Staying A- Head in Pediatric Dermatology: Common Scalp and Hair Diagnoses Matt Grisham, MD Greenville Health System Post-Graduate Seminar April 20, 2016
I have no financial disclosures or conflicts of interest.
Objectives Discuss common pediatric dermatologic diagnoses affecting the scalp and hair Identify key features on history and exam to help narrow the differential diagnosis Generate appropriate therapeutic plans for these conditions
Born at term gestation by C/S without complication No maternal medications or infections Prenatal US and quad screening were both normal
Cutis Aplasia Congenita Born at term gestation by C/S without complication No maternal medications or infections Prenatal US and quad screening were both normal
Cutis Aplasia Congenita 80% occur at the vertex o Can occur on face, trunk, and extremities Majority are single lesions Healing over weeks to months, forming a hairless scar Larger lesions may warrant plastic surgery
Trisomy 13 (Patau Syndrome) Midline cleft palate/lip Holoprosencephaly Omphalocoele Polydactyly Cardiac anomalies Renal anomalies
Nevus Sebaceous Congenital lesion that grows with the child and eventually thickens in adolescence
Basal Cell Carcinoma
Began on the scalp and is now spreading onto forehead Using baby shampoo daily without improvement
Seborrheic Dermatitis Began on the scalp and is now spreading onto forehead Using baby shampoo daily without improvement
Seborrheic Dermatitis Occurs in areas with highest concentration of sebaceous glands Controversial fungal etiology Self-limiting (8-12 mos) o o o o o Mineral/baby oil Selenium sulfide shampoo Zinc pyrithione shampoo Topical steroids Topical antifungal
6 Months Later Scalp issues have persisted despite antiseborrheic shampoo Cheeks and chin are now involved Loves to eat Beginning to teethe
Atopic Dermatitis Commonly affects the infant scalp Dry appearance vs. greasy scale Predictable involvement of other sites Positive family history of atopy
Mom worried about a knot on the back of his head Recent haircut and noticed this spot as well She wants to know if she needs to get rid of the family pet.
Tinea Capitis Mom worried about a knot on the back of his head Recent haircut and noticed this spot as well She wants to know if she needs to get rid of the family pet.
Tinea Capitis Black Dots = Fractured Hair Dermatophyte infection o Trichophyton tonsurans o Microsporum canis Kerion
Tinea Capitis
Tinea Capitis Black Dots = Fractured Hair Dermatophyte infection o Trichophyton tonsurans o Microsporum canis Kerion
Tinea Capitis Drug Dosage Duration Griseofulvin microsize (liquid 125 mg/5 ml) Griseofulvin ultramicros ize (tablets of varying size) Terbinafine tablets (250 mg) Terbinafine granules (125 mg and 187.5 mg) 20 25 mg/kg/day 6 wk; continue until clinically clear 10 15 mg/kg/day 6 wk; continue until clinically clear 4 6 mg/kg/day 10 20 kg: 62.5 mg 20 40 kg: 125 mg >40 kg: 250 mg <25 kg: 125 mg 25 35 kg: 187.5 mg >35 kg: 250 mg T tonsurans: 2 6 wk M canis: 8 12 wk FDA approved for children 4 y 6-wk duration for all species Fluconazole 6 mg/kg/day 3 6 wk FDA approved for children >2 y
Id Reaction Widespread papular rash Pruritic Treatment o Oral antihistamines o Topical corticosteroids
Traction Alopecia Hair loss along lines of tension Regional adenopathy is common Treatment o Discontinue hairstyling Complication o Traction folliculitis
Traction Folliculitis
Late Childhood/Early Adolescence
This middle school female is being teased o Now refusing to attend school Closer inspection of her scalp reveals
Trichotillomania This middle school female is being teased o Now refusing to attend school Closer inspection of her scalp reveals
Trichotillomania dsafsdf Association with OCD and anxiety Treatment o Address the underlying psychiatric disorder
Appendectomy 3 months ago
Telogen Effluvium Appendectomy 3 months ago
Telogen Effluvium Diffuse thinning of the hair seen 6-16 weeks after a stressful event o Thyroid disorders o SLE o Fe-deficiency anemia o Oral contraceptives Treatment: address any underlying cause + time
Single patch of hair loss over the last few days No recent stressful events or prior tinea infections Never noted scaling, pustules Anxious because dad is bald
Single patch of hair loss over the last few days No recent stressful events or prior tinea infections Never noted scaling, pustules Anxious because dad is bald
Alopecia Areata Single patch of hair loss over the last few days No recent stressful events or prior tinea infections Never noted scaling, pustules Anxious because dad is bald
Alopecia Areata New patches of hair loss may appear for 4-6 weeks (or months) o Alopecia universalis Scotch-plaid nails Treatment o Topical steroids (Class I/II) o Intralesional steroid injections o Anthralin 1% cream o 2% minoxidil solution o Psychological support Complete resolution in 95% within one year if mildly affected o 30% experience relapse
Dandruff that is not improving with selenium sulfide or pyrithione zinc shampoo
Psoriasis Dandruff that is not improving with selenium sulfide or pyrithione zinc shampoo
Psoriasis Auspitz sign
Knees and elbows commonly affected Psoriasis Positive family history
Scalp Psoriasis: Management Topical corticosteroids o Fluocinolone 0.01% in peanut oil base Shampoo options o Coar-tar based o Zinc-based o Keratinolytic Look for an occult Streptococcus pyogenes infection Avoid vigorous brushing, combing, scratching of the scalp
Pediatric Dermatology Resources Hurwitz Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence by Paller and Mancini (~$185) Atlas of Pediatric Physical Diagnosis by Zitelli and Davis (~$90) Pediatric Dermatology: A Quick Reference Guide by Krowchuk and Mancini (~$90 new edition coming in May 2016) VisualDx (online and app format- ios and Android)
Thank you for your time and attention. Any Questions?