Paediatric Dermatology: By Emily

Paediatric dermatology By Emily

Objectives  By the end of this session we should be able to: • Recognise common rashes in infants and children and know how to treat them • Manage common paediatric infestations (scabies, head lice) • Treat eczema and know when to refer

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Quiz 2 teams Shout when you know the rash Extra bonus points available Prize for winners!

What's that rash?

Milia  Epidermal inclusion cysts  Pearly, yellow, 1-3mm diameter papules  Face, chin, forehead  50% newborns  Usually resolve in first month without treatment, but may persist for several months

What's this?

Hemangioma  Most common benign tumours of infancy  Begin as barely visible telangiectasia or red macules and grow into 0.5-4cm bright red partially compressible tumours  60% occur on head and neck area  Virtually all gone by age 5yrs

What's this?

Capillary malformations 2 common types Salmon patch (naevus simplex) • Common (40% newborns) • Small flat patches pink or red, poorly defined borders • Nape of neck (stork mark), forehead (angel kiss), eyelids and sacrum • Worse with crying • Not associated with extracutaneous findings

Capillary malformations  Port wine stain • Less common • Large flat patch of purple or dark red skin with well defined borders • Persist in childhood then darkens and thickens • Extracutaneous defects

What's that rash?

Nappy rash  Caused by combination of factors, irritation to the skin by urine and faeces, occlusion and candida  Intertriginous areas usually spared  Secondary staph inf = thin-walled pustules on erythematous base  If persistent and creases involved think seborrheic dematitis, psoriasis, and candidiasis  Resolves when stop wearing nappies

Nappy Rash - prevention and treatment  Nappy off!  Change nappy frequently  Wash bottom at each change, can use aqueous cream  Use emollient (aqueous cream) and barrier (zinc oxide)  Low potency topical steroid (hydrocortisone)  Candida - antifungal eg nystatin, can add low potency steroid for few days  Sebhorrhoeic dermatitis - Emollients and steroid help, can add ketoconazole

What's that rash?

Cradle cap  Greasy, yellow scaly patches over the scalp  Seborrheic dermatitis of newborn  possibly due to overactive sebaceous glands in the skin of newborn babies  Possible relationship with skin yeasts (malassezia)  Not itchy  Treatment with mild baby shampoos. Wash regularly and brush softly to remove scales  Baby oil can help soften scales (not olive oil!)  Resolves by 6-12mths  If fails to improve can try medicated shampoo with ketoconazole or low potency steroids

What's that rash?

Chicken pox  Begins as an itchy red papules progressing to vesicles on bright red base (dew drops on a rose petal) on the stomach, back and face, and then spreading to other parts of the body  Central umbilication of blisters follows rapidly, crusting and desquamation within 10 days  Fever, sore throat, anorexia, malaise may precede rash by several days  Incubation 7-21 days  symptomatic treatment only in immunocompetent • Cool compress, calamine lotion, antihistamines

 ?Vaccinate

What's that rash?

Meningococcus What every parent worries about Rash is seldom early sign Classically non-blanching haemorrhagic rash In early stages rash may be blanching and macular or maculopapular (sometimes confused with flea bites)  Important to search whole body for small petechiae  Give IM Ben Pen and refer    

What that rash?

Impetigo  Superficial bacterial skin infection  Strep pyogenes or staph aureus  Round/oval lesions, begin as small pustular areas and rapidly extend  Lesions rupture, oozy surface with honeycovered crust  Advice about avoiding spread  Localised lesion- topical antibiotic eg Fucidin cream  Widespread infection - oral flucloxacillin or erythromycin

What's that rash?

Molluscum  Viral skin infection Pox virus  aka ‘dimple wart’  Clusters of small round flesh-coloured umbilicated papules  Often on face, trunk, axillae (warm moist places)  Harmless but can persist for months, occasionally a couple of years  No treatment necessary  Can refer for cryotherapy/curratage

What's that rash?

Measles  Prodrome; fever, malasie, dry cough, coryza, conjunctivitis, photophobia  Koplik spots on buccal mucosa  Rash 3-4th day of illness  Starts on face as blanching red macules and papules, non itchy  Spreads down trunk and extremities  Rash coincides with high fever  Lesions become confluent, older lesions develop rusty hue  Contagious 4 days before rash and 4 days after

What's that rash?

Hand, Foot and Mouth  Common, mild, viral infection caused by Coxsackie A16  Occurs in young children in summer/autumn  1-2 day fever, anorexia, sore throat followed by development of 3-6mm elongated, gray, thin-walled vesicles  May be asymptomatic or severe pruritus and burning  Symptomatic treatment  Lasts < 1 week

What's that rash?

Eyrthema infectiosum  Fifth disease, slapped cheek, Parvovirus B19  First sign is firm red cheeks, which feel burning hot  Rash follows 1-4 days later with a lace pattern on the limbs and then the trunk  Fades over 2-3wks  Usually well, may have slight fever or headache  Rare complications • Arthritis in teenagers/adults, aplastic crisis, miscarriage

What's that rash?

Herpes simplex  Gingivostomatitis commonest manifestation of primary herpes infection in kids  Clusters of red papules, evolve into vesicles and often pustules in 24-48hrs. Vesicles rupture and crust over. Heal in 10-14days  Cool compress, analgesia, consider aciclovir  Monitor hydration when oral lesions  Can be recurrent

Head Lice  Infest clean and dirty hair  Adult lice are size of sesame seed, brownish grey, and wiggle their legs  Only adult lice contagious  Spread by head to head contact  They don’t jump/fly  Normally asymptomatic  Can present with itchy scalp

Head Lice- Treatment  Insecticides - malathion, phenothrin, permethrin, carbaryl  Local policy?  2 applications 7 days apart  Shampoos not effective  Wet-comb conditioned hair with fine tooth comb until lice removed and rpt at 3-4 day intervals for 2/52  Electric combs, tea tree - no evidence

What that rash?

Scabies  Sarcoptes scabiei mite  Pruritic burrows pathognomic (irregular, tortuous, and slightly scaly)  In infants, burrows are widespread with involvement of trunk, scalp, extremities, palms and soles  Consider in infants with widespread dermamtosis that involves the palms and soles

Scabies - treatment  Permethrin (malathion)  Ivermectin in combination for ‘norwegian scabies’  Not after hot bath  All family members at same time  Whole body treatment inc, scalp, neck, face, ears and under nails  Rpt week later

Infantile eczema

Eczema  Infants • Infants less than one year old often have widely distributed eczema. • The skin is often dry, scaly and red with small scratch marks made by sharp baby nails • The cheeks of infants are often the first place to be affected by eczema. • The napkin area is frequently spared due to the moisture retention of nappies (but they can still get nappy rash)

Childhood eczema

Eczema  Toddlers and pre-school • As children begin to move around, the eczema becomes more localised and thickened. • Toddlers scratch vigorously and the eczema may look very raw and uncomfortable • Often affects the extensor aspects of joints, particularly the wrists, elbows, ankles and knees. It may also affect the genitals • As the child becomes older the pattern frequently changes to involve the flexor surfaces of the same joints • The affected skin often becomes lichenified

Eczema  School children • Older children tend to have the flexural pattern of eczema and it most often affects the elbow and knee creases. Other susceptible areas include the eyelids, earlobes, neck and scalp. • Many children develop a 'nummular' pattern of atopic dermatitis. This refers to small coin-like areas of eczema scattered over the body. These round patches of eczema are dry, red and itchy and may be mistaken for ringworm • Mostly improves during the school years

Treatment of eczema  Advice - loose cotton clothes, avoid wool, keep cool, nails short, gloves in bed  Emollients  Antihistamines  Topical steroids  Topical immunosuppressant  Bandages (zinc/ ichthammol/ Tar)  Wet wrapping - weeping eczema  ?Oral steroids  Immunosuppressant  Phototherapy