1

Skin problems Dermatitis Bacterial Viral Fungal Infestations Age specific Burns

General principles Pages 753-763

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Learning Objectives Identify Signs /Symptoms/Treatment for:

Contact Dermatitis Atopic dermatitis Impetigo Cellulitis Herpes Simplex Varicella Zoster Tinea capitis Ringworm Scabies Head lice Acne Steven-Johnson Syndrome Pediatric burns

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Contact dermatitis Localized irritation caused by

direct, external contact with a foreign substance

2 types Irritant Allergic

Hockenberry p777

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Contact dermatitis Causes

Plants Nickel/other metals Topical

medications Rubber Cosmetics Fabrics Detergents Solvents Fragrances Sun On & on

5

Contact dermatitis Symptoms

Pruritis Redness/inflammation Skin tenderness Local swelling Local warmth to exposed area Rash/lesion

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Contact dermatitis Treatment

Wash affected area-lots of water Soap may irritate the skin even more, don’t use it

Avoid scratching Keep fingernails trimmed Medications

Topical Corticosteroids Lotions

Oral Antihistamines Steroids

Skin patch testing Make sure to avoid that thing that gave you the contact dermatitis in the first place

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Contact Dermatitis Prevention

Avoid offending agent Protective clothing Sunscreen

Expectations Usually resolves in 2-3 weeks

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Atopic dermatitis (eczema)

Affects 3-5% of children before the age of 5

Genetic component- 70% have 1st degree relative with some form of AD

50-80% will develop allergic rhinitis or asthma

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Atopic dermatitis Symptoms

Dry, scaly, pruritic lesions Weeping, oozing, crusting

lesions Often erythematous Chronic relapse/remission

pattern Tend to be more susceptible

to viral skin infectionshttp://www.riskindoc.com/dermatitis_eczema.html

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Atopic dermatitis Symptoms

Typically seen on the face, inside the elbows, and behind the knees

Appearance of rash will depend on the amount of scratching

Worse in fall/winter Secondary infection

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Atopic dermatitis Treatment Topical medications Systemic medications Other topicals Other treatments

Sometimes use phototherapy (about 12 y/o and older)

Avoid triggers Tepid water for bathing

Increase humidity in winter months

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Impetigo Common, contagious,

superficial, bacterial infection

Group A β- hemolytic streptococcus Brown crusty blisters

Staphylococcus aureus Clear then cloudy blisters

Hockenberry p767http://www.cgh.com.sg/caring/issue82/Pg_6_7_8.asp

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Impetigo Preschoolers/ school

age Those In Close

Physical Contact Day care

Warm, Moist Climate Poor Hygiene

https://mayoclinic.com/health/medical/IM00401

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Impetigo Spread by direct

contact Can be itchy Can occur on any

part of the body Usually hands,

forearms, nose, & mouth

Copyright Mosby 2002

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Impetigo Treatment

Antibiotics Topical, sometimes use systemic if it’s a huge area that is

affected Gentle cleansing of crusted areas

With warm soapy water, but don’t want to break the blisters. It doesn’t speed up healing and opens up the way for infection

Cover infected areas Don’t rupture the blisters

Prevention Good hygiene

Regular hand washing Separate towels/linens Keep fingernails cut short

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Cellulitis Inflammation of the skin

and subcutaneous tissues Associated with pain,

swelling, intense redness Opportunistic

Any area of broken skin Immunocompromised/

diabetics NOT contagious

page 767

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Cellulitis Bacterial infection

Staph Strep Pasteurella multocida

Animal bites Pseudomonas

Puncture of foot through sneakers

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Cellulitis Symptoms

Inflammation with redness Pain Swelling Warm to touch Lymphangitis- streaking Fever, malaise Swollen regional lymph nodes

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Cellulitis Treatment (mild/treated at home)

Antibiotics Oral

Elevation, immobilization Warm, moist compresses Pain relievers Close monitoring

Hospitalization, if necessary

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Herpes Simplex Type I

Usual exposure- preschool years Typically found above the waist, but can be anywhere

Type II Sexually transmitted Typically found below the waist, but can be anywhere

Once exposed always present Outbreaks Very contagious Spread by direct contact No cure

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Herpes Simplex Triggers

Stress Increased exposure to

sun Viral infections Food high in arginine

http://www.minarsdermatology.com/medical/coldsores.asp

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Herpes Simplex Symptoms

Tingling, numbness, burning, itching Small erythematous, tender area

clusters of blisters Blisters begin to dry yellow crusting Possible regional lymphadenopathy Usual coarse 7-10 days

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Herpes Simplex Complications

Possible scarring Blindness (ocular)

If it gets into the eye Depression (type 2 HSV)

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Herpes SimplexTreatment Goal - control outbreaks Medication

Pain relievers Compresses Other Antivirals need to be given in

the first 24 hours after the first lesion

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Varicella zoster

Shingles Same virus that causes

chicken pox Anyone who has had

chicken pox or the vaccine can have varicella zoster

Chickenpox may follow exposure to shingle

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Varicella zoster Causes

Stress Fatigue Weak immune

system Cancer Radiation

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Varicella zoster Symptoms

Pre-eruption Intense, localized pain along a

dermatome Fever/malaise

Lesions occur 1-7 days Progress thru rupture, crusting, and

healing over 2-3 weeks

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Varicella zoster Is unilateral Follows dermatomes

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Varicella zoster Complications

Scarring Secondary infection Hearing\vision loss (facial) Postherpetic neuralgia (PHN)

Pain persists after the rash has completely healed, can last a long time (months or years). Rare in children, but it can happen

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Varicella zoster Treatment

Avoid scratching Keep fingernails trimmed Medication

Antivirals In first 24 hours! Can slow down the shingles or

prevent them from popping up in the first place Pain

Cool compresses/ baths Good hygiene

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Dermatophytoses- Tinea(aka.- Ringworm)

Fungal Infection That Lives On, Not In, The Skin, Or Nails

Spread by: Direct contact Indirect contact Contact with soil

rare

www.emedicinehealth.com/slideshow_ringworm_pictures/article_em.htm

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Tinea capitis (head) Symptoms

Begins as small lesion Enlarges, leaving scaly

patch Alopecia Worst case, develops

into kerion Like a boggy gross thing,

immune response to the ringworm

Hair usually grows back kerio

n

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Tinea capitis Treatment

Griseofulvin Topical antifungal Selenium sulfide shampoo Corticosteroids (kerion)

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Tinea corporis (body) Symptoms

Begins as small lesion

Enlarges, leaving scaly patch

Center usually clears leaving the “ring” appearance

Copyright Mosby 2004

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Tinea corporis (body) Treatment

Griseofulvin Topical antifungal

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Tinea cruris (‘jock itch’)

Symptoms Pruritic Medial proximal aspect of thigh/

crural fold (may involve scrotum in males)

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Tinea cruris Treatment

Topical antifungal Compresses/ sitz baths (comfort)

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Tinea pedis (athlete’s foot) Symptoms

Pruritis Lesions to plantar surface of foot,

between toes

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Tinea pedis Treatment

Griseofulvin Topical antifungal Severe cases- topical glucocortical

cream Eliminate causes

http://www.emedicinehealth.com/slideshow_ringworm_pictures/article_em.htm

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Sarcoptes scabei (Scabies)

Skin infestation with microscopic mite

Spread skin to skin Crowded conditions If you got one today it

would take a couple of months before you began to feel the effects

http://www.dermisil.com/products/what/scabies.asp

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Sarcoptes scabei (Scabies)

Female burrows under the skin

Lays 2-3 eggs/day Eggs hatch and in 10

days—adult mites!

http://www.dermnetnz.org/common/image.php?path=/arthropods/img/s/scabies3.jpg

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Sarcoptes scabei (Scabies)

Symptoms Severe pruritis Small, tiny lesions

develop into blisters Usually on hands or

feet

http://www.dermnetnz.org/common/image.php?path=/arthropods/img/s/scabies2.jpg

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Sarcoptes scabei (Scabies)

Treatment ?Whole family?

Yes!! Spread by close, prolonged contact. The mite takes about 45 mins to burrow under your skin

Scabicide - Permethrin (Elimite) Treat personal items

Clothes, bedding, towels, wash in hot water Lotions Topical steroid for itch Antibiotics- secondary infections

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Pediculosis capitus (head lice)

Very common, parasitic infestation

Typically affects ages 3-12

Very contagious, very annoying

http://www.haircareguide.com/lice.htm

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Pediculosis capitus Person to person

contact Object to person

contact Not carried by

animals

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Pediculosis capitus Adult Louse

Small, grayish-tan, wingless insect

Visible Can live up to 3 days away

from a human host Life span of female is 1 month

In this time can lay 100-200 eggs… eww

Use claws to hold to hair shafthttp://bioweb.uwlax.edu/bio203/s2008/koch%5Fsama/Nutrition.htm

http://www.msmosquito.com/headlice.html

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Pediculosis capitus Feed on small amounts of blood

from the scalp every 4-6 hours Eggs will hatch 1-2 weeks after

being laid

http://www.msmosquito.com/headlice.html

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Pediculosis capitus Symptoms

May note small, red lesions Persistent pruritis Nits on hair shafts Visible adult lice Regional

lymphadenopathy Secondary infection

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Pediculosis capitus Treatment

Medicated shampoos Mechanical removal of nits Wash all linens Vacuum/ dry clean non-

laundry items Repeat treatment in 7-10

days Treat secondary infection as

needed

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Acne vulgaris (acne)

Most common skin problem of adolescence

50% of adolescent population will experience acne

Not caused/worsened by foods

Has a hereditary factorHockenberry p 849-852

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Acne vulgaris (acne) Causes

Hormones Increased sebum (oil)

gland activity Comedone formation Overgrowth of

Propionibacterium acnes

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Acne vulgaris (acne) Treatment

Wash-don’t scrub Oil-free make-up Keep your hands off!! Lotions/creams Medications

Retinoids Topical Antibacterial Agent Systemic Antibiotics Oral Contraceptives

If using topicals, AVOID SUN, or AT LEAST USE SUN SCREEN

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Stevens-Johnson Syndrome (SJS)/Toxic Epidermal Necrosis (TEN)

Severe manifestation of erythema multiforme

Mortality can be as high as 25%-35% (TEN)

emedicine.medscape.com/article/756523-media

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Stevens-Johnson Syndrome (SJS)/Toxic Epidermal Necrosis (TEN) Causes

Infections 50% of patients report recent URI

Drug induced Sulfa, Penicillin, cocaine

Malignancy (adults) Idiopathic

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Stevens-Johnson Syndrome (SJS)/Toxic Epidermal Necrosis (TEN)

Signs/symptoms Cough Headache Malaise Arthralgia Mucocutaneous

lesions

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Stevens-Johnson Syndrome (SJS)/Toxic Epidermal Necrosis (TEN) Treatment

Support symptoms Many times we don’t know what’s caused it

Remove offending agent Treat lesions as burns

May get care from burn units in the hospital Cover denuded skin

Cover with gauze wet with solution Prevent secondary infection

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Pediatric Burns - Causes Extreme heat sources Cold Chemicals Electricity Radiation

Accidental – inadequate supervision, curiosity, inability to escape burning agent

Intentional (Child Abuse)

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Guides to Treatment Extent Depth Severity

Percentage of total body surface area (TBSA) burned

Location Child’s age General health

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Extent - Total Burn Surface Area (TBSA)

Rule of Nines

Lund Browder

Rule of Nines

http://emedicine.medscape.com/article/769193-print

http://www.medtrng.net/efmb/tasks/081-833-0070.htm

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Depth and Severity Depth

Superficial (1st degree ) Only epidermis, blisters, gone in days,

not scarring Partial thickness (2nd degree )

sensory is intact, moist skin, scarring is low, but takes longer to heal

Full thickness (3rd and 4th degree) Dermis, epidermis, and subq tissue, if you burn thru

this then it’s not painful because you’ve killed all the nerve cells. Don’t usually heal, may need skin grafts and what not

66

Second degree burn

http://emedicine.medscape.com/article/769193-media

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3rd degree burns

http://emedicine.medscape.com/article/769193-media

Burn Unit Referral Criteria1. Partial-thickness burns > 10% TBSA 2. Burns involving face, hands, feet, genitalia, perineum, or major

joints 3. 3rd degree burns4. Electrical burns, including lightning injury 5. Chemical burns 6. Inhalation injury 7. Preexisting medical disorders that could complicate

management, prolong recovery, or affect mortality 8. Concomitant trauma (such as fractures) in which the burn injury

poses the greatest risk of morbidity or mortality. 9. Burned children in hospitals without qualified personnel or

equipment for the care of children 10. Special social, emotional, or rehabilitative intervention

requirements

She won’t test us on this but it’s just good to know or whatever…

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Burn Care Superficial burns (sunburn)

Avoid sun, wear protective clothing, sunscreen Minor burns

Apply cold compress Analgesia Cleanse with soap /water – avoid friction Tetanus Antimicrobial ointment Loose clothing

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Care of Moderate and Severe Burns Maintain airway, Oxygen IV access/ fluids Observe closely for s/s shock Pain management Wound care Nutritional support Skin and musculoskeletal care Emotional/psychosocial support

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Parkland FormulaFluids for 24 hours = (4 х kg х % burn)

[2nd & 3rd degree burns added together]

1st 50% given over 8 hoursFollowed by 2nd 50% given over 16 hours

Example 4 X 20kg X 35% = 2800 Give 1400 in 8 hours = 175 ml/hr Remaining 1400 over next 16 hours at 88 ml/hr

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Systemic Responses/Complications

Cardiovascular system Burn shock

From loosing fluids Hemoconcentration/hyperviscosity Treatment - Fluid resuscitation

Watching urine output is key, you know they’re hydrated if their I&O is even

Commonly use Parkland formula Maintain urine output 1-2 ml/kg

Renal System Immature infant renal system Fluid loss reduces renal blood flow

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Metabolism Hypermetabolism

Pulmonary Injury 2ndary to smoke/carbon dioxide, heat Pulmonary edema

Wound Sepsis

GI System Stress ulcer

Responses/Complications

74

Burn Wound Management Excision/Debridement Topical antimicrobial agents Temporary skin substitute Synthetic Skin coverings Artificial skin Permanent skin coverings Cultured epithelium

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Complications Long term

Contracture deformities Body image

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Prevention/Parent Education

Never leave child alone Install smoke alarms – check monthly Lower hot water setting to <120 degrees Keep matches, gasoline, candles away

from children Use stove back burners and turn pot

handles

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Prevention/Education Keep hot foods/liquids away from

table edge Keep electrical cords out of reach Practice fire escape Teach - Stop, drop, and roll Place microwave at safe height

(higher than children’s faces but low enough to reach easily)