Paeds - Skin Flashcards
Purpuric non-blanching rash on buttocks and legs; abdo and joint pain
Henoch-Schonlein purpura
What is Henoch-Schonlein purpura caused by?
IgA small vessel vasculitis triggered by upper airway infection or gastroenteritis
Typical presentation of Henoch-Schonlein
Kids 3-10 years old
Previously ill: now arthralgia, skin rash, abdo pain, local oedema
Complications of Henoch-Schonlein
Intussusception, renal failure (nephrotic syndrome), arthritis
Usually self limiting tho
Young child with high fever not responding to paracetamol, bilateral red eyes and cracked lips
Kawasaki disease
What is Kawasaki disease
Medium vessel vasculitis
Kawasaki disease main presentation
Persistent high fever for over 5 days AND AT LEAST 4 Of the following:
- Red tongue and cracked lips
- red rash on trunk
- Skin peeling on palms and soles (desquamation)
- cervical lymphadenopathy
(CRASH and burn: conjunctivitis, rash, adenopathy, strawberry tongue, hands - erythem, swelling, desquamation + Fever)
Kawasaki Management
HIGH DOSE ASPIRIN AND IV IMMUNOGLOBULIN within 10 DAYS of presentation
Do ECHO to check for CORONARY ANEURYSM
NOTIFY HEALTH COUNCIL
Treatment for meningococcal septicemia
- BLOOD CULTURE AND LUMBAR PUNCTURE before starting antibiotics
If at GP: IM BENZYLPENICILLIN AND CALL 999
< 3 months: CEFOTAXIME AND AMOXICILLIN
> 3 months: Ceftriaxone or CEFOTAXIME
+ Dexamethasone to reduce swelling and neuro/hearing damage
What is Erythema marginatum
Type 2 hypersensitivity reaction (autoantibodies) triggered by rheumatic fever
Kid with malaise, fever and generalised itchy vesicular rash
Varicella zoster (chicken pox)
- can be caught via shingles contact
Spread of chicken pox rash
Red raised and blistering
Starts on trunk/face and spread across whole body
Once it scabs over it stops being Infectious
Mx of chicken pox
Mainly conservative: keep cool, trim nails, calamine lotion
If IMMUNOCOMPROMISED/ Neonate - give VARICELLA ZOSTER IMMUNOGLOBULIN
DO NOT USE NSAIDS - risk of secondary infection
DON’T go to school for 5 days after vesicles form
Complications of VARICELLA ZOSTER
- Pneumonia
- Encephalitis
- Strep pyogènes skin infection
Treatment for shingles
Oral aciclovir
Also used for pregnant people with chicken pox (otherwise can get congenital varicella syndrome)
Kid with gold-ish crusty rash around mouth or nose
Impétigo - staph aureus or less commonly strep pyogenes
What causes classic appearance of impetigo
Staph aureus makes EXFOLIATIVE TOXINS which break down proteins holding cells together
Get fluid filled vesicles (1-2 cm) and crust
Management for impétigo
Swab vesicles to confirm and get bacteria and antibiotic sensitivities
TOPICAL FUSIDIC ACID
Flucloxacillin if systemic features
Kid with flu-like symptoms, cheeks very red, lips look pale
Parvovirus B19 (erythema infectiosum)
- slapped cheek disease
Complications of parvovirus
If transmitted from mum to baby - hydrops fetalis
In people with sickle cell or thalessaemial - APLASTIC CRISIS
Baby with high fever and maculopapular rash on chest, spreading to limbs. Now getting convulsions.
Sixth disease - HUMAN HERPES VIRUS 6 (6-24 month olds)
Also causes:
- palpable posterior lymph nodes
- vomiting and diarrhoea
Treatment for sixth disease
Resolves by itself, just support
Kid with rash on chest but NOT FACE. Feels rough (like sandpaper). Fever, malaise, nausea, headache.
SCARLET FEVER from GROUP A BETA HAEMOLYTIC STREP (pyogenes)
Also get desquamation on fingers and toes
CLASSIC STRAWBERRY TONGUE
Complications of scarlet fever
Otitis media, rheumatic fever, glomerulonephritis (all linked to strep pyogenes)
Management of scarlet fever
Swab throat
ANTIBIOTICS PRONTO:
- PO PENICILLIN V or Azithromycin for 10 days
DON’T go to school till 24hrs after starting Abx
Notifiy local infectious diseases centre
Hand foot mouth rash
COXSACKIE A16 Virus and enterovirus 71
Fever, sore throat, cough, tiredness
- then the rash, starting from mouth ulcers
Management of hand foot mouth
Conservative but VERY CONTAGIOUS
Resolves in 10 days ish
Young child with fever and sore throat. Widespread Erythematous rash with peeling skin
Staphylococcal Scalded Skin Syndrome (same method of action as impetigo but more severe)
Skin is thin and wrinkled, bullae form which burst and look like scalds
Nikolsky’s sign
Skin separates on gentle pressure
(Staphylococcal Scalded Skin Syndrome)
Mangement of staphylococcal Scalded Skin Syndrome
- IV ANTIBIOTICS
- Topical FUSIDIC ACID
- Fluid and Electrolyte management
- Analgésia and paracetamol
Teen girl with high fever, hypotension, tachycardia and diffuse desquamating erythematous rash
Toxic shock syndrome
- severe systemic reaction to STAPHYLOCOCCAL EXOTOXIN
Causes of toxic shock syndrome
TAMPONS for too long
Female barrier contraception
Nasal packing for nose bleeds
Any break in skin
Présentation of toxic shock
Multi organ:
- D and V
- Confusion
- Renal failure
- Thrombocytopenia
- Hepatitis
- Rash
- FEVER AND SIGNS OF SHOCK
Management of Toxic shock
ABCDE
Oxygen
IV broad spectrum ANTIBIOTICS AND IV IG
IV fluids
Surgical debridement
Common presentation of measles
- Prodrome phase: fever, coryza, conjunctivitis, cough, irritable
- Koplik spots - white spots in mouth mucosa
- Maculopapular rash - starts behind ears and spreads to whole body
Cause of measles
Single strand negative sense RNA PARAMYXOVIRUS
Complications of measles
- Otitis media
- Pneumonia (most common killer)
- Encephalitis (1-2 weeks after)
- Sub acute sclerosing pan encephalitis (5-10 years later)
- Febrile convulsions
- Myocarditis
Management of measles
- LIVE MMR VACCINE (1, 3 and 4 years)
- immunity from mum till 9 months
When active just supportive management
NOTIFY HEALTH COUNCIL + DON’T go to school till 5 days after rash
Scarlet fever aet + epid
Caused by reaction to ERYTHROGENIC TOXINS made by STREP PYOGENES
TYpically between 2-6 years
Investigations for measles
Bloods:
- IgM Ab
- LFTs (raised)
Measles RNA PCR on ORAL FLUID
Slapped cheek presentation
Any age
- Fever, coryza, headache
- Slapped cheek + glove + stocking rash
Slapped cheek Mx
Ix: clinical diagnosis +/- serology
Tx: Supportive
- rash means it’s no longer infective
Roseola infantum Px
- HIGH FEVER typically lasting around 3 days
- Potentially:
- vomiting, diarrhoea, febrile convulsions
- Rose-coloured rash starting from trunk, spreading peripherally
- Nagayama spots: on soft palate + uvula
Roseola Infantum cause
Human Herpes Virus - 6
Roseola Infantum epid
Kids < 2 y/o
Roseola Infantum Mx
Self-resolving within 2-5 days - supportive treatment
Clinically diagnosised
Kawasaki epid
More common in JAPANESE/KOREAN or AFROCARRIBEAN kids < 4 y/o
Eczema
Chronic inflammation of dermis leading to SPONGIOTIC epidermal changes on histology
RFx for Eczema
- FHx of atopy
- Urbanisation/industrialisation
Eczema pathophys
- High number of immune cells in skin -> dermatitis
- Keratinocytes separate + become rounder -> spongy look under microscope
- If chronic: HYPERPLASIA + impaired differentiation (leading to retained nuclei in stratum corneum)
- Oft associated with + exacerbated by IgE sensitivity to environmental allergans
N/b: can get dermatitis without eczematous change
DDx for atopic dermatitis
- Atopic eczema
- Contact dermatitis (allergic or irritant)
- Seborrheic dermatitis (basically inflammed dandruff)
- Venous/stasis eczema
- Asteatotic dermatitis/eczema craquele (caused by dry skin)
- Erythrodremic eczema
- Pompholyx eczema (hands + feet)
Atopic eczema Px
- Typically in kids -> less severe with age
- Rash on face + flexors (face more common in infants)
- Itchy, ERYTHEMATOUS + OOZING - may have vesicles
- Dry + flaky
- Lichienification from scratching (thick + leathery) - Atopic PHx/FHx
Eczema Dx
Clinical diagnosis - additional investigations are done for the following:
- Prior to starting systemic DMARDs if severe
- Bloods:
- if concerned about infection
- IgE + RAISED EOSINOPHILS = atopic
- RAST IgE or Skin-prick test for allergies
- Patch test (48hr skin contact to allergen) - for allergic contact dermatitis (type 4 delayed allergic reaction)
- Swabs if infection concern
- Skin biopsy if Dx very uncertain
Severity of eczema presentation
- Mild: some dryness + infrequent itching
- Mod: some dryness, frequent itching + ERYTHEMA
- Severe: Widespread dryness + erythema; incesent itching
- Infected if weeping, crusted, pustules +/- fever/malaise
Can also get excoriation, skin thickening, bleeding, oozing, cracking + altered pigment
What are the 3 key signs of chronic eczema inflam
- Epidermal acanthosis (thickening epidermis)
- Hyperkeratosis (Thick stratum corneum)
- Parakeratosis (retained nuclei in stratum corneum)
Eczema Tx
Conservative:
- Avoid triggers + allergens
- Keep affected area cool + dry
- Sedating antihistamine can reduce itching (esp if affecting sleep)
- Liberal amounts of emollient
- Psych support as needed
Medical:
- Mild: Emollient + mild topical hydrocortisone 1%
- Moderate: emollient + moderate corticoseteroid (clobetasone butyrate 0.5%) - only put hydrocortisone on face + flexures
- Severe: emollient + BETAMETHASONE valerate 0.1% (clobetasone butyrate for face + flexures)
- Consider oral corticosteroid if severe, extensive + causing psych distress
- DEMARDs
- Biologics (Dubilumab, Barcitinib) - only if not responding
- 2nd line: Topical calcineurin inhibitors (Tacrolimus) - need specialist prescribing
Narrow band UV-B light therapy
If nothing working on severe after 1 wk refer to derm (urget if not responding after 2 wks)
Complications of eczema
Scratching:
- Poor sleep
- Poor mood
- Skin breakdown -> risk of infection
Psycho-social:
- Insecurities
- Having to avoid activites e.g. swimming
ECZEMA HERPETICUM (emergancy)
- Disseminated Herpes simplex infaection
- Vesicles + punched out errosions
- Multi organ involvement
Mx of Eczema hherpeticum
Dx with SWAB + Tzanck test (large round keratinocyte with hypertrophic nucleus, hazy/absent nucleoli + basophilic cytoplasm present)
IV ACICLOVIR + concommitant Abx
Stevens-Jhonson syndrome (SJS)
Immune-COMPLEX (type 3) mediated hypersensitivity disorder
Can be mild - most severe = Toxic Epidermal Necrolysis
Cause of SJS
- Most commonly ADVERSE DRUG REACTIONS
- Also VIRAL pathogens (bacteria/fungal less common)
Which drugs are most likely to cause SJS
- SULFONAMIDES (e.g. co-trimoxazole)
- BETA-LACTAMS
- ANtiepileptics
- ALLOPURINOL
- NSAIDs
SJS Px
- URTI like Sx within 1 week of meds/infection
- Erythematous macules within a few days
- Become TARGET SHAPED - Flaccid blisters + Nikolskey sign (skin separates when rubbed)
- Mucosal ulceration:
- Conjunctiva
- Mouth
- Pharynx
- GI tract
- Urethra
N/B: SJS only covers <10% of body surface
- if it covers > 30% it is Toxic Epidermal Necrolysis (TEN)
SJS prognosis
10% mortality rate due to:
- Dehydration
- Infection
- DISSEMINATED INTRAVASCULAR COAGULATION
DDx for SJS Px
- Erythema multiforme (target lesions typically tend to be on hands/feet; less mucosal involvement)
- Drug Rash with Eosinophilia + Sytemic Symptoms (2-6 wks after drug exposure)
- Acute Generalised Exanthematous Pustulosis (rapid + small non-follicular pustules)
SJS Dx
Clinical +/- skin biopsy
On histology:
- Necrotic keratinocytes
- Sparse lymphocytic infiltrate
SJS Mx
Supportive:
- prevent occular complication (refer to ophthal)
- Fluid + electrolyte balance (hosp admission)
- ANALGESIA
- Tx any 2ndry infections
Allergic rhinitis
Inflammation of nasal mucosa in response to environmental allergens. Often associated with allergic conjunctivitis. May have seasonal variation.
More common in people with other immune disorders e.g. atopy/asthma
Allergic rhinitis aet
IgE-mediated response to environmental allergens
Allergic rhinitis Sx
- Nasal pruritis + sneezing
- Rhinorrhoea
- Nasal congestion
Congunctivitis:
- Eye redness
- Puffiness
- Watery eye discharge
DDx for rhinitis
- Sinusitis (facial pain/pressure; anosmia)
- Nasal polyps (nosebleeds; chronic sinusitis)
- Deviated Nasal septum (bleeds, pain, headache, postnasal drip)
- Common cold (body aches + fatigue)
Allergic rhinitis Dx
Clinical usually
Ix: Skin prick test; Bloods for specific IgE Ab
- to identify allergen
Allergic rhinitis Mx
- Avoid trigger
- NASAL IRRIGATION (saline)
- Intra-nasal/oral ANTI-HISTAMINES
- Intranasal steroids if not responding
- Oral steroids if severe + affecting QoL
- Refer to ENT if:
- Red flags for serious diagnosis
- Refractory
- Allergen testing needed
Urticaria
Hives - small, itchy lumps
Oft associated with patchy erythematous rash (localised or widespread)
Can be associated with Angioedema + flushing
Urticaria pathophys
Caused by HISTAMINE + other PRO-INFLAM chemicals - released from MAST CELLS in SKIN
Acute = part of allergic reaction
Chronic = Autoimmune
Causes of Acute urticaria
- Allergies
- Contact with chemical, latex, stinging nettles
- MEDICATIONS
- Viral infections
- Insect bites
- Dermatographism (rubbing of skin)
Causes of Chronic urticaria
Autoimmune reaction where Autoantibodies cause mast cells to release pro-inflam.
Can be:
- Chronic idioptahic urticaria
- Chronic inducible urticaria
- Triggeres include:
- Sunlight, Temp change, Exercise, Strong emotions, Heat/cold, Pressure - Autoimmune urticaria (associated with underlying condition e.g. SLE)
Urticaria Mx
For acute:
- Antihistamines - FEXOFENADINE
- and/or oral steroids (if severe)
- Avoid triggers
If very severe -> specialist referral:
- Leukotrine receptor Antagonist (MONTELUKAST)
- Omalizumab (anti-IgE)
- Cyclosporin
Anaphylaxis
Acute + severe type 1 (IgE mediated) hypersensitivity.
Systemic + potentially life-threatening multiple organ invlovement caused by release of histamine + cytokines from mast cells + basophils
Atopic history = RFx
Common anaphylaxis triggers
Animals:
- Insect stings
- Animal dander
Food:
- NUTS
- SHELLFISH
- EGGS
- Milk
Meds:
- ANTIBIOTICS
- IV contrast
- NSAIDs
Anaphylaxis Sx
- Airway: Swollen lips/tongue, sneezing
- Resp: Wheeze; SOB
- Cardio: SHOCK - tachycardia, hypotension + ANGIOEDEMA
- GI: Pain, diarrhoea, vomiting
- Derm: Urticaria, pruritis, flushing
DDx for anaphylaxis
- Vasovagal reaction (no derm involvement)
- Panic attack (no skin involvement)
- Asthma exacerbation (not systemic)
- Carcinoid syndrome (typically more chronic - from serotonin release)
Anaphylaxis Ix
Bloods - Serum MAST CELL TRYPTASE (rises within an hour of onset)
Anaphylaxis Mx
- IM ADRENALINE 300 micrograms (1:1000)
- Call for help
- Remove trigger if possible
- ABCDE
- Make patient SUPINE + RAISE LEGS
Open airway + supplement O2 once equipment available
- IV fluids if in shock
- monitor for 6-12 hrs
Hydrocortisone if not as urgent
After -> SAFTY NETTING:
- 2 autoinjectors
- Written advice
- Referral for allergy service follow up
Common birthmarks
- Salmon patch (flat, pink, on face at birth)
- Infantile haemangioma (raised, strawberry marks - more common in girls - increase in size after birth)
- Capillary malformation - aka Port Wine Stain (unilateral, face/chest/back, receptive to hormones)
- Cafe-au-lait spots (>6 by 5y/o - could be neurofibromatosis)
- Mongolian spot (blueish - lowe back + buttocks)
- Congenital melanocytic naevi (noles)
Macular rash definition + examples
non-palpable rash with colour changes in limited areas (not raised)
e.g. measles, rubella
Papular rash definition + examples
palpable rash with raised, solid lesions and colour changes in
limited areas up to 0.5 cm
e.g. Gianotti-Crosti, pityriasis rosea
(quite commonly hear maculo-papular ie flat in some places raised in some)
Vsicular rash definition + examples
Elevate lesions that are filled with clear fluid less than 0.5 cm (small vesicles)
e.g. Chicken pox, herpes simplex, herpes zoster
Ulcer definition + examples
A skin or mucous membrane lesion occurring as a result of the
loss of superficial tissue, usually involving an inflammatory
process
e.g. Aphthous ulcer
What number of cafe au lait spots are suggestive of NF
5 or more
Erythema toxicum neonatorum
Common baby rash caused by being newly exposed to the environment
What is the recommendation for chickenpox to reduce risk of secondary bacterial infection
Don’t use ibuprofen, only calpol
Measles characteristic presentation
Rash + CCCK
Cough
Coryza
Conjunctivitis
Koplick’s spots (small white spots in oral mucosa)
Which populations are particularly in danger from getting erythema infectiosum (Parvovirus B19)
- Adults
- Preg
- Haemoglobinopathies (e.g. sickle cell etc)
Roseola infantum natural Hx
- Misery high fever
- May get febrile convulsions
- Gets better when rash shows up
Caused by HHV6
Which virus causes hand foot mouth
Coxsackie A16
or Enterovirus 71
Rash esp on one finger
Could Herpetic Whitlow from thumb/finger sucking when they had oral HSV
When is herpes particularly nasty
in immunocomp OR ECZMA (eczema herpeticum)
Plaque definition + example
A differentiated are on a flat skin surface area (may also occur
on a mucous membrane)
E.g. Urticarial plaque
What causes verucas
Human papilloma virus 1, 2 + 3
Nodule defintion + examples
A circumscribed swelling or an elevated lesion
e.g. Nodular prurigo
Petechiae definition + example
A small red or purple spot that is not elevated and does not
blanche when pressure is applied. Usually the result of
haemorrhages from tiny blood vessels in the skin
AKA a non-blanching rash (bigger ones are called Purpura)
E.g. Meningococcal sepsis, Henoch-Schonlein Purpura, Neutropenia from LEUKAEMIA
Most common cause of Peri-orbital cellulitis
Staphylococcus (will need IV Abx if bad)
Why is it important to act quickly if a kid has ORBITAL involvement in cellulitis
Infection can travel back up into brain / cause blood clots
Crusts defintion + examples
Hard outer layer of lesions which may be due to dried serum or
pus from ruptured vesicles
E.g. Impetigo
What symptoms can be caused by Henoch-Schonlein Purpura
- Rash
- Joint pain / swelling
- Abdo pain
- Intussuception
- Nephritis (rare)
Blisters definition + examples
A fluid-filled structure within the epidermis or under the dermis
Bullous impetigo,
bullous pemphagoid
Classic presentation of tinea capitis
Weeping + areas of hair loss
ie RING worm (actually a fungal rash)
Rash in nappy area with crease involvement + satellite lesions
Candida
Need to treat mum’s nipples too
