Paeds dermatology Flashcards
Management of eczema
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”
where does eczema affect based on age
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
side effects topical steroids
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)
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.
chicken pox
Infectivity of chicken pox
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.
Complications of chickenpox
Bacterial superinfection
Dehydration
Conjunctival lesions
Pneumonia
Encephalitis (presenting as ataxia)
shingles
Ramsey-Hunt
What increases the risk of bacterial superinfection of chicken pox
NSAID use
When is aciclovir given for chicken pox
Immunocompromised patients
adults and adolescents over 14 years presenting within 24 hours
neonates or those at risk of complications.
Management of itching chicken pox
calamine lotion and chlorphenamine (antihistamine).
how long should a child with chicken pox stay off school ?
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.
Difference between Stevens-Johnson sydnrome and toxic epidermal necrosis
SJS affects less that 10% of body surface area whereas TEN affects more than 10% of body surface area.
Medication causes of steven-Johnsons
Anti-epileptics
Antibiotics
Allopurinol
NSAIDs
Infectious causes steven-johnsons
Herpes simplex
Mycoplasma pneumonia
Cytomegalovirus
HIV
rash is typically maculopapular with target lesions being characteristic. May develop into vesicles or bullae
steven-johnsons
Management SJS/TEN
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.
Steroid ladder
Hydrocortisone
Emuovate
Betnovate
Dermovate
Bacterial infection of eczema? organism? management?
The most common organism is staphylococcus aureus. Treatment is with oral antibiotics, particularly flucloxacillin.
What is eczema herpeticum
viral skin infection in patients with eczema caused by the herpes simplex virus (HSV) or varicella zoster virus (VZV)
Patient with eczema, in contact with someone with a cold sore
eczema herpeticum cuased by HSV-1
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).
eczema herpeticum
Character of rash seen in eczema herpeticum
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.
Investigation eczema herpeticum
Viral swabs of the vesicles can be used to confirm the diagnosis, although treatment is usually started based on the clinical appearance.
Management eczema herpeticum
mild or moderate case may be treated with oral aciclovir, whereas more severe cases may require IV aciclovir.
thickened erythematous plaques with silver scales, commonly seen on the extensor surfaces and scalp. The plaques are 1cm – 10cm in diameter.
plaque psoriasis - most common form in adults
Many small raised papules across the trunk and limbs. The papules are mildly erythematous and can be slightly scaly.
guttate psoriasis
what form of psoriasis is common in children
guttate psoriasis
Pathophysiology and course of guttate psoriasis
Guttate psoriasis is often triggered by a streptococcal throat infection, stress or medications. It often resolves spontaneously within 3 – 4 months.
Auspitz sign
seen in psoriasis
small points of bleeding when plaques are scraped off
Koebner phenomenon
development of psoriatic lesions to areas of skin affected by trauma
management psoriasis
- 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 - If no improvement after 8 weeks then offer:
a vitamin D analogue twice daily - 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
androgens and acne?
Androgenic hormones increase the production of sebum, which is why acne is exacerbated by puberty and improves with anti-androgenic hormonal contraception.
Macules
flat marks on the skin
Papules
small lumps on the skin
Pustules
small lumps containing yellow pus
Comedones
skin coloured papules representing blocked pilosebaceous units
Blackheads
open comedones with black pigmentation in the centre
Pathophysiology of acne
increased production of sebum
trapping of keratin (dead skin cells)
blockage of the pilosebaceous unit.
excessive growth of Propionibacterium acnes bacteria
COCP for acne
Co-cyprindiol (Dianette)
Management of acne
- Single topical treatment:
- topical benzoyl peroxide
- topical retinoid - Combined topical treatment
- above plus topical antibiotic such as clindamycin - oral antibiotic max 3 months alongside topical retinoid or topical benzoyl peroxide (not with topical abx)
- tetracyclines
- erythromycin in pregancy - COCP dianette (co-cyrindiol) for 3 months in women instead of oral abx
- oral isotretinoin: only under specialist supervision
side effects of isoretinoin
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
Acne medications and pregnancy/breastfeeding/children
Pregnant - avoid retinoids, avoid tetracycline abx. use erythromycin instead
Childbearing age - contraception if using retinoids
Breastfeeding-
avoid tetracyclines
less than 12 -
avoid tetracyclines
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.
measles
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.
sclarlet fever
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.
rubella
rubella and school exclusion
Children should stay off school for at least 5 days after the rash appears. Children should avoid pregnant women.
complications of rubella
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.
measles and school exclusion
Children should be isolated until 4 days after their symptoms resolve
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.
parovirus B19
who is at risk of compications from parovirus b19
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.
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.
roseola infantum
pathogen roseola infantum
HHV-6
School exclsuion roseola ifnantum
dont need to be kept off unless too unwell to attend
Complications roseola infantum
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.
widespread, itchy, erythematous rash. It produces characteristic “target lesions”. It does not usually affect the mucous membranes but can cause a sore mouth (stomatitis).
erythema multiforme
management erythema multiforme
supportive
- oral antihistamines/topical steroids
- admit if bad
?mycoplasma chest xray
may require admission
difference between EM and SJS
The key difference with EM is that the lesions are typically raised or papular.
management urticaria
antihistamines
Fexofenadine is usually the antihistamine of choice for chronic urticaria.
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
urticaria
pathogen hand,foot and mouth disease
coxsackie A virus
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.
hand, foot and mouth disease
management of coxsackie A virus
supportive
try to avoid trasnmission eg sharing towels, bedding etc.
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.
Molluscum contagiosum - a type of pox virus
how is molluscum contagiosum spread
It is spread through direct contact or by sharing items like towels or bedsheets.
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.
Pityriasis rosea
self limiting
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.
seborrhoeic dermatitis
management cradle cap
- baby oil, brushing crusts off
- white petroleum jelly overnight and wash off in morning
- topical antifungal such as clotrimazole or miconazole, used for up to 4 weeks.
Management seborrhoeic dermatitis of scalp
- ketoconazole shampoo
- topical steroids
management seborrhoeic dermatitis of the face
- clotrimazole or miconazole, used for up to 4 weeks.
Localised inflamed areas may benefit from a topical steroids, such as hydrocortisone 1%.
Management ringworm
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.)
sore, red, inflamed skin in the nappy area, sparing the skinfolds.
There may be a few red papules beside the affected areas of skin.
nappy rash
sore, red, inflamed skin in nappy area, also affecting skin folds, welld emarcated border with circualr pattern. There may be large red papules
candida
management simple nappy rash
vs candida
vs bacteria
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)
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.
scabies
management of scabies
- permethrin 5% cream leave on for 8-12 hours
- malathion 0.5% is second-line
for severe/crusted scabies
1. ivermectin
management headlice
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.
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 the skin.
DDX non-blanching rash
- meningococcal sepsis
- HSP
- ITP
- Leukemias
- HUS
- Mechanical
- Traumatic
- Viral illness
Causes erythema nodosum
- IBD
- Sarcoidosis
Streptococcal throat
Gastroenteritis
Mycoplasma pneumoniae
Tuberculosis
Pregnancy
Medications, such as the oral contraceptive pill and NSAIDs
Lymphoma
Leukaemia
red, inflamed, subcutaneous nodules across both shins
erythema nodosum
“golden crust”
impetigo
Pathogens impetigo
Staph aureus
Strep pyogenes
Non-bullous vs bullous impetigo
Non-bullous = no systemic illness, can be caused by staph aureus or less commononly strep pyogenes
Bullous = systemic illness, caused by staph aureus
Management non-bullous impetigo
- hydrogen peroxide 1% cream
- fuscidic acid
Management bullous impetigo
- oral flucloxacillin
School exclusion impetigo
excluded from school until the lesions are crusted and healed or 48 hours after commencing antibiotic treatment
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.
staphylococcal scalded skin syndrome
Nikolsky sign
gentle rubbing of the skin causes it to peel away. This is positive in SSSS.
management staph scladed skin syndrome
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.
Complications SJS/ TEN
secondary infection
permanent skin damage
visual complications
Side effects of active management of the third stage?
nausea and vomiting
active management of the third stage
- IM oxytocin 10IU
- controlled cord traction whilst pressing uterus upwards
- after placenta delivered - massage uterus until contracted and firm
School exclusion
Measles 4 days after rash
Rubella 5 days after rash
Whooping cough 48 hours after abx
Scarlett 24 hours after abx
triggers psoriasis
lithium
beta-blockers
trauma
Pathogen bacterial superinfection chickenpox
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
parovirus b19 other names
- slapped cheek
- erythema infectionosum
- fifths disease
often becomes more noticeable after spending time in the sun - as the healthy skin becomes darker, the white/light brown patches become more prominent.
pityriasis versicolor, a common fungal skin infection
What is Ramsay-Hunt syndrome
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.
Name 5 types of birthmarks
Port wine stain (naevus flamellus)
Salmon patch
Hemangioma (strawberry naevi)
Mongolian spots
Congenital nevi
Presentation hemangioma
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
Management hemangioma obstructing visual field
propanolol
Presentation salmon patch
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.
Presentation port wine stain
They are deep red or purple in colour.
Treatment is with cosmetic camouflage or laser therapy (multiple sessions are required).
Presentation mongolion spots
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
Another name for port wine stain
Naevus flammeus
Erythema toxicum
(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.
name mongolion spots
Congenital dermal melanocytosis
