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Flashcards in The infant or child with a rash Deck (71):
1

Etiology

1. Viral
Chicken pox
EBV
CMV
Fifth disease
Roseola
HIV
Hepatitis B/C
HFM
Rubella
Measles
HSV
Molluscum contangiosum
2. Inflammatory
Atopic dermatitis, seborrhoeic, contact, psoriasis, pityriasis rosea, mastocytosis
3. Bacterial
Impetigo
Folliculitis
4. Fungal
Tinea corporis
Scabies
Candidiasis
5. Tick borne
RMSF
Lyme disease
6. Drug eruptions
7. Systemic bacterial
Meningicoccal, syphillis, gonorrhea, endocarditis
SSS
Scarlet fever
TSS
8. Hypersensitivity
9. Vasculitis/rheumatological
Kawasaki
JA
HSP
SLE, RF, Sarcoidosis
10. Child abuse

2

Important history

Is the child well
Could this be an inset bite or allergic reaction
Morphology
Duration
Distribution, progression
Pruritis
Systemic features
Recent viral infection/Strep throat
Family history
Recurrent
Contact, travel, exposures
Complete medical history, medications
Treatment attemtps

3

Unwell child systemic, erythematous rash etiology

1. Erythematous rash
a. Hypersenitivity->insect, bites, allergies, medications
b. Scarlet fever->desquamating, pharyngitis, contact history
c. SSS->superficial desquamation, recent infection, fever, malaise, tender skin
d. TSS->trunk, palms, soles, hyperemic oral mucosa, tampon use
e. SJS
f. RF
g. JA
h. SLE
i. Sarcoidosis
j. Lyme

4

Unwell child systemic, maculopapular

a. Meningicoccal septicemia
b. Bacterial endocarditis
c. Systemic hypersensitivity syndrome
d. Kawasaki
e. Measles
f. HBV/HCV acute
g. HIV
h. RMSF->wrists, ankles, palms and soles, spreads central, spares face, outdoor

5

Unwell child systemic, vesiculobulous

a. SJS/TEN

6

Unwell child systemic, pertehchiael/purpuric

a. Meningicoccal
b. Leukemia
c. HSP
d. RMSF

7

Well child, mild systemic

Erythema multiforme
Roseola
Erythema infectiosum
Drug reaction
CMV
EBV
Rubella
VZ
HFM
Syphilis
Gonorrhea
ITP
Child abuse

8

Well child no systemic

Psoriasis
Pityriasis rosea
Contact/irritant
Nappy rash
Atopic dermatitis
Seberroiec
Tinea
Scabies
Impetigo
Folliculitis
Mastocytosis

9

Physical examination

General, systemic involvement
Describe the rash: raised/flat, crusty/scaly, colour, blanching, size, distribution
Full examination->including LN, CVS, RS, abdominal, ENT

10

Acute rash onset history

Well/febrile
Itchy
Associated symptoms? Bleeding, arthritis and abdominal pain, stridor and urticaria
PMH
Immunisations
Contact

11

Investigations

Generally not required
Rubella serology in pregnant
Cultures if systemic/sepsis
FBC/PLT, coagulation in ITP
Widespread urticaria->RAST consider
FBC, ESR, CRP, biochemical/urinalysis in systemic
Serology->ASOT, anti-DNAse B, IgM/IgG for lyme, ELISA for S aureus in SSS
Serology HIV, HBV, HCV
Blood cultures
LP
Echo->RF, BE, Kawasaki
CXR->RF, sarcoidosis
Biopsy->SSS, SJS, DRESS, HSP

12

Features of scarlet fever: rash, presentation, treatment

Sandpaper
Blanching
Neck, axilla, groin
Face spared
Red tongue
Fever, headace
Group A strep infection, 12 hours post tonsilitis

Treatment: phenoxymethylpenicillin 15mg/kg up to 500mg BD for 10 days

13

Features of measles rash, management

Face->trunk
Koplik spots
Fever, ill, lymphadenopathy
Cough, coryza, conjunctivitis

Notifiable
Supportive care + vitamin A supplementation
Measles IgM/IgG serology

14

Features of rubella rash, complications in congenital rubella

Tiny macules->face to trunk
Generally well child
Suboccipital LN
IP of 14-21 days

Congenital->in first trimester= death, retardation, CHD, deafness, cataracts

15

Features of Fifth disease

Slapped cheeks
Lacy appearance
Mild fever
Lasts up to 6 weeks

16

Presentation of chicken pox

IP 10-21 days
Prodromal fever, lethargy, anorexia, then 3-5 days of eruption
Papules->vesicular->crusting in 10 days
+On scale, face, trunk, mouth and conjunctiva

17

Complications of chicken pox

Pneumonia
Arthritis
Hepatitis
Encephalitis
Superinfection
Cerebellitis
Reye

+in infants, >15 yo and immunocompromised children

18

Management of chickenpox

1. Consider admission IV aciclovir, discussion with consultant:
-->immunocompromised,
-->steroid received,
-->prematures,
-->impaired mental state,
-->cough/tachyP/dys and CXR shows pneumonia/nitis (add antibiotics)

2. If none of these features, >12 yo->discuss and consider oral aciclovir if

19

Exposure porphylaxis in chickenpox

Exposed, no rash

20

Symptomatic management of chickenpox

Calamine lotion
Cool compresses
Keeping skin cool
Oral antihistamines for sleep
Don't scratch, cut nails short

21

Infection precautions in hickenpox

Infectious 1-2 days prior to rash appearing, until fully crusted over. Exclude from school until fully recovered->at least one week after eruption first occurs

22

Types of nappy rash (4)

1. Ammoniacal->irritant, papulovesicular, fissure, erosisons
2. Candidial
3. Seborrhoeic
4. Psoriatic

23

Factors which contribute

Excess hydration-->water in nappy and stool, nappy change frequency
Skin trauma
Ammonia, feces, soap/deterhen, nappy wiped, napkin powders and creams

24

Treatment of nappy rash

Disposable nappies
+Frequency of nappy changing and cleansing
Disposable towel/face washers soaked in water/olive oil to cleanse
Apply barrier cream atevert change->parrafin, vaseline. Apply +++thickness
Let child sleep as long as can without nappy->lay on absorbent sheet, change when wet
If candida->imidazole/nystatin cream +/- hydrocortisone cream

Consider differential

25

Differential diagnosis of nappy rash

Seberrhoiec
Atopic
Psoriasis
Perianal cellulitis
Zinc deficiency
Threadworms
Langerhands cell histiocytosis
Malabsorption
Crohns

26

Meningicoccal rash presentation

Petechiael, purpuric, morbilliform
Shock/coma

27

History and examination assessment of meningicocemia

History:
Rapid, fever, malaise, lethargy, vomiting, myalgia, -ve LOC

Examination:
May be shocked, rash, leg pain, neck stiff, photophobia

Blanching does not exclude
Preceeding viral does not exclude

28

Investigations in meningicoccal

Blood culture (if possible before antibiotics)
Meningicoccal PCR
Glucose, UEC, coagulation
VBG/ABG

Consider LP if meningitis

29

Acute management of meningicocemia

1. ABC, get help
2. IV access
3. Blood cultures and Ix
4. Ceftriaxone or cefotaxime 50mg/kg
5. IVF->shock management, consider 2/3 maintenance following if suspect meningitis
6. Urinary catheter if shock
7. Hydrocortisone if considering meningitis (within 1 hour of antibiotics)
8. Regular analgesia, may need morphine infusion
9. If necrosis, involve plastics early
10. Admission
Isolate until >12 hours antibiotics
11. Contact tracing and prophylaxis for those within 24 hours (contact in last 7 days)->rifampicin, ceftriaxone if contraI or pregnant
12. Monitor vitals and response

30

ITP general, presentation, workup and management

Most common cause of childhood thrombocytopenia
Autoimmune hemorrhagic disorder
1. Petechial rash
2. Bleeding
3. Preceeding viral infection

FBC, PLT low, +coagulation studies

Management:
Mostly self limiting
If ++thrombocytopenia, ongoing bleeding may need admission + steroids

31

Pathogenesis of HSP and epidemiology

Small vessel leukocytoclastic vasculitis w/ IgA deposition within affected organs

Most often in winter following strep infection
More in males, 2-8 years

32

HSP triad

Purpuric rash on extensor surfaces
Joint pain
Abdominal pain

33

Assessment of HSP

1. Purpura->if atypical or unwell, consider meningiC, thrombocytopenia, other vasculitis
2. Joint pain->large joints
3. Abdominal pain usually resolves in 72 hours->look out for intussusception, bloody stool, hematemesis, perforation, pancreatitis
4. Renal involvement->hematuria
5. Subcutaneous edema of scrotum, hands, feet, sacrum
6. Rare complications of pulmonary and CNS

34

Investigations in HSP

FBC
UEC
Blood culture

35

When does Atopic dermatitis usually present, grow out of

Usually presents before 12 months, and will often grow out of it by age 5

36

Diagnosis of atopic dermatitis

Itch + three of
1. Involvement of skin creases
2. Personal hx of asthma/hay fever
3. Dry skin in last year
4, Onset under 2 (not used if under 4 years)
5. Visible flexural eczema

37

What system is used to graded severity in eczema

SCRAD

38

Management of eczema

1. Every day and avoid triggers
->avoid heat, prickly, dry skin
->Regular moisturises twice a day
->Daily cool bathing->add salt, bleach 4% for chronic infected and bath oil
->Consider oral vitamin D supplementation

2. Flaring treatments:
->Topical steroids hydrocortisone 1%
->Tar creams for lichenification
->Antibiotics/virals for infection
->IN bactroban if nasal swabs +ve for S aureus
->Wet dressings
->Cool compress with moisturiser post compress

39

Infected eczema management

Remove the crust, cool compress and soak in bath
Cortison over open skin
Cephalexin/flucloxacillin oral antibiotics. IV if unwell
King bleach 4% to cool bath water, wash scalp and face while bathing
Pool salt can be addedd

For HSV infection->start treatment w/i 48 hours oral acyclovir, IV may be required if severe/immunocompromised.

40

Advice to parents about their child's eczema

1. Identify and avoid triggers->prickly, heat, detergents, soaps, antiseptics
2. Moisturise the skin->twice daily, oils, soap free
3. Reduce itchiness with wet dressing and cool compresses
-cool towel/cloth for 10-15 minutes
-distract
-ovoid overheating
-moisturise
-keep nails short
-apply wet dressing to limbs at bedtime
-cotton clothing, remove woolen, keep house cool, educate others about dressing your child
-All foods considered innocent until guilty

41

WIll the treatment cure eczema

Not for cure, to help control
Will continue for many years in most cases

42

Advice on swimming

Yes, if the eczema is not flaring up. Prior to swimming, apply a layer of moisturiser from top to toe. Soon after swimming, wash the skin thoroughly in a cool shower or bath with some bath oil then reapply the moisturiser. If the eczema flares that night, apply a wet dressing just before your child goes to bed.

43

Define cellulitis, most common causes and predisposing

Spreading infection of subcutaneous tissue
Most common causative agents: GABHS, SA
Skin abrasions, lacerations, burns, eczematous skin

44

When is cellulitis unlikely and allergic/dermatitis often misdiagnosed

Itching only and not tender

45

Who is primarily affected by SSSS, level affected, early features

Neonates and young children
Splits upper epidermis, epidermolytic toxin
Fever and tender erythematous skin early features->discomfort when touched
Exudation and crusting early around the mouth

46

What is impetigo

Highly contagious of epidermis
Common in young children
GABHS and S aureus

47

What is Nikolsky sign

Rubbing normal skin, peels off

48

When does Nikolsky occur

SJS
SSSS

49

Complications in SSS

DeH and electrolyt
Cellulitis
Sepsis
Temperature instability

50

Scabies: causative agent, signs and symptoms, relation to ARF

Sarcoptes scabiei var. hominis
Soft hairless areas
School-aged, indigenous, resisdential
Itching, post strep, excoriations, secondary bacterial, rash
Allergic reaction to mite causes the signs and symptoms
Secondary infection->Streptococcal->ARF

51

Treatment of scabies in children older than 6 months

permethrin 5% cream (adult and child 6 months or older) topically to dry skin from the neck down, paying particular attention to hands and genitalia. Apply under the nails using a nailbrush. Leave on for a minimum of 8 hours (usually overnight) and reapply to hands if washed. Application time may be increased to 24 hours if there is a history of treatment failure. Repeat treatment in 7 days

52

Assessment in scabies

Complete history
Clinical observations
BP++
Urine
Signs of secondary
In recurrent/secondary infection->weight, BP, urinalysis->if abnormal manage/refer to pediatrics
Consider skin scraping/dermatoscopy

53

Treatment of scabies

permethrin 5% cream topically to the entire body, including the scalp but avoiding eyes and mouth. Cover hands to avoid the child sucking the medication. Leave on for 8 hours. Repeat treatment in 7 days

Or 2% sulfur

54

Treatment in scabies immunocompromised

ivermectin (adult and child 15 kg or more) 200 micrograms/kg orally with fatty food, once weekly until scrapings from a burrow are negative and there is no further clinical evidence of infestation.

55

Treatment of norweigan scabies

ivermectin (adult and child 15 kg or more) 200 micrograms/kg orally with fatty food, for 3, 5 or 7 doses depending on severity and clinical response in the first week
for a 3-dose regimen, give on days 1, 2, 8
for a 5-dose regimen, give on days 1, 2, 8, 9 and 15
for a 7-dose regimen give on days 1, 2, 8, 9, 15, 22 and 29.

56

Other aspects of scabies treatment

1. Family treated
2. All linen/bed sheets
3. Warn itch can continue for weeks
4. Repeat treatment in a week

57

Assessment and investigations of cellulitis->defining feature of inpetigo, erysipelas NF

Impetigo->bullious
NF->tender beyond skin signs, thrombocytopenia
Erysipelas->well defined

Ix:
Swab
BC + FBE if fever
ESR, XR if suspect osteoM
USS if fluctuant
Surgical if suspect NF or abscess

58

Antibiotic treatment of cellulitis, impetigo, NF

Cellulitis->Flucloxacillin or cephalexin
Impetigo->wash off crusts, apply 2% muporicin ointment tds, exclude from school/daycare etc until started treatment and cover with tegaderm
SSS->as for cellulitis
NF-> IV flucloxacillin + clindamycin, surgical consult for debridement

59

Investigations and management in SJS

Skin biopsy
Blood cultures
UEC
FBC
LFT
ABG->hypoxemia, acidosis

Management:
ABC, urgent evaluation from senior
IV access, ABG, oxygen
Removal of causative agent
Dressings, topical antibacterial, emolient
Fluids and electrolyte, strict fluid balance
Nutritional support
Oral hygeine->lidocaine mouthwash
Analgesia
IVIG
OT and physiotherapy

60

What is kawasaki disease

Systemic vasculitis, of unknown origin

61

Major concern with Kawasaki

Risk of coronary aneurysm

62

Diagnostic criteria for kawasaki

1. Fever > 5 days

4/5 of
1. Polymorphous rash
2. B/L non purulent conjunctivitis
3. Mucosal membrane changes
4. Peripheral changes->feet/soles
5. Cervical lynphadenopathy->usually SSS, TSS
-Strep->Scarlet fever, TSLS
-Juvenile RA
-Measles, +other viral exanthems
-SJS
-Drug reaction

63

Investigations in kawasaki

ASOT/Anti-DNAase B
EchoC->initial and 6-8 weeks post
PLT-> low

FBC->+neutrophils, normocytic/normochromic anemia
ESR/CRP +
+LFTs
Low albumin

64

Management of Kawasaki

1. Admit
2. IVIG over 12 hours
3. Aspirin daily for 6-8 weeks
4. Investigations->++Echo
5. Analgesia for pain
6. Organise F/U echo in 6-8 weeks following D/C
7. If your child is due a routine MMR (measles, mumps, rubella) immunisation, this should be delayed until 11 months after the gammaglobulin treatment.
8. Most children recover normally

65

Important information about molluscum and management

Viral
Self limiting
6-9 months until resolution
No restriction in activity
Mostly doesn't need treatment
If dermatitis->topical steroids
To ++immune response: consider benzyl peroxide, aluminium acetate solution (Burrow's solution), imiquimod

66

Assessment of urticaria

Extravasation of plasma into dermis
1. Onset
2. Events leading up to
3. Medication, interaction, infections, foods, bites, pressure, cold, exercise

67

Examination in urticaria

General->ensure airway patent, no respiratory distress
Circular, general/localised, polymorphic, transien

68

What to consider when recurrent angioedema without wheals

c1 esterase inhibitor deficiency

69

DDX for urticaria and distinguishing features

Erythema multifore->not itchy, mucosal involvement, persistent, target lesions

Mastocytosis
Flushing
Juvenile rheumatoid arthritis
Vasculitis
Pityriasis rosea

70

Investigationsin chronic urticaria

FBE
ESR
ANA

71

Management of urticaria

1. Remove causative agent
2. Cool compress
3. Education, explanation and reassurance
4. Modification to diet not necessary until causative agent determined
5. Anti-histamine
6. Promethazine or cetirizine (X in

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