the child with a rash lydia burland. learning outcomes by the end of the session students should; ...
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The Child with a Rash
Lydia Burland
Learning Outcomes
By the end of the session students should; Be able to recognise common rashes
presenting in childhood Know about common associations and red flag
symptoms Be able to discuss initial management options
and explain to parents Be able to answer questions on common
infectious diseases and rashes
Case 1
A 3 year old presents with a 2 day history of a pustular rash on his face and hands
He is otherwise well, but keeps picking the scabs causing them to bleed
3 other children at nursery have a similar rash
He is usually fit and well, with no PMH or allergies
Case 1
What are your differential diagnoses?
ImpetigoContact dermatitisInfected eczemaEczema herpeticumScabiesBullous pemphigoid
Case 1: Impetigo
Very common superficial skin infection
Usually due to staph. aureus or beta-haemolytic strep.
Two forms: bullous or non-bullous (70%)
Most common in pre-school children and warm (sweaty) environments
Risk factors: poor hygiene and skin conditions
Case 1: Impetigo
Non-bullous:– Initial vesicles, developing into honey-crusted plaques– Minimal surrounding erythema– Spreads rapidly– Often regional lymphadenopathy
Bullous:– Thin membranes that rupture spontaneously– More common with underlying eczema
Diagnosis is clinical, though you can swab vesicular fluid for MC+S
Case 1: Impetigo
Conservative measures:– Avoid itching/touching – Avoid towel sharing
Topical treatments:– Fusidic acid– Mupirocin (for MRSA carriers)
Systemic treatment:– Flucloxacillin– Clarithromycin (for penicillin allergy)
Case 1: Impetigo
Complications include:– Cellulitis– Lymphadenitis– Staphlococcal scalded skin syndrome– Scarlet fever– Post-streptococcal glomerulonephritis
Re-infection may occur in household contacts
Case 2
A 9 year old presents with a 3 day history of cough, coryza and mild pyrexia
In the last 24 hours a non-blanching macular rash has developed on his buttocks/legs
He also has non-specific abdominal pain, and pain/swelling of his knees and ankles
He has a PMH of asthma, and is allergic to nuts
Case 2
Obs: HR 123, RR 32, T37
OE: Alert, but cryingCoryzal, pink left TMHS I + II + 0, chest clearAbdo soft, generally tender, no masses
Case 2
Florid, non-blanching purpuric rash on LL
Pain and swelling of ankles bilaterally, with limited ROM
What’s the diagnosis?
Case 2: HSP
Henoch-Schonlein purpura
IgA mediated hypersensitivity vasculitis
90% of cases in childhood, peak 4-6 years
Risk factors;Recent infection VaccinationsEnvironmental exposure
Case 2: HSP
50-90% have preceding URTI
Rash starts as erythematous macules
Within 24 hrs becomes raised and purpuric
Lesions may coalesce and resemble bruises
Associated symptoms;Abdo pain DiarrhoeaJoint pain HaematuriaScrotal pain Headaches
Case 2: HSP
HSP is self-limiting
Management includes NSAIDs +/- steroids
Complications;Renal involvement IntussusceptionGI bleeding Pulmonary haemorrhage
Prognosis is excellent, however 25% may have recurrent symptoms
Case 3
A 17 year old mum brings her 3 month old daughter in with ‘nappy rash’
It’s been present for ‘weeks’ and is getting worse
She has been putting on regular sudocrem
What are the differentials for nappy rash?
Case 3
Case 3: Nappy Rash
Very common under 18 months
Risk factors include;Immunodeficiency DiarrhoeaIrritant soaps/detergents AtopyPoor nappy hygiene
Causes include;
1. Contact dermatitis
2. Candida infection
3. Superimposed bacterial infection
Case 3: Nappy Rash
1. Contact dermatitisErythema sparing skin foldsBorders not well defined
2. Candida infectionErythema with well defined, raised bordersNo sparing of skin foldsSatellite lesions
3. Superimposed bacterial infectionIncreased erythema and purulent discharge
Case 3: Nappy Rash Management includes;
Regular nappy changes (6-12/day)Thorough cleaning with water/baby wipes‘Naked’, nappy-free timeBarrier creams (zinc, metanium)
Topical anti-fungals for candida infection (e.g. Clotrimazole, Miconazole)
Topical antibiotics for bacterial infection (e.g. Fusidic acid)
Topical steroids may also be used in severe cases(e.g. 0.5% hydrocortisone)
Case 4
A 3 year old presents with 24 hrs of D+V
Initially vomiting 4-5x day, mostly post feeds
Now watery, offensive stools 12x day
Low grade pyrexia 37.9, but otherwise well in himself
What investigations are needed?Does he need admitting?
Case 4
Obs: HR 105, RR 43, Sat 99%, T 37.8
OE: Alert and playingMoist mucous membranes, CRT <2sHS I + II + 0, chest clearAbdo soft but diffuse discomfortNo masses or guarding
Is he dehydrated?What should we do with him next?
Case 4
NICE fluid challenge = 50mls/kg over 4 hours
He manages to drink 22mls every 10 minutes without vomiting over the next 2 hrs
His obs remain stable throughout and he is discharged home with safety netting advice
Stool culture has been sent
Case 4: Gastroenteritis
Diarrhoea +/- vomiting is very common in childhood
Risk factors include;Poor hygiene Lack of sanitationImmunodeficiency Undercooked meat
Causes include;Rotavirus (>50%) CampylobacterSalmonella NorovirusShigella E. coli
Case 4: Gastroenteritis Investigation depends on presenting features, but may
include;Stool MC+S FBC/U+E/cultures
Management involves;Appropriate hand hygieneOral rehydration where appropriateAbx only in septicaemia, salmonella + C DiffAvoid anti-diarrhoeals Safety netting advice
Majority resolve within 5-7 days
Breastfeeding and rotarix vaccine are preventative
Summary
Infectious diseases and rashes are common in childhood
For your exams;Recognise key rashes (google/patient.co.uk)Know about causative organismsBe able to recommend treatmentBe able to advise families re: infectivityKnow about important complications
Questions
Questions: MCQs
1. The most common cause of gastroenteritis is...?
a. E. Coli b. Adenovirusc. Salmonella d. Rotavirus
2. The most common cause of opthalmia neonatorum is...?
a. Chlamydia T. b. N. gonorrhoeaec. Haemophilus inf. d. Staph. aureus
Questions: MCQs
3. Bullous impetigo is most commonly caused by...?
a. Group A strep. b. Β-haemolytic strep.c. Staph aureus d. Haemophilus inf.
4. HSP is...?b. IgA mediated b. IgG mediatedc. Common in adults d. Secondary to staph. aureus
Questions: EMQ 1
a. Erythema toxicum e. Chicken poxb. Kawasaki disease f. Glandular feverc. Measles g. Mumpsd. Rubella h. Milia
1. A 2 day old baby has erythematous macules and occasional pustules on his trunk. He is otherwise well.
2. An unimmunised 3 year old presents with a rash that started on her head, and has since spread down her body. She also has a cough and bilateral conjunctivitis. There are white ‘spots’ seen inside her mouth.
Questions: EMQ 1
a. Erythema toxicum e. Chicken poxb. Kawasaki disease f. Glandular feverc. Measles g. Mumpsd. Rubella h. Milia
3. A 7 year old presents with fever and rash. The rash was initially vesicular but has now crusted over.
4. An unimmunised 3 year old presents with a pink rash and lymphadenopathy. The rash started behind her ears and has spread to her trunk.
Questions: EMQ 1
a. Erythema toxicum e. Chicken poxb. Kawasaki disease f. Glandular feverc. Measles g. Mumpsd. Rubella h. Milia
5. A newborn has several tiny raised, pearly-white papules on either side of his nose.
6. A 15 year old boy presents with several weeks of lethargy and low fever. He has a sort throat and did have a fine macular rash that has now gone.
Questions: EMQ 2
a. Staph. Aureus e. Varicella zosterb. Epstein-Barr virus f. E. Coli 0157c. Herpes simplex g. Pox virusd. Strep. Pyogenes h. Campylobacter
1. A 15 year old presents with an itchy maculopapular rash. He has just started antibiotics for tonsillitis.
2. A 7 year old with known eczema presents with rapidly worsening eczema that is painful. On examination you see multiple vesicles.
Questions: EMQ 2
a. Staph. aureus e. Varicella zosterb. Epstein-Barr virus f. E. Coli 0157c. Herpes simplex g. Pox virusd. Strep. pyogenes h. Campylobacter
3. A 4 year old presents with firm, circular papules on his torso. They are painless and have an umbilicated centre.
4. A 4 year presents with haematuria. He has had 7 days of diarrhoea, which has contained blood for the last 3 days.
Questions: EMQ 2
a. Staph. aureus e. Varicella zosterb. Epstein-Barr virus f. E. Coli 0157c. Herpes simplex g. Pox virusd. Strep. pyogenes h. Campylobacter
5. A 2 year old comes back from nursery with 2 peri-oral vesicles. The next day they have burst and left a honey-coloured scab.
6. A 12 year presents with 24 hrs of D+V. He is concerned as he has passed fresh blood per rectum.
Questions: Images
1. A child presents with a very itchy rash.
a. What is the diagnosis?
b. What treatment should be given?
c. What advice should the family be given?
Questions: Images
2. Mum notices the following in her babies mouth.
a. What is the diagnosis?
b. What treatment should be given?
Questions: Images
3. A child presents with a rash.
a. What is the diagnosis?
b. What treatment should be given?
c. What advice should the family be given?
Questions: Images
4. A child presents with a rash. He is otherwise well.
a. What is the diagnosis?
b. Does family need to keep them off school?
Answers
Answers: MCQs
1. The most common cause of gastroenteritis is...?
a. E. Coli b. Adenovirusc. Salmonella d. Rotavirus
Rotavirus is responsible for >50% of all cases of gastroenteritis. It is self-limiting and no treatment is required.
Answers : MCQs
2. The most common cause of opthalmia neonatorum is...?
a. Chlamydia T. b. N. gonorrhoeaec. Haemophilus inf. d. Staph. Aureus
Opthalmia neonatorum is conjunctivitis in the first 28 days of life.
Chlamydia is the most common causative organism, usually presenting 5-14 days after birth.
Answers : MCQs
3. Bullous impetigo is most commonly caused by...?
a. Group A strep. b. Β-haemolytic strep.c. Staph aureus d. Haemophilus inf.
The majority of impetigo is non-bullous and is caused by beta haemolytic strep or staph aureus.
If impetigo is bullous, it is almost always due to staph aureus infection.
Answers : MCQs
4. HSP is...?a. IgA mediated b. IgG mediatedc. Common in adults d. Secondary to staph. Aureus
HSP is an IgA mediated vasculitis most common in children. The underlying cause is unknown but it may follow recent infection or vaccinations.
When it does occur in older children or adolescents the disease tends to be more severe and associated with more renal complications.
Answers: EMQ 1
1. A 2 day old baby has erythematous macules and occasional pustules on his trunk. He is otherwise well.
a. Erythema toxicum
Erythema toxicum neonatorum is a non-infective rash occurring in the first 28 days of life.
It is self limiting.
Questions: EMQs
2. An unimmunised 3 year old presents with a rash that started on her head, and has since spread down her body. She also has a cough and bilateral conjunctivitis. There are white ‘spots’ seen inside her mouth.
c. Measles
Measles is due to morbillivirus infection transmitted by airbourne respiratory droplets. It presents with a rash, most commonly starting on the head and spreading downwards, coryza, conjunctivitis and koplik spots.Measles is usually self-limiting, but may be complicated by pneumonia and encephalitis. It is a notifiable disease.
Answers: EMQ 1
3. A 7 year old presents with fever and rash. The rash was initially vesicular but has now crusted over.e. Chicken pox
Chicken pox is very common and due to varicella zoster virus. It enters via the upper respiratory tract, and presents with fever and malaise, before vesicles appear around day 3-5. They are infective prior to the rash appearing until all the vesicles have scabbed over.
Patients should be advised against itching, and given antipyretics/analgesia as required.
Answers: EMQ 1
4. An unimmunised 3 year old presents with a pink rash and lymphadenopathy. The rash started behind her ears and has spread to her trunk.
d. Rubella
Rubella is usually and mild and self-limiting illness, and presents with a rash starting behind the ears and spreading down the trunk.
The main concern regarding rubella is its effect on the growing foetus.
Answers: EMQ 1
5. A newborn has several tiny raised, pearly-white papules on either side of his nose.
h. Milia
Answers: EMQ 1
6. A 15 year old boy presents with several weeks of lethargy and low fever. He has a sort throat and did have a fine macular rash that has now gone.
f. Glandular fever
Infectious mononucleosis, or glandular fever, is a self limiting infection usually caused by Epstein Barr virus. It presents with fever and malaise over a few weeks to months, sore throat and enlarged tonsils and a transient fine macular rash.
Patients may later develop transient splenomegaly and should be advised against contact sports for the next month to avoid splenic rupture.
Answers: EMQ 2
1. A 15 year old presents with an itchy maculopapular rash. He has just started antibiotics for tonsillitis.
b. Epstein-Barr virus
This is a common presentation of infectious mononucleosis – the child is treated for presumed tonsillitis with amoxicillin, resulting in a florid maculopapular rash.
Answers: EMQ 2
2. A 7 year old with known eczema presents with rapidly worsening eczema that is painful. On examination you see multiple vesicles.
c. Herpes simplex
This describes eczema herpeticum – herpes simplex infection complicating known eczema. It is characterised by fever, painful rash and clusters of vesicles.
Answers: EMQ 2
3. A 4 year old presents with firm, circular papules on his torso. They are painless and have an umbilicated centre.
g. Pox virus
This describes molloscum contagiosum – firm painless papules appearing in crops with an punctate centre. They are caused by pox virus and are self-limiting though may take months to resolve.
Answers: EMQ 2
4. A 4 year presents with haematuria. He has had 7 days of diarrhoea, which has contained blood for the last 3 days.
f. E. Coli 0157
This describes a likely cause of haemolytic uraemic syndrome which most commonly follows e.coli 0157 infection. It tends to occur 6-8 post diarrhoea and presents with haematuria, fever and lethargy.
Blood tests show haemolytic anaemia, thrombocytopenia and renal impairment.
Answers: EMQ 2
5. A 2 year old comes back from nursery with 2 peri-oral vesicles. The next day they have burst and left a honey-coloured scab.
a. Staph. Aureus/d. Strep. Pyogenes
This describes impetigo which may be due to beta haemolytic strep, such as strep pyogenes or staph aureus.
Answers: EMQ 2
6. A 12 year presents with 24 hrs of D+V. He is concerned as he has passed fresh blood per rectum.
h. Campylobacter
Campylobacter is the most common cause of bloody diarrhoea secondary to food poisoning, and is due to eating under meat, especially chicken.
Answers: Images
1. A child presents with a very itchy rash.
What is the diagnosis?Scabies
What treatment should be given?Permethrin or malathion
What advice should the family be given?
Wash all bedding and clothes
Answers : Images
2. Mum notices the following in her babies mouth.
What is the diagnosis?Oral candidiasis
What treatment should be given?
Oral antifungal, i.e. Nystatin or daktarin
Answers : Images
3. A child presents with a rash.
What is the diagnosis?Chicken pox
What treatment should be given?Supportive (unless immunosupressed)
What advice should the family be given?
Contagious until all vesicles scab overAvoid pregnant women
Answers : Images
4. A child presents with a rash. He is otherwise well.
What is the diagnosis?Molloscum contagiosum
Do parents need to keep them off school?No, infectivity is very low
Any questions?
Thanks for listening