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OK, we're back for the second part. Um And this will be on the six common charted exanthems, meaning the six common rashes you're gonna see impedes um in dermatology for that sort of child population. So the learning objectives today are to synthesize information from case studies to make differentials for common pediatric skin conditions, to apply cultural and racial awareness in the diagnosis of childhood reactive rashes, using photography depicting a wide range of skin tones and to recall the underlying pathophysiology of the classic, the six classic childhood exams. So it's gonna be set up like a case and a little bit of description of the condition related to that case. We're gonna do that six times and it's gonna end. So case one, a mother presents to A&E with her seven year old son who returned to school two weeks ago. Her son has had a persistent cough for the past week, runny nose and conjunctivitis. You notes a widespread erythematous maculopapular rash on his neck and arm which his mother said started from his head. His mother tells you that this appeared around three days ago. Upon examination, you noted small white spots inside the child's mouth temperature, 38.5 oxygen sats 99 BPA, 101/82 heart rate. 100 and 22. Given the above. What is the most likely diagnosis? Yes. Correct. Measles. So measles, um, funny enough measles is kind of a hot topic right now because, uh, lots of parents weren't giving their Children a measle vaccination. So it's actually sort of become a bit of a little epidemic recently. Um So things to be aware of is measles have a 90% transmission rate if somebody's unvaccinated and has an airborne survivability of two hours. Uh The cysts, the symptoms, you see something called a discrete morbi form rash normally described as maculopapular and it starts with the head and it moves down to the body. Remember the three CS cough coryza conjunctivitis and then also the clic spots in the bal mu mucosa, which is shown in figure two. Um I'm gonna look at figure one for the classic nasal rush. Uh measles is contagious four days before and four days after the rash. Normally, the timeline is they have about 2 to 3 weeks incubation period where they're asymptomatic. So in the question below, he went to school about two weeks ago. So maybe he went to school and got the measles. Then he had this prodrome of three days of the three CS cough, cryer cotis, a little bit of a fever and then the rashes started to appear after those three days of prodrome and the rash kind of lasts around six days. Um There are some complications of measles. Uh The key one to know which is serious but rare is subacute sclerosing panic AIS, which is SSP E and obviously measles can lead to death in pregnant women. It can cause stillbirth and miscarriages. The most common complication associated with measles is actually an ent related one which is otitis media. How do you treat you need to treat supportively? So, isolate, make sure you're managing uh the temperature. If there's food loss, you know, replace for a loss. Um You know, if the rash is itchy, giving some, you know, lotion for the skin um and you need to make sure you are preventing the spread. So you need to isolate that person and then also contact trace. So anybody they've been in contact with D during that incubation period. And then as a medical practitioner, make sure you're notifying public health England, um the only way to prevent sort of the spread of measles is vaccinations. So Children in the UK have Mmr vaccines at 12 months and a second dose at three years and four months. Um the first dose is only 80 to 90% effective. But with the second dose, it's around 97% effective. Uh and that's, that is from the CDC. So um with some skin conditions, it's really difficult to see on skin of color. So if we take a look at the image of measles in a uh personal color. So a back uh child, it's really difficult to see the measle rash here, right? It's like it's really hard to see. Maybe you can see like a little bit of like a violaceous macular papular ration in the image which is not really red. It's kind of purply brown or along the toe torso, but it could be really hard to miss if you're not looking for it or suspecting it. So, um in this case, kind of seeing if you can think of other ways to spot the measles would be quite good. So maybe looking in the oral mucosa to see if you can see the co clic spots, um maybe asking them in the three days before they felt an itchiness of a rash or saw the rash on themselves. Cos people are most more likely to understand their own skin tone, right? People are more likely to notice when their skin looks different than uh health professional. So asking them for three days before, did you notice any symptoms like cough coryza conjunctivitis, obviously in lay person? Um And then just kind of figuring out where the rash started from and where it developed um to um that would be really good to know. Uh But yeah, it's gonna color, it's more uh it's like a pop of shoe. Um and the skin maybe might show a little bit of darkening around the area. So in skin of color, make sure you have really adequate lighting. So maybe think about using external sources of lighting to really depict those rashes to see clearly. So measles is caused by the paramyxovirus. It's more common in winter and spring. That's why we're getting a, a little bit more now and we had quite a lot in the past couple of months. Um It's normally affected the primary site of the nasopharynx. And like I mentioned, it's around a 2 to 3 week in occupation period. Uh The effectivity is around four days, either side with the rash appearance. It's common commonly uh maculopapular and erythematous and it sos on the head and works its way down. Remember the three CS, remember fever as well or somebody saying that their child just feels very hot is something to be aware of. So investigations, um you would want if you suspect measles and it's kind of hard to cos it's harder because the rash may not be very clear. You would want to do analyzer test for the measle specific I GM and I GG antibodies. This is the most sensitive 3 to 14 days after the onset of the rash. Then if that is not possible, consider doing the measles RNA, which is detected by PCR and that is taken from swabs 1 to 3 days after rash onset, Children should be kept for school for at least five days after the appearance of the rash cos like I said, the rash is uh four days after the rash that's still infective. So you want to keep them off school for five days and then you want that a supportive care like antipyretics. Last thing to know is Vitamin A should be given to all Children under two with measles. And there are other additional measures based on things like immunocompromisation and pregnancies. Um And that is depicted in table one below which uh you can look at in the images um sorry in the powerpoint, which will be sent out case two, a couple present to A&E with their 10 year old child with a history of asthma. The child was ill the day before with a fever and sore throat. This morning, his mother noticed a red pinpoint rash on his trunk which feels like sound paper upon examination unit. The child's tongue looks very red and somewhat swollen. His parents say that his tongue had a white coating over it which progressively became more red. What is the most likely diagnosis? So you've got bacterial meningitis, scarlet fever, allergic reaction to asthma, inhaler rubella and measles. So I will put the answer in 54321. So the answer is Scarlett fever and also Scarlett fever was one where I think last year, a lot of the hospitals um were suffering from Scarlett fever. There's a lot of Children um with this group's a streptococcus infection. So it's a good one to know, there's average 1 to 2000 cases of scarlet fever each winter in the UK. It's quite common and it affects Children between 4 to 8 years old. It's caused by group A streptococcus genus and this cancer, sorry, this, uh, bacteria can cause peritonsillar, abscess, septicemia, meningitis, pneumonia and osteomyelitis. So, there is a lot of complications, um, based on the infection with group A streptococcus pyogenes. So, post streptococcal complications commonly would be rheumatic fever and glomar nephritis. Yeah, I any. Ah, ok. So in the question, they did say they didn't say the words, but they said his parents say that his tongue had a white coating over it which progressively became more red. So you're thinking of like a red tongue. So they didn't mention strawberry tongue or raspberry tongue in the question. Sometimes they're a bit sneaky with it, but you kind of have to think in your head. What could that possibly be given the other clinical images? Um Sorry, clinical picture. So, yes. So look. So there's a 24 hour program. So, quite short where it's sore throat, fever, headache, muscle aches, tummy, ache, nausea and vomiting. So quite nonspecific, but the skin signs are quite different in the sense that these ones are pin head rashes that are red and really generalized and they spread all over the trunk. And when you feel it, it feels like sandpaper. So we've got a really rough texture. Also the flexures such as like the antecubital fossa will have these like things called pasture lines. Um, oropharyngeal signs. Yeah. So white coated or strawberry tongue. Um The cheeks may be flushed, sometimes there may be perioral pallor. There may be some in inflamed tonsils and exudates. Uh and that's kind of relating to the group, a streptococcus causing peritonsillar abscesses. So what's next? Once you suspect it, consider doing a throat swab, consider prescribing antibiotics without delay. When I say consider do if you think it is scarlet fever, do prescribe a 10 course of pen V. So that's penicillin v. If they are allergic to penicillin, give a macrolide antibiotic, um advise self care. So rest fluids, hygiene, paracetamol, exclude the chi child from nursery or school. And also it is a notifiable disease in England. So notified public health England. So here are some images. Um So in the classic uh sort of caucasian or light skinned individual, um it would be that sandpaper, pinpoint sort of rash. Um you may get some patons that exudate um and some of the sort of pinprick sort of things in the oral mucosa and you might get those sort of flushed red cheeks. However, in a child of color, it's really hard to see. But in the abdomen, there's slight pinpoint rash that is quite generalized over the body, but it would be hard to um be aware of it if that wasn't what you were thinking of, if you weren't thinking of scarlet fever, you may miss it. Also, this tongue is, uh, a scarlet fever tongue. It's a little bit more red than the normal tongue of the child and it has a white coating but it may be missed. Um, if people aren't sort of have a high clinical er, index of suspicion. So, investigations, um, so obviously history examination. So, fever, sore throat, headache, fatigue, nausea, vomiting, uh, a branching red pinpoint rash develops on the cheek, um sorry on the trunk um and feels like a sandpaper like t texture. And then you have pasty lines which are accentuated lines in the flexures of the body. Uh examination, you may see strawy tongue, some, you might palpate some cervical lymphopathy. You might observe a flush face with some circum oral pallor or paleness around here. You might have some pharyngitis. You may have some ti i um small spots on the hard and soft palate which you saw on the image before. Um And then really good investigation to do would be the throat swab, which should come out with a group, a streptococcus pyogenes, but you wanna do the swab prior to the treatment treat as soon as you do the swab and then obviously get the results and um adjust treatment accordingly, but get the swab before you give the pen V or the macrolide and then see the results uh management. If it's severe, you want to give urgent hospital admission, but most Children can go home with PV. Um phenoxymethylpenicillin for 10 days. Case three, a six year old girl comes into the GP with her father as he has recently noticed some new red rashes on her skin. The father reports that his child has been suffering from headaches and a very bad fever. He also says that there are some small lumps felt around her neck. He said the rash started on his on her face and then passed down over her body to her feet. As a GP you know, pinpoint red macules and tei on her soft palate and uvula, her joints hurt and she has trouble breathing. There is associated tender around her eyes and posterior auricular lymphopathy. What is the most likely diagnosis? So that may be a new one to some people, but it's something called rubella, mumps, not quite mumps, it's rubella. So rubella, uh the rates of the UK are very, very low. So it's only around three cases in 2018. Uh rubella is normally uh given protection is normally given via the Mmr vaccine which is at 12 months and at three years and four months. Uh like I mentioned, the first, Mmr for R for rubella is 97% effective and then the second course is 99% effective. The incubation period is around 14 to 18 days medium, but it can range from 12 to 23 and it's uh t through inhalation of large particle aerosols So symptom wise, you're looking for a maculopapular rash and minimal systemic symptoms. The pa the exanthem. So the rash is normally pinpoint pink macular papules that start on the face and spread cordially to the trunk and extremities. This becomes generalized over 24 hours, but it only lasts around three days. The most common things that occur is arthritis and arthralgias. So think any mention of bone joint pain, um muscle around the joint pain. You're thinking maybe rubella in a sort of a pediatric dermatology, um clinical case. Um and something to be uh aware of complication wise, post infectious encephalitis occurs. Uh This is rare one in 6000. This is more common in teenagers than adults. Uh and this is usually following one week after the rash, progressive rubella, pan cephalitis can also happen. Um This is a bit more common in pregnant women, congenital rubella syndrome in the fetus, uh can occur if the mother deer contracts. Uh, rubella treatment again is supportive, but yet again, it's a notifiable disease. So you need to contact public health England and below, you can kind of have a look at the rash. It looks a bit more salmon pinky, in my opinion and it's a little bit more pinpoint it. Um So yeah, it's a bit more pinpoint, bit more some and pink in color. So, rubella is self limiting benign illness occurring in adults and Children worldwide. It is caused by the rubella virus and spread by alb airborne transmission or droplet. The incubation period for rubella is around two weeks after which a program of headaches, fever and lympho toy, which is a key feature as well can occur. Um And the infectivity period is typically from seven days before to around seven days after the onset of the characteristic rash, rubella, salient points. Um part two rubella is most commonly associated with the characteristic macular pacha rash, starting on the face and passing over the body to the feet. In addition, you get fever, tender osal and auricular lymphadenopathy. Those are really common. So if uh you get a pediatric dermatology case where the patient has posterior auricular lympho dermopathy, you want to consider rubella, like I mentioned uh joint pains or arthritis, arthritis are really common. Uh There might be some respiratory involvement and you might get something called for spotss. Uh These are pinpoint red macules and te I which may be seen on the soft palate and uvea. So those are the red spots that kind of are like around the uvea and soft palet um in the mouth. And those are called for shyer spots investigation. Obviously, if you can do it clinically, that would be great, but it's really hard to distinguish from other viral illnesses uh such as Parvovirus B12, measles, dengue and HH B6. So you want to rely on clinical or lab sorry, laboratory confirmation, especially if it's uh during pregnancy. You don't want the risk of uh congenital rubella syndrome because the potential consequences of the fetus are really bad. So yet again, do immuno G and immuno gobbling um Eliza um like assays for the specific um rubella um virus. So it's not viable to public health England. Um and do this based on clinical suspicion, Children with uh rubella shoulder remain off school for at least five days from the onset of the rash. And women should always avoid, you should always tell them to avoid pregnancy after three months after immunization with rubella. And these are a list of complications here. Uh So, congenital defects can be caused by congenital reverse syndrome. Um And the highest rate is if this occurs within the 1st 12 weeks of pregnancy. There are some other uh complications associated listed in the table. One here, case four, a mother brings a child to the GP complaining that her child has had a rash which began on the chest and has since spread to the back and face. The rash is itchy and it consists of fluid filled blisters, some of which have turned into scabs. The child is febrile and is not up to date with vaccinations. What is the most likely dia diagnosis? So you've got measles, scabies, chicken pox, varicella, sepsis and roseola infantum. Good. We've got chicken pox in the comments. Brilliant. So chicken pox is caused by varicella zoster virus. VZ V. This is the average incubation period 14 to 16 days. There's a mild program of fever malaise and 1 to 2 days prior having the appearance of the rash. And this program however, is quite often less common in Children where the first thing you will notice is the rash. The rash is quite distinct in the sense that it's itchy, really blistering and this turns into scabs, um especially scabs called panc corporal varicella lesions. Uh notes there is a possibility of reactivation of latent infant um varicella zoster virus. This as adults is called herpes zoster virus. And this will cause shingles which is very dangerous in adults. So this is the classic look of chicken pox and they will have these fluid filled vesicles which can scab um over and crust investigations. So chicken pox is a little bit easier to diagnose than the other one. So you can do it by uh examination and history. If it's still hard to identify, you can do the PCR testing for the VZ V virus. Um or you can do DFA testing management. Normally, there's not much medical management needed. It's kind of based on the symptoms. Uh the patient has that you want to support. So for example, antihistamines for the itching, paracetamol for pain and fever Cine lotion for the itching, cool bath with baking soda, aluminum acetate or oatmeal. However, if it's a really severe presentation and it's happening within the 24 hours of the onset of the rash, you can give a, a Aciclovir, aciclovir. Yeah, Aciclovir. So case five, there was a spelling mistake in the last one. That's why I said it wrong. A two year old boy presents with fever and nonspecific symptoms on examination, his cheeks look uh like they have been slapped. Uh This is more accurately described by the GP as a confident erythematous edematous rash with patches or plaques on his cheek with sparing of the nasal avial bridge and the periorbital areas on trunk and lib inspection. There is a maculopapular rash with some lacy areas. The mother tells the GP that her child often winces in pain when moving his joints. What is the most likely diagnosis? So we have eryth erythema multiforme chicken pox, Steven Johnson syndrome, erythema infectiosum and our erythema ab in. So we've got a erythema multiforme. Shall we have a look? Not quite, but you're on the right line. So it's something called erythema infectiosum. So, uh this classically presents um as a rash like on the face and the baby looks like they've been slapped. So sometimes it's called slapped cheek syndrome and if and it affects the face, but it tends to spare the periorbital area. So the area around the eyes are normally spared and the nasal labial fo folds. So this sort of area on the babies, um I tend to be sort of spared, but their cheeks are really red. So they look like they've been slapped. So it's caused by Parvovirus B12. So sometimes it's also known as parvovirus B12 infection. It's spread by respiratory droplets or can be passed from mother to fetus or in blood transfusions has a 4 to 14 day incubation period with a maximum of 21. And the efe effectivity starts as soon as there is exposure to it and the patient contracts it and it lasts all the way until the symptoms appear. So, yeah. So classically, it's known as Slap Cheek syndrome because of the facial appearance. Uh the rest the rest of the body. The distinguishing feature is that there are lacy white, sort of white lacy bits around the maculopapular rash. Um when the rash fades uh clinical associations. Another one key one is arthropathy, arthropathy. So, joint pain, Henoch purpura autoimmune disorders and a bunch of other ones listed below investigation. We don't need many uh if they're pregnant or immunocompromised or have a hemo glomer patients should um sort of receive I GM antibodies around 10 days, uh lasting max three months or sorry, they shouldn't receive it, they should get the testing for it. So the Ezer testing for either IgM or IgG G. So it just depends on when you do the testing I GM around 10 days and I GG around 14 days onwards, management is like all the other ones, mostly self limiting, give things like analges for joint pain transfusion for aplastic crisis. So, um erythema infect shows some tensor affect red blood cells a lot more than the other conditions causing various forms of hemoglobin hemoglobinopathies. So they might have um a aplastic crisis. You wouldn't wanna treat that, you know, giving the appropriate management. You might want to give vi GS containing pooled neutralized anti uh Parvovirus B 19 antibodies. These are for patients who are immunocompromised and if they're pregnant, refer to an obstetrician for regular monitoring and follow up and finally case six. So a parent brings their eight month old child to Ed after they've developed a rash. Upon examination, the rash is widespread on the chest and neck as well as the child's shoulders, thighs and buttocks. Her temperature is 39. Upon examination, the rash is a mixture of pink macules and papules surrounded by a fine white halo. You notice some swelling of the cervical lymph nodes given this, what is the patient's most likely diagnosis? So, acne rosacea shingles, measles, rubella, roseola, and phantom. So we've already done two of these. So you got a more higher chance of getting this one correct. Pop your answers in the chat. E Yeah, really good. So, Rosie in Phantom, so Rodeo Roseola phantom is caused by the H HV six virus. So herpes virus six, sometimes it can be caused by the herpes virus. Seven normally affects infants. So this is one where it normally affects six months to 18 month year olds. Um incubation period is 5 to 15 days, key features would be temperature that like goes up, but it falls rapidly, very quickly on the fourth day and it's quite a high temperature that they get up to and then it just rapidly falls pharyngitis. So, like, you know, sore throat, lymphadenopathy and around the face and neck. Um And then the rash looks rose pink. It's macular and it's surrounded by these fine white halos. So an exam questions just look out for fine white halos and this often disappears within two days. So it's really hard to appreciate here. Um But it's a bit more macular. So it's a little bit more wider than the other ones we've seen. Um And there would be some fine white halos around in skin of color. It's really hard to appreciate it and it could easily look like, you know, something like a allergic reaction if you are aware. So it's a little bit harder to see in skin of color. Um But it's usually that macule and then you get kind of like a lighter skin tone between the macules investigations, clinical diagnosis based on examination inspection. Uh and in line with the history management, supportive give antivirals for immunocompromised individuals. So IV immunoglobulin, IV immunoglobulins, but beware of contact with pregnant women and Children under four weeks of age. So overall, I hope you've been able to synthesize information from case studies to make differentials of common pediatric skin conditions. You've been aware to apply cultural and racial awareness in the diagnosis of childhood, reactive rashes using photography, depicting a wide range of skin tones. And you should be able to recall the underlying pathophysiology of the sixth classic childhood exanthems. Um If there's anything that you take away from it is all the time, it's a lot to do with the clinical picture, the history. And if all that fails, think about doing an adviser test or a PCR, any questions, do we have access to the slides? Yes. As soon as this is over, I will um I'll put the slides up on our uh the K CL ACMS uh medal page and you should have access to them. Um I'd really appreciate it if you uh completed um an evaluation form. One for the UK MLA one and one for the pediatric Dermatology one. It would be so useful to get feedback. Thank you very much. Any more questions. And here are the references, the feedback link I can pop here right now.