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Flashcards in Child with a rash Deck (49):
1

Presentation of eczema

Rash - erythema, wet weeping areas, dry scaly, thickened skin.
Commonly on flexor surface.
Intense itch
Linked to food and environmental allergens in some cases. And other atopic problems.
Onset commonly at 12m
Pattern of remitting and relapsing course

2

Diagnostic criteria for eczema

Must have itch plus 3 or more of the following
- History of involvement in skin creases
- PmHx of asthma or hayfever or FmHx of atopic disease in 1st degree relative if child is under 4yr
- Hx of dry skin n the last year
- onset under the age of 2 yr (not used if under 4yr)
- visible flexural eczema

3

Tx for eczema

Most children grow out of it by 5 yrs
Prevention - Every day treatment and avoid trigger. Trigger - heat, prickly.rough material, Dry skin. Regular moisturiser top to toe, daily cool bath with bath oil, don't rinse. Consider Vit D oral supplements
Flare up - Topical steroids/anti inflammatory eg hydrocortisone for face and stronger for the body, tar cream for lichenifcation, Tx 2rd infections. Wet dressings eg Tubifast. Depending on severity it could be 2-3 times a day. Cool compressing to relieve itch.
Complete an eczema Tx plan
Follow up with GP or outpatient

4

Area of distribution of eczema rash

Infant - CHeecks, trunk, extremities - extensor areas
Child - Antecubital and popliteal foesea - flexors and neck
Older children - Neck, flexors, hands and feet

5

Presentation of measles

Morbilliform rash - starts at hairline and moves down then become confluence.
Fever
Cough or coryza or conjunctivitis or Koplicks spots
Onset 10-14 days after exposure
Transmission is airborne from day 1 to prodrome to 4 days post rash onset

6

Ix Measles

IgM at time of rash onset
PCR of viral culture of throat swab or Koplik spots

7

Tx of measles

Vaccination at 12m, 18m and 4yr?
Symptoms relief
Exclude from school for 5 day from the appearance of the rash.
Contacts vaccinated within 72hrs from exposure if immunised and older than 9m.
If greater then 72 HR then immunoglobulin IM within 7days

8

Cx of measles

Otitis media
Pneumonia
Encephalitis
Subacute sclerosing panencephalitis

9

Presentation of varicella zoster

Onset 14-17 days after exposure
Pattern - fever than rash (macule, vesicles, crusting) may have mucosal involvement eg mouth and genitalia
Short prodrome of fever, lethargy, anorexia
Rash 3-5 days
Crusted over by 10 days
On scalp, face, trunk, mouth and conjunctiva

10

Cx of varicella

Pneumonia
Secondary infection
Encephalitis

11

Mx of varicella

Symptom relief
Excursion Infections from 1-2 days before rash to when lesion crest over

12

What are the concerns with varicella and pregnancy

Cx
Mother - pneumonia,
Fetal - limb hypoplasia, microcephaly, cortical atrophy, cataracts, psychomotor retardation, convulsions, IUGR
At risk if infection 7 days prior to 7 days after birth.
Ix - Materal anti-VZV, Ig G and IgM
Tx with VZV immunoglobulin IM within 96hrs of exposure
If severe infection acyclovir every 8 HR to mum.
Infected infant needs VZIG and acyclovir.

13

Presentation of rubella

Onset 14-21 days after exposure
Pale morbiliform rash moves down body

14

Cx and Tx of Rubella

Cx - pregnancy is severe fetal anomalies if mother infected in first trimester. Congenital rubella syndrome:Cataract, deafness, heart, IUGR, thrombocytopenia, Hepatosplenomegaly and vasculitis, Renal artery stenosis.
Ix - serology prior and during pregnancy
Tx - Symptom relief,

15

Presentation for fifth disease

Mild illness with low grad fever
Slapped check appearance
Rash maculepapular rash: proximal extensor surfaces, flexor surfaces and trunk, then fades over next few days then central clearing then reticular pattern after 7 days.
Last up to 6 weeks.

16

Ix, Cx and Tx for fifth disease

PCR on blood and serology but Dx clinical
Cx - arthritis, aplastic crisis, bone marrow suppression, foetal Hydrops in newborns.
Tx - symptomatic, blood transfusion if sever haemolytic anaemia or Utero Hydrops.
No exclusion as it is non infective after rash appears.

17

Presentation of scabies

Intense itchy
Papular eruption several millimetres in length
Seen on palms, soles, axilla, umbillicus, frown and genitalia is common
Head is usually spared.
Onset 2-6weeks after exposure or 1-4 days after reexposure

18

Mx for scabies

Permethrin 5% cream - apply everywhere and leave on for 8 HR
Oval ivermectin
Tx all family member
Wash linen, clothes etc.
Itch take a few weeks to resolve.
Notify contact eg school etc..

19

Types of nappy rash

Irritant dermatitis
Candida nappy rash
Seborrhoeic nappy rash
Psoriatic nappy rash.

20

Irritant dermatitis

Cause - irritation from excretions and chemical
Factors that contribute
- Excess skin hydration - water in Raine and stool, nappy change frequency
- Skin trauma - friction between nappy and skin
- Irritants - ammonia, faeces, soap and detergent reside,
- Candidiasis.
Features - erythema tours or papulovesicular lesion, fissures and erosions. Skin folds are spared.

21

Tx of nappy rash

Regular washing and changing, exposure to air and use of protective creams
Use disposable nappies
Frequent nappy changing
Nappy free time

22

seborrhoaic nappy rash

Pick greasy lesion with yellow scale
Often in skin folds
Non itchy
Cradle cap may be present
Tx with hydrocortisone 1% with nystatin or ketoconazole

23

Presentation of candida nappy rash

Bright red rash with clearly demarcated edge
Satellite lesion beyoud border
Inguinal folds usually involved
May or may not have oral thrush.
Tx with nystatin cream and orally if necessary

24

Presentation of psoriatic nappy rash

FmHx of psoriasis
Pick, greasy lesion with yellow scale other in skin folds
Similar to seborrhoea dermatitis
Other plaques commonly seen extensor surfaces, generalised small lesions.
Nail changes seen in early childhood.
Tx - Tar preparation and 1% hydrocortisone

25

Common transient neonatal rashes

Erythema toxic us neonatorum
Milia
Miliaria

26

Pigmentation disorders

Pigmented naves
Cafe au lait
Depigmentation

27

Vascular birthmark

Capillary haemangioma
Capillary malformation
Mongolian blue spots

28

Infectious causes of rash

Staph scalded skin syndrome
Meningococcal
Chickenpox
Measles
Scarlet fever
Rubella
Fifth disease
Molluscum contagiosum
Tina corporis
Cold sore
Common wart
Impetigo
Scabies
head lice

29

Common inflammatory condition that cause rash

Atopic dermatitis/eczema
Seborrhoaic dermatitis
Contact dermatitis
Psoriasis
Acne
Urticaria
He notch-Schonlein purport
Kawasaki diseas

30

Q to ask on Hx for a child with a rash

Is the child Ill or febrile?
how long has the rash or skin lesion bee present
Could it be an insect bite or allergic reaction
Is it a recurrent problem
Is it itchy
Has there been contact with anyone else with a rash

31

Way to describe a rash

Describe the rash in the following term
- Raised or flat
- crusty or scaly
- Colour
- Blanching on application of pressure
- Size of the lesions
- Distribution - discrete or generalised or limited to certain sites on the body

32

Rash of meningococcaemia

Starts as a macular papular rash that disappears after 12-24 HR then the patient worsens
Non blanching rash.

33

Presentation of idiopathic thrombocytopenia purpura

Acquired thrombocytopenia due to shortened PLT survival
Immune mediated
2-10 yrs
Bruising and petechiae. Oral bleeding, epistaxis, rectal bleeding, or haematuria.
Recent Hx of virus
Previously well child.

34

Tx of Idiopathic thrombocytopenia purpura

PLT resolve generally in 3-6m
Tx
- steroids and IVIG to increase PLT count but doesn't change the natural history of disease.
May not Tx in milder condition.
Avoid contact sports and rough activity
Avoid aspirin and NSAIDs
Relapse occur with viral infections in the year after Dx.
Chronic refer to specialist - paediatric haematologist

35

Henoch-Schonlein purpura

Onset 2-8yr
Presents with 1 or more of the following
- evolving crops of palpable purpura - predominantly butt and legs
- abdominal pain (occasionally Malaena) may precede rash
- Lg joint migratory arthritis of variable duration and severity
- Nephritis
- other eg oedema dorsum of the feet and hands, acute scrotal swelling and bruising, fever and fatigue
Exclude other causes
Ix - FBC, urinalysis - Haematuria, proteinuria, U and E
Mx - Supportive with bed rest and analgesia. Corticosteroids reduces duration of abdominal pain,
Refer if renal dysfunction, hypertension or surgical complication develop.

36

Scarlet fever

PRodrome - sudden onset of high fever, vomiting malaise, headache and abdominal pain.
Erythema out rash - blanching, diffuse, involving torso and skin folds
Sand paper like skin
Pale around lips
Strawberry tongue, pharyngotonsillitis
Inflamed tongue, strawberry appearance.
Cx - glomerulonephritis, rheumatic heart disease, otitis media, retropharyngeal abscess, quinsy, meningitis.
Dx with throat swab
Tx - penicillin. Exclude from school until treated for 24 hrs
DDX - Kawasaki disease, strept or staph toxic shock syndrome, viral infection.

37

Impetigo

Group A strep or staph
Areas of ooze and honey coloured crusts on face, trunk or limbs
Can be bullous. Round and well demarcated, grouped and asymmetrical. Can be solitary and widespread.
Rapid onset
Mx
- bathe off crust
- Topical mupirocin 2% every 8 hours or flucoxacillin orally
- Isolation until lesion covered or treated.
- Treat any underlying condition
-

38

Kawasaki criteria

Fever for 5 days or more plus 4/5 of the following
- Polymorphous rash - macular erythema tours rash
- bilateral (non purulent) conjunctival injection
- Mucous membrane changes eg reddened or dry cracked lips, strawberry tongue, diffuse redness of oral or pharyngeal mucosa
- Peripheral changes eg erythema of palms or soles, oedema of the hands or feet, and in convalescence desquamation
- Cervical lymphadenopathy greater then 15mm, usually unilateral, single, non purulent and painful.
Need to exclude the following
- staphylococcal infection eg SSS, toxic shock syndrome
- Streptococcal eg scarlet fever, toxic shock like syndrome not just isolation from throat.
- Measles
- Other viral exam theme
- Steven's Johnson Syndrome
- Drug reaction
- Juvenile rheumatoid arthritis
Other features
- Arthritis
- Diarrhoea
- vomiting
- coryza
- cough uveitis
- Gall bladder hydrous

39

Cx of Kawasaki's

Coronary artery aneurysms

40

Ix for Kawasaki's

ASOT/Anti DNAase B
Echocardiography at initial presentation and at 6-8 weeks
PLT count - marked thrombocytosis in 2rd week.
Raised ESR and CRP
Neutrophilia
Mild normochromic, normalcytic anaemia
Raised transaminases
Hypoalbuminaemia

41

Tx for Kawasaki

Admit
IV Immunoglobulin over 10 hrs in the first 10 days
Aspirin 3-5mg/kg daily for 6-8 weeks
Follow up - echo at 6-8wks

42

DDX for nappy rash

Seborrhoaic dermatitis - Non-itchy salmon pink flaky patches may appear on the face, trains and limbs and involves skin folds
Atopic dermatitis
Psoriasis - sharply demarcated, non scaly, bright erythema tours plagues either isolated or similar lesion in other intertriginous areas such as the axilla etc.
Perinatal streptococcal cellulitis - localised well-demarcated erythema that covers a circular area 1-2 cm radius around the anus with fissuring the macerated skin. Can present with painful defecation and or constipation.
Zinc deficiency - sharply defined, red, often extensive, anogenital rash. Look for period all, perinatal and a real (hand and foot) dermatitis, alopecia, diarrhoea, and failure to thrive.
Threadworms - in older children, threadworms are common cause of itchy anogenital rash. Look for worms at night and Tx with oral mebendazole.
Langerhan's cell histiocytosis - chronic inguinal or anogenital rash, with brownish/red scale and petechiae which is often erosive and unresponsive to Tx. A scaly Paula's, eruption of the scalp or trunk may appear. Purpura, fever diarrhoea or Hepatosplenomegaly may be present.
malabsorption syndrome - Malabsorption from any cause eg CF can present with diarrhoea, erosive dermatitis and failure to thrive. There may be progressive intractable napkin rash contribute to both by the diarrhoea and by secondary nutritional deficiencies
Crohn's disease

43

DDX for petechiae/purpura with fever

Viral infection eg enterovirus and influenza
Neisseria meningitis
Bacteremia eg strep pneumoniae and Haemophilus influenza
Henoch Schonlein purpura, ITP and Leukaemia
Illness of vomiting or coughing causing petechiae around head and neck.
All should be review by a registrar or consultant.

44

Indicators of meningococcal disease in a unwell child with fever and petechiae.

The unwell child
Purpura greater than 2mm unless clinical picture suggests HSP
Abnormal blood indices eg abnormal level of WCC and CRP

45

Signs of an unwell child

Abnormal vital signs - Tachycardia, tachypnea or desaturation, increase systolic to diastolic difference in BP
Poor peripheral perfusion - cold extremities, prolonged capillary refill
Altered conscious state - Irritability, lethargy

46

Purpura in well child

Greater than 2mm may be an indicator of meningococcal disease.
If clinical picture suggestive of HSP eg purpura on the lower limbs and buttocks in a well child, with or without arthritis or abdo pain.
treat as HSP

47

Petechiae in well children due to mechanical causes

Clear cause does not require Ix and can be discharged with review in 12-24hr
Mechanical causes
- coughing or vomiting leading to petechiae around head and neck
- Local physical pressure such as a tight tourniquet or being hel tightly for procedures. If doubt to cause manage as unknown cause.

48

Petechiae in well children not due to mechanical causes

If fever and petechiae with no mechanical cause need blood tests to exclude ITP and leukaemia
Children with all of the following features fave a very low risk of meningococcal disease and may be discharged after 4 hrs of observation if
- well
- WCC normal
CRP less then 8
No deterioration n clinical state or progression of the rash over 4 HR

49

Presentation of urticaria

Pruritic elevated skin lesion surrounded by erythema base commonly called hives.
Need t observe for dyspnoea or dysphasia for the first few hours
DDX - erythema multiforme which isn't itchy, target legion, does not move around. Mastocytosis, flushing. Juvenile Rheumatoid arthritis, vasculitis eg HSP, Pityriasis rosea
Mx - cool compress, explanation, and reassurance. Anti histamine eg phenergan.