Topic A – Inflammation and Infection

• Epidemiology, Risk factors, Features, Management

• Inflammatory
– Eczema
– Psoriasis
– Acne
DermIS Medical Students –
–
Lichen sclerosus
Lichen planus
Dermatology Revision Lecture 2018 • Infection
– Cellulitis/Erysipelas
• Paediatrics
– Haemangiomas
Dr Sarah Gamboni – Kawasaki disease
– Meningococcal disease
BSc (Hons), BMBS, FACD – Erythema Infectiosum
– Measles
Dermatologist – Rubella
– Roseola Infantum
– Hand, foot and mouth
– Impetigo

Terminology and Morphology

Nodule
Raised, round
Macule >5mm
Flat <1cm

Vesicle
Clear fluid
Patch <5-10mm
Flat >1cm

Bulla
Papule Fluid-filled
Raised <5mm >10mm

Plaque Pustule
Raised length > width Purulent fluid
<5mm
 Topical corticosteroids
• Anti-inflammatory, anti-proliferative effects
• Topical, oral, intralesional steroids

Potency of topical steroids (cream vs ointment)

• Hydrocortisone 0.5-1% - low potency (face)
• Methylprednisolone
• Betamethasone dipropionate
INFLAMMATORY
• Mometasone furoate
• Clobetasol propionate - super potent

Eczema Eczema
• “My child has an itchy rash on her arms and • Eczema = dermatitis
legs”
• Inflammatory condition of epidermis
• Describe rash using appropriate terminology
• Types:
• Develop a management plan and give eczema
advice to parent – atopic dermatitis
• RCH – contact dermatitis: ACD, ICD
– discoid/nummular eczema
– seborrhoeic dermatitis/dandruff
 Atopic dermatitis Eczema Management Plan
• Ix: IgE, RAST
• Common, children, pruritic • Avoid triggers/irritants
• IgE, allergic dermatitis • Cool showers, soap free cleanser, emollient
• Atopic triad: eczema, asthma, hayfever • Face: topical calcineurin inhibitors (pimecrolimus, tacrolimus)
(allergic rhinitis) • Body: topical steroids, wet wraps
• Risk factors: Th2 cell-mediated, genetics • RCH Bleach baths
(Family Hx atopy), environmental,
weather/temp à defects in skin barrier • Secondary infection/impetiginisation (Staph aureus, Strep
pyogenes): antibiotics à cephalexin, flucloxacillin
• Children: flexural elbows/knees, eyelids,
neck, back • Antihistamines nocte (helps sleep)
• Buzz words: pruritus (itchy), xerosis (dry), • Severe:
lichenified (chronic, thickened), excoriated – short courses prednisolone
(scratched), impetiginised (secondary – Phototherapy (narrow band UVB)
infection) – immunosuppressant (mycophenolate, azathioprine, cyclosporine)
• Complications: – Admission to hospital for wet wraps
– bacterial infection – staph aureus – Dupilumab: biologic – monoclonal Ab against IL-4, IL-13 in Th2
– viral infection - eczema herpeticum (HSV) pathway

Wet wraps/dressings
How wet dressings help eczema Royal Children’s Hospital bleach baths
• reduce itch by cooling the skin
• treats infection
• moisturiser rehydrates the skin
• protect the skin from scratching, and helps healing

Procedure
• Soak in bath with water or add QV bath oil for 20 minutes
• Apply topical corticosteroid to affected areas with eczema
• Apply moisturiser over the corticosteroid ointment
• Put on bandages

Adapted from RCH Wet Dressings for Eczema poster

https://www.rch.org.au/uploadedFiles/Main/Content/derm/eczema-bath-information.pdf
 Allergic contact
Contact Dermatitis dermatitis
• Contact dermatitis • Allergic reaction to allergen in contact with skin
• Type 4 or delayed hypersensitivity, 48-72hr after exposure
– Allergic Contact Dermatitis • Allergens: nickel, acrylates, PPD (hair dye), fragrances etc
– Irritant Contact Dermatitis • Metal workers, hairdressers, beauticians, healthcare workers, florists
• Eczema localised to site of allergen
• “I can’t go to work, as my hands are terrible • Management:
since I started this job at the florist” – Patch testing with dermatologist
– Avoid allergen
• Possible exam question: Hand dermatitis – Standard eczema management

Irritant Contact Dermatitis Psoriasis

• Skin injured by friction, environment (cold, water exposure, wet work),
chemicals (detergents, acids, alkalis), saliva
• Chronic inflammatory skin condition
• Occupational hand dermatitis: cleaners, hairdressers, food handlers • Multifactorial: genetics, immune-mediated
• No specific test • Symmetrical, well-defined, erythematous plaques, silvery
• Management:
scale
– Avoid irritants
• Scalp, extensor elbows/knees, nails
– Wear gloves
• Less itchy than eczema
– Soap free wash • Subtypes: chronic plaque psoriasis, guttate psoriasis
– Topical corticosteroids • Aggravating factors: strep infections, trauma
– Emollients
(koebnerisation), obesity, smoking, alcohol, stress,
medications, steroid withdrawal
– Treat secondary infection (antibiotics)
• Associations: psoriatic arthritis, IBD, metabolic syndrome
 Psoriasis Management Acne vulgaris
• Management
– Calculate Psoriasis Area and Severity Index (PASI • Chronic inflammatory condition
Score) • Pilosebaceous unit (hair follicle, oil glands)
• Face, neck, shoulders, chest, back
– Avoid smoking and oral corticosteroids (risk • Risk Factors: genetic, hormonal (androgens), PCOS, stress,
withdrawal flare) corticosteroids, cosmetics, diet (dairy, high-glycaemic, protein)
– Topical corticosteroids, calcipotriol (Vitamin D • Features: Inflamed papules, pustules, open comedones
(blackheads) and closed comedones (whiteheads), nodules,
analogues), coal tar, dithranol pseudocysts, scarring, seborrhoea
– Phototherapy (nbUVB, PUVA)
– Systemic (methotrexate, cyclosporin, acitretin)
– Biologics

Acne Treatment SAQ: 28yo female with acne on her face, back
and trunk
• Comedonal: benzoyl peroxide, azelaic acid,
retinoids, hormonal therapy
• 1) Potential contributing causes
• Inflammatory: antibiotics (tetracyclines)
• Anti-androgens: combined oral contraceptive pill
• Severe nodulocystic: Isotretinoin • 2) First line treatment options
– Vitamin A
– Dermatologist only
– SE: • 3) Considerations before starting isotretinoin
• Common: dry lips and mucosa, fragile skin, photosensitivity
• Dangerous: teratogen (2 x contraception), depression,
headache (raised ICP)
• Other: deranged LFTs, myalgia, arthralgia,
hypertriglyceridaemia
 SAQ: 28yo female with acne on her face, back
and trunk
Lichen sclerosus
• Chronic inflammatory disease,
anogenital. Childhood,
• 1) Potential contributing causes menopause.
– Genetics (family history) • Genetics, autoimmune, infection
– Hormonal (PCOS) • Pruritus, “figure of eight”, pallor,
– Cosmetics/stress/diet atrophy, fissures, scarring,
purpura, loss of normal
architecture of vulva, phimosis
• 2) First line treatment options
– Soap free wash, cleanser, decrease oil-based makeup, dietary, Benzoyl
• Management
peroxide, antibiotics (doxycycline/minocycline), topical retinoids – Soap substitute, emollient
– Topical corticosteroids
• 3) Considerations before starting isotretinoin – Topical calcineurin inhibitors
– Pregnant? Plans for fertility? (teratogen) – Surgery
– History of depression/anxiety? (mood disturbance) – Circumcision
– Alcohol intake (deranged LFT) – Monitor scarring and risk
squamous cell carcinoma
– Hypertriglyceridaemia

Lichen planus
• Inflammatory disease of skin, hair, nails and
mucous membranes, middle-aged adults
• Features: Flat-topped violaceous papules
and plaques
• wrists, forearms, genitalia, shins, nails, oral
buccal mucosa, scalp, Wickham’s striae
• Management
INFECTIONS
– Topical, intralesional or oral corticosteroids
– Topical calcineurin inhibitors
– Narrowband UVB, PUVA
– Hydroxychloroquine
– Immunosuppressant/Immunomodulatory
(Methotrexate, Mycophenolate,
Cyclosporine)
 Cellulitis
• Bacterial infection, lower dermis, subcutaneous tissue
• Unilateral, warm, red, painful, swollen, systemic Sx

Cellulitis vs Erysipelas • Risk Factors: fissuring of toes (tinea pedis), venous disease, trauma,
immunodeficiency, diabetes, kidney and liver disease, obesity,
pregnancy
• Strep. pyogenes (2/3), Staph. aureus (1/3)
• Complications: sepsis, necrotising fasciitis, endocarditis
• Treatment: rest and elevation, mark out involved area, antibiotics
(penicillin, cephalosporins, vancomycin)

Erysipelas
• Bacterial infection, upper dermis, superficial cutaneous lymphatics
• Cheeks, legs, sharp raised border, bright red, firm and swollen,
finely dimpled (orange skin), blistering, warm, pain
• Risk Factors: spider bite, ulcer, trauma, nasopharyngeal infection,
venous disease, immunodeficiency, diabetes, obesity, nephrotic
PAEDIATRICS
syndrome, pregnancy
• Streptococcus pyogenes (Group A beta haemolytic strep)
• Complications: abscess, gangrene, thrombophlebitis, sepsis,
The child with rash +/- fever
lymphatic damage, post-strep GN, cavernous sinus thrombosis
• Treatment: cold packs, analgesia, elevation, compression, penicillin,
erythromycin, vancomycin
 Kawasaki disease
Infantile Haemangioma • Acute febrile illness with inflammation of small and medium-sized blood
vessels, especially coronary arteries
• 1-2yo, cause unknown
• Benign vascular lesion due to • CRITERIA = CLOPE. Fever >39deg for 5 days + 4 out of 5:
proliferating endothelial cells lining – Conjunctival injection
blood vessels – Lymphadenopathy (unilateral, cervical)
• Present shortly after birth – Oral mucosal changes (strawberry tongue)
– Polymorphic exanthem (rash)
• Head, neck – Extremities changes (swollen hands/feet, desquamation)
• Proliferate (grow) 5-18mth then • Complication: coronary artery aneurysm
involute (regress) by 10yo • Mx: aspirin (reduce clotting), IVIg (reduce inflammation), cardiac follow up
• Complication: facial segmental
haemangioma – PHACES syndrome:
abnormalities of posterior fossa,
haemangiomas, arterial, cardiac, eye
• Management: propranolol, timolol eye
drops, vascular laser

Meningococcal disease Meningococcal disease

• MEDICAL EMERGENCY = DEATH
• Bacteria Neisseria meningitidis, airborne droplets, • Ix: blood culture, lumbar puncture CSF
children 6mth -4yo, complement deficiency, asplenic,
immunodeficient
• Management:
– Early recognition vital, can spread within hours
• Meningococcal meningitis: (child >1yr) neck stiffness,
resulting in death
headache, N/V, fevers, photosensitivity,
irritability/confusion – ED/ICU
• Meningococcemia: petechiae on trunk, extremities, – Penicillin
necrosis if severe, fever, headache, neck stiffness, low – Mx of sepsis/shock: O2, ventilation, IV fluids,
back and thigh pain, N/V, confusion, seizures, noradrenaline, blood products
unconsciousness, signs of sepsis – Meningococcal vaccination, antibiotic
chemoprophylaxis to close contacts
 Erythema Infectiosum (Fifth disease,
“Slapped cheek”) Measles
• Parvovirus B19, respiratory droplets,
young children • Highly contagious viral infection, measles
• Fever, red burning cheeks, lacy rash on virus, airborne respiratory droplets
limbs • Risk factors: Unvaccinated,
• Complications: polyarthropathy, aplastic immunodeficient, pregnant women
anaemia, hydrops, miscarriage • Fever, rash
• Mx: supportive (cold flannel), RBC • 3C’s = conjunctivitis, cough/coryza,
transfusion, fetal USS cephalocaudal rash
• SLAP • Koplik spots in mouth, morbilliform rash
– Slap cheek • Complications: GIT, ears, resp, cardiac,
– Lacy reticulated haem, eyes, renal, CNS, preg (fetal loss)
– Aplastic anaemia, Arthralgia • Management: immunisation, supportive –
– Pregnancy (TORCH), Papular-purpuric rest & fluids, paracetamol for fever,
gloves and socks, Parvovirus B19 Vitamin A for malnourished

Rubella (German measles) Roseola Infantum (Exanthem subitum)

• RNA virus, respiratory droplets • HHV-6, 6-9mths old,
• Fever, headache, URTI, transmitted saliva
cephalocaudal rash • Well-appearing infant, fever
• Forchheimer’s spots in mouth, 39-40deg, “rose-red” macules
lymphadenopathy • Trunk, proximal extremities,
• Complications: arthralgia, neck, face
hepatitis, myocarditis, • Nagayama’s spots (soft palate),
anaemia, thrombocytopenia, eyelid oedema,
encephalitis, congenital rubella lymphadenopathy
(TORCH) • Complication: febrile seizures
• Management: supportive, • Management: self-limited, rash
immunisation (MMR) fades 1-2 days
 Hand, foot and mouth Impetigo
• Enterovirus: Coxsackie A16,
Enterovirus 71
• Faecal-oral or respiratory • Acute superficial bacterial skin infection
• Highly infectious, fever, • Children, atopic eczema, scabies, trauma
malaise, prodrome • Pustules, honey-coloured crusted erosions “school sores”,
lymphadenopathy, fever, malaise
• Vesicular eruption palms/soles, • Staph aureus > Strep pyogenes
erosive stomatitis (mouth) • Complications: infection (cellulitis), lymphangitis, sepsis,
• Management: self-limited, Staph scalded skin syndrome
• Mx: avoid contacts, cleanse and remove crusts, antiseptic,
supportive (antiseptic MW, antibiotics (cephalexin, flucloxacillin, erythromycin)
analgesia, fluids)

References
• www.dermnetnz.org
• Dermatology – Bolognia 4th edition Questions?
• Rook’s Textbook of Dermatology 9th edition
• Royal Children’s Hospital website
www.rch.org.au