Rashes: Paediatric Dermatology

Ellis Hon
Chinese University of Hong Kong
Skin 皮 膚
 皮膚是人體最大的器官
保 護身體的第一道防線
自 成 一 體 的 免 疫 系 統
 指 甲，毛 髮，粘 膜 都 是 皮 膚 一 部份
 皮 膚 生 病，可 能 是 本 身 問 題，也 可
能是體內其他疾病引起
Symptoms

 Pain
 Itch
Itch
3 year-old girl
 Generalised Itching
 Anaemia
 Fe Deficiency



Hepatic Failure
Thyroid Disease
Drugs
癢
 Lymphoma
 Polycythaemia rubra vera
 Malignancies
Primary lesion Definition Morphology Example

Vesicle Papule that

contains clear fluid Herpes

Bulla Vesicle >0.5 cm Bullous impetigo

SJS

Pustule Purulent material Chicken pox,

impetigo

Cyst Nodule that

Acne,
contains fluid or
inclusion cyst
semisolid material
Primary lesion Definition Morphology Example

Macule Flat Café au lait

circumscribed vitiligo
discoloration

Papule Elevated Molluscum

solid lesion
<0.5 cm
Nodule >0.5 cm Lipoma

Wheal Firm, oedematous

plaque Urticaria

Plaque Elevated, Psoriasis,

confluence of eczema
papules
Secondary lesion Definition Morphology
Cellular debris, dried
Crust serum and blood; a
scab. Antecedent
lesion is usually a
vesicle, bulla, or
pustule

Scale Thick stratum corneum

that results from
hyperkeratosis

Scar A collection of new

connective tissue. Implies
dermoepidermal damage
Secondary lesion Definition Morphology

Fissure Vertical loss of

epidermis and dermis
with sharp defined
walls

Excoriation Linear erosion induced

by scratching

Erosion Partial local loss of

epidermis, heals without
scarring

Ulcer Full thickness, focal loss

of epidermis and dermis,
heals with scar
 DDx

 Blanching vs Nonblanching
 Papules vs Macules
 Napkin rash-
Irritant contact dermatitis

» Precipitated by constant moisture, occlusion,

and frictional forces
» Involves skin where contact with napkin is
greatest
» Intertriginous areas spared
» Treatment
– barrier cream, exposed nursing, light treatment
Candida napkin dermatitis
念珠菌尿布感染
» Sharp margin, scaling, satellite lesions,
involvement of the intertriginous areas
» Oral cavity should be checked for oral flush
» Treatment
– topical anti-fungal
Infantile seborrhoeic dermatitis

 Controversial whether it is a discrete entity or

one type of atopic dermatitis
 Mainly affect scalp, face and flexural areas
(seborrhoeic areas)
 Cradle cap: yellow or white greasy scales
 Aetiology unknown
 Starts from 2-3 weeks, usually clears in a few
weeks and never recur
 Can occur in adults
 Erythema
Oozing
Excoriation
Crusting
Atopic eczema: a clinical diagnosis
 Atopic eczema異位性皮炎
 Affects 10-20% of children
 Associated with other atopia
 Genetic/environment factors
 Immunological dysfunction
 Treatments:
» Emollients
» Topical steroids
» Immuno-modulating agents
– Systemic v.s. topical
» Others
 AD 異位性皮炎

 3-5% infants
 75% onset before 1 year
 90% onset before 5 years
 Remission by age 15 years in 90%
Allergens
Aeroallergens vs food allergens
Eczema Herpeticum
 Common Viral Warts 尋常疣

 DNA-Papillomavirus
 Disappear spontaneous within 3 years
 Molluscum Contagiosum
傳染性軟疣

 病毒感染
 常見的兒童傳染病
 直接接觸患者而傳染
 手、眼瞼、頸部、軀幹及生殖器周圍
 腐食性藥水、冷凍治療、電燒
 Hand-foot-mouth disease

• Enteroviruses, mostly coxsackie A-16

• Highly contagious
• Symptomatic treatment
 Overcrowding

Poor hygiene
 Impetigo 膿痂疹

• Staphylococcus aureus, maybe

complicated by streptococcus
•抗生素葯膏或葯丸。
Fungal skin infection 皮膚之黴菌感染

Dermatophyte

Candida

Tinea Versicolor

Adult & Paed Derm

Pityriasis versicolor 汗斑
 又稱花斑癬,屬於表淺
之黴菌感染
 小孩及成年人
 可能會癢
 白色或棕色之皮屑斑點
 面部、頸、肩、手臂、
軀幹及腿上
Tinea 圓癬
 分為體癬及股
癬,患處呈環狀
脫屑之紅斑邊
緣凸起
 黴菌感染
 身體各處,包括
頭皮
Unilateral palm lesion
Tinea pedis 香港腳

 常在趾間,會
有脫皮,可能
會癢
 黴菌會慢慢
蔓延到整個
足底及趾甲
(灰甲)
 Prevention
 黴菌喜愛濕熱的環境, 所以趾間、股間及翼下等
處, 宜保持乾燥
 不要赤足在潮濕地板上 (如浴室、廁所及游泳
池邊), 這些地方黴菌容易滋生
 避免使用他人之尿布、毛巾、梳子等, 因為黴菌
非常容易傳染
 儘量穿著純綿之襪子及涼鞋, 因為尼龍襪及包鞋
會使足部潮濕
 保持健康飲食及適當運動,營養不平衡及疲倦會
使身體抵抗力減弱而更易感染黴菌
 Treatment

 治療黴菌之藥膏,一回2-3次,最少三星期
 當病灶完全好了,不可立即停止治療,必須經皮膚
科醫生診斷後才可停止使用藥膏。白色汗斑治
療後,顏色恢復較慢,可遵照醫生指示耐心等待
 如有需要,可用口服抗黴菌藥治療
 汗斑之預防及治癒均可使用洗劑,每晚洗澡後,以
洗劑塗抹上半身,並停留15分鐘後清水沖洗,必
須連續使用2-4星期
 Scabies 疥 瘡

 Sarcoptes scabies var. hominis

 Highly contagious and pruritic
 Skin manifestations are variable:
» Burrows on hands, finger webs, feet
» Erythematous papules
» Excoriations
» Nodules
» Vesicopustular or bullous
 Diagnosis: clinical and skin scrapping
 Scabies 疥 瘡

 Treatment:
» Topical application of insecticides
– Lindane
– Permethrine
– Sulphur
– Benzyl benzoate
– Crotamiton (Eurax)
» Apply below the neck in older children and in adults,
whole body for toddlers and infants
» Treat all household members and repeat as necessary
Sarcoptes Scabiei 疥 瘡
Scabies 疥 瘡
Mother’s palms
 Erythema multiforme

 Association
» Definitely HSV, Orf virus and histioplasmosis
» Possibly mycoplasma, drugs
 Target lesions with damaged skin in the
central zone(dusky, bullous, crusted)
 Fixed lesions for 7 days at least
 All lesions appear within 72 hours
 Not as common as thought, giant urticaria
may have been be misdiagnosed
 EM

 Minor
 Major
 Severe major (Stevens-Johnson)
 Stevens-Johnson syndrome

 Variable skin rash plus at least 2 mucosal lesions

 Usually preceded by a respiratory prodrome
 Erythematous macules rapidly evolve into bullae,
skin necrosis and denudation
 Mucosal lesions:
» Purulent conjunctivitis
» Haemorrhagic crust, erosions, or necrosis over lips,
peri-anal, urethral opening etc
 Stevens-Johnson syndrome

 Causes:
» Drugs: NSAIDs, sulphonamides, anti-
convulsants, penicillins, tetracycline etc
» Infections: HSV, mycoplasma, viruses etc
 High mortality due to dehydrations and
infections
 Morbidity as ocular sequelae, scarring of
skin, stricture of oesophagus etc.
Itchy rash
 Urticaria

 Antihistamines, i.v. hydrocortisone with

angioedema
 i.m. adrenaline
» 1:1000=1 mg/ml
» 0.05 – 0.5 ml
引起皮膚過敏之食品與藥物
 飲 料：汽 水、果 汁（碳 酸、人 工 色 素）
 刺 激 品：酒、辣 椒、咖 啡、咖 哩
 海產類：魚、蝦、蚵仔、蟹、蛤仔、魷魚
 菜 類：筍 子、香 菇、木 耳、芋 仔、糯 米、 茄
子、紅 蘿 蔔
 水 果：芒 果、荔 枝、龍 眼、番 茄、葡 萄
 藥 品：感 冒 藥（匹 林）、磺 氨 劑、消 炎 劑、
解熱鎮痛劑
 其 他：罐 頭 食 品、花 生、蛋、肝、巧 克 力、
可 可、不 新 鮮 之 食 物
 Drug eruption
 身体對口服藥或注射葯物的特殊反應，
因人而異
 可能影響皮膚，或身体多個器官 (如
肝臟)
 當知道對某些葯物過敏，必須終身避
免該類葯物，否則誤服可能致命
Drug reaction

May kill！
Severe
Urticaria\Angiodedema\Anaphylaxis

•蕁痲疹(起青毛) ,像被蚊叮, 會起一顆顆癢

癢的疹子, 抓一抓會腫起來。嚴重時面, 唇
及眼臉均腫大,會呼吸困難甚至窒息
•在服藥後60分鍾內發生
 Erythema Multiforme-
Stevens Johnson Syndrome

•Mucous membranes
(口唇、口腔、生殖器及眼睛)
•Dangerous!
SJS
Milder Drug Reactions
 麻疹樣 \ 斑疹樣反應
Maculopapular

最常見的皮膚藥物過敏。紅色、細小而密
的癢疹或紅斑, 可在服藥後數天才發生
Fixed Drug reaction
服藥後數天才發生, 呈
固定範圍的紅斑, 圓或
橢圓形, 久了變深色,
慢慢褪去。用了同類
藥會在相同範圍再發
生相同疹子
 Which ones?

任何藥物都會, 但是最常見者有:

1. 止痛藥和風濕藥 (阿斯匹靈)
2. 抗生素 (盤尼西林、四環素、璜氨藥)
3. 抗痙攣 (抽筋) 藥
 What to do？

1. 停服所有藥物, 但先不要丟掉
2. 回去請教替你開藥之醫生
3. 如要請教別的醫生, 該把所有長期
或當時服用之藥物都提供給醫生參考
4. 每次看病都要說出對何種藥物過敏
Toxic Epidermal Necrolysis

 Erythroderma
 Extreme form of SJS
 High mortality
 Should be treated as
burn
Birth Marks
Classification of vascular anomalies
ISSVA 11th International Workshop 1996

Vascular tumours Vascular malformations

 Haemangiomas Pure types
Fast flow
 Kaposiform
AM
haemangioendothelioma
AVF(single direct AVF)
 Tufted angioma AVM(with multiple AVFs)
 Others Slow flow
VM
LM
CM
Complex combined types
CLM, CVM, CLVM, LVM, ACM,
CAVM, CAVLM
Common in children and young adults
 Guttate psoriasis

 Persists for months

 Prolonged remission then
 Bland applications
Psoriasis 乾癬

Roxburgh
 Psoriasis

 牛 皮 癬，銀 屑 病
 Extensor (頭 部、肘、膝、腰 薦 骨 部)
 表 皮 增 生、發 炎 性 之 慢 性 皮 疾
指
 Nails
乾癬性關節炎
Drowsy infant with purpuric rash
 Meningococemia

 Cultures: blood, CSF, skin lesions

 Antibiotic
 Shock
Non-palpable rash followed varicella
 ITP

 Spontaneous recovery within months

A common condition
 HSP

 Preceding URTI in 1/3 patients

 Vasculitis with RBC extravasation
 Edema, arthritis, GI symptoms
 Transient microscopic haematuria
HSI + S pyogenes
HSI + S Pyogenes
Fever and rash
 Kawasaki Disease

 My
» Mucosal chapped lips andstrawberry tongue
» Hand reddened, edema, desquamation
» Eye bilateral conjunctival injection without discharge
» Adenopathy >1.5 cm
» Rash truncal
» Temp 1040F >5 days
Measles
German Measles