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Kawasaki's disease (mucocutaneous lymph node syndrome)

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

Fever persisting for more than 5 d plus at least 4 of:

• 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

Followed by desquamation of fingertips (a characteristic)

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

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

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.

• 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%.

Keloid or hypertrophic scar

Prevention: Avoid procedures on Keloid-prone individuals. Use compression and silicone dressings.

• 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.

Consider:

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

• intralesional cytotoxics (esp. fluorouracil)

• re-excision of hypertrophic scar

Keratoacanthoma

• 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

Note: Can be misdiagnosed instead of SCC.

Keratoses (solar and seborrhoeic)

Seborrhoeic keratoses

• 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

Decolourisation or removal:

• 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.

Solar keratoses

• Reduce exposure to sunlight

• Can disappear spontaneously

• Liquid nitrogen ...