: Lungs \200 CXR, sputum culture, and cytology; CT lungs; bronchoscopy and biopsy if indicated. CT sinus es +/ \200\223 nasendoscopy and biopsy. Histology: vasculitis in respiratory tract. necrotizing, giant cell, granulomatous, medium vessel Course and treatment \200 Systemic to induce remission. Remission maintenance with MTX or AZA. Minimize total steroid load. Only stop after min. 12mths disease-free. Subacute respond to MTX alone or with low dose steroids. Long-term co-trimoxazole in remission reduces pulmonary infection and relaps e rates. 10yr survival 75%; morbidity considerable. disease: treated with pulsed IV cyclophosphamide and steroids and limited disease: have variable (milder) course; may 20_McClure_20.indd 790 11/14/2012 3:24:10 PM TAKAYASU \200\231S ARTERITIS (PULSELESS DISEASE) 791 Takayasu \200\231s arteritis (pulseless disease) Rare chronic granulomatous panarteritis af fecting aorta and large arteries. Adolescent Asian (Japanese) girls and young women most su sceptible. Clinical features \200 Subclinical growth, unexplained fevers, and episodic arthritis (50%). Pulseless phase: diag noses often made incidentally. \200 prepulseless phase may last years: anorexia, fatigue, poor diminished peripheral pulses and aortic dilatation on CXR or hypertension and renal artery stenosis; dramatic presentation with severe hypertensive encephalopathy and seizures; conge stive cardiac failure; aortic valvulitis and aortic regurgitation; pulmonary stenosis; s to paroxysmal hypertension or paroxysmal tachycardias syncope with facial \202 ushing heada ches, chest pain, dyspnoea, and palpitations. May be triggered by changes in posture or mic turition (i.e. baroreceptor hypersensitivity). Investigations \200 FBC (normochromic normocytic anemia, thrombocytosis); ESR and gamma globulins very elevated even in the prepulseless phase. Imaging: show characteristic arterial dilatation, post-ste notic dilatation, aneurysm, thrombosis, and occlusion of the proximal branches of the aorta . high resolution carotid US, angiography, or MR angiography Treatment \200 -blockers and ACE inhibitors. Avoid Manage hypertension: vasodilators. initially high dose steroids (prednisolone 1mg/kg/ Treat vasculitis: day or equivalent) with MTX or AZA as steroid-sparing drugs. Cyclophosphamide for severe or resistant cases. range from angioplasty to bypass grafting. Surgery: Prognosis 10yr survival 90%, although the majority (75%) have some impairment of daily livi ng, and 50% are disabled. Prognosis depends on hypertension and aortic incompetence. Succes sful planned pregnancy is possible. 20_McClure_20.indd 791 11/14/2012 3:24:10 PM This page intentionally left blank 793 Chapter 21 Adolescent health Communication 794 Adolescence: overview 796 Adolescent health problems 798 Substance misuse 800 Sexual health problems 801 Adolescence and chronic illness 802 21_McClure_21.indd 793 11/14/2012 3:29:53 PM CHAPTER 21 Adolescent health 794 Communication See also b pp.575 \200\223576, 1034, 1038. The primary goal of any consultati on with an adolescent, regardless of the presenting complaint, is to establish a relationsh ip of trust. This calls for effective and ef \201 cient communication. However, achieving this is often dif \201 cult and challenging, particularly when faced with a personality wh o is undergoing rapid psychological and social change, and who does not have an adult \200 \231s perspective of health issues and society. Young people may be seen by themselves, as well as with their parents. Parents should not be excluded, but it is important to emphasiz e that the adolescent is the center of the consultation. Communication of information shoul d be in a manner appropriate for development. Have a style of communication that is: open; sensitive; empathetic; non-judgemental. \200 \200 \200 A positive regard and respect for any differing values and practices should be exhibited. A t all times there must be reassurances about con \201 dentiality. \200 \200 \200 \200 Use an open-ended questioning style. Avoid medical jargon and inappropriate reassurance of normality. Allay fears and anxieties. Abstract concepts should be avoided. The HEADSS protocol (Box 21.1) is a psychosocial history toolkit speci \201 - cally design ed for adolescent health-related consultations.1 Box 21.1 The HEADSS protocol* Home life including relationship with parents H E Education or employment, including \201 nancial issues A Activities including sports (also note friendships and social relationships, especially clo se friendships) A Affect (mood, particularly whether mood is responsive to situations) D Drug use, including cigarettes and alcohol S Sex (information on intimate relationships and sexual risk behaviors may be important in bo th acute and chronic illnesses in adolescents) Suicide, depression, and self-harm Sleep S S Reproduced from Christie D, Viner R. (2005). Adolescent development. Br Med J 330: 301 \200 \2234, with kind permission from BMJ (adapted from reference 1). Reference 1 Goldenring J, Cohen E. (1998). Getting into adolescents HEADSS. Contemp Pediatr Jul, 75 \200\22380. 21_McClure_21.indd 794 11/14/2012 3:29:53 PM COMMUNICATION 795 21_McClure_21.indd 795 11/14/2012 3:29:53 PM CHAPTER 21 Adolescent health 796 Adolescence: overview Adolescence is the transition period before adulthood. A number of ph ysi- cal and psychological objectives are achieved. Physical and psychological objectives of adolescence \200 \200 \200 \200 \200 \200 Achievement of physical maturation. Achievement of sexual maturation. Attainment of persona l identity. Establishment of independence. Establishment of autonomy. Development of sexual relationships. Adolescence is therefore \201 lled with major changes that need to be taken into account when caring for adolescents with health-related problems. Management of adolescents: key areas to consider Communication issues Appreciation of adole scent-relevant issues, e.g. sex/drugs/smoking. Physical examination \200 \200 Privacy and personal integrity. Pubertal assessment. Psychosocial issues \200 Personal identity. \200 Compliance. Ethical and legal issues \200 \200 \200 Consent. Competence. Con \201 dentiality. All those working with adolescents need to acquire the appropriate skills to manage and com municate effectively with young people. Psychological development Adolescence marks the beginning of the development of more comple x thinking processes. These include: \200 \200 \200 \200 \200 \200 The ability for abstract thinking (thinking about possibilities). The ability to reason fro m known principles (form own new ideas or questions). The ability to consider many points o f view according to different criteria (i.e. compare or debate ideas or opinions). The abil ity to think about the process of thinking. 21_McClure_21.indd 796 11/14/2012 3:29:53 PM ADOLESCENCE: OVERVIEW 797 During adolescence, young people acquire the ability to think systemati- cally about all lo gical relationships within a problem. The transition from concrete thinking to formal logic al conclusions occurs over time. Each adolescent progresses at varying rates in developing his/her ability to think in more complex ways. Some adolescents may be able to apply logica l operations to school work long before they are able to apply them to personal dilemmas. W hen emotional issues arise, they often interfere with an adolescent \200\231s ability to th ink in more complex ways. The ability to con- sider possibilities, as well as facts, may in \202 uence decision-making, in either +ve or \200\223ve ways. The interactions that occu r between puberty and psy- chological development are important, esp. in the context of dev eloping self-esteem and a sense of sexuality and body image. Social development Adolescence marks the period of time during which there is a gradual shi ft in the balance between dependence on others to position of indepen- dence. The timing of this process is variable and will depend on the social and cultural environment. Physical development Psychological and social changes occur against a background of physica l changes of puberty. 21_McClure_21.indd 797 11/14/2012 3:29:53 PM CHAPTER 21 Adolescent health 798 Adolescent health problems The WHO de \201 nes adolescence as the period between 10 and 19yrs of age and, in most dev eloped countries, this accounts for 13 \200\22315% of the popula- tion. In the UK adolescen t health problems are increasing. This is thought to be a re \202 ection of poor investmen t in health care delivery to young people, and also of the increasing proportion of adolesc ents who are of low socioeconomic status and who belong to ethnic minority groups. Adolescent mortality The improvement in mortality rate observed in other age groups over re cent decades has not been mirrored in adolescents. The most common cause of death in this a ge group is traumatic injury (particularly road traf \201 c accidents) and poisoning. Suic ide among late teenage males has doubled in the last 3 decades. Adolescent health problems The pattern of adolescent illness is distinct. Some of the most common concerns that we see in adolescents are summarized in the Box 21.2. An increasing trend has been observed in the following adolescent health problems in recent years: \200 b p.800). \200 \200 \200 Substance misuse ( Sexual health problems ( Mental health problems (see Obesity (see b p.801). b pp.568, 578 \200\223585). b p.400). 21_McClure_21.indd 798 11/14/2012 3:29:53 PM ADOLESCENT HEALTH PROBLEMS 799 Box 21.2 Common adolescent-related health problems \200 \200 b p.822) Acne ( Chronic illness \200 \200 \200 Chronic fatigue ( Somatic symptom disorders ( \200 \200 Constitutional delay in growth and puberty ( b p.800) Substance abuse ( \200 \200 \200 \200 Psychological problems \200 \200 \200 \200 \200 b p.406) diabetes mellitus ( cystic \201 brosis ( cancer b p.270) \200 b p.990) b p.592) chronic pain headache ( b p.516) \200 b p.468) alcohol smoking illicit drugs cannabis b p.600) ADHD ( anxiety disorders ( conduct/behavior disorders ( b p.578) depression ( eati ng disorders \200\224anorexia nervosa ( (b p.596) b p.991) school phobia ( stress-related s ymptoms ( b p.584) b p.598) b p.594); bulimia nervosa \200 Gynecological disorders \200 \200 Sexual health problems \200 teenage pregnanc y ( \200 sexually-transmitted infections (STIs) ( Obesity ( Sports-related injuries b p.586) oligomenorrhoea/dysmenorrhoea polycystic ovarian syndrome b p.801) b p.801) \200 b p.400) 21_McClure_21.indd 799 11/14/2012 3:29:53 PM CHAPTER 21 Adolescent health 800 Substance misuse Misuse of alcohol, tobacco, and illicit drugs is becoming common amongst a dolescents, and causes health problems in this age. Alcohol and tobacco are the most common ly used substances, and are thought to account for 95% of the morbidity and mortality in th is age range. Most adolescents who use alcohol or tobacco do not progress to using illicit substances. However, most users of illicit drugs will have used alcohol and tobacco. \200 Alcohol: drunk alcohol. \200\230Binge \200\231 drinking is prevalent in certain societies. Smoking: by 15yrs, 21 \200\22326% admit to smoking regularly. Illicit drugs: in most devel oped countries. 30% have had experience by 15yrs. in the UK, by 15yrs of age, 40 \200\22350% of adolescents will have smoking rates have not changed in the last 20yrs. In the UK, cannabis is the most commonly used substance in teenagers Risk factors for substance misuse The adolescent and his/her environment \200 \200 \200 Personality traits: Behavioral problems: Familial factors: inconsistent parenting practices . Early age experience of substance misuse. Peer group pressure. Poor social environment an d relationships. antisocial personality disorder. conduct disorder; depression. favorable attitudes to substance use; poor or \200 \200 Signs of substance misuse \200 Non-speci \201 c: \200 \200 \200 \200 \200 \200 \200 \200 Signs of drug us age: \200 \200 Withdrawal effects: \200 agitation/tremor; \200 dilated pupils. emotional changes; personality changes; depression; mood swings; social dif \201 culties; decline in school attendance/performance; behavior changes; physical changes, e.g. increase d fatigue. pupil constriction; skin changes: venepuncture marks. Signs of substance dependence \200 \200 \200 Dif \201 culty controlling/limiting substance use. Tolerance: the need for greater amounts to achieve same effect. Signs and symptoms of withdrawal when substance unavailable. 21_McClure_21.indd 800 11/14/2012 3:29:54 PM SEXUAL HEALTH PROBLEMS 801 Sexual health problems See also b pp.576, 1002. Sexual health is a priority for adolescent care. The median age of \201 rst sexual experience in the UK is around 16yrs of age. Sexual health matters: areas that should raise concern \200 \200 \200 \200 \200 \200 Age <13yrs. Suspect age or power imbalance in relationships. Evidence of bribery and coerci on. Overt aggression. Misuse of substances as a disinhibitor. Whether the behavior places h im/her at risk so that he/she is unable to make an informed choice. Attempts to secure secr ecy made by the sexual partner. Whether the sexual partner is known to social services or p olice. Whether the child denies, minimizes, or accepts concerns. \200 \200 Experience of sex at an early age is often associated with unsafe sex prac- tice. This may be due to lack of knowledge, or access to contraception, being under the in \202 uence of drugs, or inability to resist peer pressure. Unsafe sex practices may lead to unwanted preg nancies and STIs. Adolescent pregnancy The UK has one of the highest rates of teenage pregnancy in Europe (ap prox 20 \200\22325 per 1000 women aged 15 \200\22319yrs). Many such pregnan- cies occur wit hin marriage. Most unwanted teenage pregnancies occur in the context of poverty, low educat ional achievement, and adverse social factors (e.g. mental health problems, sexual abuse, a nd crime). Infants of teenage mothers are at increased risk of being low birth weight (SGA) . Prevention of teenage pregnancies is a high priority. Health promotion and sex education are successful in this area. Sexually transmitted infections Rates of STIs in UK 16 \200\22319yr olds in the UK are incr easing. The highest rates of infection occur in Afro-Caribbeans and Africans. 30 \200\22340 % of sexu- ally active girls in high-risk groups may be infected with Chlamydia. Adolescents: risk factors for STIs \200 \200 \200 \200 Avoidance of barrier contraception methods. Multiple, sequential, or concurrent partners. M ental illness. Substance misuse. Clinical symptoms and signs similar to adults. Symptoms of Chlamydia in adolescents \200 \200 asymptomatic (50%); urethritis or discharge. Males: Females: asymptomatic (70%): con \201 dential screening/testing programs have been proposed and a national Chlamydia program has been available in the UK since 2006; vaginal discharge (especially early adolescence); pelvic in \202 ammatory disease. 21_McClure_21.indd 801 11/14/2012 3:29:54 PM CHAPTER 21 Adolescent health 802 Adolescence and chronic illness A chronic illness is de \201 ned as a condition lasting at least 6mths. The num- ber of young children surviving into young adulthood with a congenit al or chronic health problem is increasing. In addition, the prevalence of certain chronic lifelong conditions (e.g. type 1 diabetes) is increasing. It is estimated that 20 \200\2233 0% of young people may have a chronic illness. Impact on the adolescent Teenagers with a chronic illness are disadvantaged compared with t heir healthy peers. Their illness can impact on physical, psychological, emo- tional, and s ocial development and well-being: Consequences of chronic illness on adolescent development Physical Constitutional delay in growth and pubertal development (b p.468). Psychological \200 \200 \200 \200 \200 \200 Poor self-esteem. \200\223ve body self-image. Sense of alienation. Depression. Anxiety. Be havioral problems. Social and educational \200 \200 Poor school performance. Social isolation/integration. Impact on the family Chronic illness can adversely impact on the adolescent \200\231s famil y. Parents have to provide additional time for care and support of the teenager with a chro nic illness, often with \201 nancial consequences. Parents may experi- ence guilt, frustr ation, and anxiety, and the frequency of mental health problems is increased. Siblings are also disadvantaged, often missing out on parental time and attention. The support of speci \201 c agencies and child and adolescent psychology services is often required and may be helpful. Impact on health professional relationships Young people are usually more concerned about t he \200\230here and now \200\231 issues of adolescence, and less interested in the long-te rm consequences of their treatment and their behavior towards it. This often leads to a con \202 ict of priorities between health professionals (and parents) and the adolescent, and may lead to problems with compliance. Improving compliance may be helped by the following: 21_McClure_21.indd 802 11/14/2012 3:29:54 PM ADOLESCENCE AND CHRONIC ILLNESS 803 Treatment discussions \200 \200 \200 \200 Should be developmentally and cognitively appropriate. Should be alone and in con \201 den ce. Adopt a non-judgemental approach. Explore understanding of illness and treatment. Corre ct any misunderstanding and educate. Identify potential barriers to adherence. Avoid medica l jargon. Encourage treatment \200\230routine \200\231. \200 \200 Treatment goals \200 Should be relevant to (current) adolescent issues, e.g. appearance, socializing, recreation al opportunities. Include the adolescent in negotiations. Keep goals short-term (weeks \200 \223months). Use simplest regimen possible. Tailor to the adolescent \200\231s daily routin e. \200 \200 \200 Treatment application \200 \200 \200 Give written instructions. Suggest simple reminder strategies, e.g. \200\230stickies \200 \231, calendar. Enlist support and help from parents, family, peers. Transition to adult health services Adolescents requiring ongoing specialist hospital care will eventually need transfer to \200\230adult \200\231 health care services. This transit ion requires more than a \200\230simple \200\231 transfer of medical records from one serv ice to another. There are many different models of transition of care (e.g. direct pediatri c to adult service or indirect via an intermediary \200\230adolescent \200\231 or young ad ult service). Transition should be carefully planned and the adolescent pa- tient, and thei r family, should be given plenty of time to consider and prepare. Transition should not tak e place at a \201 xed, predetermined age, but rather at a point when the adolescent is re ady and has the necessary coping skills to deal with the adult clinic. Personalized transit ion plans are needed for each patient and careful communication, co-ordination, and organiz ation are required between the pediatric and adult teams. 21_McClure_21.indd 803 11/14/2012 3:29:54 PM This page intentionally left blank 805 Chapter 22 Dermatology Assessment of a rash 806 Atopic eczema/dermatitis 808 Red scaly rashes 810 Papular rashes ( 1) 812 Papular rashes (2) 814 Vesiculobullous rashes 816 Red blanching (erythematous) rashe s 818 Pruritus 820 Pustular rashes 822 Purpuric rashes 823 Lymphoedema 823 Blood vessel dis orders 824 Skin infection: viral and bacterial 826 Fungal skin infections 828 Parasitic ski n infections 829 Protozoal skin infections 829 Hair disorders 830 Nail disorders 832 Photos ensitivity and light eruptions 834 Pigmentation disorders 836 Collagen and elastin disorder s 838 Connective tissue disorders 839 Miscellaneous skin conditions 840 22_McClure_22.indd 805 11/14/2012 3:29:32 PM CHAPTER 22 Dermatology 806 Assessment of a rash History \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 When did the rash start? Where did the rash start? Any exacerbating or relieving factors? I s it itchy? Any contacts with patients with the same rash? General drug history? Recent med ications or skin treatments? Past medical history? Family history? Any recent foreign trave l? Examination \200 \200 Undress child and inspect all the skin. Describe \200 macule \200 papule \200 nodule \200 plaque-like \200 vesicle \200 bulla \200 pustule \200 erythematous purpura \200 extravasation of red cells; petechia telangiectasia blanch on pressure; wheal . scaly p lesion morphology: \200\224 \202 at circumscribed lesion <1cm diameter; \200\224raised palpable circumscribed lesion <1cm diameter; \200\224palpable mass >1cm diameter; \200 \224large disc-shaped lesion; \200\224blister containing clear \202 uid <0.5cm diameter; \200\224blister containing clear \202 uid >0.5cm diameter; \200\224visible blister containing pus; \200\224blanching and red; \200\224red-purple non-blanching discoloration of the skin due to \200 \200\224purpuric lesions <2mm diameter; \200\224permanently dilated visible small blood vessels that \200 Describe distribution of Look for and describe: s \200 \200 \200 \200 \200 \200 \200\224raised, itchy, white papule surrounded by red \202 are; \200 p lesion, e.g. diffusely scattered, linear. changes, e.g. excoriation (scratch marks); pigmentation; scarring; atrophy (thinning of the skin); licheni \201 cation (skin thickeni ng); sclerosis (induration of skin, often due to increased collagen production); erosion (p artial thickness loss of epidermis); ulceration (full thickness loss of epidermis and possi bly dermis); crusting (due to dried exudates). \200 \200 Palpate: test if it blanches on pressure. General examination: may be impalpable, hard, \201 rm, soft, tender, hot. If lesion is red, taking care to examine nails, scalp, and mouth. 22_McClure_22.indd 806 11/14/2012 3:29:32 PM ASSESSMENT OF A RASH 807 22_McClure_22.indd 807 11/14/2012 3:29:32 PM CHAPTER 22 Dermatology 808 Atopic eczema/dermatitis The terms atopic eczema and atopic dermatitis are used interchange ably. \200 One of the most common skin diseases affecting children, with a prevalence of 5 \200\22315% in developed countries. The age of onset is less than 6mths in 75%. Flare-ups are commonly due to dry skin, irritants, infection, sweating/ heat, emotional stress, and occasionally allergies. \200 Etiology \200 \200 \200 \200 Genetic susceptibility. Impaired epidermal barrier function. Immune dysregulation. Allergen (food and airborne) sensitization and infection play a lesser role. Presentation See Plate 1. \200 \200 \200 Acute eczema may be erythematous and weeping. Chronic eczema may be licheni \201 ed and dr y. There are often hyperpigmentation and infection. Infant eczema often affects cheeks, elb ows, and knees with crawling. Childhood eczema is often \202 exural; also affects the wri sts and ankles. Adolescent and adult eczema is also \202 exural, but may also affect the head and neck, nipples, palms, and soles. s changes of excoriation, post-in \202 ammatory hypo/ \200 \200 Treatment \200 General measures: soap avoidance, e.g. soap free bath oil or wash. Limit showers/baths to 5 \200\22310min in lukewarm water. Moisturize immediately after showering. Wear loose \201 tting cotton undergarments. Avoid over heating. Keep \201 nger nails short. Speci \201 c measures: use topical corticosteroids daily until the eczema is clear, then taper off on alternate days for 1wk and then twice weekly before stopping. If the eczema returns resume once daily application until clear and then recommence taper. \200 \200 \200 ointments are generally better than creams; wet dressings improve ef \201 cacy and can be done at home; swab suspected infection (viral PCR, immuno \202 uorescence or culture and b acterial cuture); treat promptly with antibiotics or antivirals after this; sedative antihi stamines may improve sleep at night for those older than 2yrs. \200 b In those not improving, review the causes for \202 are-ups (see \200\230Presentation \200\231, above). They may need admission to hospital for intensive wet dressings or referr al to a dermatologist for consideration of phototherapy or systemic therapy. For mild eczem a: 1% hydrocortisone, is appropriate daily for anywhere on the body. a mild potency topical corticosteroid ointment, e.g. 22_McClure_22.indd 808 11/14/2012 3:29:32 PM ATOPIC ECZEMA/DERMATITIS 809 For mild to moderate eczema, a moderate potency topical corticosteroid ointment: e.g. clobe tasone butyrate 0.05%, is appropriate and safe for daily use on the face and body, but not the groin. For moderate to severe eczema, a potent topical corticosteroid ointment, e.g. mo metasone furoate, is appropriate daily for the body, but not the face or groin. Complications \200 \200 \200 \200 \200 \200 \200 Sleep disturbance. Emotional upset. Family dysfunction. Eczema herpeticum (HSV) Staphylococ cus aureus Growth delay. Atopic cataracts. infection Prognosis The natural history tends towards resolution with age. Predicting this is dif- \201 cult, however, early onset severe disease with associated atopy (hayfever and asthma), and elevated IgE may be associated with a worse prognosis. 22_McClure_22.indd 809 11/14/2012 3:29:33 PM CHAPTER 22 Dermatology 810 Red scaly rashes Atopic eczema See b p.808. Psoriasis Psoriasis affects 1 \200\2232% of the population. One third develops the disease before age 20. It is an immune mediated disorder of T cells. There is a strong genetic comp onent in childhood psoriasis, however, environmental factors such as infection (streptococc al and HIV), stress, smoking (pustular psoriasis) and drugs (beta blockers, calcium channel blockers, thiazides, lithium, interferon and antimalarials) also play a role. Presentation See b Plate 2. \200 \200 \200 Red, well-demarcated plaques with overlying silvery scale. Classically affects elbows, knee s, and scalp. However, facial (40%) and napkin (25%) psoriasis is a common presentation in children. The clinical appearance may be site-modi \201 ed in the scalp (concretions), gen ital area (glazed), palms and sole (pustules). Variant presentations include guttate (small plaque), annular (ring-like), pustular and erythrodermic (>90% skin affected). Common nail signs include pitting, onycholysis (separation of the nail plate from the nail bed) and su bungual hyperkeratosis (distal thickening). Psoriatic arthropathy may develop (see b p.777). Treatment General measures \200 Soap avoidance. \200 Moisturize immediately after bath/ shower. \200 Provide emotional support (very important). \200 Remove any precipitating triggers. Speci \201 c measures \200 \200 \200 \200 Topical steroids Topical tar and salicylic acid creams Topical calcipotriol (vitamin D deri vative) Those patients that do not respond to topical therapy and general measures may be r eferred to a dermatologist for consideration of phototherapy and systemic agents (acitretin , cyclosporin, methotrexate and biologics). Prognosis May be life-long or spontaneously remit. 22_McClure_22.indd 810 11/14/2012 3:29:33 PM RED SCALY RASHES 811 Contact dermatitis Irritant contact dermatitis In children irritant contact dermatitis due to urine, feces and friction in the napkin area is common. It spares the folds, favors conv exities and there may be s Candida infection. Frequent nappy changes, drying after bathing and use of a barrier cream may help to prevent this. Hydrocortisone cream in combination wi th an antifungal cream are the treatment of choice. Allergic contact dermatitis Allergic contact dermatitis (delayed type IV hypersensitivity) less common; often occurs in older children. Strong reactions often cause an acute blis- te ring and weeping eczema. Common allergens include nickel (earrings), colophony (sticking pl asters), topical medicaments (topical neomycin and preservatives), some henna tattoos, plan ts (e.g. poison ivy) and rubber. Treatment is allergen withdrawal and topical steroids. Seb orrhoeic dermatitis See b pp.196, 841. Pityriasis rosea Self-limiting condition common between ages 1 and 6yrs. Cause Probably s r eaction to viral infections. Presentation \200 Distinctive initial truncal (usually) oval, red, scaly \200\230herald patch \200\231 (2 \200\2235cm diameter). Several days later generalized smaller scaly, yellowish-pink patches develop over trunk and proximal limbs. Characteristic \200\230Christmas tree \200\231 dis tribution common. Patches follow lines parallel to ribs. Pruritus, malaise, lymphadenopathy may occur. Treatment Reassurance. Antipruritics may be required. Prognosis Resolves after 4 \200\2236wks usually, but may persist for several months. Tinea infections See b p.828. 22_McClure_22.indd 811 11/14/2012 3:29:33 PM CHAPTER 22 Dermatology 812 Papular rashes (1) Urticaria (hives) Acute urticaria affects 10% of the population at some time. Pathophysiology Adverse stimulus l mast cell degranulation l histamine release l loca lized vasodilatation and i capillary permeability. Causes Usually idiopathic or triggered b y recent viral infection. Other causes in- clude: \200 \200 Allergens (e.g. drugs, foods, inhalants, insect bites). Trauma (physical urticarias), e.g. dermographism due to light skin trauma (commonest), pressure, cold, heat, sunlight. Chronic urticaria (de \201 ned as acute urticaria not resolving after 2mths) is idiopathic in >90%, but may be caused by: \200 \200 Chronic bacterial, fungal (e.g. oral Rarely, ingested food dyes. Candida), or parasitic infection. Presentation See b Plate 3. \200 Rapidly developing erythematous eruption with raised central white wheals and occasionally local purpura. Any part of body can be affected and often itchy. Lesions last 4 \200\22324h r. May have associated fever and arthralgia (serum sickness). \200 \200 Investigation Apart from good history investigation is usually not necessary. Skin prick te sting is rarely helpful. If chronic, consider: \200 \200 \200 \200 \200 FBC; throat swab (streptococcus); urine culture; exclude threadworms; food and symptom diar y. Treatment \200 \200 \200 Oral antihistamines. Oral prednisolone, short course if severe. Avoid triggering factors, e .g. ingested food dyes and non-steroidal drugs. 22_McClure_22.indd 812 11/14/2012 3:29:33 PM PAPULAR RASHES (1) 813 Angioedema Variant of urticaria with signi \201 cant swelling of subcutaneous tissues, oft en involves lips, eyelids, genitalia, tongue, or larynx. If severe, may cause acute upper o r lower respiratory tract obstruction and may be life-threatening. Causes As for urticaria. Hereditary angioedema is a rare AD condition caused by active C1-e sterase inhibitor de \201 ciency. Investigations and management As for urticaria. If hereditary angioedema is suspected then measure serum C4 complement level initially. Treatment for severe angioedema \200 \200 \200 \200 Give facial oxygen. IM 0.1mL/kg adrenaline 1:10 000. IM/IV hydrocortisone 12-hourly. Nebuli zed salbutamol. Prophylaxis In severe and recurring cases of hereditary angioedema, tranexamic acid or anab olic steroids (e.g. danazole boosts liver production of C1-esterase inhibitor) are effectiv e, but the latter is rarely used in childhood due to its androgenic effects. Molluscum contagiosum Common pox virus infection affecting infants and young children. Presentation Pink umbilicated (central dimple) papules. Usually affects moist areas, but ca n occur anywhere. Exacerbated by active eczema or topical steroids. Treatment None if uncomplicated as usually spontaneously resolves within a year. If problem atic: \200 \200 \200 \200 Scabies See b p.829 Viral warts See b p.826 Treat any associated eczema. Pinch forcep liquid nitrogen cryotherapy. Lesion curettage. Ap plication of benzoyl peroxide 5% daily. 22_McClure_22.indd 813 11/14/2012 3:29:33 PM CHAPTER 22 Dermatology 814 Papular rashes (2) Papular urticaria Hypersensitivity reaction to insect bites. Itchy small red papules or vesicles evolve into 1 \200\2235mm papules +/ \200\223 surrounding urticari a or surface crusting. Usually on limbs and buttocks. May last for weeks and be exacerbated by new bites elsewhere. Secondary infection common. Treatment \200 \200 \200 Prevent new bites. Antipruritics (e.g. oral antihistamines, topical steroids). Antibiotics for any s infection. Keratosis pilaris Common. Any age. Horny plugging of follicles causes asymptomatic rough pa pular rash +/ \200\223 erythema. Affects upper outer arms, front of thighs, cheeks. Treatment Reassurance; emollients, especially urea-based creams. Papular acrodermatitis (Gianotti \200\223Crosti syndrome) \200 \200 Acute, non-itchy, red papules appear over face, limbs, and buttocks. Asymptomatic or accomp anied by malaise, hepatomegaly, lymphadenopathy. Causes \200 \200 \200 \200 Enteroviruses. EBV. Adenovirus. Mycoplasma. Treatment Reassurance. Prognosis Spontaneously resolves after a few weeks. 22_McClure_22.indd 814 11/14/2012 3:29:33 PM PAPULAR RASHES (2) 815 22_McClure_22.indd 815 11/14/2012 3:29:33 PM CHAPTER 22 Dermatology 816 Vesiculobullous rashes Erythema multiforme Cause Immunologically mediated syndrome. May be idiopathic, but usually pre- cipitated by infection (e.g. mycoplasma, herpes simplex, other viruses) or drugs (e.g. sulfonamides, penicillin). Presentation See b Plate 4. \200 Crops of characteristic symmetric \200\230target \200\231 lesions develop with pallid or p urple center surrounded by erythematous ring. May also be haemorrhagic, red macules or larg e bullae. Lesions last 2 \200\2233wks and affect hands, feet, elbows, knees. Typically, muc ous membrane ulcers occur (buccal, eye, genitalia). \200 \200 Treatment If precipitating infection recurs treat early as tends to cause rash again, e.g. topical aciclovir for recurrent HSV. \200 \200 \200 \200 Fluid maintenance. Analgesic mouthwashes. Lip emollient ointment. Oral antihistamines. Prognosis Complete recovery, but may recur. Stevens \200\223Johnson syndrome/toxic epidermal necrolysis Severe, and overlapping conditi on with erythema multiforme except usu- ally drug induced with viral infection rarely impli cated. Presentation See b Plate 5. \200 Widespread blisters/bullae over erythematous, purple macular, or haemorrhagic skin. Mucous membranes often affected with haemorrhagic crusting. Rubbing may cause skin separation at e pidermodermal junction (= positive Nikolsky sign). Also possible fever, arthralgia, myalgia , prostration, renal failure, pneumonitis, conjunctivitis, corneal ulceration, blindness. \200 Treatment \200 \200 \200 \200 (cid:1) \200 Supportive, as for severe burns (e.g. hydration, airway protection). Identify causative ant igen and remove/treat. Frequent emollient ointment. Specialist eye care. Systemic corticosteroids or immunoglobulin used in \201 rst 2 \200\2233 days may be helpful if life-threatening. Prognosis Can be life-threatening. Recovery usually occurs in 3 \200\2234wks. 22_McClure_22.indd 816 11/14/2012 3:29:33 PM VESICULOBULLOUS RASHES 817 Staphylococcal scalded skin syndrome Exotoxin-mediated epidermolysis s to Staphylococcus au reus infection (which may be trivial). Occurs in children <5yrs. Presentation \200 Extensive tender erythema with \202 accid super \201 cial blisters/bullae ( \200\230scal ded appearance \200\231). Erosions and +ve Nikolsky sign. Crusting around eyes and mouth, f ever. \200 Treatment \200 \200 \200 Supportive treatment and analgesia. IV anti-staphylococcal antibiotics. Gentle skin care, e mollient ointments. Prognosis Rapid recovery without scarring. Impetigo Highly contagious Staphylococcus aureus or B-haemolytic streptococcal super \201 cial skin infection. May be p or complicate other skin disease (e.g. HSV infection, eczema, scabies). Risk factors include overcrowding and poor hygiene. Presentation \200 Super \201 cial, rapidly spreading initially clear blisters that rapidly develop into stra w-colored \200\230dirty \200\231 looking lesions with yellow crusting. Often starts around nose and face; neonates may develop bullous impetigo. Risk of staphylococcal scalded skin syndrome or acute glomerulonephritis (streptococcal). Investigation Skin swabs for bacterial culture and sensitivity. Treatment Rapidly resolves if: \200 \200 \200 Eczema herpeticum See b p.826 bathe crusts off using antiseptics (contain infectious bacteria); antibiotics (e.g. topical mupirocin 2% ointment or oral \202 ucloxacillin); treat any predisposing condition. Traumatic blisters Caused by friction, burns, or insect bites. Sterile aspiration of bliste r within 12hr after appearance, and pressure dressing may be curative. Epidermolysis bullos a See b Plate 6 and b p.840 Other viruses See b pp.826 \200\223827 22_McClure_22.indd 817 11/14/2012 3:29:33 PM CHAPTER 22 Dermatology 818 Red blanching (erythematous) rashes Causes vary with age. Viral causes commonest in younger children. In older children, eczema, psoriasis, and drug reactions (e.g. reaction to am- p icillin in glandular fever) predominate. Viruses (exanthem) See b pp.704 \200\223709. See b Plate 7. Culprits include: \200 \200 \200 \200 \200 \200 \200 \200 \200 adenovirus; enteroviruses (coxsackie or echovirus); EBV; in \202 uenza; parain \202 uenza ; human herpes virus 6 (roseola infantum); parvovirus b19 (erythema infectiosum); rubella; measles. Usually associated with fever and widespread non-speci \201 c macular or mac- ular \200 \223papular erythematous rash. If child is signi \201 cantly unwell, lethargic, or periphe ral perfusion is reduced, admit and investigate (may be bacterial sepsis). Otherwise, simpl y reassure and advise symptomatic treatment. Drug eruptions Erythematous macular \200\223papular rash commonest (e.g. to penicillins, ce pha- losporins, anticonvulsants). Drugs may also cause: \200 \200 \200 Urticaria (e.g. opiates, NSAIDs, penicillins, cephalosporins). Exfoliative dermatitis (e.g. sulphonamides, allopurinol, carbamazepine). Erythema multiforme or Stevens \200\223Johnson syndrome/toxic epidermal necrolysis (e.g. anticonvulsants, antibiotics and allopurinol). Treatment \200 \200 Discontinue offending drug, may need prick or patch testing to identify. Symptomatic treatm ent (e.g. antihistamines or emollients for pruritus). Erysipelas and cellulitis Conditions overlap. Erysipelas is super \201 cial skin infection whereas cellulitis involves deeper subcutaneous tissues. Usually due to Strep. pyogenes or Staph. aureus; occasionally Haemophilus in \202 uenzae. Presentation \200 \200 \200 \200 Tender, warm, spreading, sharply marginated erythema +/ \200\223 oedema. May also have asce nding red streaks of lymphangitis. Regional lymphadenopathy, fever, malaise. Deeper infecti on may co-exist, e.g. osteomyelitis. Management \200 \200 \200 