Childhood Rashes Flashcards
What is eczema?
Eczema is a chronic atopic condition caused by defects in the normal continuity of the skin barrier, leading to inflammation in the skin. There is a genetic component to eczema and it tends to run in families, however there is no single inheritance pattern. It has significant variation in the severity of the condition. Some patients can have very occasional mild patches that respond well to emollients, where others have large areas of skin that are severely affected and require strong topical steroids or systemic treatments.
How does eczema normally present?
Eczema usually presents in infancy with dry, red, itchy and sore patches of skin over the flexor surfaces (the inside of elbows and knees) and on the face and neck. Patients with eczema experience periods where the condition is well controlled and periods where the eczema is more problematic, known as flares.
What is the pathophysiology?
The simplified pathophysiology is that eczema is caused by defects in the barrier that the skin provides. Tiny gaps in the skin barrier provide an entrance for irritants, microbes and allergens that create an immune response, resulting in inflammation and the associated symptoms.
How can eczema be managed?
Management can be thought of as maintenance and management of flares, similar to the management of chronic and acute asthma.
The key to maintenance is to create an artificial barrier over the skin to compensate for the defective skin barrier. This is done using emollients that are as thick and greasy as tolerated, used as often as possible, particularly after washing and before bed. Patients should avoid activities that break down the skin barrier, such as bathing in hot water, scratching or scrubbing their skin and using soaps and body washes that remove the natural oils in the skin. Emollients or specifically designed soap substitutes can be used instead of soap and body washes when showering or washing hands.
Some patients find certain environmental factors play a role in making their eczema symptoms worse or better. For example, it may completely resolve on holiday in warm, humid countries, only to flare on returning to the cold air in the UK. Environmental triggers, such as changes in temperature, certain dietary products, washing powders, cleaning products and emotional events or stresses can also play a role.
Flares can be treated with thicker emollients, topical steroids, “wet wraps” (covering affected areas in a thick emollient and applying a wrap to keep moisture locked in overnight) and treating any complications such as bacterial or viral infections. Very rarely IV antibiotics or oral steroids might be required in very severe flares.
Other specialist treatments in severe eczema include zinc impregnated bandages, topical tacrolimus, phototherapy and systemic immunosuppressants, such as oral corticosteroids, methotrexate and azathioprine.
Which choices are available in terms of emollients?
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
Which options are available when it comes to topical steroids for eczema?
The general rule is to use the weakest steroid for the shortest period required to get the skin under control. Steroids are very good for settling down the immune activity in the skin and reducing inflammation, but they do come with side effects. They can lead to thinning of the skin, which in turn make the skin more prone to flares, bruising, tearing, stretch marks and enlarged blood vessels under the surface of the skin called telangiectasia. Depending on the location and strength of the steroid there may be some systemic absorption of the steroid. The risks of using steroids need to be balanced against the risk of poorly controlled eczema.
The thicker the skin, the stronger the steroid required. Only weak steroids used very cautiously should be applied to areas of thin skin such as the face, around the eyes and in the genital region. It is best to completely avoid steroids in these areas in children.
The steroid ladder from weakest to most potent:
Mild: Hydrocortisone 0.5%, 1% and 2.5%
Moderate: Eumovate (clobetasone butyrate 0.05%)
Potent: Betnovate (betamethasone 0.1%)
Very potent: Dermovate (clobetasol propionate 0.05%)
How is bacterial infection of eczema managed?
Opportunistic bacterial infection of the skin is common in eczema. The breakdown in the skin’s protective barrier allows an entry point for infective organisms. The most common organism is staphylococcus aureus. Treatment is with oral antibiotics, particularly flucloxacillin. More severe cases may require admission and intravenous antibiotics.
What is eczema herpeticum?
Eczema herpeticum is a viral skin infection in patients with eczema caused by the herpes simplex virus (HSV) or varicella zoster virus (VZV). Patients can be very unwell.
How does eczema herpeticum present?
A typical presentation is a patient who suffers with eczema that has developed a widespread, painful, vesicular rash with systemic symptoms such as fever, lethargy, irritability and reduced oral intake. There will usually be lymphadenopathy (swollen lymph nodes).
What is psoriasis?
Psoriasis is a chronic autoimmune condition that causes recurrent symptoms of psoriatic skin lesions. There is a large variation in how severely patients are affected with psoriasis. There appears to be a genetic component but no clear genetic inheritance has been established. Around a third of patients have a first degree relative with psoriasis. The symptoms start in childhood in a third of patients.
How does psoriasis normally present?
Patches of psoriasis are dry, flaky, scaly, faintly erythematous skin lesions that appear in raised and rough plaques, commonly over the extensor surfaces of the elbows and knees and on the scalp. These skin changes are caused by the rapid generation of new skin cells, resulting in an abnormal buildup and thickening of the skin in those areas
What types of psoriasis are there?
Plaque psoriasis features the thickened erythematous plaques with silver scales, commonly seen on the extensor surfaces and scalp. The plaques are 1cm – 10cm in diameter. This is the most common form of psoriasis in adults.
Guttate psoriasis is the second most common form of psoriasis and commonly occurs in children. It presents with many small raised papules across the trunk and limbs. The papules are mildly erythematous and can be slightly scaly. Over time the papules in guttate psoriasis can turn into plaques. Guttate psoriasis is often triggered by a streptococcal throat infection, stress or medications. It often resolves spontaneously within 3 – 4 months.
Pustular psoriasis is a rare severe form of psoriasis where pustules form under areas of erythematous skin. The pus in these areas is not infectious. Patients can be systemically unwell. It should be treated as a medical emergency and patients with pustular psoriasis initially require admission to hospital.
Erythrodermic psoriasis is a rare severe form of psoriasis with extensive erythematous inflamed areas covering most of the surface area of the skin. The skin comes away in large patches (exfoliation) resulting in raw exposed areas. It should be treated as a medical emergency and patients require admission.
How does psoriasis present? Which specific signs are suggestive of psoriasis?
In children the distribution and presentation of psoriasis may differ from adults. Guttate psoriasis is more common in children, often triggered by a throat infection. Plaques of psoriasis are likely to be smaller, softer and less prominent.
There are a few specific signs suggestive of psoriasis:
Auspitz sign refers to small points of bleeding when plaques are scraped off
Koebner phenomenon refers to the development of psoriatic lesions to areas of skin affected by trauma
Residual pigmentation of the skin after the lesions resolve
The diagnosis can be made based on the clinical appearance of the lesions.
How is psoriasis managed?
Management depends on the severity of the condition. Psoriasis in children is usually managed and followed up by a specialist. It can be difficult to treat and psychosocial support is very important. The treatment options include:
Topical steroids
Topical vitamin D analogues (calcipotriol)
Topical dithranol
Topical calcineurin inhibitors (tacrolimus) are usually only used in adults
Phototherapy with narrow band ultraviolet B light is particularly useful in extensive guttate psoriasis
Rarely, where topical treatments fail with severe and difficult to control psoriasis, children may be started on unlicensed systemic treatment under the guidance of an experienced specialist. This might include methotrexate, cyclosporine, retinoids or biologic medications.
There are two products that contain both a potent steroid and vitamin D analogue that are commonly prescribed and worth being aware of. These not licensed in children and will be guided by a specialist.
Dovobet
Enstilar
What are some other symptoms associated with psoriasis?
Nail psoriasis describes the nail changes that can occur in patients with psoriasis. These include nail pitting, thickening, discolouration, ridging and onycholysis (separation of the nail from the nail bed).
Psoriatic arthritis occurs in 10 – 20% of patients with psoriasis and usually occurs within 10 years of developing the skin changes. It typically affects people in middle age but can occur at any age.
Psychosocial implications of having chronic skin lesions, which may affect mood, self esteem and social acceptance and cause depression and anxiety.
Other co-morbidities that increase the risk of cardiovascular disease are associated with psoriasis, particularly obesity, hyperlipidaemia, hypertension and type 2 diabetes.
