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MD 3: Paeds > Rash > Flashcards

Flashcards in Rash Deck (54):
1

What are important questions to ask in HOPC?

Are they well or unwell?
Acute onset vs. chronic issue
New issue or previous occurrences?
Progression - Worsening or resolving, Changing in its nature

Description of rash
Appearance – colour, shape, individual vs. clusters of lesions, crusting/scabbing/scaling, vesicles/fluid filled/blistering, oozing/weeping/bleeding
Distribution - Diffuse vs. localized, Region of body, Surface of body – flexural vs. extensor vs. palmer/dorsal surfaces
Itchy
iSigns of infection or inflammation

2

Important associated features?

Fever
Localising features
-Meningism – headache, photophobia, neck pain/stiffness, unwell
-URTI – cough, congestion, coryza, wheeze/SOB
-Joint pain, swelling
-GIT – diarrhoea, abdominal pain

3

Other important information to obtain from history?

Triggers/modifying factors
i. Allergies
ii. Stress/emotion
iii. Irritants - Soaps/detergents, wool

Context
a. Travel history
b. Sick contacts

Past & family history
a. Antenatal and birth history
b. Growth and developmental history
c. Asthma
d. Allergies
e. Eczema

4

What are DDx for vesicular rash?

Impetigo (school sores)
Coxsackie (hand, foot & mouth)
Varicella

5

What are DDx for papular (raised) rash?

Urticaria
Molluscum
Warts
Rubella

6

What are DDx for red blanching rash?

Fever + exanthema
Roseola
Kawasaki disease
Parvovirus (erythema infectiousum)
Measles
Drug reactions

7

What are DDx for purpuric rash?

Enteroviral, HIB, pneumococcus
Septicaemia
Leukaemia
Henoch-Schoenlein purpura
ITP
Trauma/child abuse

8

What are DDx for red/dry/scaly rash?

Eczema
Psoriasis
Tinea
Nappy rash

9

What are DDx for blue/black rash?

Vascular malformations
Haemangioma
Mongolian spots

10

What Ix shoudl be considered for rash + fever?

Bloods
a. FBE
b. CRP
c. ESR
d. Blood cultures

CXR
Lumbar puncture

11

Roseola infantum (HSV-6)

What is the description of the rash?

Erythematous, maculopapular papular

Blanching

Not itchy or painful

Trunk & limbs
Rarely spreads to face & neck

Often confused as drug rash

12

Roseola infantum (HSV-6)

Clinical features?

Common, mild

Sudden onset, high fever lasting 3 – 5 days

URTI symptoms

Rash appears ~3-5 as fever is subsiding (fever is not always followed by the rash)

Complications – febrile convulsions (causes 1/3 in <2yrs), aseptic meningitis, hepatitis

13

Roseola infantum (HSV-6)

Management?

Supportive and symptomatic treatment

14

Coxsackie (Hand, foot & mouth disease)

Rash description?

Vesicles – cheeks, gums, tongue

Papulovesicular rash (can look haemorrphagic)
– palms, soles, fingers, toes, buttocks, genitals, limbs

15

Coxsackie (Hand, foot & mouth disease)

Clinical features

Sore throat

Fever

Anorexia

16

Coxsackie (Hand, foot & mouth disease)

Management?

Symptomatic
a. Analgesia
b. Fluids

Infection precaution
a. Exclusion from school until fluid in blisters is dried only
b. Excreted in faeces for weeks

17

Parvovirus (Erythema infectiousum)

Rash features?

Three stages of the rash:

1. Slapped cheek appearance of rash – red, blanching, lasts 1-3 days, feels burning hot

2. Maculopapular rash – limbs +/- trunk

3. Reticular rash – lace-like pattern that appears in heat, cold and friction

18

Parvovirus (Erythema infectiousum)

Clinical features?

Non-specific prodrome/viral symptoms

+/- fever (15 – 30%)

Rash can persist for 6 weeks intermittently – reappears when hot

Mainly clinical diagnosis but PCR & serology available

Complications – arthritis, bone marrow suppression, foetal hydrops

19

Parvovirus (Erythema infectiousum)

Management?

Supportive & symptomatic management

Highly infectious until rash appears, therefore school exclusion inappropriate

Identify if pregnant contacts



20

Varicella Zoster (Chicken pox)

Rash description?

Rash erupts over 3 – 5 days following prodrome

Crops of small papules that quickly become vesicular and crust over

Can occur anywhere

Most typical locations scalp, face, trunk, mouth, conjunctivae

21

Varicella Zoster (Chicken pox)

Clinical features?

Prodrome (short) fever, lethargy, anorexia

Natural Hx

Infectious 1-2 days before rash appears

Generally benign, self-limiting

Usually unwell for ~5-7 days

Complications - Bacterial superinfection, pneumonia, Encephalitis, cerebillitis, Reye syndrome

Complications more common in infants & > 15 yrs

22

Varicella Zoster (Chicken pox)

Management?

Prevention
a. Vaccination recommended for children > 12 months without hx of varicella

Infection precautions
a. Infectious from 1-2 before rash and until all lesions have fully crusted over
b. Mus be excluded from school until full recovery (all lesions crusted over) or at least one week after the eruption first appears

Symptomatic Rx
a. Calamine lotion, pinetarsal bath
b. Cool compress
c. Oral antihistamines at night to improve sleep
d. Avoid itching

If immunocompromised or some neonates, consider admission and:
a. IV acyclovir
b. ZIG

23

Rubella (German Measles)

Rash description?

Maculopapular rash

Small, discrete lesions

Starts on face and spreads to trunk and limbs over 24 hrs

LAD proceeds rash by 5-10 days

24

Rubella (German Measles)

Clinical features?

Mild febrile illness prodrome – general viral and coryza symptoms

Prodrome lasts 1-5 days

LAD – post-auricular, occipital

Asymptomatic in some (25-50%)

Complications only if perinatal infection

25

Rubella (German Measles)

Management?

School exclusion – 5 days from onset of rash

Check pregnant contacts

Symptomatic & supportive management

Diagnosis - Serology

26

Molluscum

Rash description?

Firm, pearly dome-shaped lesions

Central umbilication

May last months

27

Molluscum

Clinical features?

Eczema may develop in surrounding skin – usually this prompts presentation

Eczema can obliterate the primary lesions

Can become secondarily infected (bacterial)

28

Molluscum

Management?

Education
– very common, caused by a virus, benign, they may develop a few or more and they can last months (will not resolve until full immune system developed) – Don’t share towels but no other restrictions

Treatment of surrounding eczema

Uncomplicated lesions should be left alone
Bothersome, isolate lesions – cryotherapy

Larger areas – immune stimulation agents, 5% benzyl peroxide

29

Kawasaki disease

Rash description?

Polymorphus rash
1. Measles like (red, blotchy, raised)
2. Maculopapular
3. Generalised erythema
4. Target-like

Desquamation may occur later

30

Kawasaki disease

Clinical features?

Predominantly affects <5 years

More common in boys

Diagnosis often delayed as presentation similar to many other viral Exanthems

Complications – coronary artery dilation or aneurysm formation

Clinical features can occur sequentially or may not be all present at the same time – infants less than 12 mths often have incomplete symptoms to meet diagnosis

Clinical diagnosis
Fever > 5 days AND 4/5: polymorphous rash, bilateral conjunctivitis, mucus membrane changes, peripheral changes or cervical LAD
Fever – needs to last at least 5 days for diagnosis

Head & Neck
Bilateral ‘dry’ conjunctivitis – no exudate (differentiates from other viral causes)

Mucus membrane changes - strawberry tongue, dry cracked lips, redness of oropharyngeal mucosa

Cervical LAD – usually unilateral, single, painful

Peripheries
Non-pitting, uncomfortable oedema in feet and hands – reluctance to walk

Arthralgia in hip and knee

Palmar erythema – no pattern to redness, may be fluctuate in intensity
Erythema of soles

31

Kawasaki disease

Management?

Exclude other DDx – staphylococcal infection (scaled skin syndrome, TSS), streptococcal (scarlet fever), measles, Steven’s Johnson syndrome, drug reaction, rheumatoid/juvenile arthritis

Investigations – all patients must have:
a. ASOT/Anti-DNAase B – exclude strep infection
b. Platelet count – marked thrombocytosis in 2nd week of illness
c. ECHO – at least 2; one initially and at 6-8weeks later

3. IV immunoglobulin – preferably within 10days of illness

4. Aspirin daily for 6-8 weeks

32

Meningococcal disease

Petechial and purpuric rash
Non-blanching

Late sign – can appear 12-36 hrs later)

33

Meningococcal disease

Peak < 2 years and adolescence

Preceding viral infection or a blanching rash does not exclude meningococcal disease

Sudden onset of symptoms; often deteriorate rapidly

General viral type – fever, malaise, arthralgia, myalgia, headache, vomiting

Lethargy, reduced conscious state

Suggestive of meningococcal disease
- Leg pain
- Confusion
- Photophobia – late sign > 12 hrs
- Neck pain/stiffness – late sign > 12 hrs

May present with signs of shock

May present with pneumonia, URTI or occult bacteraemia

34

Meningococcal disease

Management?

Commence empirical IV antibiotics as soon as meningococcal disease suspected
a. Ceftriaxone or Cefotaxime
b. Penicillin if cephalosporin’s unavailable
c. IM can be used if IV access can’t be obtained within 15 minutes

Dexamethasone

ABCD
a. Fluid bolus – careful with fluids if suspect meningitis as often increased ADH secretion

Blood cultures

Other investigations within first hour
a. Meningococcal PCR if blood cultures obtained after antibiotic administration
b. FBE
c. U&Es
d. Glucose
e. Coagulation screen – if appropriate (DIC complication)
f. LP – usually not in acute management, consider if suspect meningitis

Infection control
a. Contact precautions
b. Treatment of contacts

35

Impetigo (Strep & Staph)

Rash description?

Infection of the epidermis
Causes GABHS, S. aureus

Lesions are rounded, well demarcated and are grouped & asymmetrical

Areas of ooze + crusts

Commonly on face, trunk or limbs

Can be bullous lesions

Painless
Progressive – rapidly spread/increase




36

Impetigo (Strep & Staph)

Clinical features?

Highly contagious

Common particularly in young children and in hotter months

Clear up in a few days, but may need to be treated again

May be associated with fever

If strep – monitor for post-strep glomerulonephritis

37

Impetigo (Strep & Staph)

management?

Localised, uncomplicated
a. Wash crusts off
b. Saline baths – dry lesions
c. Topical mupirocin 2% ointment

Extensive
a. Swabs - MCS
b. May require antibiotics flucloxacillin or cephalexin

Infection precaution
a. Excluded from school until treatment is started and the sores are completely covered with watertight dressing

38

Scarlet Fever (Group A Strep – S. pyogenes)

Rash description?

Diffuse red flushing

Torso and skin folds

Blanching

Circumoral pallor (pale around mouth)

‘Sand-paper’ like feel




39

Scarlet Fever (Group A Strep – S. pyogenes)

Clinical features?

Peak age = 5 – 10 yrs; extremely uncommon <5yrs

Prodrome – sudden onset high fever
+/- headache, abdo pain, vomiting, malaise

+/- strawberry tongue (initially may be white)

Cervical + submandibular LAD

Pharyngo-tonsillitis – usually starts as this

Rash appears within ~2hrs of prodrome

Complications – Post-strep GN, quinsy, acute rheumatic fever

40

Scarlet Fever (Group A Strep – S. pyogenes)

management?

1. Clinical diagnosis may be confirmed with:
a. Throat swab – less useful as many school-aged children are normal carriers
b. ASOT + anti-DNAase B more specific
2. Penicillin




41

Staphylococcal scalding syndrome

Rash description?

Widespread blistering rash caused by toxin

Distribution – umbilicus (neonates), nose, nasopharynx or throat, conjunctiva

Starts with macular erythema initially on face & major flexures – becomes more generalised

Flaccid bullae develop 2 days later, skin wrinkles and shears off – most marked in groin, neck fold

Mucosae uninvolved

Skin is exquisitely tender

42

Staphylococcal scalding syndrome

Clinical features?

Primarily affects neonates and young children

Usually febrile

Fluid loss rarely significant

Heal over 4-8 days with no sequelae


43

Staphylococcal scalding syndrome

Management?

1. Cultures
a. Obvious sites of infection or nasopharynx and throat
2. Supportive
a. Nursed naked on non-stick material with minimal handling
b. Avoid topical agents in early stages
c. Analgesia
3. Flucloxacillin is treatment of choice
a. Emollients once skin dries and desquamation commences

44

Measles (Rubeola Virus)

Rash description?

Appears 3-4 days later

Red, blotchy, raised

Starts in hairline and moves down the body

Becomes confluent and later may become desquamate – the more confluent, the more severe

Lasts 4-7 days

45

Measles (Rubeola Virus)

Clinical features?

Prodrome – Fever, coryza, conjunctivitis,
Koplick spots – white spots on red buccal mucosa

Infectious from 2 days before illness to 5-days after rash onset

46

Measles (Rubeola Virus)

Management?

Diagnosis – serology (IgM positive after rash), PCR (nasopharyngeal aspirate)

Symptomatic & supportive Rx

Consider Vitamin A supplement in immunocompromised and young infants with severe disease

Complications – otitis media, pneumonia, encephalitis & sclerosing panencephalitis

Can be fatal (bacterial complications most commonly)

47

Urticaria (Hives)

Rash description?

Pruritic elevated skin lesions, surrounded by erythematous base (wheal)

Due to extravasation of plasma into dermis

May be local or generalised

Well circumscribed but often coalesce

May see excoriation

Vary in size

Transience of indivudal lesions

48

Urticaria (Hives)

Clinical features?

Common condition

May be idiopathic or associated with preceding cause

Possible causes – medications, infections, foods (infrequently), bites/stings, physical (pressure, cold, exercise)

Observe for dyspnoea or dysphagia in first few hours (anaphylaxis)

Most common DDx = erythema multiforme – not itchy, not transient, target lesions, often mucosal involvement

49

Urticaria (Hives)

Management?

1. Remove identifiable causes if any
2. Cool compress
3. Education – explanation, information, reassurance
4. Anti-histamines – itching
a. Promethazine (Phenergan) if >2 yrs
b. Cetirizine (Zyrtec) if >1 yr
c. Steroid creams and diet manipulation not indicated/effective

50

Eczema

Rash description?

Rash
Dry, itchy, inflammatory chronic skin disease

Remitting, relapsing course

51

Eczema

Epidemiology

Typically begins in childhood

Affects ~30% children

Onset usually before 12 months

Most ‘grow out of it’ before age 5

52

Eczema

Diagnosis

1. Itch
2. AND 3 or more of:
a. Hx of involvement in skin creases
b. Personal hx of asthma or hayfever
c. Hx dry skin in last year
d. Onset < 3 yrs
e. Visible flexural eczema

53

Eczema

Maintenance Rx?

1. Education
a. Triggers
b. Avoid irritants i.e. soaps, overheating, pets, prickly/woolly clothing
2. Moisturiser
a. Prevent dryness of skin
3. Daily cool bath
4. Control itch
a. Distract child if scratching
5. Consider Vitamin D supplement

54

Eczema

Flare Rx?

Used if acute deterioration (flare) increased erythema and itch

1. Topical steroids
a. Hydrocortisone 1%
2. Tar creams (lichenification)
3. If secondary infection
a. Antibiotics or antivirals
b. Cool bath with added salt, 4% bleach and bath oil
4. Wet dressings
5. Cold compressing relief of itch
6. Consider referrals
a. Eczema workshop
b. Allergy testing and advice
Outpatient clinic