Infectious Diseases and Dermatological Problems Pityriasis Rosea



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Infectious Diseases and Dermatological Problems

Pityriasis Rosea




    • Common, benign, often asymptomatic, of ? etiology (higher incidence in cold mos)

    • Rash: Herald patch (2-10 cm) oval lesion with central clearing on trunk, precedes appearance of rash by7-14 days; erythematous macules progressing to papules (become oval); fine scale present; rash run in parallel formation creating a “Christmas tree” distribution on trunk; mild itching; duration 4-8 weeks




    • Tx: generally none needed; may tx mild pruritus; sunlight exposure will hasten disappearance of lesions (caution against sunburn)

Pediculosis (capitis)




    • Common in children of all socioeconomic groups, but less common in African-Am.

    • Spread of disease: by direct contact or indirect by contact with personal belonging (combs, headphones, bed)

    • Head lice survive 1-2 days away from scalp

    • Excoriation from scratching, secondary bacterial infections, and cervical adenopathy are common

    • Nits (ova) generally seen (hatched, old nits farther out from scalp); few adult lice seen

    • Tx: Permethrin 1% cream (OTC), leave on 10 minutes/rinse; Lindane 1% cream, leave on 4 minutes/rinse. Repeat in 7-10 days

    • Comb out nits (tedious)

Scabies




    • Infestation: Common in children and institutionalized

    • Female mites lay eggs and fecal pellets, hatch 10-30 days post contact

    • Presentation: burrows “S” shaped (esp initial infestation) – web spaces, side of foot; vesicles; papules; intense pruritus (awakens at night), can last 1-4 weeks post tx

    • Dx: microscopic identification




    • Tx: Scabicide (5% permethrin drug of choice); Elimite (apply/leave on 8-14 hours/wash off. Repeat in 14 days if live mites still present)

      • Apply to entire body below head for 8-14 hrs, remove by bathing, (infants/toddlers tx head and neck down but avoid eyes) Do not over treat

      • All household members should be tx’d at same time

Tinea (capitis, corporis, pedis, cruris)

    • Alias “Ringworm” – fungal infection of keratin

    • Tinea capitis: mainly in 2-10 yr olds; erythema, scaling of scalp; patchy hair loss; boggy, tender scalp lesion (kerion with hypersensitivity rx to fungus)

    • Tinea corporis: (face and body) common in warm climates; well-demarcated, circular lesion with central clearing and raised, scaly, vesicular border; pruritus common

    • Tinea pedis: common in adol/adults; scaly, pruritic vesicular lesions of feet

    • Tinea Cruris: common in males, esp obese; sharply demarcated, scaly, pruritic patches


  • Tinea versicolor: Upper trunk, face in children; most common in adolescent/ young adults

Tinea Management

    • Capitis: Requires systemic antifungal tx

      • Griseofulvin 10-20 mg/kg/day x 4-8 weeks. May be given as daily dose (max 1gm) or divided bid (cont until clinically gone 2 wks)

      • Take with high fat foods for best absorption

      • Selenum sulfide, 2.5% shampoo 2x/week

      • If kerion present may need short course oral steriods to reduce inflammation

      • Clean (in bleach soln) combs, hair tools

      • Hair re-growth may be slow

    • Corporis, cruris, pedis: antifungal cream (clotrimazole, miconazole,) bid x 2-4 weeks


  • Versicolor: topical - selenium sulfide 2.5% lotion (selsun) or ketoconazole shampoo; oral tx not usually recommended in children
      • F/O in 2 weeks if no improvement

Contact Dermatitis




    • Skin inflammation due to irritants or allergens

    • Irritant contact derm: intensity of inflammation r/t concentration of irritant

      • Frequent hand washing with harsh soaps common causing erythema, dryness, fissuring (weeping and oozing occurs with chronic exposure)

    • Allergic contact derm: genetically predisposed sensitivity rx (fabrics, nickel, poison ivy, antibiotic ointments are common ones)

      • Distribution provides clue to diagnosis

      • Lesions vesicular/blisters on erythematous base

    • Tx: Pruritus control (Atarax, Claritin); for moderate dermatitis – topical steroid crm (ie. Triamcinolone 0.1% thin layer daily, not face or groin); avoidance/protection from irritant

Atopic Dermatitis- Eczema

    • 3 Phases:

      • Infantile: onset 1 - 6 mos, (until 2 yrs)

      • Childhood: onset 3 to 10 yrs

      • Adult: onset after 12 yrs (on-going thru life)




    • Probable immunologic cause (elevated IgE seen in most pts) with strong family hx




    • SXS: abnormally dry skin; severe itching (esp in evenings); pattern of severe pruritus and erythema leading to skin changes (dry and scaly); may be red, papular lesions or lichenification; periods or exacerbation/remission

    • Diff. Dx: seborrhea, contact derm, pityriasis rosea, psoriasis, fungal infections

  • Eczema Management




    • Tx Goals: hydration and lubrication of skin; antipruritic agents to break itch-scratch cycle; topical steroids; monitor/prevent secondary infections

    • Educate Pt/Fam on breaking itch/scratch cycle:




      • Keep environment slightly cool and humid

      • Daily soaks in tepid water with mild soap

      • Wear 100% cotton; avoid wool or synthetics

      • Use fragrant-free laundry products

      • Emotional stress can worsen (but not cause) condition

      • Refer if has severe skin eruptions or don’t respond to tx after 2 week trial

Seborrheic Dermatitis (scalp and dandruff)




    • Common, chronic inflammatory disease with fine, dry, white or yellow scale on inflamed base (remissions/exacerbations)

    • Infants: cradle cap

    • Small children: face and diaper area

    • Adolescents: scalp, eyebrows, nasal folds, external ear canals/post auricular folds

    • Tx: Cradle cap – bland shampoos (ie. Johnson’s baby shampoo) left on 5-10 minutes then rinsed; Face or diaper area – low potency hydrocortisone lotion 1% q day no longer than 2 wks; leave diaper area open to air as much as possible.


Adolescents: medicated shampoo (coal tar, selenium, sulfur & salicylic combination)

Dyshidrosis (pompholyx)





  • Recurrent eczematous dermatitis of unknown etiology

  • Sudden eruptions of itchy vesicles on the palms, or lateral fingers, or feet

  • Tx: cold compresses; topical corticosteroids; antihistamines for itching



Keratosis pilaris





  • An eruption consisting of follicle-based, scaling papules most commonly on the posterolateral aspects of the upper arms, anterior thighs, and the buttocks that is common in person with atopic dermatitis

  • Follicular plugging and inflammation

  • Peak occurrence in adolescents, aggravated by dry skin

  • Goose bump appearance; skin surface feels rough and dry




  • Tx: lubricants to tx dry skin; if moderate or severe – alpha hydroxy acids lotions; lactic acid 12% cream (Lac-Hydrin) applied BID. Tepid baths/showers and mild soaps (Dove, Basis etc)



Warts




    • Common in children, benign, skin tumors caused by HPV (human papillomavirus)

    • Incidence: 10% of school-age children; incubation 1-6 mos; resolution 65% by 2 yrs)





  • Types:



    • Common warts (verrucae vulgaris)- often found on hands esp around nails

    • Plantar warts – found on heel/ball of foot; cause significant pain; wt bearing areas at increased risk; may be clustered; look for black dots than can be seen with shaving of outermost horny layer of lesion

    • Flat warts (verrucae planae): common on face, arms, legs; occur in clusters; are pink, light brown or yellow; resistant to tx; resemble nevi





  • Management: Most nongenital warts will eventually resolve spontaneously, if not: topical salicylic acid q HS for 6-8 weeks; liquid nitrogen with follow-up in 2-4 weeks for repeat.

Refer – flat warts for removal (resistant and usually on face or extremities)

Molluscum Contagiosum




    • Wart-like papule; 3-12 wk incubation; grows to 5mm; waxy, umbilicated with soft, white center; spread thru scratching; commonly on axillae, trunk, face, genitals

    • Cause: poxvirus

    • Tx: Topical salicylic acid (as per wart tx), dc tx when curd-like core is expelled; if extensive molluscum – liquid nitrogen or curettage (may need to refer)

Acne Vulgaris




    • Affects 30-90% of adols (males>females); begins 1-2 yrs before puberty

    • Obstruction of sebaceous follicles




      • Comedone open: blackhead

      • Comedone closed: whitehead

    • P. acnes (normal flora) but increased with acne




    • Tx: Benzoyl peroxide (BPO) 2.5 – 10% (antimicrobial) BID; Topical retinoids (Retin-A) start with lowest dose )0.025% cream BID and increase as needed

    • Treat emotional aspects of acne as well (can be devastating to self-esteem/self-image (frequent follow-up)




Candidiasis (Monilia)




    • Yeast-like fungus, Candida albicans, part of normal flora; becomes invasive when moisture, warmth, and breaks in skin cause overgrowth

    • Rash: pruritic; diaper area – beefy red, well-demarcated, creases involved, scrotum may be involved (may be satellite pustules/papules, erosions); intertriginous areas – most often in obese pts, red moist, glistening plaque or papules & pustules

    • TX: Diaper area- wash with plain H2O, cry well; dc all powders/creams, Nystatin cream 3-4x per day for 7-10 days; Intriginous areas- Nystatin or Lotrimin cream BID x 10 days



Impetigo (weepy lesions)




    • Bacterial skin infection of epidermis by Staph. aureus or Strep. Pyrogenes




    • Rash: multiple 1-2mm superficial vesicles easily ruptured leaving erosions covered with moist, honey-colored crust

    • Face and extremities most common sites

    • Diff. Dx: tinea, herpes simplex, contact derm, 2nd degree burn

    • Tx: If only few lesion- Mupirocin (Bactroban) tid x7-10days; for multiple lesions – dicloxacillin for 10 days (2nd generation cephalosporin also effective)

    • Instruct on contagious nature of lesions


Fifth’s Disease (Erythema infectiosum)

    • Mild viral disease with erythematous eruptions caused by parvovirus B19

    • Common in school-aged and adolescents

    • Incubation: 4-14 days; rash and joint symptoms 2-3 weeks after infection

    • Most communicable before onset of rash

    • Rash: bright, red rash to cheeks and forehead “slapped cheek”; with/without mild fever, HA, cold sxs; rash spreads to trunk and distal extremities with lace-like appearance; rash becomes transient with heat/cold

    • Exposure during pregnancy – risk of fetal death

    • Tx: usually none, or symptomatic

Roseola (Exanthem subitum)




    • Acute viral infection primarily in children < 3 years cause by herpes virus-6

    • Incubation: 5-15 days (most communicable during febrile stage)

    • Acute fever (3-4 days) as high as 105 followed by rash

    • Rash- pinkish maculopapular rash starting on trunk, spreading to face and extremities; typically children are playful and no change in appetite even with high fever




    • TX: symptomatic

Rubeola (Measles)




    • Highly communicable viral illness with fever, rash, cough, conjuctivitis, coryza (one of most serious exanthems)

    • Incubation: 8-12 days (spread by droplets) Infectious 1-2 days before onset of sxs (3-5 days prior to rash)

    • Child usually is very ill for 1-4 days

    • Koplik’s spots are common finding

    • Rash- deep ,red macular rash beginning on face and neck, spreading to trunk/extremities




    • Tx: symptomatic (rest, fluids, avoid bright lights

Rubella (German measles)




    • Viral disease with diffuse maculopapular rash, mild sxs (rubella virus)

    • Associated with high incidence of congenital anomalies

    • Incubation: 14-21 days; communicable 1 week before and 5-7 days after rash

    • Rash-

    • Lymphadenopathy is significant with post auricular/suboccipital enlargement

    • Dx: Rubella IgM antibody titre




    • TX: symptomatic; check need for tx of exposed persons (esp pregnant)




Scarlet Fever (Scarlatina)

    • Acute infectious disease usually associated with strep pharyngitis (response to bacterial exotoxin)

    • Common in 6-12 yrs olds

    • Incubation: 3-5 days

    • Communicable: during incubation and illness (appx 10 days) (on antibiotics > 24 hrs – OK)

    • Rash- fine, pin-point, sandpaper texture, generalizes, fades after 3-4 days;

    • SXS: abrupt onset of fever, pharyngitis, HA, stomache (less often); rash follows initial sxs; circumoral pallor, strawberry tongue, general adenopathy, skin desquamation

    • Tx: PCN 40-60mg/kg/day; or E-mycin

    • 30-50mg/kg/day.

Varicella (Chicken pox)




    • Highly contagious,pruritic, vesicular, exanthem caused by varicell-zoster virus

    • Spread by airborne respiratory secretions

    • Incubation:10-21 days

    • Rash- macular then to papular, then vesicles, all within 24 hrs

    • Communicable: 1-2 days before rash until all vesicles have crusted (usually 5 days)

    • In children, illness mild; adol/adults more severe illness with increased mortality

    • Sxs: low fever, malaise, pruritis




    • Tx: consider oral acyclovir for adol/adults; treat itching

Kawasaki’s Disease




    • Generalized vasculitis also referred to as mucocutaneous lymph node syndrome

    • Leading cause of acquired heart disease in children in US

    • 80% of cases in children < 5 years

    • Rash - red rash over entire body

    • Sxs: fever; swollen, tender, red palms/ soles; cervical adenopathy, conjunctival injection; strawberry tongue; dry cracking, lips; cardiac sxs; arthritis; diarrhea

    • Baseline echo

    • Hospitalization and supportive care




Cat Scratch Fever




    • Infection causing unilateral regional adenitis usually due to scratch of a cat

    • Bartonella henselae cause in most cases

    • 80% of cases are in < 20 yr olds

    • Dx base on + criteria (3 out of 4)

      • Hx of animal (cat) contact with scratch

      • Pos cat scratch disease skin test

      • Regional adenopathy

      • Bx lymph node

    • Sx: adenopathy occurs after 7-12 days; mild malaise, HA, achiness




    • TX: antibiotics not recommended for health pts

Lyme Disease




    • Infection caused by Borrelia burgdoferi

    • Tick transmitted (usually when small)

    • 1st stage: localized erythema migran (red macule or papule which enlarges over days to weeks, with central clearing)

    • 2nd stage: characteristic rash – annular erythematous lesions; arthralgia; HA; fatigue; myalgia; conjunctivitis; palsies

    • 3rd stage: (mos or yrs after bite) recurrent arthritis; CNS – neuropathies/cephalopathies




    • TX: Doxycycline or amoxicillin for 14-21 days

Rocky Moutain Spotted Fever




    • Systemic, febrile illness with rash, resulting from tick bite (Ricettsia rickettsii)

    • Incubation: 2-14 days, persists up to 3 wks

    • Rash - maculopapular rash before 6th day of illness, spread from wrists/ankles to trunk, neck and face (may becomes petechial or purpuric);

    • SXS: high fever; HA; myalgia; n/v; conjunctivis; thrombocytopenia;

    • 15-20% mortality rate if untreated




    • TX: Vibramycin (if > 8yrs) chloramphenicol if < 8; monitor for signs of menigitis (instruct pt); close follow-up; instruct on tick avoidance




Fever of undetermined origin (FUO) vs Fever without source (FWS)





  • FUO: - fever >101F persisting for 3 weeks and eluding one week of intensive diagnostic testing

  • FWS: - unexplained fever > 100.4 rectal, of brief duration or lasting < 5-7 days were source of illness is not apparent after a careful history and exam

  • Signs of a Toxic Infant or Child:

    • Altered level of consciousness

    • Abnormal breathing

    • Rapid pulse

    • Fever

    • Skin abnormalities

    • Head bobbing

    • Delayed capillary refill

    • Poor muscle tone



Common Cold (nasopharyngitis, URI)


  • Viral – most common are rhinovirus, coronavirus, RSV

  • Incubation – 12 hours to 5 days (average 48 hrs)

  • Average # per year: 3 – 8 for children

  • Sxs – malaise, nasal congestion, sneezing, cough, sore throat, watery eyes

  • Duration – 5-7 days; can predispose for OM, sinusitis, pneumonia, etc.

  • Txs – Symptomatic (decongestants, hydration, increased humidity, saline nasal spray, educate parent on use of bulb syringe for infants; zinc if initiated with 24 hours; Vit. C 1 gm/day (controversial). Not recommended: antihistamines or expectorants


Infuenza


  • Viral – Influenza A (99%) of cases

  • Incubation – 1 – 4 days with 2 days average; most contagious 24 hours before onset of sxs and during peak of sxs

  • Sxs - Abrupt onset of fever, malaise, myalgia, headache, rhinitis, and nonproductive cough. Cough and malaise may last for 1-2 weeks.

  • Rapid flu nasal swab diagnostic

  • Tx – symptomatic (rest, fluids, fever management); anti-virals (i.e osletavir or amantadine if > 1 year old) if started within 48 hrs of onset of sxs; prevention

Directory: ~ddwilso2


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