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Kawasaki's disease (mucocutaneous lymph node syndrome)

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An acute multisystemic vasculitis of unknown aetiology (? infective) in children usually <5 yrs presenting with an acute febrile illness.

++ Diagnostic features and criteria
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Fever persisting for more than 5 d plus at least 4 of:

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  • bilateral conjunctival congestion (non-purulent)

  • dryness, redness and cracking of the lips ± erythema of tongue, buccal mucosa

  • maculopapular polymorphic rash esp. trunk, genitalia

  • cervical lymphadenopathy >1.5 cm

  • erythema and swelling of palms and soles

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Followed by desquamation of fingertips (a characteristic)

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Diagnosis with 5/6 features or 4/6 plus evidence of coronary aneurysm (plus exclusion of other diseases).

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Above features may be variable/incomplete and not all present concurrently.

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No specific test but elevated ESR, neutrophilia, thrombocytosis and various +ve antibody tests (e.g. antiendothelial cell). Generally benign and self-limiting but early diagnosis is important to prevent complications, esp. coronary aneurysms (15–30% in untreated) and also myocardial infarction, pericarditis and myocarditis.

++ Management
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  • Echocardiography and ECG are indicated.

  • Treat with aspirin (start ASAP) and high-dose normal gammaglobulin.

  • Avoid corticosteroids.

  • Most children recover and the overall mortality is <3%.

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Keloid or hypertrophic scar

++ Various treatment methods
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Prevention: Avoid procedures on Keloid-prone individuals. Use compression and silicone dressings.

++ Multiple pressure injections
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  • First ‘soften’ with application of liquid nitrogen.

  • Spread film of corticosteroid solution over scar.

  • Apply multiple pressure through solution with a 21-gauge needle held tangentially (about 20 superficial stabs per cm2).

  • Avoid bleeding.

  • Repeat in 6 wks or Intralesional injection of triamcinolone (after liquid nitrogen) or topical class III–IV corticosteroid ointment with occlusion.

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Consider:

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  • X-ray treatment of surgical wounds within 2 wks of operation

  • intralesional cytotoxics (esp. fluorouracil)

  • re-excision of hypertrophic scar

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Keratoacanthoma

++ Management
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  • Remove by excision perform biopsy (at least 2–3 mm margin)

  • If clinically certain—curettage/diathermy

  • Treat as SCC (by excision) if on lip/ear

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Note: Can be misdiagnosed instead of SCC.

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Keratoses (solar and seborrhoeic)

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Seborrhoeic keratoses
++ Management
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  • Usually nil apart from reassurance

  • Does not undergo malignant change

  • Can be removed for cosmetic reasons

  • Light cautery to small facial lesions

  • May drop off spontaneously

  • If diagnosis uncertain, remove for histopathology

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Decolourisation or removal:

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  • liquid nitrogen (regular applications, e.g. every 3 wks) or

  • concentrated phenol solution (with care) repeat in 3 wks or

  • trichloracetic acid: apply to surface and instil with multiple small needle pricks (25 g). Repeat twice wkly for 2 wks.

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Solar keratoses
++ Management
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  • Reduce exposure to sunlight

  • Can disappear spontaneously

  • Liquid nitrogen ...

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