MRCPCH Clinicals > Derm > Flashcards

Derm Flashcards

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1
Q

A 6 year old child comes in with an itchy rash, particularly over the flexural areas such as their knees, wrists and ankles. They have asthma and is allergic to nuts. What is their diagnosis and management?

A

Atopic dermatitis = eczema

Management:
1) Emollients - soap substitutes
2) Topical corticosteroids - use lowest effective potency
3) Adjuncts i.e. topical calcineurin inhibitors e.g. tacrolimus/pimecrolimus

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2
Q

What are some triggers for atopic dermatitis?

A

Soaps
Heat
Stress
Dry skin
Infections
Allergens

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3
Q

Name 2 complications of eczema

A

Secondary infection from Staph aureus
Eczema herpeticum (HSV - emergency)
Sleep disturbance
Psychosocial impact

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4
Q

What is the difference between naevus simplex vs port wine stain?

A

Naevus simplex is a common, benign capillary malformation which fades spontaneously and requires no treatment
- Salmon patch
- Stork bite

Port Wine stain is darker, unilateral and does not fade

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5
Q

What are the key clinical features of port wine stain?

A

Congenital capillary malformation causing a flat, pink-purple vascular patch present at birth that does not regress.

  • Unilateral, well-demarcated
  • Flat initially - may darken and thicken with age
  • Persists for life
  • Commonly is found on the face in the trigeminal nerve distribution
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6
Q

What is an important association of port wine stain?

A

Sturge-Weber syndrome = congenital, non-inherited neurocutaneous disorder with vascular malformations affecting skin, brain and eyes
- Facial port wine stain in V1 distribution

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7
Q

What are the clinical features of Sturge Weber syndrome?

A

STURGE mnemonic:
Seizures
Tram-track calcifications (on neuroimaging)
Unilateral port-wine stain (commonly V1,V2 distribution of trigeminal nerve)
Retardation
Glaucoma
Epilepsy

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8
Q

What is the difference between port wine stain and infantile haemangioma?

A

Port wine stain is a congenital capillary malformation whereas infantile haemangioma is a vascular tumour

PWS has no growth phase or involution whereas infantile haemangioma does

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9
Q

Name 2 differentials for port wine stain

A

Infantile haemangioma
Naevus simplex

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10
Q

What is the management of port wine stain?

A

Medical:
- Ophthalmology review - glaucoma risk
- Neurology - if seizures/V1 involvement
- Community paediatrician - development
- Dermatology - pulsed dye laser (cosmetic improvement, best started early)

Psychological support

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11
Q

Would you treat port wine stain with propranolol?

A

NO

Propranolol is used for infantile haemangiomas NOT port wine stains
- PWS are capillary malformations and managed with laser therapy

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12
Q

What is an infantile haemangioma?

A

Benign, vascular tumour of infancy characterised by rapid postnatal proliferation followed by gradual spontaneous involution

Appearance:
- Bright red, raised
- Blanches with pressure

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13
Q

What is the natural progression of infantile haemangioma?

A

1) Proliferative phase: 0-6/9 months
2) Involution phase: begins after 1 year and continues over several years
- 50% resolved after 5 years; 90% resolved by 9 years

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14
Q

What are the red flags/complication of infantile haemangioma?

A

Location:
- Periorbital: visual impairment
- Airway (beard distribution): airway obstruction
- Large facial lesion: PHACE syndrome (rare condition linking infantile haemangioma with defects in brain, arteries, heart and eyes)

  • Ulceration: pain, infection
  • Multiple 5 or more: risk of hepatic haemangiomas = heart failure
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15
Q

How many infantile haemangiomas put you at risk of heart failure and how?

A

5 or more
Hepatic haemangiomas can cause heart failure

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16
Q

What is the management of infantile haemangioma?

A

Conservative (majority): reassurance and regular review

Medical:
Propranolol
- Indicated if functional impairment, ulceration, cosmetic risk or airway/eye involvement
Topicol timolol (small superficial lesions)
Surgery/laser (selected cases)

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17
Q

What is important to monitor for in the context of starting propranolol?

A

Must have a baseline assessment first: HR, BP and glucose

Monitor for:
- Bradycardia
- Hypotension
- Hypoglycaemia
- Bronchospasm

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18
Q

Name 3 causes of cafe au lait spots

A

Neurofibromatosis type 1
McCune-Albright Syndrome
Legius syndrome
Noonan syndrome

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19
Q

How many cafe au lait spots are significant?

A

6 or more = NF1
Size:
- > 5 mm in pre-pubertal children
- > 15 mm in post-pubertal children

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20
Q

What is McCune Albright syndrome?

A

Cafe au lait spots + fibrous dysplasia (bone pain, fractures, deformity) + precocious puberty

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21
Q

What is vitiligo?

A

Acquired autoimmune condition causing well-demarcated depigmented macules due to destruction of melanocytes

Depigmented lesions (NOT hypopigmented)

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22
Q

What other conditions are vitiligo associated with?

A

T1DM
Autoimmune thyroid disease
Addison disease
Pernicious anaemia

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23
Q

What is the Koebner phenomenon?

A

Vitiligo at sites of trauma

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24
Q

What is albinism?

A

A genetic disorder of melanin production = generalised hypopigmentation of the skin, hair and eyes with visual impairment

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25
What are the 2 types of albinism?
Oculocutaneous albinism (most common) - affects skin, hair and eyes Ocular albinism - mainly eye involvement, X-linked
26
What other organ can be implicated in albinism?
Eyes - nystagmus Can have reduced visual acuity, photophobia or strabismus. Visual impairment affects development.
27
What is SJS?
Stevens Johnson Syndrome Severe, life-threatening mucocutaneous hypersensitivity reaction - Most commonly drug induced
28
How is SJS and TEN differentiated?
Body surface area SJS = < 10% BSA Toxic epidermal necrolysis = > 30%
29
Name 3 causes of SJS
Drugs: - Antibiotics: penicillin - Antiepileptics: carbamazepin, lamotrigine, phenytoin) - NSAIDs - Allopurinol Infections: - Mycoplasma pneumoniae
30
What are the complications of SJS?
Sepsis Fluid loss + electrolyte imbalance AKI Permanent scarring Visual loss
31
What is the management of SJS?
MEDICAL EMERGENCY 1) Stop causative drug 2) Admit to HDU/PICU/Burns unit 3) Supportive care: IV fluids, temperature control, analgesia, wound care 4) Early ophthalmology input 5) MDT approach: immunomodulatory treatments
32
What is the difference between SJS and SSSS?
SJS involves the mucosa where SSSS does not
33
A 4 year old child with a background of eczema presents to ED with painful, non-itchy vesicles. She has fever and is lethargic. What is the diagnosis, differentials, investigations and management?
Eczema herpeticum DDx: - Impetigo - Eczema flare - Chickenpox Ix: - Mainly clinical diagnosis but can do HSV PCR swab - Bloods Mx: MEDICAL EMERGENCY 1) IV aciclovir 2) IV fluids + analgesia 3) IV Abx if secondary antibiotics present 4) Urgent ophthalmology if facial/eye involvement
34
What is the important complication of eczema herpeticum to monitor for?
Eye involvement - Herpetic keratitis leading to blindness
35
What is psoriasis?
Chronic, immune-mediated inflammatory skin condition characterised by well-demarcated erythematous plaques with silvery scales
36
What are the different types of psoriasis?
1) Chronic plaque psoriasis (most common) - extensor surfaces 2) Guttate psoriasis - acute onset of small drop-like lesions; often follows strep infection 3) Flexural psoriasis
37
What is the management of psoriasis?
Mild to moderate: - Emollients - Topical steroids - Vitamin D analogues Moderate to severe: - Phototherapy - Systemic therapy e.g. methotrexate, biologics
38
What other conditions are associated with psoriasis?
Psoriatic arthritis Obesity
39
What is acne?
Chronic, inflammatory disorder of the pilosebaceous unit due to follicular obstruction, increased sebum production and inflammation
40
What is the management of acne?
Mild: - Topical benzoyl peroxide - Topical retinoids Moderate: - Topical retinoid + benzoyl peroxide Severe/refractory: - PO isotretinoin (specialist only): must monitor for mood changes, teratogenicity, LFTs and lipids Gentle skin care Avoid picking/squeezing 6-8 weeks to improve Acne is NOT due to poor hygiene
41
What is SSSS?
Staphylococcus Scalded Skin Syndrome Toxin mediated exfoliative skin condition caused by S aureus - widespread superficial skin blistering and desquamation
42
What is the management for SSSS?
MEDICAL EMERGENCY 1) IV anti-staph Abx e.g. flucloxacillin 2) Supportive care: IV fluids, temperature control, pain relief, gentle skin care 3) Infection control measures
43
A 10 month old child presents with fever and an erythematous, vesicular rash on the left side of V1 distribution. What is the diagnosis, differentials and management?
Herpes zoster infection (shingles) DDx: Varicella Eczema herpeticum Impetigo Mx: MEDICAL EMERGENCY - involves V1 risk of herpes zoster ophthalmicus 1) Aciclovir - if immunocompromised, severe disease, ophthalmic involvement, early presentation (< 72 hours) 2) Analgesia 3) Skin care 4) Treat secondary infection 5) Infection control: cover lesions, avoid contact with pregnant women, neonates, immunocompromised (until lesions crusted)
44
What is shingles?
Herpes zoster = reactivation of varicella-zoster virus causing a painful unilateral dermatomal vesicular rash Does not cross midline
45
What are the different types of steroid in order of potency?
H-C-B-C Hydrocortisone - mild (0.5-1%) Clobetasone - moderate (Eumovate) Betamethasone - potent Clobetasol - very potent (Dermovate)
46
Give an example of a very potent topical steroid
Clobetasol (Dermovate)
47
Give an example of a potent steroid
Betamethasone
48
Give an example of a moderate topical steroid
Clobetasone (eumovate)
49
Give an example of a mild topical steroid
Hydrocortisone 0.5-1% - Can be used on face, flexures and infants
50
What topical steroid can be used for eczema?
Mild to moderate - Hydrocortisone 0.5-1% - Clobetasone (eumovate)
51
What topical steroid can be used to treat psoriasis?
Potent steroid e.g. betamethasone - Short course
52
Name 3 causes of acanthosis nigricans
Most commonly caused by insulin resistance (obesity, T2DM) Endocrine - Cushing syndrome, acromegaly Drug induced - systemic steroids
53
How would you describe a skin lesion?
SPECL SCAB Size Pattern Elevation Colour Location Shape Consistence and Borders
54
How would you complete a skin examination?
- Examine the eyes, genital/hernial orifices (if indicated) - Examine for lymph nodes, hepatosplenomegaly and PGALS exam - Plot height, weight and head circumference - Full set of observations
55
Name 3 differentials for an itchy rash
Scabies Eczema Contact dermatitis Lichen planus
56
Name 3 differentials for a scaling rash
Psoriasis Pityriasis rosea Tinea infection
57
Name 3 differentials for a hypopigmented rash
Albinism Vitiligo Fungal infection Post-inflammation
58
Name 3 differentials for a hyperpigmented rash
Cafe au lait spots Acanthosis Haemochromatosis
59
What is HSP?
Henoch-Schonlein purpura = small vessel IgA-mediated vasculitis - Typically following an URTI Age 3-10 years Boys > Girls
60
A 8 year old boy presents to ED with a purpuric rash on his legs and buttocks associated with left knee pain and abdominal pain. He has just recovered from an URTI 1 week ago. What is the diagnosis, differentials and management?
HSP DDx: ITP HUS Other vasculitides Meningococcal sepsis Mx: Usually self limiting Bedside - Urinalysis - BP measurement Bloods: - FBC (check platelets) - U&Es Supportive management - Analgesia (NSAIDs if renal function normal) - Hydration - Rest - If severe abdominal pain, can give steroids
61
Name 3 important complications of HSP
IgA nephritis Intussusception Hypertension Chronic kidney disease
62
What is the follow up for HSP?
Regular urine dip and BP weekly for first month If NAD, urine dip and BP fortnightly for next 5 months Total monitoring ~6 months to detect delayed renal involvement
63
How would you explain HSP to a parent?
HSP is a type of inflammation of the small blood vessels Common in children but in most cases gets better on its own One part we need to keep an eye on is the kidneys - kidney involvement can happen after the rash has gone, even if your child seems completely well We will arrange regular urine checks and BP over the next 6 months Safety net advice: dark or red urine, swelling around the eyes or legs, reduced urine output, persistent tummy pain
64
What is ectodermal dysplasia?
A group of inherited disorders characterised by abnormal development of ectoderm-derived structures e.g. hair, teeth, nails, sweat glands
65
What is the most common type of ectodermal dysplasia?
Hypohidrotic ectodermal dysplasia - X-linked recessive Reduced/absent sweating Sparse, fine scalp hair Missing/peg shaped teeth Hypoplasia of ectodermal structures e.g. thin, dry skin
66
What is the management of ectodermal dysplasia?
Avoid overheating: cool environment, water sprays Early dental referral Emollients for dry skin MDT care: paeds, dentistry, genetics, ENT
67
A 5 year old girl presents with a brown, swirling hyperpigmented rash, developmental delay, seizures and peg-shaped teeth. What is the diagnosis, differentials and management?
Incontentia pigmenti - Rare X-linked dominant neurocutaneous disorder - Usually lethal in males Ddx: Ectodermal dysplasia Ix: - Bedside examination - Full history - Ophthalmology review - may have retinal vascular abnormalities, retinal detachment, visual impairment Bloods: genetic testing Mx: - Neurology (seizures) - Community paeds (development) - Ophthalmology - Dental follow up - Clinical geneticist PT/OT SENCO
68
You perform a general examination of Laura, a 13 year old girl with a background of epilepsy. She has an erythematous, acniform rash on her cheeks and nose, brittle nails with growths at nail margins consistent with fibromas. She has a hypopigmented lesion on her right arm, 2 x other macules on the lower back 2cm and a separate raised, painless papule on her back. What is your diagnosis, differentials and management?
Diagnosis: tuberous sclerosis - Ash leaf macules and shagreen patch DD: NF1 SLE Mx: - Neurology: epilepsy - Community paediatrician: development delay - Cardiology: cardiac rhabdomyoma - can cause arrhythmias - Respiratory: can have abnormal smooth muscle growth in lungs creating cysts - General paediatrician School - School nurse - Educational psychologist - EHCP
69
A 2 year old girl presents to ED appearing unwell and with a fever. She has brought her emollients with her. HR 120, RR slightly raised, BP slightly raised, SpO2 normal, temperature 38 degrees. She has a diffuse, punched out, vesicular rash over her face on a background of dried skin with weeping. No mucosal involvement and no conjunctival involvement. Cervical lymphadenopathy present. No swelling of joints. What is your diagnosis, differentials and management?
Diagnosis: eczema herpeticum DDx: Impetigo Varicella Mx: A to E approach - IV aciclovir + flucloxacillin - Blood culture, skin swab (viral and MC&S) - FBC, U&E, LFT, CRP - HSV serology - If feeding poor, NGT/IV fluids - Admit - with a view to involve dermatology - Infection control - Keep rash clean and dry - Consider ophthalmology review if any eye involvement
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