COMMON SKIN CONDITIONS

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COMMON SKIN CONDITIONS

• PART 1

199
P Lawrence and Prof. M A Kibel
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QUESTION 1

• This infant of 6 months was wrongly labled as
  having Iseborrhoeic dermatitis'. Why do you think
  this was incorrect?

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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.

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Question 2

• What is the treatment?

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Answer 2

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

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Question 3

• What are wet wraps?

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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.

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Question 4

• What is this cutaneous disorder called?

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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.

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Question 5

• What is the cause of the rash around this girl's
  mouth?

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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.

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Question 6

• What are these well-defined, coin-shaped plaques
  of eczema called?

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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.

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Question 7

• This lesion is slightly raised, and in a line.
  What is it?

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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
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7 Continued

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

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Question 8

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

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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.

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Question 9

• What is the first line of treatment you should
  try for psoriasis?

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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.

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Question 10

• What if this does not work?

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Answer 10

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

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Question 11

• Are there any dangers to the use of steroids?

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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.

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Question 12

• Do you know of any other forms of therapy?

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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.

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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?

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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.

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Question 14

• These lesions frequently affect the hands and
  fingers in children. What are they?

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Answer 14

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

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Question 15

• How would you treat them?

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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
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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.

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Question 16

• These flat, elevated, flesh-coloured papules,
  usually on the face, characteristically appear
  over scratch marks (Koebner effect). What are
  they?

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Answer 16

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

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Question 17

• What are these dome-shaped, umbilicated lesions?

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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
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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)

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Slide A
40
Slide B.
Contd
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17 Continued

• Or pierce each lesion with the tip of a wooden
  toothpick which has been moistened with 50
  trichloroacetic acid.

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Question 18

• This child presented with marked scaling of the
  scalp and patchy loss of hair. What is his
  complaint?

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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
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18 Continued

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

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Question 19

• What is the most likely cause of this
  well-defined scaly lesion?

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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.

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Question 20

• What is the treatment?

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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.

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Question 21

• These patchy macular patches on the arms cause no
  complaints but are unsightly. What are they?
• As shown on the next slide

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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.

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21 Continued

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

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Question 22

• What treatment would you advise?

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Answer 23

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

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Question 24

• Do you know of any other superficial fungal skin
  infections?

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Answer 24

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

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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?

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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
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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.

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Question 26

• What are these circumscribed, red, slightly
  raised, intensely itchy lesions?

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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.

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Question 27

• What is the treatment of urticaria?

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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.

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27 Continued

• Subcutaneous administration of 0.1-0.5 ml of
  adrenaline (11000) 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.

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Question 28

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

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Answer 28

• 'Mucous patches' of secondary syphilis.

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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?

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Answer 29

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

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Question 30

• This 6 year old girl,complained of itching and
  discomfort in the vaginal area. What are these
  hypopigmented lesions?

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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.

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30 Continued

• Pruritis is present in more than 50 of cases.
  The condition sometimes occurs in boys, affecting
  the prepuce.

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Question 31

• Is any treatment effective?

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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