Pediatric Dermatology - PowerPoint Presentation

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Pediatric Dermatology - PPT Presentation

Top Ten Sandra Leipheimer MSN APRN BCPNP Heidelberg High School Copyright 2013 S Leipheimer 1 Cool Facts About Skin Continually renewed Stores fat and water Provides protection Gets rid of waste ID: 606394

2013 leipheimer skin copyright leipheimer 2013 copyright skin amp tinea fever strep inflammation mrsa symptoms days caused treatment water

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Pediatric DermatologyTop Ten

Sandra Leipheimer MSN, APRN, BC-PNPHeidelberg High School 

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Cool Facts About SkinContinually renewed

Stores fat and waterProvides protection Gets rid of wasteRegulates temperatureLargest organ of the body

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Cool Facts about bugsBed Bugs:

Cimex lectularius (Cimidieae

)Harmful?Do not transmit any infectious agentsOnly stay on skin to feed on a few drops of bloodTreatmentAimed at itch- AH and corticosteroidsTreat secondary infections from scratching

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Cool facts about bugsLice

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 bodyLice feed on human blood

Not a sign of poor hygeineTransmitted by direct contactDo not spread disease

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FactsWhat 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) liceIf infested –treatIf not – need not be treatedMyths and Treatment folklore ARE THEY ACTUALLY INFESTED?

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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 Fever

URIPrevious illness or treatment ExamSkin + other symptoms

#10 Infections

Superficial InfectionsBacterialFungalViral 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 commonRequires antibioticExcluded for 24 hrs and keep covered at school (contagious) 1-3 days incubation

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Bullous

Staph. aureus- fluid filled blistersNon-Bullous

S. aureus & streptococcus – crustedMRSA 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. aureusAvoid triggerAntibiotics 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 AthletesSpread Skin to Skin

Touching contaminated objects (drainage)Regular Cleaning and DisinfectingNo evidence that spraying or fogging rooms or surfaces with disinfectant works better than focusing on frequently touched surfacesWash hands: soap and water alcohol-based sanitizersTake showers: immediately after exercise; don’t share items

Use barriers: cover cuts; towels on itemsWash uniform: dry completely in dryer; wash after each use

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Recommendations CDC & National Athletic Trainers’ Association

Culture suspicious lesionsNot return to play until:Appropriate antibiotic taken for at least 72 hoursDrainage from wound has stoppedNo new lesions in past 48 hoursCDC: 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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TatToosNontuberculous mycobacteria (NTM) “various types”M.

chelonae exists in tap water MRSA and “others”… Persistent inflammatory reactionLocated within margins of recent intradermal tattooCause- ? using tap water or distilled water for ink

TattooWhat do you think??

Education “THINK BEFORE YOU INK”www.fda.gov Tattoos & Permanent Makeup

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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 fungusNamed 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)ItchyRed scaly ring with central clearing

Treat topically with anti-fungal ointment

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Tinea CapitisTinea in the scalp

Patchy areas of hair loss or breakage and scaleMust be treated with oral medicationsCan extend to a kerion (hypersen- sitivity reaction)

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Trichotillomania Non scarringNoninflammatory alopecia

Twist or pull hairDeny behaviorDone in private7 X > kids than adults 2 X Girls > Boys Scalp most commonEyelashes and eyebrows

Tinea PedisMoist 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 centerUsually starts in creases of upper thigh and does not involve scrotum/penis but may spread to anus causing itching and discomfortUsually 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 allergyLong-term swelling and redness (inflammation of skin)May lack certain proteins in the skin which leads to greater sensitivityOften accompanies asthma

Eczema = compromised skin barrier @ critical point in development Strong link with food allergies

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Risk

Eczema + Food Allergies + Asthma ANAPHYLAXIS

ATopic DerMatitis

Very, very itchyRed/salmon colored patchesCan look like pustulesLikes the

antecubetal and popliteal fossaActually allergy mediated Treated with emollients/steroids

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Atopy

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Keratosis Pilaris

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UrticariaSubgroup of disorders results from hypersensitivity to physical or mechanical factors

Cold urticariaPressure -induced urticaria and angioedemaAquagenic urticariaSolar urticariaExercised- induced urticariaHistory and distribution Confirmed by challenge Cold Challenge ( immediate … 4 hours later)

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Dermographism Trauma –induced pressure

urticariaInitial white line = reflexive vasoconstriction followed by pruritic, erythematous swelling

Wheal or Flare ReactionChronic ? CauseInterferes with skintesting = false +

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#7 EYES

Eye “rashes” or ConjunctivitisBacterialViralAllergic Vernal Chemical

Irritant Drugs

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Bacterial ConjunctivitisBacterial etiology

Very contagiousRed conjunctiva, itchy not painful, purulent drainageShould not be associated with feverTreat with topicals

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STI conjunctivitis Chlamydia

Gonoccocal

Herpes

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Viral ConjunctivitisTypically associated with an upper respiratory infection

Watery, red, irritatedDoesn’t usually have any dischargeRefer anyone who wears contacts and has a red eye to a doctor

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Allergic ConjunctivitisTypically occurs in someone with seasonal allergies (hay fever)

Itchy/bumpy/puffy and redImproves with topical drops and oral anti- histamines

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Measles SymptomsURI & Cough

Red, Watery EyesTiredKoplik’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 virusCommon – fingers and toenailsSubungual (under) periungual ( around) nailsPlantar- 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 VulgarusViral etiology

Difficult to treatCan occur anywhereMost therapies aimed at triggering the immune system Treat with topical irritant/duct tape/cryo/laser

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Warts + Eczema = no Topicals

Molluscum ContagiousumAlso viral (poxvirus)

Difficult to treatContagious Center has viral load Most advocate leaving them alone, though can currette or treat with topical irritantIf many lesions- may be immune system concern

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#5 Reactions Non-specific reactions

IrritantsInfectionsImmune System DiseaseAllergiesCold & HeatChemicals

WindSun 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 ?? = idiopathicRefer if S&S of other system: cough/wheeze or swelling of lips/tongue; N & V

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Erythema Multiforme (minor)Acute hypersensitivity reaction

Can be seen in response to drugs, illness (viruses, bacteria) foods and immunizationsMay look similar to hives, but typically not pruritic, look like targets, can be painful, and unlike hives, persist (are fixed)No treatment

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EMDrugsBarbiturates

PCNsPhenytoinSulfonamidesEM Minor – better in 2-6 weeks; can recur Herpes simplexMycoplasmaEM Major = SJS

Reaction to medicationInfections; radiation Rx; UV lightEpidermal necrolysis – morality risk high

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Stevens Johnson SyndromeDrug reaction- Medical EmergencyAtypical antipsychoticsAntibiotics

Sulpha Penicillins Other as listed Skin and mucous membranes reactionWidespread painFacial swellingTongue swelling Top layer of skin>> necrosis & sloughing

Blistering & Erosion

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Pityriasis Rosea

Starts with a herald patch (~ 1-3 weeks)Confused as tinea Fine scaling oval macules/papules

Pinkish brownChristmas tree patternLasts 6-12 weeks, no treatment

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Pityriasis RoseaVery 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 SimplexOral = “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 asymptomaticMost commonly presents as gingivostomatitisCharacterized by fever, and painful vesicles on oral mucosa/gingiva

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Herpetic WhitlowDigital Herpes

Painful ContagiousVirus enters break in skin (torn cuticle) – from own skin or others60 % HSV-1 40 % HSV-2

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Varicella/ZosterChickenpox – many are vaccinated

Can be fatal for the neonateFever, painful or puritic versicles, typically start on the trunk and spreadShingles = Zoster

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Dermatomes

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ZosterReactivation of varicella

Very painfulOccurs in dermatomal distributionCan be treated if recognized early

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Ramsay Hunt SyndromeZoster infects nerve on headFacial nerve near inner ear

Painful rash on TM, canal, earlobe, tongue, roof of mouth, on same side as weakness or faceEye closing; motor movements -Hearing loss on sideVertigo Urgent referralPrompt RX Steroids

Antivirals

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#3 STrep

Streptococcal infections (Group A strep or strep pyogenes)

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Strep ThroatFever, sore throat, malaise, stomach s/s

ContagiousTreat with 10 days of penicillinCan go back to school after 24 hrs on antibiotics

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Scarlet Fever

Strept Throat with rash S/T; Fever; H/A

Sequelae of Strep

Can also cause glomerulonephritis (coke colored urine), rheumatic fever, impetigoAlso associated with severe invasive infections – pneumonia, arthritis, sepsis, toxic shock syndrome, etcRheumatic 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 aspleniaVaccine in US

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#2Mumps and Measles

Must always keep in mind based upon local immunization policiesWorld travel – one small planet Immunization: concern with waning immunity over timeWHO Travel Advice

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MumpsViral infection that causes systemic disease and swelling of the salivary glands

More severe disease the older you getNot vaccinated against in some countries (Japan)

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MeaslesCharacterized by fever, cough,

rash, conjunctivitisEncephalitis with permanent brain damage 1:1000Death 1-3:1000

Worse if young, sick and/or malnourished

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#1Petechiae, Purpura and Vasculitis

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PetechiaeRed blood cells outside the vessel walls – don’t blanch

Seen with low plateletsCan also been seen with trauma, cough, increased pressure (pertussis, asthma)

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Petechiae/bruising

Never forget about abuse – bruising or petechiae, or other signs of trauma – in multiple stages of healing, unusual places, in strange shapesObligated to report !!!!!!!!!!!!!!!!!!!!!!!

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Purpura

Large areas of cutaneous hemorrhageRefer to doctorUsually bad, may be life threateningMeningococcemia, something wrong with bone marrow

HSP(Henoch-Schönlein Purpura

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HSP Usually Self-LimitingUsually childrenSmall minority of cases can cause severe kidney and bowel disease

Follows URI ~ 10 days following Mean age 5.9 yearsPurpura 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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Terminology

ErythemaIndurationTemperature LesionPapulePustuleMacule

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 timeMark areasAggravating or Alleviating FactorsAssociated Signs or Symptoms

Discussion

1 + 1 + 1 = 3 History2 Associated S & S Exam

Discussion

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Referenceshttps://identitfy.us.com

SchoolNurse.com CD Head Louse Infestations: Evidence-Based Strategies & Best Practices for Tackling Head LicNASN S.C.R.A.T.C.H. http://www.cdc.gov/mrsa/groups/

http://www2.aap.org/new/idphotos.htm MedlinePluswww.cdc.gov www.fda.gov

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