Flashcards in Derm/ENT/Opthalm | Deck (75):
At what age do children usually present with atopic eczema?
What age is it uncommon in?
1st year of life
Uncommon in first 2 months of life
What is the pathogenesis of eczema?
Uncertain - Enhanced antigen penetration with a genetic defect in skin barrier function
Positive family history is present
What are possible exacerbating factors of eczema (5)?
2. Allergens (chemicals, food, dust)
5. Severe stress
What would you check for in the family history for a child with eczema (3)?
Family Hx of atopic disorders:
3. Allergic rhinitis
What are the clinical features of eczema (4)?
1. Itchy rash - pruritis is the main symptoms at all ages, resulting in scratching and exacerbation of rash
2. Excoriated areas become erythematous, weeping and crusted
3. Dry skin
4. Scratching and rubbing of skin can lead to lichenification
What are the ddx for an itchy rash (8)?
1. Atopic eczema
3. Urticaria/allergic reactions
4. Contact dermatitis
5. Insect bites
7. Fungal infections
8. Pityriasis rosea
What is the stepwise management of eczema (6)?
1. Regular emollients
2. Topical corticosteroids
3. Wet wraps/specialised clothing
5. Systemic therapy
6. Also avoid exacerbating factors
What is the main defining feature of eczema?
What investigations should be done in eczema (3)?
1. Investigations to exclude ddx
2. Identify triggers
3. Consider screening by skin prick or IgE blood test
What are the different severities of eczema (5)?
1. Clear - no eczema
2. Mild - areas of dry skin and infrequent itching (with or without small areas of redness)
3. Moderate - areas of dry skin, frequent itching and redness (with or withoutexcoriation and localised skin thickening
4. Severe - widespread areas of dry skin, incessant itching and redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking and alteration of pigmentation)
5. Infected - if eczema is weeping, crusted, or there are pustules with fever or malaise.
What is the management for mild eczema (3)?
1. Generous amounts of emollient
2. Consider a mild topical steroid e.g. hydrocortisone 1% for areas of red skin
3. Avoid triggers
What is the management for moderate eczema (5)?
1. Generous amounts of emollients
2. If skin is inflamed, prescribe moderately potent topical steroid e.g. Eumovate
3. Prescribe mild potency corticosteroid for delicate areas of skin
4. Avoid triggers
5. Consider mittens for young infants to stop scratching at night
What is the management for severe eczema (9)?
1. Generous amounts of emollients
2. Potent topical steroid e.g. Betnovate
3. Mild-moderate potency steroid for delicate areas
4. Dry bandages may help
5. Consider oral corticosteroid
6. If severe itching, consider antihistamine e.g. cetirizine
7. Avoid triggers
8. Consider mittens
9. May need psychological support if causing distress
What would you advise parents of children with eczema with regards to avoiding irritants and precipitants (3)?
1. Stop soap and biological detergents
2. Clothing next to skin should be pure cotton, avoiding nylon and pure woolen garments
3. Nails need to be cut short to reduce skin damage from scratching, mittens at night
How would you advise the parent of a child with eczema to use an emollient (3)?
1. Apply liberally 2 or more times a day and after a bath to moisturise and soften skin.
2. Ointments are preferable to creams when skin is very dry
3. A daily or alternate day bath using emollient oil as a soap substitute can help
How do you treat infected eczema?
Mild infection - Topical Abx with hydrocortisone
Widespread or severe infection - systemic Abx
How would you advise the parent of a child with eczema to use topical corticosteroids (3)?
1. Mildly potent topical steroids can be applied to eczema areas once or twice daily
2. Moderately potent topical steroids should be used in acute exacerbations but use should be kept to a minimum
3. Mod potency steroids -
apply cream thinly and use on face should be generally avoided due to side effects of skin thinning
What must you check/ask parents if a child does not seem to be responding to treatment for eczema?
Check they are using the creams - how often are you applying it? How long does it take to get through one tube of cream?
How does herpes manifest cutaneously (3)?
1. Core sores - recurrent lesions on gingival/lip margin in the same place
2. Eczema herpeticum - Widespread vesicular lesions develop on eczematous skin
3. Herpetic whitlows - painful erythematous, oedematous white pustules on the site of broken skin, especially fingers
What is the first line treatment for herpes?
What is impetigo? What is it caused by?
A localised, high contagious, staphylococcal or streptococcal skin infection
Which group of people are most susceptible to impetigo?
Infants and young children
What is a risk factor for impetigo?
Having a pre-existing skin disease e.g.eczema
Where are impetigo lesions usually found (3)?
Describe the lesions present with impetigo (3)
1. Begin as erythematous macules that may become vesicular/pustular or even bullous
2. Rupture of the vesicles with exudation of fluid leads to confluent honey-coloured crusted lesions
3. Infection is readily spread to adjacent areas by autoinoculation of the infected exudate
How are different severities of impetigo managed?
Mild: Topical Abx e.g. mupirocin
Moderate-severe: Flucloxacillin or co-amoxiclav
What advice would you give to parents of children with impetigo?
Avoid nursery/school until lesions are dry
What is Staphylococcal scalded skin syndrome (SSSS)? What is its cause?
Caused by an exfoliative staphlococcal toxin which causes separation of the epideral skin through the granular cell layers
Which age group are more commonly affected by SSSS?
Infants and young children
What are the clinical features of SSSS (6)?
3. Purulent, crusting and localised infection around the eyes, nose and mouth
4. Widespread erythema and tenderness of skin
5. Areas of epidermis separate on gentle pressure - Nikolsky sign, leaving denuded areas of skin
6. Subsequently they dry and heal, generally without scarring
How is SSSS managed (3)?
1. IV antistaphlococcal abx e.g. flucloxacillin
3. Monitoring of hydration and fluid balance
How does urticaria present (2)?
Hives or redness
What is the pathophysiology of urticaria?
Activation of mast cells which release histamine causing itchiness.
Also leads to local vasodilation and increased permeability of capillaries and venules
What are some causes of acute urticaria (2)? How long does the rash last with each type?
1. Viral infection (rash lasts a few days)
2. Allergen exposure (rash lasts for hours)
when does urticaria lead to angioedema? Where does angioedema usually occur?
When urticaria involves deeper tissues to produce swelling
Lips and soft tissues around eyes
What is complication associated with allergy, especially food allergy?
How is urticaria treated?
What are the clinical features of a primary varicella rash (5)?
1. 50-500 lesions start on head and trunk, progressing to peripheries
2. Appear as crops of papules, vesicles with surrounding erythema and pustules at different times for up to 1 week
3. Lesions may occur on the palate
4. Itchy and scratching can lead to a permanent, depigmented scar formation or secondary infection
5. New lesions appearing beyond 10 days suggest defective cellular immunity
What are the clinical features of a secondary varicella rash?
Vesicular eruption in the dermatomal distribution of sensory nerves, most commonly on the thoracic region
What is the pathophysiology of acne (4)?
1. 1-2 years before onset of puberty, increased androgenic stimulation of the sebaceous glands occur
2. Increased sebum excretion rate also occurs
3. Obstruction to the flow of sebum in the sebaceous follicle initiates the process of acne
4. Inflammation is also present
What are the different lesions present in acne (6)?
1. Open comodones - blackheads
2. Closed comodones - whiteheads
These progress to:
What is the 1st line treatment for acne?
Usually: Benzoyl peroxide
OR topical Abx/retinoids
What yeast infection normally complicates nappy rash?
What are the clinical features of a nappy rash infected with candida (3)?
2. Affects skin flexures
3. May be satellite lesions
What is the treatment of nappy rash infected with candida?
Topical antifungal agent
What are the features of the rash of erythema multiforme?
Target lesions with a central papule surrounded by an erythematous ring
Lesions can be vesicular or bullous
What are some causes of erythema multiforme (5)?
1. Herpes simplex
2. Mycoplasma pneumoniae infection
3. Other infections
4. Drug reaction
What are the features of the rash of erythema nodosum?
What are some possible non-cutaneous manifestations (2)?
Tender nodules over the legs
What are some causes of erythema nodosum (5)?
1. Streptococcal infection
2. Primary tuberculosis
4. Drug reaction
What type of skin infection does 'ringworm' describe?
Fungal infections with dermatophyte fungi, which invade dead keratinous structures, such as the horny layer of the skin, nails and hair
What does the term 'ringworm' describe?
The ringed (annular) appearance of skin lesions caused by fungal infections.
What is a kerion?
A severe inflammatory pustular ringworm patch
What are the clinical features of tinea capitis?
Scaling and patchy alopecia with broken hairs
What is the 1st line treatment of fungal infections?
Topical antifungal preparations
What is pediculosis capitis?
Head lice infestation
How does pediculosis capitis present (4)?
1. Itching of scalp or nape
2. Identifying live head lice on scalp
3. Identifying nits (empty egg cases) on hairs
4. Suboccipital lymphadenopathy
What is the medical and non-medical treatment for head lice (2)?
1. Demeticone 4% lotion or an aq solution of malathion 0.5% is rubbed onto hair and scalp, and left overnight and hair shampooed following morning. Repeated a week later
2. Wet-combing with a fine-tooth comb to remove live lice every 3-4 days for at least 2 weeks
What is the most common type of psoriasis present in children?
What is a common trigger for guttate psoriasis?
Streptococcal or viral sore throat or ear infection
What are the clinical features of guttate psoriasis rashes (2)?
1. Small, raindrop-like
2. Round or oval erythematous scaly patches on the trunk and upper limbs
How long does an attack of guttate psoriasis usually last for?
What is the treatment for guttate psoriasis?
What is the treatment for plaque psoriasis (2)?
1. Coal tar preparations
2. Calcipotriol. a Vit D analogue
What is scabies caused by?
Infestation with the eight-legged mite 'Sarcoptes scabiei' which burrows down the epidermis along the stratum corneum
What are the clinical features of scabies (5)?
1. Severe itching 2-6 weeks after infestation
2. Itching worse in warm conditions and at night
3. Papular (pimple-like) itch
4. Burrows in the skin - pathognomonic
Where is the scabies rash usually distributed (4)?
1. Skin between fingers and toes, axillae
2. Flexor aspects of the wrists, belt line
3. Around nipples, penis and buttocks
4. Palms, soles and trunk in young infants/children
What is a helpful indicator of scabies in the history?
Itching in other family members
What is the treatment for scabies (3)?
Whole family should be treated, whether or not there is evidence of manifestation
1. Permethrin cream 5% applied below neck to all areas and washed off after 8-12 hours.
2. Benzyl benzoate emulsion (25%) applied below the neck only left on for 12 hours
3. Malathion lotion (0.5% aq) below neck and left on for 12 hours
What is the infantile seborrhoeic dermatitis/cradle cap?
Seborrhoeic dermatitis is a papulosquamous disorder affecting the areas with most sebum, such as the scalp, face, and trunk. This is thought to be due to a reaction to the yeast Malassezia spp
What age does cradle cap usually present at?
In the first 3 months of life
What are the clinical features of cradle cap (4)?
1. Starts on scalp as an erythematous scaly eruption
2. Scales form a thick yellow adherent layer - cradle cap
3. Scaly rash may spread to the face, behind ears and extends to flexure and napkin area.
4. Not itchy, and child is not affected by it
What is the risk of cradle cap?
Increased risk of developing atopic eczema
What is the treatment for cradle cap (3)?
1. Mild cases - emollients
2. Scales on the scalp - Ointment containing low-conc sulphur and salicylic acid applied to the scalp daily for a few hours and washed off
3. Widespread body eruption - mild topical corticosteroid either alone or mixed with an antibacterial and antifungal agent
What are the clinical features of viral warts (2)?
1. Usually on fingers and soles (verrucas)
2. Typically small, rough, and hard growths that are similar in color to the rest of the skin