1
Q
What is acne vulgaris?
A
Chronic inflammatory dermatosis caused by the obstruction of the pilosebaceous follicles in the face and upper trunk > results in comedones, inflammation and pustules
2
Q
What are the causes of acne vulgaris?
A
Infantile acne (<3m)
Transient and usually due to increase in maternal androgens
Adolescent acne
Increased sebum production / impaired flow of sebum / Propionibacterium acnes
Associations
Puberty, POS, Cushing’s (excess cortisol)
3
Q
What are the different types of acne lesions?
A
Comedones
Dilated sebaceous follicle
- Top is closed = whitehead
- Top is open = blackhead
Papules / pustules
Inflammatory lesions formed from follicles bursting and releasing irritants
Nodules / cysts
Excessive inflammatory response
- Ice-pick scars and hypertrophic scars
4
Q
What are the S/S of acne?
A
- Greasy face
- Lesions
- Psychological impact > low self-esteem
- Can be painful
5
Q
What are the investigations for acne?
A
Clinical diagnosis
If signs of androgen excess > free testosterone, FSH, LH, 24hr urinary cortisol
6
Q
What is the management for acne?
A
Conservative:
- Cleaning face > avoid over-cleaning
- Avoid picking / squeezing due to risk of scarring
Medical:
1. Single topical therapy:
- Topical benzoyl peroxide or topical retinoids (e.g. adapalene)
2. Topical combination therapy:
- Topical abx (clindamycin 1%) + BPO/adapalene
3a. Oral abx (max 3m) + BPO/adapalene:
- 1st line = tetracyclines (lymecycline, doxycycline) > avoided in pregnancy
- 2nd line = macrolides (erythromycin) > can be used in pregnancy
3b. COCP + BPO/adapalene
- Alternative to oral abx
4. Dermatologist referral & oral isotretinoin
- Must be on 2 forms of contraception
- SE > dryness, pruritis, conjunctivitis, muscle aches, deranged LFTs
- Associated with low mood and suicidal ideation
Support
- NHS Choices leaflet on acne
- British Association of Dermatology
7
Q
What is atopic dermatitis (eczema)?
A
Chronic, relapsing, inflammatory skin condition characterised by an itchy, red rash, commonly on flexures
8
Q
What is the presentation of eczema in different age groups?
A
Typically presents before 2yrs but clears in ~50% by 5yrs and 75% by 10yrs
Infant = face and trunk
Older child = extensors of limbs
Young adult = localises to flexures
9
Q
What are triggers of eczema?
A
- Irritants
- Contact allergens
- Extremes of temperature (worse in winter)
- Abrasive fabrics
- Sweating
- Dietary factors
- Inhaled allergens
10
Q
What are the S/S of eczema?
A
Mild
- Areas of dry skin
- Infrequent itching
- +/- small areas of redness
Moderate
- Areas of dry skin
- Frequent itching
- Redness
- +/- excoriation and localised skin thickening
Severe
- Widespread areas of dry skin
- Incessant itching
- Redness
- +/- excoriation, extensive skin thickening, bleeding, oozing, cracking and alteration of pigmentation
11
Q
What are the investigations for eczema?
A
- Infants with moderate/severe eczema + hx of immediate reaction to food = skin prick testing to common food allergens
- Eczema herpeticum = obs, swabs (bacterial superinfection)
12
Q
What is the management of eczema?
A
Mild:
- Simple emollients, large quantities (50/50, Dermol, e45)
- Mild topical steroids (applied 30 mins after emollients)
Moderate:
- Emollients
- Moderate topical steroids (or topical calcineurin inhibitors e.g. Protopic)
- Wet wraps
Severe:
- Emollients
- Potent topical steroids (or topical calcineurin inhibitors)
- Wet wraps
- Systemic therapy (oral ciclosporin)
- Phototherapy
Infected:
- Oral flucloxacillin (erythromycin if pen allergic)
- Skin swab and culture
+ antihistamines if severe itching / urticaria
+ Information and support > itchywheezysneezy.co.uk , BAD , National Eczema Society
13
Q
What is the management of eczema herpeticum?
A
Dermatological emergency
Rare but serious viral infection, normally causes by HSV
- Oral acyclovir
- If around the eyes > same day ophthalmologist referral
- Health education
14
Q
How are emollients used in eczema?
A
- Use in large amounts and often
- Apply on the whole body
- Use as a soap substitute (also instead of shampoo or use unperfumed shampoos)
- Examples = e45, cetraben, diprobase, aveeno
15
Q
Describe the steroid ladder?
A
- 1) Hydrocortisone
- 2) Eumovate
- 3) Betnovate
- 4) Dermovate
> SEs = infections, thin skin, stretch marks, systemic SEs
16
Q
What is Naevus Flammeus?
A
Port-wine stain in distribution of trigeminal nerve
Vivid red/purple macule
- Sturge-Weber syndrome
- Parkes Weber syndrome
- Kippel-Trenaunay syndrome
- Proteus syndrome
> Mx = pulse dye laser
17
Q
What is Naevus Simplex (salmon patches/stork bites/angel’s kiss)?
A
- A common, benign capillary vascular malformation
- Presents at birth as a pink or red patch
- Most often observed on nape of the neck, eyelid, or forehead
- Goes redder when the infant cries
18
Q
What are the investigations for vascular malformations?
A
Clinical diagnosis
+ Imaging
1st = USS
2nd = MRI (Sturge-Weber)
19
Q
What is the management for vascular malformations?
A
Conservative
20
Q
What is a haemangioma?
A
Benign tumour made up of blood vessels that typically appear during the first weeks of life as blue or pink macules or patches, then enter a proliferative phase and become elevated above the surrounding skin surfaces
21
Q
What’s the difference between infantile and congenital haemangioma?
A
Infantile haemangioma = develops a few days/weeks after birth.
Congenital haemangioma = always present at birth. Much rarer.
22
Q
What are the RFs for haemangioma?
A
- LBW, prematurity
- White ethnicity
- Female
- Maternal multiple gestation
- Advanced maternal age
23
Q
What are the S/S of haemangioma?
A
Superficial (50-60%)
- Bright red area of skin and feels warm
- Upper eyelids, midforehead, nape of neck
Deep (15%)
- Blue in colour, forms a lump
- May just look like a lump of normal skin
Mixed
- Bright red area on blue, forms a lump
Kasabach-Merritt
- Haemangioma with thrombocytopenia
24
Q
What is the difference between a haemangioma and a vascular malformation?
A
Hemangiomas are vascular tumours that are rarely apparent at birth, grow rapidly during the first 6 months of life, involute with time and do not necessarily infiltrate but can sometimes be destructive.
Vascular malformations are irregular vascular networks defined by their particular blood vessel type, grow slowly throughout life but do not shrink, and usually require treatment.
25
What are the investigations for haemangioma?
**Clinical diagnosis**
- Doppler USS used to distinguish infantile haemangioma from vascular malformation
- USS > MRI/MRA gold standard to dx complex vascular tumours if lesions are:
o Deep
o Multiple haemangiomas
o Single large capillary haemangioma
o Near the eye
- Medical photography
26
What is the management for haemangioma?
**Conservative:**
- Education and reassurance
**If functional impairment / cosmetic disfiguration:**
- Topical beta blocker and/or CS
- Surgical excision as the adjunct
**If ulceration:**
- Add astringents and barrier protection
- Adjunct > topical abx, becaplermin, analgesia
27
What is erythema toxicum?
- Common rash seen in full-term newborns
- Usually appears in first few days after birth and fades within a week
- Up to half of all newborns will have it
28
What are the S/S of erythema toxicum?
- Maculo-papular-pustular lesions > last for 1 day at a time
- Wax and wane over the first few days / weeks of life
- Begins on face and spreads to limbs
- **Must exclude congenital infection**
29
What is the management of erythema toxicum?
Self-limiting
30
What is Milia?
White pimples on nose and cheeks from retention of keratin and sebaceous material of the pilosebaceous follicle
31
What is strawberry naevi?
**= Infantile haemangioma**
*Common type of birthmark that is usually red or purple*
- Can occur anywhere (usually on face, often on the head and neck areas)
- Develop shortly after birth (presents ~3m)
- Complications = ulceration, bleeding, infection
32
Describe neonatal milia
- Affects ~50% of newborns
- Often nose, but also mouth, palate, scalp, face, upper trunk
- Heal spontaneously within a few weeks
33
Describe primary milia
- Around eyelids, cheeks, forehead, genitalia
- Should clear in a few weeks
- Associated with trauma
34
What is the management for milia?
Self-limiting
35
What is molluscum contagiosum?
Common viral skin infection caused by molluscum contagiosum virus (MCV) (a poxvirus)
36
How is molluscum contagiosum spread?
Not very contagious
- Skin-to-skin transmission, or
- Indirect skin contact with fomites such as bath towels / sponges
37
When does molluscum contagiosum occur?
Maximum incidence 1-4yrs
Majority of cases in children with atopic eczema
38
What are the S/S of molluscum contagiosum?
**Characteristic pinkish / pearly white papules with central umbilication**
- Up to 5mm in diameter
- Lesions appear in clusters in areas anywhere on the body (NOT palms or soles)
- Commonly seen on trunk and in flexures, or anogenital lesions
- Painless but itchy occasionally
39
What is the management for molluscum contagiosum?
**Acute = self-resolving**
- 6-9m, but normally within the year
- No need to avoid school
- Long-sleeve clothes
- Avoid sharing towels, clothing and baths
- Encourage not to scratch
**Chronic (>2yrs) = cryotherapy**
- If eczema or infection develops around the lesions, treat appropriately (e.g. emollients and steroids or antibiotics)
40
What are Mongolian blue spots?
**Flat bluish- to bluish-gray skin markings commonly appearing at birth or shortly thereafter**
- Commonly at base of spine, buttocks and back
- Can appear on shoulders
- Benign and not associated with any conditions or illnesses
- More common in Afro-Caribbean or Asian infant
41
What is the management of Mongolian blue spot?
Self-limiting
Fade slowly after first few years (by 4yrs)
42
What is impetigo?
Superficial bacterial skin infection usually caused by staph aureus or strep pyogenes
43
How is impetigo spread?
**VERY CONTAGIOUS**
- Spread by direct contact with discharge from scabs > bacteria enter skin through minor abrasions then spread to other sites by scratching
- Spread mainly by hands, but indirect spread via toys, clothing, equipment, and the environment may occur
44
When does impetigo occur?
- Primary infection, or
- Complication of existing condition e.g. eczema, scabies, insect bites
Common in children, particularly during warm weather
45
What are the S/S of impetigo?
- Golden-yellow, crusted appearance
- Lesions tend to occur around the mouth, or on the face, flexures and limbs not covered by clothing
46
How is impetigo managed?
**Conservative:**
- Wash areas with soapy water
- Wash hands after touching lesions
- Avoid scratching affected areas and keep nails short
- Avoid sharing towels/bathwater etc
**Medical:**
*Limited, localised disease:*
- 1st line = topical hydrogen peroxide 1% cream
- 2nd line = topical fusidic acid (2%) abx
- > Topical mupirocin if fusidic acid resistance is suspected
*Extensive disease / bullous impetigo:*
- Oral flucloxacillin (erythromycin if pen-allergic)
**School exclusion:**
- Until lesions are crusted/healed, or
- 48hrs after commencing abx
**Arrange RV if no improvement after 7d:**
- RV diagnosis
- Check compliance with treatment and hygiene measures
- Take a swab
- Consider oral antibiotics if fusidic acid was initially used
47
What is nappy rash?
Inflammation of the skin in the area covered by a nappy > most common form of contact dermatitis
48
When does nappy rash occur?
Babies 3-15m
49
What irritants cause a nappy rash?
Urine, faeces, faecal enzymes, nappy components, friction
50
What are the S/S of a nappy rash?
**Erythematous macules and papules in genital area**
*Irritant*
- Well-demarcated variety of erythema, oedema, dryness, scaling
- Sparing skin folds (just skin in contact with nappy)
*Candida albicans*
- Erythematous papules and plaques with small satellite spots or superficial pustules
- Sharply demarcated redness
- > check for oral candidiasis
*Seborrheic*
- Cradle cap and bilateral salmon pink patches
- Desquamating flakes
- In skin folds
51
What is the management of nappy rash?
**Health education:**
- Nappy type > high absorbency, proper fit, disposable
- Leave nappy off as much as possible to help skin dry
- Clean/change every 3-4hrs / ASAP after soiling
- Use water or fragrance-free or alcohol-free baby wipes
- Dry gently after cleaning
- Bath child daily > do NOT use soap, bubble bath, lotions or talcum powder
**If mild erythema + child asx:**
- Advise on the use of a barrier preparation (OTC)
- e.g. Zinc and castor oil ointment
**If moderate erythema + discomfort"**
- If >1m then hydrocortisone 1% cream OD (max 7d)
**If rash persists and Candidal infection is suspected / confirmed on swab:**
- Advise against use of barrier protection
- Topical imidazole cream (e.g. clotrimazole, econazole, miconazole)
**If rash persists and bacterial infection suspected / confirmed on swab:**
- Oral flucloxacillin 7d (clarithromycin if pen-allergic)
- Arrange RV
52
What is Seborrhoeic Dermatitis?
Relatively common skin disorder seen in children that affects the scalp, nappy area, face, and limb flexures
53
What are the S/S of seborrhoeic dermatitis?
- Dandruff / flaking skin on scalp > presents in first 6w, resolves over following weeks
- Erythematous, yellow, crusty, adherent layer that can spread to behind ears, face, flexures > Cradle Cap > non-itchy, associated with Malassezia yeasts
54
What are the investigations for seborrhoeic dermatitis?
- **Clinical diagnosis**
- Skin scrapings for Malassezia
- Culture of swabs
55
What is the management of seborrhoeic dermatitis?
**Conservative:**
- Reassure parents (it is NOT a serious condition)
- Spontaneous resolution by 8m
- Regular washing with baby shampoo
- Gentle brushing to remove scales
- Baby oils
**Mild-moderate:**
- Bathe infant >=1/d using emollient as a soap substitute
- Topical imidazole cream
**Severe:**
- Mild topical steroids e.g. 1% hydrocortisone
56
What is tinea?
Tinea is a contagious fungal skin infection
57
What are the 3 types of tinea?
**Tinea capitis** = scalp
**Tinea corporis** = trunk, legs or arms
**Tinea pedis** = feet
58
What are the S/S of tinea?
Ringed appearance +/- kerion (severe inflamed ringworm patch), red or silver rash
59
What is the management of tinea?
**Mild:**
- Topical antifungals e.g. terbinafine cream, clotrimazole
**Moderate:**
- 1% hydrocortisone
**Severe:**
- Oral antifungals e.g. terbinafine or itraconazole
**Tinea capitis:**
- Oral antifungal e.g. griseofulvin or terbinafine
**Tinea Faciei, Tinea Corporis, Tinea Cruris or Tinea Pedis:**
- Topical antifungal (e.g. terbinafine, naftifine, butenafine)
- Topical aluminium acetate (in some)
**Advice:**
- > VERY contagious so take steps to prevent spread
- Loose-fitting cotton clothing
- Dry thoroughly after washing
- Do not share towels
- Wash affected areas of skin daily
- Avoid scratching
- Wash clothes and bed linen frequently
- No need for school exclusion
60
What are the red flags for neck lumps?
- Sepsis/unwell
- Stridor
- Poor feeding
- Change in voice
- Rapid progression
61
Describe a thyroglossal cyst
- Anterior triangle, midline and below the hyoid
- Derived from remnants of thryoglossal duct
- Moves with swallowing / rising the tongue
- Thin walled and anechoic on USS
62
Describe a brachial cyst
- Lateral congenital mass (failure of pharyngeal clefts to involute)
- Usually located anterior to the sternocleidomastoid near the angle of the mandible
- Anechoic on USS
- Cyst, sinus, or fistula, may be infected
63
Describe lymphadenitis
- Transiently enlarged, tender lymph nodes
- Often multiple small tender bumps
64
What are the investigations for neck lumps?
- Clinical examination
- Systemic symptoms = FBC and blood film
- Thyroglossal cyst = USS
- Atypical lymphadenopathy = TB PPD test, bartonella henselae, EBV, CMV, HIV, toxoplasmosis serology
65
What is the management for lymphadenitis?
- Self-limiting (6w)
- Secondary ix for atypical lymphadenitis
- Abx if secondary bacterial infection
66
What is the management for thyroglossal cyst / branchial cleft abnormality?
Asx = conservative
Sx = Sistrunk’s procedure (surgical removal)
67
What are the investigations for cellulitis?
- Mark the area of cellulitis
- FBC
- Purulent focus culture and molecular diagnostics
- Do NOT take blood or swabs routinely if mild
68
What is the management for cellulitis?
**High-dose flucloxacillin for 7d:**
- Penicillin allergy: clarithromycin
- Arrange RV in 48hrs by phone or in person
**Near eyes or nose:**
- Co-amoxiclav
**If cellulitis occurring on top of VZV:**
- Flucloxacillin + amoxicillin
- Penicillin allergy: ciprofloxacin + metronidazole / clarithromycin
**Advice:**
- Paracetamol or ibuprofen to relieve pain or discomfort
- Safety net - seek help if it gets worse or doesn’t improve in 24-48 hours
69
What are the S/S of eczema herpeticum?
- Rapid onset
- Clusters of itchy and painful blisters
- They are often blood-stained i.e., red, purple or black
- They may weep or bleed.
- Older blisters crust over and form sores (erosions)
- Fever
- Swollen local lymph nodes
70
What is Pityriasis Rosea?
Reaction to a viral infection (reactivation of HSV6 and HSV7)
71
What are the S/S of pityriasis rosea?
- **'Herald patch'** - initial truncal, oval, red, scaly, 2-5cm
- **Followed by secondary rash 1-20d later** - smaller, scaly patches mostly distributed on chest and back
72
What is the management of pityriasis rosea?
**Self-limiting, resolves in 6-12 weeks**
**Conservative:**
- Emollients
- Bathing/showering with plain water and bath oil, or another soap substitute
**Medical:**
- Moderate topical steroid and oral antihistamines may reduce itch
- If severe itching - treatment with zinc oxide, calamine lotion, and even oral steroids may be helpful
- Severe cases - 7d course of aciclovir may lead to faster resolution of lesions and help to relieve itching
- Extensive/persistent cases - phototherapy
73
What is scabies?
Rash caused by parasitic mite > hypersensitivity to mite faeces after 4-6wks
74
How is scabies transmitted?
Skin-to-skin contact
Bedding / furnishings
75
What are the S/S of scabies?
- Itchy rash
- Worse at night
- In web spaces between fingers, on palms and wrists
- Truncal in infants
76
What is the management of scabies?
**TREAT WHOLE HOUSE AND CLOSE CONTACTS**
- Permethrin 5% cream
- Provide information on scabies
- Advice - wash all bed linen and clothes
77
What is Stevens-Johnson syndrome (SJS)?
A rare, serious disorder of the skin and mucous membranes
Usually caused by an allergic reaction to medication or infection
78
What causes SJS?
Most commonly associated with anticonvulsants and antibiotics
79
What are the S/S of SJS?
- Prodromal illness for several days (like UTRI)
- Followed by abrupt onset of tender skin rash
- Starts on trunk then spreads to face and limbs within hours (scalp, palms, soles = usually spared)
- Lesions = diffuse erythema / targetoid > becomes flaccid blisters
- Top layer of affected skin then dies, sheds and begins to heal after several days
- Nikolsky sign = blisters and erosions appear when skin is slightly rubbed
- At least 2 mucosal surfaces are affected
80
What is the management of SJS?
**MEDICAL EMERGENCY, usually requires admission**
- Stop offending drug
- Supportive care e.g. pain relief, fluids, wound care
- +/- topical steroids, abx, IVIG
81
Dermoid cyst?
- Multiloculated and heterogeneous
- Most are located above the hyoid, and their appearances on imaging differentiate them from thyroglossal cysts.
- Contain variable amounts of calcium and fat
82
Cystic hygroma?
- Soft and transilluminate
- Most are located in the posterior triangle
Paeds
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