Paediatric Skin

SKIN

1. Develop an understanding of why rashes occur.

2. Differentiate between a blanching and non blanching rash and understand the underlying aetiology.

3. Awareness of Clinical Red flags and when to refer for immediate treatment.

4. Identify the most common causes of rashes in children

LOs : 4

Rash is due to inflammation or discolouration of the skin, which changes the skin’s normal appearance, colour and texture

Aetiology: allergies, infections, irritants, autoimmune conditions

Clinical presentation: itching, swelling, lumps, spots, or blisters

Dry scaly patches/lesions

What is a rash?

A rash that disappears or fades when you press on it, generally less serious

Cause: inflammation or vasodilatation of the blood vessels in the skin, usually due to viral infection, allergy, heat rash, and urticaria

Blanching rash definition and why it happens, what are the common causes

a rash that does not fade, or change in its colour when pressed

Why: erythrocyte extravasation ; blood that has leaked underneath the skin, it does not fade as not confined to blood vessels

common causes: meningococcal septicaemia, vasculitis, thrombocytopenia, trauma

LIKELY A RED FLAG ? Medical emergency

Non-Blanching rash definition and why it happens, what are the common causes

Non-blanching rash presence,

press the side of a glass firmly against a rash so you can see if it fades under pressure. If it doesn’t fade this will be classed as a non blanching rash

What is a glass test for?

1. Is this a non-blanching rash, do they appear systemically unwell

2. Any signs of anaphylaxis, ABCDE assessment

3. Abnormal physical obvs: NEWS OR POPS ( under 16s score)

4. Associated symptoms of fever, neck stiffness, photophobia, N&V

5. involvement of the mucus membranes, conjunctiva, oral cavity- think SJS (Stevens-Johnson Syndrome / Sepsis

6. Extreme pain - possible causes, shingles is particularly painful, as a clinical marker

7. is the skin peeling blistering? SSS ( children)

8. Has the patient recently been commenced on any new medication ( possible ADR or allergic reaction)

9. Has the child been fully immunised ( e.g., the current meningitis vaccine is only children born after 2015, new schedules may be updates with more ages to be included)

What are the RED flags to rule out for skin rash? 9

1. Onset and duration: does the rash come and go

2. has the rash changed in appearance, is it spreading elsewhere

3. Where did it first appear

4. associated symptoms: recent illness, fever, pain, itch, oozing, bleeding and blistering

5. Exposures:, travel, medications, pets, bites or stings, recent sports ( golf) , new products/ lotions or potions, contact with others and outdoor exposures

Based on physical observation of the child, i.e. are they appearing full of energy, no systemic symptoms, have they recently been unwell: possibly a post-viral rash that appears after the child has fully recovered and rash appars post-immune response ( not a red flag), if they are still in diapers, more indication to check the less exposed areas, as rash could be hidden

Clinical assessment questions to assess the complication: 5

Notifiable disease report to UK Health Security Agency (UKHSA)

Highly contagious for those who haven’t been immunised

Symptoms include:

1. Coughin and sneezing

2. runny nose

3. fever

4. Red/sore eyes

5. Spots ( Koplik ) in mouth

6. Blanching rash which starts on the face and behind the ears

Measles: what does it look like, and clinical presentations: 6 points

1. Self-limiting illness normally improving after 1 week

2. Important to reduce cross-infection to others by self-isolating for 4 days after rash develops

3. Self-Care advice: constant hydration, eye warm water bathing, managing pyrexia

4. Advise patients of RED flags to observe for such as confusion, lethargy and signs of dehydration

5. High risk patients include, under 5s, pregnancy, immune suppresed

What is the treament of measles?

Highly contagious airborne virus, caused by the varicella zoster virus, commonly in younger children

can be difficult to diagnose initially, especially if the child is presenting with mild cold symptoms and only a few spots

Symptoms:

1. Extremely itchy rash

2. Fever

3. Abdominal pain

4. Swollen glands

5. Headache

Chicken pox: what does it look like, and clinical presentations: 5 points

1. Aciclovir (POM) is only indicated for the seriously il patients, not usually indicated in normal presentation of unincomplicated chicken pox of healthy person

2. Manage symptoms: OTC, paracetamol, chlorphenamine, soothing creams; that prevent itching, scarring and 2ndary infection, Poxclin ( a relatively new foam formulation), and calamine and (aq) cream, in order to prevent itching as it’s vital to protect against scarring and 2ndary infection

3. Ibuprofen in contraindicated as it affects the immune response, and masks 2ndary infection, actual reason is still thereotical

4. Incubation period is 14-21 days, (long) before clinical symptoms appear

What is the treatment plan for chicken pox treatment? 4

A common, benign, viral skin infection. causing small, firm, dome shaped pink or skin-colored bumps, usually with a central, shiny dimple. It’s contagious, via skin-to-skin contact or shared items, commonly in children, who are between 1-10 and is self-resolving, however can last from anywhere from, days to months and years

Molloscum contagiosum: what does it look like and how is it clinically presented?

1. caused by Staph, A infection

2. Pustules & honey coloured crusty erosions

3. If left untreated, 2ndary infection, will occur and skin lesions will spread to other parts of the body

4. Strict infection prevention is required to prevent spread of infection to others

5. Topical treatment is 1st line

Impetigo: what does it look like, and clinical presentations: 5 points

If there’s less than 3 lesions/clusters and its not localised non bullous lesions

• hydrogen peroxide 1% for 5 days

• Fusidic acid 2% cream for 5 days

If there’s more than 4 lesions/clusters (widespread non-bullous lesions), give flucloxacillin for 5 days

What is the the treatment pathway for impetigo in pharmacy 1st?

1. characterised as raised, itchy welts, on skins, with varying sizes

2. Triggers can be anything from allergies, emotions, illness, environmental, viral illness

3. Duration short or long depending on trigger

4. Caution: obsserve for signs of allergy, ABCDE assesssment

5. Though often only itchy, may also be burning or stinging sensation

Urticaria ( Hives): clinical presentation

Triggers and duration (5)

Acute Urticaria o

• Non-sedating anti-histamine (Cetirizine, Loratadine, Fexofenadine) until GP review.

• Topical Anti-pruritic treatment- Calamine in aqueous cream or topical menthol 1% in aqueous cream)

• Sedating anti-histamine- Chlorphenamine-nighttime itch

• Prickly heat

• Non-sedating anti-histamine (Cetirizine, Loratadine, Fexofenadine)

• • Topical Anti-pruritic treatment- Calamine in aqueous cream or topical menthol 1% in aqueous cream)

• Hydrocortisone cream- depending on age (OTC)

• General advice- apply a cool damp towel for up to 20 minutes

What is the community pharmacy treatement/advice for acite urticaria ( hives or prickly heat)

Hair follicles that become trapped with sweat and lead to inflammation, i.e. could be observed in men’s beard, when shaving using blunt/unhygienic razors

• usually, Hot tub, slip & slide, especially if not showering right after event, can lead to build-up of bacteria

• 

Aetiology and clinical representation of Hot Tub follicuulitis

1. Prevention (removing used swimwear, shower immediately after using, wash swimwear after use, regular cleaning, and maintenance of the hot tub.)

2. Topical antiseptics (to prevent infection) such as Dermol or Chlorhexidine

3. Mid topical steroids (to help reduce inflammation and itch)- Hydrocortisone OTC

4. Antibiotics

Treatment for Hot Tub Folliculitis: 4

1. Fluid-filled blisters on torso, between fingers, hands, and feet -viral, self-limiting

2. the actual virus stays in the childs’ faeces till 8 weeks, thus when changing nappies at home or nursery, important to let whoever changes their nappy to be aware, and caution with those pregnant

3. 

Hand, Foot and Mouth disease: Slapped Cheek syndrome, clinical presentation

1. Viral- Antibiotics unsuitable (unless secondary infection

2. Paracetamol/Ibuprofen to ease symptoms

3. Mouthwash (Chlorhexidine Digluconate, Hydrogen Peroxide 1.5%)

4. Ulcer treatment- e.g Anbesol/Bonjela oSore throat spray- (Benydamine 0.15% spray)

5. General advice- keep hydrated, soft foods, avoid spicy/salty foods.

1. Slapped cheek syndrome

2. Viral- Antibiotics unsuitable (unless secondary infection)

3. Paracetamol/Ibuprofen to ease symptoms

4. Rest and fluids to prevent dehydration

Community Pharmacy treatment for HFM disease: ( very similar to measles) 5

Scarlett Fever Rash : very similar to other rashes, i.e measles, urticaria, how the actual rash presents clinically is somewhat different; strawberry tongue, fever and sandpaper fee

Clincal presentation of this rash

Clinical Pathway Pharmacy first for Sore Throat

• important to differentiate between Scarlet Fever and Acute Bacterial Sore throat.

• Scarlet fever- sand paper rash on torso, strawberry tongue, fever, sore throat.

• Acute Bacterial sore throat- Pus/inflamed tonsils, sudden onset, no cough, fever.

Trearment:

Scarlet Fever:

• Antibiotic – Phenoxymethylpenicillin first line (or Clarithromycin if pen v allergic) for 10 days

• (Consider Pill school counselling for patients- Tablets better adherence as medicine very bitter.

• Acute Sore throat- Treatment, Antibiotic – Phenoxymethylpenicillin first line (or Clarithromycin if pen v allergic) for 5 days (Pharmacy First)

How to differentiate Scarlet fever from other ailments and treatment pathway

1. Meningitis:non blanching  purpuric type rash,  bruising beneath the skin.    Likely due to  meningitis- importance here is to identify that the rash is non blanching and  where to safely sign post to- likely AED for immediate assessment and  treatment

   •Differentials- HSP/ ITP/ Kawasaki syndrome. 

   

2. SSS: scalded skin syndrome, caused by Staph A. bacteria.  Superficial blistering and  peeling of the skin resembles  scald injury but no history of burns.

   •Child is normally pyrexic with general lethargy. 

   •Painful blistering rash appears 24-48 after initial symptoms start.  

   

   3.•HSP- Henoch- Schoenlein Purpura- non blanching rash normally forms in lower limbs and  lower part of torso.   

   •Auto immune condition- multiple triggers-form of vasculitis.  Affects the blood vessels,  causing them to rupture beneath the skin.

   Child will experience abdo pain and  general myalgia ( joint pain

   

What are the 3 red flag rashes, and their clinical presentations

UKHSA ( UK Health Security Agency)

1. Condition to be aware of in Community Practice

2. Scarlet Fever- Routine notice ( within 3 days)

3. Chickenpox- Routine notice

4. Measles- Urgent notice ( 24 hours )

5. Meningitis- Urgent notice

What are the notifiable diseases 5 and what organisational body is that?