Atopic dermatitis Usually starts t in early infancy Xerosis (dry skin) Pruritus Eczematous lesions

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1 An Update on Eczema & Common Skin Infections in Children Nelly Rubeiz, MD Dept. of Dermatology American University of Beirut

2 Atopic dermatitis Usually starts t in early infancy Xerosis (dry skin) Pruritus Eczematous lesions

3 Pathophysiology Genetic predisposition Xerosis - defective lipid barrier Immune defect

4 Atopy

5 Skin barrier

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8 The itch scratch cycle

9 Atopic dermatitis The itch that t rashes

10 Very common Atopic dermatitis affects % of children Adults: 0.9% Increased incidence in urban populations p

11 Age Most prevalent in infancy & childhood In 85% %ofcases:inthe1 st year of life 95% of cases: before 5 years

12 Infantile Eczema After 6-8 weeks of life Dry skin - usually spares the diaper area Face, scalp, chest, and extensor extremities Erythematous exudative patches Child often very irritable and sleeps poorly because of itching

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14 Childhood Skin is dry and rough Pallor of the face Dennie-Morgan folds Flexures (antecubital and popliteal fossae), neck, back, ankles & wrists Pruritus / Lichenification Excoriations and crusting are common

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19 Adulthood Lesions become more diffuse The face is commonly involved Xerosis is prominent Lichenification

20 Adults

21 Diagnosis Pruritus Distribution Chronic recurring course Strong family history of atopy

22 Differential Diagnosis Contact Dermatitis Nummular Dermatitis Psoriasis Scabies Seborrheic Dermatitis Tinea Corporis

23 Disease course Tendency for sensitive skin may remain Most cases, eczema gradually improves ~2/3 of children outgrow their eczema Few continue to have eczema

24 Kissling S. Hautarzt 1994;45:

25 Associations 30% develop asthma 35% have nasal allergies Urticaria and anaphylactic reactions to food occur with increased frequency peanuts, eggs, milk, soya, fish, and seafood.

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27 Associated Conditions

28 Eczema - impetigo

29 Herpes simplex

30 Molluscum contagiosum

31 Warts

32 To help protect your privacy, PowerPoint prevented this external picture from being automatically downloaded. To download and display this picture, click Options in the Message Bar, and then click Enable external content. Triggers of Eczema Tobacco smoke Excessive temperatures (hot or cold) Harsh chemicals such as solvents, detergents.. Skin care products: alcohol, soaps.. Irritating fibers such as wool and synthetics Cosmetics and perfumes Emotional stress Food allergens (milk, fish, eggs, peanuts..) Other allergens (pollen, pets, dust mites) Sweat

33 Treatment Hydration - Emollients Avoid irritants / allergens Topical steroids Topical immunomodulators Systemic therapy Systemic antibiotics Antihistamines Systemic steroids: rarely used

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35 Topical immunomodulators Tacrolimus Pimecrolimus

36 Pimecrolimus (Elidel ) Topical steroid-free medication with immune-modulating modulating and anti-inflammatory inflammatory properties Inhibits calcineurin Selectively l blocks T-cell & mast cell inflammatory cytokine production

37 Pimecrolimus (Elidel ) Available as a 1% cream Provides a steroid-free alternative It relieves the itch and inflammation caused db by atopic dermatitis

38 Pimecrolimus (Elidel ) Approved for short-term term intermittent long-term treatment patients over 3 months of age In some countries, it is only approved for children over 2 yrs

39 How to use Pimecrolimus Affected area(s) twice daily Do not use occlusive dressings Minimize i i sun exposure Stop use once signs or symptoms resolve Use an emollient as maintenance therapy

40 How to use Pimecrolimus Restart t treatment t t at first sign of recurrence itch If condition does not improve within 6 weeks of treatment or if it worsens, stop applying pimecrolimus cream May need a short course of topical steroid to control a flare of eczema

41 Pharmacokinetics studies Adults & children with extensive AD Negligible absorption of pimecrolimus through the skin Greatly likelihood lih of systemic effects after topical application

42 Pimecrolimus side effects The most common side effect at the site of application Sensation of warmth or burning Mild to moderate in severity Clears within a few days

43 Pimecrolimus side effects slightly increased susceptibility to skin infections such as folliculitis, impetigo, herpes simplex and molluscum contagiosum.

44 Pimecrolimus - precautions Avoid use in areas affected by active, cutaneous bacterial and viral infections

45 Wahn, U. et al. Efficacy and Safety of Pimecrolimus Cream in the Long-Term Management of Atopic Dermatitis in Children. Pediatrics 2002;110:e2

46 Wahn, U. et al. Pediatrics 2002;110:e2

47 Pimecrolimus group Significantly fewer AD flares Regardless of baseline severity At 6 months and 1 year, patients with no flare twice as much Longer flare-freefree period Less topical steroid required Wahn, U. et al. Pediatrics 2002;110:e2

48 Studies to date concerning infants and children using the cream for up to a year have shown that pimecrolimus appears to be well tolerated in all age groups.

49 However, as this is a new drug, the full safety yp profile of the medication is unknown; the main concerns relate to its effect on the immune system.

50 Tacrolimus - Protopic Mechanism of action similar il to pimecrolimus Children: tacrolimus ointment 0.03%. Adults: 0.1% ointment

51 Impetigo Superficial skin infection Staph or Strep Highly contagious Children

52 Treatment Topical antibiotic: localized Systemic antibiotic: widespread

53 Localized Fusidic acid (Fucidin)----resistance Mupirocin (Bactroban)

54 Retapamulin (Altabax ) A new class of antibacterials called pleuromutilin FDA-approved for the treatment of impetigo (2007) Indicated for use twice daily for 5 days in patients > 9 months of age

55 Topical retapamulin versus oral cephalexin in the treatment of infected dermatitis. J Am Acad Dermatol 2006;55:

56 Topical retapamulin versus topical fusidic acid in impetigo. Dermatology 2007;215:

57 Extensive

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59 Extensive impetigo Systemic antibiotics Community-acquired MRSA

60 Tinea capitis

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65 Kerion

66 Diagnosis: KOH

67 Diagnosis Fungal culture Trichophyton Microsporum Epidermophyton

68 Treatment: Systemic antifungal

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70 Meta-analysis of 6 studies comparing terbinafine and griseofulvin for the treatment of childhood tinea capitis Fleece, D. et al. Pediatrics 2004;114:

71 Microsporum canis Griseofulvin

72 Asymptomatic fungal carriage in household contacts of patients with tinea capitis 209 contacts examined 7.2% clinically evident disease 44.5% silent fungal carriage on scalp Children < 16 more likely carriers Males less than females Eradicate potential reservoir J Eur Acad Dermatol Venereol 2007;21:

73 Pediculosis capitis

74 Head lice The most common ectoparasites using humans as a host. Control is difficult because lice are becoming resistant to insecticides.

75 Pediculus humanus capitis Gray/tan and white 3 to 4 mm in length Mouth adapted to suck blood and legs adapted d to grip hairs

76 What do head lice look like? There are three forms of lice: the egg (nit) the nymph the adult

77 Egg/Nit Very small, hard to see Often confused with dandruff Eggs are glued to the hair in egg casings (nits) with chitin and are deposited close to the scalp

78 Egg/nit Nits take ~ 8 days to hatch Eggs likely to hatch are usually located within 1 cm of the scalp Newly laid or viable intact t eggs are opalescent, whereas eggs that have hatched are white

79 Nits

80 Nit

81 Nymph The nit hatches into a baby louse called a nymph. Nymphs mature into adults ~ 8 days after hatching. To live, the nymph must feed on blood.

82 The adult louse The adult female lays her eggs (7-10 per day) near the base of hair shaft Adult lice can live up to 30 days on a person's head To live, adult lice feed on blood Lice can crawl and climb but cannot jump or fly!

83 Adult lice can survive for 2 days away from the scalp Nits, on the other hand, can survive for up to 10 days away from the human host

84 Clinical Manifestations Asymptomatic Pruritus is the most common symptom Excoriations and secondary bacterial infection Occipital and posterior cervical lymphadenopathy are common

85 Pyoderma due to lice

86 Treatment Pediculicides are the most effective treatment for pediculosis capitis Many pediculicides are available Pediculicides id with long residual effect are more likely to be ovicidal

87 The pediculicide should be applied to the entire scalp The use of hair conditioners should be avoided before application of a pediculicide because they coat the hair and protect the lice and nits

88 Permethrin 1% Pyrethrin Gamma benzene hexachloride 1% Malathion 0.5% Trimethoprim/sulfamethoxazole Ivermectin*200 µg/kg (>5yrs)

89 Permethrin The treatment t t of choice because of efficacy and lack of toxicity 1% permethrin is applied for 10 minutes and then rinsed off Permethrin is both pediculicidal and ovicidal. It leaves a residue on the hair and remains active for 2 weeks after application A second treatment 7 to 10 days later to ensure cure

90 Gamma benzene hexachloride The 1% shampoo is applied to dry hair and left on for 10 minutes Because of its low ovicidal activity, repeated application 7 to 10 days later Potential for neurotoxicity and bone marrow suppression

91 Trimethoprim/sulfamethoxazole Trimethoprim 10 mg/kg/day and sulfamethoxazole, 50 mg/kg/day in two divided doses) for 10 days +/- shampoo Destroys the gut flora of the louse, thereby interfering i with its ability to synthesize vitamin B Death ensues from vitamin B deficiency For cases not responsive to traditional pediculicides or suspected cases of lice- related resistance to therapy

92 Hair Dryers 169 children aged 6 years Head lice Treated for about 30 min Goates, et al. Pediatrics 2006;118:

93 Hair Dryers Goates, et al. Pediatrics 2006;118:

94 Further research may be needed to determine the optimal way to use domestic hairdryers and their effectiveness.

95 Nit removal Combing Soak the hair with white vinegar (3-5% acetic acid) or 8% formic acid rinses to soften the cement of nits before combing the hair. Mechanical nit and louse removal

96 Environmental measures Household members and close contacts should be examined & treated if infested Treat bedmates prophylactically Machine wash all clothing and bed linens. Use the hot water (130 F) cycle. Dry laundry at high heat for at least 20 minutes.

97 Environmental measures Store all clothing, stuffed animals,... that cannot be washed or dry cleaned into a plastic bag and seal for 2 weeks Soak combs and brushes for 1 hour in alcohol, Lysol, or wash with soap and hot (130 F) water Vacuum the floor and furniture

98 Treatment failures Noncompliance Improper application of pediculicides Reinfestation Resistance to pediculicides

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