A teenage girl is brought to A&E by ambulance with a high fever and hypotension.

She is confused and has abdominal pain and diarrhoea. A macular rash has been
present for five days, which is now desquamating. She has not been abroad or in
contact with any infections, she is currently menstruating.
What is the most likely diagnosis?
Gastroenteritis
Scarlet fever
Kawasaki disease
Toxic shock syndrome

Correct answer

Pelvic inflammatory disease

Toxic shock syndrome (TSS) is caused by a toxin that triggers a cytokine cascade
and has multi-system effects. Features include high fever, macular erythaema
leading to desquamation, hypotension and symptoms of other system
involvement eg diarrhoea or vomiting, myalgia, thrombocytopenia and renal
failure. TSS was initially associated with tampon use but can be generated by
seemingly trivial staphylococcal infections. The mainstay of treatment is
resuscitation, antibiotics and removal of precipitating factors; intensive care can
be required.
At the 6-week baby check the GP notices a blue discoloration across the buttocks of
an Asian baby. The child is small for his age but there is nothing else to find on
examination. He lives in a rather chaotic household with five other siblings.
What is the most likely diagnosis?
Accidental bruising
Non-accidental injury
Clotting disorder
Mongolian blue spot

Correct answer

Contact dermatitis
A Mongolian blue spot is commonly seen across the lumbosacral region and
buttocks of babies of Asian and Black descent. They also occur in approximately
10% of White babies. A Mongolian blue spot is a grey/blue macular
discoloration, histologically a dermal melanocytic naevi. They usually fade
spontaneously. It is important to be able to recognise and differentiate these
birthmarks from possible non-accidental injury.
A teenager presents to A&E unwell with a high fever. He is known to have eczema
and numerous allergies. You notice crusting lesions across his torso with generalised
erythaema. He also has blisters around his mouth.

What is the most likely diagnosis?

Eczema herpeticum

Correct answer

Infected eczema
Impetigo
Psoriasis
Dermatitis herpetiformis
Children with eczema are at risk of becoming infected with herpes simplex virus
and developing eczema herpeticum. This condition can be severe, as the virus
can become disseminated. Secondary bacterial infection is common. Encephalitis
and ocular complications may occur. The lesions themselves may become
haemorrhagic. Although not all children with eczema herpeticum need to be
admitted to hospital the condition must be taken seriously in light of the possible
complications. Intravenous and topical aciclovir is required as well as treatment
with a broad-spectrum antibiotic to deal with any secondary bacterial infection.
A 15-year-old girl attends her GP complaining of a rash, which has developed over
the preceding week. The lesions are small and well circumscribed over her trunk and
arms; they are pink with silvery scales. She is usually well but had a bad throat
infection requiring antibiotics two weeks previously. On further examination her nails
appear to be splitting from the nail bed and small pits are noted.
What is the appropriate management for this girl? Choose three of the following:
Commence topical corticosteroids

Incorrect

Commence topical antibiotics

Incorrect

Commence antiviral therapy

Incorrect

Send skin scrapping

Incorrect

Commence methotrexate

Incorrect

Commence Lassars paste

Incorrect

Commence coal tar preparations (creams and shampoo)

Incorrect

PUVA

Incorrect

Commence topical corticosteroids

Commence Lassars paste
Commence coal tar preparations (creams and shampoo)
The most common form of psoriasis in children is guttate (drop-like) psoriasis
occurring over the trunk and limbs, often following a streptococcal infection. It
usually lasts 23 months and responds to simple treatment measures such as
Lassars paste, coal tar preparations and topical corticosteroids. PUVA and
systemic treatments such as methotrexate and ciclosporin are reserved for more
severe cases.

Other forms of psoriasis include: psoriasis vulgaris, commoner on older

teenagers and more chronic, affecting scalp and extensor surfaces; pustular
psoriasis localises to palms and soles. Nail psoriasis consists of onycholysis, nail
pitting and oil droplet formation. Psoriatic arthropathy often involves distal
interphalangeal joints.
A 10-year-old girl presents to A&E unwell, miserable and feverish. She has had a
cough and coryzal symptoms for 72 hours. A rash began to develop 2 hours ago,
beginning as patches around her ears and neck, which is now spreading down her
torso.
What is the most likely diagnosis?
Viral illness
Measles

Correct answer

Rubella
Chickenpox
Erythaema infectiosum
Measles has an incubation period of 814 days followed by coryzal symptoms
and Kopliks spots (white patches on the buccal mucosa). Fever and
lymphadenopathy develop, followed by an erythaematous maculopapular rash,
which classically begins as patches becoming confluent and spreads from around
the ears to the legs by day 3 when the face begins to clear. Children are miserable
and unwell.
Complications include pneumonia, otitis media, encephalitis, myocarditis and
lymphopenia. Subacute sclerosing panencephalitis (SSPE) can occur 510 years
after the initial infection.
A 2-year-old girl is brought to the Emergency Department. She has become
increasingly unwell over the last 24 hours. She has been grumpy, lethargic and does
not like being held. Her skin has become red in colour.
On examination the girl is miserable and pyrexial. She has bilateral non-purulent
conjunctivitis, cervical lymphadenopathy and red lips. She is tachycardic but well
perfused. Cardiovascular, respiratory and gastrointestinal examination is normal. Her
skin is generally red, especially around the right axilla. A blister has formed on her
left big toe where the saturations probe was initially sited.
Which two of the following investigations will potentially give the most useful
information?
Full blood count (FBC)

Incorrect

C-reactive protein (CRP)

Incorrect

Eye swab

Incorrect

Skin swab

Incorrect

Throat swab

Incorrect

Blood culture

Incorrect

Skin swab
Blood culture
Staphylococcal scalded skin syndrome (SSSS) is caused by exfoliative toxin
producing strains of Staphylococcus aureus. These strains may be located in
areas of infection. The widespread clinical manifestation is initiated through
release of toxin into the blood. The toxins are encoded either by the bacterial
DNA itself or via plasmid DNA.
SSSS is mainly seen in infants and pre-school children. The skin manifestations
may be localised or more global. A prodrome of lethargy, fever and distress may
precede the red tender skin eruption. Conjunctivitis may be present and may be
purulent. Peri-oral erythaema and lip redness with erosions are seen.
Nikolskys sign is demonstrated; shearing forces lead to separation of the
epidermis in the subcorneal layer leading to sterile blister formation. Generalised
desquamation occurs after 25 days and after 2 weeks the skin heals.
Diagnosis is aided by isolating the bacteria and phage typing. Skin swabs and
blood cultures may enable this and prove the haematogenous spread of the
bacterium.
Flucloxacillin is the treatment of choice.
A child presents to A&E with the formation of blisters on her hands and knees where
she has started crawling. She has no other skin lesions or scarring and is systemically
well.
What is the most likely diagnosis?
Allergic reaction
Epidermolysis bullosa simplex

Correct answer

Dystrophic epidermolysis bullosa (recessive type)

Contact dermatitis
Hand, foot and mouth disease
Epidermolysis bullosa is a rare skin condition that affects different layers of the
skin. Epidermolysis simplex affects the basal cell layer of the dermis. It is
autosomal dominant and ranges from a mild to severe condition. Blisters are
usually noticed on contact areas of the skin eg hands and knees, when the child
first begins to crawl. Junctional epidermolysis bullosa (autosomal recessive)

presents at birth with a generalised distribution of blisters. Dystrophic

epidermolysis bullosa has a milder autosomal dominant form that tends to
present with blisters at the onset of crawling. The autosomal recessive form is
much more severe with blistering in the upper layer of the dermis affecting the
mouth, mucus membranes. Nail loss and dystrophy, plus syndactyly are
common, as is oesophageal strictures. Prognosis is guarded.
A 4-month-old little boy is brought to his GP with a scaly, weeping rash across his
scalp and cheeks. His mother is concerned as he is itchy and unsettled. The family
recently completed a course of treatment for scabies.
What is the most likely diagnosis?
Scabies
Contact dermatitis
Seborrhoeic dermatitis (cradle cap)
Tinea corporis
Eczema

Correct answer

Half of all patients who develop eczema will have symptoms in the first year of
life. The peak onset is 26 months old. Approximately 90% of patients will be
symptom free by 18 years old. Babies are affected primarily on the cheeks and
face, which spreads to involve the neck, wrists, hands and extensor surfaces. Preschool children are affected on the flexor surfaces of the popliteal and
antecubital fossas, behind the ears, face and neck. Older children often have
lichenification, scaling and scarring; areas affected include popliteal and
antecubital fossas, forehead, wrists and dorsa of hands and feet.
A 4-year-old boy known to have eczema presents to A&E with an acute flare up of
eczema across his face, hands and legs. He is systemically well and apyrexial. His
parents say they have been using emollients and soap substitutes as directed by their
GP.
What is the most important next management step?
Talk to parents about compliance
Prescribe topical steroid creams

Correct answer

Prescribe antihistamines
Prescribe oral antibiotics
Admit to hospital for wet wraps and iv antibiotics
All aspects of acute flare-ups of eczema should be considered but the most
important in this case is the instigation of topical steroids. These should be as
least potent as possible with only mild creams used on the face. Antihistamines
are also important to prevent scratching; wet wraps and extra emollients can

also be effective. Antibiotics are often required to treat secondary bacterial

infection. Parental education and help needed must also be addressed, as
compliance with treatment is difficult. Soap substitutes, bath oils and regular
emollient use must be continued after the flare up has settled.
Eczema has a genetic component, ie if both parents are affected there is
significant increased risk of the child also being affected; a dietary component,
eg exacerbations triggered by dairy products; and exacerbating factors eg
woollen clothing, humidity. These must also be considered when discussing longterm management.
A child is referred to paediatric outpatient clinic with recurrent skin infections. There
are pustules and honey coloured crusting around his face. Otherwise he is well and
growing and developing as expected.
Hand, foot and mouth disease
Chickenpox
Herpes simplex infection
Impetigo

Correct answer

Immunodeficiency
Impetigo can be caused by staphylococcal or streptococcal infection. It can be
recurrent if the child is a carrier of the organism (usually in the nose). Usually
the organism enters the skin via an insect bite, dermatitis or scabies. Impetigo is
contagious and simple rules of hygiene such as hand washing and separate towels
should be followed. Treatment is usually a course of oral antibiotics; topical
antibiotics can be used to try and eliminate carriage and if there are only a few
lesions. If many bullae are present the infection is termed bullous impetigo.
Impetigo can have serious complications including pneumonia and osteomyelitis.
Choose the most appropriate diagnosis from the list below:
A StevensJohnson syndrome
B Chickenpox
C Aphthous ulcers
D Herpes simplex
E Scarlet fever
F Second-degree burns
G Kawasaki disease
Scenario 1

Incorrect
A young girl presents to A&E with a fever and generalised rash over her trunk, when
examining her rash has a sandpaper like feel and dark red lines are apparent in the
skin creases. She also has pharyngitis.

0 Your answer
E Correct answer
Scarlet fever
Scarlet fever is produced b group A streptococcal infection. The rash is a diffuse
erythaema mainly over the trunk, abdomen and skin folds; it is likened to
sandpaper; Pastias lines are dark red lines seen in the skin creases. There is
perioral pallor, a strawberry tongue and sometimes desquamation of skin from
fingers and feet.
Scenario 2

Incorrect
A teenage boy is being treated by his GP for pneumonia and has begun a course of
antibiotics. A painful, erythaematous rash developed on his lower limbs, which has
now progressed. He has ulcers in his mouth making it difficult to eat and he
complains of difficultly micturating.
0 Your answer
A Correct answer
StevensJohnson syndrome
StevensJohnson syndrome is a severe, bullous form of erythaema multi-forme
and involves mucous membranes eg mucositis, conjunctivitis, corneal ulceration,
uveitis and/or genital ulceration. There are associated problems of pneumonia,
polyarthritis, fluid and electrolyte imbalance, urine retention and inability to eat
and drink. Management must include removal of cause, monitoring of fluid and
electrolytes and antibiotics to treat secondary bacterial infection.
Scenario 3

Incorrect
A five-year-old girl is seen by her GP with a rash at varying stages of development
from erythaema to vesicles. She has a fever and is miserable. Her older sister reports
something going round at school but is not sure what.
0 Your answer
B Correct answer
Chickenpox

Chickenpox has an incubation period of 1014 days followed by inset of fever

and malaise. The rash begins on the trunk with macules progressing to papules
then to vesicles, which eventually crust over. There are usually lesions at all
stages. Mucous membranes may be involved making fluid management a
problem. Complications include pneumonia, encephalitis and secondary
bacterial infection.
Choose the most appropriate diagnosis from the list below:
A Idiopathic thrombocytopenic purpura
B Meningococcal disease
C Pertussis
D HenochSchoenlein purpura
E Acute leukaemia
F Non-accidental injury
G Clotting dysfunction
Scenario 1

Incorrect
A 2-month-old baby girl is brought to A&E after parents noticed small purple spots
appear around eyes. She has a fever and is generally unwell, parents report she seems
to be struggling with her breathing. After careful examination there are no spots or
rashes elsewhere.
0 Your answer
C Correct answer
Pertussis
Periorbital petechiae can be seen with coughing spasm, non-accidental injury
and parturition (when the cord is wrapped around the infants neck). Pertussis
(whooping cough) has been described as the hundred-day cough. In young
children an inspiratory whoop with the coughing spasm is not always heard;
babies can present with apnoea. Treatment is supportive although a course of
erythromycin can be given to eliminate nasal carriage.
Scenario 2

Incorrect
A 6-year-old boy attends the GP surgery one week following a viral upper respiratory
tract infection. His parents have noticed excessive bruising after a football game at
school.
0 Your answer

A Correct answer
Idiopathic thrombocytopenic purpura
Superficial bruising, petechiae and sometimes mucosal bleeding from gums and
nose can be the initial presentation of idiopathic thrombocytopenic purpura. It
often follows a viral infection and, apart from signs of bleeding, children are
usually well. There is thought to be immune destruction of circulating platelets.
The serious complication to consider is intracranial haemorrhage.
Scenario 3

Incorrect
A 2-year-old girl is rushed to the A&E department with fever and a maculopapular
rash. She was well at breakfast but has deteriorated rapidly over the morning and is
now semi conscious.
0 Your answer
B Correct answer
Meningococcal disease
Meningococcemia is a rapidly progressive life threatening condition. The rash is
classically non-blanching petechiae and purpura but can be maculopapular. The
type of rash does not dictate the clinical course. The rash may progress to
haemorrhagic purpura and purpura fulminans. Urgent resuscitation and prompt
antibiotics are required for any child suspected of meningococcal septicaemia.
A six-year-old girl who has been under treatment for diabetes mellitus for the last
three years was referred by her GP for an evaluation of weight loss over the past five
months. You have ascertained from her parents that she has been taking insulin
regularly and her records show that her diabetic control has been satisfactory. On
examination you have recorded that her weight is in the 5th percentile for her age.
You also notice pallor, a few apthous ulcers, wasting in the gluteal region and a few
vesicles on the elbows. Other than this there were no abnormal findings.
The results of investigations are given below:
Haemoglobin

9. gm/dl

Total Lymphocyte
count

8 x 10 9/l

Neutrophils

55%

Lymphocytes

40%

Eosinophils

3%

Platelets

240 x10 9/l

ESR

16 mm fall in first hour

C-reactive Protein

7 mg/l

Blood sugar Fasting

8 mmol/L

HbA1C

8%

Serum creatinine

88 mol/L

Urinalysis

4 pus cells/high power field. No proteins or

Sugar detected.

Nitrate test

negative

Stool Examination

Fat content increased

Chest X-ray

normal

Biopsy of the skin

lesions

IgA deposits in the dermis on

immunoflorescence

What are these skin lesions called?

Pyogenic granuloma
Dermatitis herpetiformis

Correct answer

Dermatitis artefacta
Pemphigus
Molluscum contagiosum
This is a common association with coeliac disease. It presents as grouped vesicles
onthe elbows, knees, sacrum and scalp that leave behind pink excoriated papules
and plaques.

Incorrect
What is the likely cause of weight loss in this child? Choose One Answer.
Cystic fibrosis
Crohns disease
Coeliac disease

Correct answer

Addisons disease
Insulin autoantibodies
The clinical features in this patient are suggestive of coeliac disease, which is
associated with type I diabetes mellitus.
A neonate is transferred back to the Special Care Baby Unit from the tertiary surgical
centre following an operation for severe necrotising enterocolitis; he now has an
ileostomy. He was born at 26 weeks gestation and required ventilation for 6 days,
followed by 4 days of continuous positive airway pressure (CPAP). He was initially
given total parenteral nutrition, then an increasing amount of expressed breast milk.
On review he is noted to have an eczematous reaction around his nappy area, which

has vesicular and bullous lesions. The discharge letter from the surgeons reports that
the rash has not responded to emollient or steroid creams. The rest of his skin is
normal, apart from a small haemangioma on his left upper arm. His growth has fallen
across 2 centiles to below the 3rd centile for weight and length. His chest is clear. His
ileostomy site is healing well. The nurses have commented on how well the mother is
coping with the bag, although she is changing it 68 times per day.
Given all the features, which ONE problem may account for this boys
examination findings?
Iron deficiency

Incorrect

Candida dermatitis

Incorrect

Napkin dermatitis

Incorrect

Trace metal deficiency

Incorrect

Langerhans cell histiocytosis

Incorrect

Secondary bacterial infection of the nappy area

Incorrect

Trace metal deficiency

Neonates who have had severe necrotizing enterocolitis (NEC) may have short
gut syndrome leading to nutritional deficiencies. Zinc deficiency has been
described in pre-term infants and subclinical deficiency is probably more
prevalent than is currently believed. Zinc absorption occurs in the small
intestine. It is bound in the blood by albumin and 2-macroglobulin. Breast milk
contains enough zinc for term infants, but may have insufficient levels for preterm infants.
Clinical manifestations include eczematous perioral, perineal and scalp skin
lesions, diarrhoea, stomatitis, growth faltering and hair loss. Diagnosis is with
low serum zinc levels; a low alkaline phosphatase level is associated.
Acrodermatitis enteropathica is a rare autosomal recessive condition of defective
zinc absorption from the gut, with the same clinical manifestations as above.
Treatment is with zinc supplementation. Zinc supplementation has been shown
to improve growth in children in the developing world.
A seven-year-old girl presented with painless, red patches on her trunk, which she said
had increased in number for the last fortnight. There is no history of pruritus. Her
mother gave the history that the patches had followed a solitary ringworm infection
on the same site. On examination, you notice a healthy cheerful child with
erythematous scaling plaques in the axillary and mammary regions. One of the
plaques was bigger in size as compared to the rest.
What is the likely diagnosis? Choose one answer.
Pityriasis alba

Pityriasis versicolor
Pityriasis Pytriasis rosea

Correct answer

Tinea corporis
Scabies
This is a self-limiting condition that occurs in healthy children and lasts for
about two months. The lesion starts as a herald patch that looks similar to a
ring worm lesion. This is followed by the typical rash that has a Christmas tree
distribution.
A 12-year-old boy is referred by the GP. He has had a flu-like illness in the last 3 days
but presented to the surgery this morning with a developing skin rash. He is quiet,
well perfused and hydrated, with a few crackles on auscultation of his chest. He has a
non-itchy red rash covering his trunk and limbs, with macules and papules present.
On his right hand he has two lesions that have a pinkpurple spot surrounded by
normal skin, then a circle of erythaema. His conjunctiva and oral mucosa is
unaffected. He is normally fit and well and is not on any regular medication.
Which TWO investigations may be most helpful in the diagnosis of this boys
condition that is associated with the rash?
Full blood count (FBC)

Incorrect

C-reactive protein (CRP)

Incorrect

Liver function tests (LFTs)

Incorrect

Urine m/c & S

Incorrect

Chest X-ray

Incorrect

Mycoplasma titres

Incorrect

Throat swab

Incorrect

Full blood count (FBC)

Mycoplasma titres
Erythaema multiforme is characterised by a rash that can include macules,
papules, vesicles, bullae or urticaria. Target lesions are the typical lesions that
then develop. The oral mucosa may be affected, but other mucosal surfaces are
generally not involved, hence differentiating it from StevensJohnson syndrome.
The underlying abnormality is probably related to a cell-mediated immune
response causing keratocyte damage.
Investigation of children with erythaema multiforme is guided by the history and
other examination findings. Many infective causes have been described, but the
most common are herpes simplex virus and Mycoplasma pneumoniae. Acute and
convalescent titres for mycoplasma are necessary to confirm that particular
diagnosis. Another important cause that it is prudent to rule out is leukaemia

and lymphoma. Many drugs have been reported to cause erythaema multiforme
including various antibiotics and antiepileptics.
Treatment is symptomatic and for the underlying cause.
A 6-year-old girl presents to A&E with an evolving purpuric rash across her lower
limbs. Her parents thought the rash was related to a change in washing powder as the
previous day it had looked like hives. However she began to complain of knee pain
and her feet were slightly swollen.
What is the most likely diagnosis?
Reactive arthritis
SLE
Juvenile idiopathic arthritis
HenochSchoenlein purpura

Correct answer

Hereditary angio-oedema
The rash of HenochSchoenlein purpura can present initially as urticaria and
then progress to the classic non-thrombocytopenic purpura, mainly distributed
across the legs and buttocks. There is often associated arthralgia and
arthropathy but this is transient and remains within the same joints eg ankles,
knees and hips. Oedema of ankles and feet are sometimes seen, but are also
transient. It is important to distinguish generalised oedema, which may be an
indicator of renal impairment. Differential diagnosis of an acute painful joint
includes haemophilia, sepsis, trauma, reactive arthritis, sickle-cell disease crisis
and tumour.
A 15-year-old girl is seen in the Emergency Department with her mother. She has
been lethargic and had a fever for 6 days; she has now developed a rash over her
shins. She is otherwise a fit and healthy teenager, who has never been to hospital
previously. An aunt has severe rheumatoid arthritis. The girl is not on any regular
medication. On examination she has a few shotty cervical lymph nodes, but otherwise
systemic examination is unremarkable. Her lower legs are covered in 23 cm, hot,
tender nodules.
Which of the following may be the cause of her rash?
Mycoplasma

Incorrect

Tuberculosis

Incorrect

Crohns disease

Incorrect

Juvenile idiopathic arthritis

Incorrect

EpsteinBarr virus (EBV) infection

Incorrect

Lymphoma

Incorrect

Mycoplasma
Tuberculosis
Crohns disease
EpsteinBarr virus (EBV) infection
Erythaema nodosum is characterised by painful subcutaneous and dermal
nodules. It is a hypersensitivity reaction to various pathological stimuli. There
are several causes and all must be considered in the assessment of erythaema
nodosum, whether by careful history taking or investigation.
Infectious causes include EBV, hepatitis B, Streptococcus, Mycoplasma,
Chlamydia, tuberculosis, Yersinia, histoplasmosis and coccidioidomycosis.
Crohns disease may present with erythaema nodosum and ulcerative colitis is
also an association. Autoimmune conditions such as sarcoidosis, systemic lupus
erythematosus (SLE) and Behets disease may manifest in this way.
Sulphonamides and the oral contraceptive pill have been reported to cause
erythaema nodosum.
The nodules generally fade over 24 weeks. Treatment is symptomatic with nonsteroidal anti-inflammatory drugs (NSAIDs) and bed-rest may be appropriate.
An 8-year-old boy is admitted with five days of high fever. He has no coryzal or
respiratory symptoms. He is miserable and complains of a headache but has no signs
of meningism. On examination his lips are red and cracked and he is mildly
dehydrated. He has a generalised maculopapular rash widely distributed across his
back, torso and legs.
Which other clinical signs would help you confirm your diagnosis? Choose two of
the following:
Cervical lymphadenopathy

Incorrect

White-coated tongue

Incorrect

Suppurative conjunctivitis

Incorrect

Blisters on hands and feet

Incorrect

Non-suppurative conjunctivitis

Incorrect

Arthritis

Incorrect

Cranial nerve palsy

Incorrect

Diarrhoea

Incorrect

Cervical lymphadenopathy
Non-suppurative conjunctivitis
Kawasaki disease is a clinical diagnosis made on the basis of a high fever for at
least five days and four of the following criteria: polymorphous rash
(maculopapular most common); cervical lymphadenopathy; mucosal
involvement with dry cracked kips and strawberry tongue; erythaema and

oedema of fingertips and toes followed by desquamation after about 10 days;

non-suppurative conjunctivitis.
Other complications include aseptic meningitis, urethritis and sterile pyuria,
arthritis, diarrhoea and vomiting and mild hepatitis. The most important
consequence to consider is cardiovascular compromise. Coronary artery
aneurysms and thrombosis can develop between 24 weeks from the onset.
Treatment to try and combat these problems involves high-dose -globulin and
aspirin. Cardiology review and echocardiogram are required.
A two-year-old girl is referred to A&E with evolving blisters across her torso and
upper limbs; some blisters have burst leaving red sore patches and she dislikes her
skin being touched. There is no history of trauma. She has a fever of 38.5oC and is
generally miserable and lethargic. There is no involvement of mucous membranes and
no signs of meningism. She is mildly dehydrated. Chest X-ray (CXR) and urine
dipstick are normal.
What are you next management steps? Choose three of the following:
Perform a lumbar puncture

Incorrect

Take blood for culture

Incorrect

Give an emergency fluid bolus

Incorrect

Commence intravenous antibiotics

Incorrect

Take samples of the blister fluid

Incorrect

Prescribe emollients and analgesia only

Incorrect

Discharge and review in 24 hours

Incorrect

Commence aciclovir and antibiotics

Incorrect

Refer to dermatology

Incorrect

Exhibit the Nikolsky sign

Incorrect

Take blood for culture

Commence intravenous antibiotics
Take samples of the blister fluid
Staphylococcal scalded skin syndrome (SSSS) is caused by Staphylococcus
aureus phage group 2, which produces toxic epidermal necrolysis. Large blisters
develop which burst leaving areas of red raw underlying skin. The skin exhibits
the Nikolsky sign, whereby gentle pressure exerted on the blister results in its
extension as layers of epidermis separate. Other manifestations include crusting
and fissuring around the eyes, nose and mouth. SSSS is usually accompanied by
fever and malaise. Secondary bacterial infection, generalised sepsis, fluid and
electrolyte imbalance are important consequences. The bullae are usually sterile
but samples of the fluid and blood culture samples should be taken; skin biopsy
is not required. Treatment is with antibiotics either oral or intravenous
depending on severity. Emollients and analgesia are also used, but topical
antibiotics are unnecessary.

At the six-week baby check the GP notices a large, 22-cm brown nevus across the
back of the baby. There is nothing else to find on examination and the baby is
thriving. The parents are not unduly concerned about the lesion and say it is not
progressing in size or changing.
What is the most important next step in management?
Review by the GP in 3 months time
Urgent referral to a dermatologist (46 weeks)

Correct answer

Non-urgent referral to a dermatologist (46 months)

Prescribe topical steroid creams
Review at parents request
Giant (>20 cm) congenital melanocytic naevi are very rare. Melanocytic naevi,
more common in later childhood can also be congenital but are <20 cm diameter.
Lesions may be flat or elevated and can be various shades of brown/black. Giant
hairy naevi are also seen. There is an increased risk of transformation into
malignant melanoma. Currently giant congenital pigmented naevi are surgically
removed before three months of age. There is controversy about the treatment of
medium-sized naevi but referral to a plastic surgeon and dermatologist with
regular review are recommended.
A 3-year-old girl was brought to A&E by her concerned parents when she developed a
diffuse erythaematous, macular rash across her lower arms and legs, face and neck.
There was marked sparing of areas which had been covered by clothes and she
seemed unperturbed by the rash. The little girl had spent the afternoon in her
grandparents house and garden.
What is the most likely diagnosis?
Sunburn
Contact dermatitis
Allergic reaction
SLE
Phytophotodermatitis

Correct answer

Phytophotodermatitis has a classical distribution on peripheral sun exposed

areas of skin. A combination of sunlight and many different plants are
responsible for the reaction. It can cause concern to parents and medical staff
but rarely presents a problem to the affected child. The skin changes are selflimiting but can sometimes leave residual pigmentary changes.
Other disorders exacerbated by light include psoriasis, herpes simplex and SLE.

Choose the most appropriate diagnosis from the list below:

A Urticaria
B Erythaema multi-forme
C Erythaema nodosum
D Erythaema marginatum
E Erythaema chronicum migrans
F Staphylococcal scalded skin syndrome
G Infected eczema
Scenario 1

Incorrect
A family return from a holiday to the USA and attend their GP because the five year
old has developed an erythaematous rash. There are discrete round lesions, which
seem to be spreading.
0 Your answer
E Correct answer
Erythaema chronicum migrans
Lyme disease is an infection caused by Borrelia burgdorferi, transmitted by
infected ticks found in parts of the USA, Australia and Europe. The rash, called
erythaema chronicum migrans, begins as an erythaematous annular lesion
gradually increasing in size. Serious complications include meningoencephalitis,
cranial nerve palsies, pancarditis and arthritis.
Scenario 2

Incorrect
A teenager presents to her GP complaining of a strange rash with individual red rings,
which seem to have creeping borders. She had an upper respiratory tract infection two
weeks ago but is otherwise well. On examination small subcutaneous nodules are
noted.
0 Your answer
D Correct answer
Erythaema marginatum
Approximately one-fifth of patients with rheumatic fever have erythaema
marginatum. The rash is characteristically a flat, non-painful with normal areas
of skin surrounded by red rings with creeping borders. Erythaema marginatum

constitutes a major criteria for rheumatic fever, the others are: polyarthritis,
carditis, subcutaneous nodules over joints and tendons and chorea.
Scenario 3

Incorrect
A 5-year-old boy is brought to A&E with a fever and cough. He is noted to have small
target lesions on the front of both legs.
0 Your answer
B Correct answer
Erythaema multi-forme
Erythaema multi-forme can be minorsymmetrical target-shaped lesions most
commonly on hands, feet and extensor surfaces or majorvesicular/bullous type
where the bullae are central or around the periphery of the lesion. Lesions are
non-puritic, which helps distinguish them from urticaria and usually resolve
spontaneously after 46 weeks. There are many causes including idiopathic;
infections eg herpes simplex, mycoplasma, EBV or drugs eg sulphonamides.
A 12-year-old girl is seen in your clinic with a history of painful swellings over the
lower aspect of her shins which started three days ago. Her mother says that she had
recovered from an attack of flu a few days back. On examination you notice a few
tender, red nodules around 10mm in diameter on the anterior aspect of her tibia. A few
similar lesions with a darker hue were also noticed. She appeared well nourished. She
had mild pallor, and a few cervical lymph nodes were enlarged but were non-tender
and mobile. Her pharynx was congested.
Investigations revealed:
Haemoglobin

11.7 gm/dl

Total Lymphocyte
count

12 x 10 9/l

Neutrophils

40%

Lymphocytes

55%

Platelets

200 x 10 9/l

ESR

14 mm fall in first hour

C-reactive Protein

7 mg/l

Urinalysis

4 pus cells/high power field. No

proteins or Sugar detected

Nitrate test

negative

Chest X-ray

normal

What is the likely diagnosis? Choose one correct answer

Erythema multiforme
Erythema chronicum migrans
Erythema nodosum

Correct answer

Erythema toxicum
Erythema Marginatum
Erythema infectiosum

Incorrect
What are the common causes of these typical lesions. Choose Three correct
answers.
Rheumatic fever

Incorrect

Lyme disease

Incorrect

Tuberculosis

Incorrect

Malaria

Incorrect

Oral contraceptives

Incorrect

Following Oral Polio Vaccine

Incorrect

Sulphonamides

Incorrect

Steroid therapy

Incorrect

Tuberculosis
Oral contraceptives
Sulphonamides
The lesions are typical of erythema nodosum. The lesions come in crops for 3-6
weeks and may be associated with malaise, fever or arthropathy. The lesions are
typical of erythema nodosum. The lesions come in crops for 3-6 weeks and may
be associated with malaise, fever or arthropathy. They are associated with
streptococcal infection, tuberculosis, and mycoplasma amongst others.
A teenage girl presents to her GP with acutely painful legs. She has recently been on
an outward-bound course with her school. On examination red, shiny, painful lesions
are noted on her lower limbs.
What is the most likely diagnosis?
Erythaema nodosum
Erythaema multi-forme
Accidental injury
Localised allergic reaction

Correct answer

Insect bites
Erythaema nodosum are classically erythaematous, indurated, painful nodules
that appear on the shins. They are more common in women and rarely present
below the age of 6 years. They develop over a few days and then fade, looking
like bruises; they can leave patches of hyperpigmentation. There are many
causes, including infection eg streptococcal, mycoplasma, salmonella, EBV;
drugs eg penicillin, sulphonamides, oral contraceptive pill; inflammatory bowel
disease; connective tissue disease; sarcoidosis.
A child visits her GP with small popular pearly lesions across her face and neck. They
have been present for two weeks and are not itchy or painful.
What is the most likely diagnosis?
Chickenpox
Herpes simplex
Molluscum contagiosum

Correct answer

Impetigo
Warts
Molluscum contagiosum is a common infection caused by poxvirus. Lesions are
classically discrete, pearly/flesh coloured, approximately 3-mm papules. They
have a central umbilication. Lesions may occur anywhere on the body but
typically on the face, neck and axillae. Lesions do resolve spontaneously but are
often treated as they can persist for months and are infectious. Individual lesions
can be cleared by pricking the centre with a sharp instrument dipped in liquid
phenol. This treatment, though popular, can lead to scarring.
The senior house officer calls to request a review of a baby on the post-natal ward.
The midwife has noticed some blistering of the babys skin on the feet and hands. On
examination the baby is well, not dysmorphic and all the mucosal surfaces are normal.
Congenital infection is not suspected. The baby is feeding well and has passed
meconium. This is the mothers first child; there is no family history of note.
At which level of the skin is blister formation most likely to be occurring in this
child? Select ONE.
Subdermal
Deep to lamina densa
Within the lamina densa
Within the lamina lucida
Intraepidermal

Correct answer

Epidermolysis bullosa simplex is inherited in an autosomally dominant fashion;

sporadic mutation can occur. A keratin abnormality leads to breakdown of the
keratinocytes and subsequent blister formation. The condition is non-scarring.
Blisters develop in the neonatal period and affect the hands, feet, limbs and
scalp. The mucosal surfaces may be mildly affected. Treatment involves
puncturing the blisters when they form and antibiotic treatment if infection is
present.
Junctional epidermolysis bullosa is autosomal recessive with blisters forming in
the lamina lucida. All of the body is affected, including the mucosal surfaces and
nail beds. Scarring is present, which may lead to oesophageal strictures. It is a
life-limiting condition with death by 3 years of age.
Dystrophic epidermolysis bullosa may be autosomal recessive or dominant.
Blisters occur deep to the lamina densa. The recessive form is more severe and
may be life-limiting due to infection or oesophageal strictures. Webbing and
deformity of the digits occurs.
Psychological support for the child and the family is required.
A child presented to his GP with a history of fever and sore throat. The GP prescribed
oral amoxicillin. Shortly after taking the first dose the boy developed a diffuse
macular papular rash.
What is the most likely diagnosis?
StevensJohnson syndrome
Allergic drug reaction
Measles
Streptococcal tonsillitis
Glandular fever

Correct answer

Glandular fever (infectious mononucleosis) is caused by the EpsteinBarr virus.

Full blood count typically shows a lymphocytosis and the presence of atypical
lymphocytes. The test for heterophile antibodies (PaulBunnell test) is positive in
about 60% of cases. Clinical features usually include cervical lymphadenopathy,
sore throat, fever and enlarged tonsils. Generalised lymphadenopathy and
splenomegaly are common. Hepatitis with mildly deranged liver function tests
and jaundice can also occur. A macularpapular rash can occur in the natural
course of the illness but occurs in 80% of patients given amoxicillin.
For each of the following descriptions choose the most likely diagnosis.
A Enterovirus infection
B Streptococcal infection
C Staphylococcal infection
D Dermatophyte infection
E Scabies

F Kawasakis disease
G Juvenile idiopathic arthritis
Scenario 1

Incorrect
A 2-year-old infant presents with a week of high fever, lethargy and a rash. He is
miserable and looks unwell, with a temperature of 38.6 oC. He has red eyes, red
cracked lips and a blanching maculopapular rash. He has cervical and inguinal
lymphadenopathy, with some nodes being around 12 cm.
0 Your answer
F Correct answer
Kawasakis disease
Kawasakis disease is an acute vasculitis of unknown origin, which is found
worldwide. It is probably secondary to an infection. Its incidence varies between
ethnic groups, with children in South-East Asia having the highest. It mainly
affects pre-school children. The reason for the importance of correct diagnosis
lies in the associated complications. Vasculitis is found in all blood vessels, but
medium-sized arteries are especially affected including the coronary vessels.
This predisposes to the formation of aneurysms and the associated risk of acute
coronary symptoms and death from infarction. If untreated then 20% of
children will suffer coronary artery abnormality.
Scenario 2

Incorrect
A 2-year-old child presents with a week of swinging fever, lethargy and a rash. He is
miserable and looks unwell, with a temperature of 38.6 oC. The pink rash involves his
trunk and is more visible when the temperature increases. He has cervical and
inguinal lymphadenopathy. His liver and spleen are slightly enlarged.
0 Your answer
G Correct answer
Juvenile idiopathic arthritis
Juvenile idiopathic arthritis may present in a similar fashion to Kawasakis
disease. Classically the rash is described as salmon-pink in colour and varies in
intensity with the temperature. It should be considered a diagnosis of exclusion,
as initial presentation does not always include joint symptoms or signs. As there
is often hepatosplenomegaly and lymphadenopathy a haematological malignancy
must be excluded.

Scenario 3

Incorrect
A 2-year-old child presents with a week of fever, lethargy and a rash covering his
trunk. Initially he vomited and was rubbing his head. He is miserable, has cervical
lymphadenopathy and red tonsils, tongue and lips. There is a blanching red rash over
his face, trunk and limbs; there is some peeling of the skin over the truncal rash.
0 Your answer
B Correct answer
Streptococcal infection
Group A streptococcal infection exhibits itself in several different clinical guises,
both with direct infection or as a result of toxin production. Scarlet fever
represents streptococcal infection with an erythrogenic exotoxin producing
strain. The temperature associated with scarlet fever normally peaks on day 2 of
the illness and then gradually returns to baseline by one week. The temperature
will respond to treatment with penicillin rapidly. Early in the illness a coated
white strawberry tongue is found with subsequent sloughing to leave a red
strawberry tongue. The red rash starts around the neck and in the axillary and
inguinal regions, spreading to include the trunk and limbs. Desquamation of the
skin occurs from the trunk outwards. The rash may feel dry and coarse.
For the following skin problems match the most appropriate diagnosis.
A Albinism
B Incontinentia pigmenti
C Hypomelanosis of Ito
D Ocular albinism
E Oculocutaneous albinism
F Partial albinism
G Vitiligo
H Waardenburg syndrome
Scenario 1

Incorrect
A 5-year-old child is seen in the special needs school clinic for annual review. She has
had hypopigmented linear lesions along her limbs since birth. Her antiepileptics are
increased and an appointment is made to see the optometrist.
0 Your answer
C Correct answer

Hypomelanosis of Ito
Hypomelanosis of Ito is a rare disorder of localised hypopigmentation that is not
inherited. The melanocytes in these areas are deficient in melanin and also
smaller than expected. Unlike incontinentia pigmenti, the hypopigmented areas
are present from birth and do not undergo any changes. They appear as welldefined streaks and whorls following the lines of Blaschko. There are associated
seizures, learning problems, microcephaly, scoliosis, abnormal limbs, eye defects
and congenital heart disease.
Scenario 2

Incorrect
A 3-year-old child attending the local health visitor clinic for child surveillance. He
has hypopigmented areas over his chest and face and a white forelock. His mother has
similar features. He is not dysmorphic and is developmentally normal in all areas.
0 Your answer
F Correct answer
Partial albinism
Partial albinism (or piebaldism) is an autosomal dominant disorder, where
melanocytes are not present in defined areas of skin; this may derive from a
failure of normal differentiation or migration from the neural crest. It is a nonprogressive form of albinism. Waardenburg syndrome is also autosomal
dominant and is associated with a high frequency sensorineural deafness. The
affected individual may also demonstrate heterochromia, dystopia cactorum and
have a thin nose and square face.
Scenario 3

Incorrect
A 10-year-old child is seen in the paediatric outpatient clinic. She has developed
increasing numbers and sizes of hypopigmented areas. She is otherwise fit and well.
0 Your answer
G Correct answer
Vitiligo
Vitiligo is an acquired hypopigmentation, which presents in people aged less than
20 years old 50% of the time. It is important to recognise, as it may be associated
with other conditions, such as insulin-dependent diabetes mellitus (IDDM),

pernicious anaemia and other endocrine disorders. Careful examination of all

the skin must be made to exclude malignant melanomas.
A 14-year-old girl is seen in clinic with acne. She is a fit and healthy teenager with no
other medical problems. She exercises regularly and represents her school in the
hockey team. She is not on any regular medication. The only soap she uses is a
fragrance-free preparation. Her mother has bought her several commercial
preparations for spots that contain antiseptic chemicals. She does not have a
boyfriend. On examination she has an athletic build. Systemic examination is
unremarkable. She has widespread inflamed pustular acne over her face and some
spots on her shoulders. No nodular or cystic lesions are found.
Which TWO of the following treatments are most appropriate for initial
management?
Benzoyl peroxide

Incorrect

Topical antibiotic

Incorrect

Oral antibiotic

Incorrect

Topical retinoid

Incorrect

Oral contraceptive pill

Incorrect

Isotretinoin

Incorrect

Benzoyl peroxide
Topical antibiotic
Benzoyl peroxide is a useful topical antimicrobial solution that is widely available
without prescription. It has been proven to be highly effective in mild to
moderate acne. It is used 12 times daily to wash the face. It may cause excess
dryness of the skin.
When treating moderate acne of moderate severity, benzoyl peroxide should be
used in combination with an antibiotic. Recent research has indicated that
topical antibiotics aid in the treatment of inflammatory predominant acne. For
practical reasons oral antibiotics are probably more useful if the acne is
widespread. Topical retinoids should be used if the acne is mainly comedogenic;
decreasing the number of comedones decreases the degree of inflammation.
If these measures do not succeed in reducing the acne then hormonal therapy
should be considered for teenage girls. If the acne is severe then oral isotretinoin
can be used.
A 3-year-old-boy is admitted to the general paediatric ward with severe infected
eczema from primary care. He has been treated by the GP before this without success.
His mother does not speak any English, but brings his current medication. This
includes an aqueous moisturizing cream, hydrocortisone cream and fucidin cream. He
is also asthmatic. Although he is systemically well, he has widespread infected
eczema, with lichenification over his arms. His mother also offers his sisters hands

for you to examine. You notice she is scratching furiously and has pinprick-sized
papules over her hands, between the fingers and around her wrists.
Which THREE of the following should be prescribed to the boy?
Fucidin cream

Incorrect

Oral antibiotics

Incorrect

Hydrocortisone cream

Incorrect

Beclomethasone cream

Incorrect

Aqueous Malathion solution

Incorrect

Alcohol-based Malathion solution

Tacrolimus

Incorrect
Incorrect

Oral antibiotics
Hydrocortisone cream
Aqueous Malathion solution
Eczema affects around 10% of children and varies tremendously in severity.
Initial treatment includes the liberal application of emollients and topical
corticosteroids. For mild eczema hydrocortisone is usually effective. Widespread
severe eczema may require a more potent corticosteroid; although only
hydrocortisone should be used on the face.
Secondary infection is common and will often respond to topical antibiotics.
Severe infection may require enteral or parenteral antibiotics if the child is
systemically unwell.
Scabies is due to an infestation with the mite Sarcoptes scabei. It is easily spread
among family members and infestation in one requires treatment of the entire
household. Alcohol-based Malathion solution should not be used in children with
broken skin, as it will cause severe irritation.
According to the recent National Institute for Clinical Excellence (NICE)
guidelines tacrolimus and pimecrolimus should be used only if optimum
corticosteroids are unable to control the eczema.