Rashes of infancy

Causes of napkin rashes
1. common
  1. but irritant rxns less problematic w/ widespread use of disposable nappies, as they are much more absorbent
2. irritant (contact) dermatitis
  1. commonest napkin rash
  2. may occur if
    1. nappies not changed often enough
    2. diarrhoeal
    3. even if napkin area cleaned regularly
  3. rash is due to irritant effect of urine on skin in suscep infants
    1. urea splitting orgs in faeces increases alkalinity & chance of rash
  4. rash description
    1. distribution
      1. convex surface of buttocks
      2. perineal region
      3. lower abdo
      4. top of thighs
      5. flexural sparing
        differentiates it from other nappy rashes
    2. configuration
      1. confluent?
    3. morphology
      1. erythematous
      2. possible scalded surface
      3. if severe
        erosions
        ulcers
  5. Mx
    1. mild
      1. protective emollient
    2. more severe
      1. mild topical corticosteroids
    3. leave child w/o napkin
      1. not practical @ home
3. Candidia infection
  1. common
  2. cause or complicate nappy rashes
  3. DCM of rash
    1. flexural
    2. erythematous
    3. some satellite lesions
  4. Rx w/ topical antifungal
4. infantile seborrhoeic dermatitis (common)
5. atopic eczema (common)
6. rare
  1. acrodermatitis enteropathica
  2. Langerhans cell histiocytosis
  3. Wiskott-Aldrich syn
infantile seborrhoeic dermatitis
1. cause unknown
2. eruption presents 0-2 months old
3. DCM
  1. initially erythamatous scaly rxn on scalp
    1. scales form thick yellow adherent layer (cradle cap)
  2. start on scalp
    1. spread to face, behind ears
      1. then to flexures & napkin area
4. NOT ITCHY
  1. infant not bothered by it
5. assoc w/ increased risk of subseq atopic eczema
6. Mx
  1. mild cases
    1. emollients
  2. scales on scalp
    1. low conc sulphur & salicylic acid ointment
      1. apply daily for a few hours & wash off
  3. widespread body eruption
    1. mild topical corticosteroid +/- antibacterial or antifungal mixed in
atopic eczema (dermatitis)
1. prevalence in UK kids= 20%
2. onset in 1st year of life
  1. but uncommon in 1st 2 months (unlike infantile seborrhoeic dermatitis)
3. genetic def of skin barrier function imp to pathogenesis
4. often fam hx of atopy
  1. eczema
  2. asthma
  3. allergic rhinitis (hayfever)
5. ~1/3 of kids w/ atopic eczema will develop asthma
6. exclusive breastfeeding
  1. may delay onset in exposed kids
  2. doesn't affect prevalence in later childhood
7. mainly disease of childhood
  1. most severe & trouble in 1st year of life
  2. resolves in 50% by 12 yrs old
  3. resolves in 75% by 16 years
8. diagnosis
  1. clinical
  2. possible tests
    1. elevated total plasma IgE in most kids
    2. if hx to suggest particular allergic cause
      1. also ID food & other allergens that may -> anaphylaxis
        skin prick test
        radioallergosorbent (RAST) tests
  3. if unusually severe, atypical or assoc w/ unusual infections or failure to thrive
    1. exclude immune deficiency disorder
  4. immunological changes in atopy might be 2ndary to enhanced antigent penetration through deficient epidermal barrier
9. clinical features
  1. main sx @ all ages
    1. ITCHING (pruritus)
      1. -> scratching & exacerbation (scratch-itch-scratch cycle)
        excoriated areas become erythematous, weeping & crusted
        prolonged scratching & rubbing
        -> lichenification
        accentuation of normal skin markings
  2. distribution changes w/ age
    1. infants < 2 months old
      1. predominantly face, also trunk
    2. older child
      1. frictional areas
        neck
        wrists
        ankles
      2. skin flexures
        cubital fossae
        popliteal fossae
  3. usually dry skin
10. complications
  1. causes of exacerbations
    1. bacterial infection
      1. Staph spp
        inflammation increases avidity of skin for Staph & reduces antimicrobial peptide expression
        thrives on atopic skin
        releases superantigens which maintain & worsen eczema
      2. Strep spp
    2. viral infection
      1. HSV
        less freq but potentially serious
        spreads rapidly on atopic skin->eczema herpeticum
        widespread vesicular rxn
    3. allergen ingestion e.g. egg
    4. contact w/ irritant or allergen
    5. env: heat, humidity
    6. unexplained
      1. frequently
    7. change/reduction in meds
    8. psychological stress
  2. regional lymphadenopathy
    1. common & marked in active eczema
    2. resolves when skin improves
11. Mx
  1. avoiding irritant & precipitants
    1. avoid soap & bio detergents
    2. pure cotton clothing next to skin if possible
      1. avoid nylon & pure wool clothes
    3. reduce scratching
      1. cut nails short
      2. mittens @ night in the very young
    4. avoid allergens e.g. cow's milk proven to precipitants
  2. emollients
    1. mainstay of Rx
    2. moisturise & soften skin
    3. include ointments
      1. e.g. equal parts of white soft paraffin & liquid paraffine
      2. preferable to cream when skin dry
      3. emollient oil as soap substitute daily or alternate days beneficial
    4. apply liberally 2+ times/day & after baths
  3. topical corticosteroids
    1. effective, but use w/ care
    2. mildly potent e.g. 1% hydrocortisone
      1. apply to eczematous areas 2x/day
    3. moderately potent
      1. for acute exacerbations
      2. use minimally
      3. thin application
      4. avoid using on face
    4. excessive use
      1. ->skin thinning
      2. systemic S/Es
  4. Immunomodulators
    1. in kids > 2 years old
      1. for eczema not controlled by topical corticosteroids
      2. if risk of imp S/E from further topical steroid use
    2. e.g. tacrolimus & pimecrolimus
  5. occlusive bandages
    1. helpful over limbs when scratching & lichenification are probs
    2. impregnate w/ zinc +/- tar paste
    3. wear overnight for 2-3 days at a time til skin improved
    4. widespread itching in young kids
      1. short-term use of wet stockinette wraps
        diluted topical steroids mixed w/ emollients applied to skin & damp wraps for trunk & limbs applied w/ overlying dry wraps or clothes
  6. dietary elimination
    1. food allergy may be present
      1. if child reacted w/ immediate sx to a food
      2. in infants & young kids w/ moderate eczema & gut dysmotility (colic, vomit, altered bowel habit)
      3. if failure to thrive
      4. in young infants w/ severe eczema who are only breast-fed @ same time
      5. commonest foods
        egg
        cow''s milk
        trial of exclusively hydrolysed protein formula or amino acid formula instead recommended in bottle
        fed infants < 6 months w/ severe atopic eczema uncontrolled by optimal emollient & mild topical corticosteroid use
        peanut
      6. kids usually tolerate offending food allergen by age 3-4 years
        exception- peanut allergy- persists
    2. for 4-6 weeks to detect a response
    3. do under advice of dietician
      1. so diet remains adequate
    4. food challenge is needed to be fully objective
  7. psychosocial support
    1. eczema mild in most kids & controlled by emollients &mild steroids
      1. psychosocial suport not needed
    2. eczema can be severe enough to disrupt child's & fam's lives
      1. help from
        health professionals
        other eczema sufferers
        National Eczema Society in UK

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Rashes of infancy

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	Created by v.djabatey almost 11 years ago