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Paediatric rashes

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Paediatric rashes

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Paediatric rashes

  1. 1. Paediatric Rashes Dan Pixley 2018
  2. 2.  How to describe a rash  Recognise the visual diagnoses for paediatric rash presentations  Patterns, distribution, special features  Broaden differentials for rash and identify the commonly misdiagnosed presentations  Treatments for rash  Recognise the critical rash Objectives
  3. 3. Anatomy Epidermis - Protective barrier - melanin and immune Dermis - sweat: - Nerves - Sebaceous: - blood vessels Hypodermis (Subcut fat) - Attaching the dermis to your muscles and bones: - blood vessels and nerve cells: - Controlling your body temperature: - Storing your fat
  4. 4.  Macule –  Circumscribed are of change <1cm  Patch –  Large area of skin change  Papule –  solid raised lesion <1cm  Nodule –  solid raised lesion >1cm  Plaque –  circumscribed confluent area of nodules  Vesicle –  fluid filled are <1cm  Bulla –  fluid filled area >1cm  Pustule –  circumscribed area containing pus  Furuncle –  skin abscess (usually from staph)  Carbuncle –  collection of furuncles connected Describing a rash
  5. 5.  Viral  Bacterial  Fungi  Drug Reactions  Allergic  Autoimmune  mites Aetiologies
  6. 6.  4 year old child brought in by parents. Itching vigorously. Common Rashes
  7. 7.  Highly contagious skin infestation by the mite Sarcoptes scabiei  itchiness and a pimple-like rash  1st infection: symptoms in between two and six weeks  Second infection: Sxs develop in 24 hours  Symptoms secondary to an allergic reaction (Type IV)  zigzag or S pattern of the burrow will appear across the skin  Rx: Permethrin 1. Scabies
  8. 8. 2. ACNEPropionibacterium acnes
  9. 9. 2. Acne Comedomes Pustules, nodules
  10. 10. 2. Acne
  11. 11. Common Rashes 3. Contact Dermatitis
  12. 12.  Irritant dermatitis  Allergic Dermatitis  Treat with removal of exposure, protective barrier and/or steroids 3. Contact Dermatitis
  13. 13. 4. Atopic Dermatitis (Eczema)
  14. 14.  Infant  4months to 5 years  Cheeks  Extensor surfaces  Diaper area 4. Atopic Dermatitis (Eczema)  3 year old - adult  Flexor surfaces  Neck  Face  Upper chest Rx: steroids and moisturisers Cotton clothing Dry well after bathing Antibiotics for superimposed infection
  15. 15. Common Rashes 5. Impetigo
  16. 16.  Staphylococcus aureus or Streptococcus pyogenes  Highly contagious  Treated with mupirocin ointment or POABs  E.g Flucloxacillin  Isolate from day care  Occasionally admit  Risk of leading to Osteomyeltisis and PSGN 5. Impetigo
  17. 17. Tinea
  18. 18. Tinea Tineas Capitis Tinea Versicolour
  19. 19.  Treatment  Corporis: Topical antifungals e.g Clotrimazole, Terbnafine  Versioclour: Topical antifungals plus Selenium sulfide shampoo  Capitis: Griseofulvin for 6 weeks plus Selenium shampoo Tinea
  20. 20. Non specific Viral Rash (exanthomata)
  21. 21.  The majority of Exanthems are nonspecific and difficult to categorise  Associated with non specific sxs like headache, lethargy, mayalgia and GI complaints  Most resolve in less than a week  Cause  Thought to be from enteroviruses and adenovirus/rhinovirus/parainfluenza Non specific Viral Rash (exanthomata)
  22. 22.  First Disease  Measles  Second Disease  Scarlet Fever  Third Disease  Rubella  Fourth Disease  Dukes -Controversial (possibly a misdiagnosis)  Fifth Disease  Erythema Infectiosum (Parvovirus B19)  Sixth Disease  Roseola (HHV6) Specific Exanthems
  23. 23. Exanthems First Disease -Measles
  24. 24.  Incubation: 7-14 d  Prodrome: 4 -5 d before rash fever, malaise, rhinorrohea, cough, Koplik spots 1-3 d before rash  Rash: day 4-7 of illness starts behind ears, forehead, around mouth dusky red, florid maculopapular rash spreads over trunk and limbs. Lasts 5 d.  Infectivity: prodrome to 4 d after the rash  Transmission: respiratory droplet or direct contact  Complications: ears & OM, lungs & pneumonia conjunctivitis CNS encephalitis at d 10, SSPE after several years Measles
  25. 25. Exanthems Rubella – 3rd Disease
  26. 26.  Also called German Measels  often mild with half of people not realizing that they are infected  A rash may start around two weeks after exposure and last for three days  starts on the face and spreads to the rest of the body  Infection during early pregnancy (below 20 weeks) may result in a child born with congenital rubella syndrome (CRS) or miscarriage.  Once recovered, people are immune to future infections.  Vaccine preventable Rubella
  27. 27. Exanthems Scarlett Fever 2nd disease Pastia’s lines
  28. 28.  Can occur as a result of a group A streptococcus (group A strep) infection  It most commonly affects children between five and 15 years of age  Complications:  Suppurative: peritonsillar or retropharyngeal abscesses, cellulitis, mastoiditis or sinusitis  Non-suppurative: Rheumatic fever, RHD, PSGN, Reactive Arthritis Scarlett fever
  29. 29. Exanthems 5th Disease – Parvovirus B19
  30. 30. Roseola (6th disease) - 3 year old child presents with 3 day history of fevers, cough and runny nose - Fevers stopped yesterday but suddenly patient woke up with this rash.
  31. 31. Emergent Rashes Pyotr Nikolsky (1858–1940)
  32. 32. Erythema Multiforme
  33. 33. Immune dysfunction  Causes: Viral (HSV)  Drugs  antibiotics (including, sulphonamides, penicillin)  anticonvulsants (phenytoin, barbiturates)  aspirin, antituberculoids, and allopurinol and many others.  Infections: Viral (HSV), bacterail and fungal  Other: Mutliple myeoloma, Lymphoma, Vasculitis Erythema Multiforme
  34. 34. SJS/TEN
  35. 35.  Spectrum of disease  Widespread blisters predominant on the trunk and face, mucous membrane erosions;  SJS: epidermal detachment is less than 10% TBSA  TEN: epidermal detachment is more than 30% TBSA  Cross over between 10-30% SJS/TENS
  36. 36.  Often start with fever, sore throat, cough, and burning eyes for 1 to 3 days  Type IV hypersensitivity reaction – secondary to immune system being triggered by drugs/infections  Ulcers and other lesions begin to appear in the mucous membranes  - almost always in the mouth and lips, but also in the genital and anal regions.  Problems eating and drinking due to pain of ulcers  Conjunctivitis occurs in about 30%  Rash of round small lesions arise on the face, trunk, arms and legs, but usually not the scalp SJS/TENS
  37. 37.  Mortality rate:  5% for SJS  30-40% for TENS  Treatment  discontinuation of the causative factor – most important  Move to a burns unit  Supportive cares and IVH  IV anti-biotics  Immunomodulatory: steroids, cyclophosphamide, plasmapheresis, acetylcysteine, infliximab SJS/TENS
  38. 38. Meningitis
  39. 39.  Characterizing Viral Exanthems – Medscape  Nguyen T, Freedman J. Dermatologic emergencies: diagnosing and managing life- threatening rashes. Emerg Med Pract. 2002;4(9):1-28.  Emergent Diagnoisis of the unknown rash. Jounral Emergency Medicine 2010. Heather Murphy-Lavoie, MD, FAAEM, andTracy Leigh LeGros, MD, PhD, FACEP, FAAEM  Morens DM, Katz AR. The "fourth disease" of childhood: reevaluation of a nonexistent disease. Am J Epidemiol. 1991 Sep 15;134(6):628-40.  Powell KR. Filatow-Dukes' disease. Epidermolytic toxin-producing staphylococci as the etiologic agent of the fourth childhood exanthem. Am J Dis Child. 1979 Jan;133(1):88- 91.  3Weisse ME. The fourth disease, 1900-2000. Lancet. 2001 Jan 27;357(9252):299-301.  Maverakis, Emanual; Wang, Elizabeth A.; Shinkai, Kanade; Mahasirimongkol, Surakameth; Margolis, David J.; Avigan, Mark; Chung, Wen-Hung; Goldman, Jennifer; Grenade, Lois La. "Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis Standard Reporting and Evaluation Guidelines" JAMA Dermatology. doi:10.1001/jamadermatol.2017.0160. References

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