The infant or child with a rash Flashcards
Etiology
1. Viral Chicken pox EBV CMV Fifth disease Roseola HIV Hepatitis B/C HFM Rubella Measles HSV Molluscum contangiosum 2. Inflammatory Atopic dermatitis, seborrhoeic, contact, psoriasis, pityriasis rosea, mastocytosis 3. Bacterial Impetigo Folliculitis 4. Fungal Tinea corporis Scabies Candidiasis 5. Tick borne RMSF Lyme disease 6. Drug eruptions 7. Systemic bacterial Meningicoccal, syphillis, gonorrhea, endocarditis SSS Scarlet fever TSS 8. Hypersensitivity 9. Vasculitis/rheumatological Kawasaki JA HSP SLE, RF, Sarcoidosis 10. Child abuse
Important history
Is the child well Could this be an inset bite or allergic reaction Morphology Duration Distribution, progression Pruritis Systemic features Recent viral infection/Strep throat Family history Recurrent Contact, travel, exposures Complete medical history, medications Treatment attemtps
Unwell child systemic, erythematous rash etiology
- Erythematous rash
a. Hypersenitivity->insect, bites, allergies, medications
b. Scarlet fever->desquamating, pharyngitis, contact history
c. SSS->superficial desquamation, recent infection, fever, malaise, tender skin
d. TSS->trunk, palms, soles, hyperemic oral mucosa, tampon use
e. SJS
f. RF
g. JA
h. SLE
i. Sarcoidosis
j. Lyme
Unwell child systemic, maculopapular
a. Meningicoccal septicemia
b. Bacterial endocarditis
c. Systemic hypersensitivity syndrome
d. Kawasaki
e. Measles
f. HBV/HCV acute
g. HIV
h. RMSF->wrists, ankles, palms and soles, spreads central, spares face, outdoor
Unwell child systemic, vesiculobulous
a. SJS/TEN
Unwell child systemic, pertehchiael/purpuric
a. Meningicoccal
b. Leukemia
c. HSP
d. RMSF
Well child, mild systemic
Erythema multiforme Roseola Erythema infectiosum Drug reaction CMV EBV Rubella VZ HFM Syphilis Gonorrhea ITP Child abuse
Well child no systemic
Psoriasis Pityriasis rosea Contact/irritant Nappy rash Atopic dermatitis Seberroiec Tinea Scabies Impetigo Folliculitis Mastocytosis
Physical examination
General, systemic involvement
Describe the rash: raised/flat, crusty/scaly, colour, blanching, size, distribution
Full examination->including LN, CVS, RS, abdominal, ENT
Acute rash onset history
Well/febrile Itchy Associated symptoms? Bleeding, arthritis and abdominal pain, stridor and urticaria PMH Immunisations Contact
Investigations
Generally not required Rubella serology in pregnant Cultures if systemic/sepsis FBC/PLT, coagulation in ITP Widespread urticaria->RAST consider FBC, ESR, CRP, biochemical/urinalysis in systemic Serology->ASOT, anti-DNAse B, IgM/IgG for lyme, ELISA for S aureus in SSS Serology HIV, HBV, HCV Blood cultures LP Echo->RF, BE, Kawasaki CXR->RF, sarcoidosis Biopsy->SSS, SJS, DRESS, HSP
Features of scarlet fever: rash, presentation, treatment
Sandpaper Blanching Neck, axilla, groin Face spared Red tongue Fever, headace Group A strep infection, 12 hours post tonsilitis
Treatment: phenoxymethylpenicillin 15mg/kg up to 500mg BD for 10 days
Features of measles rash, management
Face->trunk
Koplik spots
Fever, ill, lymphadenopathy
Cough, coryza, conjunctivitis
Notifiable
Supportive care + vitamin A supplementation
Measles IgM/IgG serology
Features of rubella rash, complications in congenital rubella
Tiny macules->face to trunk
Generally well child
Suboccipital LN
IP of 14-21 days
Congenital->in first trimester= death, retardation, CHD, deafness, cataracts
Features of Fifth disease
Slapped cheeks
Lacy appearance
Mild fever
Lasts up to 6 weeks
Presentation of chicken pox
IP 10-21 days
Prodromal fever, lethargy, anorexia, then 3-5 days of eruption
Papules->vesicular->crusting in 10 days
+On scale, face, trunk, mouth and conjunctiva
Complications of chicken pox
Pneumonia Arthritis Hepatitis Encephalitis Superinfection Cerebellitis Reye
+in infants, >15 yo and immunocompromised children
Management of chickenpox
- Consider admission IV aciclovir, discussion with consultant:
- ->immunocompromised,
- ->steroid received,
- ->prematures,
- ->impaired mental state,
- ->cough/tachyP/dys and CXR shows pneumonia/nitis (add antibiotics) - If none of these features, >12 yo->discuss and consider oral aciclovir if
Exposure porphylaxis in chickenpox
Exposed, no rash
Symptomatic management of chickenpox
Calamine lotion Cool compresses Keeping skin cool Oral antihistamines for sleep Don't scratch, cut nails short
Infection precautions in hickenpox
Infectious 1-2 days prior to rash appearing, until fully crusted over. Exclude from school until fully recovered->at least one week after eruption first occurs
Types of nappy rash (4)
- Ammoniacal->irritant, papulovesicular, fissure, erosisons
- Candidial
- Seborrhoeic
- Psoriatic
Factors which contribute
Excess hydration–>water in nappy and stool, nappy change frequency
Skin trauma
Ammonia, feces, soap/deterhen, nappy wiped, napkin powders and creams
Treatment of nappy rash
Disposable nappies
+Frequency of nappy changing and cleansing
Disposable towel/face washers soaked in water/olive oil to cleanse
Apply barrier cream atevert change->parrafin, vaseline. Apply +++thickness
Let child sleep as long as can without nappy->lay on absorbent sheet, change when wet
If candida->imidazole/nystatin cream +/- hydrocortisone cream
Consider differential
Differential diagnosis of nappy rash
Seberrhoiec Atopic Psoriasis Perianal cellulitis Zinc deficiency Threadworms Langerhands cell histiocytosis Malabsorption Crohns
Meningicoccal rash presentation
Petechiael, purpuric, morbilliform
Shock/coma
History and examination assessment of meningicocemia
History:
Rapid, fever, malaise, lethargy, vomiting, myalgia, -ve LOC
Examination:
May be shocked, rash, leg pain, neck stiff, photophobia
Blanching does not exclude
Preceeding viral does not exclude
Investigations in meningicoccal
Blood culture (if possible before antibiotics)
Meningicoccal PCR
Glucose, UEC, coagulation
VBG/ABG
Consider LP if meningitis
Acute management of meningicocemia
- ABC, get help
- IV access
- Blood cultures and Ix
- Ceftriaxone or cefotaxime 50mg/kg
- IVF->shock management, consider 2/3 maintenance following if suspect meningitis
- Urinary catheter if shock
- Hydrocortisone if considering meningitis (within 1 hour of antibiotics)
- Regular analgesia, may need morphine infusion
- If necrosis, involve plastics early
- Admission
Isolate until >12 hours antibiotics - Contact tracing and prophylaxis for those within 24 hours (contact in last 7 days)->rifampicin, ceftriaxone if contraI or pregnant
- Monitor vitals and response
ITP general, presentation, workup and management
Most common cause of childhood thrombocytopenia Autoimmune hemorrhagic disorder 1. Petechial rash 2. Bleeding 3. Preceeding viral infection
FBC, PLT low, +coagulation studies
Management:
Mostly self limiting
If ++thrombocytopenia, ongoing bleeding may need admission + steroids
Pathogenesis of HSP and epidemiology
Small vessel leukocytoclastic vasculitis w/ IgA deposition within affected organs
Most often in winter following strep infection
More in males, 2-8 years
HSP triad
Purpuric rash on extensor surfaces
Joint pain
Abdominal pain
Assessment of HSP
- Purpura->if atypical or unwell, consider meningiC, thrombocytopenia, other vasculitis
- Joint pain->large joints
- Abdominal pain usually resolves in 72 hours->look out for intussusception, bloody stool, hematemesis, perforation, pancreatitis
- Renal involvement->hematuria
- Subcutaneous edema of scrotum, hands, feet, sacrum
- Rare complications of pulmonary and CNS
Investigations in HSP
FBC
UEC
Blood culture
When does Atopic dermatitis usually present, grow out of
Usually presents before 12 months, and will often grow out of it by age 5
Diagnosis of atopic dermatitis
Itch + three of 1. Involvement of skin creases 2. Personal hx of asthma/hay fever 3. Dry skin in last year 4, Onset under 2 (not used if under 4 years) 5. Visible flexural eczema
What system is used to graded severity in eczema
SCRAD
Management of eczema
- Every day and avoid triggers
- >avoid heat, prickly, dry skin
- >Regular moisturises twice a day
- >Daily cool bathing->add salt, bleach 4% for chronic infected and bath oil
- >Consider oral vitamin D supplementation - Flaring treatments:
- >Topical steroids hydrocortisone 1%
- >Tar creams for lichenification
- >Antibiotics/virals for infection
- >IN bactroban if nasal swabs +ve for S aureus
- >Wet dressings
- >Cool compress with moisturiser post compress
Infected eczema management
Remove the crust, cool compress and soak in bath
Cortison over open skin
Cephalexin/flucloxacillin oral antibiotics. IV if unwell
King bleach 4% to cool bath water, wash scalp and face while bathing
Pool salt can be addedd
For HSV infection->start treatment w/i 48 hours oral acyclovir, IV may be required if severe/immunocompromised.
Advice to parents about their child’s eczema
- Identify and avoid triggers->prickly, heat, detergents, soaps, antiseptics
- Moisturise the skin->twice daily, oils, soap free
- Reduce itchiness with wet dressing and cool compresses
- cool towel/cloth for 10-15 minutes
- distract
- ovoid overheating
- moisturise
- keep nails short
- apply wet dressing to limbs at bedtime
- cotton clothing, remove woolen, keep house cool, educate others about dressing your child
- All foods considered innocent until guilty
WIll the treatment cure eczema
Not for cure, to help control
Will continue for many years in most cases
Advice on swimming
Yes, if the eczema is not flaring up. Prior to swimming, apply a layer of moisturiser from top to toe. Soon after swimming, wash the skin thoroughly in a cool shower or bath with some bath oil then reapply the moisturiser. If the eczema flares that night, apply a wet dressing just before your child goes to bed.
Define cellulitis, most common causes and predisposing
Spreading infection of subcutaneous tissue
Most common causative agents: GABHS, SA
Skin abrasions, lacerations, burns, eczematous skin
When is cellulitis unlikely and allergic/dermatitis often misdiagnosed
Itching only and not tender
Who is primarily affected by SSSS, level affected, early features
Neonates and young children
Splits upper epidermis, epidermolytic toxin
Fever and tender erythematous skin early features->discomfort when touched
Exudation and crusting early around the mouth
What is impetigo
Highly contagious of epidermis
Common in young children
GABHS and S aureus
What is Nikolsky sign
Rubbing normal skin, peels off
When does Nikolsky occur
SJS
SSSS
Complications in SSS
DeH and electrolyt
Cellulitis
Sepsis
Temperature instability
Scabies: causative agent, signs and symptoms, relation to ARF
Sarcoptes scabiei var. hominis
Soft hairless areas
School-aged, indigenous, resisdential
Itching, post strep, excoriations, secondary bacterial, rash
Allergic reaction to mite causes the signs and symptoms
Secondary infection->Streptococcal->ARF
Treatment of scabies in children older than 6 months
permethrin 5% cream (adult and child 6 months or older) topically to dry skin from the neck down, paying particular attention to hands and genitalia. Apply under the nails using a nailbrush. Leave on for a minimum of 8 hours (usually overnight) and reapply to hands if washed. Application time may be increased to 24 hours if there is a history of treatment failure. Repeat treatment in 7 days
Assessment in scabies
Complete history Clinical observations BP++ Urine Signs of secondary In recurrent/secondary infection->weight, BP, urinalysis->if abnormal manage/refer to pediatrics Consider skin scraping/dermatoscopy
Treatment of scabies
permethrin 5% cream topically to the entire body, including the scalp but avoiding eyes and mouth. Cover hands to avoid the child sucking the medication. Leave on for 8 hours. Repeat treatment in 7 days
Or 2% sulfur
Treatment in scabies immunocompromised
ivermectin (adult and child 15 kg or more) 200 micrograms/kg orally with fatty food, once weekly until scrapings from a burrow are negative and there is no further clinical evidence of infestation.
Treatment of norweigan scabies
ivermectin (adult and child 15 kg or more) 200 micrograms/kg orally with fatty food, for 3, 5 or 7 doses depending on severity and clinical response in the first week
for a 3-dose regimen, give on days 1, 2, 8
for a 5-dose regimen, give on days 1, 2, 8, 9 and 15
for a 7-dose regimen give on days 1, 2, 8, 9, 15, 22 and 29.
Other aspects of scabies treatment
- Family treated
- All linen/bed sheets
- Warn itch can continue for weeks
- Repeat treatment in a week
Assessment and investigations of cellulitis->defining feature of inpetigo, erysipelas NF
Impetigo->bullious
NF->tender beyond skin signs, thrombocytopenia
Erysipelas->well defined
Ix: Swab BC + FBE if fever ESR, XR if suspect osteoM USS if fluctuant Surgical if suspect NF or abscess
Antibiotic treatment of cellulitis, impetigo, NF
Cellulitis->Flucloxacillin or cephalexin
Impetigo->wash off crusts, apply 2% muporicin ointment tds, exclude from school/daycare etc until started treatment and cover with tegaderm
SSS->as for cellulitis
NF-> IV flucloxacillin + clindamycin, surgical consult for debridement
Investigations and management in SJS
Skin biopsy Blood cultures UEC FBC LFT ABG->hypoxemia, acidosis
Management: ABC, urgent evaluation from senior IV access, ABG, oxygen Removal of causative agent Dressings, topical antibacterial, emolient Fluids and electrolyte, strict fluid balance Nutritional support Oral hygeine->lidocaine mouthwash Analgesia IVIG OT and physiotherapy
What is kawasaki disease
Systemic vasculitis, of unknown origin
Major concern with Kawasaki
Risk of coronary aneurysm
Diagnostic criteria for kawasaki
- Fever > 5 days
4/5 of
- Polymorphous rash
- B/L non purulent conjunctivitis
- Mucosal membrane changes
- Peripheral changes->feet/soles
- Cervical lynphadenopathy->usually SSS, TSS
- Strep->Scarlet fever, TSLS
- Juvenile RA
- Measles, +other viral exanthems
- SJS
- Drug reaction
Investigations in kawasaki
ASOT/Anti-DNAase B
EchoC->initial and 6-8 weeks post
PLT-> low
FBC->+neutrophils, normocytic/normochromic anemia
ESR/CRP +
+LFTs
Low albumin
Management of Kawasaki
- Admit
- IVIG over 12 hours
- Aspirin daily for 6-8 weeks
- Investigations->++Echo
- Analgesia for pain
- Organise F/U echo in 6-8 weeks following D/C
- If your child is due a routine MMR (measles, mumps, rubella) immunisation, this should be delayed until 11 months after the gammaglobulin treatment.
- Most children recover normally
Important information about molluscum and management
Viral Self limiting 6-9 months until resolution No restriction in activity Mostly doesn't need treatment If dermatitis->topical steroids To ++immune response: consider benzyl peroxide, aluminium acetate solution (Burrow's solution), imiquimod
Assessment of urticaria
Extravasation of plasma into dermis
- Onset
- Events leading up to
- Medication, interaction, infections, foods, bites, pressure, cold, exercise
Examination in urticaria
General->ensure airway patent, no respiratory distress
Circular, general/localised, polymorphic, transien
What to consider when recurrent angioedema without wheals
c1 esterase inhibitor deficiency
DDX for urticaria and distinguishing features
Erythema multifore->not itchy, mucosal involvement, persistent, target lesions
Mastocytosis Flushing Juvenile rheumatoid arthritis Vasculitis Pityriasis rosea
Investigationsin chronic urticaria
FBE
ESR
ANA
Management of urticaria
- Remove causative agent
- Cool compress
- Education, explanation and reassurance
- Modification to diet not necessary until causative agent determined
- Anti-histamine
- Promethazine or cetirizine (X in
