doctor i'm a pediatric doctor and i'll just be going through a few sbas relating to elements of pediatric dermatology coupled with a few questions with children who have rashes and fevers okay so we'll get started and um feel free to ask questions i'll probably better advancing things from pediatric perspective than a dermatological perspective um and i'll answer any questions at the end but feel free to post them okay so as said we'll cover things um relating to pediatric dermatology and some of those will cover um rashes in children who are federal now just due to copyright issues i don't have too many images on this um powerpoint um but all the images are copyright free or they've been taken with creative commons licenses most from wikimedia commons but right at the end just for those of you that do want some really good resources that you can access online or by your libraries i will signpost you to a few really good places to go so um i i offered to put this talk on partly because i think pediatric rashes just seem like a complete um minefield of a topic either when you approach things from a histological perspective it's all a pink mess and then when you look at a child in real life in clinic that's also just pink and blotchy as well and it's really hard to distinguish between all of these things on gross inspection straight away so i think the first thing to point out is a lot of the time no one's expecting you to get a spot diagnosis and actually for those of you that are purely assessment-minded um you might not even get provided a picture in the first place and that's because the key to tackling this topic is understanding the natural trajectory of the conditions so knowing the detail of the history knowing where the rash starts where it spreads its texture whether it's accompanied with a fever or not where does the rash go in in relation to the fever all of these things will be really helpful in helping you get the diagnosis and actually it's really satisfying once you know these conditions really well because when you then are confronted with the child actually taking quite a detailed history pretty much nails the diagnosis sometimes before you even get to look at the rash and it does map out clinically really well so i would encourage you to not just focus on very quickly doing a spot diagnosis because a lot of the time you might not be able to but actually paying some attention to the more sort of theoretical aspect of it as well okay but i think it is daunting it's daunting for medical students it's daunting for foundation doctors it's daunting for junior trainees and even right up until as you become quite senior i think rashes are a bit of a worrisome topic for a lot of people but it's worth getting the basics down and those go a long way okay so we'll start off with the first question so shall i give you a minute or so to read this and answer the question and then we can pick up again but it's a four-year-old boy with a rash on his face his arithmetism weepy and he's got a slight temperature and it's asking what is the most appropriate treatment um shankar are we going to launch the questions so um yep so i'll launch it i'll give them like one minute 30 because then it blocks up the question when you put it on sure um should i end the pool now yeah i think i'll spend plenty of time okay oh i think the options yeah um i think for the next question we might just need to write abcde and so just one to five is ate in that order all right cool um so um okay so we've got a range of responses um there's pretty much an even split between the middle three options b c and d um and then each we're around 25 to 30 percent of you have gone for each of those and roughly 10 to 15 percent of either one of option a or e so the correct answer here is d okay so um this here is a the diagnosis the child has here is impetigo and the description given in the question was quite a classical description so um impetigo is a rush that's typically caused by staph aureus but it's also caused by um streptococci as well and it typically starts off around the mouth of the nose but it can usually then spread to other areas of the face in particular um it doesn't also it does not be confined to the face either and the reason um it has that golden crusting is very classical of staff aureus so for anyone who might know some latin aureus and aurum i mean gold of that um same root so um for the most part most staph infections if they are simple they can be treated with fucilic acid which acts similarly to flucloxacillin but you might also see um some doctors giving flucoxacillin as well okay so either pieces that fused that constant of fluoxacillin would be a valid answer and the key thing to note with impetigo is that it is highly contagious okay so for that reason um you want to essentially advise the moment you see somebody with impetigo that they should be isolated from school or work and they should not share towels at all and really not be sharing like pillowcases or cushions and things like that and they should be isolated until either the lesions crossed over or until they've had 48 hours of antibiotic therapy okay um just to quickly explain why the other answers aren't correct so paracetamol would be helpful in maybe in regulating temperatures but um in pediatrics we don't tend to really give paracetamol unless it's really affecting the child and that the temperature is over 38 a cyclovir is used for viral infections so that would not apply to impetigo hydrocortisone does have some role to play in impetigo though it's not commonly used and you wouldn't use hydrocortisone in isolation for the most part you would give fucilic acid or fluke oxygen and that will suffice and chlorhexidine and neomycin um well you know typically use things like that for like um mrsa and things and once again we do not use anything like that for um simple first line treatment for impetigo okay so going on to question two i'll give you a chance to read that and answer the question okay so the most popular answer is um half of you guys going for option c seven days and then around 20 of you going for option d and roughly 10 percent each going for the others so the correct answer in this case um is actually e okay so the diagnosis here is chickenpox and you can see here some vesicles at different stages some have dried over crossed over some at first and this is a fairly classical question and it tests knowledge test knowledge in different ways so it's asking you to pick up those chicken pox and then you need to have some knowledge of chickenpox in particular over firstly how long the incubation period is and secondly when people can become infectious okay and this forms key part of counseling parents of children who have chickenpox so um chicken box also caused by the processed varicella zostavirus um its incubation period can be up to three weeks okay and people become infectious from a couple of days before they first start getting the lesions appear okay and they remain infectious right up until the very last vesicle is crusted over so it's quite a long window okay and there's these are key bits of information today when counseling people and you essentially have to keep someone off school or away from work um until the very last lesion is tried over now for chickenpox for the most part treatment is supportive okay we do not give anything other than maybe um an antipyretic which will usually be paracetamol for children with chickenpox and the only reason we might give a cycler there is if somebody is an older teenager if they present within the first 24 hours we can give them a cycle of year because there is some evidence that reduces the rate of complications but otherwise treatment is primarily supportive which essentially is just trying to get the children to avoid scratching um the evidence isn't too strong for using antihistamines we definitely do not use things like calamine lotion anymore so it's just a matter of trying to distract the child and just control any temperatures there is a vaccine available and depending on where you are from around the world um and where you're listening from um you might have had the vaccine but it is not routinely on the uk schedule though it is available in places like australia and in the middle east in particular [Music] but it is a very common infection and it is one worth knowing about so question three this is a slightly tricky one i'm probably because the image isn't the best quality but hopefully some people can pick it up it's more of a stretch and challenge question okay and we've got another mix of options here so once again there's around 25 percent of you've each gone to options a b or c seven percent option d and 14 for option e so the correct answer here is actually e okay so um the rash here scene is a rash that covers the face goes up to the nasal bridge and it also covers the eyelids as well okay we can slightly see that the this is the arithmetic area and this is what this girl's normal skin is like okay so the diagnosis here or one that would be one of the primary differentials especially given that it's a face on her rash and then there's a similar rush on her hands is um the mata myositis or in this case this is pediatrics juvenile dermatomyositis now jdm doesn't typically have a characteristic antibody it does have something called myositis specific antibodies um and those are only present in around 50 of cases okay um but none of these options here are more likely than the esr to be raised so an anti-streptolysin oh tighter and that's for streptococcal infections the ana that could potentially be raised but not commonly um and that's more commonly seen in lupus but you also have to bear in mind that a a is a non-specific antibody and we also have to consider what tighter it is as well so probably when you cover rheumatology and you'll learn a lot more about that um anti-dns dsdna is once again for lupus and anti-bergdorferi antibodies are for lyme disease okay now the reason these options are here is because these can all be conditions that do cause a facial rash okay so just um it was tricky to find um copyright free pictures of children in particular with facial rashes so you'll just have to use these ones um but one thing you might want a typical question lots of people ask is how might you distinguish between lupus and jdm um i think at your level the key thing to bear in mind is the classical history and classical presentation will be jdm classically includes um the eyelids and you get that heliotrope rash um but of course lupus would be a differential for this condition for this presentation as well depending on your medical school some may want you to learn the sle diagnostic criteria i do think that's a bit harsh um and just bear in mind which adm you don't typically get the majority of patients having auto antibodies and if they do there's something called myositis specific antibodies other conditions you might want to consider with diffuse facial rashes when you're reading up is parvovirus b19 where they get bright red cheeks scarlet fever um erysipelas which is caused by a group a infection and lyme disease okay so this is an example of aerosplash and then this is also um sorry this example starts even the other ones of aerospace okay question four okay all right so the most popular answer this time is option b forty percent of you going for it and then twenty five percent of you have gone for options a and c with a handle for the last two options as well so yes um the correct answer here is a lumbar puncture okay so over here you've got the febrile child so any child who's born under three months of age must be brought into the emergency department okay and they must have a full medical assessment now the key thing we're worried about here is sepsis and neonatal sepsis in particular okay and if you are worried that the child is quite unwell and you cannot very readily find a clear cause for why they might have these temperatures such as let's say corrosive symptoms which means they've probably got something quite benign you do need to do a full septic screen and part of this includes doing blood cultures and a lumbar puncture and given that the boy is around two months old you probably can also do a urine culture as well and those would be your baseline investigations okay we do not routinely do stool microbiology as part of the septic screen unless you have reason to believe that there is a gi source and you're worried about it and likewise an abdominal ultrasound wouldn't really shed much light either and we wouldn't typically do an mri head or ct abdomen um for this presentation unless we thought there was some sort of introductory pathology or we were really worried in which case we might do a ct head but not an mri head in the acute setting so the key thing to bear in mind with neonatal sepsis is that any neonate with the temperature you must cancel you must tell parents before they leave the maternity unit that if they do have a temperature do bring them in to the hospital where a emergency medic or a pediatrician can assess them and depending on their age will depend on which of the investigations we do but as mentioned typically we'll do a blood culture and a lumbar puncture and especially if they are if they've left the hospital and they've come back you'd also consider a urine culture but if it's the first few days of life um the nice guidelines advise against doing a urine culture because it's rarely a uti okay you would only do a chest x-ray if you think there is a chest source so your first do a clinical examination and only if you want further confirmation of the chest source and your examination findings point towards the chest would you do a chest x-ray otherwise we tend to avoid ionizing radiation in pediatrics and then of course you just want to find any other source of bugs so if you think there is a bit of skin or somewhere else that is infected you would swap those areas now your empirical treatment so for neonatal sepsis for newborns um you guys will have learned it's been pan and gent but if you are at all worried about meningitis and especially as they've come out of hospital now um most hospitals will have empirical treatment of a cephalosporin and amoxicillin so we tend to use kefir taxes neonates um especially rather than keftrox and partly because kef triaxone displaces bilirubin from albumin and that's a worry for neonates given um the immature blood brain barrier and there's risk of them developing connectors so kefir taxi is the preferred catholic sporin and we tend to use amoxicillin to cover the rare instances of listerial meningitis okay but most typically you'll see this as the empirical treatment but depending on where you are you might want to check your local guidelines or to medical school teachers for what they say the empirical treatment should be okay but the reason we do this and the reason we go all guns blazing is because neonatal sepsis is really hard to find the source based on clinical history so that's why we do need to be quite invasive with finding these getting microbiological samples of lots of different potential sites of infections okay okay so 45 percent if you've gone for option a 27 for option c and then roughly an even spread for all the other options so yeah well the correct answer here is discoid eczema okay and the key things that give this away are the fact that there are multiple lesions of a similar nature they're circular of a discord shape and that they're very pruritic okay um discord lupus is unlikely given that there's no mention of any other systemic features so you wouldn't make the diagnosis of disco lupus um purely in isolation tinea corpus may be another one but we don't typically tend to see it in people of this age and typically we don't tend to see so many lesions of this nature okay but it too is also itchy and quite erythematous and the other thing that points away from it is the fact that um you can see this picture and tinier corpus tends to have a very marked erythematous ring with some very um slightly normal skin in the middle okay but this is um quite classical of a discoidx eczema okay and gut takes psoriasis um so garlic means like raindrops so you would actually see lots of tiny red lesions across the surface and they wouldn't tend to be six centimeters in diameter and warts um i think we'll just take a look at some pictures of warts um they wouldn't tend to be this speckled they tend to get like very discreet um well circumscribed lesions okay so the most likely um diagnosis here is discoid eczema okay so the key thing to bring in mind with eczema is that it is itching okay and discolored eczema in particular is very itchy now for the most part um the way we manage discolored eczema is the same way we manage just normal eczema okay and you just go through the same ladder of treatment with regards to emollients and steroids so the key things to know for eczema generally and this is essential knowledge for um anyone treating children um is you need to know a bit about emollience and how to apply emollients and then you got to know a bit about emollient and steroid ladders so you then you start off low and you then go up okay and if the child does need a lot of steroids so it needs steroids quite frequently this is when you start going to specialist territory and you can then start prescribing steroid spuring agents and going way down the line um there are therapies such as infrared therapy and monoclonal antibodies that are now licensed for children but once again you need specialist authorization for that so the final points there are just something to bear in mind in the back of your head um but the key things to know about are how to use and counsel about emollients and steroids the other thing to know about eczema is that and we're worried about it because of a lot of the complications so you can have superimposed infections on top of the eczema because essentially your skin is a really good protective barrier and the issue with eczema is that it causes breaks in your skin so the most common the most classical bacterial supreme infection on top of eczema is a staph infection purely because staph is the most common commensal bacteria on your skin and the most common viral infection is herpes simplex virus so this is what we call eczema hepatican now both of these can make you really unwell and they can produce like a bacterial or viral sepsis so you can become really unwell with this um the other key complication with really widespread economies the risk of dehydration because once again you're having a break in your skin and there's also a rare complication of eczema called erythroderma which is an emergency the final thing i put in here is something to bear in mind which is that eczema is really itchy and it is really really intrusive to people's lives and it can actually disrupt sleeping and this is something well worth asking about it's actually mandated in the nice guidelines for x-men children that you should actually ask about if the eczema affects the child's sleep because this actually does form part of assessing the severity for eczema so that's worth bearing in mind as well and obviously having sleep disrupted will affect their behavior their concentration their performance in school and a lot of other aspects of their life so it's worth keeping an eye on that as well okay and then the other thing worth mentioning with eczema is the fact that like with almost any dermatological condition it's very visible potentially and that can make them make patients highly self-conscious about their skin their appearance and it can have a psychological impact as well so sensitively exploring that is also really important going on to question 6. okay once again got a good spread of answers so one third of you have gone to option c or option d and around a quarter of you have gone for option b with a around five to ten percent of options a or e now the correct answer here is um streptococcus so this here is a classical description of scarlet fever and the key things that point towards this are the fact that there is this facial rash and the thing to pick up is it's macular popular but the fact that it is rough and you might often read in textbooks that the scarlet fee brush looks and feels like a sand a red sandpaper rash and this is quite classical and what helps further reinforce this is the fact that it's not near her mouth on the so it's what we call peri-oral sparing so you'll see people with bright red rash on their face quite rough but around the lips and mouth there is no rash okay but when you do look at the oral cavity it is bright red okay and all of these things can be keeping with scarlet fever coupled with the fact that it's often caused by a streptococcal infection often starting off as a throat infection and so you will get palpable cervical lymph nodes now private virus can also cause a facial rash as mentioned earlier it typically doesn't make people this unwell and the rash is not so rough and so we don't tend to wouldn't typically associate this with parvovirus measles um it is macular popular though once again we don't tend to see as rougher rash and measles often it comes coupled with um the 3c so you have a cough and conjunctivitis and then what you also have with it is it typically starts off by the ears or the face and then spreads down the spreads down the neck and across the torso okay kawasaki disease once again this might have some appearance of kawasaki disease and the child's been prepared for three days so not the classical five and the issue with uh kawasaki disease is that children of kawasaki disease are really really really unwell so the fact that the child is relatively active is a very positive sign and typically if ever you positive differential of kawasaki disease to pediatricians all they do is often take a quick look at the childhood the child is often sitting up and playing you'll often be told that they're a bit too well for kawasaki disease okay but um the description here does tick some of the does superficially take some of the boxes for kawasaki disease but doesn't quite hold up to inspection and herpes syntax virus so um no it's not in keeping with herpes simplex normally the description you have for that would be you'd see one or two vesicles or you might see a cluster of lesions most likely around the mouth or around the lips which just doesn't fit the description at all so yeah the most likely cause is streptococcal infection okay so um scarlet fever caused by streptococcus otherwise known as second disease um i'm sure you guys all know you treat streptococcal infections with penicillin as the first line treatment some of you might find this mnemonic helpful for scarlet fever um you know it's caused by strep infection which typically um might start off as a sore throat this is the perioral spiraling i was telling you about you do get a rash you can get lymphadenopathy um complications of some of the infection is driven by an erythrogenic toxin and the tongue can also be bright red as well okay and um depending on where you're taught about infectious diseases or dermatology or just a lot of these things um complications of strep infections can be wide-ranging which is why we really want to get on top of these infections when we pick them up and it is not uh something to be taken lightly these while a sore throat might seem quite benign and the complications are awful so yeah it can locally complicate to an abscess but afterwards you could uh after the primary infection you could get post-traumatic glomerular nephropathy um and that is where the you know the antibodies um against the streptococcal bacteria antigens accumulate in your glomerulus they get stuck and then they activate your complement pathway and it causes a lot of renal damage you can get rheumatic heart disease due to molecular mimicry and that can knock people into heart failure and you can also get reactive arthritis and a rare complication is something called citizens korea where you essentially get sorry i forgot the mechanism of this now but you essentially get um a reaction happening in your brain i'm not sure whether it's i think it is autoimmune mediated um and it results in some movement disorders but that is quite rare now thankfully all of these are rare due to penicillin um you now pretty much in the uk never hear of people getting rheumatic heart disease or certain career and very rarely do you hear about people getting post-trapped cochlear glomerulonephritis question seven okay okay so um one third if you have gone for option c ray syndrome and then there's a roughly even split between options a b and d and ten percent of big one for options e so the correct um so the diagnosis here is firstly this child actually has kawasaki disease okay and we'll go through the options but the correct answer is a peeling skin or you might see this in your textbooks as destimation disclaimation okay now we'll just go through the other options so rheumatic fever is not something we typically see in kawasaki disease um that's as that was from the previous question where you might see it following a streptococcal or a poorly treated strap infection um the cardiac complication of kawasaki diseases coronary artery aneurysms okay and those in turns can cause other complications including st elevation in children which is probably one of the only causes of doing so rey syndrome is not typically seen with kawasaki either so ray syndrome is a neurological condition that is um that's poorly understood actually there is some asses there is some association with between the use of aspirin um in children while they have a viral infection and the development of ray syndrome so it's for that reason we do not give aspirin to children but we wouldn't expect somebody to develop ray syndrome if they have kawasaki disease thrombocytopenia is not correct either we'd actually see a thrombocytosis with kawasaki disease and we would not see a plastic anemia either so the thing that might cause a rash and a fever and somebody getting an aplastic crisis at least transiently would be something like a pathovirus b19 infection okay but the typical thing you would see with kawasaki is peeling skin and this does not happen early on this is actually quite late on into the disease as they're recovering they will often especially on their hands and fingers um you'll start to notice that the entirety of the skin on the hands can be peeled away and it's quite it's quite interesting to see it's quite satisfying after reading so much about in the textbook but it is quite a late stage sign so you will never make a diagnosis of kawasaki based on this and just to reinforce the point children with kawasaki disease are really unwell they're essentially flat so in this case he's had fevers for five days and the classical history you often get is pediatricians will imperially start treating them for infections quite serious infections but despite this their crp will not go down partly because the inflammatory process is not being driven by a bacterial infection but by an autoimmune condition so kawasaki disease um the mnemonic i've always found helpful there's quite a lot of mnemonics to memorize the elements of kawasaki disease but the one i've always found helpful and quite satisfying is crash and burn so to make the diagnosis of kawasaki disease classically you need somebody to have confirmed fever for five days okay and you need four of these things so the conjunctivitis okay is a non-oxidative concentritis there must not be any discharge from the eyes the rash can be pretty much any sort of rash that does not have that's not a bullish type rash um adenopathy is cervical i do not think and it's usually unilateral and then you get a strawberry tongue as well so you get cracked lips and a bright strawberry tongue and it's called a strawberry tongue because you can almost see the papillae being really big so it has the appearance of strawberry and usually there is a rash or swelling of the hands or the feet okay so this is what makes the diagnosis of kawasaki i put incomplete kawasaki here is a red stamp purely because um there's been a move to try and get people to make the jump towards kawasaki disease a lot earlier on to minimize complications so you might see some people say somebody has incomplete kawasaki if they match most but not all the criteria here and that's something you might come across on the wards when you discuss things with your consultants now the treatment for kawasaki disease is high-dose aspirin and ivig okay and one of the main complications we watch out for is coronary artery aneurysms so if you do suspect somebody has kawasaki disease um you do need to get them an urgent echo by a pediatric cardiologist and if they do have coronary artery aneurysms they will then need to be under surveillance [Music] question 8. okay got quite a spread of options so a third of you have pretty much gone for options a or d and 15 percent of you have each gone for options b and c and um under five percent of your contraption so um the description here is actually of quite a well child who just seems to have a non-blanching rash um primarily along their legs um so in the child and we can see that their observations are normal and they're the flu like illness a little bit earlier so um the key thing to point out here is that not every person with a non-blanching rash has you know what you're classically almost behavioristically trained to think about is sepsis or meningococcal septicemia so um you know we wouldn't typically give keftroxane to somebody fitting this profile um another reason for non-parching rash which is the instance in this case is um itp okay and the classical description of somebody with itp is often a child and they often have had a flu-like illness sometimes up to like one to two months before the rash develops and apart from these non apart from this fine non-blanching rash they're otherwise completely well okay and if you have itp that means you have low platelets and essentially it's immune mediated so immune thromboside to penic purpura and with due to low platelets you get all of these micro bleeds that end up forming the non-blanching rash and if you get lots of them in the same place that's when they will merge so that's why you start seeing the confluence now for the most part the management for itp is purely supportive okay we do not do anything we if they're happy with them we discharge them and give safety netting advice the only time we might do something is the platelets are so low that we might consider giving iv ig or steroids but i've seen children with platelets as low as 20 something's going towards 10 and even then we've held off okay so for the most part we don't give any treatment the one time you might want to consider doing something is if there's a history of a catastrophic injury or when you give safenet advice telling parents you won't do anything you will tell them if they do fall over or like bang their head please bring them back as we will need to monitor them and assess them so you just want to make sure they haven't had a bleed in the brain now what we typically would do is we would send them home and we'd have a repeatable blood count usually within one week's time and that's for two reasons one is to make sure the platelet count is slowly rising and that it is not at minimum it's not plummeting furthest down and the other thing is what could be diagnosed as itp could actually be the first press or the first element of bone marrow failure so this could be the first sign that somebody has something like leukemia you know so as part of bone marrow failure you have white cells red cells and platelets and the low platelets could literally just be the start and then perhaps after serial monitoring you start seeing other elements of pancytopenia okay so you'll want to monitor them and just to repeat for blood count in a week a bone marrow biopsy would be indicated only if you had strong suspicions of somebody having some sort of like bone marrow source of things like malignancies would be the main one and once again you wouldn't jump to that straight away and nor would it absolutely feature in somebody presenting like this so i put this question here just for you guys to think about non-blanching rashes um and consider that there are lots of other differentials for it so um when i teach medical students about this this is a list that often comes up and that's fine and i think a lot of you might try and learn things this way but if you look at this list the diagnoses are generally quite quite separate and if you know the basic history of each of them it's quite hard to confuse them so i would recommend when you try and look at non-blanching rashes is to focus on the history and the history will pretty much rule out most the other options okay so we have itp hsb does have that characteristic non-blanching vasculative rash along the buttocks on the lower limbs you can get it from trauma or non-accidental injury and that is something to always consider okay and um one thing to bear in mind is that you can't get a particular rash after prolonged vigorous coughing so if a child is coughing a lot or if they've got something like a human cuff they can get petechiae especially in the superior vena cava distribution so if they're particular from the face and the neck that is because the raised pressure and you get all these micro bleeds but that is essentially a form of trauma but it is not itp nor is it a form of abuse okay so that's just something to bear in mind and then finally um yes a non-blanching rash can feature as part of somebody who has um sepsis of any sort so you will typically people often say mention cochlear septicemia um but just bear in mind only one in three people um classically used to get in non-blanching rash when they had meningococcal septicemia so most wouldn't yeah so it is not necessarily reassuring if they don't have a rash but um the prevalence of meningococcal septicemia is rapidly going down and partly because we vaccinate against so many different strains of nicer meningitis okay but it's important to bear in mind that essentially any form of sepsis can cause a non-launching rash especially if it does progress towards developing lots of different cardiologists like dic okay but this is just something to keep in mind that um i think a lot of medical students often see the word non-launching rash and they jump straight towards sepsis and jump straight towards kept track saying that there are other things to take into account as well and pediatric sepsis is a hot topic it's always a hot topic unfortunately we it's a clinical diagnosis we don't yet have a magical test to say whether somebody's septic or not this is a graphic produced by um a medical education group called medicines who have lots of great resources so it's worth checking them out um and the latest guidance have actually updated so you actually have three hours to initiate the pediatric substance six if you aren't sure if the child is septic or not if you have a strong suspicions of a child being septic you should do it within one hour but the latest guidelines have been updated since this graphic was created a few years ago and you have up to three hours okay but the key thing to note is that the pediatric substance six is slightly different to the adult ones and the key things to know is that part of it is a senior review that forms part of the six and obviously you will not be doing this as f once but children with sepsis true sepsis tend to deteriorate very quickly so there's a consideration which your registrars will be doing to consider inotropes early okay but all the other elements are the same so that's just something to bear in mind final question okay so sixty percent of you have gone for option a um 15 for option e and then roughly 10 for the others cool so the correct answer is option a okay so the diagnosis here is rosiola okay and that is generally a very benign viral infection um the key thing is the history here so somebody having high fevers being quite irritable and then once the fever subsides so in this case there has not had any rashes since the rash there sorry has let me start again the key thing here is when children have a high grade fevers are quite irritable and then shortly after the fever subsides they then get this widespread macular papular blanching rash that is not itchy and that is quite in keeping with rosiola it is very benign and you just need to reassure the parents that this will fade time so that's all you need to do it is not a notifiable disease and then all the other options are well fluconazole is for fungal infections which is not the case here um we're not suspecting a bacterial infection or that she's quite unwell so we will not give an antibiotic and gun cyclovir we do not tend to give antivirals for this and um but can cyclovir would be an antiviral you might consider um for certain types of herpes virus infections okay so rosiola is caused by hhv-6 it's called sixth disease and this is a very very very classical pattern um when you actually do meet parents and see children with it it it pretty much follows its narrative so clearly um wait they have um fevers and irritability and then the fever disappears and the rash flourishes and i said you just got to reassure the parents you don't need to isolate them they can even go to school if they want and it'll all subside now i've got this table here so i'm going to leave it on the screen for a bit i'm not going to talk through it as it's quite didactic but i just put this together to help you separate some very similar presentations between rosiola measles and rubella if you want to take a screenshot and stuff you can and i'm sure if you want to make notes on it when this video is up you'll be able to do so as well but the key thing to bear in mind is that brazil is quite benign there's no vaccine it's supportive management and no isolation is needed measles super serious highly highly highly infectious you need to isolate it's a notifiable condition you can prevent it with either the mmr or the separate vaccines and it has profound complications okay and we need to have a vaccination rate of roughly 95 of the population to essentially protect the public from measles outbreaks it's really infectious and then you have rubella and that's caused by the rubella virus it is also notifiable condition requires isolation also can be prevented with the mmr or the separate vaccine and generally people who get a rubella infection will typically be fine the main risk it has is to those who are pregnant okay and that has complications um for the fetus so the main reason we actually vaccinate um people doing it's rubella is not for like the children getting the primary infection whereas to protect um vulnerable pregnant women okay um but that brings us to the end so i just thought i'd show one more useful resource that came through that has been floating around since i was a medical student so it's quite old but it's from i'm a health authority near manchester um because i always find it a pain to know about isolation periods for um pediatric rashes in particular so and these are some of the ones worth knowing that say it's worth knowing about chickenpox impetigo hand foot and mouth um and say not monsters again um slap cheek syndrome so private virus um and depending on where you get so i don't know where you guys would have been taught your pediatrics or your dermatology because this these topics would come up either in gp or in dermatology or in pediatrics depending on where you get taught might depend on what elements of counseling you need to know but i found this graphic quite helpful and once again you might want to screenshot it or make notes notes on it later when you get the video and then finally some useful resources so dermatology is a very visual subject obviously so um the really accessible books i'd recommend are one of these two are the dermatoglans or an illustrator color guide your medical school library should have ample copies of them probably online as well the other really useful resource is produced by the british association of dermatology if you literally just google this you can download an entire pdf designed for undergraduates on basically dermatology and it's perfect for your exams and then i'm sure you guys all know about dermnet which is a new zealand website once again perfect for undergraduates and patient info for uk guidelines one thing i really do want to emphasize to you guys is this website called skindeep it's produced by a pediatric online education group called don't forget the bubbles um and it's really um it's really kicked off in the last one to two years and i must admit i am still getting i'm still learning a lot about dermatology but one thing that was always a conversation when i was a medical student is the fact that most the textbooks only tend to show rashes quite often on pale caucasian skin and you don't often tend to see what rashes look like on people who have different degrees of pigmentation and that's something that you will often see written as a letter in medical journals by medical students every couple of months and it's an ongoing issue but there is efforts being done now to diversify the content scene and i must admit it wasn't until last year that i first saw a rash um somebody of afro-caribbean descent and i had no idea what it was and it actually turned out to be chickenpox but i just really wasn't used to i i've never seen somebody with chickenpox um on really dark skin and this website is fantastic it's free and has lots of useful pictures of lots of rashes of different severities on all different skin types so i'd highly recommend this it's really important and i still frequently go and double check things on there so i do hope you get to use it and i do hope as time goes on textbooks will start incorporating a more diverse range of pictures and because the presentations do look slightly different on different colored skin okay i think that brings us to the end um if we stop recording and then i'll answer any questions that people are posted