Child Healthcare: Skin condition

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Child Healthcare addresses all the common and important clinical problems in children, including:immunisation history and examination growth and nutrition acute and chronic infections parasites skin …

Child Healthcare addresses all the common and important clinical problems in children, including:immunisation history and examination growth and nutrition acute and chronic infections parasites skin conditions difficulties in the home and society.

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  • 1. 12 Skin conditions persist (become chronic). Any part of the body Objectives may be affected by a rash. However, if the rash only affects the skin of certain parts of the When you have completed this unit you body, this may help with the diagnosis. While should be able to: most rashes are mild and recover quickly, • Recognise the common types of rashes. some are serious and need urgent treatment. • Diagnose and treat common skin There are many types (appearances) of rashes. infections. • Diagnose and treat rashes caused by A rash is a skin disorder which causes a change in skin parasites. the normal appearance of the skin. • Manage rashes caused by skin irritations or insect bites. • Manage rashes due to allergy. 12-3 What are the common types of rash? • Manage mild acne. • Macule: This is a flat spot that can be seen but not felt. Macular rashes are usually pink or red (erythematous macules) andINTRODUCTION disappear (blanch) for a few seconds after pressing on them. This is because these macules consist of dilated, small capillaries.12-1 Are skin conditions common in Rubella infection is one of the many causeschildren? of a pink macular rash. Pale or brownYes. Skin conditions are common in children, macules also occur, and are due to changesas young skin is sensitive. As a result a child’s in the amount of pigment in the skin. Theyskin is easily irritated or damaged. This may are often seen as part of the healing ofcause a rash. damaged skin and do not disappear when pressed. • Papule: This is a raised spot (a skin lump),12-2 What is a rash? which can be both seen and felt. A papuleA rash is a skin disorder which causes a feels solid and can be any colour, althoughchange in the normal appearance of the skin. they are often pink or red or the colourIt may appears suddenly or gradually and most of normal skin. Papular urticaria (allergicrashes disappear after days or weeks. Some reaction to an insect bite) is one of therashes may recur (come back repeatedly) or
  • 2. 196 SK IN CONDITIONS many causes of a papular rash. A nodule is NOTE A naevus (mark) may be pigmented (does larger than a papule. not blanch on pressure) or vascular (blanches on• Vesicle: This is a small fluid filled blister pressure). that can be both seen and felt. The fluid in a vesicular rash is clear and may look like 12-5 How are skin conditions managed? serum or water. If the vesicles leak, oozing First you need to make a diagnosis, if possible. of the fluid makes the skin wet (weepy). Then the correct treatment must be given. As When the fluid dries it leaves a crust. If a with many illnesses, even if a definite diagnosis vesicle bursts it leaves a small ulcer. Fever cannot be made, many skin conditions can still blisters (cold sores) and acute eczema are be treated symptomatically. typical of a vesicular rash.• Pustule: This is a small pus-filled blister. A All local (topical) treatments need to be pustular rash can be both seen and felt. If carefully explained and demonstrated to the a pustule bursts it also forms a small ulcer, caregivers. Otherwise the treatment will fail as which may crust. Bacterial skin infection is the local treatment is not applied correctly. one of the many causes of a pustular rash. 12-6 Which groups of skin conditions areSee the full-colour illustrations of skin conditions common in children?at the back of the book. Skin conditions caused by:One type of rash often changes into another. • Local infectionsFor example, in chicken pox the rash starts • Systemic infectionsas red macules, which develop into papules • Skin parasitesand eventually change into vesicles that heal • Skin irritationsleaving pale or dark macules or sometimes • Allergiesscars. Although identifying the type of rash • Conditions of unknown causedoes not necessarily give the diagnosis, itis an important step in limiting the rangeof possible diagnoses. Therefore a detaileddescription of the rash is needed. LOCAL VIRAL INFECTION It is important to describe the type of rash 12-7 What local viral infections are accurately. common? • Molluscum contagiosumSome rashes are caused by bleeding into the • Wartsskin, e.g. petechiae (purpura) or bruises (small • Cold soresor large pink or purple spots which do notfade with pressure). 12-8 How is molluscum contagiosum NOTE Haemorrhagic rashes do not blanch with recognised and treated? pressure but change colour from pink (red) to Molluscum contagiosum is a papular rash blue to yellow over a few days as they resolve. caused by a viral skin infection. The condition is most common in children between 2 and 512-4 Do all skin conditions present as a years of age. Papules usually occur on the face,rash? trunk and back of the hands but can occurNo. Some skin conditions do not present as anywhere. The virus is spread by direct contacta typical rash. They usually last for years or with other children. Molluscum contagiosumare permanent, e.g. a ‘birth mark’. Most ‘birth is common and often extensive in childrenmarks’ present at or soon after delivery. infected with HIV. In these children with a
  • 3. SK IN CONDITIONS 197weak immune system, the papules may be then covered with a piece of plaster for 24large and not respond to standard treatment. hours. When the plaster is removed the wart should be softened by soaking in warm water.The molluscum papules have a typical, easily The softened surface of the wart is then gentlyrecognised appearance. They are pearly white scraped to remove any loose pieces. The areaand dome shaped with a central dimple. The of skin should be washed well and dried beforepapules vary in size but usually are as big as a applying more wart paint. Repeat the processmatch head. The rash is not itchy or painful, daily until the wart has completely disappeared.and usually clears spontaneously leaving no Genital warts and warts which do not respondscars. Secondary bacterial infection of the to treatment should be referred to a skin clinic.papules can occur causing inflammation andpain. NOTE Warts are caused by the human papilloma virus. Wart paint consists of 1 part salicylic acid, 1It is best to leave them alone as they will part lactic acid and 3 parts colloidion.disappear on their own after a few months.However, they can be treated by pricking 12-10 What are cold sores and how are theyeach papule with a sharp stick (tooth pick). If managed?necessary the contents can be gently squeezedout. With many papules, sedation or a general Cold sores (fever blisters) are caused byanaesthetic may be needed before treatment. infection with the Herpes simplex virus. TheyWart paint, benzoyl peroxide or liquid present as small, painful blisters, which occurnitrogen have also been used. on and around the lips, often after exposure to excess sunlight or if the child is ill or emotionally stressed. They usually start with a Many common, mild skin infections may become tingling, itching, burning sensation for a few severe and persistent in children with HIV hours before the painful blister develops. The infection. blister bursts after a few days and then dries, leaving a crust, which disappears in a week or12-9 How are warts recognised and two. The problem with cold sores is that theymanaged? often recur at the same site. The outbreaks of cold sores usually occur every few months butMost children will have one or more warts tend to become less frequent over time.during childhood. Warts are harmless growthson the surface of the skin. Most warts are The management consists of applying povidoneskin coloured, raised, hard and have a rough iodine (Betadine) ointment or 2% vioformsurface. Sometimes they are flat, especially in zinc cream twice daily to prevent bacterialwhen on the face. infection. Local antiviral agents are of limited use. In severe cases, oral acyclovir can be used.Warts are caused by a virus and usually NOTE Herpes simplex virus, which remains indisappear on their own after 6 to 12 months. nerve ganglia, causes recurrent attacks of coldThey are mildly infectious as the virus is spread sores. A history of a primary infection of herpesby direct contact. Rarely warts can occur on stomatitis with many painful, small ulcers of thethe soles of the feet (plantar warts) where they mouth and tongue, together with fever, may orare very painful when walking. Warts can be may not be obtained. Often the primary infectionextensive in children who are infected with with herpes virus is asymptomatic. Cold soresHIV. Genital warts may indicate sexual abuse. typically occur when immunity is depressed.Warts are best left alone, especially flat wartson the face. They can be treated by applyingwart paint daily. The clear wart paint is appliedto the wart, using a tooth pick, and allowedto dry (becomes white). The painted wart is
  • 4. 198 SK IN CONDITIONSLOCAL FUNGAL • Infection of the nail causes discolouration (yellow or white nails) with abnormal nailINFECTIONS growth (crumbly nails). HIV-infected children may develop extensive,12-11 What local fungal infections are severe fungal skin and nail infections which docommon in children? not respond to standard treatment.• Ringworm 12-14 How should ringworm be treated?• Athlete’s foot• Tinea versicolor 1. Ringworm of the skin and feet is usually• Dandruff treated with clotrimazole ointment (e.g.• Candida Canesten) or 2% miconazole cream (Daktarin) twice daily for 2 to 4 weeks12-12 What is ringworm? until the rash has cleared. Ideally treatment should be continued for 1 to 2 weeks afterRingworm is not a worm. It is a rash caused by the rash has healed.a fungal infection of the skin. Ringworm of the 2. Ringworm of the scalp can be improvedscalp (tinea capitis) is common. Less common but not cured with local ointmentis ringworm of the skin, feet (athlete’s foot) (cream or shampoo). Fortunately it oftenand nails It is infectious and is spread by disappears on its own over time (especiallydirect contact with infected humans (touching at puberty). If left untreated it may infectheads), things they use (sharing brushes, other children.combs and clothes) or pets. Athlete’s foot is 3. To prevent athlete’s foot, dry the feet wellinfectious and usually caught from the wet after washing, especially between the toes,floors of bathrooms and changing rooms at wear clean socks every day and use openschool. Pets may also have ringworm. sandals. 4. Scalp ringworm and severe or chronic Ringworm is not a worm but a rash caused by a infection of skin, can be treated with oral fungus. griseofulvin 10 mg/kg/day for 6 weeks. Any secondary bacterial infection should be treated with antibiotics.12-13 How is ringworm recognised? 5. Fungal infections of the nails should be• Ringworm of the scalp commonly presents treated with oral griseofulvin 10 mg/kg/ as dry, scaly patches with hair loss (bald day for 3 months or until the nail returns patches). Occasionally, the infected scalp to normal. It rarely gets better without becomes red and lumpy with pustules. This treatment. can easily be confused with impetigo. Every effort should be made to prevent the• Ringworm may present on the face or spread of ringworm to others. Families should trunk as a group of itchy, scaly, pink avoid sharing clothes, towels and combs. papules. Often the rash forms a ring with NOTE Because prolonged treatment is needed a well defined raised edge and normal skin to cure fungal infection of nails, it is best to in the centre. Vesicles may also occur along confirm the diagnosis by sending some crumbly the edge. discoloured nail for fungal culture.• Athlete’s foot presents as a painful crack between the toes, usually between the 12-15 What is tinea versicolor? small and next toe. It may also affect the sole of the foot. You do not need to be an Tinea versicolor is caused by a fungal infection athlete to catch athlete’s foot. of the skin and presents as pale or pigmented patches on the neck or trunk. The patches do
  • 5. SK IN CONDITIONS 199not itch but are often covered with fine scales. common nappy rash which is worse overAfter treatment the pale patches may remain exposed skin and spares creases.for a few months. Management consists of keeping the skin dryTreat with selenium sulphide shampoo. Spread and applying mycostatin cream. For severethe shampoo over the whole body and leave cases, oral mycostatin may be needed to clearit on overnight before washing it off. Treat the fungus from the gut and stool.weekly for 3 weeks. After treatment, the rashwill take a few weeks to disappear. The rashmay recur despite adequate treatment. LOCAL BACTERIALTinea versicolor should not be mistaken for INFECTIONSpityriasis sica alba, the common small, pale,scaly patches on the face, neck or arms. NOTE The causeof pityriaisis sica alba is not 12-18 What local bacterial infections are known. The pale patches tend to come and go common? but eventually disappear. Treatment is usually not • Impetigo needed although 1% hydrocortisone cream for • Boils one week speeds up healing. 12-19 What is impetigo?12-16 How should you manage dandruff? Impetigo is a common superficial skinDandruff is very common and is also caused by infection of children caused by bacteriaa fungus. It is usually mild and presents with (Streptococcus or Staphylococcus). Impetigo isfine flakes of skin on the scalp, in the hair and an infectious condition and children can catchon clothing over the shoulders. Mild dandruff it from one another. It often complicates otherdoes not need treatment although it often skin conditions (secondary infection) whereimproves with a change of shampoo. Treatment the skin is broken, e.g. cuts, eczema, nappyis needed if the dandruff becomes severe, the rash, scabies, papular urticaria and cold sores.scalp becomes very itchy or red, or the scales If impetigo persists or recurs, always look forbecome thick and greasy (seborrhoeic eczema). one of these underlying skin conditions.Dandruff usually recurs throughout life. Peoplewith dandruff often have greasy skin. The rash of impetigo starts as a group of small blisters, which soon burst leaving a raw areaTreat with selenium sulphide (Selsun) or that becomes covered by a yellow crust of driedketoconozole (Nizshampoo) or zinc pyrethium serum. The rash is not painful and does not(Selsun Blue; Head and Soulders) or tar itch. Even when extensive the child is usuallyshampoos. To remove thick scales, 2 to 10% well and has no fever. Without treatment thesalicylic cream can be applied for 2 hours in rash may last for weeks and often spreads toinfants or overnight in older children before other areas. In small infants, impetigo maybeing washed off with shampoo. present as pus filled blisters (bullous impetigo) which later burst leaving crusts or scabs.12-17 How should you recognise and treata candida rash? Treat by gently removing the crust, after soaking the area in warm water or aCandida is a fungus which grows in warm, dilute antiseptic solution (e.g. Savlon).moist creases where it causes a red rash. A Dry and apply 2% vioform ointment, 10%candida rash (monilial rash) presents with povidone iodine (Betadine) ointment orgroups of pustules. If severe the rash may an antibiotic ointment, e.g. mupirocinulcerate. It is typically seen in the creases (Bactroban). Impetigo should heal in a fewcovered by a nappy. This differs from the days if correctly treated. If the impetigo is
  • 6. 200 SK IN CONDITIONSwidespread, give an oral antibiotic such as RASHES DUE TO SYSTEMICflucloxacillin or erythromycin for 7 days. INFECTIONSSometimes the infection can spread todeeper layers of the skin to cause veld sores(ecthyma). They present as crusted ulcers, 12-21 What common systemic infectionsparticularly on the lower legs of older children. cause a rash?Treatment is the same as for impetigo. These are usually viral infections such as: • Rubella (German measles) Impetigo due to bacterial infection often • Measles complicates other skin conditions. • Chicken pox and shingles • AIDSImpetigo due to Streptococcus can result inacute glomerulonephritis. These infections are discussed in Unit 10 on common childhood illnesses and Unit 9 on AIDS.12-20 How are boils diagnosed andmanaged? NOTE Some serious systemic bacterial infections, such as meningococcal septicaemia, also presentBoils are common in childhood. They occur with a rash. Many drugs used to treat systemicwhen bacteria (Staphylococcus) infect a infections and other conditions may also causehair follicle. Boils present as very painful, rashes. Petechiae (purpura) associated with feverred lumps under the skin. After a few days is a dangerous sign and these children must be referred immediately for investigation andpus collects and a yellow head forms which treatment. A purple rash suggests necrotic skineventually bursts onto the surface of the skin. or bleeding into the skin, and should always beOnce the boil has burst it usually heals with taken seriously.some scarring.Healing of a boil can be speeded up if an 12-22 How do you know that the rash isoral antibiotic, such as flucloxacillin or due to a systemic infection?erythromycin, is given. Oral antibiotics should Because the child is usually generally unwellalso be given if the local lymph nodes are with a fever. In some infections the rashenlarged or the child is pyrexial. If the boil appears when the child first becomes unwell.bursts, clean away the pus with an antiseptic In other infections the rash may only appearsolution (e.g. Savlon) and then apply 2% when the child has been ill for a few days.vioform ointment.Children who have repeated boils shouldwash their body and hair twice weekly LOCAL PARASITICwith povidone iodine (Betadine). Put0.5% chlorhexidine cream or mupirocin INFESTATIONS(Bactroban) ointment into the nostrils twicedaily for a week and keep the nails short to 12-23 What local parasites cause skindecrease the number of bacteria on the skin. conditions in children? NOTE Boils sufferers often carry Staphylococcus in their nose, on their skin and under their nails. • Scabies If boils occur repeatedly, screen the child for • Head lice diabetes. They may also be nasal carriers of • Sandworm Staphylococcus.
  • 7. SK IN CONDITIONS 20112-24 What is scabies? 12-26 How is scabies treated?Scabies is a common, very itchy rash caused by It important to treat all members of the familymites. The female mites burrow into the outer at the same time. Even members with nolayers of the skin to lay their eggs. The eggs symptoms of scabies must be treated as theyhatch and the young mites start new burrows. may still carry mites. Scabies can be treatedThe mites irritate the skin and result in a rash with a local application of 12.5% benzylwhich is very itchy. Mites are passed very benzoate (Ascabiol) lotion (half strength),easily from person to person by touching or which is applied from the neck down to theholding hands. Therefore, both the mother and whole body. Only dress once the lotion hasother close contacts often also have scabies. It dried. In children over 2 years and adults,is common to have scabies among a group of wash the lotion off after 24 hours. In childrenfriends at school and in overcrowded homes from 2 months to 2 years, use a 6.25% lotionwith shared beds. (quarter strength) and wash off after 12 hours. NOTE The rash of scabies is due to an allergy to the After treatment, bath and dress in clean Sarcoptes scabiei mite. After infestation with mites, clothes. Wash all used clothes and change the it takes about a month for the child to become bed linen. Remember that this lotion can be sensitized to the mites. Only then does the itch very irritating and may cause discomfort. A and rash start. 1% hydrocortisone cream can be used after treatment to help control the itching.12-25 What are the typical symptoms and Infants under 2 months should rather besigns of scabies? treated with 5% sulphur ointment nightly forThe rash of scabies presents as many small, 3 days. Antiscabies soap alone is not effectivevery itchy papules or vesicles, especially over treatment. Keeps nails short. Wash clothes andthe wrists, between the fingers, on the hands bedding in hot water.and feet and waist. A few itchy papules in theskin folds of the axilla (arm pit), around the The whole family must be treated for scabies atnipples and umbilicus, and on the scrotum are the same time.common presentations in infants. The face canalso be affected in small children. The itchingis worse at night when the skin is warm. If there is additional bacterial infectionBlisters, sores and scabs often result from the (impetigo), treat locally with 2% vioform inscratching. Bacterial infection (impetigo) zinc ointment. Oral penicillin may be neededof the blisters and sores, which have been if the infection is severe, especially if thescratched open, is common. local lymph nodes are enlarged or the child is pyrexial. Treat the bacterial infection first before treating the scabies. Scabies presents as a rash which is very itchy, Secondary bacterial infection of scabies especially at night. (impetigo) is a very important cause of acute glomerulonephritis. NOTE Sometimes the mite’s burrows can be seen as thin lines under the skin between the fingers NOTE Lindane, also known as gamma benzene and on the wrists. The mite may be seen as a hexachloride (Gambex), and pyrethrines (Lyclear white or black dot at the end of the burrow. and Nitagon), are less irritating but more Some affected people have no symptoms as they expensive. are not sensitive to the mite. 12-27 How does lice infestation present? Head lice are very small insects, which live on blood, which they suck from the scalp. They
  • 8. 202 SK IN CONDITIONSattach their small, white, shiny eggs (nits) to 12-29 How are sandworms recognised andshafts of hair. Each egg is the size of a flake of treated?dandruff. Lice are spread from person to person Sandworms are the larvae of the dog orby direct contact and also by sharing brushes cat hookworm which burrow under theand combs. Epidemics of lice at schools are skin, especially over the feet, buttocks andcommon, especially in girls with long hair. genitalia. Infestation usually occurs when theHead lice usually present as itching and child stands or sits in sand contaminated withscratching of the scalp. Many small red spots dog or cat faeces. The pink, raised, red S-can be seen on the scalp. While it is difficult shaped burrows of the larvae can be seen andto see the lice, their eggs are easy to recognise are very itchy. Treat with oral albendazole 1as they are firmly attached to the hairs. tablet daily for 3 days.Unlike dandruff, nits are not easy to remove. NOTE Thiabendazole 10% in petroleum jellyRarely lice may also infest other parts of the (Vaseline) can also be applied locally, but isbody. Some children have head lice without difficult to obtain. Ethyl chloride spray can also beitching or scratching and only the nits are applied to the affected area but it is very painful.noticed. All children with head lice canspread the lice to others.As with scabies, the scratching can cause RASHES DUE TO SKINsecondary bacterial infection (impetigo) IRRITANTSwhich must also be treated. Lice infestation presents with itching and 12-30 What skin irritants are common? scratching of the scalp. • Sunburn • Nappy rash • Insect bites and stings12-28 How should you treat head lice? • MiliariaMassage about 30 ml 1% gamma benzenehexachloride shampoo (Gambex or Quellada 12-31 How should sunburn be managed?shampoo) into the affected areas and leave onfor 5 minutes before rinsing off thoroughly. Every effort must be made to prevent severeBenzyl benzoate (Ascabiol) 12.5% (i.e. diluted sunburn as it may permanently damage the50:50) can also be used and applied to the skin and increase the risk of melanoma andwhole scalp overnight and then washed off skin cancer in adulthood. Children shouldin the morning. Do not get the lotion into not be exposed to prolonged periods in thethe eyes as it burns. Pyrethroid shampoos sun, especially between 10 am and 4 pm. Hats,(Lyclear and Nitagon) are also effective in protective clothing and sunscreens shouldkilling lice. The nits can be removed with become part of a national campaign againsta fine comb. Using hair conditioner after sun damage. This is particularly important inwashing the hair helps to remove the nits as infants and fair-skinned children who have veryit makes the hair slippery. It is not necessary sensitive skins. Sunburn presents with rednessto cut or shave the hair off although this is and pain in areas exposed to excessive sunlight.an effective treatment. It is best to treat the Blisters and swelling can occur in severe cases.whole family and look for nits in friends. Put a sunscreen on the child’s exposed skinOral antibiotics should be given if impetigo is whenever he or she goes into the sun. Alwayspresent. Do not share hairbrushes and combs. use a sunscreen with a sun protection factor of at least 15.
  • 9. SK IN CONDITIONS 203When the sunburn is first noticed, cool cream. In severe cases, oral mycostatin for athe child in a bath or shower. A simple few days may also be needed to clear fungusmoisturizing cream can be used to sooth from the stool. Any severe nappy rash that doesthe inflamed skin. Give children with severe not improve after 5 days treatment should besunburn frequent drinks of water to correct referred to a skin clinic.dehydration. Paracetamol may be needed forpain. The redness and pain resolves in a few 12-33 How should common insect bitesdays. This is often followed by peeling and and stings be managed?itching of the affected skin. Insect bites and stings are usually due to fleas, mosquitoes and bed bugs at night. All cause Children should be protected by a hat, clothing a red, papular, itchy rash. Flea bites occur on and sunscreen when going out into the sun. skin covered by clothing or on the feet and lower legs. In contrast, mosquito bites occur NOTE Ultraviolet rays penetrate and damage on exposed skin, especially the face and hands. the skin. Ultraviolet ray damage in childhood is Bed bug bites tend to occur in rows as the bug an important cause of later skin cancer. Topical bites as it walks along. steroids may be used in severe sunburn. Children who are allergic to insect bites develop papular urticaria, which presents as12-32 What is nappy rash? raised, swollen and very itchy wheals. TheNappy (diaper) rash is a red rash which occurs papular urticaria should be managed byon the buttocks and perineum of infants who preventing the insect bites.wear nappies. Most infants have mild nappy Prevent mosquito bites with insect repellentrash at times, especially if the stools are loose. (Tabard, Peaceful Sleep). Remove any poolsPainful vesicles and small ulcers may develop of standing water where mosquitoes breed,if the nappy rash is severe. Secondary bacterial and use bed nets. As fleas often come fromor fungal infection is common. Seborrhoeic carpets and pets, vacuum the carpets anddermatitis may also present in the nappy area deflea cats and dogs. Bed bugs live in cracks inas a nappy rash. wooden beds. Therefore spray the bed with anNappy rash is usually caused by urine and insecticide and place the mattress in the sun.stool in the nappy irritating the skin. The rash Calamine lotion helps to relieve the itching.is worse on exposed parts of the skin while the Oral antihistamines are useful in more severecreases are often protected. cases. Do not use local antihistamine creams.Frequent nappy changes, together with a With bee stings, scrape the sting off with aprotective zinc cream or petroleum jelly blunt knife. Do not try to pull it out. The pain(Vaseline), usually protects against nappy of both bee and wasp stings can be relieved byrash. The best treatment is to keep the skin rubbing the area with ice. Bee stings can causedry by removing the nappy for a few days and severe allergic reactions.allowing the infant to lie on an open cleannappy. Expose the buttocks to warm, dry airas often as possible. Linen or toweling nappies 12-34 What is miliaria?must be washed and well rinsed before use. Do This is the very common heat rash usuallynot use plastic pants over nappies. seen on the neck of small infants who have aA rash in the nappy area can also be caused by fever or who have been allowed to get too hot.a fungus (Candida). A fungal rash (candidiasis) The rash consists of small pink macules, whichis very red, often has small satellite spots, and fade when pressed. The rash is caused by sweatis worse in the creases. Treat as for nappy rash irritating the infant’s sensitive skin. Miliariabut also cover the affected skin with mycostatin usually disappears when washed with cold
  • 10. 204 SK IN CONDITIONSwater. Prevent by not overheating the child. NOTE Children with atopic eczema have anAvoid excessive clothes or blankets, especially inherited tendency to produce IgE. This resultsin summer. in an immunological reaction in the skin, which causes inflammation. IgE testing or skin prick tests for common allergens is needed to confirm the clinical diagnosis of atopic eczema.RASHES DUE TO ALLERGIES 12-38 How should atopic eczema be12-35 What rashes are caused by allergies? managed?• Eczema Atopic eczema is rare in newborn infants• Urticaria and usually starts during the first months of life. In most children it disappears as they become older. In others it recurs or becomes12-36 What is atopic eczema? chronic. A common pattern is mild chronicEczema (or dermatitis) is an itchy, scaly rash, eczema with repeated flare-ups of acutewhich has many causes. The most common eczema. Therefore, both the child and familyform of eczema in children is atopic or allergic need ongoing counselling and support as theeczema. Atopic eczema is a form of allergy of condition may last for years.the skin and occurs in about 5% of children. Unless the eczema is mild, the child should beMost children with atopic eczema have a family referred to a skin clinic at a hospital, if possible,history of asthma, hay fever or eczema. These for the management of acute eczema and thechildren start with atopic eczema before 2 years planning of management for chronic eczema.of age and often later develop other forms of Specific management consists of the following:allergic disorder. They all have very dry skins. 1. Local management of the skin is most important in atopic eczema. Liberal Children with atopic eczema usually have a family amounts of emulsifying creams history of allergy. (moisturizing creams or emollients), such a ‘aqueous cream’, are used in acute12-37 What are the clinical features of eczema and emulsifying ointments, suchatopic eczema? as ‘HEB’ in chronic eczema. Emulsifying creams and ointments are used as first lineIn young children, the rash of atopic eczema treatment to prevent the skin from dryingconsists of a red, very itchy, oozing and out. This helps to prevent inflammation.crusting rash on the cheeks (acute eczema). Emulsifying creams or ointments shouldThe rash may spread to the scalp, the chest, be applied at least twice a day.the front of the elbows, the wrists and behind 2. For mild or moderate eczema, 1%the knees. These children are very irritable and hydrocortisone in an emulsifying creamunhappy and want to scratch all the time. or ointment (emollients) should beIn older children the rash is usually chronic applied twice daily. Stronger steroidsand consists of dry, itchy, thickened, scaly (betamethasone) can be used on the trunkpatches on the face, neck, front and back of and limbs if 1% hydrocortisone fails tothe elbows and wrists, front and back of the control the rash in 2 to 3 days. Do notknees and ankles (chronic eczema). Bacterial use strong steroids for longer than oneinfection often complicates eczema as a result week without specialist advice. Do not useof the scratching. strong steroids on the face. Oral steroids must be avoided. The need for steroids is reduced if emulsifying cream or ointment The rash of acute eczema is very itchy. is used to protect the skin. Many children
  • 11. SK IN CONDITIONS 205 with mild eczema can be adequately stocking bandages (Stockinette) that have been managed with regular use of emulsifying moistened with warm water and covered in cream or ointment alone. generous amounts of emulsifying ointment or3. 5% coal tar in emulsifying ointment is used aqueous cream. The wet wrap is placed over the skin where steroid has been applied. It ensures on patches of chronic eczema. deep penetration of the steroid, and rehydrates4. If secondary bacterial infection (impetigo) the skin, lessens inflammation, reduces itching is present, povidone iodine (Betadine) and discomfort and hastens healing. Wet wraps cream or ointment dressings are applied alone reduce the need for local steroids. for 3 to 5 days. An oral antibiotic may be needed with widespread infection. 12-39 What is ‘lick eczema’?5. An oral antihistamine can be given for the itch and to provide some sedation in acute This is a rash around the mouth caused by eczema. Local antihistamine creams are excessive licking or thumb-sucking. The lips of no help. It is very difficult to stop small are also dry and sore. The saliva irritates the children from scratching. Unfortunately, lips and skin. Lip-licking and thumb-sucking scratching causes further itching and may are habits. The red scaly rash around the introduce secondary bacterial infection. mouth, and the dry, chapped lips, get better Gloves or socks over the hands may reduce when the habit stops. scratching. Do not let the child get too 1% hydrocortisone cream for a few days clears warm as this makes itching worse. Keep the rash. Petroleum jelly (Vaseline) can then the nails short. be used to protect the skin. Lip cream will6. The child should wash daily with aqueous moisturize and protect the lips. cream instead of soap. Do not use soaps, shampoos, bubble baths or washing 12-40 What is seborrhoeic dermatitis? detergents as they often make the rash worse. Showers are better than baths. The cause of this condition is unknown. It Aqueous cream or emulsifying ointment presents with a red rash covered with greasy, (or petroleum jelly) should be applied sticky scales, especially over the face, behind every day immediately after washing and the ears, the scalp, and the nappy area. drying. It usually does not itch. The rash is most7. Removing specific items from the diet may common in infants and usually disappears be useful in young infants but is less helpful after a few months. Seborrhoeic dermatitis of in older children. Encourage breastfeeding. the scalp in infants is called ‘cradle cap’.8. Do not let the child overdress and get too The skin and scalp rash can be treated with 1% hot. Avoid wool or nylon next to the skin. hydrocortisone ointment. Use baby oil or olive Cotton clothing is best. oil or 2% salicylic acid in vaseline to loosen the9. Avoid people with cold sores, as secondary thick, yellow scales in severe cradle cap. They herpes virus infection is dangerous in can then be washed off with shampoo. children with eczema.10. If the acute eczema is not much improved Seborrhoeic dermatitis is becoming more after a week of treatment, refer to a common as it is associated with HIV-infected specialist skin clinic. children. NOTE As with atopic eczema, severe seborrhoeic dermatitis may need to be treated with a dilute Emulsifying cream or ointment, with or without steroid cream under a covered dressing. 1% hydrocortisone, is most important in treating eczema. NOTE If possible, wet wraps should be used at night to manage acute eczema. Wet wraps are
  • 12. 206 SK IN CONDITIONS12-41 How is acute urticaria diagnosed and the child to sleep. Do not use antihistaminetreated? cream. In severe cases, use 1% hydrocortisone cream for a few days as for eczema. Treat anyAcute urticaria is a very itchy raised rash, secondary impetigo.which appears suddenly and fades within afew hours. It often reappears daily for a few NOTE Non sedating antihistamines such asdays to weeks. The raised areas of skin are pale cetirizine (Zyrtec) and loratidine (Clarityne) arewith pink borders. It can also present with effective but expensive.larger areas of raised, swollen skin (wheals).Rarely, other signs of an acute generalizedallergic reaction, such as wheezing, collapse OTHER SKIN CONDITIONSand shock, may occur. IN CHILDRENThe cause in children is usually unknown butis probably caused by a viral infection. Lesscommonly, urticaria is a reaction to a specific 12-44 What is ichthyosis?food. These foods must be avoided. This is a group of inherited conditions, whichUrticaria can usually be treated with an cause very dry, thickened and scaly skin. Itoral antihistamine. Local calamine lotion or may only involve the palms and soles, but in1% hydrocortisone cream may help. Local some other children it affects the whole body.antihistamine cream is not effective. If the The pattern of ichthyosis is the same for allurticaria is recurrent, the child should be affected members of the family.referred for a specialist opinion. Treatment consists of keeping the skin soft and moist with aqueous cream. 10% urea in12-42 What is papular urticaria? emulsifying ointment can be used in older children with severe ichthyosis. Severe casesPapular urticaria is common and presents as must be referred to a skin clinic at a hospital.groups of very itchy papules. The papules maydevelop into small blisters. The itching results NOTE Emulsifying ointment is a mixture ofin scratching and keeps the child awake at emulsifying wax, soft white paraffin and liquidnight. It often recurs or may become chronic. paraffin. It is a very useful bland base for steroidsSecondary infection causing impetigo is a and vioform.common complication of scratching. 12-45 What is psoriasis?Papular urticaria is caused by an allergy toinsect bites, especially fleas, mosquitoes and This is a chronic skin condition, whichbed bugs. It is particularly common in young presents with thickened, red patches ofchildren. skin covered with silvery scales. 5% tar in emulsifying ointment helps in mild cases. Severe cases should be referred to a skin clinic Papular urticaria due to flea or mosquito bites is a at a hospital for further management. common cause of a very itchy papular rash. 12-46 What is acne?12-43 How is papular urticaria managed? Acne is a common condition in teenagers.Insect control is most important. Treat the It presents with ‘blackheads’, pimples andrash with calamine lotion which decreases pustules on the face. Severe acne can alsothe itching. An oral antihistamine syrup, affect the neck, back and chest, and resultssuch as chlorpheniramine (Chortrimetron), in cysts and scarring. Acne is more commonpromethazine (Phenegan) or hydroxyzine in boys, especially if there is a family history(Aterax), also decreases itching and helps
  • 13. SK IN CONDITIONS 207of acne and greasy skins. Acne may cause 12-48 What is ‘vaseline dermatitis’?embarrassment and emotional problems. This is a common rash on the face of infantsAt puberty, sex hormones result in an increase when petroleum jelly (Vaseline) is rubbedin secretion from sebaceous glands. This onto the skin. Vaseline blocks the sebaceouscauses acne in some people. The ducts of the glands causing many small papules. It may alsosebaceous glands become blocked (giving cause contact dermatitis. The rash disappearsblackheads) and bacterial colonisation in the when petroleum jelly is no longer used. Greasyglands breaks down the sebaceous secretions substances, such as petroleum jelly, should notcausing inflammation (pimples) and pus be used on the face.formation (pustules). Diet has no affect onacne. Acne cannot be cured but the severitycan be controlled until it clears spontaneously Vaseline is a common cause of a fine papular rashin adulthood. Acne is not infectious and not on the face of infants.caused by poor hygiene (not washing).12-47 What is the management of acne? TYPICAL PRESENTATIONMost mild cases can be managed with local OF RASHEStreatment:1. Washing the face daily with water and a 12-49 Which rashes typically cause itching? regular soap.2. Acne cream (tretinoin) to promote mild • Scabies peeling to open the blocked ducts of the • Ringworm sebaceous glands is the first line treatment • Atopic eczema of mild acne. This is best used at night. • Urticaria Stop treatment for a few days if the skin becomes red and tender. 12-50 Which rashes are typically painful?3. A local antiseptic cream (benzoyl • Cold sores peroxide) to reduce inflammation in the • Athlete’s foot sebaceous glands. • Plantar warts4. Mild exposure to sunshine.5. No squeezing, picking or scrubbing the spots. 12-51 Which rashes are typically scaly?If the acne does not improve in 2 months, or if • Ringwormit is severe, the patient should be referred to a • Chronic eczemaskin clinic at a hospital. • Psoriasis NOTE Topical antibiotics (clindamycin or erythromycin) or systemic antibiotics (doxycycline), oral contraceptives, especially if CASE STUDY 1 they contain cyproterone (Diane 35), in girls, or oral retinoids (which can cause congenital A mother brings her 7-year-old son to the malformations if given during pregnancy) can clinic as she is worried about bald patches be used in severe cases. Usually 6–8 weeks of which have developed on his scalp. On treatment is needed before improvement is examination, you find a number of areas of noted. Resistance to topical antibiotics, used to pale, scaly skin with hair loss. decrease the number of Propionibacterium acnes in the skin, is becoming a problem. 1. What is the diagnosis? Ringworm of the scalp.
  • 14. 208 SK IN CONDITIONS2. Is this caused by a worm? 3. What are the white spots in the hair?No. It is caused by a fungus. Probably the nits (eggs) of lice attached to the hairs. Unlike dandruff, nits cannot be easily3. Is this an infectious skin condition? combed out as they are tightly attached to the hairs. Lice suck blood from the scalp leavingYes. It is common in school children, who small red spots, which itch.often borrow each others’ combs, brushes orcaps and touch heads when they play. Pets may 4. Why would it be important to examinealso have ringworm. the mother?4. What is the correct treatment? Because she may also have scabies and lice. Both are infections and are spread by directOral griseofulvin 10 mg/kg/day for 6 weeks. contact, such as sleeping in the same bed.Ringworm of the scalp will improve but not becured with local treatment only. 5. How should you treat this child?5. Can this condition affect other parts of First use 2% vioform in zinc ointment onthe body? the rash for a few days to treat the bacterial infection. Then put 12.5% benzyl benzoateYes. Ringworm often presents as a group of lotion over his whole body, except the face.itchy, scaly, pink papules on the face or trunk. Wash the lotion off after 24 hours and thenThe rash typically forms a circle with normal dress him in clean clothes. Wash the bed linen.skin in the centre. Vesicles may also occur. The mother and other family members mustTreat with clotrimazole (Canesten) ointment be similarly treated.twice daily for 2 to 4 weeks. The lice should be treated with 1% gamma benzene hexachloride shampoo (Gambex orCASE STUDY 2 Quellada). This should be rubbed onto the head and then left for 5 minutes before washing off. Comb out the nits with a fine comb. The rest ofA mother brings her 3-year-old son to the the family should also be treated.clinic as he has an itchy rash over his wrists.He scratches both the rash and his scalp atnight and sleeps badly. When you examine 6. Should the child’s head be shaved?the child you notice that the rash is red and No. There is no need to cut the hair or shavepustular with scratch marks. You also see his head.small, shiny white spots in the child’s hair.1. What do you think is the cause of the CASE STUDY 3rash?The history is typical of scabies with an itchy A 4-year-old child presents with groups ofrash on the wrists. The itching is much worse very itchy, red papules on her face, arms andat night when the child is warm. Usually the legs. She is generally well but her mother saysrash is papular. Scratch marks are common. she is restless at night because of the itching.2. Why is this rash pustular? 1. What is the most likely diagnosis?Because the scabies has been complicated by Papular urticaria.secondary bacterial infection (impetigo). This isa common complication caused by scratching.
  • 15. SK IN CONDITIONS 2092. What is the cause? 4. How is an acute flare up of atopic eczema managed?An allergy to insect bites. As the rash is onexposed areas of skin, the allergy is probably Mild or moderate cases can be treated with 1%due to mosquito bites. hydrocortisone in an emulsifying cream on the face twice daily. A stronger steroid ointment3. How should the rash be treated? can be used for a few days on the rash over other parts of the body. The rash shouldLocal calamine lotion is soothing. An oral respond and the treatment stopped in a week.antihistamine will reduce the itching. Never use strong steroids on the face.4. What can be done to prevent the 5. What is the long-term management ofcondition? atopic eczema?Every effort must be made to prevent the The skin must be kept moist and soft withmosquito bites. Insect repellent is helpful. regular use of an emulsifying ointment or aqueous cream twice daily .The child should wash daily with aqueous cream instead of soap.CASE STUDY 4A grandmother brings her grandson to clinic CASE STUDY 5and complains that his atopic eczema hasbecome much worse during the past few days. A teenager complains of blackheads andHe is irritable and scratches all the time. pimples on his forehead and cheeks. He has had the rash for 6 months. He also has warts1. What is the appearance of the rash in on his hand. Both make him embarrassed.acute atopic eczema?The rash is red, oozing and crusted. It is very 1. What is the rash on his face?itchy and usually presents on the face and Acne. It is common at puberty, especially inmay spread to the scalp and chest, front of the boys. It presents with blackheads, pimpleselbows and wrists and back of the knees. and pustules on the face. Severe cases can also involve the neck, back and chest.2. What is a common complication of thescratching? 2. What is the cause?Impetigo due to secondary bacterial infection. Acne is due to an increased secretion of sebaceous glands which happens at puberty3. How is this complication diagnosed and due to increased sex hormone production.treated? Acne is more common in families with greasyImpetigo presents as a group of small skins. It is not caused by poor hygiene or anblisters which soon burst leaving a raw area incorrect diet.that becomes covered by a yellow crust. Itshould be treated with 2% vioform or an 3. What is the treatment?antibiotic cream. An oral antibiotic, such as Most cases of acne respond to tretinoin cream,flucloxacillin, may be needed. which causes mild peeling, and benzoyl peroxide cream to reduce inflammation. Mild exposure to sunshine also helps. The rash may take a few months to respond. The patient should not pick, squeeze or scrub the rash.
  • 16. 210 SK IN CONDITIONS4. When should patients be referred to a 5. How should warts be treated?special skin clinic? Many warts disappear spontaneously after aIf the acne is severe or does not respond in 2 few months without treatment. Warts are bestmonths. treated with daily applications of wart paint.