Diagnosis and Management of Common and Infective Skin Diseases in Children at primary care level

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1 Diagnosis and Management of Common and Infective Skin Diseases in Children at primary care level Dr Ng Su Yuen Paediatrician and Paediatric Dermatologist Hospital Pulau Pinang

2 Outline Common inflammatory infective and noninfective skin diseases Key features of common skin diseases in children Management of atopic eczema

3 History of rash Onset Inciting factors Evolution of lesions Presence or absence of pruritus

4 Examination of rash Distribution Single or multiple Localized or generalized Symmetric or asymmetric Flexural or extensor Mucous membranes Teeth Hair Nails Morphology Size Colour Configuration Texture

5 Morphology Primary lesions arise de novo, most characteristic of the disease process Secondary lesions modification of primary lesions

6 Macule/patch Flat discolouration <1cm (macule) >1 cm (patch)

7 Papule Elevated lesion, < 1 cm

8 Nodule Elevated lesion, > 1 cm (nodule tends to have a deeper component)

9 Plaque Elevated and flat-topped lesion, generally much more broad than raised

10 Vesicle/Bullae Elevated collection of fluid, < 1 cm Bullae > 1cm

11 Pustule Elevated collection of pus (white blood cells)

12 Wheal Elevated lesion characterised by transient edema

13 Secondary lesions Evolutionary changes that occur later in the course of the cutaneous disorder

14 Erosion and Ulcer Erosion Part or all of the epidermis lost Ulcer Necrosis of epidermis and dermis/subcut tissue

15 Scale Formed by an accumulation of compact desquamating layers of stratum corneum

16 Lichenification Thickening of epidermis with exaggeration of skin markings

17 Approach to Diagnosis of Common Skin Diseases

18 Questions Is it red and scaly? Is it red and non scaly? (maculopapular rash) Are there are vesicles or pustules? Is it a blistering skin condition? Is it papular rash?

19 RED and SCALY

20 Eczematous Papulosquamous

21 UK Working Party Diagnostic Criteria For Atopic Eczema (sensitivity: 87.9%; specificity: 92.8%) Must have an itchy skin condition in the last 12 months and 3 or more of the following: History of involvement of the skin creases A personal/family history of asthma or hay fever A history of generally dry skin during the last year Visible flexural dermatitis Onset under the age of 2

22 Management Holistic approach Initial assessment of disease history, extent and severity Impact Identify potential trigger factors Consider other differentials

23 Red flags Failure to thrive Chronic diarrhoea Recurrent infections Unresponsive to standard treatment

24 Management Education Explanation Empathy Natural History Complications Prognosis Avoid/control triggering factors Control not cure How to use (demonstrate) Psychological support

25 3 components to tackle Dry skin Moisturiser Inflammation/Itch Topical Corticosteroids Topical Calcineurin inh. Infection Antibiotics Antiseptics

26 Bathing Bath daily Lukewarm water Soap substitute (aqueous cream) Pat dry, apply creams Non-slip bath mat

27 Moisturizers Use frequently to prevent drying Massage in along direction of hair growth Prescribe 500gm Do not use at same time as steroid

28 Moisturizers (Vehicle) Ointment: fewest additives, most occlusive Cream and lotion: higher percentage of water, easier to apply, can be irritating

29 Moisturizers The moisturizer that works best is the one that the patient finds acceptable and affordable E.g. Aqueous cream Paraffin Ung Emulsificant Vaseline Glycerine

30 How to use steroid creams Potency Vehicle Age Site, extent Method of Application

31 Know your topical steroid potency

32 Location, location, location Face, flexures, groin Low potency steroid (VI,VII)

33 Location, location, location Limbs, trunk Medium potency steroid (IV, V) Thick stubborn plaques or nodules on limbs High potency steroid (II, III) for a few days

34 Practical Tips Infants: use low potency steroids (VI, VII) For stubborn eczema in children: use a more potent topical steroid to induce remission within 3-5 days Then switch to a less potent topical steroid

35 How to apply TCS Apply over red, itchy or rough areas Apply a thin layer 1 fingertip unit = tip of adult index finger to 1 st crease About 0.5g, enough to cover area of 2 flat adult hands

36 Personalized Plan

37 Secondary bacteria infection 90% colonized with S. aureus More erythema Crusting Serous discharge Does not respond to emollient or topical steroid treatment Treadwell PA. Pediatr Infect Dis J. 2008

38 Eczema herpeticum

39 Papulosquamous Eruption Seborrhoeic dermatitis Psoriasis Nummular/Discoid eczema Superficial fungal infections Pityriasis rosea Secondary syphilis

40 Seborrheic Dermatitis First 10 weeks Asymptomatic, mildly pruritic Yellowish red, greasy, scaly macules and papules coalescing into plaques Scalp, diaper area diffuse, Face and trunk - discrete

41 Difference between Seborrheic dermatitis and Atopic dermatitis Infantile seborrhoeic dermatitis Atopic eczema Age <3 months >2-3 months General Condition Good Irritable Pruritus Nil ++++ Sleep Normal Restless Distribution ofrash May involve nappy area Nappy area usually spared F/H Atopy Usually negative Often positive Skin test o RAST Usually negative Positive (80%)

42 Superficial fungal infections Dermatophytosis (tinea or ringworm) Pityriasis versicolor (formerly tinea versicolor) Candidiasis (moniliasis)

43 Dermatophytoses Caused by dermatophytes which are able to invade and colonize the stratum corneum of the skin and keratinized tissues such as hair and nails Microsporum, Trichophyton, Epidermophyton Described using the Latin word tinea followed by the Latin name of the site eg tinea capitis.

44 Tinea corporis vs Discoid eczema Advancing edge Lacks central clearing, KOH negative Very pruritic May exhibit weeping, cracking, vesicles, or crusts

45 Tinea capitis Microsporum canis (cats) Children Hair loss Scaling and erythema Occipital lymphadenopathy