PEDIATRIC DERMATOLOGY
TOP TEN
Sandra Leipheimer MSN, APRN, BC-PNP
Heidelberg High School
Copyright 2013 S Leipheimer 1
COOL FACTS ABOUT SKIN Continually
renewed Stores fat and
water Provides protection Gets rid of waste Regulates
temperature Largest organ of
the bodyCopyright 2013 S Leipheimer 2
COOL FACTS ABOUT BUGS Bed Bugs:
Cimex lectularius
(Cimidieae) Harmful?
Do not transmit any infectious agents
Only stay on skin to feed on a few drops of blood
Treatment Aimed at itch- AH and
corticosteroids Treat secondary
infections from scratching
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COOL FACTS ABOUT BUGS Lice
Pediculosis (place)
FactsNot “medically
necessary” to remove NITS
Most are non-viable (dead or hatched)
Personal decision by parent
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LICE – HEAD OR BODY Lice feed on
human blood Not a sign of poor
hygeine Transmitted by
direct contact Do not spread
disease
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FACTS What to put on school fact sheet?
Not a major health issueNuisance factorRX: Least intrusive to Most intrusive
treatment Mechanically remove lice (risk reduction) OTC treatment ( oovacidal) Rx Examine all family members for live (crawling)
lice If infested –treat If not – need not be treated
Myths and Treatment folklore
ARE THEY ACTUALLY INFESTED?Copyright 2013 S Leipheimer 6
COMMONLY MISDIAGNOSED – TREAT THEN RETURN TO SCHOOL
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ASSESSMENT: LOOKING FOR?
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ASSESSMENT: 1 + 1 + 1 = 3 History
When started?What else going on?Other S & S?Rx = better or worse?Exposure?
Associated Signs & Symptoms FeverURIPrevious illness or treatment
ExamSkin + other symptoms
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#10 INFECTIONS Superficial Infections
BacterialFungalViral Tattoos
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IMPETIGO Caused by S. aureus a
normal skin colonizer in up to 50% of people
Yellow, oozing, crusty sore, often starts in nose Itch is common
Requires antibiotic Excluded for 24 hrs and
keep covered at school (contagious)
1-3 days incubation
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Bullous Staph. aureus- fluid filled
blisters Non-Bullous
S. aureus & streptococcus – crusted
MRSA becoming more common
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GROUP A STREPTOCOCCAL Skin lesions usually caused by different
strain than those causing “strep throat” Can cause glomerulonephritis if strain is
GrA B-hemolytic Blood or brown sugar (maple sugar; coke)
urine May culture lesions to be sure what is
infectious agent
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FOLLICULITIS Caused by
inflammation to the hair follicles shaving/friction from
tight clothes; ingrown Typically infected
with S. aureus Avoid trigger Antibiotics if
infection suspected
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FURUNCLES, CARBUNCLES AND ABCESSES
Usually caused by S. aureus Increased frequency
with MRSA and other antibiotic resistant organisms
Need oral antibiotics and often need drainage
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MRSA Methicillin Resistant Staphylococcus
Areas
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MRSA (COMMUNITY ACQUIRED) Exclusion Policy for Schools?
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MRSA
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MRSA
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PROTECTING STUDENT ATHLETES Spread
Skin to Skin Touching contaminated objects (drainage)
Regular Cleaning and Disinfecting No evidence that spraying or fogging rooms or
surfaces with disinfectant works better than focusing on frequently touched surfaces
Wash hands: soap and water alcohol-based sanitizers
Take showers: immediately after exercise; don’t share items
Use barriers: cover cuts; towels on items Wash uniform: dry completely in dryer; wash after
each useCopyright 2013 S Leipheimer 20
RECOMMENDATIONS CDC & NATIONAL ATHLETIC TRAINERS’ ASSOCIATION
Culture suspicious lesions Not return to play until:
Appropriate antibiotic taken for at least 72 hours
Drainage from wound has stoppedNo new lesions in past 48 hours
CDC: do not exclude unless MD directed… Sport-specific guidance should be in place Excluded if wounds cannot be properly
covered“properly covered” = securely attached
bandage/dressing containing all drainage and remain intact during activity
No water; whirl pools; therapy pools
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TATTOOS Nontuberculous mycobacteria (NTM)
“various types”M. chelonae exists in tap water
MRSA and “others”… Persistent inflammatory reaction Located within margins of recent
intradermal tattoo Cause- ? using tap water or distilled water
for ink Many believe distilled or reverse-osmosis
water is sterile Many other reasons… Cartilage piercings >> delay healing “Allergies” >>> contact dermatitis Copyright 2013 S Leipheimer 22
TATTOO What do you think??
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EDUCATION “THINK BEFORE YOU INK” www.fda.gov Tattoos & Permanent
Makeup NOV 00 JUN 08 FEB 10 AUG 12 FDA
Notices related to unregulated materials and health risks
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#9 TINEA “RINGWORM” Tinea – sounds like a bug, but really a
fungus (trichophyton, microsporum) Name of group of diseases caused by
fungus Named for location of infection Acquired by touching infected person,
damp surfaces, pets
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TINEA CORPORIS Generally a circular
lesion (hence the name “ring worm”
Raised (can be blistery)
Itchy Red scaly ring with
central clearing Treat topically with
anti-fungal ointmentCopyright 2013 S Leipheimer 26
TINEA CAPITIS Tinea in the scalp Patchy areas of
hair loss or breakage and scale
Must be treated with oral medications
Can extend to a kerion (hypersen- sitivity reaction)
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TRICHOTILLOMANIA Non scarring Noninflammatory
alopecia Twist or pull hair Deny behavior
Done in private 7 X > kids than
adults 2 X Girls > Boys Scalp most
common Eyelashes and
eyebrows
Psychosocial issues
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TINEA PEDIS Moist area between toes Itchy, red, blisters, cracking, peeling Nails can also become infected= tinea
unguium
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TINEA CRURIS Itching in groin, thigh folds, anus Red, raised, scaly patches that blister
and oozePatches have sharply-defined edgesRedder around outside with normal skin
tone in center Usually starts in creases of upper thigh
and does not involve scrotum/penis but may spread to anus causing itching and discomfort
Usually less severe than other tinea infections but lasts longer
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#8 ATOPIC DERMATITIS Also known as eczema: “the itch that
rashes” Hypersensitivity reaction similar to
allergy Long-term swelling and redness
(inflammation of skin) May lack certain proteins in the skin
which leads to greater sensitivity Often accompanies asthma Eczema = compromised skin barrier @
critical point in development Strong link with food allergiesCopyright 2013 S Leipheimer 31
RISK Eczema + Food Allergies + Asthma
ANAPHYLAXIS
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ATOPIC DERMATITIS Very, very itchy Red/salmon colored
patches Can look like pustules Likes the antecubetal
and popliteal fossa Actually allergy
mediated Treated with
emollients/steroids
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ATOPY
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KERATOSIS PILARIS
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URTICARIA
Subgroup of disorders results from hypersensitivity to physical or mechanical factors
Cold urticaria Pressure -induced urticaria and
angioedema Aquagenic urticaria Solar urticaria Exercised- induced urticaria History and distribution Confirmed by challenge
Cold Challenge ( immediate … 4 hours later)
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DERMOGRAPHISM Trauma –induced pressure urticaria Initial white line = reflexive vasoconstriction followed by pruritic, erythematous swelling Wheal or Flare Reaction Chronic ? CauseInterferes with skintesting = false +
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#7 EYES Eye “rashes” or Conjunctivitis
Bacterial Viral Allergic Vernal Chemical Irritant Drugs
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BACTERIAL CONJUNCTIVITIS Bacterial etiology Very contagious Red conjunctiva,
itchy not painful, purulent drainage
Should not be associated with fever
Treat with topicals
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STI CONJUNCTIVITIS Chlamydia
Gonoccocal
Herpes
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VIRAL CONJUNCTIVITIS Typically
associated with an upper respiratory infection
Watery, red, irritated
Doesn’t usually have any discharge
Refer anyone who wears contacts and has a red eye to a doctor
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ALLERGIC CONJUNCTIVITIS Typically occurs in
someone with seasonal allergies (hay fever)
Itchy/bumpy/puffy and red
Improves with topical drops and oral anti- histamines
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MEASLES Symptoms
URI & CoughRed, Watery EyesTired
Koplik’s spots (2-3 days after above) Blotchy Rash (3-5 days after symptoms)
Starts on face at hairlineSpreads downward to neck, trunk, arms,
legs, feetFever spike with rash (~ 104 F 40 C)
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#6 WARTS Caused by infection of human papilloma
virus Common – fingers and toenails
Subungual (under) periungual ( around) nails
Plantar- soles of feet (painful) Genital – STI (condyloma) Flat – appear wear shaving ( most
common in children however) Trends:
Children- warts tend to go awayAdults- tend to stay
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VERRUCA VULGARUS Viral etiology Difficult to treat Can occur
anywhere Most therapies
aimed at triggering the immune system
Treat with topical irritant/duct tape/cryo/laserCopyright 2013 S Leipheimer 46
WARTS + ECZEMA = NO TOPICALS
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MOLLUSCUM CONTAGIOUSUM Also viral (poxvirus) Difficult to treat Contagious
Center has viral load Most advocate leaving
them alone, though can currette or treat with topical irritant
If many lesions- may be immune system concern
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#5 REACTIONS Non-specific reactions
Irritants Infections Immune System DiseaseAllergiesCold & HeatChemicalsWindSun Evil Eye
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URTICARIA (HIVES) Typically associated
with an allergic reaction
Can be seen as a response to viral infection, foods, medications or ?? = idiopathic
Refer if S&S of other system: cough/wheeze or swelling of lips/tongue; N & V Copyright 2013 S Leipheimer 50
CONTACT DERMATITIS
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ERYTHEMA MULTIFORME (MINOR)
Acute hypersensitivity reaction
Can be seen in response to drugs, illness (viruses, bacteria) foods and immunizations
May look similar to hives, but typically not pruritic, look like targets, can be painful, and unlike hives, persist (are fixed)
No treatmentCopyright 2013 S Leipheimer 52
EM Drugs
Barbiturates PCNs Phenytoin Sulfonamides
EM Minor – better in 2-6 weeks; can recur Herpes simplex Mycoplasma
EM Major = SJS Reaction to medication
Infections; radiation Rx; UV light Epidermal necrolysis – morality risk high
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STEVENS JOHNSON SYNDROME Drug reaction- Medical Emergency
Atypical antipsychoticsAntibiotics
Sulpha Penicillins
Other as listed Skin and mucous membranes reaction
Widespread painFacial swellingTongue swelling
Top layer of skin>> necrosis & sloughingBlistering & Erosion
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PITYRIASIS ROSEA Starts with a
herald patch (~ 1-3 weeks)Confused as tinea
Fine scaling oval macules/papulesPinkish brown
Christmas tree pattern
Lasts 6-12 weeks, no treatment
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PITYRIASIS ROSEA Very itchy in 50 % Can be concentrated in groin, forearms, shin Some report feeling mildly ill 1- 2 week before herald patch
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#4 HERPES VIRUSES Herpes Simplex
Oral = “cold sores” Type 1Genital = Type 2 But can occur in either area and either type
Herpes Zoster
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HERPES SIMPLEX Most infections
with Type I are asymptomatic
Most commonly presents as gingivostomatitisCharacterized by
fever, and painful vesicles on oral mucosa/gingiva
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HERPETIC WHITLOW Digital Herpes
Painful Contagious Virus enters break in skin (torn cuticle) –
from own skin or others 60 % HSV-1 40 % HSV-2
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VARICELLA/ZOSTER Chickenpox – many
are vaccinated Can be fatal for the
neonate Fever, painful or
puritic versicles, typically start on the trunk and spread
Shingles = Zoster Copyright 2013 S Leipheimer 60
DERMATOMES
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ZOSTER Reactivation of
varicella Very painful Occurs in
dermatomal distribution
Can be treated if recognized early
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RAMSAY HUNT SYNDROME Zoster infects nerve on
head Facial nerve near inner ear Painful rash on TM, canal,
earlobe, tongue, roof of mouth, on same side as weakness or face Eye closing; motor
movements -
Hearing loss on side Vertigo Urgent referral Prompt RX
Steroids Antivirals
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#3 STREP Streptococcal infections (Group A strep
or strep pyogenes)
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STREP THROAT Fever, sore throat,
malaise, stomach s/s
Contagious Treat with 10 days
of penicillin Can go back to
school after 24 hrs on antibiotics
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SCARLET FEVER Strept Throat
with rash S/T; Fever; H/A Abd pain; N/V + lymph nodes Rash appears
1-2 days: red and sandpaper texture After 7-14 days skin rubs off / peels
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SEQUELAE OF STREP Can also cause glomerulonephritis (coke colored urine),
rheumatic fever, impetigo Also associated with severe invasive infections –
pneumonia, arthritis, sepsis, toxic shock syndrome, etc Rheumatic Fever
Appears 2-4 or 1-5 weeks following Strep infection Inflammation is the cause of symptoms:
Inflammation of the heart - chest pain, fatigue, SOB Inflammation of the joints - arthritis symptoms Inflammation of the skin - skin rashes and nodules Inflammation of the CNS (central nervous system) -
chorea (jerking), personality changes Increased risk of fulminant bacteremia from strep pneumo
in kids with asplenia Vaccine in US
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#2 Mumps and Measles
Must always keep in mind based upon local immunization policies
World travel – one small planet Immunization: concern with waning
immunity over timeWHO Travel Advice
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MUMPS Viral infection that
causes systemic disease and swelling of the salivary glands
More severe disease the older you get
Not vaccinated against in some countries (Japan)Copyright 2013 S Leipheimer 69
MEASLES Characterized by
fever, cough, rash, conjunctivitis
Encephalitis with permanent brain damage 1:1000
Death 1-3:1000 Worse if young,
sick and/or malnourished
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#1 Petechiae, Purpura and Vasculitis
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PETECHIAE Red blood cells
outside the vessel walls – don’t blanch
Seen with low platelets
Can also been seen with trauma, cough, increased pressure (pertussis, asthma)Copyright 2013 S Leipheimer 72
PETECHIAE/BRUISING
Never forget about abuse – bruising or petechiae, or other signs of trauma – in multiple stages of healing, unusual places, in strange shapes
Obligated to report !!!!!!!!!!!!!!!!!!!!!!!
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PURPURA Large areas of
cutaneous hemorrhage
Refer to doctor Usually bad, may be
life threatening Meningococcemia,
something wrong with bone marrow
HSP(Henoch-Schönlein Purpura
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HSP Usually Self-Limiting Usually children Small minority of cases
can cause severe kidney and bowel disease
Follows URI ~ 10 days following
Mean age 5.9 years Purpura is due to vasculitis
not low platelets (IgA in walls of blood vessels)
Steroids ease symptoms and may disrupt abnormal immune response
Tetrad:PurpuraArthritis & Arthralgia
Swelling around jointsKidney inflammationAbdominal pain
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PROGRESSION
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TERMINOLOGY Erythema Induration Temperature Lesion Papule Pustule Macule Vesicles Hyper / Hypo pigmentation Linear Oval Circular Target Concentric
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ASSESSMENT & DESCRIPTION Size of each or all lesions Color Description of shape/distribution of
lesion(s) Location
What areas are spared? Trend or Changes over time
Mark areas Aggravating or Alleviating Factors Associated Signs or Symptoms
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DISCUSSION 1 + 1 + 1 = 3 History 2 Associated S & S Exam Potential Assessment & Recommendations
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DISCUSSION
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REFERENCES https://identitfy.us.com SchoolNurse.com CD Head Louse
Infestations: Evidence-Based Strategies & Best Practices for Tackling Head Lic
NASN S.C.R.A.T.C.H. http://www.cdc.gov/mrsa/groups/ http://www2.aap.org/new/idphotos.htm MedlinePlus www.cdc.gov www.fda.gov
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