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Child and Adolescent Health (CAH) > Skin Rashes and Dermatology > Flashcards

Skin Rashes and Dermatology Flashcards

1
Q

What is the diagnostic criteria for KAWASAKI DISEASE?

A

Fever for FIVE DAYS plus at least FOUR out the following five features:

  1. conjunctivitis (bilateral, non-purulent)
  2. rash (confluent, urticarial)
  3. adenopathy (cervical)
  4. strawberry tongue / oral involvement
  5. hands and feet swollen / painful
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2
Q

Outline some features of KAWASAKI DISEASE that may be present, but are NOT part of the diagnostic criteria.

A 
✔️ irritability 
✔️ aseptic meningitis 
✔️ nausea and vomiting
✔️ abdominal pain
✔️ arthritis / arthralgia
✔️ aseptic pyuria
✔️ inflammation at recent BCG injection site
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3
Q

Outline some differential diagnoses for KAWASAKI DISEASE.

A 
✔️ Henoch Schloin Purpura
✔️ non-specific vasculitis 
✔️ non-specific viral infection (e.g. CMV, EBV)
✔️ GAS infection (e.g. ARF, tonsillitis, Scarlet fever(
✔️ Stephen Johnson Syndrome
✔️ meningococcal disease
✔️ DIC
✔️ acute drug reaction
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4
Q

Describe the appropriate management of KAWASAKI DISEASE.

A
  1. Primary survey (ABCDE)
  2. Admit the patient onto the Paediatrics Ward
  3. Appropriate fluid balance (enteral or IV)
  4. Paracetamol for fever management
  5. Aspirin 3 to 5 mg / kg (be cautious of Reye’s Syndrome)
  6. Corticosteroids in high risk patients (prednisolone 2mg)
  7. IV Ig infusion (2g / kg) –> commence within TEN DAYS of symptom onset to reduce the risk of coronary aneurysm
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5
Q

Describe how patients with KAWASAKI DISEASE should be followed up.

A
  1. Cardiology F/U (echocardiogram at admission, 2 weeks and 6 weeks post-admission)
  2. Paediatric F/U (follow up for Reye syndrome within 6 weeks)
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6
Q

Outline the clinical presentation of ACUTE MENINGOCOCCAL DISEASE.

A

✔️ acute onset (<12 hours) fever, lethargy, irritability, reduced feeding
✔️ vomiting + diarrhoea
✔️ non-blanching petechial / purpuric skin rash
✔️ headache, neck stiffness, photophobia (if bacterial meningitis is present)

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7
Q

What are the appropriate investigations for ACUTE MENINGOCOCCAL DISEASE?

A
  1. Primary survey
    ✔️ airways –> check own and patent
    ✔️ breathing –> give O2 if < 90%
    ✔️ circulation –> insert 2 x large bore IVCs and collect appropriate bloods BEFORE commencing antibiotics
    ✔️ disability –> check GCS and pupil size
    ✔️ exposure
  2. Commence empirical antibiotic therapy IMMEDIATELY
    ✔️ IV ceftriaxone for 5 days
    ✔️ readjust once blood culture results have been returned
  3. IV fluids
    ✔️ resuscitation (20mL per kg of 0.9% NaCl)
    ✔️ bolus (%age dehydration x 10 x weight of 0.9% NaCl)
    ✔️ maintenance (4:2:1 of 0.9% NaCl + 5% dextrose +/- 5 or 20 mmol / L K+)
  4. Notify public health
  5. Chemoprophylaxis of close contacts
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8
Q

Which bacteria is responsible for STAPH SCALDED SKIN SYNDROME?

A

Epidermolytic toxins A and B produced by toxic strains for Staph. aureus.

SSSS is most common in infants < 5 years of age.

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9
Q

Describe the clinical presentation of SSSS.

A

✔️ localised Staph infection
✔️ subsequent exudate and weeping
✔️ tender and erythematous skin
✔️ high fever
✔️ formation of serous blisters that rupture, exposing underlying dermis
✔️ Nikolsky’s Sign –> rubbing of skin causes exfoliation of the epidermis
✔️ irritability is worse when the child is patted and comforted

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10
Q

Outline the management of SSSS.

A
  1. Admit patient
  2. Consult burns team for most appropriate management of burns
  3. Supportive care
  4. IV antibiotics against Staph aureus (IV flucloxacillin or vancomycin if MRSA)
  5. Look for and treat focus of infection
  6. Monitor temperature, fluids and electrolytes
    some say that fluids help to excrete the toxin in the kidneys
  7. Handle skin carefully
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11
Q

What are some complications of SSSS?

A 
✔️ significant dehydration
✔️ electrolyte imbalances
✔️ cellulitis
✔️ poor temperature control
✔️ septicemia
✔️ pneumonia
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12
Q

Outline the diagnostic criteria of HENOCH SCHOLEIN PURPURA.

A

Petechial / purpuric rash plus at least ONE of the following:

  1. abdominal pain
  2. nephritis
  3. arthritis / arthralgia
  4. leukocytoclastic vasculitis
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13
Q

Define HENOCH SCHOLEIN PURPURA.

A

HSP is the most common vasculitis in children. The exact cause is unknown. It is believed to be an IgA mediated vasculitis.

Key features are: 
✔️ petechia / purpuric rash
✔️ abdominal pain
✔️ nephritis 
✔️ arthritis / arthralgia 
✔️ leukocytoclasic vasculitis
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14
Q

Describe the rash seen in HSP.

A

✔️ bilateral
✔️ common in gravity - dependent areas (lower limbs, buttocks)
✔️ petechial / purpuric
✔️ blanching

The rash is present in 75% of cases.

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15
Q

Identify complications of HSP.

A 
RENAL PROBLEMS
✔️ nephritic syndrome
✔️ glomerulonephritis
✔️ hypertension
✔️ renal impairment
✔️ end stage kidney disease
NEUROLOGICAL PROBLEMS
✔️ labile mood
✔️ apathy 
✔️ hyperactivity 
✔️ encephalopathy
✔️ acute intracranial haemorrhage

RESPIRATORY PROBLEMS
✔️ diffuse alveolar haemorrhage

GASTROINTESTINAL PROBLEMS
✔️ intussusception

DERMATOLOGICAL PROBLEMS
✔️ non-pitting subcutaneous oedema

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16
Q

Describe the appropriate management of HSP.

A
  1. Primary survey
  2. Discuss with senior registrar / consultant
  3. NOT for antibiotics
  4. Consider prednisolone 2mg / kg for moderate to severe joint pain
  5. Appropriate fluid balance / management
  6. Paracetamol for pain relief
17
Q

Ddx for PETECHIAL / PURPURIC RASH

A

VASCULITIS
✔️ HSP
✔️ Kawasaki’s Disease
✔️ Drug induced thrombocytopenia

INFECTIVE
✔️ Acute bacterial meningococcal disease
✔️ Non-specific viral infection (e.g. adenovirus, enterovirus)

HAEMATOLOGICAL
✔️ DIC
✔️ Idiopathic thrombocytopenia
✔️ Aplastic anaemia
✔️ Acute lymphocytic leukaemia

MECHANICAL
✔️ trauma
✔️ coughing or vomiting

18
Q

Outline appropriate investigations for HSP.

A

Bedside Ix
✔️ urine dipstick + MCS

Laboratory Ix
✔️ FBC + WCC
✔️ Inflammatory markers
✔️ UECs + eLFTs
✔️ coags (exclude DIC)
✔️ blood culture
✔️ ASOT and anti-DNAse B antibodies
✔️ ANA, ANCA, C3 and C4 if cause for renal impairment is unknown

Imaging Ix
Nil.

19
Q

Describe the appropriate management of HSP.

A

Non-pitting subcutaneous oedema –> bed rest and elevation of the affected area

Joint pain –> NSAIDS (e.g. ibuprofen) OR corticosteroids for moderate to severe pain (prednisolone 1mg per kg)

20
Q

Describe appropriate follow up for a patient with HSP.

A

If urinalysis and MCS is normal at the time of diagnosis, F/U with GP or paediatrician for urinalysis and BP is required at the following intervals:
✔️ weekly from weeks 1 to 4
✔️ fortnightly from weeks 5 to 12
✔️ single review at 6 and 12 months
✔️ discharge if no abnormalities at 12 months

21
Q

When would it be appropriate to consider admission for HSP?

A

✔️ child appears unwell
✔️ pain unable to be managed with simple analgesia
✔️ testicular involvement
✔️ respiratory or neurological involvement
✔️ peritonism
✔️ abnormal urinalysis or BP

22
Q

What is the aetiology of SCABIES?

A

Sarcoptes scabiei v.. homonis

Transmission is from person to person or through contact with infected fomites.

The scabies mite can live on infected fomites for 1-2 days, or 3-4 days if the infected person is around.

23
Q

Describe the clinical presentation of SCABIES.

A

The timing of clinical presentation depends on the number of exposures / infestations the individual has experienced.

First exposure: symptoms develop 4 to 6 weeks after infestation

Subsequent exposure: symptoms develop within a few hours of infestation

Clinical presentation includes:
✔️ papules, pustules, vesicles
✔️ burrows seen in webbing of fingers, toes, buttocks and breasts (areas of skin WITHOUT hair)
✔️ intense widespread itch, worse at night
✔️ secondary bacterial infection –> S. aureus

24
Q

Identify risk factors for SCABIES infection.

A 
✔️ low socioeconomic status
✔️ overcrowding 
✔️ poor hygiene and sanitation
✔️ immunocompromised individuals (more likely to develop Norweigan Scabies)
✔️ ATSI
✔️ poor health literacy
25
Q

Describe the management of CLASSICAL SCABIES.

A

NON-PHARMACOLOGICAL MANAGEMENT
✔️ all sheets, towels and clothing to be washed in > 50°C
✔️ all lounges, couches, beds etc. to be covered and stored away for 1 week
✔️ all floors to be mopped / vacuumed
✔️ keep children home from school / day care
✔️ keep adults home from work
✔️ avoid itching and scratching of lesions due to risk of secondary bacterial infection
✔️ clip nails prior to applying cream
✔️ re-apply cream if hands are washed within 8 hours of applying
✔️ put mittens on children to avoid scratching

PHARMACOLOGICAL MANAGEMENT
1. Permethrin 5% cream –> apply to entire body from the neck day and leave for 8 hours (overnight); reapply in 7 to 10 days if symptoms have not subsided (NOT suitable for children < 6 months of age or pregnant women).

  1. Benzyl benzonate 25% cream –> apply to entire body and leave for 24 hours.
  2. Ivermectin –> oral tablet; repeat in 7 to 10 days.

Note that the itch may take up to 4 weeks to subside.

26
Q

What are some complications of SCABIES?

A

✔️ secondary bacterial infection (e.g. impetigo, cellulitis)
✔️ RHD
✔️ PSGN
✔️ recurrence and incomplete eradication

27
Q

What organism is most commonly the cause of IMPETIGO?

A

Staph. aureus

28
Q

What are some risk factors for IMPETIGO?

A 
✔️ school-aged children
✔️ ATIS children
✔️ immunocompromised 
✔️ overcrowding
✔️ poor hygiene / sanitation
✔️ poor health literacy 
✔️ sibling / close contact with confirmed disease
29
Q

Describe the three presentations of IMPETIGO.

A

There are three ways in which impetigo can present:

  1. non-bullous
  2. bullous
  3. ecthyma

NON-BULLOUS

  • Begins as small papule on the hands and face –> develops into pustule with crusted top
  • Erythematous base
  • Golden crust
  • Most commonly located on the hands and face
  • Highly contagious
  • Heals without scarring
  • Most commonly caused by S. aureus

BULLOUS

  • Begins as a small vesicle –> develops into a flaccid bulli over a couple of days
  • Burst
  • Heal without scarring
  • Most commonly caused by S. pyogenes

ECTHYMA

  • Begins as non-bullous impetigo
  • Develops into large, punched-out ulcers
  • Heals WITH scarring
30
Q

Outline appropriate management of IMPETIGO.

A

NON-PHARMACOLOGICAL
✔️ keep children home from school/ day care until sores have completely healed
✔️ cover sores with a waterproof dressing to avoid contamination
✔️ avoid scratching
✔️ encourage use of individual towels and linen by all household members
✔️ practice appropriate hygiene and sanitation

PHARMACOLOGICAL
✔️ 2% muprocin cream, applied TDS for 7 to 10 days
✔️ oral antibiotics if initial treatment fails

31
Q

Outline appropriate management of ECZEMA.

A

LIFESTYLE MODIFICATIONS
✔️ avoid known triggers
✔️ encourage bathing in lukewarm bath; pat dry
✔️ encourage use of cotton clothing; nil synthetic fabrics
✔️ avoid scratching lesions as this can cause secondary bacterial infection
✔️ avoid soaps and shampoos with fragrances
✔️ avoid surfaces that may damage skin

TOPICAL EMOLLIENTS
✔️ apply a fragrance-free emollient (e.g.Sorbolene, QV cream) TWICE per day –> increase to four times per day during an acute eczema flare
✔️ apply occlusive dressings

ANTIBIOTICS
✔️ use topical antibiotics sparingly, only if secondary bacterial infection is suspected
✔️ flucloxacillin or ceftatexin

TOPICAL CORTICOSTEROIDS
✔️ 1% hydrocortisone for face
✔️ 0.05% bethamethasone diproprionate for trunks and limbs

32
Q

Describe the characteristics of NECROTISING FASCITIS.

A

✔️ acute onset rash, unilateral, usually in lower limb
✔️ very, very painful
✔️ rapidly spreading
✔️ “dusky” purple appearace
✔️ crepitus beneath skin (if caused by Clostridium)

33
Q

Outline the management of NECROTISING FASCITIS.

A

✔️ immediate surgical referral
✔️ surgical debridement of necrotic tissue
✔️ immediate IV antibiotics (penicillin, clindamycin, metronidazole, cephalosporins, carbapenems, vancomycin, and linezolid)
✔️ IV fluids and oxygen
✔️ consider hyperbaric therapy if anaerobic organism is cultured

34
Q 
SCARLET FEVER
✔️ aetiology
✔️ risk factors
✔️ clinical presentation
✔️ mangement 
✔️ complications
A

AETIOLOGY
Develops after GAS infection (pharyngitis / tonsillitis or impetigo).

RISK FACTORS
✔️ overcrowding
✔️ poor sanitation and hygiene
✔️ low SES
✔️ immunocompromised 
✔️ known contact with GAS infection
✔️ age < 2 years or > 10 years

CLINICAL PRESENTATION
✔️ rash develops 12 to 48 hours after fever
✔️ bright red blotches that become widespread
✔️ rash located below the neck, armpits etc.
✔️ “sandpaper” skin
✔️ resolves within 7 days (without antibiotics) or within 24 hours (with antibiotics)

MANAGEMENT

  1. Oral penicillin for 10 days or a single dose of IM penicillin.
  2. Encourage hydration and oral intake.
  3. Paracetamol for headache, fever and joint pain.
  4. Oral antihistamines if rash is itchy.
COMPLICATIONS
✔️ ARF
✔️ RHD
✔️ PSGN
✔️ Septicemia
✔️ Pneumonia
✔️ Acute otitis media
✔️ Osteomyelitis
35
Q 
HSV GINGIVOSTOMATITIS
✔️ aetiology
✔️ risk factors
✔️ clinical presentation
✔️ mangement 
✔️ complications
A 
AETIOLOGY
HSV1 virus (most commonly); occasionally HSV2 virus.

Transmission is through direct contact with someone with active lesions.

RISK FACTORS
✔️ immunocompromised
✔️ young age
✔️ poor hygiene / sanitation

CLINICAL PRESENTATION
✔️ multiple erythematous-based ulcers located in the mouth and oral area
✔️ extremely painful
✔️ drooling
✔️ refusal to eat or drink
✔️ symptoms last 10 to 14 days

MANAGEMENT

  1. Fluid replacement (NGT or IV)
  2. Topical analgesia (e.g. lidnogaine gel)
36
Q 
HAND FOOT AND MOUTH DISEASE
✔️ aetiology
✔️ risk factors
✔️ clinical presentation
✔️ mangement 
✔️ complications
A

AETIOLOGY
✔️ Coxsackie Virus
✔️ Echovirus
✔️ Enterovirus

RISK FACTORS
✔️ child < 10 years
✔️ attends day care
✔️ known contacts
✔️ immunocompromised

CLINICAL PRESENTATION
✔️ non-specific, viral prodrome
✔️ blisters on palmar surface of hands, dorsum of feet and mucosal surface of mouth
✔️ reduced oral intake, leading to dehydration

MANAGEMENT
✔️ do NOT burst the blisters
✔️ cover blisters to avoid contact with others
✔️ keep home from school / day care
✔️ paracetamol for fever
✔️ antiseptic mouth wash
✔️ maintain hydration

COMPLICATIONS
✔️ dehydration
✔️ meningitis (rare)

37
Q 
ROSEOLA
✔️ aetiology
✔️ risk factors
✔️ clinical presentation
✔️ mangement 
✔️ complications
A

AETIOLOGY
✔️ Human Herpes Virus 6 or 7

CLINICAL PRESENTATION
✔️ macules / papules that blanch
✔️ some macules / papules may be surrounded by a lighter halo
✔️ begins on trunk and spreads to face, limbs etc.
✔️ high fever (as high as 40°C)
✔️ lethargy, irritability, reduced feeding

MANAGEMENT

  1. Encourage oral intake
  2. Paracetamol for fever
  3. Self-limiting infection

Child and Adolescent Health (CAH) (6 decks)

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