Paediatric rashes

Question 1

Terminology

Answer 1

Macule – flat lesion ,usually a circumscribed change of colour

• Papule – small , solid, elevated lesion
• Nodule – a large , solid , palpable and elevated lesion
• Plaque – a lesion slightly raised over a larger area
• Blister – an elevated lesion ,fluid filled
• Ulcer – depressed lesion with loss of surface epithelium
• Atrophy – a depressed lesion with intact surface epithelium
• Crust – a mixture of scale and serum – yellowish accretions on the surface of a lesion
• Petechiae – non raised red-brown non blanchable lesions

Question 2

Chicken-pox , Varicella zoster virus

Answer 2

1 Chicken-pox , Varicella zoster virus

2 Crops of vesicles mainly on the trunk and head.

*Pass through various stages of papule, vesicle, pustule and crust.

3 Symptomatic :analgesia – paracetamol for discomfort and pyrexia.

*pruritis – antihistamine or calamine lotion

*acyclovir only for those at risk of complications or immunocompromised.

Question 3

Impetigo

Answer 3

• 1 Impetigo
• 2 staph aureus and streptococcal pyogenes
• 3 Thin–roofed vesicles or bullae surrounded by narrow margin of erythema. The vesicles /bullae rupture to release thin cloudy yellow fluid. This fluid dries to form thick yellow crusts.
• 4 topical-bactroban(mupirocin) ointment/betadine cream

*antibiotics – flucloxacillin or erythromycin

Question 4

Erythema Multiforme

Steven-Johnson Syndrome (mucous membrane involvement)

Answer 4

1 Erythema Multiforme

Steven-Johnson Syndrome (mucous membrane involvement)

2 Drug

most commonly associated-Allopurinol5

Recent drugs- Nevirapine, lamotrigine, sertraline, pantoprazole, tramadol

Antibiotics- Sulphonamides, including co-trimoxazole, penicillin cephalosporins, fluoroquinolones, vancomycin

NSAIDs- Piroxicam, fenbufen, ibuprofen, ketoprofen, naproxen, tenoxicam, diclofenac, sulindac

Anti-TB- Rifampicin, ethambutol, isoniazid, pyrazinamide

Anticonvulsants- Barbiturates, carbamazepine, phenytoin, valproate, lamotrigine

Infective herpes simplex

3 target lesion –round ,erythematous papules contain central blister or darker area of necrosis

Question 5

Kawasaki Disease

(systemic vasculitis)

Answer 5

Classical features of Kawasaki disease

• Fever lasting ≥5 days
• Marked irritability of the child
• Erythema, swelling and desquamation affecting the skin of the extremities
• Bilateral conjunctivitis
• Rash
• Inflammation of the lips, mouth and/or tongue
• Cervical lymphadenopathy

Coronary artery aneurysms

Intravenous Immune Globulin 2g/kg x1

Aspirin:

80-100 mg/kg/day until fever  x 14 day, then

3-5mg/kg/day x ≥ 6-8 weeks

echocardiograms

Question 6

Scabies
(Mite –sarcoptes scabeii)

Answer 6

Scabies-Mite –sarcoptes scabeii

• Clothes, towels, and bed linen should be machine-washed (at 50 degrees Celsius or above) to prevent re-infestation and transmission.
• Items that cannot be washed can be kept in plastic bags for at least 72 hours to contain the mites until they die.

Treatment:

• benzyl benzoate lotion ,apply for 24hours ,may be repeated in 1 week
• permethrin cream
• Antiscabial soap alone is not an effective treatment
• Babies <2 months -5% sulphur ointment

Question 7

Measles

(Single stranded RNA Morbillivirus from the paramyxovirus family)

Answer 7

Symptoms:

• Prodrome - lasts 2-4 days with fever, runny nose, mild conjunctivitis and diarrhoea.
• Koplik spots are pathognomic and appear on the buccal mucosa opposite the second molar teeth as small, red spots each with a bluish-white speck (sometimes compared to a grain of rice) in the centre.6
• They occur in 60-70% of patients during the prodrome and for up to 2-3 days before the onset of the rash.
• Rash - (morbilliform = measles-like) first seen on forehead and neck and spreads, involves trunk and finally limbs over 3-4 days. It may become confluent in some areas.
• Rash then fades after 3-4 days in the order of its appearance. It leaves behind a brownish discoloration sometimes accompanied by fine desquamation.

Uncomplicated measles is usually self-limiting and treatment is mainly symptomatic with paracetamol or ibuprofen and plenty of fluids. Patients should remain at home to limit disease spread.

Notifiable disease

Question 8

Erythema infectiosum, slapped cheek disease,

slapped cheek syndrome, fifth disease, Parvovirus B19 (PV-B19), Sticker’s disease

Answer 8

Parvovirus B19:

• 3 After 3-7 days, the classic ‘slapped cheek’ rash appears as erythema on the cheeks, sparing the nose, peri-oral and peri-orbital regions.6 This disappears after 2-4 days.
• About 1-4 days after the facial rash appears, an erythematous macular/morbilliform rash develops on the extremities, mainly on the extensor surfaces.
• Usually not itchy in young children, but may be itchy in older children and adults.
• This gradually fades over the next 3-21 days, but may recur in reaction to various stimuli such as exercise, heat and sunlight

It is usually mild and self-limiting in healthy people. It may also cause foetal loss or foetal hydrops, reactive arthritis in adults, and severe anaemia in those with haematological conditions or who are immunocompromised. Detection in pregnancy is important for monitoring and possible treatment.

Question 9

Napkin dermatitis

Contact dermatitis

Answer 9

Napkin dermatitis - Contact dermatitis

• prolonged exposure to urine and faeces, friction
• mild erythematous ,glazed appearance
• Seborrhoeic dermatitis
• salmon coloured greasy lesions and a predilection for intertriginous areas.

Candidiasis

• beefy red in colour with pin point pustulo-vesicular satellite lesion

Frequent nappy changes:

• barrier cream zinc and caster oil
• apply hydrocortisone 1% in aqueous cream bd
• if candidiasis suspected -10% steriod and nystatin 20% in zinc cream

Question 10

Tinea capitis

Answer 10

• Fungal infection by a group of organisms called dermatophytes
• Griseofulvin for 6 weeks ,10mg/kg

Question 11

Meningococcal meningitis

Answer 11

• Neisseria meningitidis
• Cefotaxime

Question 12

Molluscum Contagiosum

Answer 12

From direct innoculation of pox virus

Tend to heal spontaneously within 6 months – 1 year

• liquid nitrogen 2-3 weeks
• express contents with sharp curette
• benzoyl peroxide cream apply daily

Question 13

Miliaria

Answer 13

Miliaria is a common disorder of the eccrine sweat glands that often occurs in conditions of increased heat and humidity. It is thought to be caused by blockage of the sweat ducts, which results in the leakage of eccrine sweat into the epidermis or dermis.

Two types:

• Miliaria crystallina-clear superficial pinpoint vesicles
• Miliaria rubra –(prickly heat )-small discrete red papules,vesicles,papulovesicles
• No compelling reason to treat miliaria crystallina exists because this condition is asymptomatic and self-limited. he prevention and treatment of miliaria primarily consists of controlling heat and humidity so that sweating is not stimulated.
• Measures may involve treating a febrile illness; removing occlusive clothing; limiting activity; providing air conditioning.

Topical treatments that have been advocated involve lotions containing calamine