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KAWASAKI DISEASE (MUCOCUTANEOUS LYMPH NODE SYNDROME)

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

Diagnostic features and criteria

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

  • bilateral conjunctival congestion (non-purulent)

  • Mucous membrane changes—dryness, redness and cracking of the lips ± erythema of tongue, buccal mucosa

  • maculopapular polymorphic rash esp. trunk, genitalia

  • cervical lymphadenopathy >1.5 cm usu. unilaterial

  • 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). It is a clinical diagnosis.

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 life-threatening complications, esp. coronary aneurysms (15–30% in untreated) and also myocardial infarction, pericarditis and myocarditis.

Management

  • Echocardiography and ECG are indicated

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

  • Corticosteroid use is controversial; check with consultant if necessary.

  • Most children recover and the overall mortality is <3%; often benign and self limiting

KELOID OR HYPERTROPHIC SCAR

Various treatment methods

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

Management of scarring: options

  • Intradermal injection of corticosteroids in early stages (most commonly used, several might be required)

  • Silicon sheets/gels applied over long periods

  • Potent topical corticosteroids (best under occlusion)

  • Intralesional cytotoxics (e.g. fluorouracil)

  • Liquid nitrogen may help flatten keloid

  • Laser (pulse dye laser) may help reduce redness

  • Consider re-excision of hypertrophic scarring

KERATOACANTHOMA

Management

  • 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

Management

  • 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

Management

  • Reduce exposure to sunlight

  • Can disappear spontaneously

  • Liquid nitrogen if superficial or

  • 5-fluorouracil 5% cream daily for 3–4 wks

  • Surgical excision for suspicious and ulcerating lesions

  • Biopsy if doubtful

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