Dermatology Flashcards
(241 cards)
1
Q
Distribution of eczema in infants
A
In infants, atopic eczema usually involves the face and extensor surfaces of the body as opposed to its classical flexural distribution
2
Q
What organism is ‘head lice’
A
Pediculus humanus capitis parasite
3
Q
What are ‘nits’?
A
Pediculus humanus capitis parasite egg shells that have hatched or contain unviable embryos and not the lice themselve
4
Q
What are pediculus humanus capitis parasites?
A
Head lice are the Pediculus humanus capitis parasite, which causes infestations of the scalp, most commonly in school aged children.
Head lice are commonly known as nits, however nits are egg shells that have hatched or contain unviable embryos and not the lice themselves.
5
Q
How are head lice transmitted?
A
Head lice are spread by close contact with someone that has head lice, usually in schools or amongst family members.
Transmission is by head to head contact or by sharing equipment like combs or towels.
6
Q
Presentation of headlice?
A
Infestation causes an itchy scalp.
Often the nits (eggs) and even lice themselves are visible when examining the scalp.
7
Q
Management of headlice?
A
Dimeticone 4% lotion can be applied to the hair and left to dry.
This is left on for 8 hours (i.e. overnight), then washed off.
This process is repeated 7 days later to kill any head lice that have hatched since treatment.
Special fine combs can be used to systematically comb the nits and lice out of the hair.
They can be used for detection combing to check the success of treatment.
NICE clinical knowledge summaries recommend The Bug Buster kit.
8
Q
What lotion is used to treat headlice?
A
Dimeticone 4%
Left on dry hair for 8 hours and then washed off
9
Q
What is ‘scabies’ and what happens in a scabies infestation?
A
Scabies are tiny mites called Sarcoptes scabiei that burrow under the skin causing infection and intense itching.
They lay eggs in the skin, leading to further infection and symptoms.
10
Q
What does the mite sarcoptes scabiei cause?
A
Scabies
11
Q
How long does it take for symptoms or a rash to appear after the initial infestation with sarcoptes scabiei to occur?
A
Up to 8 weeks
12
Q
How does scabies present?
A
Scabies presents with incredibly itchy small red spots, possibly with track marks where the mites have burrowed.
The classic location of the rash is between the finger webs, but it can spread to the whole body.
13
Q
What is seen here?
A
Sarcoptes scabiei (scabies)
14
Q
How is scabies managed?
A
PERMETHRIN CREAM:
Treatment is with permethrin cream. This needs to be applied to the whole body, completely covering skin.
It is best to do this when the skin is cool (i.e. not after a bath or shower) so that a layer of cream remains on top of the skin and does not get absorbed.
The cream should be left on for 8 – 12 hours and then washed off.
This should be repeated a week later to kill all the eggs that survived the first treatment and have now hatched.
ORAL IVERMECTIN
Oral ivermectin as a single dose that can be repeated a week later is an option for difficult to treat or crusted scabies.
CONTACT TREATMENT
Scabies is contagious to all household and close contacts. When one person is diagnosed, all household and close contacts should also be treated in exactly the same way, even if asymptomatic. This is because they may be infected and not yet have symptoms.
All clothes, bedclothes, towels and other materials in contact with scabies need to be washed on a hot wash to destroy the mites. Thorough hoovering of carpets and furniture is also essential.
Itching can continue for up to 4 weeks after successful treatment. Crotamiton cream and chlorphenamine at night at night can help with the itching.
15
Q
What is an option for difficult to treat or crusted scabies?
A
Oral ivermectin as a single dose that can be repeated a week later
16
Q
What is ‘‘crusted scabies” and how is it managed?
A
Crusted scabies is also known as Norwegian scabies.
It is a serious infestation with scabies in patients that are immunocompromised.
These patient may have over a million mites in their skin. They are extremely contagious.
Rather than individual spots and burrows, they have patches of red skin that turn into scaly plaques.
These can be misdiagnosed as psoriasis.
Immunocompromised patients may not have an itch as they do not mount an immune response to the infestation. They may need admission for treatment as an inpatient with oral ivermectin and isolation.
17
Q
What causes hand foot and mouth disease?
A
Coxsackie A virus.
18
Q
What is the incubation period of Coxsackie A virus?
A
3 – 5 days.
19
Q
How does hand foot and mouth disease present?
A
Starts with URTI symptoms: tiredness, sore throat, dry cough, fever
After 1-2 days:
Small mouth ulcers appear, followed by
Blistering red spots across the body- most notable on hands, feet and around mouth
Painful mouth ulcers, particularly on the tongue are a key feature
Rash is sometimes itchy
20
Q
What is seen here?
A
Hand foot and mouth disease - cause by the Coxsackie A virus
21
Q
Management/infection control of hand foot and mouth disease?
A
Diagnosis is made based on the clinical appearance of the rash (blistering red spots, most notable on hands, feet and around the mouth)
.
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.
22
Q
After how long should the rash and illness resolve spontaneously without treatment in hand foot and mouth disease?
A
7-10 days
23
Q
Rarerly, hand foot and mouth disease ( oxsackie A virus) can cause complications - such as?
A
Dehydration
Bacterial superinfection
Encephalitis
24
Q
What is seen here?
A
Infantile seborrhoeic dermatitis (of the face - usually seen on the scalp - cradle cap)
25
What is seborrhoeic dermatitis, and what does it affect?
Seborrhoeic dermatitis is an inflammatory skin condition that affects the sebaceous glands (the oil producing glands in the skin)
It affects areas that have a lot of these glands, such as the scalp, nasolabial folds and eyebrows.
It causes erythema, dermatitis and crusted dry skin.
In infants it causes a crusted dry flaky scalp, often called cradle cap.
26
What organism is thought to play a role in seborrhoeic dermatitis and therefore what treatment may improve it?
Malassezia yeast colonisation
Anti-fungal treatment improves the condition
27
How does infantile seborrhoeic dermatitis usually present?
Infantile seborrhoeic dermatitis (cradle cap) causes a crusted flaky scalp.
28
By what age infantile seborrhoeic dermatitis has resolved spontaneously?
Usually resolves by 4 months of age, but can last until 12 months.
29
What is the first line treatment of cradle cap (infantile seborrhoeic dermatitis)
First line treatment is by applying baby oil, vegetable oil or olive oil, gently brushing the scalp then washing off.
30
Management of cradle cap (infantile seborrhoeic dermatitis)
First line treatment is by applying baby oil, vegetable oil or olive oil, gently brushing the scalp then washing off.
When this is not effective, white petroleum jelly can be used overnight to soften the crusted areas before washing off in the morning.
The next step is a topical anti-fungal cream such as clotrimazole or miconazole, used for up to 4 weeks.
Severe or unresponsive cases may need referral to a dermatologist.
31
If cradle cap is resitance to first line management (baby oil, and the white petroleum jelly) what anti-fungals can be used?
A topical anti-fungal cream such as clotrimazole or miconazole, used for up to 4 weeks
32
How does Seborrhoeic Dermatitis of the Scalp present?
Mild seborrhoeic dermatitis of the scalp presents with flaky itchy skin on the scalp (dandruff).
More severe cases cause more dense oily scaly brown crusting.
(This commonly occurs in adolescents and adults rather than children)
33
What is seen here?
Seborrhoeic Dermatitis of the Scalp
34
How is seborrhoeic dermatitis of the scalp managed?
First line treatment is with ketoconazole shampoo, left on for 5 minutes before washing off.
Topical steroids may be used if there is severe itching.
It often reoccurs after successful treatment.
35
How does Seborrhoeic Dermatitis of the Face and Body present?
Seborrhoeic dermatitis of the face and body presents with red, flaky, crusted, itchy skin.
It commonly affects the eyelids, nasolabial folds, ears, upper chest and back.
36
Where does seborrhoeic dermatitis of the face and body typically affect?
Eyelids
Nasolabial folds
Ears
Upper chest
Back
37
What is seen here?
Seborrhoeic Dermatitis of the Face
38
Management of seborrhoeic dermatitis of the face and body?
First line treatment is with an anti fungal cream, such as clotrimazole or miconazole, used for up to 4 weeks.
Localised inflamed areas may benefit from a topical steroids, such as hydrocortisone 1%.
Severe or unresponsive cases should be referred to a dermatologist or paediatrician.
39
What is seen here?
Ringworm
40
What is ringworm and what is it also known as?
Ringworm is a fungal infection of the skin.
It is also known as TINEA and DERMATOPHYTOSIS
41
What is dermatophytosis more commonly known as?
Ringworm/(tinea)
42
Tinea capitis refers to what?
Tinea capitis refers to ringworm affecting the scalp
43
Tinea pedis refers to what?
Tinea pedis refers to ringworm affecting the feet, also known as athletes foot
44
Tinea cruris refers to what?
Tinea cruris refers to ringworm of the groin
45
Tinea corporis refers to what?
Tinea corporis refers to ringworm on the body
46
Onychomycosis refers to what?
Onychomycosis refers to a fungal nail infection
47
What is fungal nail infection known as?
Onychomycosis
48
What is ringworm on the body known as?
Tinea corporis
49
What is ringworm affecting the scalp known as?
Tinea capitis
50
What is athletes foot known as?
Tinea pedis - ringworm affecting the feet
51
What is the most common type of fungus that causes ringworm/dermatophytosis/tinea?
Trichophyton
52
What is trichophyton and what does it cause?
dermatophytosis/tinea/ringworm
53
How is trichophyton spread?
Contact with infected individuals, animals or soil.
54
Rash in ringworm?
an itchy rash that is:
- erythematous
- scaly
-w ell demarcated
There is often one or several rings or circular shaped areas that spread outwards, with a well demarcated edge.
The edge is more prominent and red and the area in the centre is more faint in colour.
55
How does tinea capitis present?
Tinea capitis can present with well demarcated hair loss.
There will also be itching, dryness and erythema of the scalp.
(This is more common in children than adults)
56
What is seen here?
Tinea capitis (ringworm of the scalp)
57
How does athelets foot (tinea pedis present)?
white or red, flaky, cracked, itchy patches between the toes
The skin may split and bleed.
58
What makes people prone to tinea pedis?
Athletes foot
This is often the result of sharing changing rooms with someone that has athletes foot and is more likely to occur when feet are sweaty and damp for prolonged periods.
59
What is seen here?
Tinea pedis (atheltes foot)
60
What is Onychomycosis?
Onychomycosis
61
How does onychomycosis present?
Thickened, discoloured and deformed nails.
62
How is fungal nail infection (onychomycosis) treated?
Amorolfine nail lacquer for 6 – 12 months.
Resistant cases may need oral terbinafine, however the patient will need their LFTs monitoring before and whilst taking this.
63
What can be used to treat resistant onychomycosis and what must be monitored while this treatment is taken?
Oral terbinafine,
Patient will need their LFTs monitoring before and whilst taking this.
64
Diagnosis of tinea?
The diagnosis is usually clinical. This is supported by a good response to anti fungal medications. It is possible to scrape some of the scales off and send them for microscopy and culture to identify the causative organism and confirm the diagnosis.
65
Ringworm is managed with antifungal medications - such as?
Anti-fungal creams such as clotrimazole and miconazole
Anti-fungal shampoo such as ketoconazole for tinea capitis
Oral anti-fungal medications such as fluconazole, griseofulvin and itraconazole
66
How is dermatophytosis managed?
Anti-fungal creams such as clotrimazole and miconazole
Anti-fungal shampoo such as ketoconazole for tinea capitis
Oral anti-fungal medications such as fluconazole, griseofulvin and itraconazole
A mild topical steroid can help settle the inflammation and itching. A common combination is miconazole 2% and hydrocortisone 1% cream (Daktacort).
Simple advice should be given to help recovery, prevent spread and avoid recurrence. Fungal infections grow best in warm, moist areas. Advise includes:
Wear loose breathable clothing
Keep the affected area clean and dry
Avoid sharing towels, clothes and bedding
Use a separate towel for the feet with tinea pedis
Avoid scratching and spreading to other areas
Wear clean dry socks every day
67
Advice to prevent spread and recurrence of fungal infection?
Wear loose breathable clothing
Keep the affected area clean and dry
Avoid sharing towels, clothes and bedding
Use a separate towel for the feet with tinea pedis
Avoid scratching and spreading to other areas
Wear clean dry socks every day
68
What is tinea incognito and when does it occur?
Tinea incognito refers to a more extensive and less well recognised fungal skin infection that results from the use of steroids to treat an initial fungal infection.
This often occurs when the initial presentation of ringworm was misdiagnosed as dermatitis and a topical steroid was prescribed.
The steroid improves the itching and inflammation but accelerates the growth of the fungal infection by dampening the immune response in the local area.
When the steroid is stopped the itchy rash caused by the fungus returns and is much worse than previously.
It may be less recognisable as ringworm due to a less well-demarcated border and fewer scales, giving rise to the incognito name.
69
What is nappy rash and why does it occur?
Nappy rash is contact dermatitis in the nappy area. It is usually caused by friction between the skin and nappy and contact with urine and faeces in a dirty nappy.
Most babies will get nappy rash at some point, and it is most common between 9 and 12 months of age.
Additionally, the breakdown in skin and the warm moist environment in the nappy can lead to added infection with candida (fungus) or bacteria, usually staphylococcus or streptococcus.
70
In nappy rash (contact dermatitis in nappy area), the breakdown in skin and the warm moist environment in the nappy can lead to added infection - what organisms are most common?
candida (fungus) or
bacteria, usually staphylococcus or streptococcus.
71
When is nappy rash most common?
Between 9 and 12 months of age
72
What is seen here?
Nappy rash (contact dermatitis)
73
Risk factors for nappy rash?
Delayed changing of nappies
Irritant soap products and vigorous cleaning
Certain types of nappies (poorly absorbent ones)
Diarrhoea
Oral antibiotics predispose to candida infection
Pre-term infants
74
How does nappy rash present?
Sore, red, inflamed skin in the nappy area.
The rash appears in individual patches on exposure areas of the skin that come in contact with the nappy.
It tends to spare the skin creases, meaning the creases in the groin are healthy.
There may be a few red papules beside the affected areas of skin.
Nappy rash is uncomfortable, may be itchy and the infant may be distressed.
Severe and longstanding nappy rash can lead to erosions and ulceration.
75
Candida in the nappy area (thrush) is a common finding. Signs that would point to a candidal infection rather than simple nappy rash include what?
Rash extending into the skin folds
Larger red macules
Well demarcated scaly border
Circular pattern to the rash spreading outwards, similar to ringworm
Satellite lesions, which are small similar patches of rash or pustules near the main rash
Check for oral thrush with a white coating on the tongue, as this is likely to indicate a fungal infection in the nappy area.
76
Management of nappy rash?
Simple measures can be taken to improve skin health and treat nappy rash within a few days:
- Switching to highly absorbent nappies (disposable gel matrix nappies)
- Change the nappy and clean the skin as soon as possible after wetting or soiling
- Use water or gentle alcohol free products for cleaning the nappy area
- Ensure the nappy area is dry before replacing the nappy
- Maximise time not wearing a nappy
Infection with candida or bacteria warrants treatment with an anti-fungal cream (clotrimazole or miconazole) or antibiotic (fusidic acid cream or oral flucloxacillin).
77
Complications of nappy rash?
Candida infection
Cellulitis
Jacquet’s erosive diaper dermatitis
Perianal pseudoverrucous papules and nodules
78
What is molluscum contagiosum and what causes it?
Molluscum contagiosum is a viral skin infection caused by the molluscum contagiosum virus, which is a type of poxvirus.
79
What is seen here?
Molluscum contagiosum
80
Features of molluscum contagiosum?
Molluscum contagiosum is characterised by small, flesh coloured papules (raised individual bumps on the skin) that characteristically have a central dimple.
They typically appear in “crops” of multiple lesions in a local area.
It is spread through direct contact or by sharing items like towels or bedsheets.
The papules resolve by themselves without any treatment, however this can take up to 18 months.
Once they resolve the skin returns to normal.
Scratching or picking the lesions should be avoided as it can lead to spreading, scarring and infection.
81
How is molluscum contagiosum spread?
It is spread through direct contact or by sharing items like towels or bedsheets.
82
How is molluscum contagiosum managed?
No treatment or change in lifestyle is required and children can continue all their normal activities. They should avoid sharing towels or other close contact with the lesions to minimise the risk of spreading the infection. Usually just simple reassurance and education is enough.
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
83
Molluscum contagiosum management: 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 what?
Topical:
Potassium hydroxide
Benzoyl peroxide
Podophyllotoxin
Imiquimod
Tretinoin
Surgical removal and cryotherapy - may lead to scaring
84
What is pityriasis rosea and what causes it?
Pityriasis rosea a generalised, self limiting rash that has an unknown cause. It often occurs in adolescents and young adults.
It may be caused by a virus such as human herpes virus (HHV-6 or HHV-7), but no definitive causative organism had been established.
85
What is seen here?
Pityriasis rosea
86
How does pityriasis rosea present?
There may be prodromal symptoms prior to the rash developing.
These include headache, tiredness, loss of appetite and flu-like symptoms.
The rash starts with a characteristic HERALD PATCH
This is a faint red or pink, scaly, oval shaped lesion that is 2cm or more in diameter, usually occurring somewhere on the torso. It appears 2 or more days prior to the rest of the rash. If you suspect pityriasis, ask and look for a herald patch. Most, but not all, patients have a herald patch.
The rash consists of widespread faint red or pink, slightly scaly, oval shaped lesions, usually less than 2 cm in diameter. On the torso they can be arranged in a characteristic “christmas tree” fashion, following the lines of the ribs.
In dark skinned patients the lesions can be grey coloured, lighter or darker than their skin colour.
Other symptoms may be present:
Generalised itch
Low grade pyrexia
Headache
Lethargy
87
What is a herald patch, and what type of rash is it seen in?
Occurs in pityriasis rosea
This is a faint red or pink, scaly, oval shaped lesion that is 2cm or more in diameter, usually occurring somewhere on the torso.
It appears 2 or more days prior to the rest of the rash.
If you suspect pityriasis, ask and look for a herald patch. Most, but not all, patients have a herald patch.
88
What is seen here and when does it occur?
A herald patch
Occurs in pityriasis rosea, 2 or more days prior to the rest of the rash (widespread, faint red or pink, slightly scaly, oval shaped lesions, usually less than 2 cm in diameter. On the torso they can be arranged in a characteristic “christmas tree” fashion, following the lines of the ribs.)
89
Pityriasis rosea - disease course?
The rash resolves without treatment within 3 months.
It can leave a discolouration of the skin where the lesions were, however these will also resolved within another few months.
90
Management of pityriasis rosea?
There is no treatment for the rash. It will resolve spontaneously without any long term effects.
Patient education and reassurance is all that is required. It is not contagious and they can continue all their normal activities.
They may require symptomatic treatment if bothered by itching.
This may include emollients, topical steroids or sedating antihistamines at night to help with sleep (e.g. chlorphenamine).
91
Managing a non-blanching rash in a child
Patients with a non-blanching rash always require urgent referral and investigation unless there is a clear and unconcerning cause. The extent of the investigation depends on the clinical picture. Where there is doubt, patients are usually treated as meningococcal sepsis without waiting for investigations.
Definitive management will depend on the underlying cause.
92
What investigations may be helpful in a non-blanching rash and why?
FULL BLOOD COUNT
Anaemia can suggest HUS or leukaemia.
Low white cells can suggest neutropenic sepsis or leukaemia.
Low platelets can suggest ITP or HUS.
UREA AND ELECTROLYTES
High urea and creatinine can indicate HUS or HSP with renal involvement.
CRP
This is a non-specific indication of inflammation or infection and can be useful but not definitive in excluding sepsis.
ESR
This is a non-specific indication of inflammatory illness such as a vasculitis (HSP) or infection.
COAGULATION SCREEN including PT, APTT, INR and FIBRINOGEN
Can diagnose clotting abnormalities.
BLOOD CULTURE
This can be useful but not definitive in diagnosing or excluding sepsis.
MENINGOCOCCAL PCR
This can confirm meningococcal disease, although this should not delay treatment.
LUMBAR PUNCTURE
To diagnose meningitis or encephalitis.
BLOOD PRESSURE
Hypertension can occur in HSP and HUS. Hypotension can occur in septic shock.
URINALYSIS
Proteinuria and haematuria can suggest HSP with renal involvement, or HUS.
93
Typical viral causes of a non-blanching rash
influenza and enterovirus
94
What is meant by a 'mechanical' non-blanching rash?
Strong coughing, vomiting or breath holding can produce petechiae in a “superior vena cava distribution”, above the neck and most prominently around the eyes.
95
Non blanching rash in a child - differentials?
MENINGOCOCCAL SPETICAEMIA or any other bacterial sepsis
This presents with a feverish unwell child. Any features of meningococcal septicaemia indicate emergency management with immediate antibiotics. This can lead to significant morbidity and mortality if treatment is delayed.
HENOCH-SCHONLEIN PURPURA
This typically presents as a purpuric rash on the legs and buttocks and may have associated abdominal or joint pain.
IDIOPATHIC THROMBOCYTOPENIC PURPURA
This develops over several days in an otherwise well child.
ACUTE LEUKAEMIA
This presents with a gradual development of petechiae, potentially with other signs such as anaemia, lymphadenopathy and hepatosplenomegaly.
HAEMOLYTIC URAEMIC SYNDROME (HUS)
This is associated with oliguria (very low urine output) and signs of anaemia. This often presents in a child with recent diarrhoea.
MECHANICAL
Strong coughing, vomiting or breath holding can produce petechiae in a “superior vena cava distribution”, above the neck and most prominently around the eyes.
TRAUMATIC
Tight pressure on the skin, for example in non-accidental injury, or occlusion of blood in an area of skin can lead to traumatic petechiae.
VIRAL ILLNESS
This is often the explanation when other causes and serious illness are excluded. Typical causes are influenza and enterovirus.
96
What is seen here?
Purpura are larger (3 – 10mm) non-blanching, red-purple, macules or papules created by leaking of blood from vessels under the skin.
97
What is seen here?
Petechiae are small (< 3mm), non blanching, red spots on the skin caused by burst capillaries.
98
What is a non-blanching rash?
Non-blanching rashes are caused by bleeding under the skin.
Petechiae are small (< 3mm), non blanching, red spots on the skin caused by burst capillaries.
Purpura are larger (3 – 10mm) non-blanching, red-purple, macules or papules created by leaking of blood from vessels under the skin.
99
What is erythema nodosum and why does it occur?
Erythema nodosum is a condition where red lumps appear across the patient’s shins. Erythema means red and nodosum directly translates from Latin as “knots”, referring to lumps.
It is caused by inflammation of the subcutaneous fat on the shins.
Inflammation of fat is called panniculitis.
It is caused by a hypersensitivity reaction. In around half of patients there is no identifiable cause.
It is associated with a number of triggers and underlying conditions.
100
What is seen here?
Erythema nodosum
101
Erythema nodosum is caused by a hypersensitivity reaction, and there is often an identifiable cause such as what?
Streptococcal throat infections
Gastroenteritis
Mycoplasma pneumoniae
Tuberculosis
Pregnancy
Medications, such as the oral contraceptive pill and NSAIDs
102
Erythema nodosum is often associated with chronic diseases such as?
Inflammatory bowel disease
Sarcoidosis
Lymphoma
Leukaemia
103
Presentation of erythema nodosum?
Erythema nodosum presents with red, inflamed, subcutaneous nodules across both shins.
The nodules are raised and can be painful and tender.
Over time the nodules settle and appears as bruises.
When you suspect someone has erythema nodosum it is important to look for signs and symptoms of potential triggers and underlying medical conditions.
104
Investigating erythema nodosum?
The diagnosis of erythema nodosum is based on the clinical presentation.
Investigations can be helpful in assessing the underlying cause:
- Inflammatory markers (CRP and ESR)
- Throat swab for streptococcal infection
- Chest xray can help identify mycoplasma, tuberculosis, sarcoidosis and lymphoma
- Stool microscopy and culture for campylobacter and salmonella
- Faecal calprotectin for inflammatory bowel disease
- Further imaging and endoscopy may be required under specialist guidance.
105
How is erythema nodosum managed?
Management mainly involves investigating for an underlying condition and treating the underlying cause.
Erythema nodosum is managed conservatively with rest and analgesia. Steroids may be used to help settle the inflammation.
Most cases will fully resolve within 6 weeks, however it can last longer.
106
After how long do most erythema nodosum cases resolve?
Within 6 weeks
107
When might impetigo occur?
Staphylococcal scalded skin syndrome (SSSS) is a condition caused by a type of staphylococcus aureus bacteria that produces epidermolytic toxins.
These toxins are protease enzymes that break down the proteins that hold skin cells together.
When a skin infection occurs and these toxins are produced, the skin is damaged and breaks down.
This condition usually affects children under 5 years. Older children and adults have usually developed immunity to the epidermolytic toxins.
108
How can impetigo be classified?
Impetigo can be classified as non-bullous or bullous.
109
Management of non-bullous impetigo
Topical fusidic acid can be used to treat localised non-bullous impetigo. Draft NICE guidelines from August 2019 suggest using antiseptic cream (hydrogen peroxide 1% cream) first line rather than antibiotics for localised non-bullous impetigo.
Oral flucloxacillin is used to treat more wide spread or severe impetigo. Flucloxacillin is the antibiotic of choice for staphylococcal infections.
Advise about measure to avoid spreading the impetigo. Patients should be given advice about not touching or scratching the lesions, hand hygiene and avoiding sharing face towels and cutlery. They need to be off school until all the lesions have healed or they have been treated with antibiotics for at least 48 hours.
110
What is non-bullous impetigo?
Non-bullous impetigo typically occurs around the nose or mouth. The exudate from the lesions dries to form a “golden crust”. They are often unsightly but do not usually cause systemic symptoms or make the person unwell.
111
What is bullous impetigo and how does it differ from non-bullous?
Bullous impetigo is always caused by the staphylococcus aureus bacteria. These bacteria can produce epidermolytic toxins that break down the proteins that hold skin cells together. This causes 1 – 2 cm fluid filled vesicles to form on the skin. These vesicles grow in size and then burst, forming a “golden crust”. Eventually they heal without scarring. These lesions can be painful and itchy.
This type of impetigo is more common in neonates and children under 2 years, however it can occur in older children and adults. It is more common for patients to have systemic symptoms. They may be feverish and generally unwell. In severe infections when the lesions are widespread, it is called staphylococcus scalded skin syndrome.
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How might bullous impetigo be investiagted?
Swabs of the vesicles can confirm the diagnosis, bacteria and antibiotic sensitivities. Treatment of bullous impetigo is with antibiotics, usually flucloxacillin.
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How is bullous impetigo managed?
This may be given orally or intravenously if they are very unwell or at risk of complications. The condition is very contagious and patients should be isolated where possible.
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Impetigo usually responds well to treatment without any long term adverse effects. Rarely there can be complications, such as?
Cellulitis if the infection gets deeper in the skin
Sepsis
Scarring
Post streptococcal glomerulonephritis
Staphylococcus scalded skin syndrome
Scarlet fever
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What is staphylococcal scaled skin syndrome?
Staphylococcal scalded skin syndrome (SSSS) is a condition caused by a type of staphylococcus aureus bacteria that produces epidermolytic toxins.
These toxins are protease enzymes that break down the proteins that hold skin cells together.
When a skin infection occurs and these toxins are produced, the skin is damaged and breaks down.
This condition usually affects children under 5 years. Older children and adults have usually developed immunity to the epidermolytic toxins.
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Staphylococcal Scalded Skin Syndrome presentation?
SSSS usually starts with generalised patches of erythema on the skin. Then the skin looks thin and wrinkled.
This is followed by the formation of fluid filled blisters called bullae, which burst and leave very sore, erythematous skin below. This has a similar appearance to a burn or scald.
Nikolsky sign is where very gentle rubbing of the skin causes it to peel away. This is positive in SSSS.
Systemic symptoms include:
Fever
Irritability
Lethargy
Dehydration
If untreated it can lead to sepsis and potentially death.
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Management of staphylococcal scaled skin syndrome?
Most patients will require admission and treatment with IV antibiotics.
Fluid and electrolyte balance is key to management as patients are prone to dehydration.
When adequately treated, children usually make a full recovery without scarring.
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What are SJS and TEN?
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are a spectrum of the same pathology, where a disproportional immune response causes epidermal necrosis, resulting in blistering and shedding of the top layer of skin.
Generally, SJS affects less that 10% of body surface area whereas TEN affects more than 10% of body surface area.
Certain HLA genetic types are at higher risk of SJS and TEN.
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SJS vs TEN - proportion of body affected by epidermal necrosis?
SJS - less than 10%
TEN - more than 10%
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What medications might cause SJS/TEN?
Anti-epileptics
Antibiotics
Allopurinol
NSAIDs
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What infections might cause SJS/TEN?
Herpes simplex
Mycoplasma pneumonia
Cytomegalovirus
HIV
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How does SJS/TEN present?
The condition has a spectrum of severity. Some cases are mild whilst others are very severe and can potentially be fatal.
Patients usually start with non-specific symptoms:
-fever
-cough
-sore throat
-sore mouth
-sore eyes
-itchy skin
They then develop a purple or red rash that spreads across the skin and starts to blister.
A few days after the blistering starts, the skin starts to break away and shed leaving the raw tissue underneath.
Pain, erythema, blistering and shedding can also happen to the lips and mucous membranes.
Eyes can become inflamed and ulcerated. It can also affect the urinary tract, lungs and internal organs.
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SJS and TEN management?
SJS and TEN are medical emergencies and patients should be admitted to a suitable dermatology or burns unit for treatment.
Good supportive care is essential, including nutritional care, antiseptics, analgesia and ophthalmology input.
Treatment options include steroids, immunoglobulins and immunosuppressant medications guided by a specialist.
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SJS/TEN management?
Secondary infection: The breaks in the skin can lead to secondary bacterial infection, cellulitis and sepsis.
Permanent skin damage: Skin involvement can lead to scarring and damage to skin, hair, nails, lungs and genitals.
Visual complications: Depending on the severity, eye involvement can range from sore eyes to severe scarring and blindness.
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What is chicken pox and what causes it?
Chickenpox is caused by the varicella zoster virus (VZV).
It causes a highly contagious, generalised vesicular rash.
It is common in children.
Once a child has had an episode of chickenpox, they develop immunity to the VZV virus and will not be affected again.
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Presentation of chicken pox
Chickenpox is characterised by widespread, erythematous, raised, vesicular (fluid filled), blistering lesions.
The rash usually starts on the trunk or face and spreads outwards affecting the whole body over 2 – 5 days.
Eventually the lesions scab over, at which point they stop being contagious.
Other symptoms:
- Fever is often the first symptom
- Itch
- General fatigue and malaise
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Infectivity of chicken pox?
Chickenpox is highly contagious and spread through direct contact with the lesions or through infected droplets from a cough or sneeze.
Patients become symptomatic 10 days to 3 weeks after exposure.
The stop being contagious after all the lesions have crusted over.
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Potential chicken pox complications?
Bacterial superinfection
Dehydration
Conjunctival lesions
Pneumonia
Encephalitis (presenting as ataxia)
After the infection the virus can lie dormant in the sensory dorsal root ganglion cells and cranial nerves reactivate later in life as shingles or Ramsay Hunt syndrome.
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Where does the varicella zoster virus (VZV) sit formant?
Sensory dorsal root ganglion cells and cranial nerves
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What might VZV reactivate as later in life after sitting dormant in the sensory dorsal root ganglion cells and cranial nerves?
Shingles
Ramsay Hunt Syndrome
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Prevention/treatment of neonatal chikcen pox?
Pregnant women that are known to be immune to chickenpox are not at risk when in contact with chickenpox.
When they are not immune, varicella zoster immunoglobulins can be given to protect them against the virus after exposure.
Chickenpox in the mother around the time of delivery can lead to life threatening neonatal infection and is treated with varicella zoster immunoglobulins and aciclovir.
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Before what gestation does chicken pox infection have the potential to cause congenital varicella syndrome?
28 weeks
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Management of chikcen pox?
Chickenpox is usually a mild self limiting condition that does not require treatment in otherwise healthy children.
Aciclovir may be considered in immunocompromised patients, adults and adolescents over 14 years presenting within 24 hours, neonates or those at risk of complications.
Complications such as encephalitis require admission for inpatient management.
Symptoms of itching can be treated with calamine lotion and chlorphenamine (antihistamine).
Patients should be kept off school and avoid pregnant women and immunocompromised patients until all the lesions are dry and crusted over. This is usually around 5 days after the rash appears.
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When might aciclovir be considered in mgx of chicken pox?
Aciclovir may be considered in immunocompromised patients, adults and adolescents over 14 years presenting within 24 hours, neonates or those at risk of complications.
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In chicken pox, children should be kept off school and avoid pregnant women and immunocompromised patients until all the lesions are dry and crusted over.
How long does this usually take?
This is usually around 5 days after the rash appears.
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What is seen here?
Urticaria
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What is urticaria?
Urticaria are also known as hives.
They are small itchy lumps that appear on the skin.
They may be associated with a patchy erythematous rash.
This can be localised to a specific area or widespread.
They may be associated with angioedema and flushing of the skin.
Urticaria can be classified as acute urticaria or chronic urticaria.
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Why does urticaria occur?
Urticaria are caused the release of histamine and other pro-inflammatory chemicals by mast cells in the skin.
This may be part of an allergic reaction in acute urticaria or an autoimmune reaction in chronic idiopathic urticaria.
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What might trigger acute urticaria?
Acute urticaria is typically triggered by something that stimulates the mast cells to release histamine.
This may be:
- Allergies to food, medications or animals
- Contact with chemicals, latex or stinging nettles
- Medications
- Viral infections
- Insect bites
- Dermatographism (rubbing of the skin)
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Sub classifications of chronic urticaria?
Chronic idiopathic urticaria
recurrent episodes of chronic urticaria without a clear underlying cause or trigger.
Chronic inducible urticaria
episodes of chronic urticaria that can be induced by certain triggers, such as:
- Sunlight
- Temperature change
- Exercise
- Strong emotions
- Hot or cold weather
- Pressure (dermatographism)
Autoimmune urticaria
chronic urticaria associated with an underlying autoimmune condition, such as systemic lupus erythematosus.
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Management of urticaria?
Antihistamines are the main treatment for urticaria.
Fexofenadine is usually the antihistamine of choice for chronic urticaria.
Oral steroids may be considered as a short course for severe flares.
In very problematic cases referral to a specialist may be required to consider treatment with:
- Anti-leukotrienes such as montelukast
- Omalizumab, which targets IgE
- Cyclosporin
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What is usually the antihistamine of choice for chronic urticaria?
Fexofenadine
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What is seen here?
Erythema multiforme
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What causes erythema mutliforme?
Erythema multiforme is an erythematous rash caused by a (type IV) HYPERSENSITIVITY REACTION
The most common causes are viral infections and medications.
It is also notably associated with the herpes simplex virus (causing coldsores) and mycoplasma pneumonia.
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What infections are notably associated with erythema multiformE?
herpes simplex virus (causing coldsores)
Mycoplasma pneumonia.
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Presentation of erythema multiforme?
Erythema multiforme produces a widespread, itchy, erythematous rash.
WIDESPREAD, ITCHY, ERYTHEMATOUS RASH
CHARACTERISTIC TARGET LESIONS
It does not usually affect the mucous membranes but can cause a sore mouth (stomatitis).
The symptoms come on abruptly over a few days.
It may be associated with other symptoms of:
Mild fever
Stomatitis (sore mouth)
Muscle and joint aches
Headaches
General flu-like symptoms
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Diagnosis/investigation of erythema multiforme?
The diagnosis is made clinically based on the appearance of the rash.
It is important to identify the underlying cause:
- Where there is a clear underlying cause, for example a recent coldsore or treatment with penicillin, it may be managed supportively.
- Where there is no clear underlying cause it may be worth investigating further, for example doing a chest xray to look for mycoplasma pneumonia.
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Management of erythema multiforme?
Most of the time erythema multiforme is mild and resolves spontaneously within one to four weeks without any treatment or lasting effects.
Cases may be recurrent, particularly associated with recurrent coldsores.
Severe cases may require admission to hospital, particularly where it affects the oral mucosa.
Treatments used in severe cases include IV fluids, analgesia and steroids (systemic - controversial or topical).
Antibiotics or antivirals may be used where infection is present.
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What is an exanthem?
An eruptive widespread rash
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What are the six viral exanthems?
First disease: Measles
Second disease: Scarlet Fever
Third disease: Rubella (AKA German Measles)
Fourth disease: Dukes’ Disease
Fifth disease: Parvovirus B19
Sixth disease: Roseola Infantum
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What sign is pathognomonic for measles?
Koplik spots - greyish white spots on the buccal mucosa.
They appear 2 days after the fever.
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In measles, after how long to Koplik spots appear?
2 days after fever
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What are Koplik spots?
Koplik spots
Greyish white spots on the buccal mucosa. They appear 2 days after the fever.
They are pathognomonic for measles
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What is seen here?
Koplik spots
Greyish white spots on the buccal mucosa. They appear 2 days after the fever. They are pathognomonic for measles, meaning if a patient has Koplik spots, you can diagnose measles.
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Characteristic rash in measles?
The rash starts on the face, classically behind the ears, 3 – 5 days after the fever.
It then spreads to the rest of the body.
The rash is an erythematous, macular rash with flat lesions.
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Which of the “viral exanthemas” are notifiable disease?
First disease: Measles
Second disease: Scarlet Fever
Third disease: Rubella (AKA German Measles)
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What rash is Scarlet fever characterised by?
It is characterised by a red-pink, blotchy, macular rash with rough “sandpaper” skin that starts on the trunk and spreads outwards.
Patients can have red, flushed cheeks.
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Features of rash in rubella?
It presents with a milder erythematous macular rash compared with measles.
The rash starts on the face and spreads to the rest of the body.
The rash classically lasts 3 days.
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What is 'fourths disease'?
non-specific viral rash
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Rash in Roseola Infantum?
When the fever settles, the rash appears for 1 – 2 days.
The rash consists of a mild erythematous macular rash across the arms, legs, trunk and face and is not itchy.
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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.
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How does eczema 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.
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Basic pathophysiology of eczema?
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.
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Eczema management - maintennce
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.
Avoid triggers
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What might cause an eczema flare?
Cold, dry environments (ie. it may completely resolve on holiday in warm, humid countries, only to flare on returning to the cold air in the UK)
Changes in temperature
Certain dietary products
Washing powders
Cleaning products
Emotional events
Stresses can also play a role.
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Management of eczema flare?
Thicker emollients
Topical steroids
“wet wraps” (covering affected areas in a thick emollient and applying a wrap to keep moisture locked in overnight)
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
- systemic immunosuppressants, such as oral corticosteroids, methotrexate and azathioprine.
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What systemic immunosuppressant agents may be used in managing eczema?
oral corticosteroids
methotrexate
azathioprine
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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.
Examples of thin creams?
E45
Diprobase cream
Oilatum cream
Aveeno cream
Cetraben cream
Epaderm cream
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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.
Examples of thick, greasy emollients?
50:50 ointment (50% liquid paraffin)
Hydromol ointment
Diprobase ointment
Cetraben ointment
Epaderm ointment
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Use of steroid cream in eczema - considerations
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%)
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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%)
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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.
What is a common organism/management?
The most common organism is staphylococcus aureus. Treatment is with oral antibiotics, particularly flucloxacillin. More severe cases may require admission and intravenous antibiotics.
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What is eczema herpeticum and what causes it?
Eczema herpeticum is a viral skin infection caused by the herpes simplex virus (HSV) or varicella zoster virus (VZV).
Herpes simplex virus 1 (HSV-1) is the most common causative organism, and may be associated with a coldsore in the patient or a close contact.
It usually occurs in a patient with a pre-existing skin condition, such as atopic eczema or dermatitis, where the virus is able to enter the skin and cause an infection.
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What is the most common cause of eczema herpeticum
Herpes simplex virus 1 (HSV-1) is the most common causative organism, and may be associated with a coldsore in the patient or a close contact.
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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).
The rash is usually widespread and can affect any area of the body. It is erythematous, painful and sometimes itchy, with 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.
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Eczema herpeticum investigations + management
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.
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Eczema herpeticum - Complications
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.
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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.
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Characteristics of psoriasis patches?
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.
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Basic pathological process in psoriasis?
Autoimmune skin changes caused by the rapid generation of new skin cells, resulting in an abnormal buildup and thickening of the skin in those areas.
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Presentation + diagnosis 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.
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What type of psoriasis is more common in children and what normally triggers it?
Guttate psoriasis is more common in children, often triggered by a throat infection.
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What is Auspitz sign?
refers to small points of bleeding when plaques are scraped off - sign seen in psoriasis
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What is the Koebner phenomenon?
refers to the development of psoriatic lesions to areas of skin affected by trauma
sign seen in psoriasis
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Treatment options for psoriasis?
- 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
biologic medications.
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There are two products that contain both a potent steroid and vitamin D analogue that are commonly prescribed but not licensed in children and will be guided by a specialist. What are they called?
Dovobet
Enstilar
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Psoriasis - associations
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.
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What nail changes may be seen in psoriasis?
pitting, thickening, discolouration, ridging and onycholysis (separation of the nail from the nail bed).
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What is plaque psoriasis?
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.
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What type of psoriasis is seen here?
Plaque psoriasis
thickened erythematous plaques with silver scales, commonly seen on the extensor surfaces and scalp
around 1cm-10cm in diameter
most common tpe in adults
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What is guttate psoriasis?
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.
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How long does it take for guttate psoriasis to resolve spontaneuously?
Often 3-4 months
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What is seen here?
Guttate psoriasis
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.
It is the second most common form of psoriasis and commonly occurs in children. Guttate psoriasis is often triggered by a streptococcal throat infection, stress or medications. It often resolves spontaneously within 3 – 4 months.
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What is pustular psoriasis?
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.
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What type of psoriasis is seen here?
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.
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What is erythrodermic psoriasis?
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.
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What type of psoriasis is seen here?
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.
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What two types of psoriasis are emergencies?
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.
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What is acne vulgaris?
Acne vulgaris (acne) is an extremely common condition, often affecting people during puberty and adolescence. Most people are affected at some point during their lives, and symptoms can range from mild to severe.
200
Acne vulgaris - pathophysiology
Acne is caused by chronic inflammation, with or without localised infection, in pockets within the skin known as the pilosebaceous unit (tiny dimples in the skin that contain the hair follicles and sebaceous glands, The sebaceous glands produce the natural skin oils and a waxy substance known as sebum)
Acne results from increased production of sebum, trapping of keratin (dead skin cells) and blockage of the pilosebaceous unit.
This leads to swelling and inflammation in the pilosebaceous unit.
Androgenic hormones increase the production of sebum, which is why acne is exacerbated by puberty and improves with anti-androgenic hormonal contraception.
Swollen and inflamed units are called comedones.
The Propionibacterium acnes bacteria is felt to play an important role in acne.
This is a bacteria that colonises the skin. It is thought that excessive growth of this bacteria can exacerbate acne. Many of the treatments of acne aim to reduce these bacteria.
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What bacteria that colonises the skin is thought to play an important role in the pathophysiology?
The Propionibacterium acnes bacteria
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Why does acne get worse during puberty?
Acne results from increased production of sebum, trapping of keratin (dead skin cells) and blockage of the pilosebaceous unit.
This leads to swelling and inflammation in the pilosebaceous unit.
Androgenic hormones increase the production of sebum, which is why acne is exacerbated by puberty
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Why does the COCP improve acne?
Acne results from increased production of sebum, trapping of keratin (dead skin cells) and blockage of the pilosebaceous unit. This leads to swelling and inflammation in the pilosebaceous unit. Androgenic hormones increase the production of sebum, which is why it improves with anti-androgenic hormonal contraception.
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Macule
Macules are flat marks on the skin
205
Papule
Papules are small lumps on the skin
206
Pustule
Pustules are small lumps containing yellow pus
207
Comedomes
Comedomes are skin coloured papules representing blocked pilosebaceous units
208
Blackheads
Blackheads are open comedones with black pigmentation in the centre
209
What are ice pick scar
Ice pick scars are small indentations in the skin that remain after acne lesions heal
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Hypertrophic scars
small lumps in the skin that remain after acne lesions heal
211
Rolling scars
Rolling scars are irregular wave-like irregularities of the skin that remain after acne lesions heal
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Potential management options - acne
No treatment may be acceptable if mild
Topical benzoyl peroxide reduces inflammation, helps unblock the skin and is toxic to the P. acnes bacteria
Topical retinoids (chemicals related to vitamin A) slow the production of sebum (women of childbearing age need effective contraception)
Topical antibiotics such as clindamycin (prescribed with benzoyl peroxide to reduce bacterial resistance)
Oral antibiotics such as lymecycline
Oral contraceptive pill can help female patients stabilise their hormones and slow the production of sebum
Oral retinoids for severe acne (i.e. isotretinoin) is an effective last-line option, although it is only prescribed by a specialist after other methods fail.
This needs careful follow-up and monitoring and reliable contraception in females. Retinoids are highly teratogenic.
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How does isotretinoin treat acne?
Oral isotretinoin (Roaccutane) is very effective at clearing the skin.
It is a retinoid, and works by reducing production of sebum, reducing inflammation and reducing bacterial growth.
It can only be prescribed under expert supervision by a dermatologist. It is strongly teratogenic (harmful to the fetus during pregnancy). Patients need to have effective and reliable contraception and must stop isotretinoin for at least a month before becoming pregnant.
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Most effective COCP for acne management?
Co-cyprindiol (Dianette) is the most effective combined contraceptive pill for acne due to it’s anti-androgen effects.
It has a higher risk of thromboembolism, so treatment is usually discontinued once acne is controlled and it is not prescribed long term.
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Oral retinoid side effects?
Dry skin and lips
Photosensitivity of the skin to sunlight
Depression, anxiety, aggression and suicidal ideation. Patients should be screened for mental health issues prior to starting treatment.
Rarely Stevens-Johnson syndrome and toxic epidermal necrolysis
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What are salmon patches?
Salmon patches are a vascular birthmark which usually self resolve
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Which infectious agents can cause a maculopapular rash?
Barrelia burgdorferi (Lymes disease)
Group A streptococcus (Scarlet Fever)
Herpes 6/7 (roseola infantum)
Morbillivirus - measles
Parvovirus B19 - slapped cheek disease
Salmonella typhi - typhoid fever
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. Erythema toxicum neonatorum
* Migratory raised erythematous rash concentrated on the trunk.
* Overlying papules or pustules containing eosinophils.
* Onset at 2-3 days and resolves spontaneously after 3-5 days.
* Pathogenesis unclear.
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Atopic dermatitis
* Presents with dry, erythematous itchy skin (note skin breakdown from scratching).
* Distribution differs with age:
* Infants: face, neck, scalp and extensor surfaces. Nappy area is mostly spared.
* Childhood: Flexural surfaces (antecubital and popliteal fossae)
Volar aspect of the wrists; neck and ankles.
* Majority of infantile eczema will resolve.
* Eczema more wet and weepy in infants; can be thickened and pigmented in children.
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Mila
* Sometimes referred to as ‘milk spots’.
* White papules present at birth found most commonly on the nose and cheeks.
* Caused by build up of sebaceous material in skin follicles.
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Transient neonatal pustular melanosus (E).
* Benign idiopathic condition present at birth.
* Distinctive features of vesicles, superficial pustules and pigmented macules.
* Occur on forehead, chin, neck, chest, back and buttocks and less commonly palms
and soles.
* Vesicles rupture easily and resolve within 48 hours leaving macules that persist for
several months
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Seborrhoiec dermatitis
* Self-limiting eruption of non-inflammatory erythematous greasy plaques.
* Occurs in early infancy (<1 month) and can last to 12 months.
* Distribution favours the scalp (also called ‘cradle cap’), behind the ear, eyebrows and
nasolabial folds as these are rich in sebaceous glands.
* Can spread to flexures and napkin area.
* In contrast to eczema it is not itchy and infant is not disturbed
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How would this rash be described?
. Morbilliform (B)
* The term morbilliform refers to a rash that looks like measles.
* A morbilliform rash consists of a rose-red flat (macular) or slightly elevated (maculopapular) eruption of circular/elliptical lesions 1-3mm in diameter with intervening
healthy-looking skin.
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How would this rash be described?
Petechiae are small (1-2 mm) red, brown or purple sots on the skin (or conjunctivae)
caused by minor bleeding into the skin caused by capillary rupture.
* Usually flat to touch – although classically palpable in Henoch-Schonlein purpura.
* Non-blanching.
* Other terms for cutaneous bleeds are determined by size: purpura 2-10 mm and
ecchymosis > 10 mm.
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How would this rash be described?
. Maculopapular (A).
* Macules are flat discoloured areas (usually red) and papules are raised bumps.
* Both variable in size, particularly macules.
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Causes of fever + maculopapular rash in a child?
VIRAL
Roseola infantum (Human herpes virus-6 or7)
‘Slapped cheek’ rash of erythema infectiosum (Fifth Disease) (Parvovirus B19)
Enterovirus rash
Measles (morbilliform)
German measles (morbilliform)
BACTERIAL
Scarlet fever (group A streptococcus)
Rheumatic fever – erythema marginatum
Typhoid fever (Salmonella typhi) (Classically rose spots)
Lyme disease – erythema migrans
OTHER
Kawasaki disease
Systemic onset juvenile idiopathic arthritis
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Causes of vesicular, bullous or pustular rashes in a child with a fever?
VIRAL
Varicella zoster infection – chickenpox or shingles
Herpes simplex virus
Hand foot and mouth disease (Coxsackie A16 virus infection)
Molluscum contagiosum infection (Pox virus)
BACTERIAL
Impetigo
Boils
Staphylococcal bullous impetigo
Staphylococcal scalded skin syndrome
OTHER
Erythema multiforme/Stevens-Johnson syndrome/Toxic epidermal necrolysis
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Causes of peticheal/pustular rash and fever in a child?
VIRAL
Enterovirus, adenovirus and other viral infections
BACTERIAL
Meningococcal, other bacterial infections
Bacterial endocarditis
OTHER
Thrombocytopenia (Immune thrombocytopaenic purpura, Leukaemia)
Henoch-Schonlein purpura
Vasculitis
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Acute urticaria management
Cetirizine – high dose
High dose (up to 4x recommended dose) non-sedating
antihistamines is recommended as first-line treatment for acute urticaria (and often to
control chronic urticaria). Standard doses may not control symptoms leading to
unnecessary use of other agents e.g. oral prednisolone or alternate antihistamines.
Cetirizine Fexofenadine (Telfast ®)
Levocetirizine (Xyzal®) Mizolastine (Mizollen®)
Loratadine (Clarityne®) Rupatadine (Rupafin®)
Desloratadine (Neoclarityne®)
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Epimax and Balneum are what kind of emmolient?
Creams
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Examples of cream emollients
Epimax cream, Balneum cream
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What kind of emmolient is Doublebase?
Lotion
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50%WSP/50%LP, Hydromol, Zeroderm are examples of what kind of emolients?
Ointments
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EXAMPLES of mild topical steroids
1% hydrocortisone, 2.5% hydrocortisone, Synalar 1 in 10
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1% hydrocortisone, 2.5% hydrocortisone, Synalar 1 in 10 are what strength topical steriods?
mild
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Eumovate, Betnovate RD, Synalar 1 in 4 are examples of what strength topical steroids?
moderate
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Examples of moderate topical steroids ?
Eumovate, Betnovate RD, Synalar 1 in 4
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Examples of potent topical steroids?
Betnovate, Metosyn, Synalar
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Betnovate, Metosyn, Synalar are examples of which strength corticosteroids?
Potent
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Dermovate is an example of what strength topical steroid?
very potent
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Example of very potent topical steroid?
Dermovate
