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Description : Check out this medical presentation on Staphylococcal Scalded Skin Syndrome, which is titled "Dermatological infections in children", to know about the Dermatological infections in children including bacterial, fungal, and viral.

Tags : Staphylococcal Scalded Skin Syndrome, Dermatological infections, children, bacterial, fungal, viral

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Slide 1-

DERMATOLOGIC INFECTIONS IN CHILDREN ROBERTA C. ROMERO, M.D., F.P.D.S. TROPICAL DISEASE FOUNDATION
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DERMATOLOGICAL INFECTIONS BACTERIAL IMPETIGO/SSS FOLLICULITIS, FURUNCULOSIS FUNGAL TINEA VERSICOLOR DERMATOPHYTOSIS CANDIDA VIRAL HAND FOOT AND MOUTH DISEASE MOLLUSCUM CONTAGIOSUM
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6 YEAR OLD BOY -SKIN LESIONS OF 4 DAYS DURATION GOLDEN YELLOW CRUSTS ON SHALLOW EROSIONS ON FACE NOT TENDER, NOT ITCHY, SLIGHT FEVER DIAGNOSIS?????
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DIAGNOSIS: Impetigo Contagiosa Recognition Rapid evolution: Erythematous macule  papulovesicle  pustule  superficial erosions with honey-colored crusts (“mamaso”) Not tender, not painful, +/- fever Areas: face, extremities, buttocks Etiologic agents: Mainly Staph aureus, sometimes GABHS
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Typical clinical presentation of Impetigo Contagiosa (Mamaso) Starts with a single 2-4 mm erythematous macule Form “honey- colored” crusts Vesicles easily rupture Direct extension rapidly follows Several individual or coalesced macules/patches Courtesy of Dr. B.Bince Vesicles form
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Courtesy of Dr. R. Romero-Francisco
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Courtesy of Dr. R. Romero-Francisco
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3 year old girl Skin lesions of 3 days duration See superficial blister on left underarm Diagnosis????
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IMPETIGO CONTAGIOSA BULLOUS IMPETIGO Staph aureus produces epidermolysin (exfoliatoxin) Cleavage of superficial layer of epidermis formation of a superficial blister Bullous impetigo or erosion of epidermis (mamaso)
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Blister has been unroofed erosion Courtesy of Dr. R. Romero-Francisco
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Impetigo Contagiosa: Management Topical antibiotics: 1. few, localized lesions 2. superficial lesions 3. asymptomatic child Meds: Mupirocin, Fusidic acid 3x a day Oral antibiotics if multiple and widespread: Cloxacillin, Erythromycin
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13 month old baby girl 1 day duration of whole body erythema with superficial erosions Baby is very irritable Diagnosis??????
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Staphylococcal Scalded Skin Syndrome or SSSS A child less than 5 y/o with diffuse tender erythema  scarlatiniform eruption accentuated in flexures and periorificial areas  “wrinkled” appearance and superficial desquamation Severe cases with diffuse sterile flaccid blisters and erosions
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Characteristic facies: peri-orificial erythema and scaling  distinctive radial crusting and fissuring May have pharyngitis, conjunctivitis and superficial erosions of the lips with sparing of oral mucosa SSSS: Recognition
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Courtesy of Dr. R. Romero-Francisco
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Courtesy of Dr. R. Romero-Francisco
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Staphylococcal Scalded Skin Syndrome (SSSS) A toxin mediated infection Due to exfoliative toxins A, B released by Staphylococcus aureus phage Type II
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SSSS: Management: Remember that this is a Systemic Staph infection Anti-Staph antibiotics for 7-10 days Aggressive fluid and electrolyte management Denuded phase: NSS compresses Desquamation phase: emollients Heals without scarring in 10-14 days
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2 year old boy with pustules over the upper lip of 4 days duration Painful Diagnosis??
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C A R B U N C L E S Folliculitis Fu-run-cles
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Major Bacterial Infections of the Skin
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Furuncles and Carbuncles If single and not involving the dangerous triangle of the face: simple incision and drainage may suffice. May apply topical mupirocin on surrounding skin to avoid inoculation with pathogen
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Historical perspective Comparison of Bacterial Isolates: *1995 **2005 Staphylococcus aureus 84.5% = 85.5% Sensitivity to Oxacillin 97.7% 55.4% *Romero R, et. al. Bacterial Isolates among primary and secondary skin infections in the community. Research paper in fulfillment of fellowship. Phil Children’s Medical Center ** Romero, R., et al.Efficacy and safety of mupirocin in superficial bacterial infection. Phil J Int Med. 2006
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Why the sudden change? Possibilities: (Philippine scenario) Incomplete intake of prescribed antibiotics Self medication – availability of antibiotics from local drugstores w/o prescription Application of “penicillin” powder on infected wounds
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Community Acquired Methicillin Resistant Staph Aureus (CA-MRSA) What is MRSA (CDC Definition)? MRSA is, by definition, any strain of Staphylococcus aureus bacteria that has developed resistance to beta-lactam antibiotics which include the penicillins (methicillin, dicloxacillin, nafcillin, oxacillin, etc.) and the cephalosporins. Community acquired MRSA is a hybrid strain from a previously hospitalized patient who developed MRSA and the strain normally found in the community.
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Community Acquired Methicillin Resistant Staph Aureus (CA-MRSA) The resistance of MRSA to beta-lactam antibiotics is due to the presence of the mecA gene sequence. The mecA gene produces transpeptidase PBP2a (penicillin-binding peptide) that decreases the bacterial affinity of the beta-lactam antibiotics. Most CA-MRSA hybrid strains may acquire a virulence factor not seen with HA-MRSA
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Management of CA-MRSA Most cases do not need hospitalization For furuncles and carbuncles: Incision and drainage Get culture and sensitivity Initiate antibiotic therapy Trimethoprim 160 mgs, Sulfamethoxazole 800mgs: 1 tablet 2 x a day or Clindamycin HCl 450 mgs 3x a day Frei, C.R. TMP or Clindamycin for CA-MRSA Skin Infections. J AM Board of Fam Med 2010:23(6):714=719
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No improvement or worsening after 2 days of antibiotics. Severe pain. Fever, nausea, vomiting, other constitutional signs and symptoms Recognition of Severe MRSA infection
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Management of CA-MRSA Most cases do not need hospitalization For furuncles and carbuncles: Incision and drainage Get culture and sensitivity Initiate antibiotic therapy Trimethoprim 160 mgs, Sulfamethoxazole 800mgs: 1 tablet 2 x a day or Clindamycin HCl 450 mgs 3x a day Note: in severe cases: HOSPITALIZE Frei, C.R. TMP or Clindamycin for CA-MRSA Skin Infections. J AM Board of Fam Med 2010:23(6):714=719
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2 year old boy with recurrent crops of carbuncles and furuncles responsive to oral cloxacillin. Problem: Why recurrent?
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Recurrent Furunculosis Frequent attacks of furuncles/carbuncles: (1 or more episodes per month despite oral antibiotics) Look for source of staphylococcus! May have to do culture of anterior nares of patient or caregiver(s) If +: Apply mupirocin 4x a day for 5 days to anterior nares Or Rifampicin plus Cloxacillin for 7 days
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Recurrent Staph infections Look for the source of infection (auto-inoculation? Personal contact?) “Reservoirs” of Staph aureus: 1. anterior nares 2. ears 3. throat 4. hands 5. axillae 6. perineum/anus
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Algorythm for recurrence Mupirocin BID-QID x 5 days applied on the internal nares Culture other sites (perineum, fingernails, Toe webs, axilla) Add rifampicin Or Rifampicin plus minocycline Rifampicin plus co-trimoxazole **MRSA Guay D. Treatment of bacterial skin and skin structure infections. Expert Opin Pharmacother 2003; 4(8): 1259-75.
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Fungal Infections Candida Pityriasis versicolor Tinea capitis
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Diaper Candidiasis Infant with “diaper rash” of one week duration No response to cortisone cream Diagnosis?
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Diaper Candidiasis Note: Satellite pustules Glazed, beefy red shiny skin Diagnosis: Candidal Diaper Dermatitis
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Other signs of candidal infection: fine scaling on border of erythematous lesions White cheesy material Courtesy of Dr. R. Romero-Francisco
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Diaper Candidiasis: Recognition usually presents as well demarcated erythema with peripheral scale and satellite papules/pustules inguinal creases are involved in some instances, erythema has been described as “beefy red”
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White plaque difficult to scrape Courtesy of Dr. R. Romero-Francisco
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Oral Thrush: Recognition “Thrush”: pseudomembranous Candidiasis white to gray, “cheesy” looking colonies that form pseudomembranes gentle removal reveals a raw red base
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Candidiasis: Management Topical anti-candidal agent (nystatin or an azole preparation) +/- topical steroid NOTE: after the eruption has cleared, continue the anti-candidal agent for three more days Oral mycostatin or fluconazole if recurrent and extensive
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16 year old male Increasing number of hypopigmented patches Asymptomatic Other lesions on upper chest Diagnosis????
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KOH Smear
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Pityriasis Versicolor: Recognition Small round to oval macules or minimally elevated plaques with “wrinkling” and superficial scale (“fingernail sign”) Lesions may be erythematous to brownish to hypopigmented (“an-an”)
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Most common on the chest, back and proximal arms Face involved in younger children May be mildly pruritic Etiologic agent: Pityrosporum ovale or Malassezia furfur Pityriasis Versicolor: Recognition
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Pityriasis versicolor: Management Selenium sulfide or Zinc pyrithione 10-15 mins/day for 1-2 weeks Ketoconazole shampoo 5 mins/day for 3 days Ketoconazole cream Oral ketoconazole discouraged Advise on residual pigmentation
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12 year old girl with a mass on L parietal area, asymptomatic Several weeks duration + cerviical lymph nodes but appears to worsen with anti-biotics Diagnosis????
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Note the mass: Boggy and soggy erythe-matous mass (Kerion) Presence of alopecia Diagnosis: Tinea Capitis
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Courtesy of Dr. R. Romero-Francisco
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Another presentation of Tinea capitis: Suspect in a prepubertal child with scaly alopecia Courtesy of Dr. R. Romero-Francisco
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KOH smear
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Tinea Capitis”Management Oral anti-fungals: 1. Griseofulvin: 15-25 mkd (max: 1 g/d) 6-12 weeks 2. Terbinafine: 3-6 mkd face/body/scalp: 2-4 weeks Ketoconazole shampoo
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4 year old boy with shallow small ulcers on tongue Has difficulty eating and with low grade fever Similar lesions on hands, feet and buttocks Diagnosis?????
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Courtesy of Dr. R. Romero-Francisco
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Coxsackie A16 virus: Recognition: HFM Distinct pattern: Hand, Foot and Mouth distribution Lesions vary: maculopapular, roseola-like, urticarial, but most common is vesicular Usual evolution: erythematous small macules and papules  superficial gray vesicles on an erythematous base  some may ulcerate, leaving superficial scabs
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Shallow grayish ulcer on erythematous base
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Coxsackie A16 virus: Recognition Hand, Foot and Mouth disease > areas involved: mouth, hands and feet, buttocks; may also be seen on face and extremities > rash usually lasts for 2-7 days > (+/-) fever, sore mouth, anorexia, malaise, abdominal pain
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5 year old child with multiple flesh colored papules on trunk Asymptomatic but increasing in number Diagnosis????
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Molluscum Contagiosum Note: Flesh colored papules Central umbilication Not inflamed as a rule
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Flesh colored papules Central umbilication
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Molluscum contagious: Recognition Flesh colored to pinkish to pearly white discrete papules with central umbilication Most common areas: axillae, lateral trunk, lower abdomen, thighs, face May have a dermatitis in 10% of cases Etiologic agent: Molluscipox virus
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Molluscum contagiosum: Management “Benign neglect”: spontaneous resolution in 6-9 months May have a more persistent, progressive course **Tx options: 1. Curettage 2. topical Cantharidin 3. Tretinoin cream 4. Imiquimod cream
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Molluscum contagiosum: What can the Pediatrician do? Recognize Refer Please do not give topical steroids May try: 1. Tretinoin or Imiquimod 2. nail polish??!!
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DERMATOLOGICAL INFECTIONS BACTERIAL IMPETIGO/SSS FOLLICULITIS, FURUNCULOSIS FUNGAL TINEA VERSICOLOR DERMATOPHYTOSIS CANDIDA VIRAL HAND FOOT and MOUTH DISEASE MOLLUSCUM CONTAGIOSUM
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THANK YOU FOR YOUR KIND ATTENTION