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Year 4 PAEDS > Dermatology > Flashcards

Dermatology Flashcards

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1
Q

List the different forms of eczema

A

1) Atopic dermatitis
2) Contact dermatitis
3) Dyshidrotic dermatitis
4) Nummular dermatitis
5) Neurodermatitis
6) Sebhorreic dermatitis

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2
Q

What is the most common form of eczema?

A

Atopic dermatitis

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3
Q

What is eczema?

A

Chronic, relapsing, inflammatory skin condition characterised by an itchy red rash that favours skin creases such as folds of elbows or behind the knees (flexor surfaces)

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4
Q

What are some trigger factors for atopic eczema?

A 
Exogenous:
Irritants eg soap
Skin infection eg s aureus
Contact allergens
Extremes of temp and humidity (worse at winter / sweating)
Abrasive facbrics eg wool
Dietary factors (50% children)
Inhaled allergen eg pollen

Endogenous:
Genetic mutations affecting filaggrin
Stress
Hormonal changes in women eg premenstrual flare-ups / deterioration in pregnancy

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5
Q

What is filaggrin?

A

A protein critical to the conversion of keratinocytes to the proteins/lipid squames (flake of skin) that make up the stratum corneum (outermost layer of skin)

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6
Q

What is the diagnostic criteria for atopic eczema?

A

Itchy skin plus 3 or more of:

1) Hx of itchiness on flexor surfaces
2) Hx asthma or hay fever (or hx atopic disease in a first degree relative <4yr)
3) Generally dry skin in preceding year
4) Visual flexural eczema
5) Onset in first 2 years of life

= no itching - probs not eczema

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7
Q

Where may atopic eczema present in children 18 months or under?

A

Cheeks

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8
Q

What is eczema herpeticum?

A

HSV-1 infection superimposed onto active atopic eczema

DERMATOLOGICAL EMERGENCY

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9
Q

How does eczema herpeticum present?

A

Areas of rapidly worsening, painful eczema

Clustered blistered with early-stage cold sores

Punched out erosions = circular, depressed, ulcerated lesions) usually 1-3mm that are uniform in appearance. They may coalesce to from larger areas of erosion with crusting

+/- fever, lethargy, distress, LN

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10
Q

What is the treatment of eczema herpeticum?

A

Immediate acyclovir either PO/IV

Immediate same day referral

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11
Q

What are some complications of eczema herpeticum?

A

Scarring from blisters

Infection in the cornea (herpetic keratitis) left untreated can lead to blindness

Rarely organ failure and death if virus spreads to brain, lungs and liver

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12
Q

Ddx of atopic eczema

A

1) Psoriasis - but this is extensor surfaces
2) Contact dermatitis
3) Seborrheic dermatitis
4) Fungal infections
5) Lichen simplex chronicus
6) Scabies

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13
Q

What investigations are done for atopic eczema?

A

Clinical diagnosis

IgE and specific radioallergosorbant tests (RASTs) only confirm atopic nature of individual

Swabs useful if not responding treatment identify abs-resistant s aureus or additional step infections

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14
Q

What other atopic disease are associated with atopic eczema? (3)

A

Asthma
Hay fever
Allergic rhinitis

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15
Q

What is the management of atopic eczema?

A

Avoid triggers
Emollient therapy to keep skin hydrated = at all times
Topical steroids - hydrocortisone 1% initially and increase as required
PO antihistamine may reduce itching

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16
Q

What is the ideal use of an emollient?

A

Best when skin is moist but useful at all times
Use liberally
Combo of cream, ointment, bath oil and emollient soap = max effect
- Dry areas = oil based
- Wet areas = water based

Freq of every 4 hrs or 3-4 times/day
250g/week prescription for a child

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17
Q

What is the treatment of a bacterial infection in eczema?

A

14-day course of flucloxicillin for s aureus

Erythromycin if penicillin allergy

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18
Q

What is lichenification?

A

Thick leathery patchers of skin resulting form repeated scratching

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19
Q

What is the treatment lichenification?

A

Corticosteroid

Bandages containing ichthammol paste (reduces pruritus) + zinc oxide cn be applied

Coal tar can be useful in some cases

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20
Q

What are the two types of contact dermatitis?

A

Irritant

Allergic

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21
Q

Where does dyshidrotic dermatitis affect?

A

Hands and feet

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22
Q

Who does nummular dermatitis affect?

A

M>F

Men usually first outbreak 50’s

Women get it in adolescence / early adulthood

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23
Q

How does nummular dermatitis present?

A

Coin shaped red marks

Legs, backs of hangs, forearms, lower back, hips

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24
Q

How does neurodermatitis arise?

A

Skin irritation develops in spots frequently scratched

Usually skin outbreak doesn’t get any bigger but skin can grow thick and wrinkled

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25
What is sebhorreic dermatitis? Where does it arise?
aka dandruff - causes skin to fall off in flakes In infants = scalp Adults also eyebrows / sides of nose / behind ears Overgrowth of yeast that normally lives in these areas as well as well as overgrowth and rapid shedding of cells on scalp
26
What is the management of sebhorreic dermatitis?
Shampoo containing salicylic acid, selenium sulfinde, zinc pyrithione, or coal tar Antifungal treatments can be rubbed into the areas Steroid lotions
27
What is stasis dermatitis?
Results from inadequate venous return from lower limb Over time can cause skin to develop brown stains (hemosiderin)
28
What is the prognosis of eczema?
Infantile eczema resolves by 2yrs in 50% Atopic eczema resolves by age 13yr in 60% Eczema herpeticum usually resolves in 4 weeks
29
What is impetigo?
Common superficial skin condition divided into non-bullous and bullous forms Highly infectious
30
What is the more common type of impetigo?
Non-bullous
31
What are the most common causative organisms of non-bullous impetigo?
Staph aureus Strep pyogenes MRSA rising
32
What are some RF for impetigo?
Poor hygiene Skin conditions leading to a break in skin - atopic eczema, bites, trauma to skin, scabies, chicken pox, burns, contact dermatitis
33
How does non-bullous impetigo present?
Start as tiny pustules / vesicles that evolve into honey-crusted plaques (tend to be <2cm diameter) Usually around mouth and nose (but can be on extremities eg bites / scabies) Satellite lesions from auto inoculation +/- itching Little / no surrounding erythema or oedema Regional LN enlarged
34
How does bullous impetigo present?
Bullous lesions with thin roof that tend to rupture spontaneously Usually on face, trunk, extremities, buttocks or perineal regions More likely to occur on top of other disease eg atopic eczema More common in neonates but can occur in any age More likely to be painful and be associated with symptoms of malaise
35
What is ecthyma?
Begins as non-bullous impetigo but ulcerates and becomes necrotic It is deeper and may occur with lymphadenitis
36
List some ddx for impetigo
``` Contact dermatitis Scabies Viral skin infection eg Herpes simplex / herpes zoster Bullous pemphigoid Erysipelas Atopic eczema Burns TJS TEN ```
37
What investigations are done for impetigo?
Diagnosis clinical Swab can be useful if severe / MRSA suspected / recurrent or failing to respond to treatment
38
How is impetigo managed?
Hygiene advice Do not attend school until lesions are dry / scabbed over or the affected person has been on abx for 48hrs 1st line - topical fusidic acid 2nd line - topical mupirocin (if MRSA suspected) 3 times a day for 7 days
39
What may be given in severe or resistant causes of impetigo?
Given if <5 lesions 7 day course of flucloxacillin PO 2nd line - clarithromycin or erythromycin NB bullous infection usually requires oral abx
40
What are some complications of impetigo?
If causative organism is step pyogenes, rarely can cause: - Scarlet fevere - Glomerulonephritis (but most caused by staph) Cellulitis, lymphangitis, suppurative lymphadenitis and staphylococcal scalded skin syndrome can occur
41
What is a macule?
Discrete flat lesion of any size or shape that are pink or red in colour Blanching Eg rubella or roseola
42
What is a papule?
Solid palpable projections above the surface of the skin Eg insect bite
43
What is is a maculopapular lesion?
Mixture of macule and papules which tend to be confluent Eg drug rash
44
What are purpura and petechiae?
Purple lesions caused by small haemorrhages in the superficial layers of the skin Generally indicate a serious condition Non-blanching Petechiae = tiny purpuric lesions
45
What can cause purpura and petichiae?
Meningococcal septicaemia Idiopathic thrombocytopenia purpura HSP Leukaemia
46
What are vesicles?
Raised fluid lesions <0.5cm in diameter Large = bulla Eg chicken pox
47
What are wheals?
Raised lesions with a flat top and pale centre of variable size Eg urticaria
48
What is desquamation?
A loss of epidermal cells producing a 'scaled' eruption Eg post-scarlet fever
49
List 4 causes of nappy rash
1) Ammoniacal dermatitis 2) Candidiasis 3) Seborrhoeic dermatitis 4) Psoriasis
50
Why is nappy rash common?
Area is warm and moist Usually tightly enclosed in a waterproof covering Contact with urine which is an irritant
51
What is the most common type of nappy rash?
Usually simple irritant rash with candidiasis superimposed In prolonged, resistant rash, consider seborrheic dermatitis and psoriasis
52
How may a nappy rash caused by ammoniacal dermatitis present?
Erythematous +/- papulovesicular or bullous lesions, fissures and erosions Patchy or confluent Skin folds characteristically spared From prolonged contact with urine, bacteria convert urea to ammonia which is an alkaline irritant
53
How may a nappy rash caused by candida present?
Bright red, with sharply demarcated edge and satellite lesions Inguinal folds involved - warm moist area promotes growth of yeast Oral thrush may be found
54
How may a nappy rash caused by seborrheic dermatitis present?
Pink, greasy lesions with yellow scale Often in skin folds Cradle cap may be found
55
How may a nappy rash caused by psoriasis present?
Like seborrheic dermatitis +ve FH
56
What conditions may cause itching in a child? (8)
1) Atopic dermatitis 2) Contact dermatitis 3) Urticaria 4) Scabies 5) Chicken pox 6) Sebhorrhoeic dermatitis 7) Head lice 8) Threadworms
57
What are some common infectious skin lesions?
1) Warts 2) Impetigo 3) Molluscum contagiosum 4) Tinea 5) Herpes simplex 6) Brith marks
58
How is a nappy rash caused by ammoniacal dermatitis managed?
Regular changing and washing area Exposure to air Protective creams eg zinc and castor oil ointment Consider mild hydrocortisone cream Anticandida cream can be helpful (as superimposed candida infection is v common)
59
How is a nappy rash caused by candida diagnosed?
Usually clinically Confirmation can be made on potassium hydroxide (KOH) preparation
60
How is a nappy rash caused by candida managed?
Anticandidal agent eg nystatin applied at each change If oral thrush present give PO nystatin
61
How is a nappy rash caused by psoriasis managed?
Usually supportive and treatment kept to a minimum Application of coal tar preparations after a bath can be helpful Salicylic acid ointment is useful for removing scale but extensive treatment can lead to salicylate poisoning (esp young children) Topical corticosteroids are effective but must be used with caution
62
What is Stevens-Johnson syndrome (SJS)?
Immune-complex-mediated hypersensitivity disorder
63
What are the ranges of severity of SJS?
Ranges from mild skin and mucous membrane lesions to a severe, sometimes fatal systemic illness - toxic epidermal necrolysis (TEN) TEN and SJS overlap and form spectrum of severe cutaneous adverse reactions (SCAR)
64
What is erythema multiforme?
Previously considered milder form of SJS without mucosal involvement Now distinct disorder in which there are usually only a few spots and resolve quickly
65
How is SJS classified?
Type of lesion Distribution of lesion Extent of epidermal detachment: <10% = SJS 10-30% = SJS-TEN overlap >30% = TEN
66
In which populations is SJS more common?
HIV Females Ages 10-30 Associations with HLA
67
What causes SJS?
``` 75% = medications 25% = others ```
68
What drugs are most commonly associated with SJS?
Allopurinol Carbamazepine Sulfonamides: - Trimethoprim-sulfamethoxazole - Sulfadiazina - Sulfasalazine Antiviral agents: - Nevirapine - Abacavir Anticonvulsants: - Phenobarbital - Phenytoin - Valproic acid - Lamotrigine Others: - Imidazole anti fungal agents - NSAIDS (oxicam type eg meloxicam) - Salicylates - Sertraline - Bupropion (rarely)
69
Other than drugs, what can cause SJS?
``` Infections Immunisations eg measles, hep B Viruses Bacteria Fungal infections Protozoa ```
70
How does SJS initially present?
Nonspecific URTI associated with fever, sore throat, chills, headache, arthralgia, d&v, malaise
71
What may follow initial presentation of SJS?
Mucocutaneous lesions suddenly develop and clusters of outbreaks last 2-4 weeks Lesions not usually pruritic Mouth - severe oromucosal ulceration Respiratory involvement may cause a productive cough with thick purulent sputum Pt with genitourinary involvement may complain of dysuria or inability to pass urine Ocular symptoms - painful red eye, purulent conjunctivitis, photophobia, blepharitis
72
What general signs are associated with SJS?
General examination: - Fever - Tachycardia - Hypotension - Altered LOC - Seizures - Coma
73
Which regions of the skin are most commonly affected in SJS?
Lesions can affect anywhere but most commonly affect palms, soles, dorm of hands and extensor surfaces If confined to one area of body = usually trunk
74
Describe the skin lesions associated with SJS
Rash begins as macule that develop into papules, vesicles, bull, urticarial plaques or confluent erythema Centre of lesions may be vesicular, purpuric or necrotic TARGET LESIONS = pathognomonic Lesions may become bullous and later rupture - susceptible to 2ndary infection Urticarial lesions are usually not pruritic
75
What is nikolsky sign and what is it in SJS?
Mechanical pressure to skin leading to blistering within minutes or hours Nikolsky sign positive in SJS
76
Describe mucosal involvement in SJS
``` Erythema Oedema Sloughing Blistering Ulceration Necrolysis ```
77
Describe eye involvement in SJS
Conjunctivitis | Corneal ulcerations
78
Describe genital involvement in SJS
Erosive vulvovaginitis or balanitis
79
What investigations are performed for SJS?
Serum electrolytes, glucose and bicarb to assess severity and level of dehydration Diagnosis based on clinical classification and histopathology Skin biopsy - show bullae are subepidermal - Epidermal cell necrolysis may be seen and perivascular areas are infiltrated with lymphocytes
80
What is the management of SJS?
MDT as many systems affected Identify and remove cause eg drug Use of ALDEN = Algorithim for assessment of Drug-induced Epidermal Necrolysis Rapid assessment of prognosis using SCORTEN Supportive - Airway - Haemodynamic stability - IV fluids - Pain control - Mouthwashes, topical anaesethics - Eye drops inc abx / steroid PRN Treat infections
81
What is SCORTEN?
Score for Toxic Epidermal Necrolysis = used to predict mortality rate in SJS and TEN
82
What are the seven criteria of SCORTEN?
1) Age >40yrs 2) Presence of malignancy 3) HR >120bpm 4) Initial % of epidermal detachment >10% 5) Serum bicarb <20mmol/L 6) Serum urea >10mmol/L 7) Serum glucose >14mmol/L Score >3 = ICU
83
What are some complications of SJS?
``` Dehydration Shock VTE and DIC GI ulceration, necrolysis, stricture and perforation Secondary skin infection and scarring Respiratory failure from mucosal shedding in tracheobronchial tree Corneal ulceration and anterior uveitis Vaginal stenosis and penile scarring ```
84
What is erythema nodosum?
Thought to be a hypersensitivity reaction Dermatological manifestation of disease
85
How may erythema nodosum present?
Fever, aching, arthralgia | Painful rash appears within a couple of days
86
Describe the course of skin lesions in erythema nodosum
Usually on shins Begin as red, tender nodules with poorly defined boarders 1st week: become tense hard and painful 2nd week: fluctuant, similar to abscess but do not suppurate or ulcerate Last for 2 weeks
87
What is erythema nodosum usually indicative of?
Usually infectious disease but cause is not always found Some underlying causes are not infectious
88
What is the most common underlying cause of erythema nodosum?
Streptococcal infection May be a feature of other diseases eg scarlet fever and rheumatic fever
89
What are other underlying causes associated with erythema nodosum?
1) Sarcoidosis 2) TB 3) Leprosy = clinical picture of erythema nodosum but histologically different 4) Gastroenteritis causes 5) Lymphogranuloma venerum 6) Mycoplasma pneumonia 7) Fungal infections eg coccidioidomycosis 8) Drugs eg sulfonamides, sulfonylureas, gold and oral contraceptives 9) IBD - coincide with flare up 10) Precede diagnosis of Hodgkin's and non-Hodgkin's lymphoma by months, and can accompany Beçhet's syndrome 11) Idiopathic
90
What causes of gastroenteritis are associated with erythema nodosum?
Yersinia enterocolitica Salmonella spp Campylobacter spp
91
What investigations are done for erythema nodosum?
Exclude serious underlying cause - Throat swab for strep - Anti-strep O (ASO) titre - FBC and ESR - Stool sample - Sarcoidosis = calcium and ACE raised - CXR may show bilateral hilarity lymphadenopathy = sarcoidosis - Intradermal skin tests to exclude TB or coccidioidomycosis
92
How is erythema nodosum managed?
Most cases are self-limiting and need only symptomatic relief Treat infective cause RICE NSAIDs
93
What is scabies?
Scabies infection is caused by mite which is transmitted by direct contact
94
How may scabies present?
Intensely purpuric eruption Worse at night Consisting of wheals, papules, vesicles and a superimposed eczematous dermatitis Pathognomonic lesion = mite burrow appears as a thread-like line often in interdigital spaces, but often obliterated by scratching In older children, head, neck, palms and soles are usually spared but often affected in babies
95
How is scabies diagnosed?
Microscopic examination of mites obtained from scrapings
96
How is scabies managed?
Application of scabicides - malathion or permethrin Use with extreme caution in babies due to their toxic effects Treat all of household and bedding and clothes washed in hot water
97
Why may eczematous reaction and pruritus persist for some time following treatment of scabies?
Due to ongoing hypersensitivity to dead mites

Year 4 PAEDS (23 decks)

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