Skin, eye and ear

Question 1

Acne - mx

Answer 1

Mx

a. Immediate - lifestyle
1. Eat a sensible, nutritious diet. Avoid foods that seem to aggravate acne (e.g. chocolate, milk for some people)
2. Wash skin gently twice/d with a high fat non-perfumed soap, e.g. Neutrogena/baby soap
3. Avoid using creams/cosmetics on the face
4. Avoid sunburn but do try to get a little sun on the skin each day

b. Immediate - pharmacological
1. Topical comedolytic cream/ointment to dry out pimples, e.g. tretinoin 0.05% cream nocte, benzoyl peroxide 10% mane
2. If basic topical tx not effective, try topical abx, e.g. clindamycin lotion or erythromycin gel applied twice daily
3. Next stage = oral tetracycline, e.g. doxycycline or switch to minocycline (if doxy unsuccessful)
4. Emphasise that tx must be taken daily and for at least 4-6 wks on full dosage. May take 2-3mo before significant improvement. Warn about photosensitivity
5. Arrange F/U for 1-2mo

c. Long-term
1. If oral tetracyclines do not result in significant improvement improvement, refer to dermatologist for consideration of prescribing isotretinoin (can only be prescribed by dermatologist)

Question 2

Acne - prevention

Answer 2

1. Regular exercise

2. Relaxation techniques, stress management

Question 3

Acute otitis media - mx

Answer 3

a. Immediate
1. Abx indications = bulging drum, fever, irritability - suggestion of suppuration. First line = amoxycillin, second-line = amoxycillin + clavulanate, third line = cefuroxime
2. Decongestant or antihistamine. Can also relieve congestion by blowing up balloon for 2-5yo
3. Child may be more comfortable sleeping with head of cot/bed propped up

b. Fever management
1. Paracetamol 4hrly (consider rectal, if child vomiting)
2. Fluids to avoid rapid rises/falls in temperature
3. Review in 7-10d to see if infection has cleared

c. Long-term
1. Stress importance of F/U, to avoid situation of undetected chronic effusion
2. Possible need to refer if problem does not resolve after 6wks, recurs or if there is evidence of impaired hearing (check if recurrent anyway)
3. Review child in 7-10d to see if infection has cleared

Question 4

Acute otitis media - prevention

Answer 4

Aim to prevent deafness by proper treatment and follow-up

Question 5

Atopic dermatitis - mx

Answer 5

a. Immediate
1. Short-term topical 1% hydrocortisone ointment (sparingly) BD to active areas for 3-5d. May require fluorinated steroid for limbs/trunk but only hydrocortisone (lowest strength) for face
2. Remove trigger if apparent. Avoid hot baths, overheating, wool next to skin
3. Cool flannels to irritated skin. Wear soft, light, loose clothing - e.g. cotton garments
4. Avoid soap and perfumed products - use aqueous cream as soap substitute
5. Antihistamine at night to avoid scratching and allow sleep
6. Nails should be kept short to allow scratching
7. F/U in 5-7d

b. Long term
1. Avoid soaps, shampoos, bubble baths. Use cleansers, e.g. Hamilton’s bath oil, QV bath oil
2. Daily moisturiser such as sorbolene (with 10% glycerine) or paraffin creams (e.g. Dermeze)
3. Creams such as Egoderm (active ingredient ichthammol) for subacute skin irritations
4. Use topical steroids in cyclic fashion for chronic problems, e.g. 10d on and 4d off

Question 6

Atopic dermatitis - prevention

Answer 6

1. Avoid scratching
2. Avoid contact with people with ‘sores’, esp. herpes
3. Avoid sandpits
4. Minimise contact with carpets
5. Check immunisations
6. Check how mother/father is coping if lack of sleep, demands of other children
7. Ascertain if any risks of child abuse

Question 7

Nappy rash - mx

Answer 7

a. Immediate
1. Frequent nappy changing
2. Leave nappy off as much as possible
3. Do not wash in soap. Remove exudate with warm water and pat dry
4. Apply protective barrier cream at every change, e.g. aqueous cream or vaseline (lightly). Avoid lanolin-containing creams
5. Rinse cloth nappies very well
6. For healing of severe cases, use combination of 1% hydrocortisone cream mixed with nystatin (Mycostatin, Nilstat) cream topically. Apply twice daily until rash clears
7. Arrange F/U for 1 wk or sooner as required, if rash not improving

b. Long-term/preventive
1. Frequent nappy changes to keep area dry
2. Barrier creams
3. Some of the better disposable nappies keep nappy area driest
4. Avoid plastic pants and powder

Question 8

Nappy rash - prevention

Answer 8

1. Immunisations

Question 9

Skin cancer (suspected) - mx

Answer 9

a. Immediate
1. Need to remove lesion to obtain pathological dx
2. May do this yourself or refer to plastic surgeon depending on site and size of lesion and own level of experience
3. Excision margins:
- Suspicious lesion = 4mm margin
- Melanoma in situ = 5mm margin
- Melanoma 4mm thick = 2cm margin
4. Arrange F/U for early removal of lesion, i.e. within one week

b. Long-term
1. Possible need for further ix and tx, e.g. liver scan, depending on pathology results
2. Need for regular F/U
3. Educate about signs of possible further skin cancers and the need to present early

Question 10

Skin cancer (suspected) - prevention

Answer 10

a. Need to educate about sun protection
1. Avoid direct sunlight
2. Broad-brimmed hat and long-sleeves
3. Factor 15+ sunscreen on exposed areas, e.g. hands
4. Be wary of reflected sun on cloudy days

b. Other preventive health strategies
1. Discuss tobacco use and alcohol consumption
2. Discuss need for regular medical check-up of BP, etc.