Common paediatric skin disease Emma King Nurse Practitioner Dermatology Department and Private Suites The Royal Children’s Hospital Melbourne, Australia Diagnosis? Hand Foot and Mouth Disease (Coxsackie virus) • An abrupt onset of scattered papules that progress to oval or linear vesicles in an acral distribution • Children are not usually ill and are normally afebrile • Incubation period is 3-5 days • Virus enters via the enteric route • Contagious from 2 days before to 2 days after the onset of the eruption • But… virus is excreted in faeces for up to 2 weeks • NO TREATMENT needed unless flaring eczema. Diagnosis? Pityriasis Rosea   Absent or minimal prodrome 'Herald patch' in 80%    Eruption occurs hours to days later     usually near proximal joint larger than other patches symmetrical and proximal long axis of patch in Christmas tree distribution free edge of scale internally Usually lasts 3-6/52  topical steroids and/or UVB for symptoms Diagnosis? Pityrosporum Folliculitis/6 week rash • Otherwise known as ‘milk spots’, infantile acne • Is really a yeast folliculitis • Fades as sebaceous glands settle to quiescent childhood levels Treatment • • • Sebizole shampoo 1:5 water • Apply to affected areas with a cotton ball • Leave on for a couple of hours then rinse off in the bath • Wash the face, body and scalp with the sebizole and rinse off Hydrozole cream to affected areas bd until clear Usually clears within 3 days Diagnosis? Scabies • • • • • • • • • Caused by a mite – Sarcoptes scabiei Direct skin-to-skin contact, close physical contact Not from animals Burrows a tunnel and releases toxic secretions Incubation – 3 weeks Itching develops after 4-6 weeks due to sensitisation, allergic reaction to the presence of the mite Eczematous changes Itch exacerbates at night Scaly burrows on fingers and wrists Scabies treatment • Lyclear (Permethrin) – wash off after 8-24hrs • Repeat treatment one week later • Treat the whole family • Wash linen and clothes day after treatment • Remove soft toys • Mites survive for a max. of 36 hrs away from host • Eczema treatments • Return to school after 2 treatments completed • Itching may take 3 weeks to resolve Diagnosis? Irritant Napkin dermatitis  The skin barrier function is impaired > increased irritation by urine, faeces, Candida albicans, bacterial overgrowth, soaps and nappy wipes  Settle inflammation  Treat any secondary infection; Hydrozole cream bd  Use disposal nappies  10%Olive oil in zinc paste/Bepanthan ointment  Frequent nappy changes  Nappy free time when possible  Wash with diluted bath oil/olive oil using cotton balls or Rediwipe towels  Dab gently rather than wipe vigorously  Bath oil and no other irritants in bath  No antiseptics/cleansers/napkin wipes etc Diagnosis? Molluscum Contagiosum • Caused by a harmless virus (MCV) • Poxvirus • Very common in children • Transmitted by swimming pools, sharing baths, towels and direct contact • In adults most often a sexually acquired infection • Pearly papule • Central dimple and core Treatment • Self limiting, but may take up to 2 years • Complicated by atopic eczema • Treatment involves irritating the lesions – Burow’s solution diluted 1:10, Benzac gel, occlusive tape, Aldara, Cantharone • Squeeze, curette, cryotherapy - ? scaring • Shower rather than bath • Infection control measures • Atrophic scarring with or without treatment Diagnosis? • Treatment • • Capitis • Oral griseofulvin or Lamisil (give with fatty food) • Identify sources if possible • No sharing of hair combs/brushes or head wear • Hair growth is slow • Antifungal shampoo – reducing shedding of spores Corporis • • Topical antifungals – ketoconazole, miconazole Pedis • Oral griseofulvin or Lamisil Diagnosis? Eczema (atopic and discoid) • The most common skin disease, especially in early childhood (30%) • Onset is most common in the 1st year of life. • The hall marks are chronic, pruritic and relapsing skin dryness, inflammation and erythema • Improves with time most children grow out of it • It can be linked with asthma and allergic rhinitis • An associated immune response to environmental and food allergens and irritants • If not managed effectively secondary bacterial skin infections are common. • It can affect any part of the skin however it is most common on the face and flexures. • A primary disturbance of the epidermal barrier function • Dry skin (decreased filaggrin and ceramides) • Staph Aureus • Signs • Papules and Vesicles • Erythema • Secondary erosions and lichenification • Skin infection • Dry skin • Itch Assessment Look for 1. 2. 3. 4. 5. 6. 7. 8. Extent % Infection /3 Broken skin /3 Erythema /3 Lichenification /3 Xerosis /3 Sleep pattern /10 Itch /10 (SCORAD http://adserver.sante.univnantes.fr/Scorad.html ) Principles of management • Manipulation of environment • • Education on removal of heat, dryness, prickle, allergies Adequate skin care • Regular application/use of emollients; even on clear skin • Aggressive use of adequate topical steroids • • • Trial hydrocortisone for mild eczema and face otherwise need a prescription for elocon or advantan Wet dressings/clothes within 24-48 hours if the eczema is not controlled with emollients and steroids Adequate treatment of skin infections • Removal of crusts ASAP, by bathing and wiping away • Oral antibiotics if needed • Bathing with bleach and salt • Adequate education, demonstration and support • If not responding to these measures consider other options • Referral to GP or Hospital Infected eczema • • • • • Crusted Weeping Acute flare Itchier Plan; • Remove crusts ASAP in the bath with a wet soft towel • Apply steroids and moisturisers to open areas once crusts removed • +/- oral antibiotcs • May also need wet dressings and cool compressing The role of allergy in eczema • Allergic contact dermatitis • Look for patterned eczema • Environmental allergen • Older children/adults • House dust mite, grasses, pollens • Foods • Babies rather than older children • Urticarial eczema • Flare within 2 hours of ingesting food Food intolerance • • • • • Reaction to food through non-allergic means Perioral eczema 18/12 to 5yo May have hand involvement May have napkin dermatitis • Consider acidic and junk foods • Consider using SLS free toothpaste Topical Treatments • Steroids use aggressively and NOT THINLY when flaring • Face- hydrocortisone 1%(Sigmacort) or pimecrolimus (Elidel), bd, prn • Body- mometasone furoate (Elocon) ointment, cream or methylprednisolone aceponate (Advantan) fatty ointment, ointment, lotion, nocte, prn • Emollients- use often every day • QV Kids Balm, QV Cream, Cetaphil cream, Dermeze, Hydraderm, aqueous cream, Avene cream, good quality sorbolene CREAM, 10% liquid paraffin, 10% soft white paraffin, 10% glycerine in aqueous cream, Stelatria, Stelatopia, Kenkay • Bath oils, QV, Hamiltons, Avene, Dermaveen, Kenkay • Use wet dressings within 48 hours if the eczema has NOT improved with the above. • Tar for lichenified or discoid eczema (not to face or groin). e.g. Hamiltons eczema cream. Bathing • Very important, 1-2/day • Assists by • Physically removing staph • Cool temperature assists in reducing inflammation • Salt (pool); less stinging, cooling, antiseptic, anti inflammatory • 100 grams/10 litres water • Bleach; antisepetic • 12 ml/10 litres water • Every day for 1 month then reduce if possible • Cool – 29-31 degrees Why apply wet dressings? Tubifast OR Chux • Reduce itch • Treat Infection • Moisturise the skin • Protect the skin • Promote sleep Wet clothes can be used to reduce cost and if other not available Treatment for moderate and severe facial eczema 1. Advantan for 3-5 nights 2. Elidel bd of not improving with hydrocortisone. Then if not improving. 3. QV Kids Balm/ Stelatria/QV Cream or Cetaphil cream QID 4. Cool compressing QID 5. Antibiotics if infected Treatment for mild facial eczema • Hydrocortisone bd prn • QV cream/Cetaphil/Avene/Kenkay, Sorbolene bd-tds Case four. What is the plan? ACUTE FLARE • Advantan ointment to face nocte for 3-5 nights, then hydrocortisone bd prn or Elidel cream if still moderate • Cool compressing to the face QID, QV Balm post • QV Kids Balm/Stelatria to the face QID for 3-5 days then cream • Cool bleach, salt and oil bath daily • Advantan ointment to limbs and trunk nocte prn • QV/Cetaphil cream to limbs and trunk tds • Wet Dressings nocte • Wet singlet bd until clear • Keflex 7/7 If the above is undertaken there will be 90% improvement in 3 days. Thank you Dermatology nurses; Emma King, Liz Leins, Robyn Kennedy, Danielle Paea, Leigh Fitzsimons, Claire Borlase, Lauren Weston Email; [email protected] Phone; 9345 4803 Web; www.rch.org.au RCH Private Suites; 9345 6438 Outpatient clinics; Mon am, Wed pm, Thurs pm Eczema Workshops; Tues and Wed am phone; 9345 4691 Eczema Community clinics; Monday; Collingwood, Thursday; Broadmeadows