Pedi Skin - Pedi Skin PDF

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EXAM II

SKIN DISORDERS PEDI Skin Disorders covered: • 1 - Infectious disorders — • 1A - Impetigo Contagiosa • 1B - Cellulitis • 1C - Pediculosis Capitis • 1D - Scabies • 2 - Inflammatory disorders — • 2A - Poison Ivy / Poison Oak • 2B - Acne Vulgaris • 2C - Contact Dermatitis • 2D - Atopic Dermatitis (Eczema) • 2E - Diaper Dermatitis • 3 - Insect/Animal Bites / Stings — • 3A - Basic insect bites • 3B - Bees, Wasps, Hornets, Yellow Jackets, Fire Ant Bites • 3C - Tick bites • 3D - Mammal Bites • 3E - Snake Bites • 4 - Burns ——————————————————————————————————————— Recall: What are the 5 functions of Skin? • Protection against infection and injury • Prevention of loss of inner body fluids • Regulation of body temperature • Principle Sensory Organ • Identification **Important to think about these 5 functions as we discuss Skin disorders, and which function might be compromised with each particular skin disorder, and how that can affect the person’s health + how it affects the care of your patient **The skin is the window of the evaluation of the internal health of the body. The skin can tell you a whole lot about the state of the person.

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EXAM II What are some of the characteristics of young skin & the symptoms of skin disorders in infants/young children as opposed to adults? • young skin is more susceptible to superficial bacteria infection • infants & young children are more likely to experience systemic symptoms with some infections (the infection can flourish more rapidly and go systemically more frequently than in an adult) • young skin is more reactive to irritants • young skin is more likely to be affected by eczema What is the cause (etiology) of skin lesions? • MANY causes — • Contact with an infectious organism or toxic chemical • Physical trauma • Hereditary factors • Allergens • Systemic Disease • Age consideration • What are some examples of skin lesions that are associated with certain age groups? • infants —> birthmarks • school-age —> Tinea Capitis • Adolescents —> Acne • Elderly —> Actinic Keratoses If you see a skin disorder, you want to begin by asking the proper questions to know what could be wrong… Recall: it is so important to get a GOOD HX!! • Examples of questions to ask: • Recent contact with anything? • Any hereditary factors? • Any known allergies? • Any recent systemic infection? • Where do they play? • When did this start? • Has it gotten worse? • Eaten anything new recently? • Has anything recently changed within the household? • Any new Laundry detergent? (A COMMON ONE) • Is mom wearing a new perfume? • Use of any alternative creams or treatments? (e.g. tea tree oil) What are 2 important parts of the physical exam you would do when assessing a skin disorder/lesion? • inspect • palpate

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EXAM II Review all the lesions —> important to know your lesions!! • be able to describe/document: • distribution • size • morphology (is it a macule, papule, nodule, vesicle, etc.) • arrangement • primary/secondary

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EXAM II

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EXAM II If there is a presenting skin disorder, you would also obtain lab studies. Why are lab studies necessary? • to rule out other things —> e.g. collagen vascular disorders, immunodeficiency disease, allergies, etc. What are 2 specific lab studies you would obtain? • WBC • ESR (Erythrocyte Sedimentation Rate) - indicates generalized inflammation • Why is the ESR done when you are able to obviously see inflammation? • it gives you a baseline of the person’s inflammation • then you can keep checking the ESR to see if the treatment is working • (Treatment may be working and this is reflected in a lower ESR, however, the skin may not appear to be getting better) What are the 4 phases of Wound Healing? • 1st - Inflammation • What is occurring during this phase? • Edema • Angiogenesis • Phagocytosis • 2nd - Granulation/Proliferation • What is occurring during this phase? • Collagen is secreted • (Lasts 4 - 5 weeks) • 3rd - Contraction • What is occurring during this phase? • Fibroblasts bring wound edges together • 4th - Maturation • What is occurring during this phase? • Scar forms and changes over time What are the 3 different ways wounds can heal? • Primary Intention • How does the skin heal by ‘primary intention’? • the wound margins are neatly approximated (i.e. stitches, staples, glue) • Is there scarring? • there is minimal scarring • Example • surgical incision • Secondary Intention • How does the skin heal by ‘secondary intention’? • the wound edges are not approximated 5  of 46

EXAM II •

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If a skin wound is healing by secondary intention, the skin must be _________ and there is an increased potential for __________. • debrided • infection • Examples • Third Degree Burn • Avulsion • Definition: Avulsion • the action of pulling or tearing away Tertiary intention • How does the skin heal by ‘secondary intention’? • There is lots of granulation tissue present • Is there scarring? • there is a larger/deeper scar • Example • Suturing delayed after injury • Wound breaks down

What are the 2 general ‘categories’ of wounds? • Acute • Chronic • What is the main difference? • Acute —> • heals uneventfully • Chronic —> • Does not heal in the expected time frame • Associated with many complications • 2 examples of Chronic Wounds: • Pressure Ulcers • Burns Examples of ‘wound infection’ characteristics (what are you going to see in a wound to know it is infected?) • purulent • tenderness/warmth • redness • edema

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Care of Children with Infectious Disorders

EXAM II

1A - IMPETIGO CONTAGIOSA What bacteria is the primary cause of Impetigo Contagiosa? • Staph aureus • NOTE: it is NOT MRSA How is Impetigo transmitted? • direct contact What are the manifestations of Impetigo? • 1st - Reddened, Macular • 2nd - Becomes Vesicular • 3rd - Vesicle ruptures, there is erosion • 4th - Honey-colored crusting (Hallmark sign) What else is a significant symptom of Impetigo? • very itchy (pruritis) Where does the ‘impetigo’ culprit (the Staph aureus) colonize before the impetigo outbreak occurs? • in the nares • under the nails Do most people actually get this disorder or are most people carriers? • most people are carriers • specifically, Nasal Carriers (20-30%) • However, some children respond to it by flaring up • But some children are not affected with it • (just depends on their environment, the child’s immune system, and other factors) Is Impetigo Contagiosa contagious? • yes! very contagious —> via direct contact Impetigo Contagiosa may occur in combination with __________. • eczema How is Impetigo Contagiosa treated? • with an antibiotic cream

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EXAM II So how do you know the infection is “MRSA” vs something else, like Impetigo which is not caused by MRSA? • a MRSA infection presents differently • abscesses • redness • won’t be on the nose • will occur more on the extremities • usually ends up being in an area that is hot, reddened, and swollen • and these areas are more prone to MRSA because they are incapsulated • and the the Tx for a MRSA infection is an I&D What is involved in the management of care for a patient with Impetigo Contagiosa? • Removal of _______. • Crusts (the honey-colored crusts) • How are these crusts removed? • with 1:20 Burrow’s Solution Compresses (“Domeboro”) • its an astringent with antibacterial properties (its OTC) • What type of antibiotic ointment will be put on it? • bactericidal • Mupirocin • NOTE: they may get oral antibiotics, but its usually just a cream • What do you want to prevent? • the spread of infection • So what would you teach the child? • to keep their hands off of the skin there • What would you teach the caregiver? • hand washing before AND after touching the child • to emphasize to the entire family the importance of hand washing • NOTE: HANDWASHING VERY IMPORTANT because Impetigo is VERY CONTAGIOUS • to separate linens before doing laundry Is scarring a concern with Impetigo? • no How long does it take for the Impetigo to clear up? • 2 - 3 weeks ———————————————————

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EXAM II

1B - CELLULITIS What bacteria is the primary cause of Cellulitis? • H. influenza (most common) • Strep • Staph What are the clinical manifestations of Cellulitis? • redness • swelling • firm infiltration • warmth • lymphangitis (“streaking”) • may progress to abscess • painful/tender • NOTE: could potentially be caused by IV infiltration What is involved in the management of care for a patient with Cellulitis? • Oral / Parenteral ABX • hot, moist compress • rest & immobilization of affected area • may need an I&D (Incision & Drainage) if it becomes in an abscess form • they cut the wound and drain the fluid inside When would hospitalization be necessary in a patient with Cellulitis? (3) • if they are having systemic symptoms • if wound is > 2 inches • if wound is on the face or on a joint • What would they be treated with specifically after they are admitted into the hospital? • IV Antibiotics ———————————————————

1C - PEDICULOSIS CAPITIS What is Pediculosis Capitis aka? • Head lice What age range of pedi is this common in? • school-age children • Why? • exposure! • NOTE: there has been a rise in head lice in adolescents and older children too… selfies! 9  of 46

EXAM II How is Pediculosis Capitis (Head lice) transmitted? • from person to person What is the most common symptom of Pediculosis Capitis (Head lice) on a child? • itching (pruritis) What sites will the nits and lice congregate? • occipital area • behind the ears • nape of the neck • So if you suspect Pediculosis Capitis (Head lice), look at the nape of the neck, occipital area, behind the ears, (and also where the part in the hair is!) What does Pediculosis Capitis (Head lice) look like? • looks alot like dandruff, but you can’t get it off because they are hanging onto the hair shaft really tightly • will also see little red dots on the head (which is blood) — the nits are feeding on the scalp Is a secondary infection possible? • yes • How? • due to all the itching! Do African-American people get lice? • usually, no • due to the oils and kinkiness/curliness • (lice like straight, clean hair without oils) What is involved in the management of care for a patient with Pediculosis Capitis (Head lice)? • Daily removal of _______. • nits • What are 3 treatment options? • Nix (permethrin 1% creme rinse) • RID (pyrethrin with piperonyl butoxide) • Ovide (0.5% malathion) • Which of these 3 is the Drug of Choice? • Nix NOTE: some of these • (also RID) drugs that Tx the lice • (these are OTC) are no longer working in • What is important to know specifically about Ovide (0.5% some cases— they are malathion)? now finding “Super Lice” • it is for children > 6 y/o only • (can only be obtained via prescription) 10  of 46

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Why? • it is flammable All of these drugs that kill lice are _____________. • nephrotoxic • Don’t keep exposing them to these creams! (2x tops!)

What is the key to these topical medications? • you must leave it on, then COMB IT OUT, with a special, very-finetooth comb How long and how often must you do this topical treatment regimen? • EVERY DAY until they are gone? or is it a certain number of days?

What is a very important thing you need to teach your patient? • how to PREVENT FURTHER INFESTATION • Specific things to teach: • home remedies do not kill eggs very well • louse is transmitted via direct contact • so do not share hats, towels, etc. • wash the sheet EVERYDAY • put everything that is soft and furry and not able to be washed in a plastic bag and seal it for 14 days (this is how long it will take to kill the nits) • you can sanitize a piece of clothing or blanket or towers by putting it in the dryer on “hot” for 20 minutes • machine wash ALL linen/towels in hot water/hot dryer for ≥ 20 minutes • vacuum carpets, car seats, stuffed animals, etc. • inspect the child’s hair regularly Is it necessary to cut the child’s hair? • no • but it would be alot easier to just shave the head What is the “no nit” policy with school nurses? • school nurses used to have a ‘no nit’ policy saying that a child with lice could not come back to school until they were totally free of lice (some schools have gotten rid of this policy) • Why is this really not done anymore? • children were missing too much school • What is the newer policy? • if the child is being treated, the child can come back to school • ***This is a little controversial in some places ———————————————————

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EXAM II

1C - SCABIES What causes the skin disorder of “Scabies”? • Sarcoptes scabiei (scabies mite) How is scabies transmitted? • prolonged direct contact • So there is a high incidence of it being transmitted from person to person in crowded conditions • (THINK: Prisons) How long does it take for the mite to burrow under the skin? • 45 minutes • (why there needs to be prolonged direct contact) What is the hallmark sign of Scabies? • intense pruritis that is worse at night What do all the clinical manifestation arise from? • the actual inflammatory response What does scabies look like on the child? • Maculopapular lesions distributed in intertriginous areas • What are intertriginous areas? • a place where 2 skin areas rub together If the child is > 2 y/o where specifically would you see the Scabies lesions? if < 2 y/o? • > 2 y/o • lesions seen on hands/wrists • < 2 y/o • lesions seen on feet / ankles How is scabies diagnosed? • microscopic evaluation of skin scraping for mite What is Scabies treated with? • Scabicide • What is the specific preferred topical treatment? • Elimite (Permethrin 5% cream) • How old must the child be before they can get this treatment? • > 2 months old How is the Elimite applied? • it covers the entire skin (avoid eyes and mouth) • then you leave it on for 8 - 14 hours 12  of 46

EXAM II If a person cannot do the cream and they react to it, what can they take? • Oral antiparasitic (Ibumet) What is important to know about treatment? • besides treating the child for the scabies, its also important to TREAT THE ENTIRE FAMILY & CLOSE CONTACTS and DO NOT WAIT to treat until the rash appears.. just treat no matter what! What would you teach the caregiver and family? • educate them on following the scabicide instructions • wear gloves when caring for the child • wash hands • wash linen/clothing in hot water • dry linen clothing on high setting When should the itching subside? • 2 - 3 weeks What could be used to help with the itching? • Aveeno • regular oatmeal in a tub (cheaper)

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Care of Children with Inflammatory Disorders

EXAM II

2A - POISON IVY / POISON OAK What occurs during a reaction to Poison Ivy? • there is a full-blown immune response evident after about 2 days What are the manifestations of this immune response? • initial manifestations —> • redness • swelling • itching at site of contact • next —> • streaked, spotty blisters (Vesicles) • oozing serum • What does it resemble at this point? • Impetigo • last —> • lesions dry • lesions heal spontaneously When does the itching stop? • in 10-14 days What must you do AS SOON AS YOU ARE EXPOSED to the poison ivy? • flush that area of the skin with COLD RUNNING water within 15 MINUTES Would you want to wash with soap? Why or why not? • no • soap can hold onto the oils What do you do with the clothing you were wearing during exposure? • remove the clothing • launder the clothing in HOT water NOTE: Don’t forget to wash the animals! — the oils can get on their coat. but they aren’t affected by poison ivy like humans are. Because how is Poison Ivy actually transmitted? • via the oils of the plant Is it a good idea to burn the leaves of poison ivy? Why or why not? • no! • if the leaves are burning, the oils become a gas • if you breathe it in, you can have internal effects from the poison ivy 14  of 46

EXAM II Even though it will be intensely itchy, what must you keep the child from doing? why? • keep the child from scratching! • the lesions can become secondary infections • e.g. excoriation What can be used to treat the itchiness? • calamine lotion • burrow’s solution compresses • aveeno baths • regular oatmeal baths (put oatmeal in the bathtub, this turns the bathtub cloudy, and its very soothing) — much cheaper than Aveeno • diphenhydramine (Benadryl) (Caution —> Sedative) • Corticosteroids (topical or oral) • NOTE: Corticosteroids ONLY given in SEVERE circumstances and only if necessary. Its not commonly treated with Corticosteroids’ —————————————————————

2B - ACNE VULGARIS Is Acne Vulgaris common? • yes • most common skin problem treated by physicians Is it a problem from the adolescent’s perspective? • yes • the significance to the adolescent is GREAT • There may even be some psychological impact on the adolescent, which could end up requiring counseling Is timely treatment important? • yes! Acne Vulgaris involves _________ _______ and ________ __________. • sebaceous glands • hair follicles What is the general Pathophysiology of Acne Vulgaris? • there is excessive sebum production • (And sebum secretion occurs at a genetically determined sebum secretion rate) • So, some people secrete more sebum and some people secrete less sebum and this is determined by genetics • there is an overgrowth of Propionibacterium 15  of 46

EXAM II • •

This results in Papules, Pustules, Nodules, and Cysts serious cases may scar

What is involved in the management of Acne Vulgaris? • Cleaning with a Mild facial cleanser once or twice daily • Topical medications What does treatment depend on? • adolescents commitment What is the first line topical Rx for most acne? • Retinoids • What is the specific Retinoids that is considered the ‘gold standard’ of Retinoids? • Tretinoin What is another topical Rx? • Benzoyl-Peroxide If an adolescent is on Benzoyl-Peroxide, what would you need to educate them about? • decrease sun exposure • the benzoyl-peroxide can bleach your clothes What vitamins and minerals are good to include in your diet to help manage acne? • Vitamin A (NOTE: Retinoids are high in Vitamin A) • Vitamin E • Zinc What might be given if there is no response to topical therapy? • systemic therapy • (so topical therapy is always tried first) Examples of Systemic Therapy options: • Tetracycline • Erythromycin • Minocycline • Doxycycline • Clindamycin • Oral Contraceptive (For females —> to reduce endogenous androgen production) • Accutane (Isotretinoin 12-cis-retinoic acid) • When would Accutane be prescribed? • for severe, cystic acne that is unresponsive to other treatments 16  of 46

EXAM II What is important to teach a patient who is being prescribed Accutane? • they have to be on 2 forms of birth control • they must sign a pledge of abstinence • Why is this important? • ACCUTANE IS TERATOGENIC (MAJOR SIDE EFFECT) Other side effects of Accutane: • IBS • depression • very dry skin • increased cholesterol What is a major advantage of Accutane? • cystic acne can be very scarring and accutane helps to prevent scarring

————————————————————— ECZEMA NOTE: BOTH Contact Dermatitis and Atopic Dermatitis are forms of Eczema What is “Eczema”? • a general term for different types of rashes • aka “Dermatitis” • so there are many different kinds of Eczema/Dermatitis. For testing purposes, just need to know about Contact & Atopic —————————————————————

2C - CONTACT DERMATITIS What is Contact Dermatitis? • an inflammatory reaction to chemical substances, plants, animal irritants, etc. Contact Dermatitis usually occurs in _________ skin. • exposed • What does this mean exactly? • The child is responding to what that just came in contact with (touched). The reaction occurs only on the place that was exposed to the substance. • E.g. if allergic to a bracelet, you will have a scar in the shape of a bracelet around your wrist. Contact Dermatitis — reaction to flip flops

Contact Dermatitis — reaction to bracelet