chapter 35 skin (Own Notes)

Topical ivermectin

• Topical ivermectin is a single-dose, 10-minute application to dry hair. It is approved for children 6 months old and older.

pityriasis rosecea

Pityriasis rosea, meaning rose-colored flaking, is a common, mild, self-limited papulosquamous disease

candidiasis

Candidiasis is a fungal infection of the skin or mucous membranes commonly called a yeast infection or thrush. Candida albicans, a yeastlike fungus, is commonly found on skin and oral, vaginal, and intestinal mucosal tissue. Although Candida is part of the normal flora, overgrowth and penetration of inflamed skin or mucous membranes can occur when there is a localized or systemic alteration in host defenses. Candidiasis is more common in infants, obese children, adolescents, and chronically ill or immunocompromised children. It also is often seen as a secondary infection in persistent diaper rashes or with antibiotic, oral steroid, or oral contraceptive use.

Management of skin conditions

1. hydration 2.bathing-lukewarm water 3. oatmeal & bathoils 4. petrolatum and lanolin moisturizers best when applied to damp skin

Molluscum Contagiosum

A benign common childhood viral skin infection with little health risk, molluscum contagiosum often disappears on its own in a few weeks to months and is not easily treated. This poxvirus replicates in host epithelial cells. It attacks skin and mucous membranes and is spread by direct contact, by fomites, or by autoinoculation (typically scratching). It is commonly found in children and adolescents. The incubation period is about 2 to 7 weeks but may be as long as 6 months (Weston and Morelli, 2013). Infectivity is low but the child is contagious as long as lesions are present.

Folliculits and Furuncle

A superficial bacterial inflammation of the hair follicle is called folliculitis; a deeper infection with involvement of the base of the follicle and deep dermis is called a furuncle (boil) Obstruction of the follicular orifice is the most important factor contributing to the development of folliculitis, but a moist environment, maceration, poor hygiene, occlusive emollients, and prolonged submersion in contaminated water are also factors. S. aureus is a common causative organism as is Pseudomonas aeruginosa, which causes hot-tub folliculitis. Escherichia coli is also implicated. These infections are more common in males than in females.

acne vulgaris

Acne is an inflammatory disorder of the pilosebaceous unit in which excess sebum, keratinous debris, and bacteria accumulate, producing microcomedones. The microcomedones may be noninflamed or inflamed lesions. Although rarely a serious disorder, acne may cause permanent scarring and decreased self-esteem, and occasionally heralds underlying disease. It is often of significant concern to the adolescent, having a serious effect on social development

Diagnostic for skin conditions

Potassium Hydroxide (KOH)-fungal (hyphae or spores) Wright, Giemsa, or Wright-Giemsa stains are used to examine for bacteria, white cells, and multinucleated giant cells Patch or skin test by dermatologist skin biopsy CBC/ESR-inflammation

Benzyl alcohol

Benzyl alcohol, a prescription medication that is not ovicidal, is applied to dry hair and left on for 10 minutes before rinsing. Repeat the application in 7 days to kill newly hatched lice. Benzyl alcohol is contraindicated in children younger than 6 months old.

Management of Herpes zoster or shingles

Clinical Findings History Burning, stinging pain, tenderness to light touch, hyperesthesia, or tingling precedes eruption by about 1 week, although this is less common in children. The lesions can be extremely itchy and painful. Physical Examination • Two or three clustered groups of macules and papules progress to vesicles on an erythematous base. These vesicles become pustular, rupture, ulcerate, and crust. • Lesions develop over 3 to 5 days and last 7 to 10 days. Lesions may develop for up to 1 week followed by crusting and healing during the next 2 weeks. In children, delayed chronic pain, known as postherpetic neuralgia, is rare. • Lesions commonly follow the dermatomes of the second cervical to lumbar nerves and the fifth to seventh cranial nerves with scattered lesions outside these areas. • Lesions do not cross midline (key to diagnosis); sharp demarcation at the midline with occasional contralateral involvement. • Lymphadenopathy may occur. Diagnostic Studies The diagnosis is clinical. If needed, Tzanck smear or viral culture can distinguish HZ from HSV infection. Bacterial culture or Gram stain can be used to distinguish from impetigo. A DFA stain of vesicle base scrapings is beneficial in the difficult to diagnosis case and results are timely. Differential Diagnosis Local cutaneous HSV infection and impetigo are differential diagnoses. Management Management steps include the following: 1. Burow solution compresses three times a day to alleviate discomfort 2. Warm, soothing baths 3. Antihistamines for itching 4. Analgesics for discomfort; do not use salicylates 5. Ointment (such as, Aquaphor or Vaseline) to moisturize the lesions and decrease itching 6. Antiviral medications are not recommended for use in all children with HZ: • Acyclovir 30 mg/kg/day divided four times a day for 5 days may be useful for children who are immunosuppressed, have ocular herpes, or have Ramsay-Hunt syndrome (Weston and Morelli, 2013) 7. Antibiotics for secondary bacterial (usually staphylococcal) infection: • Mupirocin topically twice daily • Dicloxacillin 12.5 to 25 mg/kg/day for 7 to 10 days 8. Refer for immediate ophthalmologic examination if eyes, forehead, or nose is Complications Complications are rare except in immunocompromised children. Occasionally HZ is the initial finding in acquired immunodeficiency syndrome (AIDS), especially if more than one dermatome is involved. Eczema herpeticum may occur. Patient and Family Education • New vesicles appear for up to 1 week and take 2 to 3 weeks to resolve. Illness is usually mild. • The child is contagious for varicella until lesions are crusted. If the lesions can be covered, the child does not need to be excluded from school or childcare. If the lesions cannot be covered, the child should avoid contact with others until the lesions are crusted

clinical findings for tinea corporis

Clinical Findings History Contact with a person or animal with ringworm is sometimes reported. Physical Examination • Classical appearance of lesions: Annular, oval, or circinate with one or more flat, scaling, mildly erythematous circular patches or plaques with red, scaly borders • Lesions spread peripherally and clear centrally or may be inflammatory throughout with superficial pustules • Often prominent over hair follicles • Multiple secondary lesions may merge into a large area several centimeters in diameter Diagnostic Studies If treatment failure or questionable diagnosis occurs: • KOH-treated scrapings of border of lesion reveal hyphae and spores (see Fig. 37-2) • Fungal culture • Wood's lamp does not fluoresce most tinea infections (Trichophyton tonsurans) • Fungal culture of the lesion Differential Diagnosis Pityriasis rosea herald patch, nummular eczema, psoriasis, seborrhea, contact dermatitis, tinea versicolor, granuloma 1001annulare, and Lyme disease are in the differential diagnosis.

clinical findings of seborrheic dermatitis

Clinical Findings History Note age of onset (infancy or adolescence). Physical Examination In infants, erythematous, flaky to thick crusts of yellow, greasy (waxy appearance) scales occur predominantly on the scalp, but also on the face, behind the ears, on the neck and trunk, and in the diaper area (Fig. 37-24). In adolescents there are mild flakes with some erythema and yellow, greasy scales on the scalp, forehead, nasal bridge, and eyebrows; behind the ears; on the face and flexural surfaces; and in intertriginous areas. The dermatitis is not pruritic and has no pustules.

clinical findings lice

Clinical Findings History • A history of infestation in a family, friend, or day care contact • Dandruff-like substance in the hair • Itching of the scalp, scratching, and irritability if infestation has been present for a few weeks • Reports of a crawling sensation in the scalp Physical Examination • Head lice • Lice can be visualized; nits can be seen as small white oval cases attached tightly to a hair shaft. Nits are usually laid within 4 mm of the scalp; as the hair grows, the nits and empty shells are found farther from the scalp, indicating more long-term infestation. • Care must be taken to differentiate hair casts, epithelial cells, and other debris from nits. • Common sites are the back of the head, nape of the neck, and behind the ears; eyelashes can be involved. Scalp excoriations and occipital or cervical adenopathy can be present. • Body lice • Excoriated macules or papules may be present (secondary bacterial infection of the skin may develop). • Belt line, collar, and underwear areas are common sites. • A hemorrhagic pinpoint macule is seen where the louse extracted blood. • Axillary, inguinal, or regional lymphadenopathy can be present. • Pubic lice • Excoriation and small bluish macules and papules may be present. • Eyelashes can be involved; spread to other short-haired areas (thighs, trunk, axillae, beard) may occur. Diagnostic Studies • Microscopic examination of a hair shaft can more clearly identify nits. • Test for other sexually transmitted diseases if pubic lice found; specifically gonorrhea and syphilis. Differential Diagnosis Scabies, dermatitis herpetiformis, and necrotic excoriations are in the differential diagnosis. Rule out sexual abuse if pubic lice are found.

clinical finding and management of contact dermatitis

Clinical Findings History • Contact with any new or unusual substances • Repeated exposure to any substance or item • Diarrhea or infrequently changed diapers • Rash localized to specific area(s) Physical Examination The area of involvement offers clues to the causative agent. Often the rash is localized to one area and has sharp borders. Common examples include a linear-type rash secondary to wearing a necklace or bracelet, circular areas from snaps on clothing, or inflammation of the earlobes from jewelry or a reaction pattern on the toes and dorsum of the foot from shoes. The severity of the rash depends on the length of exposure and the concentration of the irritant. Minimal contact may produce only mild erythema, whereas prolonged or concentrated contact may produce significant erythema, edema, and blistering with possible crusting and secondary infection. Irritant reactions tend to be immediate, whereas allergic ones are delayed. • A chafed appearance with shiny, mild to severely erythematous, peeling, or dry, fissured skin or red patches and plaques with secondary scales may be seen if the reaction is due to an irritant. For example, the dorsum of the hand may exhibit the above characteristic appearance with frequent hand washing with irritating soaps. • Erythema, vesicles, and weeping may be present in the acute stage of allergic contact dermatitis. The lesions are pruritic. • Hyperpigmentation and lichenification are seen in chronic conditions. • A generalized idiosyncratic (id) reaction can develop to an allergen. An id reaction occurs as a secondary or "sympathy" rash distant from the primary site of exposure. Differential Diagnosis The differential diagnosis includes atopic dermatitis, impetigo, herpes simplex, psoriasis, and seborrhea. Management Appropriate skin care, recognizing and eliminating offending agents, and treating inflammation are key to managing contact dermatitis successfully. Identify and avoid the substance (irritant or allergen) causing the dermatitis. General treatment measures include: • Burow solution soaks or oatmeal baths and cool compresses (1 teaspoon salt/pint water) applied for 20 minutes every 4 to 6 hours to soothe vesicular rashes. • Water and either petrolatum-based or lanolin-and-petrolatum-based emollients applied to the skin to restore moisture to areas of dryness and chafing. • Petrolatum-based emollients include dimethicone, white petrolatum, and Vaseline Dermatology Formula. • Lanolin-and-petrolatum-based emollients should not be used if there is inflammation. • Topical corticosteroids used two or three times daily give relief in 2 or 3 days, although it may take 2 or 3 weeks for complete healing. Occasionally oral corticosteroids are used for short periods if the area of allergic involvement exceeds 10% of the skin surface (10 to 14 days, tapered the last 7 days). • Do not use flavored lip creams in cases of lip-licker dermatitis. Emollient lotions and petroleum-based emollients can moisturize the skin and discourage lip licking because of their bad taste. • Oral antihistamines are helpful if itching and scratching are problems. Resolution may take 2 to 3 weeks. Refer to a dermatologist or an allergist for patch testing if the dermatitis worsens, fails to respond, or recurs.image Allergic contact dermatitis can develop into chronic dermatitis if left untreated. Psoralen and UVA treatment, narrow-band UVB treatment, systemic treatment with immunomodulators, and targeted biologic therapy may be considered if unresponsive to other measures

clinical findings of acne

Clinical Findings History • Family history of acne • Stage of pubertal development and menstrual history • Facial and hair products used, especially occlusive products or pomades • Oral and topical prescription medication, especially oral contraceptives, antibiotics, or steroids • Current or previous acne treatment and results • Sports participation, especially if wearing football pads, helmets, headbands, or other protective devices • Jobs, such as cooking at a fast-food grill or working at a gas station • Other medical conditions Physical Examination Lesions most commonly are found on the face, back, and chest. • Noninflammatory lesions: • Microcomedone—a follicular plug as a result of obstruction of the pilosebaceous unit (hair follicle and sebaceous gland) typically localized on the face and trunk. • Open comedone (blackhead)—a noninflammatory lesion or papule, firm in consistency, caused by blockage at the mouth of the follicle and occurring on the face, upper back, shoulders, and chest. The black color is thought to come from oxidized keratinous material at the follicular opening. This is the main lesion in early adolescence. • Closed comedone (whitehead)—a noninflammatory lesion, semisoft in consistency, caused by blockage at the neck of the follicle. This is a precursor to inflammatory acne. • Inflammatory lesions occur secondary to rupture of noninflamed lesions into the dermis and can include papules, pustules, excoriation, lesion crusting, nodules, cysts, scars, and sinus tracts (confluent nodules likely to scar). The severity of acne is determined by the quantity, type, and spread of lesions. It is helpful to use a diagram of the face or a grading graph to identify the number and type of lesions to allow more precise patient follow-up. If only open and closed comedones are found, the disorder is called comedonal acne. Most adolescents have a combination of comedones, red papules, and pustules called papulopustular acne, which can be mild or severe. Nodulocystic acne is the most severe form and requires more intensive intervention. Specific types of acne include frictional, occurring from rubbing of bras, tight clothes, or headbands; pomadal, along the temple and forehead, as a result of pomades or oil-based cosmetics; athletic, on forehead, chin, or shoulders, caused by helmets and pads; and hormonal, with a beard distribution. Differential Diagnosis Cosmetic, mechanical, environmental, or drug-induced acne; rosacea; flat wart; milia; perioral dermatitis; and folliculitis are included in the differential diagnosis.

clinical findings of urticaria and angioedema

Clinical Findings History • Family or previous history of hives, angioedema, connective tissue disease, juvenile arthritis • Possibility of atopy • Intense itching and scratching • Ingestion (within 4 hours) of nuts, shellfish, chocolate, berries, spices, egg white, milk, fish, sesame • Ingestion or injection of medicines (e.g., penicillin, sulfa drugs, sedatives, diuretics, analgesics, acetylsalicylic acid), additives, or preservatives • Injection of diagnostic agents, vaccine, insect venom, blood • Infection with upper respiratory infectious agent, virus, streptococcus, mononucleosis; hepatitis; parasites • Inhalation of animal dander, pollen, dust, smoke, or aerosols • Flea or mite bites • Cold, heat, exercise, sun, water, pressure, or vibration Physical Examination Location of lesions may help determine the cause (e.g., a lesion around the mouth or tongue is likely due to an ingested agent). Findings can include the following: • Urticaria is seen as mildly erythematous, annular, raised wheals or welts with pale centers from 2 mm to several centimeters in diameter; however, they can be of various shapes. Such lesions typically: • Are scattered or coalesced but generalized • Appear suddenly as individual lesions and fade in anywhere from 20 minutes to less than 24 hours, reappearing in other areas later; if fixed more than 48 hours, it is not urticaria • Blanch with pressure • Seem to be intensified with heat • Appear as wheals after rubbing or stroking the skin (dermatographism) • Occur most commonly as papulovesicular lesions with central punctate lesion and wheals in toddlers (papular urticaria) • Can appear as large, blotchy, erythematous lesions with 1- to 3-mm central wheals (cholinergic urticaria) • Angioedema is seen as asymmetric, localized, nondependent and transient edema. • Typically less pruritic than urticaria • May involve the upper airway and progress to life-threatening obstruction • Can cause associated edema of eyelids, lips, tongue, hands, feet, and genitalia Diagnostic Studies If urticaria with possible anaphylaxis from an insect bite is suspected, refer to an allergist for testing and hyposensitization. If fever is present, evaluate for underlying disease. Differential Diagnosis Contact dermatitis, atopic dermatitis, scabies, erythema multiforme (lesions are fixed with dusky centers and appear within 72 hours; Fig. 37-27), mastocytosis, reactive erythemas, vasculitis, psoriasis, and juvenile arthritis are also included in the differential diagnosis

Clinical findings for scabies

Clinical Findings History • Key finding: Itching, worse at night, initially mild but progressively more intense • Fitful sleep, crankiness, or rubbing of hands and feet (infants) Physical Examination • Complaints are significantly greater than examination findings. • Characteristic lesions include curving S-shaped burrows, especially on webs of fingers and sides of hands, folds of wrists and armpits, forearms, elbows, belt line, buttocks, genitalia, or proximal half of foot and heel. • Vesiculopustular lesions tend to be found in infants and young children. They classically have vesicular lesions on palms, soles, scalp, face, posterior auriculae, and axillae, concentrated in the folds; head and neck lesions typically are red-brown vesicopustules or nodules. However, any child younger than 2 years old can have an unusual manifestation. • Secondary lesions include itchy papules, red-brown nodules from inflammatory response, crusting, excoriation, and other signs of secondary infection. • Infants classically have dozens of lesions; older children may have fewer than 10. Diagnostic Studies • Microscopic examination of scrapings from an unscratched burrow in saline or mineral oil can reveal an eight-legged mite, eggs, or feces. Do not use KOH because it dissolves the mites, eggs, and feces. Burrows and fresh papules are best for specimen collection. • Burrow ink test: Apply a drop of ink or rub a washable felt-tipped pen across suspected burrow. Wipe off excess ink and examine with magnifying glass for an ink-stained burrow. Differential Diagnosis Papular urticaria; atopic, seborrheic or contact dermatitis; insect bites; folliculitis; lichen planus; and dermatitis herpetiformis are included in the differential diagnosis.

clinical findings of drug eruption

Clinical Findings History • Medication taken within the past 3 weeks • Varying degrees of itching—can be intense • Rash worsens even after medicine is discontinued for up to 5 days • Possible systemic symptoms—low-grade fever, arthralgia, arthritis, lymphadenopathy, edema Physical Examination Findings include the following: • Condition often begins as a fairly symmetric, macular erythematous rash that becomes papular and confluent. • Patches of normal skin are scattered throughout areas of involvement. • Rash begins on the trunk, where it is a brighter red, more confluent, and extends distally to the extremities, including the palms and soles. • Rash may turn brownish red and desquamate in 7 to 14 days. • The face often has confluent areas of erythema. • Mucous membranes are typically spared. Diagnostic Studies The following are ordered if necessary for differential diagnosis: • CBC, monospot test, C-reactive protein (CRP), antinuclear antibodies, anti-streptolysin O (ASO), cold agglutinins • Chest radiograph Differential Diagnosis Viral exanthem; measles; toxic erythema, such as in scarlet fever, staphylococcal scarlatina, or Kawasaki disease; TSS; roseola; and erythema infectiosum are included in the differential diagnosis.

clinical findings folliculitis/furuncle

Clinical Findings History • Pruritus with folliculitis; tenderness with furuncle • Hot-tub exposure • Irritating surface agent • Occasional fever, malaise, or lymphadenopathy Physical Examination The child often is asymptomatic, but the following can be seen: • Discrete, erythematous 1- to 2-mm papules or pustules on an inflamed base centered around a hair follicle • Involvement of face, scalp, extremities (typically thighs and upper arms), buttocks, and back • Nodules with larger areas of erythema and tenderness (furuncle) • Pruritic papules, pustules, or deep red to purple nodules, most dense in areas covered by swimsuit 8 to 48 hours after exposure (hot-tub folliculitis) Diagnostic Studies Gram stain and culture are occasionally ordered. In the case of persistent or difficult-to-treat folliculitis, consider the possibility of MRSA.

Clinical findings Erythema Multiforme, Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis

Clinical Findings History • With erythema multiforme • Recent or current infection with herpes virus (herpes labialis or progenitalis) • Exposure to UV light or trauma to area • Low-grade fever, malaise, and myalgia • With SJS or TEN • SJS is usually caused by medication or viral illness • SJS can have a prodrome of high fever, cough, sore throat, vomiting, diarrhea, chest pain, and arthralgia that usually lasts 1 to 3 days (but can last from 1 to 14 days) followed by the onset of lesions • TEN is nearly exclusively caused by medication (Treat, 2010) • TEN begins with a fever, sore throat, malaise, and generalized sunburn-like erythema Physical Examination It is important to differentiate the clinical findings of erythema multiforme from SJS and TEN. • In erythema multiforme • Lesions vary from patient to patient, within a single episode, and with recurrence. • Lesions initially appear dusky, as red macules or edematous papules that evolve into target lesions with multiple, concentric rings of color change. • Lesions are fixed (another diagnostic clue), tend to be symmetric, and have a typical distribution predominantly on the face, extensor surface of the arms and legs, dorsum of the hands and feet, and the palms and soles. • The oral mucosa is commonly involved, and 50% of children will present with shallow oral lesions (Weston and Morelli, 2013). • In SJS or TEN • SJS skin lesions typically are erythematous macules on the head and neck and can spread to the trunk and extremities with blister formation (within hours) that is often hemorrhagic, extensive, and confluent; mucosal involvement of eyes, nose, and mouth is widespread. • The TEN rash has rapidly coalescing target lesions and widespread bullae that become full-thickness epidermal peeling or sloughing within 24 hours; Nikolsky sign (peeling of skin with a light rub that reveals a moist red surface) is present. Conjunctivae, urethra, rectum, oral and nasal mucosa, larynx, and tracheobronchial mucosa may or may not be involved with TEN. Diagnostic Studies Studies are ordered as indicated by the clinical condition of the child. Differential Diagnosis Urticaria can be differentiated by lack of itching, lability of lesions, and shorter-lasting hives that are pale centrally, not target or iris lesions (see Table 37-9). Viral exanthems are more centrally located, confluent, and less erythematous. Purpura is present in vasculitis. In SSSS, the skin peels superficially (not full thickness) and is significantly red. Also included in the differential diagnosis are Kawasaki disease and lupus erythematosus.

treatment of acne

Comedonal Open or closed comedones Choose one: Benzoyl peroxide: 5% gel daily (if mild) Tretinoin: 0.025% cream daily (if moderate) Adapalene: 0.1% gel Combine benzoyl peroxide with tretinoin or increase strength of tretinoin to 0.05% Mild papulopustular Red papules, few pustules Option 1. Choose one: Benzoyl peroxide: 5% to 10% daily Adapalene: 0.1% gel Azelaic acid: Twice a day (if mild) Plus topical antibiotic twice a day Option 2. Choose one: Erythromycin: 3% with 5% benzoyl peroxide daily to twice a day (if moderate) Clindamycin: 1% with 5% benzoyl peroxide daily to twice a day Increase benzoyl peroxide to twice a day or Combine benzoyl peroxide with tretinoin (for comedones) Substitute topical antibiotic twice a day (for inflammatory acne) Moderate to severe papulopustular Red papules, many pustules Choose one: Benzoyl peroxide: 5% and tretinoin 0.025% Adapalene: 0.1% gel Azelaic acid (if comedonal) Topical antibiotic twice a day (if no comedones) Plus oral antibiotic twice a day Increase strength of treatment or Refer to dermatologistimage Nodulocystic, scarring, or unresponsive Red papules, pustules, cysts, and nodules Choose one: Oral antibiotics twice a day and tretinoin 0.05% daily Adapalene (0.1% gel) and benzoyl peroxide (10% gel) twice a day (if comedonal) Adapalene: 0.1% gel and topical antibiotic Refer to dermatologist for oral isotretinoinimage (&, 052016, p. 1017)

contact dermatitis

Contact dermatitis is an acute or chronic inflammation resulting from a hypersensitive reaction to a substance (either irritants or allergens). Common types of contact dermatitis include the following: • Dry skin dermatitis caused by extremely low humidity (less than 30%), excess soap or cleansing cream use, or inadequate rinsing of soap products • Nickel dermatitis from contact with jewelry, belts, snaps, or eyeglasses • Lip-licker dermatitis caused by frequent lip licking, most often in dry, cold weather • Phytophotodermatitis from sun exposure following contact with plants or juices, such as limes, lemons, carrots, celery, figs, parsnips, or dill; manifests as a blistered lesion on an erythematous base and may be confused with a burn • Plant oleoresins, such as poison ivy, oak, or sumac; contact can be direct or indirect (exposure to burning plant material); oils may be inhaled, causing damage to lung tissue (Urushiol, the allergen in poison ivy, oak, and sumac can remain on contaminated items, such as clothing, animal hair, toys, and sports equipment resulting in sequential outbreaks due to reexposures.) • Juvenile plantar dermatosis, manifested as dryness, cracking, and erythema of weight-bearing surfaces of the feet, initially the big toes; it mimics tinea pedis, often found in children with atopic dermatitis • Latex dermatitis, associated with the use of products containing latex, such as protective gloves Substances such as saliva, urine, and feces; baby wipes; bubble bath; agents that dry the skin; and adhesives often cause contact dermatitis. Diaper dermatitis is the most common form (see following section). Contact dermatitis can also be caused by allergens. Allergic reactions occur as an immunologic response to an antigen penetrating the skin. There are two phases: sensitization and elicitation. Allergic dermatitis is seen only after sensitization to an allergen has occurred and a subsequent type IV delayed hypersensitivity response has activated an immune cascade. Common causes are contact with shoes (components, such as rubber and potassium dichromate); nickel; clothes with woolen or rough textures; topical medications (e.g., neomycin and lanolin); perfumed soaps or cosmetics (including lanolin); preservatives; or poison ivy, oak, or sumac. Sometimes the cause is obvious; often no specific cause can be identified. Although it occurs at any age, contact dermatitis is extremely common in children

Management of Herpes simplex

Diagnostic Studies A Tzanck smear can be done on fluid from the lesions to identify epidermal giant cells; however, it does not distinguish HSV-1 from HSV-2. Viral cultures are the gold standard for definitive diagnosis. Direct fluorescent antibody (DFA) tests, enzyme-linked immunosorbent assay (ELISA) serology, and polymerase chain reaction (PCR) tests are usually only used with severe forms of HSV infection. Differential Diagnosis The differential diagnosis includes aphthous stomatitis, hand-foot-and-mouth disease, varicella, impetigo, folliculitis, and erythema multiforme. Management Management can be guided by considering the host (e.g., age, area and extent of involvement, and immune status) and the drug needed (Table 37-5). Treatment includes: 1. Burow solution compresses three times a day to alleviate discomfort 2. Acyclovir 20 to 40 mg/kg/dose orally five times a day for 5 days, or 200 mg five times a day for 7 to 10 days (maximum pediatric dose 1000 mg/day) may be indicated to help shorten the course and alleviate symptoms for children older than 2 years old with the following conditions: • Any underlying skin disorder (e.g., eczema) • A severe case • An immunocompromised disease • Systemic symptoms with primary genital infection • Occasionally for initial severe gingivostomatitis Acyclovir is most effective if started within 3 days of disease onset. Famciclovir or valacyclovir are additional antiviral agents approved for use in adults. 3. Topical acyclovir ointment may help for initial genital herpes infections but is often not beneficial for recurrent infections. 4. Oral acyclovir 200 mg five times a day for 5 to 10 days may speed healing of herpetic whitlow (see Fig. 37-16). 5. Antibiotics for secondary bacterial (usually staphylococcal) infection: • Mupirocin: Topically three times a day for 5 days • Erythromycin: 40 mg/kg/day for 10 days • Dicloxacillin: 12.5 to 50 mg/kg/day for 10 days 6. Oral anesthetics for comfort; use with caution in children (the child needs to be able to rinse and spit): • Viscous lidocaine 2% topical • Liquid diphenhydramine alone or combined with aluminum hydroxide or magnesium hydroxide as a 1 : 1 rinse (maximum of 5 mg/kg/day diphenhydra-mine in case it is swallowed); it can also be applied to the lesions with cotton-tipped swabs 7. Newborn infant, immunosuppressed child, child with infected atopic dermatitis, or child with a lesion in the eye or on the eyelid margin; consult with or refer to an appropriate 8. Offer supportive care, such as antipyretics, analgesics, hydration, and good oral hygiene 9. Exclude from day care only during the initial course (gingivostomatitis) and if the child cannot control secretions 10. Recurrent, frequent, and severe HSV infection may be treated with acyclovir prophylaxis for 6 months Patient and Family Education Recurrence of infection, possible triggering factors, and avoidance measures should be discussed. Triggers can include physical and psychological stress, trauma, fever, exposure to UV light, illness, menses, and extreme weather. Contagiousness of lesions and oral secretions must be understood. Explanation of the course of primary disease, with fever lasting up to 4 days and lesions taking at least 2 weeks to heal, is important.

Diaper dermatitis

Diaper dermatitis is the most frequent contact dermatitis seen in children and one of the most common skin disorders of infants (Table 37-8; Fig. 37-23). The initial rash is termed irritant contact diaper dermatitis. A variation of this is called tidewater or tidemark dermatitis and is found at the diaper edges. Jacquet dermatitis, a severe form manifested by punched-out lesions or erosions primarily on the labia and buttocks, is especially prone to secondary infection

management of molluscum contagiosum

Differential Diagnosis Warts, closed comedones, small epidermal cysts, blisters, folliculitis, and condyloma acuminatum are included in the differential diagnosis. Management • Untreated lesions usually disappear within 6 months to 2 years but may take up to 4 years to completely go away. There is no consensus on the management of molluscum contagiosum and no evidence-based literature to show that any treatment is superior to placebo. Therapy may be necessary to alleviate discomfort, reduce itching, minimize autoinoculation, limit transmission, and for cosmetic reasons. Genital lesions may need to be treated to prevent spread to sexual partners. • Mechanical removal of the central core is to prevent spread and autoinoculation. Using eutectic mixture of local anesthetics (EMLA) cream (lidocaine/prilocaine) 30 to 45 minutes before the procedure reduces discomfort. Curettage is done with a sharp blade to remove the papule. Piercing the papule and expressing the plug is an option but is painful. • There are reports that irritants (such as, surgical tape, adhesive tape, or duct tape) applied each night can result in lesion resolution. • Topical medications may prove beneficial. Recheck the patient in 1 to 2 weeks to determine need for retreatment. • Liquid nitrogen applied for 2 to 3 seconds (easiest but also painful). • Trichloroacetic acid 25% to 50% applied by dropper to the center of the lesion, followed by alcohol (use with caution). Surround the lesion first with petroleum jelly. • Cantharidin 0.7% in collodion applied by dropper to the center of the lesion, followed by alcohol. Salicylic or lactic acid or KOH or podophyllin can also be used. • Podofilox 0.5% topical solution or gel, or imiquimod 5% applied daily with a toothpick or cotton-tipped swab. • Tretinoin or tazarotene cream or gel applied to lesion each night. • Silver nitrate, iodine 7% to 9%, or phenol 1% applied for 2 to 3 seconds. • Cimetidine 30 to 40 mg/kg/day in two divided doses orally for 6 weeks if topical treatment fails. • Sexual abuse of children with genitally grouped lesions should be suspected and evaluated. • Evaluate for HIV infection if hundreds of lesions are found. • Wait and see approach—spontaneous clearing occurs over years. Complications Molluscum dermatitis, a scaly, erythematous, hypersensitive reaction, can occur and will respond to moisturizer; avoid hydrocortisone because it causes molluscum to flare. Impetiginized lesions, inflammation of the eyes or conjunctiva, and scarring can occur. Patient and Family Education Patients are contagious, but there is no need to exclude them from daycare or school. Children with impaired immunity, atopic dermatitis, or traumatized skin are at greater risk for broader spread. Severe inflammation is possible several hours after application of cantharidin. Scarring is unusual.

scabies

Scabies is caused by the mite, Sarcoptes scabiei, which is an obligate human parasite that burrows into the epidermis and causes intense itching (Fig. 37-21). Scabies is a highly contagious infestation spread through close contact and shared clothing or linen. The female mite burrows into the skin, laying up to three eggs a day as she travels. The eggs hatch in about 3 to 4 days and mature into adult mites in 10 to 14 days. The female mite has a lifespan of 15 to 30 days. Sensitization, which causes intense itching, occurs approximately 3 weeks after infestation. Scabies occurs in all socioeconomic groups and in all age groups. However, infestation of African Americans is rare.

clinical findings and treatment

Factors contributing to diaper dermatitis include the following: • Improper hygiene and cleansing methods • Chemical irritation caused by prolonged contact with skin products, urine, feces, or breakdown products. Feces and its breakdown products are the major factors • Mechanical irritation from diapers or skinfolds • Occlusion of skin with use of diapers and plastic or rubber pants • Other skin dermatoses aggravated by wearing diapers (e.g., seborrhea, atopic dermatitis, or psoriasis) • In the diaper area around the anus, the rash is often due to diarrhea; if the skin is affected but the folds are spared, urine is often responsible Clinical Findings History • Type of diapers and diaper covering used; recent change in brand or laundering products • Frequency of wet diapers and stools • Frequency of diaper changes and methods of cleansing used • Any new baby care products used • Medication taken (particularly antibiotics) or used on rash • Present or recent use of antibiotics Physical Examination Erythema, edema, and vesiculation are typically the first characteristic changes observed. Chronic changes include scale, lichenification, and increased or decreased pigmentation. Other findings associated with specific causative factors can include the following: • Chemical causes • Shiny, peeling, erythematous macular or papular rash confluent in the diaper area, sparing folds • Head of penis erythematous and dry • Erythema primarily on buttocks and around anus (fecal irritation) • Mechanical causes • Erythematous, macerated (acute) or dry (chronic), hyperpigmented area prominent along edges of diaper or plastic or rubber pants • Erythematous, macerated folds caused by overlapping skin • Hygiene problems • Any finding listed previously • Poor hygiene in general Differential Diagnosis Differential diagnoses include contact dermatitis; bacterial, viral, or monilial infection; atopic dermatitis; psoriasis; seborrhea; scabies; and congenital syphilis. Management The best treatment is prevention! 1. Keep diaper area dry, clean, and aerated. • Frequent diaper changes are essential; every 1 to 2 hours is recommended with one change at night and a minimum of eight changes in a 24-hour period for infants. Cleanse the area well with water at every diaper change and use mild soap, rinsing well following a stool. Avoid vigorous cleansing because this can worsen matters. Avoid using wipes. • Use a greasy lubricant if skin is dry. • Use a protective barrier ointment or cream, such as Desitin (cod liver oil with zinc oxide), A&D Ointment, Aquaphor, petrolatum, or zinc oxide at the first sign of irritation. 2. Proper use of diapers • In addition to frequent changes, use thick or absorbent diapers. • Avoid use of rubber or plastic pants. • Cloth diapers should be soaked, prerinsed, washed in a mild soap, double rinsed with image cup of vinegar, and dried in the sun if possible. • Disposable diapers must be large enough not to bind and should never be worn with rubber pants. 3. Treatment of diaper rash • Sitz baths in warm water for 10 to 15 minutes four times a day. • Expose diaper area to air by leaving diaper off or by blow-drying with low heat three or four times a day. • Burow solution soaks or compresses four times a day if skin is weepy. • Diaper cream containing undecylenic acid or zinc oxide to decrease the friction and exposure to moisture. • Hydrocortisone 0.5% or 1% applied as a thin layer three times a day for no more than 5 days, especially if skin is dry, for moderate to severe diaper dermatitis. Do not use fluorinated steroids. • Increase intake of fluids to dilute urine. In older infants, 2 to 3 ounces of cranberry juice acidifies the urine. • If the rash has been present for more than 3 days or if there is no response to the aforementioned measures, add a topical antifungal cream, such as clotrimazole or miconazole. If there is still no response, a trial of oral antifungal is indicated (see Monilial Dermatitis section). • Any recalcitrant rash should be referred to a dermatologist.image • Follow up by phone in 1 to 2 days. If not improved, reassess within 1 week. Complications Secondary infection with bacteria, viruses, or fungi can occur (see previous sections). Red flags that could indicate systemic disease or require consultation with a dermatologist include severe erosions or ulcers; bullae or pustules; large papules or nodules, purpura, or petechiae; and redness or scaliness over entire body.

Clinical findings

History • Itching at the site • Possible exposure to molluscum contagiosum Physical Examination • Very small, firm, pink to flesh-colored discrete papules 1 to 6 mm in size (occasionally up to 15 mm) • Papules progressing to become umbilicated (may not be evident) with a cheesy core; keratinous contents may extrude from the umbilication • Surrounding dermatitis is common • Face, axillae, antecubital area, trunk, popliteal fossae, crural area, and extremities are the most commonly involved areas; palms, soles, and scalp are spared • Single papule to numerous papules; most often numerous clustered papules and linear configurations • Sexually active or abused children can have genitally grouped lesions • Children with eczema or immunosuppression can have severe cases; those with human immunodeficiency virus (HIV) infection or AIDS can have hundreds of lesions Differential Diagnosis Warts, closed comedones, small epidermal cysts, blisters, folliculitis, and condyloma acuminatum are included in the differential diagnosis.

Herpes Simplex

Herpes Simplex In the active state, herpes simplex virus (HSV) causes contagious infections of the skin and mucous membranes ranging from mild to life threatening. HSV infection can be either primary or recurrent. Primary infection occurs in individuals without circulating antibodies after direct contact with secretions or mucocutaneous lesions of an infected individual. Incubation takes days to weeks and then manifests itself anywhere from subclinical to severe infection. The virus then becomes dormant in certain nerve cells until reactivated by triggering factors, such as stress, menses, illness, sunburn, windburn, and fatigue. Recurrent infection occurs in individuals previously infected who had either clinical or subclinical manifestations of infection. HSV type 1 (HSV-1) usually affects the oral mucosa, pharynx, lips, and occasionally the eyes, causing a herpes labialis infection, commonly called cold sores or fever blisters HSV-2 infection commonly occurs as a neonatal infection or herpetic vulvovaginitis 36) or progenitalis. Type 1 can also be found in the genital area, and type 2 can be found on the lips and mouth. Herpetic whitlow, occurring on a finger or thumb, is a swollen, painful lesion with an erythematous base and ulceration resembling a paronychia. It occurs on fingers of thumb-sucking children with gingivostomatitis or adolescents with genital HSV infection. HSV is transmitted by close contact with skin, mucous membranes, and body fluids, often through a break in the skin or by autoinoculation. Lesions occur in children of all ages, are contagious as long as they are present, and have an incubation period of 2 to 12 days. Primary lesions usually occur before 5 years old, are more painful and extensive, and last longer.

Herpes Zoster or shingles

Herpes zoster (HZ) is a recurrent varicella infection commonly called shingles. Caused by reactivation of the latent varicella zoster infection from the sensory root ganglia, HZ occurs in 10% to 20% of all individuals, is rare in childhood, and occurs more frequently with increasing age (three times more common in adolescents than preschoolers). HZ is more common following mild cases of varicella infections before 1 year old (threefold to twentyfold increased risk) and in immunocompromised children.

Clinical Findings of pityriasis rosecea

History Although most are otherwise well, a small percentage (5%) of patients experience a prodrome of mild symptoms including malaise, pharyngitis, lymphadenopathy, and headache before onset of rash. Those that have prodromal symptoms tend to have a more florid rash. Physical Examination • Herald spot or patch (70% of presentations): a 2- to 5-cm solitary, ovoid, slightly erythematous lesion with a finely scaled slightly elevated border that enlarges quickly with central clearing); typical locations for the herald patch include the trunk, upper arm, neck, or thigh. • Secondary generalized lesions appear that are symmetric, small macular to papular, thin and round to oval. The lesions have thin scales centrally with thicker scales peripherally ("collarette" scales surround the lesions). They are also pale pink; more common on trunk and proximal extremities from neck to knees; typically spare the face, scalp, and distal extremities; and usually occur 2 to 21 days after the appearance of the herald patch (key finding). • Christmas tree pattern—rash, especially on back, follows dermatome skin lines with oval lesions running parallel and wrapping around the trunk horizontally. • Itching occurs in about 25% of cases particularly with secondary lesions. • Oral lesions have punctate hemorrhages, erosions or ulcerations, erythematous macules, or annular plaques; such lesions occur in about 16% of patients. • An atypical presentation can occur with lesions involving areas that are usually spared (e.g., the face, axilla, and/or groin). The face and neck are frequent areas of involvement in young children, especially African American children (Paller and Mancini, 2011). 1027 Diagnostic Studies If needed, a KOH preparation of a skin scraping is done to rule out tinea. Differential Diagnosis Include psoriasis, guttate psoriasis, nummular eczema, scabies, tinea (especially the herald patch), secondary syphilis, drug eruptions, or viral exanthems in the differential diagnosis.

Clinical Findings Herpes Simplex

History In primary herpes, fever, malaise, sore throat, and decreased fluid intake can occur. Primary genital HSV presents with painful vesicles in genital areas. In recurrent HSV infection, there is often a painful prodrome of burning, tingling, paresthesia, and itching at the involved site. Recent acute febrile illness or sun exposure may also be reported. Physical Examination The following are seen on physical examination: • HSV-1 • Gingivostomatitis: Pharyngitis with grouped vesicles on an erythematous base that ulcerate and form white plaques on mucosa, gingiva, tongue, palate, lips, chin, and nasolabial folds; lymphadenopathy and halitosis are present Herpes labialis: Cluster of small, clear, tense vesicles with an erythematous base that become weepy and ulcerated, progressing to crustiness, usually only on one side of the mouth and on the vermillion border—classic cold sore

clinical findings in candidiasis

History The history often includes antibiotic or steroid use over the previous weeks and occurrence of a rash in a moist, warm area. Physical Examination • Mouth—friable, adherent white plaques on an erythematous base on the mucous membranes (thrush); cracked lips (cheilitis); fissured and inflamed corners of the mouth (angular cheilitis) • Intertriginous areas (neck, axillae, or groin)—bright erythema in flexural folds • Diaper area—moist, beefy-red macules and papules with sharply marked borders and satellite lesions; erosions may also be present • Vulvovaginal area—thick, cheesy, yellow discharge; erythema; edema; and itching • Nail plates—transverse ridging of the nail plate, loss of cuticle, and mild proximal lateral periungual erythema (chronic paronychia) Diagnostic Studies If treatment failure or questionable diagnosis occurs, KOH-treated scrapings of satellite lesions or mucosa reveal yeast cells and pseudohyphae Differential Diagnosis The differential diagnoses include erythema toxicum, miliaria, staphylococcal pustulosis, transient neonatal pustulosis, neonatal herpes simplex, and congenital syphilis.

clinical finding for cellulitis

History • A previous skin disruption at the site or recent upper respiratory infection (H. influenzae). Note that edema that occurs within 24 hours of an insect bite is most likely to be inflammatory, whereas edema that occurs between 48 to 72 hours is more likely to be infectious. • Fever, pain, malaise, irritability, anorexia, vomiting, and chills can be reported. • Recent sore throat or upper respiratory infection. • Anal pruritus, stool retention, constipation, and blood-streaked stools.

Lindane

Lindane is a prescription organochloride that effectively kills lice and nits. It is a neurotoxin, and there are safety concerns because of potential central nervous system effects on the child and long-term environmental contamination. Therefore, it is recommended for use only in patients who have failed to respond to adequate doses of other approved agents. For head lice, a 1% lindane shampoo is used, left on the hair for 4 minutes, then rinsed; for body lice, cream or lotion may be applied for 8 to 12 hours (overnight) and then rinsed off; for pubic lice, a 1% shampoo is applied for 10 minutes, then rinsed off. Retreatment is not recommended

Clinical Findings psoriasis

History • The etiology of psoriasis includes both genetic and environmental factors; more than one third of patients have a family history of psoriasis (Cohen, 2013) • Streptococcal infection of the oropharynx or perianal area before onset (guttate) • Trauma before onset • Itching (variable) Physical Examination • The scalp (encircling the hairline and external ears), elbows, knees, and buttocks (especially the diaper area in infants) are the most common sites of involvement. In children, the face may also be involved. Lesions are often found around areas of trauma (e.g., genitalia, palms, soles). • Plaque psoriasis: Discrete, initially erythematous, symmetric, well-marginated rash becoming papular with silver scales that may be trivial to widespread. • Guttate (teardrop) psoriasis: Widespread, symmetric, round, or oval 0.5- to 2-cm lesions occurring primarily on the trunk and proximal extremities, occasionally on the face, scalp, and ears and rarely on the palms or soles. There is less scaling than in psoriasis vulgaris. • Psoriasis vulgaris: Well-circumscribed, erythematous plaques with thick, silvery white scales concentrated on elbows, knees, scalp, and hairline, but also seen on eyebrows, around ears, and in intergluteal fold and genital area. • Koebner phenomenon (isomorphic response): Psoriatic lesions occur in areas of local injury, such as scratches, surgical scars, or sunburns. • Auspitz sign: Bleeding occurs when a scale is removed. • Nail signs: Nails have "ice pick" pits and ridges, are thick and discolored (yellowing), can have splinter hemorrhages or subungual hyperkeratosis, and can be separated from the nailbed (Lyon, 2011). • Napkin or diaper area psoriasis: Appears eczematous with sharply defined plaques, bright red coloration, shiny with large drier scales, affecting inguinal and gluteal folds. Diagnostic Studies • ASO if guttate pattern • KOH-treated scrapings and culture to rule out fungal infection • Venereal Disease Research Laboratory (VDRL) to rule out secondary syphilis Differential Diagnosis Pityriasis rosea, seborrhea, Candida infection, contact or irritant dermatitis, atopic dermatitis, tinea, dyshidrosis, secondary syphilis, and other nail-pitting conditions are included in the differential diagnosis.

Management of cellulitis

Hospitalization is recommended if the child is a febrile neonate or infant, is acutely ill or toxic, or has periorbital cellulitis. • Neonates with cellulitis require a full septic workup and initiation of empiric therapy with methicillin or vancomycin and gentamicin or cefotaxime (Cohen, 2013). • Antibiotic therapy • As noted earlier, prompt administration of antibiotics is essential. • If a streptococcal infection is suspected, penicillin is the drug of choice. • A hospitalized febrile acutely ill infant or child should have penicillin, up to 2 million units per day. • Benzathine penicillin: 600,000 to 1,200,000 units IM for one dose. • Penicillin V: 30 to 60 mg/kg/day orally for 10 days. • If allergic or concern for multiple organisms a third-generation cephalosporin, such as 50 to 75 mg/kg ceftriaxone intramuscularly (IM) once a day. • If suspected organism is staphylococcus: • An initial IM dose of ceftriaxone 50 to 75 mg/kg/dose, then dicloxacillin 50 to 75 mg/kg/day orally, divided four times a day for 10 days or cephalexin 50 to 100 mg/kg/day orally, divided three times a day for 10 days. • If MRSA suspected, clindamycin 10 to 30 mg/kg/day orally divided three times a day for 10 days. • If suspected organism is H. influenzae: • Amoxicillin clavulanate 50 to 90 mg/kg/day orally for 10 days. • Methicillin or a third-generation cephalosporin is also an option. • Follow up in 24 hours to assess response and observe toxicity. Continue daily visits until child is recovering. Counsel parents to call the provider immediately or return for an urgent visit if the infection is not improving or is getting worse.

urticaria

Hypersensitive reaction; immunologic antigen-antibody response to release of histamines; often unknown cause; possible reaction to food, drug, insect bite or sting, pollen; possible reaction to infection, especially streptococcal, sinus, mononucleosis, hepatitis Key finding: Appears suddenly, fades in 20 minutes to 24 hours Family history of hives; possible atopy; intense itching; mild erythema, annular, raised wheals with pale centers; lesions scattered or coalesced; blanch with pressure; associated edema of eyelids, lips, tongue, hands, feet Quick resolution; identify and remove offending agent if possible and treat; stop antibiotic; give oral antihistamines; topical antipruritics; epinephrine or prednisone if anaphylactic, angioedema, or refractoryimage; refer if >6 weeks' duration

Erythema Multiforme

Immune-mediated hypersensitivity reaction often to infection, especially HSV; also to many other agents Key finding: Target or iris lesions: Lesions fixed, symmetric, typical distribution on hands, feet, elbows, knees, also face, neck, trunk History of infection, especially herpes labialis; variety of lesions on skin and mucous membranes—macules, papules, vesicles, early lesions, such as, urticaria; possible oral mucous membrane involvement identify, treat, discontinue trigger if possible; treat infection; supportive measures for hydration, prevention of secondary infection, relief of pain; oral antihistamines, cool compresses; oral lesions—mouthwash, topical anesthetics; lesions last 5 to 7 days, recur in batches over 2 to 4 weeks, resolve without scarring or sequelae (&, 052016, p. 1021)

Erythema Multiforme, Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis

In the past, erythema multiforme minor, Stevens-Johnson syndrome (SJS) (also known as erythema multiforme major), and toxic epidermal necrolysis (TEN) were thought to be related disorders. However, erythema multiforme minor is a distinct disorder that does not progress to SJS or TEN. Erythema multiforme is an acute, usually benign, self-limited eruption characterized by target lesions and minor mucosal involvement (papules and varying bullae); it is rarely associated with complications. SJS and TEN are considered to represent a distinct syndrome that occurs with variable expression along a continuum. SJS and TEN are associated with significant risk of morbidity and mortality. Erythema multiforme usually follows an infection, with approximately 80% of cases of classic erythema multiforme attributed to HSV, in particular, herpes labialis or progenitalis lesion(s) (see Fig. 37-31). The herpetic lesion may have healed or had a subclinical presentation but led to an immune response in the body. Erythema multiforme tends to be recurrent as do herpes lesions. Erythema multiforme may also be associated with other viruses, such as EBV, cytomegalovirus (CMV), and other herpesviruses

scabies treatment

Key finding: Itching, worse at night, and complaints are more significant than physical findings; fitful sleep, crankiness; curving burrows, especially in webs of fingers, sides of hands, folds of wrist, armpits, forearms, elbows, belt line, buttocks, proximal half of foot and heel; secondary excoriation; infants may have lesions on palms, soles, scalp, face, posterior auricle and axilla, folds, red-brown; may be <10 lesions total or may be dozens (typical of infants); lesions may occur in the form of firm nodules in infants Treat with permethrin 5%, repeated in 1 week; use antihistamine, hydrocortisone, or nonsteroidal anti-inflammatory drugs (NSAIDs) for itching; simultaneously treat family members (even if asymptomatic), friends, and school/day care contacts Cleanse environment: Linens and clothing, vacuum, store anything else in plastic bags for 2 days; rash and itch persist for up to 3 weeks after treatment; return to school 24 hours after treatment

lice treatment

Key to treatment is proper technique! First step: Apply pediculicide: permethrin or pyrethrin plus piperonyl butoxide Second step: Remove nits: comb hair with fine-toothed comb in 1-inch sections with special attention to nape of neck and behind ears Third step: Cleanse the environment: check family, friends, day care/school contacts; clean sheets, towels, clothing, and headgear; store other items in plastic for 2 days; vacuum; soak brushes and combs; follow up in 2 weeks with daily recheck at home by parent May return to school after pediculicide treatment; "no nit" policies are not recommended

Malathion Loition

Malathion lotion 0.5% is an organophosphate with a pine-needle-oil base that is available only by prescription. It is a potent lice killer that binds to the hair shaft for 4 weeks and it is considered the most effective therapy for killing lice and nits. It is not recommended in children younger than 2 years old. The drug is flammable, and if ingested causes severe respiratory distress. Malathion 0.5% lotion should be applied to dry hair, be allowed to dry, and then carefully rinsed off 8 to 12 hours later. The treatment should be repeated in 7 to 10 days if live lice are still seen

care management SJS TEN and EM

Management Care for erythema multiforme is generally supportive because the condition is self-limited. • Symptomatic and supportive care: Maintain hydration, prevent secondary infection, and relieve pain. • Mild analgesics, cool compresses, and oral antihistamines, such as diphenhydramine • Soothing mouthwashes or topical anesthetics, such as Kaopectate or Maalox, mixed in equal parts with diphenhydramine • Topical intraoral anesthetics, such as dyclonine liquid or viscous lidocaine, are sometimes used with caution in older children and adolescents • Débridement of oral lesions with half-strength hydrogen peroxide • Wound care • IV fluids if oral hydration is not adequate • Systemic antihistamines, analgesics, and antimicrobials as needed • Prevention of herpes simplex: Avoid sun exposure and use sunscreen and protective clothing. • Prophylaxis for recurrent erythema multiforme treatment: • Oral acyclovir, for child weighing less than 40 kg, 20 mg/kg/day divided twice daily, or weighing more than 40 kg, 400 mg/day divided twice daily, for a 6- to 12-month trial with periodic stopping to reassess. • Acyclovir during an acute episode of erythema multiforme does not alter its course. SJS and TEN are potentially life-threatening diseases.image Children are typically admitted to the pediatric intensive care unit (PICU) or burn unit for wound care, management of hydration and electrolyte issues, nutritional support, and pain control. IVIG should be started as quickly as possible in order to reverse the blistering and sloughing. The use of systemic corticosteroids is contraindicated in the treatment of SJS and TEN because of the increased risk of sepsis (Treat, 2010). Complications SJS and TEN are associated with significant morbidity including pneumonitis, sepsis, gastrointestinal bleeding, renal disease, keratitis, and other ophthalmologic disorders. Patient and Family Education Erythema multiforme lesions can erupt in crops that last 1 to 3 weeks, but resolve without scarring or sequelae, except for transient desquamation, scaling, or hyperpigmentation. Recurrence of erythema multiforme is common.

Management of urticaria and angioedema

Management Control of symptoms is the main goal of treatment. The following steps are taken: 1. Identify and remove the offending substance if possible. Stop all antibiotics. Avoid any possible food or environmental trigger. 2. Test for dermatographism by stroking the skin, for cholinergic urticaria by applying heat or observing immediately after exercising, for cold urticaria by applying cold packs, for pressure urticaria by applying weighted bands for several minutes, and for water urticaria by applying wet compresses. 3. Administer medications as indicated. • Oral antihistamines, such as diphenhydramine 0.5 to 1 mg/kg/dose every 4 to 6 hours as needed (maximum 50 mg/dose and 300 mg/day) or hydroxyzine 0.6 mg/kg/dose every 6 hours as needed (400 mg/day maximum) until itching and urticaria are resolved. Nonsedating antihistamines are less effective, but if needed, astemizole, cetirizine, or loratadine are best. Urticaria is less likely to recur if the antihistamine is continued for 1 to 2 weeks after resolution. • Topical antipruritics may be helpful. • Aqueous epinephrine 1 : 1000 (subcutaneously 0.01 mL/kg up to 0.3 mL) may be needed if anaphylaxis or significant angioedema with swelling of the face, mucous membranes, and airway is present.image • Prednisone: 1 to 2 mg/kg/day for 1 week with rapid taper only if refractory to other measures or if angioedema is present with swelling of lips and face. 4. Follow-up visit if not improved within 48 hours. Chronic urticaria persisting longer than 6 weeks needs evaluation for infection or systemic causes or referral for further evaluation. An emergency epinephrine kit (EpiPen Jr, 0.15 mg; or adult, 0.3 mg) should be prescribed for children after the first episode or with recurrent episodes of life-threatening urticaria or angioedema. Complications Angioedema or anaphylaxis occurs by the same mechanism as urticaria.image • Anaphylactic symptoms require emergency intervention. • Serum sickness begins with hives, but has other systemic symptoms (e.g., fever, arthralgias, malaise, lymphadenopathy, or proteinuria). • If urticaria is from a drug reaction, rechallenge with the drug is more likely to cause anaphylaxis. Patient and Family Education The following are needed: • Explanation of causes (often unknown), course, and treatment. The entire episode usually resolves in 24 to 48 hours, rarely extending beyond 3 to 4 weeks. Further evaluation is needed only if urticaria lasts longer than 8 weeks. • Papular urticaria hypersensitivity often declines within 6 to 12 months. • Physical urticarias last 2 to 4 years in most cases, but occasionally persist into adulthood. • Occasionally macular blue-brown lesions are found on resolution of urticaria. • Avoid allergen if known; wear a medical alert bracelet in case severe reaction occurs. Refer for hyposensitization if life-threatening symptoms occur.image • Carry an epinephrine kit if indicated.

management of drug eruption

Management Decisions about whether a drug is to be implicated depend on the patient's previous history of taking the drug, the experience of the general population with the drug, the morphology and timing of the rash, and other possible explanations for the rash (e.g., viral illness). The following steps are taken: 1. Discontinue the suspected drug. 2. Label the patient's medical record with the potential allergen. 3. Prescribe antihistamines if itching is present; recommend a lubricant and antipruritics as adjuncts. 4. Systemic steroids are not usually indicated in a morbilliform drug eruption (Newell and Horii, 2010). If severe reaction, give prednisone 1 to 2 mg/kg/day for 5 to 7 days. 5. Schedule follow-up visit as determined by severity of reaction and other illness. Refer to allergist for skin testing to confirm allergy if there are limited or no alternative medications, for desensitization, to clarify drug allergy, for severe parental anxiety, or if symptoms are severe and life threatening. Complications Body heat and water loss can occur if the rash is severe. Progression of the rash if medicine is continued can lead to toxic epidermal necrolysis (TEN) or SJS (see Erythema Multiforme, Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis section) or allergic interstitial nephritis. Patient and Family Education • The rash can last 7 to 14 days with itching, and it may worsen before getting better. • There is potential risk from further exposure to that drug or related ones; alternative therapies should be explained. • Identification and communication of the child's allergy are imperative. If the child has a life-threatening allergy, wearing a medical alert bracelet or necklace is essential.

Management for impetigo

Management Management involves the following: • Topical antibiotics may be used if the impetigo is superficial, nonbullous, or localized to a limited area. Topical treatment alone provides clinical improvement but may prolong the carrier state (Weston and Morelli, 2013). In localized regions, topical antibiotics (such as, bacitracin, polymyxin B, and neomycin) may be used, but, given the increasing resistance to traditional topical antibiotics, mupirocin and retapamulin are considered better choices for topical treatment Oral antibiotics are recommended for multiple lesions or nonbullous impetigo with infection in multiple family members, child care groups, or athletes. Treat for S. aureus and S. pyogenes because coexistence is common (Cohen, 2013). • Cephalexin: 40 mg/kg/day for 7 to 10 days • Amoxicillin/clavulanate: 50 to 90 mg/kg/day for 7 to 10 days • Dicloxacillin: 15 to 50 mg/kg/day for 7 to 10 days • Cloxacillin: 50 to 100 mg/kg/day for 7 to 10 days • Clindamycin: 10 to 25 mg/kg/day for 7 to 10 days • For widespread infection with constitutional symptoms and deeper skin involvement, use an oral antibiotic active against beta-lactamase-producing strains of S. aureus, such as amoxicillin/clavulanate, dicloxacillin, cloxacillin, or cephalexin. • If an infant has bullous impetigo, use parenteral beta-lactamase-resistant antistaphylococcal penicillin, such as methicillin, oxacillin, or nafcillin. • If there is no response in 7 days, swab beneath the crust, and do Gram stain, culture, and sensitivities. Community-acquired MRSA should be considered. This organism is more susceptible to clindamycin and trimethoprim-sulfamethoxazole (TMP-SMX) (see Chapter 24 for treatment of MRSA). • Educate regarding cleanliness, hand washing, and spread of disease. • Exclude from day care or school until treated for 24 hours. • Schedule a follow-up appointment in 48 to 72 hours if not improved.

management tinea pedis

Management Management is the same as for tinea corporis. Antifungal medication should be applied 1 cm beyond the borders of the rash twice daily until 7 days after clearing. Usual treatment is 3 to 6 weeks. In rare cases, griseofulvin may be required, and treatment for 6 to 8 weeks is usually recommended. Additionally: • Advise patient to keep feet dry, use absorbent antifungal powder or sprays, wear cotton socks, avoid scratching, and wear shoes that allow the feet to breathe or go barefoot when home. Thoroughly dry feet and between toes after using a commercial showering facility. • Rinse feet with plain water or water and vinegar; dry carefully, especially between the toes. Moisturize and protect feet to prevent splitting and cracking. • Aluminum chloride (Drysol, CertainDri, Xerac AC, or Arrid Extra Dry antiperspirant sprays) may be used for hyperhidrosis. • Acute vesicular lesions can be treated with wet compresses two to four times daily for 10 to 15 minutes in addition to application of topical antifungals. 1 • Moccasin-type tinea pedis may need the addition of a keratolytic agent (lactic acid or urea) with the application of antifungals. • Tennis shoes may be washed in the machine with soap and bleach. • Physical education or sports may be continued. • Follow up in 2 to 3 weeks or sooner if lesions are not responding.

management of candidiasis

Management The following steps are taken (Table 37-4): • Thrush: Oral nystatin suspension four times a day, or gentian violet 1% to 2% aqueous solution applied twice a day until 1 to 2 days after white adherent patches are gone. If breastfeeding, the mother should put the solution on her nipples to eliminate reinfection. A second course is sometimes needed to clear the infection. • If resistant to treatment, oral fluconazole 6 mg/kg the first day in a single dose; then 3 mg/kg/dose daily for 14 days (Taketomo et al, 2011). • Thrush (in older children), cheilitis and angular cheilitis: Clotrimazole troche 10 mg dissolved slowly five times a day for 14 days (Taketomo et al, 2011). • Skin infection: Topical antifungals (such as, nystatin, miconazole, clotrimazole, ketoconazole, ciclopirox, or econazole) applied to skin at every diaper change until the rash is gone plus an additional 1 to 2 days (Weston and Morelli, 2013). Avoid antifungal/corticosteroid combination medications. • If inflammation is severe, 1% hydrocortisone can be applied simultaneously to the diaper area for 1 or 2 days (Bolognia et al, 2014). Topical mupirocin applied four or five times a day may be effective (Cohen, 2013). • Keep area dry and cool. Minimize skin irritation: • Frequent diaper changes. • Leave diaper area open to air as much as possible. • Blow-dry with warm air (low setting) for 3 to 5 minutes at diaper change (especially helpful in intertriginous areas in infants and obese children). • Avoid rubber pants. • Use mild soap and water; rinse well; avoid diaper wipes. • Avoid powders and other medications not prescribed, such as baby powder. • Discontinue oral antibiotics and steroids when possible. • Discard or sterilize pacifiers. • Educate about avoiding underlying predisposing factors (e.g., lip licking). • Add topical or oral antibiotic if secondary infection is suspected. • Nail involvement (chronic paronychia) can be treated with topical application of antifungal cream twice daily, but it will take several months for the nail plate to grow out normally; oral fluconazole may be needed for severe or resistant involvement.

management of pityriasis rosecea

Management The following steps are taken: • Application of calamine lotion (or other lotions containing menthol and/or camphor or pramoxine), tepid baths with Aveeno, antihistamines, and emollients as needed for itching. • Topical steroids do not change the lesions or hasten recovery. • Minimal sun exposure can help lesions resolve more quickly. Prevent sunburn. • Oral erythromycin 250 mg four times a day for 2 weeks may hasten the resolution of the eruption (Weston and Morelli, 2013). Patient and Family Education Pityriasis rosea is a benign, self-limited, and noncontagious disease that has three cycles (emerging, persisting, and fading) with spontaneous resolution in 6 to 12 weeks. Transient pigmentary changes can occur, especially in African Americans. Recurrence is common.

Management of acne

Management The goals of acne management are to (1) reduce the excess production of sebum, (2) counteract the abnormal desquamation of epithelial cells, (3) decrease the proliferation of P. acnes, and (4) prevent or decrease scarring. Choice of treatment depends on the extent, severity, and duration of disease; type of lesions; and psychological effects the adolescent is experiencing (Table 37-7 and Box 37-7). • Education is the first priority. The adolescent must have realistic expectations and understand the pathophysiology and the process of treatment, including the fact that the acne often worsens before improving. Reading materials about acne and its treatment provide support for self-management efforts. • Wash face twice a day with a mild soap, such as Dove, Neutrogena, or Aveeno Cleansing Bar. Avoid scrubbing, rubbing, picking, and squeezing. Medication should be applied lightly. • Use of a comedone extractor can cause scarring and should be discouraged. Hot soaks applied to pustules may help their resolution. • All products used on the face should be labeled as noncomedogenic. • Identify and discontinue use of aggravating substances, such as oil-based cosmetics, pomades, hair spray, mousse, and face creams. • Identify possible aggravating factors, such as stress; hot, humid weather; and jobs involving frying oil or grease. • Reassure that no scientific evidence indicates that any particular foods adversely affect acne; however, a well-balanced diet is important to maintaining healthy skin. • Discuss psychosocial concerns and provide support. • Remind the adolescent that results take months and that adherence to treatment is essential to improvement. • Sun exposure helps clear acne for some adolescents but may worsen it for others. Sunscreen use is recommended, and caution about sun exposure should be given if a medication that increases photosensitivity is being used. • Medications used in treatment of acne vary by action, route of administration, and strength. They include topical and systemic preparations; keratolytic or comedolytic agents; those with antibacterial or antibiotic effects; hormonal agents; and preparations that have a combination of actions. • Topical keratolytic or comedolytic agents, used to minimize follicular obstruction and break up microcomedones, are the first line of acne treatment. They may be dispensed in a combination form with a topical antibacterial agent. Many strengths and forms are available, the strongest being the gels, if tolerated; creams are the least drying. A general rule is to start low (in strength) and slowly (in frequency) and advance as tolerated or needed. A useful technique to decrease the incidence of irritation is to start therapy only for 3 nights a week and slowly increase to a nightly application over a few weeks. A minimum of 4 to 6 weeks of treatment is required before improvement is seen. There are three topical retinoids (tretinoin, adapalene, and tazarotene) and two agents that possess both antibacterial and keratolytic properties (benzoyl peroxide and azelaic acid). Each works by a different mechanism. They can be used together and interchangeably. Dryness, erythema, irritation, and scaling can occur with these products, and the strength and frequency of use must be adjusted for this. • Tretinoin is a keratolytic that causes sun sensitivity. A pea-sized application should be made 20 minutes after washing the face. Initially it is used every other night, advancing to every night. Sensitivity to tretinoin is worst in the first 2 weeks of use and decreases thereafter. • Adapalene seems to cause less irritation and less photosensitivity, and it has better efficacy. • Tazarotene is a keratolytic to be used once daily. • Azelaic acid is antibacterial and keratolytic. It is useful in individuals with sensitive or dark skin and is also effective in treating acne rosacea. • Benzoyl peroxide, the most frequently used topical preparation for acne, is used once or twice a day, depending on the severity of acne and dryness of skin. It is a powerful antimicrobial with comedolytic and anti-inflammatory effects. Use in combination with topical antibiotics causes less antibiotic resistance. • Topical antibiotics are used to control the inflammatory process, usually most helpful in moderate inflammatory acne. They are used to maintain control after treatment with oral antibiotics, and are applied to the entire skin surface, not just to problem areas. They should not be applied within 30 minutes of shaving. Erythromycin can have up to a 51% resistance rate (Paller and Mancini, 2011). • Topical clindamycin, erythromycin, or sulfacetamide is used once or twice a day, either alone or in combination with other topical medications. • Topical erythromycin with benzoyl peroxide and clindamycin with benzoyl peroxide are combination products that are more effective than either drug alone and have less resistance from P. acnes. This combination is especially effective in mild to moderate inflammatory acne or as an adjunct to oral therapy (Paller and Mancini, 2011). • Oral antibiotics are used in addition to topical agents to decrease the concentration of P. acnes and to decrease the degree of inflammation if there is no response to topical agents. Systemic antibiotics should be used for the shortest time possible, rarely longer than 6 months, and often require 3 to 4 weeks to see improvement. Once improvement is noted, the dose should be tapered to a daily dose, and then discontinued. • Tetracycline should be taken with 8 ounces of water 1 hour before or 2 hours after eating. Tetracycline should not be used by pregnant or breastfeeding females or in children younger than 9 years old. Photosensitivity reactions can occur. The usual dose is 250 to 500 mg twice daily. • Erythromycin can be taken with food, but gastrointestinal upset is common, and vulvovaginal candidiasis can be problematic. The usual dose is 250 to 500 mg twice daily. • Minocycline can be taken with food, although dairy products decrease absorption. Side effects include blue-black discoloration in scars, photosensitivity, and hypersensitivity reactions. The usual dose is 50 to 100 mg twice daily. • Doxycycline can be taken with food (dairy products decrease absorption), but has the highest rate of photosensitivity reactions. The usual dose is 50 to 100 mg twice daily. • Oral retinoids are used for severe, recalcitrant nodulocystic acne. Isotretinoin is contraindicated in pregnancy (pregnancy Category X drug known for its teratogenic effect) and requires evaluation by a dermatologist before use. Its association with depression and suicide is controversial. The usual course is 20 weeks; there are many side effects, and CBC, liver function tests (LFTs), human chorionic gonadotropin (hCG), and urinalysis for pregnancy must be monitored every month while the patient is taking the medication. The iPledge program creates a registry for all patients being treated with isotretinoin. The FDA requires health care providers, female patients, and pharmacists to access the iPledge website monthly after office visits and before filling their prescription for documentation regarding pregnancy, blood donation, and contraceptive counseling. • Hormonal and other therapies: Hormonal therapies can be used in females to oppose effects of androgen on sebaceous glands, such as antiandrogens (e.g., spironolactone, flutamide) and androgen receptor blockers; oral contraceptive pills (OCPs) provide estrogen and a progestin, and some are FDA approved to treat acne vulgaris. Intralesional steroid therapy for large cysts or nodules is sometimes used; resurfacing lasers and dermabrasion are used for acne scarring. • Noncomedogenic moisturizers can be used for dryness, which is common with treatment. Noncomedogenic makeup is also available and helpful in treating these patients.

management of seborrheic dermatitis

Management Three categories of agents may be helpful in the treatment of seborrheic dermatitis in both infants and adolescents. These include antifungal agents, anti-inflammatory agents, and keratolytic agents (Goldenberg, 2013): • Antifungal: Azoles, selenium sulfide • Anti-inflammatory: Topical steroids, topical calcineurin inhibitors 1021 • Keratolytic (remove excess scale): Topical salicylic acid, urea Seborrhea in infants may be self-limited, typically resolving spontaneously in the first year of life (Cohen, 2013). There are no FDA-approved medical treatments for seborrheic dermatitis in children younger than 2 years old (Schmidt, 2011). • Mineral oil may be applied to the scalp for 5 to 10 minutes before shampooing with a mild shampoo. Scales can be removed with a soft brush or toothbrush (Weston and Morelli, 2013). For thicker scales, the scalp may be soaked in warmed mineral oil overnight then washed with a mild shampoo (Schmidt, 2011). • Treatment for adolescents with seborrheic dermatitis includes (Schmidt, 2011): • Facial dermatitis • Daily ketoconazole 2% topical preparations (cream, shampoo, gel, or foam) • Intermittent use of low-potency topical corticosteroids (0.05% desonide cream or lotion) • Calcineurin inhibitors are good for face and ears • Scalp dermatitis • Medicated shampoos (tar, salicylic acid, ketoconazole, or selenium sulfide) two or three times a week (one to four times per month for African Americans) alternated with prescription-strength shampoos (ketoconazole 2.5%, selenium sulfide 2.5%) (Schmidt, 2011). Shampoo should be left on the scalp for 5 to 10 minutes before scrubbing crusts and then rinsing. • Topical corticosteroids added weekly for recalcitrant dermatitis (leave-in foams or solutions work best) • Body and skinfold seborrheic dermatitis: The same regimens mentioned previously can be used on the body. Educate parents about the etiology, control measures, and the need to continue treatment for a few days after resolution, and arrange for follow-up in 1 to 2 weeks. Complications Secondary infection with bacteria or Candida can occur. Severe, generalized seborrhea is commonly found in persons infected with HIV.

management of tinea corporis

Management • For superficial or localized tinea corporis, topical antifungals (see Table 37-4) (such as miconazole or clotri-mazole) are generally effective. Antifungal and steroid combinations should be avoided. Apply cream to the lesion, including a zone of normal skin, twice a day until clinical resolution, which can take 1 to 4 weeks. Prescription antifungals (e.g., econazole, ciclopirox) penetrate the skin more effectively but are more expensive. • Tinea faciei (face), extensive infection, immunosuppression, coexisting tinea infections on scalp or nails, or infection that is unresponsive to topical treatment may require systemic treatment. Griseofulvin (see Table 37-4) is the systemic drug of choice for children older than 2 years old. Treatment typically lasts for 2 to 4 weeks, and the medications should be taken with fatty foods for better absorption. Because of the risk of hepatotoxicity, nephrotoxicity, and neutropenia, patients requiring extended therapy should have a CBC and liver and renal function 8 weeks after initiating therapy and every 8 weeks until treatment is stopped. Tinea corporis gladiatorum may require systemic therapy, because it is endemic among wrestling team members. • Identify and treat contacts. • Educate about communicability of lesions and length of treatment. • Exclude from day care or school until 24 hours after treatment has begun. • Follow up in 2 weeks or sooner if lesions are not responding. If unresponsive, diagnosis is incorrect or resistance is possible. Culture to confirm diagnosis and change class of antifungal used.

Management of scabies

Management involves the following: 1. Pharmacologic treatment begins with applying a thin layer of scabicide to the entire body, excluding the eyes. Areas of special importance are under the fingernails, the scalp, behind the ears, all folds and creases, and the feet and hands. In general, the scabicide should be reapplied in 7 days on all symptomatic patients. 2. Permethrin 5% cream remains the drug of choice for the treatment of scabies. Despite frequent use over the past two decades, there is no clear evidence of resistance to permethrin 5% cream for the treatment of classic scabies (Gunning et al, 2012). It is indicated for use in children as young as 2 months old (Cohen, 2013). Parents and patients should be educated on proper application of a thin layer of cream to the entire body from the neck down, and rinsing after 8 to 14 hours. Application may be repeated in 1 week (Gunning et al, 2012). Unlike adults and older children, infants generally present with lesions on the face, neck, scalp, and hands and feet; be sure to include these areas on application, avoiding the areas around the eyes and mouth (Bethel, 2014). The treatment of crusted or Norwegian scabies has proven to be more difficult due to common misdiagnosis. Ivermectin 200 mcg/kg is recommended orally on days 1, 2, 8, 9, and 15 of treatment, in conjunction with full body application of permethrin cream 5% for 7 days, then twice weekly until resolved (Gunning et al, 2012). Due to a lack of safety data, ivermectin is not recommended for children younger than 5 years old, or less than 15 kg (Cohen, 2013). Antihistamines (hydroxyzine or diphenhydramine) or topical 1% hydrocortisone can be helpful for itching, which can last for several weeks after successful treatment. 3. Simultaneous treatment of family members, friends, and school and day care contacts, even if asymptomatic, is essential. 4. At time of treatment, linens and any clothing worn during the past 48 hours should be washed with hot water, put into a hot dryer for 20 minutes, or dry-cleaned. The house should be vacuumed. 5. Store nonwashable items in sealed plastic bags for a minimum of 1 week. Resistance to medication is not common and continued infestation is usually due to treatment failure rather than resistance. Reasons for treatment failure include an incorrect diagnosis, not applying medication to the whole body, or not treating all members of the household. The child may develop postscabetic eczema that can be misdiagnosed as treatment failure. Evaluate and treat with topical corticosteroids. Complications A secondary bacterial infection is possible and should be treated. Postscabetic syndrome is common, with visible lesions and pruritus persisting for days to weeks following treatment; nodular lesions can persist for weeks to months. Norwegian scabies is a nonpruritic, crusted, scaling infestation with thousands to millions of mites occurring in immunosuppressed or institutionalized patients. Patient and Family Education Educate the family about the course of disease. Rash and itching persist for up to 3 weeks following treatment. Avoid overbathing and further irritation of the skin. The child should not be infectious 24 hours after treatment and may return to school or day care.

candidiasis

Moist, bright-red diaper rash with sharp borders, satellite lesions; may have associated white spots in mouth, mucous membranes, or corner of mouth

diagnositic for cellulitis

Most cellulitis cases are treated empirically. CBC and blood culture are done if the child is febrile, appears ill or toxic, or is younger than 1 year old. Leukocytosis is common. Positive blood cultures are low, ranging from 1% to 18% of cases. Perform Gram stain and culture of the erythematous area if unusual organisms are suspected, pus is present (which is more typical of MRSA), or the child looks toxic. An aspirate at the point of maximum inflammation is more likely to yield a causative organism than one taken from the leading edge, although the bacterial counts tend to be low with either method. Gram stains and cultures lead to identification of the causative organism in less than 25% of cases (Gunderson, 2011).

necrotizing faciatis

NF is a rare infection in children and has two subtypes Type I is generally a polymicrobial infection that usually affects children who have an underlying disease. Type II, commonly referred to as flesh-eating strep, is an acute, rapidly progressing necrotic invasion of GABHS through the skin and subcutaneous tissue to the 995fascial compartments. It is more common in otherwise healthy children or children with varicella. NF is more common in boys younger than 5 years old and children with diabetes, skin injury, surgery, immunodeficiency, IV drug use, malnutrition, and obesity. NF begins as cellulitis (usually on the leg or abdomen in infants) with severe pain, edema, fever, and bullae on an erythematous surface. It quickly progresses to ulcer, eschar, and gangrene within 2 days. Prompt treatment (hospitalization, surgical debridement, and fluid management), prolonged antibiotic treatment (penicillin), and intravenous immunoglobulin (IVIG) may be lifesaving, because the overall mortality rate is high

Patient education for impetigo

Patient and Family Education • Thorough cleansing of any breaks in the skin helps prevent impetigo. • Postinflammatory pigment changes can last weeks to months. • The patient should not return to school or day care until 24 hours of antibiotic treatment is completed.

Pediculosis (lice)

Pediculosis (lice infestation) can affect the scalp (most common), body (uncommon), or pubic area (considered a sexually transmitted disease). Infestation is defined by some as the presence of either nits (eggs) or lice and by others as presence of lice alone. Lice infestation is caused by three subspecies, Pediculus humanus capitis and corporis (head and body) or by Phthirus pubis (pubic). The adult female louse, which survives by sucking human blood, deposits 6 to 10 eggs per day on a gluelike substance about 4 mm from the scalp on the hair shaft in a waterproof shell. Nits incubate for about 1 week, hatch and grow into adult lice over another 1 to 2 weeks, then begin laying eggs. Head lice live approximately 30 days on a host and lay up to 100 nits. Transmission is by direct or indirect contact, often by sharing hairbrushes, caps, clothing, or linen or through close living quarters, or sexual activity (pubic lice). Pediculosis capitis is common in children. Head lice are not considered a health hazard, because they do not spread disease. All socioeconomic groups are affected, but lice are most common in school-age Caucasian females, with the peak season occurring from August to November. Lice are uncommon in African American children (Guenther, 2014). Pediculosis corporis is uncommon in childhood. The louse is rarely seen on the body; rather it attaches to clothing and intermittently pierces the skin. It is the only louse that can carry human disease (e.g., epidemic typhus and trench fever). Pubic lice may involve the scalp, eyebrows, or eyelashes but primarily are found in the pubic area. Clothing and bed linens are a source of residence. If pediculosis pubis is found in a child, sexual abuse must be considered.image

physical examination for cellulitis

Physical Examination • Erythematous, indurated, tender, swollen, warm areas of skin with poorly demarcated borders • Blue to purple tinge to the cellulitis is often associated with H. influenzae (Daum, 2011) • Regional lymphadenopathy • Well-demarcated perianal erythema up to 2 cm around the anus; the erythema may extend to the vulva and vagina • Erysipelas—a superficial variant of cellulitis—presents with rapidly advancing lesions that are tender, bright red, have sharp margins and an "orange peel" look and feel

tinea corporis (ringworm)

Pruritic, slightly erythematous circular lesion with a slightly raised border and central clearing; well demarcated

psoriasis

Psoriasis, a chronic papulosquamous skin disorder with spontaneous remissions and exacerbations, is characterized by thick silvery scales, varied distribution patterns, and an isomorphic (Koebner phenomenon) response (Fig. 37-29). Types of psoriasis include guttate psoriasis (following a streptococcal infection), psoriasis vulgaris, napkin psoriasis (occurring in the diaper area), inverse psoriasis (limited to areas that are normally spared), localized pustular psoriasis, generalized pustular or psoriatic erythroderma, and psoriatic arthritis.

pyrethrin

Pyrethrin, a natural extract from the chrysanthemum plant, is effective as a pediculicide but not as an ovicide. A 10-minute shampoo is applied to dry hair, with a repeat application in 7 to 10 days. Pyrethrin is contraindicated in children with allergy to ragweed. Because pyrethrin does not kill both lice and eggs, treatment failures are more common than with permethrin.

tinea cruris (jock itch)

Raised-border, scaly lesion on upper thighs and groin; penis and scrotum spared; symmetric

Drug eruption

Reaction to medication, especially penicillin, cephalexin, erythromycin, sulfa drugs, NSAIDs, barbiturates, isoniazid, carbamazepine, phenytoin Symmetric, macular, erythematous to papular, confluent morbilliform rash; intense itching; patches of normal skin throughout; begins on trunk, extends distally, including palms and soles; face with confluent erythema Stop drug and label as allergen to the child; give antihistamine, antipruritic, prednisone if severe; lubricate skin; rash can last 7 to 14 days; use medical alert bracelet (&, 052016, p. 1021)

Seborrhic dermatitis

Seborrhea is a chronic inflammatory dermatitis commonly called cradle cap in infants or dandruff in adolescents. The condition is thought to be related to overproduction of sebum because it commonly occurs in areas with large numbers of sebaceous glands. It may be an overgrowth of Malassezia ovalis (formerly P. ovale), a saprophytic yeast, which is universally present on the human body. Seborrhea occurs most often in early infancy and adolescence, is associated with blepharitis, and is more common in spring and summer.

Toxic shock syndrome

TSS is an acute febrile illness with rapid onset that causes significant fever, vomiting and diarrhea, engorged mucous membranes, hypotension, a diffuse macular or sunburn-like rash, conjunctival injection, and multiple organ system involvement. S. aureus or S. pyogenes (group A streptococci) are the causative agents associated with TSS, and incubation can be as little as 14 hours. Both organisms can be associated with invasive infection (e.g., pneumonia, osteomyelitis, bacteremia, or endocarditis) or focal tissue invasion that is rapidly progressive (Rodriguez-Nunez et al, 2011). Initially recognized in menstruating adolescents, TSS is also found in males and younger children. S. aureus is usually the causative agent in menstruating females. Nasal packing, surgical procedures, and postpartum condition are some factors linked to nonmenstrual TSS. Treatment is intensive, requires hospitalization, and consists of fluid management, antibiotics, and other supportive measures. Staphylococcal TSS has a mortality rate of 3%, whereas streptococcal TSS has a mortality rate of 30% to 60% (Berk and Bayliss, 2010). It is a reportable disease in most

management of folliculitis/furuncle

The following steps are taken: • Warm compresses after washing with soap and water several times a day • Topical keratolytics, such as benzoyl peroxide 5% to 10% twice a day for 5 days, especially if chronic or recurrent • Topical antibiotic, such as erythromycin or clindamycin, in cream, gel, solution, or ointment twice a day for 10 to 14 days for superficial folliculitis • Antistaphylococcal beta-lactamase-resistant antibiotics, such as dicloxacillin 15 to 50 mg/kg/day divided four times a day for 7 to 10 days, or cephalexin 40 to 50 mg/kg/day divided three times a day for 7 to 10 days in severe or widespread cases • Review of good personal hygiene habits; avoid shaving until resolved • Follow-up treatment in 1 week for folliculitis, in 1 day for furuncle or abscess, which may need incision and drainage • Identify and eliminate predisposing factors • If recurrent, look for nasal or skin carrier state Complications Deep abscess formation or carbuncles can occur. Sycosis barbae occurs on the chin, upper lip, and jaw, especially in adolescent African American males. Patient and Family Education Good personal hygiene and an antibacterial soap minimize spread to other household members. Hot-tub folliculitis resolves in 5 to 14 days but can recur up to 3 months after exposure.

Morbiliform/exanthematous rash

The morbilliform, or exanthematous, rash is the most common allergic skin reaction to a drug (Fig. 37-25). The rash may be an immunologic or nonimmunologic reaction to the drug. The most common drugs causing reactions are nonsteroidal anti-inflammatory drugs (NSAIDs), penicillins, cephalosporins, and sulfonamide antibiotics (including TMP-SMX combinations), anticonvulsants, and oral fluconazole or ketoconazole antifungal drugs (Weston and Morelli, 2013). The risk of this type of eruption is increased if the child also has a viral infection (e.g., the rash that appears after giving penicillin to a child with Epstein-Barr virus). Exanthematous rashes typically have their onset within 1 to 2 weeks of starting a new medication and can occur after the medication has been stopped. If there is a rechallenge of that medication, the reaction can occur within a few days (Paller and Mancini, 2011). Repeated exposure can progress to anaphylaxis.

tinea corporis

Tinea corporis, commonly called ringworm, is a superficial fungal skin infection found on the non-hairy skin of the body. It is also identified by the part of the body affected (e.g., tinea manuum [hand], tinea barbae [beard], tinea faciei [face]) (Figs. 37-11 and 37-12). Tinea corporis is most commonly caused by the dermatophytes Microsporum canis, Trichophyton, Microsporum, and Epidermophyton species (Bolognia et al, 2014; Cohen, 2013). Transmission comes as the stratum corneum is invaded following direct contact with infected humans, animals, or fomites. The exact mechanism is unknown but is probably due to a toxin causing an inflammatory response. Infection is common in children. Contact sports (especially wrestling), hot and humid climates, crowded living conditions, and immunosuppression 1000increase the risk of tinea corporis. Autoinoculation accounts for spreading lesions

tinea cruris

Tinea cruris, commonly called jock itch, is a superficial fungal skin infection found on the groin, upper thighs, and intertriginous folds. Caused by the dermatophyte Epidermophyton floccosum, Trichophyton rubrum, or Trichophyton mentagrophytes, tinea cruris rarely occurs before adolescence and is more common in males, obese individuals, or those with hyperhidrosis or experiencing chafing from tight clothes or moisture. It is extremely common. Clinical Findings History • Hot, humid weather, tight clothing, vigorous physical activity and chafing, or contact sport, such as wrestling • Often associated with tinea pedis Physical Examination • Erythematous to slightly brown, sharply marginated plaques with a raised border of scaling, pustules or vesicles; central clearing may be present • Usually bilateral and symmetric, but not always • Occurs on inner thighs and inguinal creases; penis, scrotum, and labia majora generally spared • Occasionally occurs in perianal region or on the buttocks and/or abdomen Diagnostic Studies If treatment failure or questionable diagnosis occurs: • KOH-treated scraping reveals hyphae and spores • Fungal culture Differential Diagnosis Psoriasis, candidiasis, contact dermatitis, seborrhea, intertrigo, and erythrasma are in the differential diagnosis. Management Management is the same as for tinea corporis. Duration of topical treatment is usually 4 to 6 weeks. Antifungal and steroid combinations are to be avoided. Do not use steroids because of risk of atrophy and striae. Advise the patient to wear cotton underwear and loose clothing and to use absorbent antifungal powder. If tinea pedis is suspected, advise the patient to put socks on before underwear to prevent the spread of the infection. Maintain good hygiene following a wrestling event (e.g., bathing as soon as possible, sole use of towel; dry thoroughly).

Tinea pedis

Tinea pedis is a superficial fungal skin infection found on the feet, commonly called athlete's foot. There are three clinical forms: (1) vesicles and erosions on the instep of one or both feet; (2) an occasional fissure between the toes with surrounding scale and erythema; and (3) rare diffuse scaling on the weight-bearing surface of the foot with exaggerated scaling in creases (moccasin foot) often extending to lateral foot margins. Caused by the dermatophytes T. rubrum or T. mentagrophytes, tinea pedis is uncommon in preadolescent children and is more common in males. It is acquired through direct contact with contaminated surfaces (e.g., warm moist environment of showers and locker room floors) and often occurs with tinea cruris (see Fig. 37-11). Clinical Findings History • Sweaty feet • Use of nylon socks or nonbreathable shoes • Exposure in family or at school • Itching, intense burning, stinging, foul odor • Microtrauma to feet—cracks, abrasions, nicks, cuts • Contact with damp areas (e.g., swimming pools, locker room, showers) Physical Examination • Red, scaly, cracked rash on soles or interdigital spaces and instep, especially between the third, fourth, and fifth toes • Infection initially presents as white peeling lesions becoming erythematous, vesicular, macerated, fissured, and scaly • Dorsum of foot remains clear • Chronic infection manifested by a moccasin pattern with diffuse scaling (plantar hyperkeratosis) and mild erythema Diagnostic Studies Laboratory studies are the same as those for tinea corporis. Differential Diagnosis Contact dermatitis, atopic dermatitis, dyshidrotic eczema, psoriasis, pitted keratolysis, and juvenile plantar dermatosis (red, dry fissures of weight-bearing surface) are in the differential diagnosis.

tinea versicolor

Tinea versicolor is a superficial fungal infection, also called pityriasis versicolor, that tends to be persistent and occurs predominantly on the trunk. The lesions do not tan in the summer and become relatively darker in winter months This infection is caused by a yeastlike organism, Malassezia furfur (referred to as Pityrosporum orbiculare and Pityrosporum ovale) and occurs more commonly in adolescents than in younger children, in chronically ill and immunocompromised children, and in warmer seasons and humid climates. Breastfeeding infants can acquire the organism from their mother and exhibit facial lesions. Clinical Findings History The infection is associated with warm, humid weather. Occasional mild itching may occur. Physical Examination Multiple, annular, scaling, discrete macules or patches, ranging from hypopigmented in dark-skinned individuals to hyperpigmented (salmon-colored to brown) in light-skinned individuals, are seen on the neck, shoulders, upper back and arms, chest midline, and face (especially in children). They tend to have a guttate or raindrop pattern. Diagnostic Studies KOH scrapings, though not necessary, reveal short curved hyphae and circular spores ("spaghetti and meatballs"). Scrapings fluoresce yellow-orange under Wood's lamp if not cleansed recently. Differential Diagnosis Pityriasis alba, pityriasis rosea, vitiligo, postinflammatory hypopigmentation or hyperpigmentation, seborrhea, and secondary syphilis are included in the differential diagnosis. Management The following steps are taken (Bolognia et al, 2014): • Selenium sulfide 2.5% lotion or 1% shampoo (over the counter) applied in a thin layer several hand-widths beyond lesions for 30 minutes twice a week for 2 to 4 weeks followed by monthly applications for 3 months to help prevent recurrences. Older adolescents can use ketoconazole 2% shampoo as directed earlier or for smaller areas of infection, topical imidazoles (e.g., clotrimazole, miconazole, ciclopirox, or terbinafine solution) or topical azoles (e.g., ketoconazole or oxiconazole) applied twice daily for 2 to 4 weeks. • Resistant or severe cases in older adolescents sometimes require oral antifungal treatment with fluconazole 200 to 400 mg by mouth once weekly for two to three doses. Follow up in 1 month. Patient and Family Education • Sun exposure makes lesions appear hypopigmented as the surrounding skin tans. • Repigmentation takes several months. • If the patient is taking oral antifungal medication, encourage exercise to induce sweating, because this may enhance concentration of medication in the skin. • Skin irritation occurs with overnight application. • Absence of flaking when skin is scraped is a sign of effective treatment.

treatment for wart

Treatment Options for Warts • Keratolytics eliminate the wart by causing an inflammatory response and topical peeling. They are often available over the counter, cause little pain, and are low in cost and risk, but they are slow to work. • Salicylic acid paints with a concentration of greater than 20% are applied with a toothpick once or twice a day for 4 to 6 weeks. On thick skin, a combination of 16.7% salicylic acid and 16.7% collodion is more effective. This method is useful for common or periungual warts, but it is not effective with warts larger than 5 mm in diameter. • Salicylic acid plasters with 40% concentration are cut to size and taped in place for 3 to 5 days. After the plaster is taken off, the area should be soaked for 45 minutes and the dead epidermis removed. A new plaster is then applied. Treatment can last 3 to 6 weeks. This method is useful for plantar warts. • Retinoic acid gel 0.025% to 0.05% applied once or twice daily brings resolution in 4 to 6 weeks. This method is useful for flat warts, but it does not work for common, plantar, or periungual warts. • Occlusion with duct tape: Place on for 12 hours a day for 6 days in a row, followed by soaking and scraping of epidermis; is easy, painless, and inexpensive. • Destructive agents eliminate the wart by causing necrosis and blister formation. Most techniques are painful and require patient cooperation. • Cryotherapy: Liquid nitrogen is applied for 2 to 10 seconds until an area 1 to 3 mm beyond the wart turns white or patient complains of pain; goal is to induce blister formation above the dermal-epidermal junction. Take care not to freeze the wart too vigorously. Caution should be used when freezing warts over joints and the lateral aspects of digits. This method is uncomfortable and often not tolerated by children. Retreatment is often necessary. Cantharidin 0.7% is applied directly to the wart with a toothpick and covered with tape for 24 hours. This is a potent blistering agent that creates a blister in 2 to 3 days that is sloughed after 7 to 14 days. This method is useful for periungual and some plantar warts. Do not use on other body surfaces. • Podophyllum 25% solution in compound benzoin tincture is applied to the wart with a toothpick; it should be washed off in 4 hours; may be repeated in 1 week. Podofilox, available over the counter for home use, is applied twice a day for 3 days. After a 4-day rest period, the 3-day cycle may be repeated as necessary. This technique is useful for common or genital warts. • Surgical excision of warts can lead to scarring that can be more painful than the wart itself, but can be highly effective for large individual warts. Surgery by snipping with scissors, not scalpel, is useful for filiform warts. • Laser treatments are often as effective as cryosurgery, but can be painful and require several treatments for complete resolution. • Immunotherapy modalities stimulate an immune response to HPV. These newer treatment modalities do not have controlled studies evaluating their effectiveness. • Oral cimetidine, a histamine 2-receptor-blocking agent, may improve immunity to HPV. It is used in conjunction with other modalities at a dose of 20 to 30 mg/kg divided twice a day for 3 to 4 months. • Imiquimod cream creates cell-mediated immunity in surrounding areas and is often effective as a home treatment. It is applied daily for 1 to 2 months. • Contact sensitization and interferon injection are methods used by dermatologists, usually in adult patients. HPV, Human papillomavirus.

urticaria and angioedema

Urticaria and angioedema are hypersensitivity reactions (usually a type I reaction—immunoglobulin E [IgE] mediated) commonly called hives (Fig. 37-26). Urticaria involves the superficial dermis; in contrast, angioedema involves the deeper dermis and subcutaneous tissue.

urticaria and angioedema causative factors

Urticaria and angioedema are the result of a complex interplay of immunologically mediated antigen-antibody responses to the release of histamine from mast cells and other vasoactive mediators, such as leukotrienes and prostaglandins. Vasodilation and increased vascular permeability cause erythema and the characteristic wheal of urticaria. Onset is usually rapid, and resolution occurs within a few days of onset. Possible causative factors include the following: • Reactions to foods (e.g., nuts, eggs, shellfish, strawberries, tomatoes), stings (e.g., bees, wasps, scorpions, spiders, jellyfish), bites (e.g., mosquitoes, fleas, mites), parasites (scabies), or pollen • Reaction to skin contact with antigens, such as chemicals, latex, fish, or caterpillars • Response to bacterial, viral, or fungal infections, especially streptococcal or sinus infection, mononucleosis, hepatitis, adenoviruses, and enteroviruses • Cholinergic response to physical stimuli (e.g., heat or cold, sun or water [aquagenic urticaria], tight clothing, vibrations) or stress • Reaction to drugs (about 10% of urticaria, usually acute in nature; salicylates and penicillins are the two most common) (Paller and Mancini, 2011) • Genetic origin • Concurrent with inflammatory systemic diseases (e.g., collagen-vascular or inflammatory bowel disease) • Immunologic (rare) • Idiopathic or unknown Portals of entry for the causative agent include infection (most common), ingestion, injection, or inhalation. Urticaria and angioedema are more common in children than adults, and about 50% of patients with urticaria also have angioedema. Children who get both angioedema and urticaria tend to have more severe reactions. Urticaria occurs sometime in the lives of about 15% of the population. Transient or acute urticaria lasts less than 6 weeks; chronic, recurrent, or persistent urticaria lasts more than 6 weeks. Angioedema is an extension of the reaction into the subcutaneous tissue with indistinct borders, and tends to involve the face (especially the eyes), hands, and feet (Weston and Morelli, 2013). It is gradual in onset and often involves reactions to medication. Hereditary angioedema is a rare autosomal dominant disorder that results from either a deficiency or dysfunction of the first component of complement (C-esterase inhibitor). It is life threatening and usually manifests before 10 years old, typically with exacerbations in adolescence, often following trauma (e.g., dental work, surgery, or accident). It is manifested by repeated episodes of swelling of the extremities, face, and throat, accompanied by abdominal pain that becomes progressively more severe (Paller and Manicini, 2011). Severe airway edema, if untreated, is often the cause of death.

tinea pedis (athlete's foot)

Vesicles and erosions on instep; fissure between toes with scaling and erythema; diffuse scaling on weight-bearing surfaces with exaggerated scaling in creases; pruritus

warts

Warts are common childhood skin tumors characterized by a proliferation of the epidermis and mucosa infected by the human papillomavirus (HPV). There are over 100 HPV types, and each one produces characteristic lesions in specific locations (e.g., verruca vulgaris, verruca plana, verruca plantaris, and condyloma acuminatum). Trauma promotes inoculation of the HPV (Koebner phenomenon); as a result, most warts are on the hands, fingers, elbows, and plantar surfaces of the feet. The transmission of warts from person to person depends on viral and host factors, such as quantity of virus, location of warts, preexisting skin injury, and cell-mediated immunity. Transmission is from fomites or skin-to-skin contact, and autoinoculation is frequent. Incubation is from 1 to 6 months, possibly years. Although a large percentage of all warts resolve spontaneously within 3 to 5 years, there is a high recurrence rate. Cutaneous warts are rarely a serious health concern but present cosmetic problems for children and their families Clinical Findings History The history can include exposure to someone with warts. Though most common on the extremities, warts can occur anywhere on the body, including the face, scalp, and genitalia. Physical Examination • Common warts (verruca vulgaris) are usually elevated flesh-colored single papules with scaly, irregular surfaces and occasionally black pinpoints, which are thrombosed blood vessels. They are usually asymptomatic and multiple and are found anywhere on the body, although most commonly on the hands, nails, and feet. They may be dome-shaped, filiform, or exophytic Filiform warts project from the skin on a narrow stalk and are usually seen on the face, lips, nose, eyelids, or neck. Periungual warts are common, occurring around the cuticles of the fingers or toes. Plantar warts (verrucae plantaris or mosaic) are commonly found on weight-bearing surfaces of the feet. They grow inward and disrupt skin markings. • Flat warts (verruca plana or juvenile warts) are seen commonly on the face, neck, and extremities. They are small, slightly elevated papules and number from few to several hundred. • Condylomata acuminata on genital mucosa and adjacent skin are multiple, confluent warts with irregular surfaces, light color, and cauliflower-like appearance There is no single effective treatment for warts; watchful waiting is an option. The recurrence rate is high; they typically do not resolve with just a single treatment. No treatment is necessary if the warts are asymptomatic. The decision to treat should be based on location, number and size of lesions, discomfort, and whether they are cosmetically objectionable. Treatment should not be harmful, and scarring should be avoided. Genital warts found in young children or in adolescents who are not sexually active should create suspicion of sexual abuse. Specific treatment options are outlined in. Follow up in 2 to 3 weeks to evaluate response.

topical glucocorticoids

used to reduce inflammation, decrease itching, and promote vasoconstriction without causing the widespread systemic effects of oral steroids topical steroids-brand names have more consistent base/potency ointments-more potent than creams creams-more potent than lotions foams effect in hairy areas

Spinosad

was approved in 2011 for infestations in patients 4 years old and older. It is applied to dry hair and left on 10 minutes before rinsing.

WET dressings (oozing, crusting, itching)

wet dressing decrease itching and remove crust dressing is changed every 6 hours for 24 to 72 hours

HSV-2

• Grouped vesicopustules and ulceration with edema • Primary lesions on vaginal mucosa, labia, or perineum in females and on the penile shaft or perineum in males; females may have cervical involvement; oral lesions are possible • Recurrent lesions on labia, vulva, clitoris, or cervix in females and on the prepuce, glans, or sulcus in males; generally less severe cutaneous lesions • Regional lymphadenopathy

Side effects of steroids

atrophy, striae, increased fragility of skin, hypopigmentation, secondary infection, acneiform eruption, foliculitis, milaria

first line treatment for mild acne

benzoil peroxide and retinoic acid

impetigo

contagious Presentation: honey-colored crust on the lesions and bullous bacteria: group A streptococcus Nonbullous impetigo-70% bacteria: Staph aureus risk factors: trauma, bites, abrasions, varicella, atopic dermatitis History • Pruritus, spread of the lesion to surrounding skin, and earlier skin disruption at the site • Weakness, fever, and diarrhea may accompany bullous impetigo Physical Examination The following can be found: • Nonbullous, classic, or common impetigo—begins as 1- to 2-mm erythematous papules or pustules that progress to vesicles or bullae, which rupture, leaving moist, honey-colored, crusty lesions on mildly erythematous, eroded skin; less than 2 cm in size; little pain but rapid spread • Bullous impetigo—large, flaccid, thin-wall, superficial, annular, or oval pustular blisters or bullae that rupture, leaving thin varnish-like coating or scale 993 • Lesions are most common on face, hands, neck, extremities, or perineum; satellite lesions may be found near the primary site, although they can be anywhere on the body • Regional lymphadenopathy Diagnostic Studies Gram stain and culture are ordered if identification of the organism is needed in recalcitrant or severe cases.

occlusive dressing

decrease water evaporation from the skin and enhance hydration and absorption of topical medications. plastic wrap+cream stays for at least 8 hours

sweat glands

eccrine glands-entire body ceruminous glands-external ear canal; secrete waxy substance cerumen apocrine glands-axillary, genitals, periumbilicasl areas

oral retinoid

effective with nodulistic acne isotretinoin contraindicated with pregnant lady

skin layers

epidermis-outer layer keratinization-most epidermal cells are keratinocytes-every 28 days stratum corneum-outer horny layer melanin-protects dna damage dermis-thicker layer/middle layer/regulate heat loss subcutaneous tissue-thermoregulation

low potency steroids should be use in

face, buttocks, groin and axillae

sunscreen/sunblock

fragrance free spf 30 recommended act by absorbing uv light

most commonly used antihistamines

hydroxyzine, cetirizine, fexofenadine, and diphenhydramine

Staphylococcal scalded skin syndrome

is a blistering disease that results from circulating epidermolytic toxin-producing S. aureus SSSS is most common in neonates (Ritter disease), infants, and children younger than 5 years old. It manifests abruptly with fever, malaise, and tender erythroderma, especially in the neck folds and axillae, rapidly becoming crusty around the eyes, nose, and mouth. Nikolsky sign (peeling of skin with a light rub to reveal a moist red surface) is a key finding. Treatment may include hospitalization and parenteral antibiotics, especially for young children (Berk and Bayliss, 2010). Antibiotics of choice are intravenous (IV) or oral dicloxacillin, a penicillinase-resistant penicillin, first- or second-generation cephalosporins, or clindamycin. Quicker healing without scarring results if steroids are avoided, there is minimal handling of the skin, and ointments and topical mupirocin are used at the infection site (Berk and Bayliss, 2010; Patel and Patel, 2010). Severe cases may need treatment similar to extensive burn care.

Cellulitis

is a localized bacterial infection often involving the dermis and subcutaneous layers of the skin. It is commonly seen following a disruption of the skin surface from an insect or animal bite, trauma, or a penetrating wound. Cellulitis is more common in children with diabetes and immunosuppression

Intralesional steroid injections

may be used by a dermatologist to control localized eczema, lichen planus, or psoriasis.

tinea versicolor

patches on the skin ultiple scaly, discrete oval macules on neck, shoulders, upper back, and chest; hypopigmented to hyperpigmented areas; fail to tan in summer tx:selenium shampoo

cutaneous reactions

pigment lability-post inflammatory;diaper rash, seborrhea, tinia, pityriasis alba follicular response-atopic dermatitis, rosea, syphilis or tinea versicolor mesenchymal response-causes scars and keloids ex ear pircing, burns and surgical procedures

Antimicrobial, tar, keratolytic, and detergent shampoos

re used on the hair and scalp when needed for infection, psoriasis, dandruff, dermatitis,

Permethrin 1% cream

the treatment of choice for head lice because of its safety (can be used in children older than 1 month old), efficacy, and 10-day residual. Hair should be shampooed and towel dried (damp), permethrin applied, left on for 10 minutes, and then rinsed. Hair should not be rewashed for at least 24 to 48 hours. Apply again in 7 to 10 days

oral prednisone

used in acute conditions