Paediatric Dermatology

Question 1

Which virus causes hand, foot and mouth disease?

Answer 1

Coxsackie A virus

Question 2

How does hand, foot and mouth disease present?

Answer 2

Starts as an upper respiratory tract infection- sore throat,t dry cough, fever

Then after 1-2 days -

small mouth ulcers

Blistering red spots mostly on hands, feet and around mouth

Question 3

How is hand foot and mouth disease managed?

Answer 3

Supportive

Question 4

How can you differentiate between a nappy rash and a candida infection?

Answer 4

Signs that point to candida =

Rash extending into the skin folds

Well demarcated border

Circular pattern - similar to ringworm

Satellite lesions

Question 5

How does Scabies present?

Answer 5

Incredibly itchy small red spots

Track marks where the mites have burrowed - classically between the fingers

Question 6

How is Scabies managed?

Answer 6

1st line = Permethrin cream

All household and physical contacts must be treated

Question 7

What is crusted scabies and how is it treated?

Answer 7

Crusted skin with scabies

Occurs in immunocompromised patients

Treated with ivermectin

Question 8

What is the most common causative organism of impetigo?

Answer 8

Staph aureus

Question 9

How does impetigo present?

Answer 9

Golden crusted lesions typically around the mouth

Question 10

How is impetigo managed?

Answer 10

1st line = Hydrogen peroxide 1% cream

Topical fusidic acid is an alternative

If widespread = oral flucloxacillin

Question 11

How long do children with impetigo need to be kept off school?

Answer 11

Until lesions are crusted and healed , or 48 hours after starting treatment

Question 12

What virus causes Roseola?

Answer 12

Human herpesvirus-6 (HHV-6)

Question 13

How does Roseola present?

Answer 13

High fever that comes on suddenly, lasts for 3-5 days then disappears

Then an erythematous macular rash for 1-2 days

Often diarrhoea/vomiting

Febrile convulsions can occur

Question 14

How does measles present?

Answer 14

Prodrome of fever, coryza and conjunctivitis

Koplik spots - spots on Buccal mucosa. Pathogenomic for measles

Erythematous macular rash which starts on the face - classically behind the ears

Question 15

What are complications of measles?

Answer 15

Otitis media (most common; m for measles)

Pneumonia

Encephalitis

Meningitis

Hearing loss

Vision loss

Death

Question 16

How does rubella present?

Answer 16

Milder erythematous rash than measles

Starts on face then spreads to body

Lymphadenopathy

Question 17

How does a Parvovirus B19 infection present? management:

Answer 17

“slapped cheek syndrome” aka fifth disease aka erythema infectiousum

Starts with mild fever, coryza and non-specific viral symptoms

Then a few days later - bright red rash on both cheeks

Then a reticular (net-like) erythematous rash on trunk and limbs

The illness is self limiting and the rash and symptoms usually fade over 1 – 2 weeks.

Healthy children and adults have a low risk of any complications and are managed supportively with plenty of fluids and simple analgesia.

It is infectious prior to the rash forming, but once the rash has formed they are no longer infectious and do not need to stay off school (no school exclusion)

Question 18

When is Parvovirus B19 infection infectious? (Slapped cheek syndrome)

Answer 18

Prior to rash forming - not once rash has formed

Question 19

What are complications of Parvovirus B19?

Answer 19

Aplastic anaemia - especially in those with sickle cell anaemia, thalassaemia, and haemolytic anaemias

Encephalitis/meningitis

Question 20

What is the most common complication of chickenpox?

Answer 20

Secondary bacterial infection of the lesions

Question 21

Impetigo management:

Answer 21

1. Localised, non-bullous : 1st line: Topical H2O2 1% cream
   2nd line: topical fusidic acid (2%) antibiotic
2. Widespread, non-bullous
3. Oral flucloxacillin OR 2. topical fusidic acid (2%) antibiotic
4. Bullous, systemically unwell –> Oral flucloxacillin

Question 22

how does eczema present in paediatrics:

Answer 22

itchy, erythematous rash
repeated scratching may exacerbate affected areas
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

Question 23

eczema prevalence in children:

Answer 23

Eczema occurs in around 15-20% of children and is becoming more common. It typically presents before 2 years but clears in around 50% of children by 5 years of age and in 75% of children by 10 years of age

Question 24

management of eczema in children:

Answer 24

1. avoid irritants
2. simple emollients
   large quantities should be prescribed (e.g. 250g / week), roughly in a ratio of with topical steroids of 10:1
   -if a topical steroid is also being used the emollient should be applied first followed by waiting at least 30 minutes before applying the topical steroid
   creams soak into the skin faster than ointments
   emollients can become contaminated with bacteria - fingers should not be inserted into pots (many brands have pump dispensers)

Depending on the severity of the eczema, some patients may only require thin emollients to maintain their skin barrier, whilst others with more severe eczema require very thick greasy emollients. The general rule is to use emollients that are as thick as tolerated and required to maintain the eczema.

Thin creams:

-E45
-Diprobase cream
-Oilatum cream
-Aveeno cream
-Cetraben cream
-Epaderm cream

Thick, greasy emollients:

-50:50 ointment (50% liquid paraffin)
-Hydromol ointment
-Diprobase ointment
-Cetraben ointment
-Epaderm ointment

Bathe with aqueous cream (use as soap)

3. topical steroids
   The steroid ladder from weakest to most potent:

a) Mild: Hydrocortisone 0.5%, 1% and 2.5%
b) Moderate: Eumovate (clobetasone butyrate 0.05%)
c) Potent: Betnovate (betamethasone 0.1%)
d) Very potent: Dermovate (clobetasol propionate 0.05%)

-problems: topical steroid withdrawal, eczema herpeticum
-Eczema is infected – pustules, blisters, painful, weeping – antibiotics may be needed.
-Eczema is not going away with regular daily use of topical steroids for more than 2 weeks. Eczema is causing waking
at night, missing school, mood problems. (growth problems: if used long-term, over a large area ie they may be absorbed into systemic circulation)

4. wet wrapping
   -large amounts of emollient (and sometimes topical steroids) applied under wet bandages
5. in severe cases, refer to secondary care: oral ciclosporin may be used
   -Other specialist treatments in severe eczema include zinc impregnated bandages, topical tacrolimus, phototherapy and systemic immunosuppressants, such as oral corticosteroids, methotrexate and azathioprine.

Question 25

eczema herpeticum presentation

Answer 25

A typical presentation is a patient who suffers with eczema that has developed a widespread, painful, vesicular rash (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.)
- systemic symptoms such as fever, lethargy, irritability and reduced oral intake. There will usually be lymphadenopathy (swollen lymph nodes).

Question 26

management of eczema herpeticum:

Answer 26

Viral swabs of the vesicles can be used to confirm the diagnosis, although treatment is usually started based on the clinical appearance.

Treatment is with aciclovir. A mild or moderate case may be treated with oral aciclovir, whereas more severe cases may require IV aciclovir.

-If around eyes, refer to ophthalmologist (same day)
Health education (emergency = rapidly worsening eczema, clustered blisters, punched-out erosions)

Question 27

complications of eczema herpeticum:

Answer 27

Children with eczema herpeticum can be very unwell. When not treated adequately it can be a life threatening condition, particularly in patients that are immunocompromised.

Bacterial superinfection can occur, leading to a more severe illness. This needs treatment with antibiotics.

Question 28

indications for referral with eczema:

Answer 28

1. Immediate –> eczema herpeticum
2. Urgent referral (<2 weeks) –> severe atopic eczema not responded to optimum therapy within 1-week
3. Urgent referral (<2 weeks) –> treatment to bacterially infected eczema has failed
4. Non-urgent referral (>2 weeks) –> diagnosis uncertain, atopic eczema on face not responding, contact allergic dermatitis is suspected, causing significant social and psychological problems or severe recurrent infections

N.B. eczema herpeticum looks similar to impetigo so treat for both empirically with oral/IV ABx (eg flucloxacillin) and oral/IV aciclovir

Question 29

PACES counselling for eczema:

Answer 29

o Explain the diagnosis (characterised by dry, itchy skin)
o Explain that it is very common (1 in 5 kids) , and many children grow out of it
o Explain the management (and use of steroids if necessary)
o Encourage frequent, liberal use of emollients (and as a soap substitute)
o Explain the association with other atopic conditions (hayfever/asthma)
o Advise avoidance of triggers (e.g. types of clothes, detergents, soaps, animals)
o Avoid scratching if possible (keep nails short, use anti-scratch mittens in infants)
o Safety net about signs of infection (oozing, red, fever) or eczema herpeticum
o Information and Support:
 Itchywheezysneezy.co.uk – excellent website demonstrating how to apply emollients
 British Association of Dermatologists (BAD) – has an information leaflet on atopic eczema
 National Eczema Society – has fact sheets

Question 30

what causes hand foot and mouth disease?

Answer 30

Coxsackievirus A16 is a member of the Picornaviridae family

Question 31

management of hand foot and mouth disease:

Answer 31

Diagnosis is made based on the clinical appearance of the rash.

There is no treatment for hand, foot and mouth disease. Management is supportive, with adequate fluid intake and simple analgesia such as paracetamol if required. The rash and illness resolve spontaneously without treatment after a week to 10 days

It is highly contagious and advice should be give about measures to avoid transmission, such as avoiding sharing towels and bedding, washing hands and careful handling of dirty nappies.

Question 32

complications of hand foot and mouth disease:

Answer 32

Rarely it can cause complications:

Dehydration
Bacterial superinfection
Encephalitis

Question 33

Incubation/presentation of hand foot and mouth disease:

Answer 33

Incubation 3-5 days

-The illness starts with 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. As the name suggests, 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.

Question 34

How would you describe this?

Answer 34

1. Raised papules
2. Central dimpling of lesions

Question 35

what organism causes molluscum contagiosum?

Answer 35

Molluscum contagiosum is caused by a DNA pox virus, specifically a member of the Poxviridae family. It occurs most often in children and is very common.

Question 36

management of molluscum contagiousum:

Answer 36

1st line: Reassurance: The condition lasts around a year and then spontaneously resolves usually without any scarring.

Rarely, if bacterial superinfection infection occurs in the lesions as a result of scratching, this may require treatment with antibiotics. Options include topical fuscidic acid or oral flucloxacillin.

Immunocompromised patients and those with very extensive lesions or lesions in problematic areas such as the eyelid or anogenital area may require referral to a specialist. Specialist treatment options include:

Topical potassium hydroxide, benzoyl peroxide, podophyllotoxin, imiquimod or tretinoin
Surgical removal and cryotherapy (freezing with liquid nitrogen) is an option but can lead to scarring