dermatology and common skin conditions by tlindeman

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									COMMON SKIN

                     # 199

                P Lawrence
               Prof. M A Kibel

This infant of 6
 months was wrongly
 labled as having
 dermatitis'. Why do
 you think this was

The rash is most marked on the cheeks, and is
  intensely itchy; neither of these features is
  characteristic of seborrhoeic dermatitis. The
  rash is typical of atopic dermatitis, the
  commonest form of eczema in children. In
  infancy it often starts first on the cheeks. In
  older children the flexures are commonly
  affected, as in the next slide.
Question 2

What is the
Answer 2

Topical treatment consists of
 1. Liberal use of moisturing creams
 4. Judicious use of topical corticosteroids
 3. Regular applications of 'wet wraps'.
Question 3

What are wet wraps?
Answer 3

Cotton bandages moistened with hot water are
 applied to the affected areas and kept in place
 for up to 24 hours at a time. The wet wraps are
 applied daily at first, then the frequency of
 application may be gradually reduced as skin
 heals and the itch-scratch-itch habit is
 controlled. The wet wraps should be re-
 instituted as soon as the child starts to scratch
Question 4

What is this
 cutaneous disorder
Answer 4

Pityriasis sicca alba. It is characterised by
 discrete, hypopigmented patches with a fine
 branny scale, situated on the face or neck. The
 cause is unknown. It is possibly a mild form of
 atopic dermatitis. The patches respond to 1%
 hydrocortisone ointment or 5% liquor picis
 carbonis in emulsifying base.
Question 5

What is the cause of
 the rash around this
 girl's mouth?
Answer 5

The habit of lip-licking or lip-sucking ("lick
 eczema"). Moisturising creams or low-potency
 corticosteroid creams are helpful in
 management of this disorder.
Question 6

What are these well-
 defined, coin-shaped
 plaques of eczema
Answer 6

Nummular eczema. They usually occur on the
 extensor surfaces of the arms and legs as single
 or multiple lesions on dry skin. The aetiology is
 unknown. The cause appears to be related to
 skin dryness rather than to atopy.
Effective treatment includes limiting baths (to
 avoid skin dryness) frequent lubrication Short
 courses of potent steroid ointments Control of
 any associated secondary infection.
Question 7

This lesion is slightly
 raised, and in a line.
 What is it?
Answer 7

Lichen striatus. This is a linear dermatitis of
 unknown origin, usually self-limiting. and
 causing no symptoms. It is generally unilateral
 and affects children between the ages of 5 and
 10 years.
In dark-skinned individuals the band-like areas
 are usually hypopigmented, while in the light-
 skinned it appears rose- or flesh-coloured. No
 therapy is necessary and it generally resolves
 spontaneously in 3-12 months.
7 Continued

the light-skinned it appears rose- or flesh-
 coloured. No therapy is necessary and it
 generally resolves spontaneously in 3-12
Question 8

This chronic disorder
 affects particularly
 the scalp, elbows,
 knees, extensor
 surfaces of the limbs
 and lumbosacral area.
 What is it?
Answer 8

Psoriasis vulgaris. This is a common inherited
 disorder of unknown aetiology, marked by long
 remissions and exacerbations. Response to
 therapy frequently varies from individual to
 individual, and even in the same person at
 different times.
Question 9

What is the first line of treatment you should try
 for psoriasis?
Answer 9

Using topical keratolytics, such as 5% salicylic
 acid in vaseline, alternating with tar
 preparations, such as 5% liqor picis carbonis, or
 2-5% crude coal tar in emulsifying base,
 response is usually favourable.
Question 10

What if this does not work?
Answer 10

Topical corticosteroids frequently produce rapid
 resolution, and form a useful and cosmetically
 acceptable form of therapy.
Question 11

Are there any dangers to the use of steroids?
Answer 11

The child must be weaned gradually from
 high to low potency steroids , otherwise
 there may be a 'rebound effect', or
 'pustular psoriasis' may even be
Question 12

Do you know of any other forms of therapy?
Answer 12

A Vitamin D3 preparation, Calcipitriol ointment
 (available as Dovonex) is an effective topical
 treatment for limited, localised plaques of
 psoriasis.Topical Anthralin is also effective, but
 is limited by its staining properties, and is thus
 reserved for refractory psoriasis.
Question 13

These lesions
 appeared suddenly
 over a large part of
 the child's body
 surface. They
 resemble drops of
 liquid. What is this
Answer 13

Outrage psoriasis. This is a variant of psoriasis
 vulgaris, and generally, but not invariably,
 follows a streptococcal infection. Topical therapy
 is the same as for psoriasis vulgaris. Treatment
 of underlying streptococcal infection often
 hastens resolution.
Question 14

These lesions
 frequently affect the
 hands and fingers in
 children. What are
Answer 14

Verruca vulgaris (common warts). These are
 intraepidermal tumours caused by infection with
 the human papilloma virus.
Question 15

How would you treat them?
Answer 15

There is no single effective treatment for warts.
 They are best left alone because the majority
 disappear spontaneously as the child gradually
 developes immunity to the virus.
• Simplest topical agents are keratolytics, e.g.
 salicylic acid and lactic acid in flexible collodion.
 It should be applied daily until the wart

15 Continued

• Cryotherapy with liquid nitrogen, repeated
 every 4 weeks until clear, is effective, but
 should only be used if the child is willing.
• Power of suggestion, or 'charming of warts' is
 a simple, non-traumatic form of treatment in
 susceptible children.
Question 16

These flat, elevated,
 papules, usually on
 the face,
 appear over scratch
 marks (Koebner
 effect). What are
Answer 16

Verruca plana (flat or plane warts). Nightly
 applications of tretinoin cream (Retin A) or
 benzyl peroxide cream (Quinoderm) may hasten
Question 17

What are these
 umbilicated lesions?
Answer 17

Molluscum contagiosum. This is a contagious
 viral disorder of skin and mucous membranes.
 Children with disordered immunity (especially
 HIV positive), are particularly susceptible.

17 Continued

Treatment utilises minor destructive techniques.
• The easiest method is a light 2 to 3 second
  application of liquid nitrogen to each individual
  papule or nodule. Most lesions resolve with 2 to
  3 applications at 2-4 weekly intervals.
• Other methods include piercing each papule
  with a small needle, and expression of the plug
Slide A
Slide B.

17 Continued

Or pierce each lesion with the tip of a wooden
 toothpick which has been moistened with 50%
 trichloroacetic acid.
Question 18

This child presented
 with marked scaling
 of the scalp and
 patchy loss of hair.
 What is his
Answer 18

Tinea capitis. This is the most common fungal
 infection of the skin (dermatophytosis) of
 childhood. Treatment of choice is oral
 griseofulvin at a dose of 10mg/kg/day for 6
occasionally tinea capitis maybe confused with
 seborrhoeic dermatitis, psoriasis or alopecia
 areata. Diagnosis of fungal infection can be
 made with certainty with a potassium hydroxide
 preparation of hairs and scalp scrapings.
18 Continued

This will reveal either an endothrix (spores
 within the hairshaft) of Trichophyton violaceum,
 or an ectothrix (spores around the hairshaft).
Question 19

What is the most
 likely cause of this
 well-defined scaly
Answer 19

Tinea corporis. This is a superficial fungal
 infection of the non-hairy skin. The face is
 particularly affected in children. The lesions tend
 to be oval with a well-defined border and they
 spread peripherally as they clear in the centre.
Question 20

What is the treatment?
Answer 20

Topical applications of anti-fungal creams are
 very effective. Either clotrimazole, econozole,
 ketaconozole or terbinafine could be used and
 must be applied for 2-3 weeks. The older (but
 cheaper) benzoic and salicylic acid ointment
 (Whitfield's) can be used if the others are not
Question 21

These patchy macular
 patches on the arms
 cause no complaints
 but are unsightly.
 What are they?

As shown on the next
Answer 21

They also affect the
 upper portion of the
 trunk, neck and lower
 half of the face. This
 is pityriasis versicolor,
 an extremely
 common superficial
 fungal disorder
 caused by
21 Continued

Potassium hydroxide
 slide preparations of
 skin scrapings show
 highly characteristic
 fungal hyphae and
 clusters of spores,
 resembling 'spaghetti
 and meat balls'.
Question 22

What treatment would you advise?
Answer 23

Selenium sulphide (Selsun shampoo), benzoic
 and salicylic acid ointment (Whitfield's), and the
 topical antifungals mentioned earlier are all
 effective treatments.
Question 24

Do you know of any other superficial fungal skin
Answer 24

Athlete's foot, and tinea cruris (in the groins),
 but these are not common before puberty.
Question 25

This child devloped a
 'ringworm-like' lesion
 on the chest. One
 week later, oval,
 slightly scaly lesions
 erupted on the trunk,
 as shown in the next
 slide. What is this
Answer 25

Pityriasis rosea. This is an acute, benign, self-
 limiting condition of unknown cause. Its
 seasonal clustering and sometimes prodromal
 symptoms suggest that it is a viral infection. The
 initial, or 'herald' patch is followed 5- days later
 by a symmetrical eruption that spares the face
 and follows the lines of the ribs, so that it has a
 'Christmas tree' distribution.

25 Continued

Sometimes there is mild itching which responds
 to topical antipruritics, such as calamine or
 crotamiton (Eurax). Exposure to sunshine or
 ultraviolet lamp treatment hastens resolution.
Question 26

What are these
 circumscribed, red,
 slightly raised,
 intensely itchy
Answer 26

Urticaria. This is a systemic disorder with
 cutaneous manifestations. The rash consists of
 irregular wheals which shift in situation.
 Individual wheals rarely persist longer than 12-
 24 hours.
Urticaria is referred to as 'acute' if it lasts for
 less than 6 weeks, and viruses, food or drug
 allergy are usually the culprits. Urticaria that
 recurs frequently and lasts longer than 6 weeks
 is termed 'chronic'. In 80% of patients no cause
 can be established.
Question 27

What is the treatment of urticaria?
Answer 27

Every attempt should be made to identify the
 cause and eliminate it if possible.
• The basis of symptomatic treatment is oral
    antihistamines of which hydroxyzine (Aterax)
    is cheap and effective.
• Antihistamines should not be stopped
    prematurely. They should be continued for
    1-2 weeks after all signs of urticaria have
    cleared, and then tapered gradually; this
    may prevent recurrences and the
    development of chronic urticaria.
27 Continued

• Subcutaneous administration of 0.1-0.5 ml of
     adrenaline (1:1000) is often effective in
     patients with acute severe urticaria, or
     angio-oedema (swelling associated with
• Systemic corticosteroids should be reserved
     for those patients who are unresponsive to
     other modes of therapy.
Question 28

This child has greyish
 white patches on the
 tongue which are not
 painful. What are
 they likely to be?
Answer 28

'Mucous patches' of secondary syphilis.
Question 29

These raised pale
 plaques on the
 genital area of the
 same child are
 condylomata lata,
 also characteristic of
 secondary syphilis.
 Serological testing
 confirmed this
 diagnosis. How would
 you treat her?
Answer 29

Benzathine penicillin 50,000 units per kilogram
 intramuscularly once only. Repeat in one week.
Question 30

This 6 year old
 girl,complained of
 itching and
 discomfort in the
 vaginal area. What
 are these
Answer 30

Lichen sclerosis et atrophicus (LSA). This is a
 condition of unknown aetiology which in
 children is quite benign. Sexual abuse is often
 suspected, but this is not the case, and it is not
 sexually transmitted. The anogenital region is
 involved in the majority of cases and is
 characterised by perivulval hypopigmented
 plaques in an hour-glass pattern. Within the
 plaques tiny haemorrhages and excoriations are
30 Continued

Pruritis is present in more than 50% of cases.
 The condition sometimes occurs in boys,
 affecting the prepuce.
Question 31

Is any treatment effective?
Answer 31

The majority of childhood cases remit with the
 onset of puberty. Topical corticosteroids
 (hydrocortisone 1%) and emollient creams offer
 symptomatic relief. When itching is severe more
 potent topical steroids may be used for short
 periods (1-2 weeks).


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