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Common Childhood Rashes in General Practice

Common Childhood Rashes in General Practice. Aimee Lettis. Why look at rashes?. Common problem encountered in General Practice 49.1% pre-school children affected at any one time 29.4% eczema 19.5% seborrhoeic dermatitis 15% Nappy rash 0.9% Tinea. Approach to rashes. History History

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Common Childhood Rashes in General Practice

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  1. Common Childhood Rashes in General Practice Aimee Lettis

  2. Why look at rashes? • Common problem encountered in General Practice • 49.1% pre-school children affected at any one time • 29.4% eczema • 19.5% seborrhoeic dermatitis • 15% Nappy rash • 0.9% Tinea

  3. Approach to rashes • History • History • History • Then examine! • Investigations rarely needed/ appropriate

  4. Erythema toxicum • Features • Red blotches with central white vesicle • Each spot lasts about 24 hours, moves from place to place • Spots are sterile and baby is well • Management • Reassurance • Only do swab if suspect sepsis

  5. Milia • Features • Tiny pearly-white papules on nose +/- palate • Blocked sebaceous ducts • Management • Reassure, spots disappear spontaneously in few weeks

  6. Benign Neonatal Pustular melanosis • Features • Blotchy macular erythema, with tiny yellow-white papules/pustules • Pustules rupture easily leaving pigmented macules • Mainly in pigmented skin • Appear at birth/1st day of life • Completely innocent, no treatment needed • May persist for 2-3 months

  7. Mongolian blue spot • Features • Bluish discolouration of skin, usually over buttocks/lower backs • Usually affects dark-skinned babies • Usually disappear by 1 year, harmless

  8. Umbilical granuloma • Features • 3-10mm size • Round wet pedunculated lesions • Inflammation of granulation tissue not yet epithelialized • Differential diagnosis • Patent urachus, polyp • Treatment • Observation usually sufficient & best • Silver nitrate • Beware of burning surrounding skin • Tie off

  9. Napkin dermatitis • Features • Usually die to irritant contact dermatitis which spares groins • Treat with barrier cream, frequent nappy changes

  10. Napkin rash Other causes • Satellite lesions and skin-fold involvement may indicate candida • Look for mouth lesions as well • Treat with anti-fungal cream • Seborrhoeic dermatitis • Also involves skin creases • Look for cradle cap, rash elsewhere • Treat body with emollients/hydrocortisone • Treat scalp with olive/baby oil or 2% salicyclic acid in aqueous cream, washed out with baby shampoo • Other rarer causes eg. Acrodermatitis enteropathica

  11. Staphylococcal scalded skin syndrome • Features • Sick baby, acute onset • Shedding of sheets of skin, underlying red/wet areas • Management • Emergency admission • Requires iv antibiotics/fluid rehydration

  12. Atopic eczema • Affects 15-20% school children • Usually starts <6/12 (75%) • Considerable impact on QOL • May be associated with food allergy in young children • Remission occurs by 10 years in 2/3 & by 15 years in 75% • Some have worsening symptoms in teenage/relapse later in life

  13. Atopic eczema • Presentation • Infants • Itchy exudative rash on face +/- hands, sleep disturbance usual • More then ½ affected are symptom-free by 18/12 • Children >18/12 • Rash involves antecubital & popliteal fossae, neck, wrists & ankles • Lichenification, excoriation & dry skin common • May have typical infraorbital folds (Morgans folds) • May be associated sleep disturbance/behavioural problems

  14. Atopic eczema • Diagnosis • Itchy skin PLUS at least 3 of: • Itching around skin creases or neck • Visible flexural eczema (or cheeks/forehead & outer limbs <18/12) • History of asthma/hayfever (or in first degree relative if <18/12) • Generally dry skin • Onset in 1st 2 years of life

  15. Potential triggers • Irritants • Soaps & detergents • Skin infections • Stress/humidity/extremes of temperature • Avoid if possible, cotton clothing best • House dust mites/pets • Avoidance may be helpful but difficult • Food allergy/intolerance • Egg/milk/soy etc. • Moderate-severe eczema, resistant to treatment • Few with eczema benefit from dietary change

  16. Management • Conservative measures • Clothing, wear gloves in bed, short nails • Avoid triggers • Dietary measures • Few improve with dietary manipulation, could try if moderate-severe eczema not controlled with emollients/steroid cream • NICE recommends 6-8/52 trial hydrolysed formula if <6/12 & bottle-fed • Dietician advice needed

  17. Management • Emollients, eg aqueous cream • 3-4 x daily at least • Use as soap substitute & emollient • Bath oil, eg oilatum • Topical steroid cream • Start with mild strength and increase only if necessary, short-term use only • Ointments if dry skin, cream if wet • Antibiotics – for secondary infection • Topical/systemic (severe) • Wet wraps –bandaging • Sedative antihistamines – help sleep

  18. Complications • Secondary bacterial infection • Usually Staph aureus • Suspect if crusting/weeping/worsening • Increased incidence molluscum/ warts • Eczema herpeticum • Usually need admission for IV aciclovir as can be sick • Growth restriction (severe eczema)

  19. When to refer? • Eczema herpeticum (E) • Severe eczema resistant to treatment (U) • Infection not cleared in primary care(U) • Severe social +/- psychological problems (S) • Diagnosis uncertain (R) • Help with bandaging (R) • For patch testing (R) • Growth restriction (R) • Dietary factors suspected (R) E=Emergency, U=Urgent, S=Soon, R=Routine

  20. Another case of eczema?

  21. Scabies!!! • Cause • Sarcoptes scabei mite • Features • Spread by direct physical contact • Average infection- 12 mites • Symptoms appear 4-6 weeks after infection • Intense itching • Burrows/eczematous rash on examination • Sides of fingers/hands/wrists/genitalia • May be widespread especially in infants • Management • Malathion lotion – 2 applications 1/52 apart • ALL family members need treatment • Boil all beeding/towels at same time • Itching may persist for some time after treatment

  22. Impetigo • Cause • Usually due to Staph aureus • Features • Blister bursts to leave golden crusted lesion • Can occur anywhere, most commonly face • Very contagious! • No sharing of towels/flannels etc. • Management • Topical/oral Flucloxacillin/erythromycin

  23. Molluscum contagiosum • Cause • DNA pox virus • Features • Discrete pearly pink umbilicated papules 1-3mm diameter • If squeezed release cheesy substance • Usually grouped • Spread by contact eg. Towels • Management • Untreated, resolve over months • Leave alone or will scar!

  24. Viral exanthem • Viral exanthem = a skin rash accompanying any eruptive disease/fever • Non-specific rash, child may also have: • Fever • Runny nose • Cough • D&V etc. • Differential diagnosis • Non-specific or specific viral infection • Early meningococcal disease • Scarlet fever • Kawasaki disease • Erythema multiforme • Allergy • Drug eruption

  25. Roseola • Cause • HHV6/7 • Features • Affects those aged 6-36 months • 3-5 days high fever with no obvious source • Sub-occipital nodes • Rose-pink macular rash appears once fever settles • Starts on trunk, may spread to face & extremities • Lasts up to 2 days • Management • Treat symptomatically, reassure

  26. Scarlet fever • Notifiable disease! • Cause • Group A beta-haemolytic Streptococcus • Features • Incubation 2-4 days • Bright red blanching rash (sandpaper) • First in axilae/groins, then widespread • Red face with circumoral pallor • Strawberry tongue (white then red) • Treatment • Symptomatic relief • Penicillin V 7-10 days

  27. Chickenpox • Causes • Varicella zoster virus • Features • Very common • Incubation period 14-21 days • Prodrome mild fever & malaise • Vesicles on erythematous base • Change to macule→papule→vesicle→crust • Last 3-4 days • Mainly on trunk • Can appear in mouth/genital region • Usually no scarring • Infectious for 1-2 days before rash & 5 days afterwards

  28. Chickenpox • Complications • Always look carefully at child if fever persists > 5 days after appearance rash • ?secondary bacterial infection • Pneumonitis • Encephalitis • Cerebellar ataxia • Eczema herpeticum • Risk to neonates & pregnant women 1st trimester especially • Management • Supportive – fluids/paracetamol/calamine lotion • Admit if complications suspected

  29. Shingles • Reactivation of VZV • Features • Dermatomal pattern of rash, usually unilateral • Typically painful, pain may occur first • Can catch chickenpox from affected individual but not shingles! • Infectious until all lesions scabbed • Management • Treat with aciclovir if see in 1st 72 hours • Refer urgently if eye affected

  30. Measles • Features • Incubation period 8-14 days • Prodromal illness 3-4 days • Fever, conjunctivitis, runny nose & cough • Infectious 1-2 days before prodrome • Later symptoms • Koplik spots, rash-reddish-purple macules which coalesce, spreads downwards • Management • Supportive • Symptoms usually last 10 days

  31. Measles • Complications • Otitis media • Bronchopneumonia • Encephalitis (1/1000) • Myocarditis/pericarditis • SSPE (rare) • 30% mortality in developing countries

  32. Rubella (German measles) • Features • Incubation period 14-21 days • Infectious 5-7 days before rash • No prodrome • Rash – fine pink maculopapular rash on face then trunk & limbs • Fever & lymphadenopathy • May have petechiae on hard palate & associated arthralgia/arthritis • Lasts 10 days • Management • Supportive

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