Dermatology

Question 1

Nappy rash advice

Answer 1

High absorbency nappy well fitted
Leave nappy off as much as possible to help skin drying
Clean skin and change nappy every 3-4hrs or as soon as wetting/soiling
Use water or fragrance+alcohol free baby wipes
gently dry after cleaning
bath daily NOT using soap, bubblebath, lotions or talc
NHS choices leaflet

Question 2

Nappy rash w/mild erythema or child asymptomatic

Answer 2

Barrier preparation (OTC)
Apply thinly after nappy change
(Zn or castor oil ointment, white soft paraffin)

Question 3

Nappy rash that is inflamed or causing discomfort

Answer 3

If >1m hydrocortisone 1% cream OD max 7d

Question 4

If nappy rash persists and candidal infection suspected/detected

Answer 4

Advise against barrier
prescribe topical imidazole (eg clotrimazol, econazole, miconazole)
Preparation determines frequency

Question 5

If nappy rash persists or bacterial infection suspected/confirmed

Answer 5

PO fluclox 7d (clari if allergy)

arrange r/v

Question 6

Summary of nappy rash

Answer 6

Disposable nappies better than towel
Expose area to air where possible
Barrier eg subocrem
Mild steroid 1% hydrocort. in severe cases
Candida: imidazole and cease barrier until candida settled

Question 7

Seborrhoeic dermatitis in children

Answer 7

NOT serious
will resolve in wks/months (usually by 8m)
If scalp affected:
-Regular washing + brushing
- soften w/baby oil and then wash with baby shampoo
- soak crusts overnight in white petroleum jelly or slightly warmed oil and shampoo in morning
If conservative ineffective: topical imidazole cream 2-3 times/day
Specialist if lasting 4wks
If non scalp advise bathing and using emollient and soap substitute
if severe 1% hydrocort

Question 8

Atopic eczema skin/physical severity

Answer 8

Clear: normal skin
Mild: areas of dry skin, infreq. itch
mod: mild+redness
Sev: widespread areas odf dry skin, incessant itch, redness, skin thickening

Question 9

Atopic eczema impact on life and psychosocial wellbeing

Answer 9

none: no impact
mild: little impact
mod:mod impact+disturbed sleep
Sev: severe limitation and nigthtly loss of sleep

Question 10

Atopic eczema Ix

Answer 10

Identify triggers

Consider diagnosis of food allergy

Question 11

Atopic eczema mild Mx

Answer 11

emollients

mild potency topical CS

Question 12

Atopic eczema moderate Mx

Answer 12

emollients
moderate potency topical CS
topical calcineurin inhibitors
bandages

Question 13

Severe eczema Mx

Answer 13

Emollient
potent topical CS
topical calcineurin inhibitors
bandages
Phototherapy
systemic therapy

Question 14

how long to treat flares in eczema

Answer 14

treat as soon as identified and until 48 hrs after

Question 15

Emollients in Atopic eczema

Answer 15

Large amounts and often
E45, cetraben, diprobase, aveeno
should be applied on whole body
use as soap substitute

Question 16

Topical CS in Atopic eczema

Answer 16

use O/BD
only apply to active eczema
dont use potent CS <12m w/o specialist advise
In areas prone to flares use for 2 consecutive days/wk r/v at 3-6mo
If TCS ineffective use different steroid of same potency before increasing potency

Question 17

Potency of steroid in eczema

Answer 17

Mild: hydrocortisone 1%
mod: betamethasone valerate 0.025% or clobetasone butyrate 0.05%
Potent: betamethasone valerate 0.1%, mometasone
If very severe and extensive consider PO steroids

Question 18

Topical calcineurin inhibitors Atopic eczema

Answer 18

topical tacrolimus 2L in mod-sev eczema (alt. pimecrolimus)
Apply only to active eczema
NOT under occlusive bandages

Question 19

Bandages in Atopic eczema

Answer 19

Can be used w/emollients for areas of lichenified skin
short term flares 7-14d
whole body occlusive may be used by specialists

Question 20

Antihistamines in atopic eczema

Answer 20

1 month trial of nonsedating antihistamone (fexofenadine, certirizine) if sev. itching or urticaria r/v every 3mo
Consider 7-14d of sedating antihistamine (promethazine, chlorphenamine) if causing sleep disturbance

Question 21

Infected eczema

Answer 21

Swab area
Advise maintaining good hygiene (use spatula, dont leave it open)
First line: flucloxacillin (PO if extensive topical if local)
penicillin allergy: erythro/clarithromycin use Abx for no longer than 2w

Question 22

Eczema herpeticum

Answer 22

Oral aciclovir
If widespread start aciclovir immediately and refer for same day derm
if around eyes: opthalmology r/v
Educate parents of signs: rapidly worsening/painful, clustered blisters

Question 23

Alternative treatments in eczema

Answer 23

phototherapy

homeopathy, herbal medicine, food supplements

Question 24

Indication for specialist referral in eczema

Answer 24

Eczema herpeticum (immediate)
Urgent if severe atopic has not responded to optimum therapy within 1wk or treating bacterial eczema has failed
If diagnosis uncertain, atopic on face is not responding, ?contact allergic dermatitis, causing significant impact on life, severe of recurrent infections

Question 25

PACES counselling of Atopic eczema

Answer 25

``` Dx: dry itchy skin very common many will grow out Encourage regular liberal emollients and use as soap substitutes Steroids if necessary A/w atopy avoid triggers: clothes, detergents, soaps, antivirals Avoid scratching if possible (nails short/mittens) Safety net: oozing, red, fever Info+support: itchywheezysneeze.co.uk BAD national eczema society ```

Question 26

Viral warts

Answer 26

daily administration of proprietary salicylic acid or lactic acid paint or glutaraldehyde cryotherapy w/liquid nitrogen

Question 27

Molluscum contagiosum

Answer 27

NOT Rx if immmunocompetent Resolution within 18m Advise agaisnt squeezing mollusca to avoid spreading and superinfections Avoid towel/clothing/bath sharing If eczema or infection develops give emollients/steroids chemical or physical destruction can be done by a specialist

Question 28

Ringworm

Answer 28

Mild: topical antifungal (terbinafine cream, clotrimazole) If marked inflammation consdier 1% hydrocortisone Severe: systemic Afx 1L: terbinafine, 2L itraconazole

Question 29

Tinea capitis:

Answer 29

- systemic Afc (griseofulvin or terbinafide) 2L:itra/fluconazole topical Af shampoo in some patients (ketoconazole)

Question 30

Tinea Faciei, Tinea Corporis, Tinea Cruris or Tinea Pedis

Answer 30

``` topical Afx (terbinafine, naftifine, butenafine) topical aluminium acetate ```

Question 31

Tinea infections

Answer 31

``` Loose fitting cotton cothing wash affected areas of skin daily dry thoroughly after washing Avoid scratching Do not share towels Wash clothes and bed linen frequently No need for school exclusion ```

Question 32

Scabies

Answer 32

``` Topical permethrin 5% - whole body from chin and ears down - particularly between fingers - apply to cool/dry skin and let dry before dressing - wash off after 8-12h - second application 1wk after first 2L: malathion 0.5% Babies: face and scalp included Alternative: benzylbenzoate solution applied below neck but smells bad and had irritant reaction ```

Question 33

Scabies advise

Answer 33

members of household traced and treated bedding, clothing, towels of patient and any potential contacts should be decontaminated by washing at a high temp and drying in a hot dryer Patients whose Sx persist beyond 1m after Rx should be retreated Treat post-scabietic itch w/crotimiton 10% cream or topical hydroc.) Night time sedative antihistamine Seek specialist help: crusted scabies, <2m old

Question 34

Pediculosis (head lice)

Answer 34

wet combing with fine tooth every 3-4d for 2 wees Dimeticone 4% or aqueous 0.5% malathion rubbed into sclap and left overnight shampoo next morning Repeat Rx after 1wk

Question 35

Guttate psoriasis

Answer 35

Coal tar preps useful in plaque psoriasis >6yr Dithranol: resistant plaque psoriasis Calcipotriol: plaque psoriasis >6 occasionally may develp into psoriatic arthritis Psoriasis association

Question 36

Acne vulgaris Advice

Answer 36

Avoid over cleaning (twice daily w/gentle soap adequate) Non-comedogenic products w/pH close to skin Avoid picking/squeezing Rx can take up to 8wks Healthy diet NHS choices BAD

Question 37

Mild-moderate acne

Answer 37

``` Topical: benzoyl peroxide benzoyl peroxide + clindamycin Adapalene (topical retinoid CI in preg/bf) Azelaic acid 20% - creams/lotions preferable of dry skin ```

Question 38

Moderate acne not responding to topical Rx

Answer 38

consider PO Abx: Lymecycline/Doxycycline for MAX 3mo NB. Topical retinoid or benzoyl peroxide should be co-prescribed w/PO abx to reduce risk of Abx resistance Change to alternative after 3m if no improvement If no response to 2 cycles or if scarring send to derm ?isotretinoin COCP in combination w/ topicals in girls (avoid POP)

Question 39

Refer to specialist: Acne

Answer 39

``` severe variant severe with (risk of) scarring multiple failed treatments psychological distress diagnostic uncertainty ```

Question 40

Follow up of moderate/severe acne

Answer 40

R/v each step at 8-12wks if adequate continue Rx for 3m if acne nearly cleared consider maintenance w/topical retinoids or azelaic acid if NO response: consider adherence/moving up ladder

Question 41

Hand foot and mouth disease

Answer 41

Sx Mx only no link to Dx in cattle do NOT need exclusion

Question 42

Insect bites and stings

Answer 42

``` If stinger visible remove by scraping sideways with a finger nail or credit card Clean area Specifics: - bedbugs: pest control - fleas: a/w pets - Lice: check head lice - Scabies ```

Question 43

Transient localised reaction to Insect bites and stings

Answer 43

simple analgesia oral anti-histamine or topical steroids (1%Hydrocort) OTC: crotamiton, topical antihistamines, topical anaesthetics secondary bacterial infection can be treated as cellulitis

Question 44

Animal and human bite

Answer 44

Check risk if tetanus Co-amox 7d (metro/doxy 7d if allergic) Safety net for signs of infection

Question 45

Neck masses

Answer 45

Branchial cyst: anterior to SCM near angle of mandible, anechoic Dermoid cyst: midline, suprahyoid, heterogenous on USS Cystic hygroma: posterior to SCM, painless fluid filled, hyperechoic on USS