COMMON SKIN CONDITIONS PART 1 # 199 P Lawrence and Prof. M A Kibel QUESTION 1 This infant of 6 months was wrongly labled as having Iseborrhoeic dermatitis'. Why do you think this was incorrect? ANSWER 1 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 treatment? 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 again. Question 4 What is this cutaneous disorder called? 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 called? 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. Contd 7 Continued the light-skinned it appears rose- or flesh- coloured. No therapy is necessary and it generally resolves spontaneously in 3-12 months. 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 precipitated. 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 disorder? 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 they? 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 resolves. Contd 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, flesh-coloured papules, usually on the face, characteristically appear over scratch marks (Koebner effect). What are they? Answer 16 Verruca plana (flat or plane warts). Nightly applications of tretinoin cream (Retin A) or benzyl peroxide cream (Quinoderm) may hasten resolution. Question 17 What are these dome-shaped, 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. Contd 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 (SEE NEXT 2 SLIDES) Slide A Slide B. Contd 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 complaint? 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 weeks. 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. Contd 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 lesion? 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 available. Question 21 These patchy macular patches on the arms cause no complaints but are unsightly. What are they? As shown on the next slide 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 pityrosporum orbiculare. 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 infections? 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 disorder? 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. Contd 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 lesions? 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 urticaria). • 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 hypopigmented lesions? 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 characteristic. 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). SQSKIN2/MAK
"dermatology and common skin conditions"