Sandra Leipheimer MSN, APRN, BC-PNP Heidelberg High School Copyright 2013 S Leipheimer 1

PEDIATRIC DERMATOLOGY

TOP TEN

Sandra Leipheimer MSN, APRN, BC-PNP

Heidelberg High School

Copyright 2013 S Leipheimer 1

COOL FACTS ABOUT SKIN Continually

renewed Stores fat and

water Provides protection Gets rid of waste Regulates

temperature Largest organ of

the bodyCopyright 2013 S Leipheimer 2

COOL FACTS ABOUT BUGS Bed Bugs:

Cimex lectularius

(Cimidieae) Harmful?

Do not transmit any infectious agents

Only stay on skin to feed on a few drops of blood

Treatment Aimed at itch- AH and

corticosteroids Treat secondary

infections from scratching


COOL FACTS ABOUT BUGS Lice

Pediculosis (place)

FactsNot “medically

necessary” to remove NITS

Most are non-viable (dead or hatched)

Personal decision by parent


LICE – HEAD OR BODY Lice feed on

human blood Not a sign of poor

hygeine Transmitted by

direct contact Do not spread

disease


FACTS What to put on school fact sheet?

Not a major health issueNuisance factorRX: Least intrusive to Most intrusive

treatment Mechanically remove lice (risk reduction) OTC treatment ( oovacidal) Rx Examine all family members for live (crawling)

lice If infested –treat If not – need not be treated

Myths and Treatment folklore

ARE THEY ACTUALLY INFESTED?Copyright 2013 S Leipheimer 6

COMMONLY MISDIAGNOSED – TREAT THEN RETURN TO SCHOOL


ASSESSMENT: LOOKING FOR?


ASSESSMENT: 1 + 1 + 1 = 3 History

When started?What else going on?Other S & S?Rx = better or worse?Exposure?

Associated Signs & Symptoms FeverURIPrevious illness or treatment

ExamSkin + other symptoms

9Copyright 2013 S Leipheimer

#10 INFECTIONS Superficial Infections

BacterialFungalViral Tattoos


IMPETIGO Caused by S. aureus a

normal skin colonizer in up to 50% of people

Yellow, oozing, crusty sore, often starts in nose Itch is common

Requires antibiotic Excluded for 24 hrs and

keep covered at school (contagious)

1-3 days incubation


Bullous Staph. aureus- fluid filled

blisters Non-Bullous

S. aureus & streptococcus – crusted

MRSA becoming more common


GROUP A STREPTOCOCCAL Skin lesions usually caused by different

strain than those causing “strep throat” Can cause glomerulonephritis if strain is

GrA B-hemolytic Blood or brown sugar (maple sugar; coke)

urine May culture lesions to be sure what is

infectious agent


FOLLICULITIS Caused by

inflammation to the hair follicles shaving/friction from

tight clothes; ingrown Typically infected

with S. aureus Avoid trigger Antibiotics if

infection suspected


FURUNCLES, CARBUNCLES AND ABCESSES

Usually caused by S. aureus Increased frequency

with MRSA and other antibiotic resistant organisms

Need oral antibiotics and often need drainage


MRSA Methicillin Resistant Staphylococcus

Areas


MRSA (COMMUNITY ACQUIRED) Exclusion Policy for Schools?


MRSA


MRSA


PROTECTING STUDENT ATHLETES Spread

Skin to Skin Touching contaminated objects (drainage)

Regular Cleaning and Disinfecting No evidence that spraying or fogging rooms or

surfaces with disinfectant works better than focusing on frequently touched surfaces

Wash hands: soap and water alcohol-based sanitizers

Take showers: immediately after exercise; don’t share items

Use barriers: cover cuts; towels on items Wash uniform: dry completely in dryer; wash after

each useCopyright 2013 S Leipheimer 20

RECOMMENDATIONS CDC & NATIONAL ATHLETIC TRAINERS’ ASSOCIATION

Culture suspicious lesions Not return to play until:

Appropriate antibiotic taken for at least 72 hours

Drainage from wound has stoppedNo new lesions in past 48 hours

CDC: do not exclude unless MD directed… Sport-specific guidance should be in place Excluded if wounds cannot be properly

covered“properly covered” = securely attached

bandage/dressing containing all drainage and remain intact during activity

No water; whirl pools; therapy pools


TATTOOS Nontuberculous mycobacteria (NTM)

“various types”M. chelonae exists in tap water

MRSA and “others”… Persistent inflammatory reaction Located within margins of recent

intradermal tattoo Cause- ? using tap water or distilled water

for ink Many believe distilled or reverse-osmosis

water is sterile Many other reasons… Cartilage piercings >> delay healing “Allergies” >>> contact dermatitis Copyright 2013 S Leipheimer 22

TATTOO What do you think??


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

Makeup NOV 00 JUN 08 FEB 10 AUG 12 FDA

Notices related to unregulated materials and health risks


http://www.fda.gov/

#9 TINEA “RINGWORM” Tinea – sounds like a bug, but really a

fungus (trichophyton, microsporum) Name of group of diseases caused by

fungus Named for location of infection Acquired by touching infected person,

damp surfaces, pets


TINEA CORPORIS Generally a circular

lesion (hence the name “ring worm”

Raised (can be blistery)

Itchy Red scaly ring with

central clearing Treat topically with

anti-fungal ointmentCopyright 2013 S Leipheimer 26

TINEA CAPITIS Tinea in the scalp Patchy areas of

hair loss or breakage and scale

Must be treated with oral medications

Can extend to a kerion (hypersensitivity reaction)


TRICHOTILLOMANIA Non scarring Noninflammatory

alopecia Twist or pull hair Deny behavior

Done in private 7 X > kids than

adults 2 X Girls > Boys Scalp most

common Eyelashes and

eyebrows

Psychosocial issues


TINEA PEDIS Moist area between toes Itchy, red, blisters, cracking, peeling Nails can also become infected= tinea

unguium


TINEA CRURIS Itching in groin, thigh folds, anus Red, raised, scaly patches that blister

and oozePatches have sharply-defined edgesRedder around outside with normal skin

tone in center Usually starts in creases of upper thigh

and does not involve scrotum/penis but may spread to anus causing itching and discomfort

Usually less severe than other tinea infections but lasts longer


#8 ATOPIC DERMATITIS Also known as eczema: “the itch that

rashes” Hypersensitivity reaction similar to

allergy Long-term swelling and redness

(inflammation of skin) May lack certain proteins in the skin

which leads to greater sensitivity Often accompanies asthma Eczema = compromised skin barrier @

critical point in development Strong link with food allergiesCopyright 2013 S Leipheimer 31

RISK Eczema + Food Allergies + Asthma

ANAPHYLAXIS


ATOPIC DERMATITIS Very, very itchy Red/salmon colored

patches Can look like pustules Likes the antecubetal

and popliteal fossa Actually allergy

mediated Treated with

emollients/steroids


ATOPY


KERATOSIS PILARIS


URTICARIA

Subgroup of disorders results from hypersensitivity to physical or mechanical factors

Cold urticaria Pressure -induced urticaria and

angioedema Aquagenic urticaria Solar urticaria Exercised- induced urticaria History and distribution Confirmed by challenge

Cold Challenge ( immediate … 4 hours later)


DERMOGRAPHISM Trauma –induced pressure urticaria Initial white line = reflexive vasoconstriction followed by pruritic, erythematous swelling Wheal or Flare Reaction Chronic ? CauseInterferes with skintesting = false +


#7 EYES Eye “rashes” or Conjunctivitis

Bacterial Viral Allergic Vernal Chemical Irritant Drugs


BACTERIAL CONJUNCTIVITIS Bacterial etiology Very contagious Red conjunctiva,

itchy not painful, purulent drainage

Should not be associated with fever

Treat with topicals


STI CONJUNCTIVITIS Chlamydia

Gonoccocal

Herpes


VIRAL CONJUNCTIVITIS Typically

associated with an upper respiratory infection

Watery, red, irritated

Doesn’t usually have any discharge

Refer anyone who wears contacts and has a red eye to a doctor


ALLERGIC CONJUNCTIVITIS Typically occurs in

someone with seasonal allergies (hay fever)

Itchy/bumpy/puffy and red

Improves with topical drops and oral anti- histamines


MEASLES Symptoms

URI & CoughRed, Watery EyesTired

Koplik’s spots (2-3 days after above) Blotchy Rash (3-5 days after symptoms)

Starts on face at hairlineSpreads downward to neck, trunk, arms,

legs, feetFever spike with rash (~ 104 F 40 C)



#6 WARTS Caused by infection of human papilloma

virus Common – fingers and toenails

Subungual (under) periungual ( around) nails

Plantar- soles of feet (painful) Genital – STI (condyloma) Flat – appear wear shaving ( most

common in children however) Trends:

Children- warts tend to go awayAdults- tend to stay


VERRUCA VULGARUS Viral etiology Difficult to treat Can occur

anywhere Most therapies

aimed at triggering the immune system

Treat with topical irritant/duct tape/cryo/laserCopyright 2013 S Leipheimer 46

WARTS + ECZEMA = NO TOPICALS


MOLLUSCUM CONTAGIOUSUM Also viral (poxvirus) Difficult to treat Contagious

Center has viral load Most advocate leaving

them alone, though can currette or treat with topical irritant

If many lesions- may be immune system concern


#5 REACTIONS Non-specific reactions

Irritants Infections Immune System DiseaseAllergiesCold & HeatChemicalsWindSun Evil Eye


URTICARIA (HIVES) Typically associated

with an allergic reaction

Can be seen as a response to viral infection, foods, medications or ?? = idiopathic

Refer if S&S of other system: cough/wheeze or swelling of lips/tongue; N & V Copyright 2013 S Leipheimer 50

CONTACT DERMATITIS


ERYTHEMA MULTIFORME (MINOR)

Acute hypersensitivity reaction

Can be seen in response to drugs, illness (viruses, bacteria) foods and immunizations

May look similar to hives, but typically not pruritic, look like targets, can be painful, and unlike hives, persist (are fixed)

No treatmentCopyright 2013 S Leipheimer 52

EM Drugs

Barbiturates PCNs Phenytoin Sulfonamides

EM Minor – better in 2-6 weeks; can recur Herpes simplex Mycoplasma

EM Major = SJS Reaction to medication

Infections; radiation Rx; UV light Epidermal necrolysis – morality risk high


STEVENS JOHNSON SYNDROME Drug reaction- Medical Emergency

Atypical antipsychoticsAntibiotics

Sulpha Penicillins

Other as listed Skin and mucous membranes reaction

Widespread painFacial swellingTongue swelling

Top layer of skin>> necrosis & sloughingBlistering & Erosion


PITYRIASIS ROSEA Starts with a

herald patch (~ 1-3 weeks)Confused as tinea

Fine scaling oval macules/papulesPinkish brown

Christmas tree pattern

Lasts 6-12 weeks, no treatment


PITYRIASIS ROSEA Very itchy in 50 % Can be concentrated in groin, forearms, shin Some report feeling mildly ill 1- 2 week before herald patch


#4 HERPES VIRUSES Herpes Simplex

Oral = “cold sores” Type 1Genital = Type 2 But can occur in either area and either type

Herpes Zoster


HERPES SIMPLEX Most infections

with Type I are asymptomatic

Most commonly presents as gingivostomatitisCharacterized by

fever, and painful vesicles on oral mucosa/gingiva


HERPETIC WHITLOW Digital Herpes

Painful Contagious Virus enters break in skin (torn cuticle) –

from own skin or others 60 % HSV-1 40 % HSV-2


VARICELLA/ZOSTER Chickenpox – many

are vaccinated Can be fatal for the

neonate Fever, painful or

puritic versicles, typically start on the trunk and spread

Shingles = Zoster Copyright 2013 S Leipheimer 60

DERMATOMES


ZOSTER Reactivation of

varicella Very painful Occurs in

dermatomal distribution

Can be treated if recognized early


RAMSAY HUNT SYNDROME Zoster infects nerve on

head Facial nerve near inner ear Painful rash on TM, canal,

earlobe, tongue, roof of mouth, on same side as weakness or face Eye closing; motor

movements -

Hearing loss on side Vertigo Urgent referral Prompt RX

Steroids Antivirals


#3 STREP Streptococcal infections (Group A strep

or strep pyogenes)


STREP THROAT Fever, sore throat,

malaise, stomach s/s

Contagious Treat with 10 days

of penicillin Can go back to

school after 24 hrs on antibiotics


SCARLET FEVER Strept Throat

with rash S/T; Fever; H/A Abd pain; N/V + lymph nodes Rash appears

1-2 days: red and sandpaper texture After 7-14 days skin rubs off / peels


SEQUELAE OF STREP Can also cause glomerulonephritis (coke colored urine),

rheumatic fever, impetigo Also associated with severe invasive infections –

pneumonia, arthritis, sepsis, toxic shock syndrome, etc Rheumatic Fever

Appears 2-4 or 1-5 weeks following Strep infection Inflammation is the cause of symptoms:

Inflammation of the heart - chest pain, fatigue, SOB Inflammation of the joints - arthritis symptoms Inflammation of the skin - skin rashes and nodules Inflammation of the CNS (central nervous system) -

chorea (jerking), personality changes Increased risk of fulminant bacteremia from strep pneumo

in kids with asplenia Vaccine in US


#2 Mumps and Measles

Must always keep in mind based upon local immunization policies

World travel – one small planet Immunization: concern with waning

immunity over timeWHO Travel Advice


MUMPS Viral infection that

causes systemic disease and swelling of the salivary glands

More severe disease the older you get

Not vaccinated against in some countries (Japan)Copyright 2013 S Leipheimer 69

MEASLES Characterized by

fever, cough, rash, conjunctivitis

Encephalitis with permanent brain damage 1:1000

Death 1-3:1000 Worse if young,

sick and/or malnourished


#1 Petechiae, Purpura and Vasculitis


PETECHIAE Red blood cells

outside the vessel walls – don’t blanch

Seen with low platelets

Can also been seen with trauma, cough, increased pressure (pertussis, asthma)Copyright 2013 S Leipheimer 72

PETECHIAE/BRUISING

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

Obligated to report !!!!!!!!!!!!!!!!!!!!!!!


PURPURA Large areas of

cutaneous hemorrhage

Refer to doctor Usually bad, may be

life threatening Meningococcemia,

something wrong with bone marrow

HSP(Henoch-Schönlein Purpura


HSP Usually Self-Limiting Usually children Small minority of cases

can cause severe kidney and bowel disease

Follows URI ~ 10 days following

Mean age 5.9 years Purpura is due to vasculitis

not low platelets (IgA in walls of blood vessels)

Steroids ease symptoms and may disrupt abnormal immune response

Tetrad:PurpuraArthritis & Arthralgia

Swelling around jointsKidney inflammationAbdominal pain


PROGRESSION


TERMINOLOGY Erythema Induration Temperature Lesion Papule Pustule Macule Vesicles Hyper / Hypo pigmentation Linear Oval Circular Target Concentric


ASSESSMENT & DESCRIPTION Size of each or all lesions Color Description of shape/distribution of

lesion(s) Location

What areas are spared? Trend or Changes over time

Mark areas Aggravating or Alleviating Factors Associated Signs or Symptoms


DISCUSSION 1 + 1 + 1 = 3 History 2 Associated S & S Exam Potential Assessment & Recommendations


DISCUSSION


REFERENCES https://identitfy.us.com SchoolNurse.com CD Head Louse

Infestations: Evidence-Based Strategies & Best Practices for Tackling Head Lic

NASN S.C.R.A.T.C.H. http://www.cdc.gov/mrsa/groups/ http://www2.aap.org/new/idphotos.htm MedlinePlus www.cdc.gov www.fda.gov


https://identitfy.us.com/

http://www.cdc.gov/mrsa/groups/

http://www2.aap.org/new/idphotos.htm

http://www.cdc.gov/

http://www.fda.gov/


Documents

Sandra Leipheimer MSN, APRN, BC-PNP Heidelberg High School Copyright 2013 S Leipheimer 1