Case1. 18 day old female. 5 day history of several red lesions over both cheeks. Full-term, vaginal birth with no complications

QUIZ

Case1 18 day old female 5 day history of several red lesions over both cheeks Full-term, vaginal birth with no complications Mother is a 25 year old with a history of migraines who took paracetamol

Question What is the cause of the rash? A. Paracetamol taken by mother B. Inflammatory reaction to Pityrosporum (Malassezia) species C. Allergic reaction to soap D. Cow s milk allergy E. Staph. Aureus infection

Neonatal Acne/Acne neonatorum Neonatal cephalic pustulosis Within 2-4 weeks of life, resolves spontaneously Morphology Multiple discrete erythematous papules evolve into pustules Comedones absent Distribution Face esp cheeks, forehead, extend to scalp Maternal and endogenous androgens Inflammatory reaction to Pityrosporum (Malassezia) species

Question What is the best treatment? A. Syrup cloxacillin B. Change soap C. Topical retinoids D. This is a self-limited condition that does not require treatment (some benefit from topical antifungals) E. Refer endocrinologist for precocious puberty

Case 2 3m.o baby girl Blister over left palm for 2 days Red rashes over neck and whole body and periorbital and perioral region, with peeling skin Had vaccination prior to onset of rash Low grade temperature Irritable especially on touch

Investigations Wbc 16.9, Hb 10.8, Plt 569 Urea 1.8, Na 136, K 4.4, creat 25 Eye swab c+s : staph Aureus Throat swab, swab from perineum : NG Blood c+s : NG ASOT : negative

What is the diagnosis? A. Allergic reaction to vaccination B. Viral exanthem C. Drug reaction to paracetamol D. Infected eczema E. Staphylococcal scalded skin syndrome

Treatment Hydration IV cloxacillin then oral cloxacillin Pain relief Vaseline LA Zinc oxide cream over perineum

SSSS Potentially life - threatening, toxin - mediated manifestation of localized infection with certain strains of staphylococci Most cases seen before the age of 5 years Diagnosis is made clinically Fever, irritability, skin tenderness and scarlatiniform erythema with accentuation in flexural areas Within 24 48 hours, flaccid blisters and erosions develop Harper Textbook of Paediatric Dermatology

Case 3 8/12 old baby boy C/O : fever x 4/7 Irritability Redness of the eyes Generalised rashes after taking a dose of PCM Poor oral intake No URTI/UTI symptoms

On examination Irritable Febrile Bilateral conjunctivitis Cervical, axillary and inguinal lymph nodes palpable

What is the diagnosis? A. Allergic reaction to PCM B. Viral exanthem C. Kawasaki disease D. Measles E. Staphylococcal scalded skin syndrome

Kawasaki disease Kawasaki disease, or mucocutaneous lymph node syndrome, most commonly affects children between 6 months and 5 years of age. Approximately 90% of patients have mucocutaneous manifestations Bayers S. J Am Acad Dermatol. 2013

Diagnosis Fever for 5 days and 4 of the 5 main clinical features The 5 major clinical findings are as follows: Changes in distal extremities Polymorphous eruption Changes in lips and oral cavity Nonexudative bilateral conjunctival injection (5% are exudative) Cervical lymphadenopathy, usually unilateral Bayers S. J Am Acad Dermatol. 2013

Diagnosis Incomplete Kawasaki can be diagnosed with the help of laboratory investigations In the presence of 4 principal criteria, KD can be diagnosed before day four of the illness by an experienced clinician Infants under the age of six months with fever for >7 days and no other clear etiology should be evaluated for KD even in the absence of other diagnostic criteria Yim D et al. J Paediatr Child Health. 2013

Kawasaki disease Potentially life-threatening coronary artery damage may occur Timely diagnosis and treatment are essential Yim D et al. J Paediatr Child Health. 2013

Case 4 7 months old Pruritic and painful rash over diaper area for the past 1 month Treated with hydrocortisone cream in KK a few times

What is the diagnosis? A. Irritant contact dermatitis B. Seborrhoeic dermatitis C. Candidiasis D. Psoriasis E. Langerhans cell histiocytosis

Diaper candidiasis Erythema, scaling, satellite pustules Beefy red erythema on the buttocks, lower abdomen, inner aspects of the thighs Oral thrush

Diaper Dermatitis Irritant Contact dermatitis Seborrhoeic dermatitis

Case 5 4 months old Itchy skin condition Worse at night Papules and pustules

What is the diagnosis? A. Atopic eczema B. Impetigo C. Scabies D. Tinea corporis E. Food allergy

Scabies Infestation with Sarcoptes scabiei Umbilicus, web spaces, wrists, axilla, palms and soles in infants Nodular lesions may be seen

Case 6 11 yr old Indonesian boy, immigrant Chronic plaque lesion on face for >6 months Not itchy, no respond to topical corticosteroids Hypoanaesthesia

What is the most likely diagnosis? A. Tinea corporis B. Atopic eczema C. Contact dermatitis D. Psoriasis E. Hansen s disease

Which is the most appropriate investigation to confirm the diagnosis? A. Fungal culture B. Serum IgE level C. Slit skin smear D. Patch test E. Skin prick test

Hansen s disease (Leprosy) Chronic infection caused by Mycobacterium leprae Skin, nervous system Hypopigmented to erythematous anesthetic macules, papules, plaques, nodules

Case 7 2 year old Malay boy Reddish papule left temple for 3 months Recurrent bleeding

What is the most likely diagnosis? A. Haemangioma B. Pyoderma gangrenosum C. Pyogenic granuloma D. Insect bite reaction E. Spider angioma

Which treatment is inappropriate for this condition? A. Shave excision B. Oral prednisolone C. Cautery D. Pulsed dye laser therapy E. Watchful waiting

Pyogenic granuloma Acquired benign proliferative vascular tumour Most common <5yrs old Solitary Fingers, hands, forearm, face Prone to superficial ulceration and bleeding Spontaneous regression rare

Case 8 D3 of life FTSVD, female, birth weight 3.2kg Black discolouration of face since birth No family history of significant birthmarks Mother very concerned

What is the diagnosis? A. Congenital melanocytic naevi B. Café au lait C. Mongolian blue spots D. Facial bruising E. Sebaceous naevus

Congenital Melanocytic Naevi Benign naevomelanocytic proliferations Present at birth/ 1 st year of life 1% of newborns Classification Small <1.5cm Medium 1.5-19.9cm Large/giant >20cm

Differential Diagnosis

Cafe au lait macule Mongolian blue spots

Facial bruising Sebaceous naevus

Case 9 D5 of life FTSVD, 3kg Large pink mark on forehead Antenatally uneventful Family Hx - nili

What is the most appropriate next step in diagnosis and management of this skin lesion? A. Skin biopsy B. MRI of the head and neck C. Ophthalmologic evaluation D. Reassurance and education

Naevus Simplex Salmon patch, angel s kiss, stork bite, nevus simplex, vascular stain Pale pink macules and patches Midline forehead, scalp, upper eyelids, posterior neck and back Lighten significantly or disappear within first few years of life

Port Wine Stain Nevus Flammeus Occurs in 0.3% newborn unilateral Never fade Salmon Patch Stork bite / angel kiss 40-50% of newborn Midline: glabella, forehead, occiput, nape of neck Disappear with 1-2 years

Case 10 2 months old baby girl Red patch over left side of face since birth, progressively darkening and thickening Severe coarctation of aorta

What does the patient have? A. Port wine stain B. Naevus simplex C. Pyogenic granuloma D. Segmental haemangioma E. Congenital melanocytic naevi

What syndrome does the patient have? A. PHACES B. Sturge-Weber C. Turner s D. Salmon patch E. Undeterminable

PHACES (OMIM 606519) Posterior fossa malformations Haemangiomas Arterial anomalies Cardiac abnormalities, Eye abnormalities Sternal defects

Vascular tumour Proliferative vs Vascular malformation Non - Proliferative Segmental facial Haemangioma Port Wine Stain

Case 11 10 months old baby Birth weight 3kg, current weight 5.6kg Referred as atopic eczema

What is the diagnosis? A. Kwashiorkor B. Atopic eczema C. Contact dermatitis D. Psoriasis E. Zinc deficiency

Kwashiorkor (Protein calorie malnutrition) Edema, hypoalbuminemia, dermatosis Multiple nutritional deficiencies B complex vitamins (e.g., riboflavin), vitamins A and E, zinc, copper, and EFAs Onset of weaning from breast feeding Food allergen avoidance, food fads

Kwashiorkor Circumoral pallor, angular cheilitis Hair sparse, thin, depigmented flag sign Nails thin and brittle Photosensitivity, purpura, excessive bruisability Mortality high Liu et al. Arch Dermatol. 2001; 137:630-636

Kwashiorkor vs Eczema Kwashiorkor - Erythematous - Flaky paint - No scratch marks Eczema - Erythematous - Scaly, Lichenified - Scratch marks

Acquired zinc deficiency Acquired acrodermatitis enteropathica-like disorders Malnutrition Defective secretion of zinc in mother s breast milk Prolonged parenteral nutrition without supplemental zinc Intestinal malabsorption Tabanhoglu. Pediatric Dermatology 2009; 150-154

Zinc deficiency Diarrhoea, dermatitis, alopecia Eczematous pink scaly plaques Can become vesicular, bullous, desquamative Periorificial, perineum Angular cheilitis, paronychia Secondary infection with Candida albicans Maverakis et al. J Am Acad Dermatol 2007;56:116-24

Differential Diagnosis of Eczematous Rash Nutritional Deficiencies Diseases of immunodeficiency Wiskott-Aldrich, SCID, Hyper IgE Inborn errors of metabolism Langerhans cell histiocytosis Eastlack JP. Pediatr Dermatol. 1999

What condition does this patient have? A Neurofibromatosis B Tuberous sclerosis C Sturge Weber Syndrome D Incontinentia Pigmenti E Hypomelanosis of Ito

Tuberous Sclerosis Major Cutaneous Features Hypopigmented macules and patches (3 or more) Angiofibromas ( adenoma sebaceum ) Periungual fibromas (Koenen tumors) Shagreen patches (connective tissue nevi) Look for epilepsy, learning difficulties

Tuberous sclerosis Hypopigmented macules and patches Shagreen patches (connective tissue nevi)

Tuberous Sclerosis Angiofibromas ( adenoma sebaceum ) Periungual fibromas (Koenen tumors)