Pediatric Dermatology Pearls for Those Common Referrals

Transcription

1 Pediatric Dermatology Pearls for Those Common Referrals Robin L. Hornung, MD, MPH Staff Physician and Chair, Dept of Dermatology The Everett Clinic Clinical Associate Professor, Dermatology University of Washington School of Medicine

2 Pediatric Dermatology Pearls for Those Common Referrals I have no relevant conflicts of interest to declare Will discuss some common conditions Pearls will be highlighted in yellow!

3 Pigmentary Mosaicism Infant developed hypopigmented patch on abdomen, inner thighs Borders somewhat feathery No preceding rash o/w healthy Pregnancy uneventful

4 Pigmentary Mosaicism

5 Pigmentary Mosaicism Heterogeneous group of disorders with patterned streaks of hypo/hyperpigmentation Streaks/whorls tend to follow lines of Blaschko lines of ectodermal embryologic development Reflects gene mosaicism of affected areas In extensive involvement can see gross chromosomal abnormalities (60%) Do not tend to be hereditary

6 Pigmentary Mosaicism Not always present at birth, can evolve over time Can have associated abnormalities of the bones, eyes, and/or CNS (30%) No effective treatment Other names: Hypomelanosis of Ito = incontinentia pigmenti achromians Linear and whorled nevoid hypermelanosis Nevus depigmentosus

7 Pigmentary Mosaicism This is not the same as vitiligo!

8 Atopic Dermatitis 8 month old female with 6 month history of recurrent itchy rash on cheeks, and scattered spots on extremities/trunk Difficulty sleeping at night Often improves with topical steroids then recurs

9 Atopic Dermatitis

10 Atopic Dermatitis

11 Atopic Dermatitis Inside-out theory of AD: Aberrant T cell activity important to AD pathogenesis: Excessive T cell activation in response to antigen Atopic Langerhans cells hyperstimulate T cells Altered barrier function of the skin, the outside-in theory Filaggrin mutations Leung DYM. J Allergy Clin Immunol. 1997;79: Enomoto H et al. J Hum Genet 2008;53:615 Hoffjan S et al. Br J Dermatol 2007;157:441

12 Atopic Dermatitis Altered barrier function of the skin, the outside-in theory Reduced ceramide content in the stratum corneum in AD Free fatty acids are decreased in the stratum corneum of lamellar ichthyosis patients Elevated levels of transepidermal water loss indicative of an impaired barrier function Pilgram GS et al. J Invest Dermatol 2001;117;710

13 Xerosis

14 Molluscum Contagiosum

15 Eczema Herpeticum

16 Impetigo

17 Dennie-Morgan Lines

18 Hyperlinearity

19 Ichthyosis Vulgaris

20 Keratosis Pilaris

21 Pityriasis Alba

22 Atopic Dermatitis Patient Education: Individualize therapy Chronicity of disease Difficulties in determining triggers Bathing is not harmful (soap is!) Topical steroids not harmful if used correctly Recognize quality of life issues 60% of patients/families report impairment in the performance of daily activities 80% of children experience disrupted sleep

23 Atopic Dermatitis Bathing is good: Parent-child bonding Decreases bacterial load Decreases thick stratum corneum Increases water content Avoid excessive duration of bathing Add 1 cup table salt if skin stinging Moisturizer must be applied within 3 minutes to moist skin

24 Atopic Dermatitis Avoidance of irritants and allergens: Avoid harsh soaps and detergents Cotton is best; avoid wool, polyester Avoid cold, dry air Avoid bathing in hot water Avoid allergens if known NOTE: allergens are triggers of disease, not cause of it!

25 Atopic Dermatitis Topical steroids: wide range of strength and bases Ointments (best tolerated!), creams, lotions, oils, solutions Hydrocortisone/nonfluorinated steroids safest, but stronger steroids may be used up to a few weeks or longer to recalcitrant areas Local side effects rare with low-medium strength steroids, but greater risk on face/intertriginous areas Triamcinolone ok on face for a short period!

26 Atopic Dermatitis Topical steroids: Use 3x/day!! Once clear treat a few more days! Otherwise may come right back! Chronic plaques need a slow taper! Sometimes need to do a 2x/week maintenance for several weeks

27 Atopic Dermatitis Resistance to therapy: think Staph. Aureus infection! Characterized by crusted, weeping areas Caregivers may carry S. Aureus on hands/nares Treat with 2-4 week course of anti-staph antibiotic Other measures: Rx with mupirocin ointment, ¼ - ½ cup bleach to adult size bath Also think HSV!!

28 Atopic Dermatitis

29 Atopic Dermatitis

30 Atopic Dermatitis Antihistamines (rarely needed!): Need high dosages for effect (hydroxyzine 1-2 mg/kg/day) Risk of hyperactivity as adverse reaction Possibility of tolerance Nonsedating antihistamines may be useful if allergies contribute

31 Atopic Dermatitis Other Therapies: Topical tacrolimus (Protopic = FK506) Topical pimecrolimus (Elidel) Fluocinolone 0.01% in peanut oil base (DermaSmoothe/FS) Leukotriene antagonists Phototherapy Chinese herbal therapy Systemic steroids/cyclosporin

32 Atopic Dermatitis and Vitamin D Vitamin D modulates innate immunity and reduces the risk of microbial infections Vitamin D deficiency (VDD) was positively correlated with prevalence of allergies, asthma VDD may be related to the severity of AD Antimicrobial peptides (AMPs) = Cathelicidins protect primarily against microbial infections, are vitamin D dependent Rieri M et al. Allergy Asthma Proc 2011;32:438 Peroni DG et al. Br J Dermatol 2011;164:1078 Dombrowski Y et al. Arch dermatol Res 2010;302:401

33 Atopic Dermatitis Many different manifestations, but predictably very itchy!! Need comprehensive program for treatment Suggest referral to dermatology for moderate to severe disease Suggest referral to allergy when fairly convincing evidence of allergic reactions or in severe disease

34 Folliculitis 15 year old girl with numerous itchy erythematous papules over legs (some on arms) Also with follicular pustules Started shortly after rash in axillae History of atopic dermatitis

35 Folliculitis

36 Folliculitis Refers to an infection of hair follicles Clinical appearance varies according to location and depth of follicular involvement Usually begins with yellow-white follicular pustules, often erythematous Often seen on buttocks and extremities Often occur in crops and heal with post-inflammatory hyperpigmentation

37 Folliculitis

38 Folliculitis

39 Folliculitis Staphylococcus aureus most common offender, but Strep and gram negatives can be seen In immunocompromised children can see commensals such as Pityrosporum yeast or Demodex mites Rx usually with topical antibiotics (clindamycin lotion a good one for very dry skin, mupirocin for oozing skin), systemic if extensive, antibacterial soaps Stop auto-inoculation (such as shaving of legs) Consider culture if unusual or resistant

40 Folliculitis Think about sources! If more diffuse, consider hot tub

41 Molluscum Contagiousum 9 yo with fairly rapid onset of small bumps over the course of a couple weeks Some areas associated with itching and redness Child has a h/o eczema

42 Molluscum Contagiosum Caused by pox virus Often affect head, neck & trunk, may be extensive in children with atopic dermatitis Genital MC increasing in sexually active young adults See drama!!! Molluscum dermatitis Molluscum conjunctivitis Id reaction and urticaria They scar!

43 Molluscum Contagiosum May spontaneously regress Treatments: cantharidin, cryotherapy, aldara, tretinoin cream, salicylic acid, 5-FU, imiquimod cream (curettage in adults) Cantharidin should be applied very carefully and washed off in ~4 hours! Cryotherapy only for older children who can consent to procedure

44 Hemangioma of Infancy Be wary of large hemangiomas, folded moist areas like the neck and diaper area: ulceration!

45 Hemangioma of Infancy Be wary of nasal tip, lip and ear hemangiomas

46 Hemangioma of Infancy

47 Hemangioma of Infancy 2008 propranolol rocked our world! Leaute-Labreze C, et al. NEJM (24):2649

48 Hemangioma of Infancy

49 Hemangioma of Infancy Just a reminder that a significant proportion of hemangiomas leave residual skin defects after they involute!! See in the superficial ( strawberry ) lesions where the skin becomes so stretched and atrophic, and deep ones where fibro-fatty deposits occur Prevention of significant growth is best! Early laser, or even systemic propranolol If significant residua, need to consider surgical excision

50 Hemangioma of Infancy

51 Scabies Infestation 20 yr old healthy young man developed intensely itchy red bumps on his wrists, hands, ankles and feet x months Itch often kept him awake at night

52 Scabies Infestation

53 Case Description

54 Scabies Infestation

55 Scabies Infestation Caused by Sarcoptes scabiei, the human mite Obligate parasites of all developmental stages burrow in the epidermis, laying eggs, depositing feces Adult female lifespan days, lays 1-4 eggs/day Eggs hatch in 3-4 days, mature into adults days Transmitted by direct contact, sometimes fomites Survival off the human host is only ~3 days Average incubation before symptoms is ~3 weeks

56 Scabies Infestation Initial symptom typically is pruritus, often worsening at nighttime Papules, nodules, burrows, vesiculopustules Interdigital spaces, wrists, ankles, axillae, waist, groin, in infants also on the head, palms and soles, diffuse! Scabies nodules are red-brown nodules representing a vigorous hypersensitivity response, may last x months Crusted scabies occurs in the immune compromised, highly contagious!!!

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58 Scabies Infestation Crusted scabies occurs in the immune compromised, such as HIV, or physically incapacitated Lesions may mimic eczema, psoriasis or warts, sometimes get nail dystrophy Can be minimally pruritic Highly contagious!!! Often the source of large epidemics, can carry thousands of mites Often there is a delay in diagnosis

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60 Diagnosis is made via skin scrapings under mineral oil immersion Sometimes need to scrape parents if child uncooperative See mites, eggs, feces

61 Scabies Infestation Treatment includes permethrin 5% cream applied neck down for 8-14 hours, followed by rinsing A 2 nd treatment 1 week later is often recommended In infants it should also be applied to scalp and face Apply well under finger and toenails too Warning: Sx s may not clear for several weeks! Ivermectin (off-label) extremely effective Rx: mcg/kg/dose, can repeat in 2 weeks Treatment of all close contacts too!

62 Scabies Infestation Environmental decontamination: clothing, bed linens, and towels should be machine washed in hot water and dried using a high heat setting Items that can t be washed (stuffed animals) may be dry cleaned or stored in bags for 1 week, as the mite will die when separated from the host Topical steroids and anti-histamines can be used for symptom relief Warn that nodules can take weeks or months to heal

63 Bedbug Infestation 17 yr old female on a trip to Europe started waking up with groups of itchy red welts She was otherwise very well Her trip included stays in youth hostiles

64 Bedbug Infestation Caused by Cimex lectularius Red-brown wingless blood-sucking nocturnal insects that are 3-5 mm in size Female deposits eggs on rough surfaces, cracks, crevices Avoid light by hiding during the day, then respond to warmth and carbon dioxide at night (sleeping human) Occur on any exposed areas of skin like face, neck, arms, hands Can survive without blood for 6-12 months!

65 Bedbug Infestation

66 Bedbug Infestation Treatment is directed at elimination of bugs with insecticides as well as potential hiding sites Can look for blood stains on your sheets or pillowcases, dark rusty spots of excrement, egg shells, or shed skins on sheets and mattresses, bed clothes, and walls An offensive, musty odor from the bugs' scent glands Call an exterminator! For symptom relief can use topical steroids and antihistamines The Bed Bug Registry:

67 Flea Infestation 5 yr old boy with recurrent itchy bumps on legs, but also areas on trunk, arms They have one cat and one dog, had fleas in the past but they are treated

68 Flea Infestation Caused by Pulex irritans (human flea), Ctenocephalides canis and felis (dog and cat flea) Leave urticarial wheals or papules, often with a central hemorrhagic punctum, can see tense vesicles or bullae Classic breakfast, lunch, and dinner sign for crawling or hopping insects Adults: bites around ankles, Children: bites everywhere! Often only one individual in household will be primarily affected, the tasty one!

69 Flea Infestation

70 Flea Infestation Treatment is directed at elimination of bugs with treatment of suspected animal carriers Do not forget cleaning and spraying of carpets, floors, crevices, and other potentially infested areas For every flea seen on pet, there are many more in the environment Flea collars not completely effective, sprays and powders must be repeated every 2 weeks in summer Potent topical steroids will help resolve individual lesions and symptoms.

71 Case Description 8 yr old girl with recurrent dermatitis of the lips, often irritated Eats mangoes on occasion

72 Lip Licker s Dermatitis Irritant contact dermatitis DDX: allergic contact dermatitis, atopic dermatitis RX: frequent moisturizing with thick emollients (Aquaphor), low-strength topical steroids BID-TID stop licking!!

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85 Have A Nice Day!!