Skin disease Flashcards

Question

Complications and prognosis of mongolian blue spot?

Answer 1

Fade slowly over the first few years They are of no significance unless misdiagnosed as bruises

Answer 2

Benign, keratin-filled epidermoid cysts Aka milk spots

Answer 3

Due to retention of keratin and sebaceous material in the pilosebaceous follicles (gland and hair follicles) Arise spontaneously

Answer 4

Common in all ages Affect 50% infants

Answer 5

* Superficial, uniform, white to yellowish, domed lesions * 1-2mm in diameter * Most common on face (esp cheeks, nose and around the eyes) Usually asymptomatic; occasionally itchy

Answer 6

* Clinical diagnosis

Answer 7

Reassurance

Answer 8

Harmless and benign Usually clear within a few weeks; can persist for a few months

Answer 9

* **Infantile haemangiomas**: benign vascular lesions that appear during the first few weeks of life as blue/pink macules or patches, and subsequently regress → aka strawberry naevi * **Congenital haemangiomas**: fully-formed at birth and do not involute

Answer 10

Thought originate from angiogenesis, maybe in response to hypoxia, local growth factors, cytokines and oestrogens RFs: prematurity, low BW, advanced maternal age, multiple gestation, pre-eclampsia

Answer 11

Reasonably common à 1-3% of all newborns; 14% of infants whose BW is 1000-1500g 1/3 are evident at birth

Answer 12

* Usually present in the first few weeks of life * Occasionally present at birth * Initial signs are subtle pink patches or telangiectasias * Grow rapidly during the first 3-15 months of life (proliferative phase), then gradually regress (involution) * Soft * May be flat macules or patches, or nodules * May be multiple

Answer 13

* Clinical diagnosis * Consider: * Doppler USS * To differentiate haemangioma from vascular/lymphatic malformations if necessary Biopsy

Answer 14

Education and reassurance If large or interfere with function: * Topical/oral propranolol +/- corticosteroid * Surgical excision if particularly large/obvious/may interfere with function

Answer 15

Complications: * Cosmetic disfigurement * Ulceration and bleeding (esp in areas of friction) * Interference with sight, hearing, breathing, swallowing, speaking (if large on face) * Propranolol and corticosteroid SEs * Residual skin changes: scarring, atrophy, discolouration, telangiectasia Growth is almost always complete by 9mo; regression occurs over 1-8yrs Residual changes persist in 50%

Answer 16

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

Answer 17

* Irritant (contact) dermatitis * Most common cause * Main irritants are moisture from urine and faeces, and faecal enzymes (ureases, proteases, lipases) * Other potential irritants are nappy components, friction from nappy, repeated wiping of the area or application of baby care products * May occur if nappies are not changed frequently enough or baby has diarrhoea * But can occur even if nappy area is cleaned regularly * Infection * May cause or exacerbate nappy rash * Candida is most common; also S. aureus, coxsackie virus, HSV * Underlying dermatological disorders are associated with nappy rash development: * Infantile seborrhoeic dermatitis * Atopic eczema

Answer 18

* age \<2yo, * diarrhoea, * underlying dermatological disorder, * infrequent nappy changes, * excess use of baby care products, * excess wiping, * no nappy-free time, * recent antibiotic use

Answer 19

Very common à 50% Majority of newborns have some skin breakdown in the nappy area by 1wk of age, with increasing severity by 3wks Most common in first 2yrs of life (when wearing nappies) but can occur in anyone who routinely wears nappies

Answer 20

* **Irritant**: * Acute onset * Affects convex surfaces of the buttocks, perineal region, lower abdomen and top of thighs * Flexures are spared → differentiates from other causes of nappy rash * Erythematous, may have a scalded appearance * Erosions and ulcers if severe * **Candida**: * Shiny erythematous patches * Includes skin flexures * May be satellite lesions (folds of groin, neck, axilla, oral candidiasis) * Nappy rash persisting for \>3d is frequently associated with C. albicans

Answer 21

* Clinical diagnosis * Consider if diagnostic doubt/treatment failure: * KOH test of skin scraping for Candida * Bacterial and fungal cultures of skin * Serum zinc level (zinc deficiency can cause rash)

Answer 22

**Advise good nappy practice:** * Change/inspect for soiling every 2hrs (more frequent in newborns/diarrhoea) * Remove potential irritants (wipe the area) * Use products with minimal additives * Allow nappy-free time whenever practical **Irritant**: * Mild: protective emollient * Severe: low potency topical corticosteroids, e.g. hydrocortisone BD for 3-14d * Used if suspected pain * Protective emollient applied after steroid **Candida**: * Topical antifungal, e.g. nystatin * Used if rash persists for \>3d; continue use for 3d after rash clears * Protective emollient applied after the antifungal **If secondary bacterial infection is suspected:** * Topical antibacterial therapy, e.g. mupirocin **_Refer to dermatologist for patch testing/biopsy if persists for \>14d_**

Answer 23

Complications: * Secondary bacterial infection Acute irritant contact nappy dermatitis typically resolves within 1wk Nappy rash infected with candida may take 10d-3wks to resolve

Answer 24

Common inflammatory skin disorder of the scalp that, in infants, manifests as scaling of the scalp (aka cradle cap)

Answer 25

Aetiology is unknown * May be hormonally-dependent à explains why it arises in infancy, disappears spontaneously in childhood and re-emerges after puberty * Probably due to proliferation of the resident Malassezia furfur fungus * This fungus metabolises triglycerides to form oleic acid à oleic acid causes inflammation when it filters through the epidermis

Answer 26

Most common in first 3 months of life; prevalence decreases rapidly by 1yo; incidence increases again in adults Cradle cap occurs in 42%

Answer 27

* Starts on the scalp as an erythematous scaly eruption * The scales form a thick yellow adherent layer à cradle cap * The scaly rash may spread to the face, behind the ears, and then extend to the flexures and nappy area * May be more erythematous in other areas and less yellow/scaly * Not itchy and child is not bothered by it * In contrast to atopic eczema * In adults: presents with erythema, pruritis and scaling of scalp, glabella and nasolabial folds Rare in children

Answer 28

* Clinical diagnosis

Answer 29

**_Cradle cap in infants:_** * **Emollients**, e.g. topical olive oil * **Topical corticosteroids**, e.g. hydrocortisone * If severe and hasn’t responded to emollients * **Ointment containing low-concentration sulphur** and **salicylic acid** * To clear the scales on the scalp * Applied daily for a few hrs then washed off **_Scalp seborrhoeic dermatitis in children:_** * **Topical shampoos (e.**g. coal tar) * +/- **topical hydrocortisone** **_Widespread eruptions:_** * **Topical corticosteroid** (hydrocortisone) * +/- **antibacterial/antifungal agent** * Dermatology referral

Answer 30

Complications: * Secondary bacterial infection (impetigo) * Increased risk of developing atopic eczema Self-limiting and generally declines from 4 months after birth NB in adults it has a fluctuating course and tends to flare (esp in response to stress)

Answer 31

Inflammatory skin condition characterised by dry, pruritic skin with a chronic relapsing course Aka atopic dermatitis

Answer 32

Aetiology is multifactorial à combination of genetic susceptibility and environmental factors * There is thought to be deficiency of skin barrier function (due to loss of function mutations in filaggrin protein) * Impairment of the skin’s barrier leads to increased immune sensitisation to cutaneous antigens à associations with food allergy, asthma and atopic rhinitis * Predominantly mediated by Th2 cells Can be described as acute of chronic * Acute eczema: flare-up of symptoms (exacerbation) * Intracellular epidermal oedema (spongiosis) and leukocyte infiltration * Chronic eczema: the condition when the patient develops signs of chronic inflammation (e.g. lichenification) * Thickening of epidermis and striatum corneum, and dysfunction of keratinisation

Answer 33

* FHx of atopy (eczema, asthma, allergic rhinitis), * exclusive breastfeeding delays onset but doesn’t impact prevalence in later childhood * 1/3 children with atopic eczema will develop asthma

Answer 34

Prevalence 20% in children Onset is usually in first year of life * Uncommon in first 2 months (unlike infantile seborrhoeic dermatitis)

Answer 35

* **Pruritis** (main symptom) * Results in scratching and exacerbation of the rash à excoriation * May disturb sleep * **Excoriated areas become erythematous, weeping and crusted** * **Dry skin** * **Hypopigmentation** * **Lichenification** * Accentuation of normal skin markings * With prolonged scratching and rubbing * **Distribution varies with age:** * **Infant (\>2mo):** mostly face, also trunk; spares nappy area * **Older child**: mostly flexor and friction surfaces (elbows and knees, neck, ankles)

Answer 36

* Clinical diagnosis * Skin prick testing * If allergy is suspected * Dietary elimination of food allergens may be needed for 4-6wks to detect improvement

Answer 37

**Avoid irritants and precipitants** * Avoid soap and biological detergents * Clothing next to the skin should be pure cotton where possible (avoid nylon and pure wool) * Cut nails short to reduce damage from scratching; mittens at night may help young children * Avoid allergens if they are the trigger (e.g. cows milk) **Emollients**: * Mainstay of management * Apply liberally 2-3x/d and after a bath * Baths using emollient oil and soap substitute can be used **Topical corticosteroids:** * Mild steroids, e.g. hydrocortisone: apply 1-2x/d * Moderately potent steroids, e.g. fluticasone * Used for acute exacerbations; keep use to a minimum * Apply thinly and avoid face **Immunomodulators (calcineurin inhibitors):** * E.g. tacrolimus ointment * In children \>2yo with eczema not controlled by topical steroids and where there is risk of important SEs from further topical steroid use **Bandages/wet wraps:** * Used over the limbs where scratching and lichenification is a problem * May be impregnated in zinc or tar paste * Worn overnight for 2-3d at a time until the skin has improved * Wet stockinette wraps: * Used short-term in young children with widespread itching * Diluted topical steroids mixed with emollients are applied to the skin, overlied with damp wraps and then dry wraps **Oral antihistamines:** * For itch suppression * 2^nd generations are not sedative **Antibiotics:** * Antibiotics with hydrocortisone can be applied topically for mildly infected eczema * Systemic (oral) antibiotics for more widespread bacterial infection * Should cover S. aureus, e.g. flucloxacillin **Dietary elimination:** * Food allergy may be suspected if the child reacts consistently to food, or in infants and young children with moderate-severe atopic eczema, esp if associated with GI symptoms * Trial of extensively hydrolysed or amino acid formula for formula-fed infants \<6mo * Dietician input (to ensure whole food groups are not being avoided) * Food challenge is required to be fully objective **Psychosocial** **support**: * Can disrupt child and whole family * National Eczema Society gives support and education

Answer 38

Complications: * Exacerbations * Psychological stress * Complications of steroids à skin thinning, systemic SEs * Regional lymphadenopathy * **Impetigo** * Localised, highly-contagious infection, (S. aureus or Group A Strep) * Most commonly occurs in eczema (as destruction of the epidermal barrier allows the bacteria easy access), but also occurs in other skin disease * Other RFs are poor hygiene, overcrowding, chronic colonisation with S. aureus and increased humidity * Classic honey-coloured crust * Also erythema, vesicles, pustules, sometimes bullae * Treatment: * Topical antibiotics (e.g. mupirocin) for mild cases * Oral antibiotics (e.g. flucloxacillin, erythromycin) for more severe cases * Do not go to school until lesions dry * **Eczema herpeticum** *(**see images**)* * Infection with HSV à spreads rapidly on atopic skin à extensive vesicular reaction * Grouped vesicles or pustules, may later progress to ‘punched out’ ulcerations * Often extensive skin involvement but areas of active eczema seem to be most severely affected * Emergency * IV acyclovir * In primary care give oral (then transfer to hospital for IV) Mainly a disease of childhood à most severe in 1^st year of life, resolves in 50% by 12yo and 75% by 16yo

Answer 39

Inflammatory skin condition characterised by dry, pruritic skin with a chronic relapsing course Aka atopic dermatitis

Answer 40

Aetiology is multifactorial à combination of genetic susceptibility and environmental factors * There is thought to be deficiency of skin barrier function (due to loss of function mutations in filaggrin protein) * Impairment of the skin’s barrier leads to increased immune sensitisation to cutaneous antigens à associations with food allergy, asthma and atopic rhinitis * Predominantly mediated by Th2 cells Can be described as acute of chronic * Acute eczema: flare-up of symptoms (exacerbation) * Intracellular epidermal oedema (spongiosis) and leukocyte infiltration * Chronic eczema: the condition when the patient develops signs of chronic inflammation (e.g. lichenification) * Thickening of epidermis and striatum corneum, and dysfunction of keratinisation RFs: FHx of atopy (eczema, asthma, allergic rhinitis), exclusive breastfeeding delays onset but doesn’t impact prevalence in later childhood * 1/3 children with atopic eczema will develop asthma Causes of exacerbations of eczema: * Bacterial infection (e.g. S. aureus), viral infection (e.g. HSV), irritants (e.g. soap), allergens (e.g. egg, cow’s milk protein), heat/humidity, drugs, psychological stress

Answer 41

Prevalence 20% in children Onset is usually in first year of life * Uncommon in first 2 months (unlike infantile seborrhoeic dermatitis)

Answer 42

* Pruritis (main symptom) * Results in scratching and exacerbation of the rash à excoriation * May disturb sleep * Excoriated areas become erythematous, weeping and crusted * Dry skin * Hypopigmentation * Lichenification * Accentuation of normal skin markings * With prolonged scratching and rubbing * Distribution varies with age: * Infant (\>2mo): mostly face, also trunk; spares nappy area * Older child: mostly flexor and friction surfaces (elbows and knees, neck, ankles)

Answer 43

* Clinical diagnosis * Skin prick testing * If allergy is suspected * Dietary elimination of food allergens may be needed for 4-6wks to detect improvement

Answer 44

**Avoid irritants and precipitants** * Avoid soap and biological detergents * Clothing next to the skin should be pure cotton where possible (avoid nylon and pure wool) * Cut nails short to reduce damage from scratching; mittens at night may help young children * Avoid allergens if they are the trigger (e.g. cows milk) **Emollients**: * Mainstay of management * Apply liberally 2-3x/d and after a bath * Baths using emollient oil and soap substitute can be used **Topical corticosteroids:** * Mild steroids, e.g. hydrocortisone: apply 1-2x/d * Moderately potent steroids, e.g. fluticasone * Used for acute exacerbations; keep use to a minimum * Apply thinly and avoid face **Immunomodulators (calcineurin inhibitors):** * E.g. tacrolimus ointment * In children \>2yo with eczema not controlled by topical steroids and where there is risk of important SEs from further topical steroid use **Bandages/wet wraps:** * Used over the limbs where scratching and lichenification is a problem * May be impregnated in zinc or tar paste * Worn overnight for 2-3d at a time until the skin has improved * Wet stockinette wraps: * Used short-term in young children with widespread itching * Diluted topical steroids mixed with emollients are applied to the skin, overlied with damp wraps and then dry wraps **Oral antihistamines:** * For itch suppression * 2^nd generations are not sedative **Antibiotics:** * Antibiotics with hydrocortisone can be applied topically for mildly infected eczema * Systemic (oral) antibiotics for more widespread bacterial infection * Should cover S. aureus, e.g. flucloxacillin **Dietary elimination:** * Food allergy may be suspected if the child reacts consistently to food, or in infants and young children with moderate-severe atopic eczema, esp if associated with GI symptoms * Trial of extensively hydrolysed or amino acid formula for formula-fed infants \<6mo * Dietician input (to ensure whole food groups are not being avoided) * Food challenge is required to be fully objective **Psychosocial support:** * Can disrupt child and whole family * National Eczema Society gives support and education

Answer 45

Complications: * Exacerbations * Psychological stress * Complications of steroids à skin thinning, systemic SEs * Regional lymphadenopathy * Impetigo * Localised, highly-contagious infection, (S. aureus or Group A Strep) * Most commonly occurs in eczema (as destruction of the epidermal barrier allows the bacteria easy access), but also occurs in other skin disease * Other RFs are poor hygiene, overcrowding, chronic colonisation with S. aureus and increased humidity * Classic honey-coloured crust * Also erythema, vesicles, pustules, sometimes bullae * Treatment: * Topical antibiotics (e.g. mupirocin) for mild cases AI * Oral antibiotics (e.g. flucloxacillin, erythromycin) for more severe cases * Do not go to school until lesions dry * Eczema herpeticum * Infection with HSV à spreads rapidly on atopic skin à extensive vesicular reaction * Grouped vesicles or pustules, may later progress to ‘punched out’ ulcerations * Often extensive skin involvement but areas of active eczema seem to be most severely affected * Emergency * IV acyclovir * In primary care give oral (then transfer to hospital for IV) Mainly a disease of childhood à most severe in 1^st year of life, resolves in 50% by 12yo and 75% by 16yo

Answer 46

A viral skin infection that causes benign, raised lumps

Answer 47

Caused by the molluscum contagiosum virus (a ubiquitous poxvirus) * In children it is caused by the MCV 1 and 1v subtypes * NB MCV2 causes sexually-transmitted disease in the groin in adults * The virus infects keratinocytes and mucosa à abnormal keratinocyte growth Lesions appear within a few days to up to 6wks after viral infection

Answer 48

Infection is classified according to site: * **Scalp**: tinea capitis * **Feet:** tinea pedis * **Hands**: tinea manuum * **Nail**: tinea unguium/onychomycosis * **Body** (incl trunk and arms): tinea corporis

Answer 49

* exposure to infected people/animals/soil/fomites, * atopic dermatitis, * immunosuppression, * humid weather

Answer 50

* **Tinea capitis (image):** * Can cause hair loss with broken hairs at the surface * There may be circumscribed areas of scaling and inflammation * **Tinea corporis (image):** * Skin lesions have annular scaly plaques with raised edges * May be vesicles and pustules * Characteristic pattern of inflammation à active border * Greater degree of redness and scaling at the edge of the lesion * Central clearing is often present (distinguishes from psoriasis, lichen planus) * **Tinea pedis:** * Affects web of toe à skin may be erythematous * **Tinea unguium:** * Onycholysis * Nail dystrophy with separation of the nail from the nail bed

Answer 51

* **Tinea capitis (image):** * Can cause hair loss with broken hairs at the surface * There may be circumscribed areas of scaling and inflammation * **Tinea corporis (image):** * Skin lesions have annular scaly plaques with raised edges * May be vesicles and pustules * Characteristic pattern of inflammation à active border * Greater degree of redness and scaling at the edge of the lesion * Central clearing is often present (distinguishes from psoriasis, lichen planus) * **Tinea pedis:** * Affects web of toe à skin may be erythematous * **Tinea unguium:** * Onycholysis * **Nail dystrophy with separation of the nail from the nail bed**

Answer 52

* **Clinical diagnosis** * **Potassium hydroxide (KOH) microscopy of skin scrapings and nail clippings** * To confirm diagnosis when unclear clinically (and always before starting treatment in nail infection) * Fungal spores and hyphae can be seen * **Fungal culture** * For definitive identification of fungus * **Examination of tinea capita under filtered UV (Wood’s) light** * May show bright green/yellow fluorescence of the infected hairs with some fungal species

Answer 53

**Tinea capitis:** * Systemic antifungal therapy * Griseofulvin (children \>2yo) or itraconazole * Can just treat with topical antifungals (shampoo) if mild * Topical antifungal shampoo * E.g. selenium sulphide 1-2.5% **Tinea corporis, tinea pedis:** * Topical antifungal therapy * E.g. miconazole, ketoconazole * Applied for 2-4wks **Animal sources of infection also need to be treated**

Answer 54

Complications: * **Kerion**: inflammatory, painful scalp patch associated with untreated tinea capitis * Can cause scarring alopecia * Treat with prednisolone * **Secondary bacterial infection in tinea pedis** **_Prognosis is excellent with treatment_**

Answer 55

Inflammatory skin condition characterised by red pimples on the skin, esp on the face, due to inflamed or infected sebaceous glands (pilosebaceous units)

Answer 56

Usually begins around puberty following adrenergic stimulation of the sebaceous glands and an increased sebum excretion rate * Obstruction to the flow of sebum in the sebaceous follicle (by hyperkeratosis) à distension of sebaceous follicle à neutrophil infiltration (inflammation) * External factors occasionally contribute, e.g. cosmetics, corticosteroids * Exacerbations may be associated with menstruation and emotional stress

Answer 57

* 12-24yo, * genetic predisposition, * greasy skin type, * precipitating drugs (androgens, corticosteroids) Infantile acne: * appears in \<3mo; * transient and due to maternal androgens

Answer 58

Very common (esp in adolescents – 75%) More common in boys during adolescence, but in women during adulthood

Answer 59

* Variety of lesions: * Initially closed comedones (whiteheads – contain serous fluid) or open comedones (blackheads – due to oxidation of melanin) * Progress to: * Papules * Pustules * Nodules * Cysts * Skin lesions can be described as inflammatory or non-inflammatory * Non-inflammatory are open and closed comedones inflammatory are papules/pustules/nodules/cysts * Mainly on the face, back, chest and shoulders * Leads to scarring if severe

Answer 60

* Clinical diagnosis * May investigate underlying cause if indicated (e.g. PCOS, Cushing’s)

Answer 61

**Advice**: * Non-greasy cosmetics, daily face wash * Sunlight (in moderation) can help (phototherapy can help) * Dietary restriction is not beneficial **Mild-moderate non-inflammatory acne:** * Topical retinoid (e.g. tretinoin) or salicylic acid * In children \>12yo * Topical retinoids (vit A) encourage skin to peel and reduce obstruction within follicle * Salicylic acid is keratolytic and encourages skin peeling * Apply to affected area every evening **Mild inflammatory acne:** * Topical retinoid (tretinoin) * + topical antibiotic * E.g. clindamycin, erythromycin * Retinoid and antibiotic are available separately or in combination à synergistic * +/- topical benzoyl peroxide * Keratolytic agent to encourage skin to peel **Moderate-severe inflammatory acne:** * Topical retinoid * + oral antibiotic * E.g. tetracyclines (only if \>12yo as may discolour teeth in younger children), erythromycin * +/- topical benzoyl peroxide **Severe/resistant acne:** * Oral retinoid (e.g. isotretinoin) * For severe acne in teenagers unresponsive to other treatments * SEs: depression and suicidal ideation, teratogenicity (must counsel women), myalgia, headaches * Effective contraception must be used in oral and topical retinoid use **If hormone-related in females:** * COCP * Consider anti-androgens (spironolactone)

Answer 62

Complications: * Psychological morbidity → depression, social isolation, anxiety * Scarring * Secondary infection * Dyspigmentation Usually resolves in late teens, but may persist * Persist at 25yo in 12% women and 5% men

Skin disease Flashcards

(86 cards)