Disclosures. Poll Everywhere. Learning Objectives. Atopic Dermatitis. Atopic Dermatitis

Transcription

1 39 th National Conference on Pediatric Health Care March 19-22, 2018 CHICAGO Disclosures When It s Not Eczema: Reviewing common and not so common differential diagnosis for Atopic Dermatitis No disclosures to report. Rebecca Flynn, MSN, APRN, CPNP PC APRN III Dermatology Clinic Children s Mercy Hospitals and Clinics Kansas City, MO Poll Everywhere Learning Objectives 1. Review etiology, history, symptoms and treatment of atopic dermatitis. 2. Differentiate various forms of eczema including nummular eczema, dyshidrotic eczema, and papular atopic dermatitis. 3. Identify differential diagnosis of atopic dermatitis including scabies, psoriasis, allergic contact dermatitis, papular urticaria, palmar/ plantar juvenile dermatosis, seborrhea dermatitis, keratosis pilaris and perioral dermatitis. 4. Initiate preliminary treatment plan for common differential diagnosis of atopic dermatitis including scabies, psoriasis, allergic contact dermatitis, papular urticaria, palmar/ plantar juvenile dermatosis, seborrhea dermatitis, keratosis pilaris and perioral dermatitis. Atopic Dermatitis Atopic Dermatitis Dry, rough, itchy skin Waxes and Wanes Often begins <2 years of age Some older Commonly exists with atopy Allergies, Asthma, Atopic Dermatitis Strong Family History Responds to Moisture and Topical Steroids Distribution of dermatitis Infant face, scalp, trunk, back, elbows, knees Child neck, B AC, B pop fossa, B ankles/ feet Adult Hands, feet 1

2 Atopic Dermatitis Treatment Sensitive Products Dye free, Scent free products: soap, laundry detergent, dryer sheet Moisture Bland ointment/ cream emollient Vaseline ointment, Aquaphor ointment Vanicream, Cetaphil cream Daily bathing Topical Steroid BID Ointments! Mild Hydrocortisone 2.5% ointment, Alclometasone ointment Moderate Triamcinolone 0.1% ointment Strong Mometasone ointment, Fluocinonide ointment Atopic Dermatitis Topical Steroids Face, axilla, groin Body only. Not on face, axilla, groin (Tollefson, 2014) Atopic Dermatitis Treatment Topical Calcineurin Inhibitors Elidel cream Tacrolimus (Protopic) 0.03%, 0.1% ointment. Black box warning Crisaborole (Eucrisa) Atopic Dermatitis Treatment Antihistamines Daily non sedating Zyrtec As needed for Allergy control to prevent flares Sedation effect to aid sleep Benadryl Hydroxyzine Doxepin Melatonin 1 5 mg nightly Bleach Baths ¼ cup unscented bleach to ½ tub of water Topical Antibiotics and Oral Antibiotics (cultures) Mupirocin 2% ointment Keflex & Clindamycin Wet Wraps Variations of Eczema Nummular Dyshidrotic Papular Eczema 2

3 Case Study #1 10 year old patient is evaluated in clinic with sibling dual appointment. Chief complaint: rash for 2 3 months. Involved areas include arms, legs, stomach, hands and feet. Pruritis is intense and worse at night. Sibling s rash started 1 month prior to the patient s rash. Attempted hydrocortisone 1% ointment which improved itching but rash has continued to spread. Prior to new rash 2 3 months ago patient had normal skin. Scabies Scabies mites Working for a living! Scabies Live days Lays 1 4 eggs per day, hatch 3 4 days minutes close contact transmit scabies Incubation 3 weeks Pruritis!!! Worse night time Papules, nodules, burrows, vesiculopustules Interdigital space, wrists, ankles, axilla, waist, buttock, groin, palms, soles HISTORY! Scabies Diagnosis Clinical symptoms burrows, delta sign Scabies prep skin scraping Permethrin 5% cream Head/ scalp down in infant, neck down child. Apply, leave on overnight 8 14 hours Do not use under 2 months. Repeat 7 days later Treat ALL household members (affected 2 treatments, unaffected 1 tx) Sulfur 6% compounded in Vaseline Safe for infants and pregnant or nursing moms Apply neck down for 3 consecutive nights. Rinse 24 hours later Ivermectin severe infestation resistant to topical treatment (rare) Not used under 5 years of age 3

4 Scabies Before and After Case Study #2 10 year old patient is evaluated in clinic with chief complaint of new rash. Rash started 3 4 months ago on arms, legs, scalp, and trunk including umbilicus. Affected areas are mildly pruritic but do not disturb sleep. Attempted Aquaphor ointment which decreased dryness of rash but redness has not improved. Rash has worsened over the last 2 weeks and patient has new complaint of headache, sore throat, and stomach ache. Previously patient had normal skin with the exception of numerous diaper rashes during infancy. Psoriasis Vulgaris Chronic Immune mediated disorder Rarely present at birth 1/3 of cases present before 20 years old. Highly genetic immune activation & cutaneous inflammation Known triggers: Streptococcal infection, Staph A. infection, psychological and physical stress. Characteristic Rash: round, brightly erythematous, wellmarginated plaque with greyish or silvery white overlying scale Psoriasis Vulgaris Distribution: Scalp, elbows, knees, lumbosacral, groin Inverse Distribution: Axilla, groin, umbilicus Presents within areas of trauma. Psoriasis Vulgaris Comorbidities Obesity, Early cardiovascular disease/ Metabolic Syndrome, Juvenille Idiopathic Arthritis, Crohn s disease, anxiety/ depression. Topical corticosteroids (often moderate strong) Topical calcineurin inhibitors Topical Vitamin D calcipotriene (Dovonex) UV light NBUVB therapy Systemic therapy Methotrexate, Cyclosporine, Acitretin (Dermatologist) 4

5 Guttate Psoriasis Guttate Psoriasis Often children 1 st manifestation of Psoriasis Drop like (guttate), round/ oval lesions (2 6mm) Symmetrical on trunk, extremities Often triggered by Group A Strep infection (throat, skin, anal) 40% develop plaque psoriasis Case Study #3 4 year old patient has developed a new rash on B posterior legs and inner thighs. Rash developed 6 8 weeks ago. Affected area is highly pruritic and patient often scratches until bleeding. Patient has had many new sleep disturbances related to intense pruritus of skin. No other family members are affected. Patient recently started preschool. Allergic Contact Dermatitis Allergic Contact Dermatitis Type IV hypersensitive reaction (delayed) generally 8 12 hours Sensitivity after re exposure days years Most common: poison ivy, nickel, fragrance, dyes, wet wipes, lanolin, antibiotics, rubber, formaldehyde Distribution! Sharp edges, erythema, vesicles, bullae present. 5

6 Allergic Contact Dermatitis Allergic Contact Dermatitis Treatment Identification of trigger Topical steroids Oral steroids Antihistamines Zyrtec, Benadryl or hydroxyzine Moisturizers Avoidance of triggers Identification of Triggers Patch testing 5 day test. a/wa/content?f=product truetest.html&m=spa Case Study #4 7 year old patient presents with new rash on B arms and B legs. Rash has been present for 2 3 months. Mother reports new, red spots appear on arms and legs. Patient often scratches until bleeding. Rashes often wax and wane. Mother reports it appears as if the rash never completely resolves. Attempted hydrocortisone 1% ointment without much relief. Family has 1 dog and 1 cat in the household. Papular Urticaria 6

7 Chronic, papular eruption due to hypersensitivity to bug bites Highly pruritic High risk of secondary infection due to scratching. Summer & Late Spring Papular Urticaria Papular Urticaria Insect Repellent Unscented OFF Low mid potency topical steroids Hydrocortisone 2.5% ointment Desonide ointment / Alclometasone ointment Triamcinolone 0.1% ointment Topical antibiotic Mupirocin 2% ointment Antihistamines aid sleep, relieve itch Benadryl or Hydroxyzine Flea Bites Bed Bug Case Study #5 2 year old patient presents to clinic with a 3 day history of red, itchy rash diffuse on entire body. Mother reports patient is experiencing difficulties sleeping. The mother reports the family is exhausted because the patient did not sleep well the week before due to a runny nose and cough. The rash started on patients arms the first day but has since spread to the entire body. The patient is very itchy and occasionally scratches until bleeding. Viral Exanthum Viral Exanthum Macules and Papules DIFFUSE! Within setting of fever, headache, fatigue, respiratory or GI symptoms Resolve within 1 week. Gianotti Crosti syndrome (viral exanthum) resolve within 8 12 weeks If pruritic mild potentency topical steroids Emollients New Drugs? 7

8 Case Study #6 11 year old male presents with thick, pruritic, erythematous rash on B soles of feet. Both soles of patient are affected while hands and arms are spared. Family attempted hydrocortisone 1% cream without any relief. Upon examination, sweaty palms and soles are noted. Patient has never had any skin rashes on other areas of his body prior. Rash has been present about 2 3 months. Occasionally, patient s feet become so inflamed painful cracks (fissures) develop. Juvenile Palmar/ Plantar Dermatosis Sweaty sock syndrome Distal aspects soles sparing interdigital spaces Associated with hyperhidrosis Smooth, red, glazed with fine scaling (chronicitylichenification) Juvenile Palmar/ Plantar Dermatosis Wear all cotton socks Change damp socks frequently Dust absorbent powder if desired Avoid occlusive shoes without cotton barrier Apply ointment emollient upon removing shoes Moderate potency topical steroid Triamcinolone 0.1% ointment Fissures super glue Crusting, secondary infection topical antibiotic, Mupirocin ointment Case study #7 3 month old patient presents to clinic for evaluation of a new rash. Rash appeared 3 4 weeks ago and seems to have worsened over the last several days. Affected areas include face, neck, arms, legs, axilla, and inguinal folds. Scaling is noted in patient s scalp. Red patches appear shiny in folds of skin. Mother and father report patient is sleeping well. 8

9 Seborrhea Dermatitis Self limiting erythematous, scaly or crusting eruption Etiology: unknown overgrowth of yeast (Malassezia) Onset: 2 10 weeks. Peak: 3 months Infants Scalp, intertriginous, flexural, diaper Adolescent Scalp, eyebrow, bridge of nose, nasolabial crease, post auricular Thin dry scales / well defined red patches with brown, greasy crust Pruritis absent or minimal Seborrhea Dermatitis Seborrhea Dermatitis Most clear spontaneous by 1 year Tear free shampoo with frequent washing Ketoconazole 2% shampoo/ cream Low potency topical steroids Mineral oil removal of scales Case Study #8 15 year old patient presents with concern for new rash on chest. Rash appeared 1 month ago. Over the last month the rash has spread to encompass entire chest extending to B arms and back. Rash is red, slightly scaly and pruritic. Patient attempted hydrocortisone 1% cream OTC for 2 3 days. Pruritis improved but rash remained and continued to spread. Patient is active in football. Family has 2 household cats. 9

10 Tinea Incognito (Tinea Corporis) Tinea Incognito Tinea Corporis morphed due to topical steroids Superficial fungal infection Risks: contact wrestler, kittens, gerbils Species: M. Canis, Trichophyton species Annular, red, scaly, central clearing, sharp border Topical steroid makes worse, rash spreads (hallmark presentation masked) Tinea Incognito Dermatophyte culture Topical antifungal cream Ketoconazole Twice daily until clear, additional 1 week Oral antifungal Griseofulvin Change hand towels Change shoes Case Study #9 6 year old patient presents for evaluation of new facial rash. Rash appeared 2 3 months ago. Initially appeared dry. Family moisturized rash with Vaseline ointment. The rash continued to spread and then became red and pruritic. Family attempted hydrocortisone 2.5% ointment 2 x daily. Rash continued to spread from initially under nose now extending up to surrounding patients eyes and mouth. Patient s medication list: acetaminophen, hydrocortisone 2.5% ointment, Flovent disk, albuterol. Case Study #9 6 year old patient presents for evaluation of new facial rash. Rash appeared 2 3 months ago. Initially appeared dry. Family moisturized rash with Vaseline ointment. The rash continued to spread and then became red and pruritic. Family attempted hydrocortisone 2.5% ointment 2 x daily. Rash continued to spread from initially under nose now extending up to surrounding patients eyes and mouth. Patient s medication list: acetaminophen, hydrocortisone 2.5% ointment, Flovent disk, albuterol. 10

11 Perioral (Periorificial) Dermatitis Perioral (Periorificial) Dermatitis Erythematous, discrete, inflammatory papules/ pustules Absense of Comedones Distribution Perioral, nasolabial, periocular Etiology Unknown Often triggered by steroids Topical mod high potency, inhaled, systemic Possible Treatment Topical metronidazole MetroCream Topical Calcineurin inhibitor Elidel cream, Protopic Oral tetracycline (>8 y/o for 6 8 weeks) or Oral erythromycin (< 8 y/o) Avoid topical steroids Avoid irritating skin products Rash worsens with topical/ inhaled steroids Case Study #10 5 year old patient presents for evaluation of red, itchy rash on B AC and arms for 2 weeks. Patient is often scratching affected area even during sleep. Mom reports patient previously had normal skin but has had small pimple appearing bumps on skin for the last 6 months. Several atrophic macules are noted on lower legs. Molluscum Contagiosum Molluscum Dermatitis Common viral disease of childhood Caused by the molluscum contagiosum virus (MCV), a poxvirus Benign and self limited Spontaneous resolution within 6 months to several years Inflammation precedes resolution Contagious direct contact, water 11

12 Molluscum Dermatitis Reassurance <1% intact molluscum are bacterially infected Vaseline ointment/ Aquaphor Refrigeration Avoid mid high potency topical steroids Can use mild potency topical steroids for pruritis Hydrocortisone 1%, 2.5% ointment Antihistamines Benadryl, hydroxyzine Case Study #11 13 year old patient presents for new skin rash on face, arms, legs and buttocks. Affected areas are very dry and bumpy. Rash seems to remain fixed, does not wax and wane. Affected area is occasionally pruritic but does not disturb sleep. Rash can appear red especially when patient is hot and sweaty. Keratosis Pilaris Asymptomatic no pruritis Cosmetically distressing!!! Dry, bumpy skin chicken skin Follicular hyperkeratosis Not present at birth. Appears childhood Familial inheritance Face, extensor arms, lateral legs Can be widespread Keratosis pilaris Keratosis Pilaris Moisturizers cream, ointment Avoid irritants fragrances, dyes Keratolytic agents Ammonium lactate 12% cream Salicylic acid Glycolic acid Urea Potential for irritation resulting in erythema (BALANCE) Must maintain therapy to achieve remission 12

13 Case Study #12 16 year old patient presents for evaluation of new rash on B legs. Red rash appeared 3 4 months ago. Affected area is not pruritic but rash appears to be spreading on both legs. The patient is not involved in sports activities but enjoys playing video games on a laptop for extended periods of time. Erythema ab igne Acquired skin reaction to heat Reticulated, annular, hyperpigmented, pink/ purple (pattern) Repeated exposure to moderate intensity heat (not burning) Ex. Laptop, Ipad, heating blanket, fireplace Avoid heat triggers Removing heat erythema may fade. Reticulated hyperpigmentation permanent Erythema ab igne References 13