FACULTY DISCLOSURE PRACTICE CHANGE

Transcription

1 FACULTY DISCLOSURE I have the following financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity. Spouse owns Eli Lilly &Co stocks. I do intend to discuss an unapproved/investigative use of a commercial product/device in my presentation. PRACTICE CHANGE GAP Cutaneous infections and infestations are not always diagnosed appropriately, this leads to a delay in work up and treatment PRACTICE CHANGE as a result of attending this lecture, attendees will promptly recognize the orders discussed

2 IMPETIGO CLINICAL FINDINGS Bullous vs. Nonbullous Honey colored crust Erythematous base Exposed areas affected especially, often face and extremities Clinical findings Culture IMPETIGO DIAGNOSIS IMPETIGO THERAPY Compresses Topical antibiotics Mupirocin 2% Retapamulin 1% Oral antibiotics Consideration of suspected organisms

3 IMPETIGO References Fritz SA, et al: Mupirocin and Chlorhexidine Resistance in Staphylococcus Aureus in Patients with Community Onset Skin and Soft Tissue Infections. Antimicrob Agents Chemother 2013;57: Gutierrez K, et al: Staphylococcal Infections in Children, California, USA, Emerg Infec Dis 2013;19: IMPETIGO References Klein EY, et al: The Changing Epidemiology of Methicillin resistant Staphylococcus aureus in the United States: a National Observational Study. Am J Epidemiol 2013;177: Rush J, et al: Childhood Skin and Soft Tissue Infections: New Discoveries and Guidelines Regarding the Management of Bacterial Soft Tissue Infections, Molluscum Contagiosum, and Warts. Curr Opin Pediatr 2016;28: HERPES SIMPLEX ETIOLOGY Herpes simplex type 1 Herpes simplex type 2

4 HERPES SIMPLEX CLINICAL FINDINGS Direct inoculation of any cutaneous surface Prodrome of itching, stinging, or burning Grouped vesicles with an erythematous surround May become vesiculopustular lesions Tzanck smear Fluorescent antibody Culture HERPES SIMPLEX DIAGNOSIS HERPES SIMPLEX THERAPY Analgesics Prevent secondary bacterial infection Topical docosanol 10% cream 5X s/day Topical penciclovir 1% cream 5X s/day Oral anti virals episodic or suppressive therapy

5 References Chen CK, et al: Herpetic Gingivostomatitis with Severe Hepatitis in a Previously Healthy Child. J Microbiol Immunol Infect 2012;45: Goldman RD: Acyclovir for Herpetic Gingivostomatitis in Children. Can Fam Physician 2016;62: Reference Pinninti SG, et al: Management of Neonatal Herpes Simplex Virus Infection and Exposure. Arch Dis Child Fetal Neonatal Ed 2014 Mar 3. doi: [Epub ahead of print] Sanders JE, et al: Pediatric Herpes Simplex Virus Infections: An Evidence based Approach to Treatment. Pediatr Emerg Med Pract 2014;11:1 9. CONGENITAL SYPHILIS Transplacental mode of transmission With early untreated syphilis, 40% of pregnancies result in spontaneous abortion, stillbirth, or perinatal death Transmission can occur at any stage Rate if transmission % during secondary syphilis

6 CONGENITAL SYPHILIS Desquamation Vesicobullous lesions Condylomata lata Maculopapular or papulosquamous eruptions Rhagades CONGENITAL SYPHILIS Treatment for proven or highly probable disease Aqueous crystalline penicillin G, 100, ,000U/kg/day, administered as 50,000U/kg/dose IV,q12h during first 7 days of life then every 8 hours for a total of 10 days OR Penicillin G procaine 50,000U/kg/day IM(1dose/day) for 10 days Redbook 2015 References

7 TINEA CAPITIS ETIOLOGY Trichophyton tonsurans Microsporum canis Microsporum audouini Trichophyton violaceum TINEA CAPITIS CLINICAL FINDINGS Patchy alopecia with scale Diffuse scale Crusting or pustules Occipital lymphadenopathy Kerion may develop TINEA CAPITIS DIAGNOSIS Clinical findings Potassium hydroxide examination Wood s light examination Fungal culture

8 ANTIMYCOTIC AGENTS ACTIONS Griseofulvin decreases microtubule fcn Fluconazole decreases sterol 14 alpha demethylation Itraconazole decreases fungal sterol synthesis Terbinafine decreases squalene epoxidase, increases squalene GRISEOFULVIN >40 years experience mg/kg/day (microsized )for tinea capitis 6 8 week course for tinea capitis Good safety profile Available in liquid formulation 125mg/5ml Administer with fatty foods Efficacy low for onychomycosis GRISEOFULVIN SIDE EFFECTS Headache Gastrointestinal disturbances Urticaria ID reaction

9 FLUCONAZOLE Available since 1990 s Imidazole 6 mg/kg/day for tinea capitis 20 day course for tinea capitis Liquid formulation 40mg/ml FLUCONAZOLE SIDE EFFECTS Gastrointestinal disturbances ITRACONAZOLE Available since late 1980 s Imidazole 3 5 mg/kg/day for tinea capitis 4 6 week course for tinea capitis Liquid formulation available 10mg/ml Capsule should be administered with food

10 ITRACONAZOLE SIDE EFFECTS Gastrointestinal disturbances Cyclodextrin can cause diarrhea Hepatotoxicity Headache TERBINAFINE Developed in 1979 Allyamine 62.5 mg/day (10 20kg); 125 mg/day (20 40kg); 250 (>40kg) for tinea capitis 2 4 weeks for tinea capitis No liquid formulation available (granules) Tinea capitis due to Microsporum canis responds slowly TERBINAFINE SIDE EFFECTS Gastrointestinal disturbances Taste loss ( %)

11 TINEA CAPITIS ADJUNCTIVE THERAPY Selenium sulfide shampoo 1%, 2.5% Ketoconazole shampoo 1%, 2% Antibiotics Corticosteroids References Chen S, et al: Administration of Oral Itraconazole Capsule with Whole Milk Shows Enhanced Efficacy as Supported by Scanning Electron Microscopy in a Child with Tinea Capitis Due to Microsporum canis. Pediatr Dermatol 2015;32:e312 e313. References Ely JW, et al: Diagnosis and Management of Tinea Infections. Am Fam Physician 2014;90; Shemer A, et al: Griseofulvin and Fluconazole Reduce Transmission of Tinea Capitis in Schoolchildren. Pediatr Dermatol 2015;32:

12 PERLECHE ETIOLOGY Candida albicans Other Candida species Erythema Maceration Fissures PERLECHE CLINICAL FINDINGS PERLECHE DIAGNOSIS Potassium hydroxide examination Gram stain Culture

13 PERLECHE THERAPY Avoid excessive moisture Topical anti fungal ketoconazole cream 2% bid Topical antibacterial mupirocin 2% bid retapamulin 1% bid Topical corticosteroid Hydrocortisone ointment 1% SCABIES CLINICAL FINDINGS Pruritus, especially at night Eczematous patches and papules Finger web spaces, axillae, wrists, belt line, and groin area Characteristic burrows Vesicular and nodular lesions in infants Crusted scabies in immunosuppressed patients SCABIES THERAPY Cover hands with socks or mittens Apply under the nails Apply to affected areas of the scalp in infants Clean car seat Oral antipruritics

14 SCABIES THERAPY Permethrin 5% Lindane 1% Crotamiton 10% Sulfur 15% Off label Ivermectin 200 micrograms/kg po single dose SCABIES References Banerji A, et al: Scabies. Pediatr Child Health 2015;20: Boralevi F, et al: Clinical Phenotype of Scabies by Age. Pediatrics 2014;133:e910 e916. Goldust M, et al: Treatment of scabies: The topical ivermectin vs. permethrin 2.5% cream. Ann Parasitol 2013;59: Isaacs D, et al: Scabies Control with Ivermectin. J Pediatr Child Health 2016;52:579. PRACTICE CHANGE GAP Cutaneous infections and infestations are not always diagnosed appropriately, this leads to a delay in work up and treatment PRACTICE CHANGE as a result of attending this lecture, attendees will promptly recognize the orders discussed