment of pityriasis rosea?

A

No treatment for rash - resolves spontaneously without any long term effects - not contagious

Symptomatics treatment for itching = emollients, topical steroids, sedating antihistamines (e.g. chlorphenamine) at night

120
Q

What is seborrhoeic dermatitis?

A

Inflammatory skin condition affecting the sebaceous glands (oil producing glands) in the skin - affecting scalp. nasolabial folds, and eyebrows

Causing erythema, dermatitis and crusted dry skin

= cradle cap in infants

121
Q

What is thought to colonise in seborrhoeic dermatitis?

A

Malassezia yeast (improves with anti-fungal treatment)

122
Q

What is cradle cap also known as? How does it progress?

A

Infantile seborrhoeic dermatitis - self limiting - resolves by 4 months can last 12 months

123
Q

What is the treatment for infantile seborrhoeic dermatitis?

A

Apply baby / vegetable / olive oil and gently brush scalp and wash off

White petroleum jelly can be used to soften the crusted aread overnight - washed off next morning

Topical anti-fungal cream e.g. clotrimazole or miconazole for 4 weeks

Referral to dermatologist

124
Q

How does seborrhoeic dermatitis of the scalp present?

A

Flaky itchy skin (dandruff) or oily scaly brown crusting normally in adolescents

125
Q

What is the treatment of seborrhoeic dermatitis of the scalp?

A

First line = ketoconazole shampoo (left on for 5 minutes before washing off)

Topical steroids if severe itching

Reoccurs after successful treatment

126
Q

What is the treatment of seborrhoeic dermatitis of the face and body?

A

Anti-fungal cream e.g. clotrimazole / miconazole for up to 4 weeks

Topical steroids - localised inflammed areas e.g. hydrocortisone 1%

Severe cases refer to dermatologist

127
Q

What is ringworm? What is it also known as?

A

Fungal infection of the skin

AKA tinea and dermatophytosis

128
Q

Define the following terms:

Tinea capitis

Tinea pedis

Tinea cruris

Tinea corporis

Onychomycosis

A

Tinea capitis = ringworm affecting the scalp

Tinea pedis = ringworm affecting the feet

Tinea cruris = ringworm of the groin

Tinea corporis = ringworm on the body

Onychomycosis = fungal nail infection

129
Q

Which fungus commonly causes ring worm?

A

Trichophyton - contact with infected individuals, animals or soil

130
Q

How does ringworm present?

A

Itchy rash = erythmatous, scaly and well demarcated rings (fainter in middle)

131
Q

How does tinea capitis present?

A

Well demarcated hair loss

Itching, dryness, erythema of scalp

More common in children than adults

132
Q

How does tinea pedis (athletes foot) present?

A

White / red, flaky, cracked, itchy patches between toes (may split and bleed)

Occurs after sharing changing rooms with athletes foot, & when feet are sweaty and damp for long periods

133
Q

How does onchomycosis (fungal nail infections) present?

A

Thickened, discoloured and deformed nails

134
Q

How is ring worm diagnosed?

A

Clinically (can scrape off some scales and send for microscopy and culture - to confirm)

135
Q

What is the treatment of ringworm?

A

Anti-fungal medication:

  • Cream = clotrimazole and miconazole
  • Shampoo = ketoconazole
  • Oral = fluconazole, griseofulvin, itraconazole
136
Q

What is the treatment of fungal nail infections?

A

amorolfine nail lacquer (6-12 months)

Resistant = oral terbinafine (need LFTs monitoring before and whilst taking)

137
Q

What can be given for inflammation and itching in ringworm?

A

Mild topical steroids (common combination = miconazole 2% and hydrocortisone 1% - Daktacort)

138
Q

What advice should be given to prevent spread and avoid recurrence?

A
  • Loose clothing
  • Keep area clean and dry
  • Avoid sharing towels, clothing and bedding
  • Seperate towel for tinea pedis
  • Avoid scratching and spreading to other aread
  • Wear clean, dry socks every day
139
Q

What is tinea incognito?

A
  • Extensive, less well recognised fungal skin infection
  • Ringworm misdiagnosed as dermatitis and a topical steroid prescribed (improving itching and inflammation) accelerating growth of fungal infection by dampening the immune response in the area

When steroids stopped then itchy rash returns worse than previously (less recognisable as ringworm)

140
Q

What is nappy rash?

A

Contact dermatitis (caused by friction and contact with urine / faeces)

Common between 9-12 months

Added infection with candida (fungus) or bacteria (staphylococcus / streptococcus)

141
Q

What are some risk factors for nappy rash?

A

Delayed changing of nappies

Irritant soaps and vigorough cleaning

Poorly absorbent nappies

Diarrhoes

Oral abx predisponsing to candida infection

Pre-term infants

142
Q

How does nappy rash present?

A

Sore, red, inflammed skin in nappy area

Spares the creases

A few red papules

Uncomfortable, itchy, infant will be distressed

Can lead to erosions and ulcerations

143
Q

What would indicate candidal infection rather than simple nappy rash?

A
  • In skin folds
  • Larger, red macules
  • Well demarcated scaly border
  • Satellite lesions = small similar patches of rash or pustules near the main rash
  • Oral thrush
144
Q

What measures can be used to improve nappy nash?

A
  • Highly absorbent nappies
  • Change nappy after use
  • Water / alcohol free products for cleaning area
  • Ensure nappy area is dry before replacing
  • Maximise time not wearing a nappy
145
Q

What can be given for nappy rash infected with candida or bacteria?

A

Anti-fungal cream = clotrimazole or miconazole

Antibiotic = fuscidic acid cream / oral fluclox

146
Q

What are some complications of nappy rash?

A

Candida

Cellulitis

Jacquet’s erosive diaper dermatitis

Perianal pseudoverrucous papules and nodules

147
Q

What are scabies?

A

Mites called sarcoptes scabiei

Burrow under skin and lay eggs causing infection and itching

Up to 8 weeks for symptoms / rash to appear

148
Q

How does scabies present?

A

Itchy, small red spots with track marks where the mites have burrowed - classically located between finger webs (can spread to whole body)

149
Q

What is the treatment of scabies?

A

Permethrin cream (whole body - covering skin - 8-12 hours left on then washed off - repeat a week later for eggs that have hatched) - not after bath/shower so the cream stays on top of skin

Oral ivermectin - single dose which can be repeated a week later for difficult to treat / crusted scabies

Highly contagious and all household needs treating

Wash on hot all clothes / linen / towels to desroy the mites

Thorough hoovering also needed

Crotamiton cream and chlorphenamine at night can help with itching (can contine for 4 weeks after successful treatment)

150
Q

What are crusted scabies (aka norwegian scabies)?

A

Scabies in immunocompromised patients - contagious - patches of red skin that turn into scaly plaques (misdiagnosed a psoriasis)

May have absent itchdue toimmune response to the infestation

Admit for treatment with oral ivermectin and isolation

151
Q

What parasite causes head lice?

A

Pediculus humanus capitis parasite (commonly known as nits but these are egg shells which have hatched)

152
Q

How are head lice spread?

A

Head to head contact or sharing combs or towels

153
Q

How do headlice present?

A

Itchy scale (eggs / lice can be visible)

154
Q

What is the management of head lice?

A

Dimeticone 4% lotion applied to hair and left to dry (8 hours overnight then washed off)

Repeat 7 days later to kill any lice that have hatched since

Special fine combs can be used to systematically comb the nits and lice out - can be used for detection combing after treatment (The Bug Buster Kit is recommended by NICE)

155
Q

What are non-blanching rashes?

A

Rashes caused by bleeding under the skin

156
Q

Define petechiae and purpura?

A

Petechiae = small (<3mm) non-blanching, red spots on the skin caused by burst capillaries

Purpura = larger (3-10mm) non-blanching, red-purple, macules or papules created by leaking of blood from vessels under skin

157
Q

List the differentials for a non-blanching rash?

A

Meningococcal septicaemia (other baterial sepsis) = fever need emergency abx

Henoch-Schonlein purpura (HSP) = purpuric rash on legs and buttocks associated abdo / joint pain

Idiopathic thrombocytopenic purpura (ITP) = develops over several days in otherwise well child

Acute leukaemias = gradual development of petechiae (along with anaemia, lymphadenopathy and hepatosplenomegaly)

Haemolytic uraemic syndrome (HUS) = oliguria (very low urine output) and signs of anaemia - child with recent diarrhoea

Mechanical = strongh coughing, vomiting or breath holding = petechiae in SVC distribution above neck and prominently around eyes

Traumatic = tight pressure on skin e.g. non-accidental injury can cause traumatic petechiae

Viral illness = when other causes are excluded typical causes are influenza and enterovirus

158
Q

Which investigations are there for non-blanching rashes?

A

FBC = anaemia (HUS/leukaemia) low WCC (neutropaemic sepsis / leukaemia) low platelets (ITP or HUS)

U&Es = high urea and creatinine indicates HUS or HSP with renal involvement

CRP = non-specific indication of inflammation / infection

ESR = non-specific indication of inflammatory illness e.g. vasculitis (HSP) or infection

Coagulation screen = PT, APTT, INR and fibrinogen for clotting abnormalities

Blood culture = useful but not definitive in diagnosing / excluding sepsis

Meningococcal PCR = confirms meningococcal disease, should not delay treatment

LP = diagnose meningitis / encephalitis

Blood pressure = HTN in HSP and HUS (hypotension in septic shock)

Urine dip = proteinuria and haematuria suggests HSP with renal involvement or HUS

159
Q

What is the management of non-blanching rash?

A

Urgent referral and investigation (unless clear and unconcerning cause)

If in doubt then treat for meningococcal sepsis

160
Q

What is erythema nodosum?

A

Red lumps appear across patients shins

161
Q

What causes erythema nodosum?

A

Inflammation and the subcutaneous fat on the shins (hypersensitivity reaction - associated lots of conditions)

162
Q

What is inflammation of fat called?

A

Panniculitis

163
Q

What hypersensitivity reactions cause erythema nodosum?

A
  • Strep throat infections
  • Gastroenteritis
  • Mycoplasma pneumoniae
  • TB
  • Pregnancy
  • Medications e.g. oral contraceptive pill and NSAIDs
164
Q

Which chronic diseases cause erythema nodosum?

A

IBD

Sarcoidosis

Lymphoma

Leukaemia

165
Q

How does erythema nodosum present?

A

Red, inflamed, subcut nodules across both shins

Raised, painful and tender

166
Q

What are the investigations for erythema nodosum?

A

Inflammatory markers (CRP and ESR)

Throat swab for strep infection

CXR for mycoplasma, TB, sarcoidosis and lymphoma

Stool microscopy and culture for campylobacter and salmonella

Faecal calprotectin for IBD

Further imaging / endoscopy under specialist guidance

167
Q

What is the management of erythema nodosum?

A

Investigate for underlying condition

Conservatively with rest / analgesia

Steroids help settle inflammation

Mostly resolves in 6 weeks

168
Q

What is impetigo?

A

Superficial bacterial skin infection usually caused by staphylococcus aureus bacteria - “golden crust” is characteristic

Strep pyogenes can also cause it

Contagious and children to be kept off of school during infection

169
Q

How does impetigo occur? What is associated with it?

A

Bacteria enters via a break in the skin - may be associated with eczema or dermatitis

170
Q

What are the types of impetigo?

A

Non-bullous or bullous

171
Q

Where does non-bullous impetigo usually occur?

A

Around nose / mouth

Exudate from lesions dry to form golden crust

Do not usually cause systemic symptoms

172
Q

What is the treatment for non-bullous impetigo?

A

Antiseptic cream (hydrogen peroxide 1% cream) first line

Topical fusidic acid treats localised

Oral flucloxacillin for more widespread (good for staph infections)

Advise no touching or scratching lesions, good hand hygiene, avoid sharing face towels and cutlery

Off school till all lesions healed / abx for at least 48 hours

173
Q

What is bullous impetigo?

A

1-2cm fluid filled vesicles form on skin - burst = “golden crust”

Always caused by staphylococcus aureus bacteria - produce epidermolytic toxins which break down proteins that hold skin together

Heal without scarring

Painful and itchy

174
Q

Who is bullous impetigo more common in?

A

Neonates and children under 2 years

175
Q

How does bullous impetigo present?

A

More systemic symptoms e.g. feverish and generally unwell

176
Q

What is severe bullous impetigo called?

A

Staphylococcus scalded skin syndrome

177
Q

How to confirm diagnosis of bullous impetigo?

A

Swabs of the vesicles (confirm diaganosis, bacteria and abx sensitivities)

178
Q

What is the treatment of bullous impetigo?

A

Abx usually flucloxacillin (orally / IV)

Isolate patients - condition is contagious

179
Q

What are some complications of bullous impetigo?

A

Cellulitis if infection deepens in skin

Sepsis

Scarring

Post strep glomerulonephritis

Staphylococcus scalded skin syndrome

Scarlet fever

180
Q

What is staphylococcal scalded skin syndrome (SSSS)?

A

Skin infection with staphylococcys aureus which produces epidermolytic toxins (protease enzymes which break down proteins that hold skin cells together)

181
Q

Who does SSSS typically affect?

A

Children under 5 years (older children = immunity to epidermolytic toxins)

182
Q

How does SSSS present?

A

Generalised patches of erythema (thin and wrinkled)

Formation of bullae (burst and leave sore, erythematous skin) appears like burn / scald

183
Q

What sign is positive in SSSS?

A

Nikolsky sign - gentle rubbing of skin causes it to peel away

184
Q

What are the systemic symptoms in SSSS?

A

Fever

Irritability

Lethargy

Dehydration

(If untreated can lead to sepsis and potentially death)

185
Q

What is the management of SSSS?

A

Admission and treatment with IV abx

Fluid / electrolyte balance as prone to dehydration

Adequate treatment then full recovery without scarring

186
Q

What are Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) both?

A

Spectrum of same pathology where disproportional immune response causes epidermal necrosis resulting in blistering and shedding of the top layer of skin

SJS = less than 10% body surface area

TEN = more than 10%

Usually drug related

187
Q

Which medications can cause Stevens-Johnson syndrome?

A

Anti-epileptic

Antibiotics

Allopurinol

NSAIDs

188
Q

Which infections cause SJS?

A

Herpes simplex

Mycoplasma pneumonia

Cytomegalovirus

HIV

189
Q

How does SJS / TEN present?

A

Mild / severe - lifethreatening

Non-specific symptoms = fever, cough, sore throat, sore mouth, sore eyes and itchy skin

Rash develops (purple/red) across skin and blisters

Skin breaks away and leaves raw tissue underneath (on eyes, lips and mucous membranes too)

Can also affect urinary tract, lungs and internal organs

190
Q

What is the management of SJS and TEN?

A

Medical emergency - burns unit

Supportive - nutrition, antiseptics, analgesia, ophthalmology

Steroids, immunoglobulins and immunosuppressants

191
Q

What are some complications of SJS or TEN?

A

Secondary infection - breaks in skin = cellulitis and sepsis

Permanent skin damage - scarring, damage to skin, hair, lungs and genitals

Visual complications - sore eyes to blindness

Paediatrics (18 decks)

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