Paeds dermatology

Question 1

Management of eczema

Answer 1

Emollients thin → thick
Steroid ladder
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%)

Flare:
thicker emollients, topical steroids, “wet wraps”

Question 2

where does eczema affect based on age

Answer 2

in infants the face and trunk are often affected
in younger children, eczema often occurs on the extensor surfaces
in older children, a more typical distribution is seen, with flexor surfaces affected and the creases of the face and neck

Question 3

side effects topical steroids

Answer 3

de-pigmentation in darker skin

thinning of skin

Stretch marks (striae) in armpits or groin
Easy bruising (senile/solar purpura) and tearing of the skin
Enlarged blood vessels (telangiectasia)
Localised increased hair thickness and length (hypertrichosis)

Question 4

widespread, erythematous, raised, vesicular (fluid filled), blistering lesions. The rash usually starts on the trunk or face and spreads outwards affecting the whole body over 2 – 5 days. Eventually the lesions scab over, at which point they stop being contagious.

Answer 4

chicken pox

Question 5

Infectivity of chicken pox

Answer 5

Chickenpox is highly contagious and spread through direct contact with the lesions or through infected droplets from a cough or sneeze. Patients become symptomatic 10 days to 3 weeks after exposure. The stop being contagious after all the lesions have crusted over.

Question 6

Complications of chickenpox

Answer 6

Bacterial superinfection
Dehydration
Conjunctival lesions
Pneumonia
Encephalitis (presenting as ataxia)

shingles
Ramsey-Hunt

Question 7

What increases the risk of bacterial superinfection of chicken pox

Answer 7

NSAID use

Question 8

When is aciclovir given for chicken pox

Answer 8

Immunocompromised patients

adults and adolescents over 14 years presenting within 24 hours

neonates or those at risk of complications.

Question 9

Management of itching chicken pox

Answer 9

calamine lotion and chlorphenamine (antihistamine).

Question 10

how long should a child with chicken pox stay off school ?

Answer 10

Patients should be kept off school and avoid pregnant women and immunocompromised patients until all the lesions are dry and crusted over. This is usually around 5 days after the rash appears.

Question 11

Difference between Stevens-Johnson sydnrome and toxic epidermal necrosis

Answer 11

SJS affects less that 10% of body surface area whereas TEN affects more than 10% of body surface area.

Question 12

Medication causes of steven-Johnsons

Answer 12

Anti-epileptics
Antibiotics
Allopurinol
NSAIDs

Question 13

Infectious causes steven-johnsons

Answer 13

Herpes simplex
Mycoplasma pneumonia
Cytomegalovirus
HIV

Question 14

rash is typically maculopapular with target lesions being characteristic. May develop into vesicles or bullae

Answer 14

steven-johnsons

Question 15

Management SJS/TEN

Answer 15

dmitted to a suitable dermatology or burns unit for treatment. Good supportive care is essential, including nutritional care, antiseptics, analgesia and ophthalmology input. Treatment options include steroids, immunoglobulins and immunosuppressant medications guided by a specialist.

Question 16

Steroid ladder

Answer 16

Hydrocortisone
Emuovate
Betnovate
Dermovate

Question 17

Bacterial infection of eczema? organism? management?

Answer 17

The most common organism is staphylococcus aureus. Treatment is with oral antibiotics, particularly flucloxacillin.

Question 18

What is eczema herpeticum

Answer 18

viral skin infection in patients with eczema caused by the herpes simplex virus (HSV) or varicella zoster virus (VZV)

Question 19

Patient with eczema, in contact with someone with a cold sore

Answer 19

eczema herpeticum cuased by HSV-1

Question 20

a patient who suffers with eczema that has developed a widespread, painful, vesicular rash with systemic symptoms such as fever, lethargy, irritability and reduced oral intake. There will usually be lymphadenopathy (swollen lymph nodes).

Answer 20

eczema herpeticum

Question 21

Character of rash seen in eczema herpeticum

Answer 21

The rash is usually widespread and can affect any area of the body. It is erythematous, painful and sometimes itchy, with vesicles containing pus. The vesicles appear as lots of individual spots containing fluid. After they burst, they leave small punched-out ulcers with a red base.

Question 22

Investigation eczema herpeticum

Answer 22

Viral swabs of the vesicles can be used to confirm the diagnosis, although treatment is usually started based on the clinical appearance.

Question 23

Management eczema herpeticum

Answer 23

mild or moderate case may be treated with oral aciclovir, whereas more severe cases may require IV aciclovir.

Question 24

thickened erythematous plaques with silver scales, commonly seen on the extensor surfaces and scalp. The plaques are 1cm – 10cm in diameter.

Answer 24

plaque psoriasis - most common form in adults

Question 25

Many small raised papules across the trunk and limbs. The papules are mildly erythematous and can be slightly scaly.

Answer 25

guttate psoriasis

Question 26

what form of psoriasis is common in children

Answer 26

guttate psoriasis

Question 27

Pathophysiology and course of guttate psoriasis

Answer 27

Guttate psoriasis is often triggered by a streptococcal throat infection, stress or medications. It often resolves spontaneously within 3 – 4 months.

Question 28

Auspitz sign

Answer 28

seen in psoriasis small points of bleeding when plaques are scraped off

Question 29

Koebner phenomenon

Answer 29

development of psoriatic lesions to areas of skin affected by trauma

Question 30

management psoriasis

Answer 30

1. potent corticosteroid applied once daily plus vitamin D analogue applied once daily should be applied separately, one in the morning and the other in the evening) for up to 4 weeks as initial treatment 2. If no improvement after 8 weeks then offer: a vitamin D analogue twice daily 3. If no improvement after 8-12 weeks then offer either: a potent corticosteroid applied twice daily for up to 4 weeks, or a coal tar preparation applied once or twice daily Topical vitamin D analogues (calcipotriol) can be used long term Topical dithranol Topical calcineurin inhibitors (tacrolimus) are usually only used in adults Phototherapy with narrow band ultraviolet B light is particularly useful in extensive guttate psoriasis methotrexate

Question 31

androgens and acne?

Answer 31

Androgenic hormones increase the production of sebum, which is why acne is exacerbated by puberty and improves with anti-androgenic hormonal contraception.

Question 32

Macules

Answer 32

flat marks on the skin

Question 33

Papules

Answer 33

small lumps on the skin

Question 34

Pustules

Answer 34

small lumps containing yellow pus

Question 35

Comedones

Answer 35

skin coloured papules representing blocked pilosebaceous units

Question 36

Blackheads

Answer 36

open comedones with black pigmentation in the centre

Question 37

Pathophysiology of acne

Answer 37

increased production of sebum trapping of keratin (dead skin cells) blockage of the pilosebaceous unit. excessive growth of Propionibacterium acnes bacteria

Question 38

COCP for acne

Answer 38

Co-cyprindiol (Dianette)

Question 39

Management of acne

Answer 39

1. Single topical treatment: - topical benzoyl peroxide - topical retinoid 2. Combined topical treatment - above plus topical antibiotic such as clindamycin 3. oral antibiotic max 3 months alongside topical retinoid or topical benzoyl peroxide (not with topical abx) - tetracyclines - erythromycin in pregancy 3. COCP dianette (co-cyrindiol) for 3 months in women instead of oral abx 4. oral isotretinoin: only under specialist supervision

Question 40

side effects of isoretinoin

Answer 40

Dry skin and lips Photosensitivity of the skin to sunlight Depression, anxiety, aggression and suicidal ideation. Patients should be screened for mental health issues prior to starting treatment. Rarely Stevens-Johnson syndrome and toxic epidermal necrolysis

Question 41

Acne medications and pregnancy/breastfeeding/children

Answer 41

Pregnant - avoid retinoids, avoid tetracycline abx. use erythromycin instead Childbearing age - contraception if using retinoids Breastfeeding- avoid tetracyclines less than 12 - avoid tetracyclines

Question 42

The rash starts on the face, classically behind the ears, 3 – 5 days after the fever. It then spreads to the rest of the body. The rash is an erythematous, macular rash with flat lesions.

Answer 42

measles

Question 43

It is characterised by a red-pink, blotchy, macular rash with rough “sandpaper” skin that starts on the trunk and spreads outwards. Patients can have red, flushed cheeks.

Answer 43

sclarlet fever

Question 44

Mild erythematous macular rash. The rash starts on the face and spreads to the rest of the body. The rash classically lasts 3 days. It can be associated with a mild fever, joint pain and a sore throat. Patients often have enlarged lymph nodes (lymphadenopathy) behind the ears and at the back of the neck.

Answer 44

rubella

Question 45

rubella and school exclusion

Answer 45

Children should stay off school for at least 5 days after the rash appears. Children should avoid pregnant women.

Question 46

complications of rubella

Answer 46

include thrombocytopenia and encephalitis. Rubella is dangerous in pregnancy and can lead to congenital rubella syndrome, which is a triad of deafness, blindness and congenital heart disease.

Question 47

measles and school exclusion

Answer 47

Children should be isolated until 4 days after their symptoms resolve

Question 48

mild fever, coryza and non-specific viral symptoms such as muscle aches and lethargy. After 2 – 5 days the rash appears quite rapidly as a diffuse bright red rash on both cheeks, as though they have “slapped cheeks”. A few days later a reticular mildly erythematous rash affecting the trunk and limbs appears that can be raised and itchy. Reticular means net-like.

Answer 48

parovirus B19

Question 49

who is at risk of compications from parovirus b19

Answer 49

immunocompromised patients, pregnant women and patients with haematological conditions such as sickle cell anaemia, thalassaemia, hereditary spherocytosis and haemolytic anaemia. These patients require serology testing for parvovirus to confirm the diagnosis and checking of the full blood count and reticulocyte count for aplastic anaemia. People that would be at risk of complications that have come in contact with someone with parvovirus prior to the rash forming, should be informed and may need investigations.

Question 50

It presents 1 – 2 weeks after infection with a high fever (up to 40ºC) that comes on suddenly, lasts for 3 – 5 days and then disappears suddenly. There may be coryzal symptoms, sore throat and swollen lymph nodes during the illness. When the fever settles, the rash appears for 1 – 2 days. The rash consists of a mild erythematous macular rash across the arms, legs, trunk and face and is not itchy.

Answer 50

roseola infantum

Question 51

pathogen roseola infantum

Answer 51

HHV-6

Question 52

School exclsuion roseola ifnantum

Answer 52

dont need to be kept off unless too unwell to attend

Question 53

Complications roseola infantum

Answer 53

The main complication to be aware of is febrile convulsions due to high temperature. Immunocompromised patients may be at risk of rare complications such as myocarditis, thrombocytopenia and Guillain-Barre syndrome.

Question 54

widespread, itchy, erythematous rash. It produces characteristic “target lesions”. It does not usually affect the mucous membranes but can cause a sore mouth (stomatitis).

Answer 54

erythema multiforme

Question 55

management erythema multiforme

Answer 55

supportive - oral antihistamines/topical steroids - admit if bad ?mycoplasma chest xray may require admission

Question 56

difference between EM and SJS

Answer 56

The key difference with EM is that the lesions are typically raised or papular.

Question 57

management urticaria

Answer 57

antihistamines Fexofenadine is usually the antihistamine of choice for chronic urticaria.

Question 58

small itchy lumps that appear on the skin. They may be associated with a patchy erythematous rash. This can be localised to a specific area or widespread. They may be associated with angioedema and flushing of the skin

Answer 58

urticaria

Question 59

pathogen hand,foot and mouth disease

Answer 59

coxsackie A virus

Question 60

typical viral upper respiratory tract symptoms such as tiredness, sore throat, dry cough and raised temperature. After 1 – 2 days small mouth ulcers appear, followed by blistering red spots across the body. These spots are most notable on the hands, feet and around the mouth. Painful mouth ulcers, particularly on the tongue are also a key feature. The rash may be itchy.

Answer 60

hand, foot and mouth disease

Question 61

management of coxsackie A virus

Answer 61

supportive try to avoid trasnmission eg sharing towels, bedding etc.

Question 62

small, flesh coloured papules (raised individual bumps on the skin) that characteristically have a central dimple. They typically appear in “crops” of multiple lesions in a local area. It is spread through direct contact or by sharing items like towels or bedsheets.

Answer 62

Molluscum contagiosum - a type of pox virus

Question 63

how is molluscum contagiosum spread

Answer 63

It is spread through direct contact or by sharing items like towels or bedsheets.

Question 64

adolscent The rash starts with a characteristic herald patch. This is a faint red or pink, scaly, oval shaped lesion that is 2cm or more in diameter, usually occurring somewhere on the torso. It appears 2 or more days prior to the rest of the rash. The rash consists of widespread faint red or pink, slightly scaly, oval shaped lesions, usually less than 2 cm in diameter. On the torso they can be arranged in a characteristic “christmas tree” fashion, following the lines of the ribs.

Answer 64

Pityriasis rosea self limiting

Question 65

inflammatory skin condition that affects the sebaceous glands. The sebaceous glands are the oil producing glands in the skin. It affects areas that have a lot of these glands, such as the scalp, nasolabial folds and eyebrows. It causes erythema, dermatitis and crusted dry skin. In infants it causes a crusted dry flaky scalp, often called cradle cap. flaky itchy skin on the scalp (dandruff). More severe cases cause more dense oily scaly brown crusting.

Answer 65

seborrhoeic dermatitis

Question 66

management cradle cap

Answer 66

1. baby oil, brushing crusts off 2. white petroleum jelly overnight and wash off in morning 3. topical antifungal such as clotrimazole or miconazole, used for up to 4 weeks.

Question 67

Management seborrhoeic dermatitis of scalp

Answer 67

1. ketoconazole shampoo 2. topical steroids

Question 68

management seborrhoeic dermatitis of the face

Answer 68

1. clotrimazole or miconazole, used for up to 4 weeks. Localised inflamed areas may benefit from a topical steroids, such as hydrocortisone 1%.

Question 69

Management ringworm

Answer 69

Antifungal treatments cream - clotrimazole shampoo ketoconazole oral - fluconasole amorolfine nail lacquer (Resistant cases may need oral terbinafine, however the patient will need their LFTs monitoring before and whilst taking this.)

Question 70

sore, red, inflamed skin in the nappy area, sparing the skinfolds. There may be a few red papules beside the affected areas of skin.

Answer 70

nappy rash

Question 71

sore, red, inflamed skin in nappy area, also affecting skin folds, welld emarcated border with circualr pattern. There may be large red papules

Answer 71

candida

Question 72

management simple nappy rash vs candida vs bacteria

Answer 72

simple: - high absorbant nappies - changing frequently - drying well - maximise time not wearing candida: - anti-fungal cream (clotrimazole or miconazole) bacteria: antibiotic (fusidic acid cream or oral flucloxacillin)

Question 73

incredibly itchy small red spots, possibly with track marks where the mites have burrowed. The classic location of the rash is between the finger webs, but it can spread to the whole body.

Answer 73

scabies

Question 74

management of scabies

Answer 74

1. permethrin 5% cream leave on for 8-12 hours 2. malathion 0.5% is second-line for severe/crusted scabies 1. ivermectin

Question 75

management headlice

Answer 75

Dimeticone 4% lotion can be applied to the hair and left to dry. This is left on for 8 hours (i.e. overnight), then washed off. This process is repeated 7 days later to kill any head lice that have hatched since treatment.

Question 76

Petechiae

Answer 76

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

Question 77

Purpura

Answer 77

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

Question 78

DDX non-blanching rash

Answer 78

- meningococcal sepsis - HSP - ITP - Leukemias - HUS - Mechanical - Traumatic - Viral illness

Question 79

Causes erythema nodosum

Answer 79

- IBD - Sarcoidosis Streptococcal throat Gastroenteritis Mycoplasma pneumoniae Tuberculosis Pregnancy Medications, such as the oral contraceptive pill and NSAIDs Lymphoma Leukaemia

Question 80

red, inflamed, subcutaneous nodules across both shins

Answer 80

erythema nodosum

Question 81

“golden crust”

Answer 81

impetigo

Question 82

Pathogens impetigo

Answer 82

Staph aureus Strep pyogenes

Question 83

Non-bullous vs bullous impetigo

Answer 83

Non-bullous = no systemic illness, can be caused by staph aureus or less commononly strep pyogenes Bullous = systemic illness, caused by staph aureus

Question 84

Management non-bullous impetigo

Answer 84

1. hydrogen peroxide 1% cream 2. fuscidic acid

Question 85

Management bullous impetigo

Answer 85

1. oral flucloxacillin

Question 86

School exclusion impetigo

Answer 86

excluded from school until the lesions are crusted and healed or 48 hours after commencing antibiotic treatment

Question 87

generalised patches of erythema on the skin. Then the skin looks thin and wrinkled. This is followed by the formation of fluid filled blisters called bullae, which burst and leave very sore, erythematous skin below. This has a similar appearance to a burn or scald.

Answer 87

staphylococcal scalded skin syndrome

Question 88

Nikolsky sign

Answer 88

gentle rubbing of the skin causes it to peel away. This is positive in SSSS.

Question 89

management staph scladed skin syndrome

Answer 89

admission and treatment with IV flucloxicillin. Fluid and electrolyte balance is key to management as patients are prone to dehydration. When adequately treated, children usually make a full recovery without scarring.

Question 90

Complications SJS/ TEN

Answer 90

secondary infection permanent skin damage visual complications

Question 91

Side effects of active management of the third stage?

Answer 91

nausea and vomiting

Question 92

active management of the third stage

Answer 92

1. IM oxytocin 10IU 2. controlled cord traction whilst pressing uterus upwards 3. after placenta delivered - massage uterus until contracted and firm

Question 93

School exclusion

Answer 93

Measles 4 days after rash Rubella 5 days after rash Whooping cough 48 hours after abx Scarlett 24 hours after abx

Question 94

triggers psoriasis

Answer 94

lithium beta-blockers trauma

Question 95

Pathogen bacterial superinfection chickenpox

Answer 95

whilst this commonly may manifest as a single infected lesion/small area of cellulitis, i n a small number of patients invasive group A streptococcal soft tissue infections may occur resulting in necrotizing fasciitis

Question 96

parovirus b19 other names

Answer 96

- slapped cheek - erythema infectionosum - fifths disease

Question 97

often becomes more noticeable after spending time in the sun - as the healthy skin becomes darker, the white/light brown patches become more prominent.

Answer 97

pityriasis versicolor, a common fungal skin infection

Question 98

What is Ramsay-Hunt syndrome

Answer 98

This occurs when the varicella-zoster virus affects the facial nerve and is a complication of shingles. It presents with a unilateral painful vesicular rash around the ear and weakness of the muscles supplied by the facial nerve. It is treated with antivirals and steroids.

Question 99

Name 5 types of birthmarks

Answer 99

Port wine stain (naevus flamellus) Salmon patch Hemangioma (strawberry naevi) Mongolian spots Congenital nevi

Question 100

Presentation hemangioma

Answer 100

They are usually not present at birth but may develop rapidly in the first month of life. They appear as erythematous, raised and multilobed tumours. Typically they increase in size until around 6-9 months before regressing over the next few years (around 95% resolve before 10 years of age). Common sites include the face, scalp and back. Rarely they may be present in the upper respiratory tract leading to potential airway obstruction

Question 101

Management hemangioma obstructing visual field

Answer 101

propanolol

Question 102

Presentation salmon patch

Answer 102

pink and blotchy, and commonly found on the forehead, eyelids and nape of the neck. They usually fade over a few months, though marks on the neck may persist.

Question 103

Presentation port wine stain

Answer 103

They are deep red or purple in colour. Treatment is with cosmetic camouflage or laser therapy (multiple sessions are required).

Question 104

Presentation mongolion spots

Answer 104

flat bluish- to bluish-gray skin markings commonly appearing at birth or shortly thereafter. They appear commonly at the base of the spine, on the buttocks and back and also can appear on the shoulders. most disappear

Question 105

Another name for port wine stain

Answer 105

Naevus flammeus

Question 106

Erythema toxicum

Answer 106

(neonatal urticaria) is a common rash appearing at 2-3 days of age, consisting of white pinpoint papules at the centre of an erythematous base, concentrated on the trunk.

Question 107

name mongolion spots

Answer 107

Congenital dermal melanocytosis