Dermatology Flashcards

Question

How should we treat mild eczema?

Answer 1

* Swab the affected area * Advise about maintaining good hygiene when using emollients and other creams (e.g. using a spatula, not leaving it open) * **1st line: Flucloxacillin** (oral if extensive, topical if local) * Penicillin allergy: erythromycin (alternative: clarithromycin) * Use antibiotics for no longer than 2 weeks * Recurrent infections: antiseptics (e.g. chlorhexidine) can be used to decrease bacterial load (do not use in long-term) * Eczema Herpeticum * Oral aciclovir * If widespread, start aciclovir immediately and refer for same-day dermatological advice * If around the eyes, refer for same-day ophthalmological and dermatological specialist review * Provide parents and children advice on how to identify eczema herpeticum (rapidly worsening painful eczema, clustered blisters, punched-out erosions)

Answer 2

Use emollients in large amounts and often **Examples**: e45, cetraben, diprobase, aveeno Emollients should be applied on the whole body Emollients should be used as a soap substitute (also instead of shampoo or use unperfumed shampoos)

Answer 3

* Use once or twice daily (duration can vary from 3-14 days depending on how long the skin takes to respond) * Only apply to areas of active eczema * Do not use potent corticosteroids in children \< 12 months without specialist advice For areas prone to flares, consider using topical corticosteroids for 2 consecutive days per week to prevent flares (review after 3-6 months) * If a topical corticosteroid is deemed ineffective, consider using a different type of steroid of a similar potency before increasing the potency * Mild Potency for Mild Eczema: hydrocortisone 1% * **Moderate Potency for Moderate Eczema**: betamethasone valerate 0.025% or * clobetasone butyrate 0.05% * **Potent for Severe Eczema**: betamethasone valerate 0.1%, mometasone * If very severe and extensive: consider oral steroids

Answer 4

* IMMUNOMODULATOR * Topical tacrolimus may be considered as 2nd line treatment of moderate to severe eczema in children \> 2 years that has not been controlled with steroids * Alternative: pimecrolimus * This should only be applied to areas with active eczema * Do not use under occlusive bandages

Answer 5

Can be used with emollients for areas of chronic lichenified skin Can be used for short-term flares (7-14 days) Whole-body occlusive dressings may be used by specialists

Answer 6

Eczema herpeticum (immediate referral) Urgent referral (2 weeks) if severe atopic eczema has not responded to optimum therapy within 1 week or treatment to bacterially infected eczema has failed Refer if diagnosis is uncertain, atopic eczema on the face is not responding, contact allergic dermatitis is suspected, causing significant social and psychological problems or severe recurrent infections

Answer 7

**Strawberry naevi (haemangioma)**: will often rapidly increase in size in first few months then slowly spontaneously resolve leaving almost no mark. A haemangioma is a collection of small blood vessels that form a lump under the skin. They’re sometimes called ‘strawberry marks’ because the surface of a haemangioma can look like the surface of a strawberry.

Answer 8

A haemangioma.

Answer 9

They are more common in: * girls * premature babies * low birth weight babies * multiple births (twins, triplets and quadruplets). Haemangiomas aren’t inherited, but families often say a relative had a haemangioma in childhood, because they’re very common.

Answer 10

**_Superficial haemangiomas_** * are usually a raised, bright red area of skin * feel quite warm because the abnormal blood vessels are close to the surface * might at first appear as a small area of pale skin on which a red spot develops **_Deep haemangiomas_** * might look bluish in colour because the abnormal blood vessels are deeper in the skin * aren’t always noticeable for the first few weeks, only appearing as a lump Haemangiomas don’t usually develop until a few days or weeks after a baby is born, but often grow rapidly in the first three months. It’s unusual for haemangiomas to grow after six to 10 months of age, when most of them tend to have a ‘rest period’ and start to shrink. Most haemangiomas appear on the head or neck – mainly on the cheek, lips, or upper eyelids – but they can develop anywhere on the body. Some children have multiple haemangiomas, but this mostly happens in twins or other multiple birth babies.

Answer 11

Clinical diagnosis Might need to do ultrasound and/or MRI scans on a child who has a haemangioma that is deep, near their eye, or affecting internal organs.

Answer 12

Usually are asymptomatic and undergo involution Does not necessarily need treatment Needs to be looked after as they can bleed when scratched If there is functional impairment (near eyes, nose, mouth) or cosmetic disfigurement: o Beta-blocker :PO (propranolol) o rtopical (timolol) o Corticosteroid: PO or topical o Until theoretical involution or 12m o May need surgery Cryotherapy Electrotherapy Vascular laser surgery If it is ulcerated: o Barrier protection and Burow’s solution for gentle debridement o May need topical antibiotics (metronidazole) o Beta blocker may be used if haven’t previously been treated with it

Answer 13

1-2 mm pearly white pappules which resolve spontaneously in the new born Most often appear on a newborn's upper cheeks, nose, chin, or forehead. They're harmless and very common.

Answer 14

Most cases eventually clear by themselves (within a few weeks in infants) May be removed if not cosmetically pleasing o Can do it using a fine needle o Cryotherapy can be used o Laser treatment o Dermabrasion o Chemical peeling

Answer 15

Viral skin infection caused by pox virus Transmission usually by direct skin contact

Answer 16

Firm, smooth, skin coloured, pearly umbilicated papules May be single but usually multiple Usually 2-5mm in diameter In children, tend to occur on trunk and extremities

Answer 17

Clinical exam

Answer 18

* Does not require treatment if immunocompetent (it is self-limiting), with spontaneous resolution usually occurs within 1 year * Advise against squeezing mollusca to avoid the spread of infectious material and reducing risk of super-infections * Avoid sharing towels, clothing and baths with uninfected people (e.g. siblings) * If eczema or infection develops around the lesions, treat appropriately (e.g. emollients and steroids or antibiotics) * Chemical or physical destruction may be done by a specialist and only if lesion has become symptomatic * If anogenital lesions, can use: * Podophyllotoxin 0.5% (usually used to treat anogenital warts but effective) * Apply 2 x day for 3 consecutive days * Repeat after a week if needed * Imiquimod 5% cream * Apply 3 x week and wash off 6-10 hours later **Do NOT need to be excluded from school** Refer to Dermatologist if: o Immunocompromised o Lesions are extensive and painful (although inflamed lesions may indicate resolution) o Diagnostic uncertainty

Answer 19

Molluscum contagiosum

Answer 20

**Mongolian blue spots (dermal melanosis):** benign but MUST be documented and pointed out to parents, as can be mistaken for bruises and cause concern in school etc, fade to some degree but do not necessarily totally disappear

Answer 21

Are harmless and usually disappear by 4yo Do NOT need treatment and are not a sign of an underlying condition Note: can be mistaken for bruises and thus child abuse/safeguarding issues • So should be recorded on baby’s medical records from birth

Answer 22

Inflammation of the skin in the area of the body covered by a nappy

Answer 23

* Common * Irritant (contact) dermatitis * Most common * May occur if nappies are not changed frequently or if infant has diarrhoea, but can also occur even if infant is cleaned regularly * Occurs due to the irritant effect of urine ammonia and faeces on the skin * Urea-splitting organisms in faeces increase alkalinity and likelihood of a rash * Infantile seborrheic dermatitis * Candida infection * Infections can cause or exacerbate nappy rashes * Other pathogens: Staphylococcus aureus, enteric organs * Atopic eczema * Rare * Acrodermatitis enteropathica ▪ * Langerhans cell histiocytosis ▪ * Wiskott-Aldrich syndrome

Answer 24

**• Irritant dermatitis** o Characteristic acute onset erythematous rash of convex surfaces of buttocks, perineal region, lower abdomen and tops of thighs o Flexures (creases) are characteristically spared in irritant dermatitis o More severe forms may involve erosions and ulcer formation **• Candida infection** o Erythematous rash including skin flexures o May have satellite lesions **• Seborrheic dermatitis** o Erythematous rash with flakes o May have coexistent scalp rash **• Psoriasis** o Less common cause characterised by erythematous scaly rash also present elsewhere on skin **• Atopic eczema** o Other areas will also be affected

Answer 25

Clinical examination

Answer 26

• Advise the parents/carers about self-management strategies o Consider using a nappy with high absorbency and ensure that it fits properly o Leave nappy off as much as possible to help skin drying of the nappy area o Clean the skin and change the nappy every 3-4 hours or as soon as possible after wetting/soiling, to reduce skin exposure to urine and faeces * Use water, or fragrance-free or alcohol-free baby wipes * Dry gently after cleaning * Bath the child daily- avoid excessive bathing (\>2x a day) * Do not use soap, bubble bath, lotions or talcum powder • **If mild erythema and the child is asymptomatic** o Advise on the use of barrier preparation to protect the skin (available OTC) and apply thinly at each nappy change o Options: Zinc and Castor oil ointment BP, Metanium ointment, soft white paraffin BP ointment • **If the rash appears inflamed and is causing discomfort** o If \> 1 month=**hydrocortisone 1% cream** OD (max 7 days) + barrier cream o ADVISE:apply topical hydrocortisone first and wait a few minutes before applying barrier preparation **If the rash persists and candidal infection is suspected or confirmed on swab** o Advise against the use of barrier protection o Prescribe **topical imidazole cream** (e.g.clotrimazole,econazole,miconazole) **If the rash persists or bacterial infection is suspected or confirmed on swab** o Prescribe **oral flucloxacillin** for 7 days o If penicillin allergy : clarithromycin (7 days) Arrange to review the child **Summary**![]() * Disposable nappies are better than towel nappies * Expose nappy area to air where possible * Apply barrier cream (e.g. Sudocrem) * Mild steroid cream (e.g. 1% hydrocortisone) in severe case * Manage suspected candida nappy rash with topical imidazole (cease the use of barrier cream until candida has settled) ![]()

Answer 27

Nappy rash due to candida infection

Answer 28

Eruption of unknown cause presenting in first 3 months of life o Starts on the scalp as an erythematous scaly eruption o The scales form a thick yellow adherent layer, commonly called cradle cap o The scaly rash may spread to the face, behind the ears and then to the flexures and napkin area

Answer 29

• Associated with increased risk of subsequent atopic eczema development

Answer 30

Cradle cap +/- extensive involvement Rash is NOT itchy

Answer 31

Cradle cap - seborrheic dermatitis

Answer 32

Seborrheic dermatitis with involvement of face, axillae and napkin area.

Answer 33

Superficial fungal infection in which dermatophyte fungi invade dead keratinous structures, such as the horny layer of skin, nails and hair Can be caused by various different types of fungi (dermatophytes)

Answer 34

Discoid eczema

Answer 35

Skin lesions often have a ringed, annular appearance, gradually expanding with active edge A severely inflamed pustular ringworm patch is called a kerion (abscess)

Answer 36

o Tinea pedis: athlete’s foot o Tinea ungulum: finger and toenails o Tinea corporis: arms, legs and trunks o Tinea cruris: groin area o Tinea manuum: hands and palm o Tinea capitis: scalp - sometimes acquired from dogs and cats and causes scaling and patchy alopecia with broken hairs o Tinea faeciei: face o Tinea barbae: facial hair

Answer 37

* Examination under filtered ultraviolet (Wood’s) light may show bright greenish/yellow fluorescence of the infected hairs with some fungal species * Rapid diagnosis can be made from microscopic examination of skin scrapings for fungal hyphae * Definitive identification of the fungus is by culture

Answer 38

This is a severe subcutaneous infection, often involving tissue planes from the skin down to fascia and muscle The area involved may enlarge rapidly, leaving poorly perfused necrotic areas of tissue, usually at the centre

Answer 39

The invading organism may be S aureus or a group A Streptococcus, with or without another synergistic anaerobic organism (e.g. E coli, Enterobacter) o Bacteria are introduced into the skin and soft tissue from minor trauma, puncture wounds or surgery – but no primary site of infection is identified in ~20% cases o Infection extends through the fascia and tracks along fascial planes extending beyond the area of overlying cellulitis • Systemic signs of necrotising fasciitis, e.g. fever, tachycardia, hypotension, are mainly due to action of bacterial toxins

Answer 40

Predisposing risk factors include o Diabetes mellitus o Peripheral vascular disease o Immunocompromising conditions o Chickenpox or herpes zoster o Drugs e.g. corticosteroids

Answer 41

Classic features: SEVERE PAIN + SYSTEMIC ILLNESS Severe pain or anaesthesia over site of cellulitis Fever Palpitations, tachycardia, tachypnoea, hypotension, lightheadedness Nausea and vomiting

Answer 42

Bloods o FBC o Electrolytes o U&Es o CK o Lactate Blood and tissue cultures – tissue specimens obtained from surgical debridement for definitive bacterial diagnosis

Answer 43

* Uncomplicated cellulitis can be managed at home with oral antibiotics * Complicated cellulitis (e.g. cellulitis with systemic illness) may require admitting, resuscitation with oxygen and fluids and IV antibiotics. * Switch to oral when fever settles, cellulitis has regressed and CRP is reducing * May need **surgery** for incision and drainage of abscess, debridement of necrotic tissue or treatment of compression syndromes * Consider **MDT approach** with dermatologists, microbiology, pharmacists, surgeons (and ophthalmologists if orbital cellulitis). * High-dose **flucloxacillin** for 7 days * Or co-amoxiclav for 7 days if near the nose or eyes * Penicillin allergy: clarithromycin * Arrange a review in 48 hours by phone or in person * If cellulitis occurring on top of **VZV**, prescribe **flucloxacillin + amoxicillin** * Penicillin allergy: ciprofloxacin+ metronidazole/clarithromycin * Rest the area – limb etc * Advise using paracetamol or ibuprofen to relieve pain or discomfort * Safety net: seek help if it gets worse or doesn’t improve in 24-48 hours * **Erysipelas** presents similarly but has a very clearly demarcated rash * Treated with **penicillin V**

Answer 44

* Surgical emergency * Surgical debridement of all infected and devitalised tissues, should go beyond visible areas of necrosis * IV fluids * Empirical IV antibiotics (vancomycin, linezolid, daptomycin, tedizolid phosphate, tazocin, meropenem, imipenem/cilastatin, ertapenem = 2 or 3 at the same time) * +/- intravenous immunoglobulin (IVIG)

Answer 45

Periorbital cellulitis should be treated promptly with **IV antibiotics** (e.g. high-dose ceftriaxone) o MRSA will require vancomycin o May give empirical antifungal therapy This is to prevent posterior spread of the infection which could cause orbital cellulitis Incision, drainage and culture of peri-ocular abscess may be required Consider ophthalmologist advice

Answer 46

Chronic inflammatory skin disease characterised by erythematous, circumscribed scaly papules, and plaques

Answer 47

Rarely under the age of 2 yrs

Answer 48

Guttate psoriasis is common in children and often follows a streptococcal or viral sore throat or ear infection Chronic psoriasis: very rare

Answer 49

Pathophysiology: immune response defined by T cells in the dermis, initiating release of cytokines

Answer 50

Histology: keratinocytes overproliferate so there is a thicker layer of keratin causing scales to come off the surface

Answer 51

• Guttate psoarisis o Lesions are small, rain-drop like, round or oval erythematous scaly patches on the trunk and upper limbs o An attack usually resolves over 3-4 months o Most get a recurrence within the next 3-5 years • Chronic psoriasis (with plaques or annular lesions) is less common in children

Answer 52

Usually clinical diagnosis May want to do throat swab and anti-streptolysin-O titre for guttate psoriasis

Answer 53

* Reassure that it is usually a self-limiting condition that typically resolves within 3–4 months, and reassure that it is not infectious * 1st: Phototherapy: narrow band UVB 2-3 times/week (if widespread or unresponsive to topical treatment) * Topical preparation offered: * Emollient to reduce scales and relieve itch (E45,Oilatum,Emulsiderm) * Potent topical corticosteroid with vitamin D preparation +/- salicylic acid if scales are problematic • Refer if lesions are extensive, severe or not responding to treatment The Psoriasis Association may provide much needed support to sufferers - significant effect on QOL

Answer 54

Occasionally, children with chronic psoriasis will develop psoriatic arthritis

Answer 55

Guttate psoriasis

Answer 56

Caused by Coxsackie A viruses, most commonly Coxsackie A16

Answer 57

o Painful vesicular lesions on the hands, feet, mouth and tongue ▪ Should be called hand, foot, mouth and bum disease o Systemic features are generally mild o Disease subsides within days

Answer 58

**Hand, Foot and Mouth Disease** Symptomatic treatment only (hydration and analgesia) Keep blisters clean and apply non-adherent dressings to erosions Reassurance there is no link to disease in cattle Do not necessarily need exclusion from school Will subside within days

Answer 59

If stinger is visible, remove by scraping sideways with a finger nail or credit card Clean the area with soap and water and advise on prevention * If transient localised reaction * Consider simple analgesia * If swollen, can reduce with ice pack application (15min on and off regimen) * Oral antihistamine or topical steroids (hydrocortisone 1%) may reduce itching * Can give oral steroids for patients with moderate-severe reactions, continuing for 3-5d * OTC agents can be used: crotamiton, topical antihistamines and topical anaesthetics * Secondary bacterial infection can be treated as cellulitis

Answer 60

Specific Bites **Bedbugs** – advise contacting pest control **Fleas** – often associated with contact with domesticated pets (animals should be tested and treated if necessary) **Lice** – check head lice management **Scabies** – check scabies management **Lyme disease (Borrelia)** - doxycycline, amoxicillin and cefuroxime

Answer 61

Animal and Human Bite * Check for risk of tetanus * If unknown: tetanus/diptheria/pertussis vaccine, tetanus immunoglobulin and another tetanus/diptheria vaccine \>4wks after and 6-12m later * Check for rabies risk: * Non-immunised: Rabies vaccine + rabies immunoglobulin * Immunised: rabies vaccine * **Co-amoxiclav** for 7 days * Penicillin allergy: metronidazole + doxycycline (7 days) * Safety net about signs of infection

Answer 62

Pediculosis capitis (head lice infestation) is the most common form of lice infestation in children

Answer 63

PRESENTATION: itching of the scalp and nape of the neck Live lice may be identified on the scalp or nits on hairs Nits are empty egg cases that are seen on hairs There may be secondary bacterial infection, sometimes leading to misdiagnosis of impetigo Suboccipital lymphadenopathy is common Widespread and troublesome in primary school children

Answer 64

Wet combing with a fine-tooth comb to remove live lice every 3-4 days for 2 weeks is useful and safe (BUGBUSTING) **Dimeticone 4% lotion** or aqueous solution of malathion 0.5% is rubbed into the hair and scalp and left on overnight and the hair is shampooed the following morning Treatment should be repeated a week later School exclusion NOT advised

Answer 65

Parasitic infection caused by an infestation with the eight-legged parasitic mite Sarcoptes scabiei which burrows down the epidermis along the stratum corneum

Answer 66

Severe itching occurs 2-6 weeks after infestation and is worse in warm temperature/at night

Answer 67

o Excoriation can lead to a secondary eczematous or urticarial reaction which masks the true diagnosis o Secondary bacterial infection is common

Answer 68

Severe itching In older children, burrows, papules and vesicles involve the skin between the fingers and toes, axillae, flexor aspects of the wrists, belt line and around the nipples, penis and buttocks In infants and young children, distribution often includes the palms, soles and trunk

Answer 69

* Clinical diagnosis * Although burrows are considered pathognomonic, they may be hard to identify because of secondary infection due to scratching. * Itching in other family members is a helpful clinical indicator. * Confirmation can be made by microscopic examination of skin scrapings from the lesions to identify mite, eggs, and mite faeces.

Answer 70

School exclusion until treated.

Answer 71

Caused by HPV

Answer 72

These are COMMON and usually found on the fingers and soles (verrucae)

Answer 73

Watchful waiting is most common in children Daily administration of proprietary **salicylic acid** or **lactic acid paint** or **glutaraldehyde lotion** can be useful **Cryotherapy** with liquid nitrogen is effective but can be painful (should only be used in older children)

Answer 74

Atopic eczema

Answer 75

Infantile seborrheic dermatitis

Answer 76

Acne vulgaris

Answer 77

Henoch Schonlein purpura

Answer 78

Erythema multiforme

Answer 79

Erythema nodosum

Answer 80

**Erythema infectiosum / fifth disease /slapped cheek syndrome**

Answer 81

Meningococcal septicaemia

Answer 82

This is a typical presentation of pityriasis versicolor, a common fungal skin infection. It often becomes more noticeable after spending time in the sun - as the healthy skin becomes darker, the white/light brown patches become more prominent. Treatment consists of topical antifungals - NICE recommends ketoconazole shampoo. If only a very small area is affected, a topical antifungal cream may also be appropriate. In this case, both back and chest are affected, so a shampoo would be much easier to use.

Answer 83

Pityriasis rosea. The exact cause remains unclear, although there are links to certain viruses. It is a self-limiting disease that tends to resolve within 12 weeks with no long term complications. Most patients will not require any treatment. If patients complain of itch we can consider emollients, topical corticosteroids or antihistamines. Steroids are unlikely to shorten the duration of the rash itself, so should only really be used if there is pruritus present and for the shortest amount of time.

Answer 84

This a description of scarlet fever, a bacterial infection caused by *Group A Streptococci*. It is highly contagious and usually treated with antibiotics. NICE recommends phenoxymethylpenicillin first line and azithromycin in true penicillin allergy, although this may be different where you work depending on local microbiology policies. Exam questions often mention a 'sandpaper-like rash' or a 'strawberry tongue' as described in this scenario. If you work in England, Wales or Northern Ireland you should also notify the local health protection team (in Scotland scarlet fever is no longer a notifiable disease).

Dermatology Flashcards

(122 cards)