DIAGNOSIS:
The gallbladder is a small circumscribed wheal less than 3 mm, filled with serous fluid (whitish or slightly yellowish but never disorder).
The content flows puncturing the bladder with a needle
The diagnosis may be more difficult in the presence of post-vesicular erosions (especially on mucous membranes) of content purulent lesions (secondary infection) or crusty edges.
The pustules are distinguished by their purulent vesicle content (ladle serum) and bubbles in size less than 3 mm.
The vesicles usually correspond to infectious skin diseases: viral (herpes, varicella-zoster), mycological (dermatophytes) and bacteria (impetigo), but also eczema, dermatitis herpetiformis to and disturbances in sweating (miliary ).
ETIOLOGY:
Herpes:
Diagnosis:
The primary herpes infection can take various clinical forms:
– Febrile gingivostomatitis, erosive, vesicular with dysphagia;
– IPV painful vesicular with dysuria;
– Vesicular reaching the penis.
Reaching the oral sphere is most often linked to Herpes simplex virus type 1 (HSV1) and that of HSV2 genital mucosa.
We must also think about herpes in case of vesicular rash in the newborn and in atopic (Kaposi-Juliusberg syndrome).
The diagnosis is clinical. Cytodiagnosis and PCR of the herpes group are reserved for doubtful or complicated cases to the hospital.
Herpes recurrences are usually obvious diagnosis: Vesicular eruption on vesicular erythematous base and bouquet.
They often occur in special circumstances (fever, viral, bacterial, emotional shock, or UV exposure).
They can reach the edge of the nostril, fingers, genitals. Ocular herpes localization requires specialized opinion (herpes keratitis). Prodromes can see kind of tingling, itching or burning sensation.
The vesicles spontaneously give way to a crust which disappears in eight days. In immunocompromised patients, recurrences are often torpid, more or less chronic, with large erosions, often necrotic.
The visceral when herpes recurrences are rare (esophagitis in immunocompromised patients, hepatitis in pregnant women and immunocompromised, pneumonia, encephalitis and often). In case of clinical suspicion, the patient must be hospitalized.
Recall the possibility of occurrence of erythema multiforme formed by herpes recurrences (lesions or target roundel on the extensor surfaces and hands, mucosal erosions, conjunctival). The patient should be referred to specialist.
Treatment:
Primary infection:
The treatment of primary infections was detailed in Chapter ulcerations of oral and genital mucosa.
Genital herpes and recurrences:
Herpes recurrences immunocompetent (orofacial herpes) require only symptomatic treatment. In cases of more than six recurrences per year and erythema multiforme related to herpes, preventive treatment with valaciclovir (Zélitrex® 500 mg / day for six months) is indicated.
When triggered by UV (ultraviolet), a photoprotection is necessary in case of unusual sun exposure.
In case of orofacial herpes recurrence in the near of a small atopic child, close contacts (kisses) are to be temporarily stopped.
In cases of genital recurrence, treatment is the same as orofacial recurrences.
In pregnant women:
In pregnant women, there is no need to propose systematic preventive treatment with acyclovir. If there are genital lesions at the time of entry into work room, a caesarean section is performed.
In case of primary infection, the cure follows the same rules as outside pregnancy (see ulcerations of oral and genital mucosa).
If the recurrences occurred more than 7 days
before delivery, we can offer childbirth
vaginally. Otherwise, it is an indication of cesarean section.
Chickenpox:
It corresponds to the primary infection with varicella-zoster virus (VZV). Rather, it sees in children. In adults, it occurs more frequently in persons who have not been in contact with chicken pox in childhood (Sri Lankans, for example).In immunocompromised patients, the risk is that of necrotic forms.
Diagnosis:
Clinical examination:
The rash usually starts on the scalp or ears, the neck and then down by winning the rest of the seed coat (trunk) sparing palms and soles. It is initially raised blotches on an erythematous base, initially appearing as light (dew drops) and secondarily troubling.
There are several outbreaks with different age elements. Fever is moderate and inconsistent.
The risk is that of visceral complications (neurological) especially in immunocompromised patients (ulcéronécrotiques or diffuse forms), necrotic lesions especially in cases of non-steroidal anti-inflammatory (NSAIDs) in children and in young adults smoking (potentially very serious varicella pneumonia).
If aspirin in children, remember the risk of Reye syndrome (encephalopathy and hepatic steatosis).
Secondary infection results in the appearance of crusty mélicériques closets.
In pregnant women, the risk is the transmission to the child:
– Varicella pneumonia in cases of chickenpox occur before the 20th week of gestation;
– Postnatal varicella zoster if occurs after the 20th week;
– Risk of neonatal aricelle v varicella cases occurring 5 days before or 2 days after delivery.
Further examination:
In general practice, the diagnosis is clinical and complementary examinations are unnecessary.
Treatment:
In the absence of complications, in immunocompetent, there is no need to propose an antiviral treatment. A hot shower and twice-daily application of chlorhexidine in aqueous solution on the lesions sufficient to treatment.
You should cut the nails short, do not apply talc. Oral antihistamines like cetirizine 1 cp / d are only a supplemental aid.
If superinfection occurs, it can offer treatment by Pyostacine® 1 g / 3x / day in adults.
Recall in children the obligation of school eviction until clinical recovery (in practice, until the disappearance of vesicles and crusting scabs).
The IV acyclovir (Zovirax) hospitalization is indicated for chickenpox of the newborn, severe forms of child less than a year, in pregnant women between eight days before and 10 days after childbirth, and in case of complications in immunocompromised patients.
Vaccination is recommended for people with no history of chickenpox or with negative serology, contact immunocompromised or children, and children in candidates to receive a transplant. A significant immunosuppression is an indication-cons.
In adults with no history of varicella in contact with an affected individual, it can be carried out within three days.
Zona:
This is the recurrence of VZV.
Diagnosis:
The clinical picture is often stereotyped: a closet erythematosus metameric disposition, unilateral, blisters appear grouped in bouquet, drying out after two to three days to give crusts falling ten days. Atrophic scars (on these necrotic lesions) or hypochromic can see later.
Fever is inconstant and moderate.
Radicular pain are a common complication of shingles.They can occur 3-4 days before, during or after the eruption. They are particularly insistent and prolonged in subjects over 50 years.
The most common site is the lumbar or intercostal zoster. Shingles can cause trigeminal ophthalmic reached.
It is suspect if there is an eruption of the nasal septum, especially in subjects over 50 years.
A peripheral facial paralysis accompanied by lymphadenopathy tragus, an earache and anesthesia of the anterior third of the hémilangue can be observed in case of geniculate ganglion.
In immunocompromised patients, shingles may be necrotic, ulcerative, multimétamérique. Complications are rare visceral (lung, liver, brain). In this case, a diffuse rash with varicella vesicles, preceded by a metameric eruption, may exist.
Treatment:
Local treatment is the same as chickenpox.
In patients under 50 years without complications, including ophthalmic, there is no need to prescribe antiviral treatment.
In patients over 50 years, treatment with Zélitrex® 1 g / x3 / day for 7 days is prescribed.
If facial reached, the patient is shown to the ophthalmologist to eliminate a herpes zoster ophthalmicus.
In the absence of ophthalmic complication, the Zélitrex® is given at the same dose as above. Local treatments eye, the local and systemic corticosteroid therapy is prescribed only on the advice of the ophthalmologist.
In immunocompromised patients, intravenous treated systematically hospitalization Zovirax® 10 mg / kg every 8 hours for 7 days (to be adapted to the renal function).
Analgesics have a key role (paracetamol, Laroxyl® 75 mg / d, Neurontin).
Impetigo:
It can sometimes start by vesicles. It is more common in children. In adults, it should be suspected dermatitis underlying surinfectée (scabies, for example).
Diagnosis:
The gallbladder can rupture rapidly to give mélicériques crusts, peri-orificial often in children early, with remote lesions favored by manuportage.
There is no fever most often.
The bubble can be large and more can be observed.
In immunocompromised patients, lower limbs, may be a hollow and deep form of impetigo, ecthyma.
In children is possible contagions in small intra-family or school epidemics.
A dipstick is conventionally done 3 weeks after the infection in order to eliminate a post-infectious glomerulonephritis.
Treatment:
Treatment is usually local: water wash with soap and morning and evening application of chlorhexidine in aqueous solution on the lesions, fat cream or Vaseline kind Fucidine® to bring down the crusts.
In case of extensive lesions, a general treatment Pyostacine® 1 g / 3x / day in adults can be given.
Do not forget to review and possibly treat siblings in children. The nails are cut short and the child’s towels must be personal. A school eviction until recovery is imperative.
Dermatophytes:
It is human transmission infections, animal or rarely telluric. The appearance is more inflammatory in the latter two cases.
Diagnosis:
On the hairless skin, are observed rounded lesions, pruritic, erythematous trim, vesicular and scaly, with central aspect of pseudoguérison.
On the feet, the achievement is often between the 3rd and 4th toe, with cracks, mealy hyperkeratosis of the plant, vesicles that can overflow onto the back foot.
On large folds, there erythematous plaques in many limited érythématovésiculeux edges with central aspect of pseudoguérison. Of the inguinal folds, the closet may contaminate the inside of the thigh.
Treatment:
Treatment consists of daily washing with soap and water with careful drying and the application of topical antifungals (eg Kétoderm® cream, 1-2 applications per day for 1 to 3 weeks depending on the location).
If more than five cutaneous lesions, systemic therapy is indicated after mycological sampling (Lamisil® 250 mg / d).
We must identify the transmission factors (animals, in subjects with the entourage, tap port in swimming pools).
Eczema:
The gallbladder is one of four stages of eczema (erythema, vesicles, oozing discharge, crusts).
Itching is often important.
Eczema, often easily diagnosed, may correspond to a contact dermatitis or atopic dermatitis.
Contact dermatitis:
Diagnosis:
Diagnosis is based on clinical appearance of the rash, the topography and the interrogation. Patch tests are often unnecessary (remember that a positive test does not necessarily impute the product tested in eczema).
The contact dermatitis makes erythematosus closet, crumbled, pruritic, vesicular, drawing the region in contact with the allergen.
Some remote elements are possible.
On the feet, it is often eczema-related components for footwear: Leather chrome on the back foot, vulcanizing agent of rubber on the soles.
On the face and eyelids, especially in women, it is cosmetics, nail polish, perfumes, but also paintings and volatile plant.
On the lobules of the ears, wrist, navel, there is often a nickel allergy.
The appearance also varies the affected area:
– Edema of the eyelids and genitalia;
– Pruritic vesicles embedded in the dermis on the hands (dyshidrose);
– Fissured and hyperkeratotic lesions on the palms and soles;
– In chronic eczema, lesions are readily érythématosquameuses with lichenification (thickening due to scratching).
The contact dermatitis is initially localized to the area of contact with the allergen, which took place from 24 hours to a few days before the onset of lesions. The chronology is important (disappearance during holidays or weekends for a professional factor).
The main allergens are:
– Occupational (health professions with latex, building with cement, with preferential involvement of the hands improvement during holidays);
– Cosmetics (facial damage in women);
– Photoallergen (ultraviolet exposure, achieving uncovered areas): NSAIDs gel (Kétum® gel), plants (phytophotodermatoses);
– Local drugs (balsam of Peru, neomycin, etc.).
The list of treatments used is also important (risk of sensitization to the active ingredients or excipients).
Treatment:
Treatment is based if possible on allergen avoidance. An outplacement is sometimes necessary. Wearing gloves can be recommended. It prescribes a level of dermocorticoid II, Type Diprosone® Betnéval® or cream on the body, level III, Type Tridésonit®, on the face, after the local toilet. Doses are often decreasing (on the body eg an application daily for 7 days, then an application every other day for ten days, then twice a week for 15 days and then stop).
Atopic dermatitis:
Atopic dermatitis is the atopic eczema. Lesions are originally similar to those of the contact dermatitis. There is often a personal or family history of atopy (asthma, allergic rhinitis, eczema).
Diagnosis:
In infants over three months, the affected areas are the convexity (buttocks, forehead, cheeks). During evolution, the lesions lichénifient (chronic eczema appearance), affecting the popliteal, retro-auricular folds, wrists. There is often a skin xerosis.
In children, there may eyelid folds under and infra-orbital pigmentation. The immunoglobulin E (IgE) and total amounted there may be a small hypereosinophilia.
Remember the risk of Kaposi-Juliusberg syndrome in case of primary herpes infection in an atopic child.
Treatment:
The treatment is a long-term care. It is based on the application of topical corticosteroids, especially in case of thrust, the type of emollient cream with Dexéryl® use syndets toilet (eg Lipikar Syndet®). Cures can be useful in children.The eviction of aggravating factors is necessary (fight against mites, dwellings of aeration, removal of pets).
In the most severe cases, it may be necessary to use immunosuppressive cyclosporin kind in children, PUVA therapy in adults. Topical tacrolimus (Protopic, 0.03% tube, for example) must be used only on expert advice (risk of complications related to the local immunosuppression). The local antisep ticks are used sparingly if pushed.
OTHER CAUSES:
Prurigo strophulus:
Prurigo in children strophulus realizes papulovesicles on the legs due to insect bites.
Treatment is symptomatic.
Miliary:
The sweat retention in children can result in miliary:
– Crystalline miliary: appearance at a fever
by heavy sweating, clear thoracoabdominal elements dewdrop, not itchy, drying himself in a few hours;
– Red miliary (pruritic vesicles on the folds of the friction zones).
Treatment is symptomatic.