PEDIATRIC DERMATOLOGY: COMMON OFFICE … · Objectives Upon completion of this session,...

PEDIATRIC DERMATOLOGY:

COMMON OFFICE PROBLEMS

Kristen Hook, MD, FAAD

Assistant Professor of Dermatology &

Pediatrics

Founding Director, Division of Pediatric

Dermatology

University of Minnesota

hans1635@umn.edu

• I have no relevant conflicts of interests but will discuss

off-label use of medications

Objectives

Upon completion of this session, participants should be

better able to:

1. Review common pediatric dermatology diagnoses,

and distinguishing factors

2. Identify less common mimickers of common

diseases

3. Initiate treatment for common diagnoses

Pediatric Dermatology

What do we see?• Eczema

• Warts/molluscum

• Acne

• Tinea/skin infections

• Exanthems

• Lumps and bumps

• Birthmarks: pigmented and vascular

• Inherited skin disease: ichthyoses, blistering disorders

• Associated syndromes: hemihypertrophy, overgrowth

Topics

1. Eczema!

2. Pediatric viral exanthem pearls

3. Papular urticaria & more!

4. Acne-when to worry

Itch

• First symptom to be mentioned by parents

• Ratings of itch intensity, both self-reported and parent reported, inversely correlated with parents’ quality of life

• Older children’s itch negatively correlated with quality of life, and positively with depressed mood and catastrophic thinking.

• The mechanisms underlying AD-associated itch remain unclear

• Chamlin SL, Cella D, Frieden IJ, et al. Development of the Childhood Atopic Dermatitis Impact Scale: Initial validation of a quality-of-life measure for young children with atopic dermatitis and their families. J Invest Dermatol2005;125:1106-11. PMID

Sleep disturbance

• Nighttime itching affects both parents and children

• Parental depression correlates more strongly with sleep

deprivation than severity of their child’s AD

• Sleep deprivation also has consequences for school-age

children (patients and siblings), affecting cognitive function and

behavior

Chamlin SL, Cella D, Frieden IJ, et al. Development of the Childhood Atopic Dermatitis Impact Scale: Initial validation of a quality-

of-life measure for young children with atopic dermatitis and their families. J Invest Dermatol 2005;125:1106-11. PMID

Regimen

• Daily baths

• Moisturizer: cream based

• Dilute bleach baths: ¼ cup per 4-6 inches of bath water

• Topical steroids twice daily

• Antibiotics?

• Antivirals?

• Antihistamines?

• Wet wraps?

Guidelines of care for the management of atopic dermatitis: Section 1,2,3,4

J Am Acad Dermatol 2014.

Relative risk reduction of 50% in developing atopic dermatitis with

daily emollient use in infants 3 weeks to 6 months

sunflower seed oil, Cetaphil cream, Aquaphor ointment

Bleach bath bonanza!

• Act to reduce staph aureus

colonization/infection and AD

disease severity

• Clinical benefit seems greater

than simply antimicrobial

properties especially at such

dilute concentrations

• is there more to the story?

Courtesy S. Maguiness

• anti-inflammatory and anti-aging?

• Hypochlorite inflammation via NFkB pathway

• Mice with radiation dermatitis healed more quickly,

less ulceration

keratinocyte hyperplasia = more youthful

appearance of skin in aged mice!

Leung TH, Zhang LF, Wang J, Ning S, Knox SJ, Kim SKTopical hypochlorite ameliorates NF-κB-mediated skin diseases in mice. J Clin Invest. 2013

Dec;123(12):5361

Bleach Baths

• To decrease bacterial colonization, add ¼- ½ cup of plain Clorox bleach to a full tub of bath water several times a week

• Clorox ‘concentrated bleach’ (~8%) is replacing traditional 6% sodium hypoclorite solution, (1/3 cup per full tub is appropriate)

• The concentration is similar to a swimming pool and it is safe to expose the head and neck areas

Huang, J et al. Treatment of Staphylococcus aureus colonization in atopic dermatitis decreases disease severity. Pediatrics. 2009 May;123(5):e808-14

Practical PointsSimplify. Minimize things that the child is exposed to, and when exposed it

should be hypoallergenic

Bathe often in warm water for up to 10 minutes

Add nothing to the bathwater

Gently pat dry and while skin is still moist, apply (meds first then)

moisturizer

Use a non-soap hypoallergenic cleanser

Recommend moisturizer in all patients with atopic dermatitis

Twice daily application

Choose an easy to apply, hypoallergenic cream

Choosing the steroid strength and the

vehicle • Choose 3 from different classes and familiarize yourself

with them

• Vehicle affects potency• Ointment>cream>lotion

• Reserve the high strength for older children, stubborn areas• Distal extremities tend to need higher potencies

Eichenfield et al. Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies. J Am Acad Dermatol 2014 Jul:71(1):116-32. Also section 1,3,4.

Example:

low: hydrocortisone 2.5% ointment

medium: triamcinolone 0.1% ointment

high: mometasone 0.1% ointment

Systemic medications

• Systemic corticosteroids

Systemic medications

• Systemic corticosteroids

• Effective but no endpoint

• Severe rebound flares

• Serious long-term side effects

• Consider only in very specific situations

2007 National Survey of Children’s Health

• Association confirmed between AD and ADHD using

population-based data of over 90,000 children in the US

• Dose-dependent relationship between the reported

severity of AD and the prevalence of ADHD, suggesting

causality

• Association confirmed between AD and other mental

health disorders, including anxiety, depression, conduct

disorder, and autism

Yaghmaie P, Koudelka CW, Simpson EL. Psychiatric comorbidity in pediatric eczema. J Invest Dermatol. 2011;131(Supplement 1): S41. Abstract #246.

Yaghmaie P, Koudelka CW, Simpson EL. Mental health comorbidity in patients with atopic dermatitis. J Allergy Clin Immunol 2013; 131:428–433. The dose-dependent

relationship of AD and mental health comorbidities indicates that the potential consequences of uncontrolled AD have now expanded to areas not traditionally associated with AD.

Prospective studies are needed to confirm that the severity of AD changes the strength of association, and to investigate potential mechanisms underlying the relationship

between AD and mental health conditions

Dermatitis and Mental health

• Quality of life issues are real

• It is important to treat itch!

• It is important to make sure the patient (and their family)

SLEEPS!

• Not controlling these things may lead to mental health

issues later in life (ADHD)

• Perhaps consider psychology referral earlier in the

disease course

• More to come…

What is the appropriate treatment for this

patient?

A. Oral erythromycin and

topical metronidazole

B. Oral prednisolone and

topical neomycin

C. Oral cephalexin and

topical

diphenhydramine

D. Oral acyclovir,

cephalexin, and

topical corticosteroid

Courtesy I. Polcari MD

Eczema Herpeticum

• Herpes simplex infection in individuals with atopic dermatitis• Face, body, or both

• Monomorphous, “punched-out” erosions, crusts• Rarely vesicles

• Fever, malaise, secondary bacterial superinfection

• Tx: hydration/electrolyte imbalance, antibiotics, pain control

• Literature supports the role of topical corticosteroids

Aronson PL, Shah SS, Mohamad Z, Yan AC. Topical corticosteroids and hospital length of stay in children with

eczema herpeticum. Pediatr Dermatol. 2013 Mar-Apr;30(2):215-21

Courtesy I. Polcari

MD

Eczema Herpeticum

Courtesy I. Polcari MD

Eczema Coxsackium

• >50% with lesions focused in areas of atopic dermatitis

• Treat AD

• Culture• Mimics eczema herpeticum

• Consider antivirals

• Benign course

Mathes et al. “Eczema Coxsackium” and unusual cutaneous findings in an enterovirus outbreak. Pediatr 2013

Jul:132(1)e149-57.

Photo courtesy of Dr. S.

Maguiness

12 yo with rash x 4 days and fever

3 year old with nail changes

Which of the following is not a likely etiology of this

condition?

A. EBV

B. Coxsackie virus

C. Psoriasis

D. Accutane

E. Tetracycline

Which of the following is not a likely etiology of this

condition?

A. EBV

B. Coxsackie virus

C. Psoriasis

D. Accutane

E. Tetracycline

Nail matrix arrest (onychomadesis)

• Full, but temporary arrest of growth of the nail matrix

• Beau’s lines: transverse grooves that originate under

proximal nail fold

• Nonspecific reaction to stressor that affects nail matrix growth

• Visible several weeks after event that caused them

• Normal nails completely regrow in 4 months

Causes of onychomadesis

• Antibiotics, chemotherapeutics, retinoids, radiation

• Coxsackie virus infection, febrile illness, Kawasaki’s,

syphillis,

• Stevens-Johnson syndrome, epidermolysis bullosa

• Hypoparathyroidism

This well-appearing child presents with a 2 week history of

an asymptomatic, unilateral rash. The ‘statue of liberty’

sign pictured, best characterizes which entity:

A. Contact dermatitis

B. Eczema

C. Molluscum associated dermatitis

D. Unilateral laterothoracic exanthem

E. Urticaria

This well-appearing child presents with a 2 week history of

an asymptomatic, unilateral rash. The ‘statue of liberty’

sign pictured, best characterizes which entity:

A. Contact dermatitis

B. Eczema

C. Molluscum associated dermatitis

D. Unilateral laterothoracic exanthem

E. Urticaria

Unilateral laterothoracic exanthem

• Aka Asymmetric periflexural exanthem of childhood (APEC)

• Rash starts unilaterally (statue of liberty sign), may spread bilaterally

• Presumed viral

• Resolves in 4-6 weeks

• Path: dermatitis with lymphocytic eccrine/perieccrine inflammation

Another example…..

Asymptomatic rash x 3 weeks duration

What is the best diagnosis?

A. Psoriasis

B. Tinea corporis

C. Lichen striatus

D. Linear vesicular eruption of childhood

What is the best diagnosis?

A. Psoriasis

B. Tinea corporis

C. Lichen striatus

D. Linear vesicular eruption of childhood

Lichen striatus

• Self-limited eruption, usually unilateral

• Extremity> face, trunk, buttocks

• Can be papular, hypopigmented, scaly

• Blashkoid distribution

• No treatment necessary, occasionally topical steroids

helpful for pruritus

• Resolves in 3-12 months, but can last up to 3 years

Paraviral exanthems?

• Paraviral exanthems are skin diseases suspected to be

caused by viruses, with a single virus-exanthem

relationship not universally accepted.

Expert Rev Anti Infect Ther. 2016 Jun;14(6):601-11. doi: 10.1080/14787210.2016.1184084.Paraviral exanthems.

Fölster-Holst R, Zawar VP, Chuh A.

Gionotti-Crosti

• Papular acrodermatitis of childhood

• Any season

• Flesh to pink “juicy” papules on acral sites

• Possibly EBV, HepB, HSV1

• URI prodrome, Mild LAD, HSM

• Resolves in few weeks

Papular Urticaria

• Prolonged hive like reaction: recurrent ‘crops’ of papules

• Sparked by arthropod insult often

• Hypersensitivity reaction

• Biopsy?

• Treatment: antihistamines, topical steroids

Classification of Acne

• Comedonal

• Inflammatory

• Mixed: Comedonal and Inflammatory

• Cystic

• Mild

• Moderate

• Severe

Acne Through the Ages

TABLE 2 Expert Panel Consensus: Pediatric Acne Categorized by Age

Acne Type Age of Onset

Neonatal Birth to </6 weeks

Infantile 6 weeks to </1 year

Mid-childhood 1 year to <7 years

Preadolescent >/7 years to </ 12 years or

menarche in girls

Adolescent >/12 years to </ 19 years or after

menarche in girls

Eichenfield et al. Pediatrics. 2013;131:S163-186.

Neonatal acne

• No acneiform papules or comedones

• “Neonatal cephalic pustulosis”

• First weeks of life

• Erythematous papules and pustules

• Face, scalp, neck, torso

• May be associated with Malassezia species

• Treatment:

• Self-limited

• May respond more quickly with anti-yeast (e.g. ketoconazole

cream)

Ayhan M et al. JAAD 2007;57:1012-18.

Infantile Acne

• Onset first few months of life to first year

• Comedones usually present

• May have associated papules, pustules, cysts, nodules

and scars!

Infantile acne: Treatment

• Topicals

• Benzoyl peroxide

• Retinoids

• Antibiotics

• Combinations

• Systemic therapy

• Oral antibiotics

• Isotretinoin

Mid-childhood acne

• Onset 2-6 years: Most worrisome!

• Premature adrenarche, Cushing’s syndrome, CAH,

gonadal/adrenal tumors, true precocious puberty

• If persistent or virilizing

• Growth chart, evaluation including bone age, tanner state,

Total/free testosterone, DHEAS, Androstenedione, LH, FSH,

prolactin, 17-OH progesterone

• Treatment: Topicals, orals (no cyclins <8)

Bree A, Siegfried E. Pediatr Dermatol 2014.31:27-32.

Pre-adolescent acne

• Comedones common early

• Forehead, mid-face

• Truncal less common

• May precede other signs of puberty

• Correlates with sebum output and sebaceous follicle numbers

• P. acnes colonization in follicles is key

• Prevalence and severity of acne correlates with advanced pubertal maturation

Lucky AW et al. Arch Dermatol 1991;127:210-6

Lucky AW et al. Arch Dermatol 1994;130:308-14

Mourelatos K et al Br J Dermatol 2007;156:22-31.

Non-prescription/OTC

• Over the counter• Benzoyl peroxide

• Salicylic acid

• Sulfur compounds

• Alpha-hydroxy acids

• Herbals

• Adjunctives• Washes,

• Astringents

• Pore-cleaners

• Green based cover up

• Heat/light devices

❖Effective for mild acne

Topical acne therapy: inflammatory

Benzoyl Peroxide• 2.5-10%

• Gel, lotion, cream, pad, cleanser

• All OTC now

• Bleaches clothing and linens

Benzoyl peroxide• Used since the 1930s due to its antibacterial, keratolytic, and comedolytic

properties

• In mild to moderate acne studies• no statistically significant difference between 5% topical BPO twice daily and oral doxycycline

100 mg 4 times daily

• BPO was actually shown to be the most cost-effective treatment in these investigations

Mareledwane NG. A randomized, open-label, comparative study of oral doxycycline 100 mg vs. 5% topical benzoyl peroxide in the treatment of mild to moderate acne vulgaris. Int J Dermatol. 2006

Dec;45(12):1438-9.

Ozolins M, Eady EA, Avery AJ, et al. Comparison of five antimicrobial regimens for treatment of mild to moderate inflammatory facial acne vulgaris in the community: randomised controlled trial. Lancet.

2004 Dec;364(9452): 2188-95.

• 6% BPO cleanser effectively reduced tetracycline-resistant P. acnes populations 1 week after treatment—reductions were >1 log after 2 weeks and ≥2 log after 3 weeks

Leyden JJ, Wortzman M, Baldwin EK. Antibiotic-resistant Propionibacterium acnes suppressed by a benzoyl peroxide cleanser 6%. Cutis. 2008 Dec;82(6): 417-21.

Topical acne therapy

• Inflammatory

• Topical antibiotics (erythro or clinda)

• Topical dapsone

• Sodium sulfacetamide and sulfur

• Azelaic acid

• For comedonal lesions

• Retinoids

• Azelaic acid

• Salicylic acid

• Combination products

Topical acne therapy: Inflammatory

• Topical antibiotics

• Erythromycin: 2% soln, gel, pad, cream

• Clindamycin: 1% lotion, solution, gel, pledgets

• Resistance is rapidly emerging

• Not recommended for use alone

• Topical dapsone gel 5%

• Rx: Aczone gel

• Anti-inflammatory and antibiotic properties

Topical acne therapy: Comedonal

• Tretinoin (Retin-A, Avita, Atralin, and generics)

• 0.025, 0.05, 0.1% cream

• 0.01, 0.025% gel

• 0.05% liquid

• 0.04, 0.1% Micro gels

• Adapalene (Differin and generics)

• 0.1, 0.3% gel

• 0.1% cream

• 0.1% lotion

• Tazarotene (Tazorac)

• 0.05, 0.1% cream, gel

Topical acne therapy

Combination products• BP/erythromycin 5%/1% (Benzamycin, generics)

• Refrigeration, 3 month shelf life

• BP /clindamycin (2.5%-5%/1%) (Benzaclin, Duac, Acanya

and generics)

• Variable shelf life

• BP /Adapalene (2.5%/0.1%) (Epiduo gel)

• Clinda /Tretinoin 1.2%/0.025% (Zianna, Veltin gels)

• Combinations with benzoyl peroxide may prevent

antibiotic resistance.

Oral acne therapy:

Antibiotics• Cyclines

• Tetracycline (250-500 bid)

• Doxycycline (50-100 bid

• Minocycline (50-100 bid)

• Safe to use after age 8 as tooth enamel is laid down

• GI irritation

• Sun protection

• Pseudo tumor cerebri rare

Oral acne therapy:

Antibiotics• Minocycline (allergic reaction, autoimmune hepatitis,

lupus-like syndrome, pigment changes)

• Autoimmune disease (SLE 8.8 cases per 100,000 person-years)

risk ↑ with duration of use

• Others: erythromycin, clindamycin, trimethoprim-sulfa,

cephalexin, amoxicillin may work, but they are not

recommended routinely because of resistance

A Controversial Proposal: No More

Antibiotics for Acne!

“For dermatologists, eliminating all antibiotic use for the

treatment of acne (and rosacea) is a first step in assuming

responsibility for helping combat the serious problem of

antibiotic resistance.”

Muneeza Muhammad, BA and Ted Rosen, MD

Department of Dermatology, Baylor College of Medicine, Houston, TX, USA

Skin Therapy Letter Jul-Aug 2013.

• Antibiotic monotherapy (topical or oral) is not

recommended due to the availability of clinically superior

regimens.

• Systemic antibiotics are important for managing moderate

to severe acne and should be used for a limited duration

of time (3-4 months).

• Topical antibiotics should be paired with benzoyl peroxide

to limit potential for resistance. Eur J Dermatol. 2014 Apr 11. [Epub ahead of print]

Antibiotic stewardship in dermatology: limiting antibiotic use in acne.

Minocycline

• Effective treatment for moderate to moderately-severe

acne vulgaris, no evidence that it is better than any of the

other commonly-used acne treatments.

• One company-sponsored RCT found minocycline to be less

effective than combination treatment with topical erythromycin and

zinc. Also, no evidence to guide what dose should be used

• Concerns remain about its safety compared to other

tetracyclines.Cochrane Database Syst Rev. 2012 Aug 15;8:CD002086. doi:

10.1002/14651858.CD002086.pub2.

Minocycline for acne vulgaris: efficacy and safety.

Garner SE et al.

Lee et al. J Am Acad Dermatol online 4/8/14.

Not all are the same

Vascular Anomalies:

Revised ISSVA Classification

Mulliken JB Young AE. Vascular Birthmarks: Hemangiomas & Malformations.

Philadelphia: Saunders; 1988.

VASCULAR ANOMALIES

(Infants and Children)

TUMORS MALFORMATIONS

Low Flow (PWS, VM,

LM, Combined)

High Flow (AVM)

Tufted Angioma

Kaposiform HE

Spindle-cell HE

Hemangioma of

Infancy

Pyogenic Granuloma

RICH

NICH

Vascular Anomalies:

Revised ISSVA Classification

Mulliken JB Young AE. Vascular Birthmarks: Hemangiomas & Malformations.

Philadelphia: Saunders; 1988.

VASCULAR ANOMALIES

(Infants and Children)

TUMORS MALFORMATIONS

Low Flow (PWS, VM,

LM, Combined)

High Flow (AVM)

Tufted Angioma

Kaposiform HE

Spindle-cell HE

Hemangioma of

Infancy

Pyogenic Granuloma

RICH

NICH

Tools to Help Classify

• Growth History

• Present at birth?

• Proliferative or static?

• Involutional or persistent?

• Imaging

• Flow voids?

• Histopathology

Growth Rate

• Infantile hemangiomas

• Growth phase

• Plateau phase

• Involutional phase

• Malformations

• Static

Paller A, Mancini A.

Hurwitz 3rd Ed.

6 week old presents with this progressive

plaque that was not present at birth.

What is your diagnosis?

A. Mixed infantile

hemangioma

B. Superficial

hemangioma

C. Lymphatic

malformation

D. Other tumor NOS—

needs a biopsy!

What is your diagnosis?

A. Mixed infantile

hemangioma

B. Superficial

hemangioma

C. Lymphatic

malformation

D. Other tumor NOS—

needs a biopsy!

Superficial Mixed

Deep

Treatment Factors: Location

Treatment factors: Growth rate

• Age of patient?

• Significant change in four

weeks time?

• Associated ulceration?

Treatment Factors

What will remain?

When to worry

• Segment 1:

• CV and ocular

• Segment 3:

• CV and ventral

defects

Segmental hemangioma patterns.

Haggstrom A N et al. Pediatrics 2010;126:e418-e426

©2010 by American Academy of Pediatrics

Posterior Fossa Abnormalities

Hemangiomas

Arterial

Cardiac

Eye

Sternal cleftMetry DW et al. J Ped 2001;139:117

Drolet BA, Dohil MA, et al.: Pediatrics 2006 Mar;117(3):959-64

Beard distribution-

Check the Airway!

Perineal Hemangiomas-

SACRAL, PELVIS, LUMBAR Syndromes

SACRAL: Spinal dysraphism, Anogenital anomalies, Cutaneous abnormalities,

Renal and urologic anomalies, Angioma of Lumbosacral localization

PELVIS: Perineal haemangiomas, External genital malformations,

Lipomyelomeningocele, Vesico-renal anomalies, Imperforate anus, Skin tag.

LUMBAR: Lower body IH, Urogenital anomalies (and ulceration), Myelopathy,

Bony, Anorectal and arterial, Renal

Potential Adverse Effects

• Hypoglycemia

• Hypotension

• Bradycardia

• Heart block

• Decreased cardiac contractility

• Bronchospasm/Respiratory Distress

• Hyperkalemia (1 reported episode)

• Pediatrics 2010;126:e1589

When should we NOT use it?

• Respiratory Disease

(Asthma, RAD)

• Cardiac disease,

arrythmias

• Diabetes- caution

• PHACES- Use with

extreme caution

Thank you!

• Acknowledgments: Atopic dermatitis practical points slides courtesy I. Polcari, Bleach bath slides courtesy S. Maguiness, Eczema coxsackium courtesy C. Boull

Resources

1. Soutor C, Hordinsky M. Clinical Dermatology 1st Edition. McGraw-Hill Professional; 2013.

2. Mancini A, Paller A. Hurwitz Clinical Pediatric Dermatology 4th Edition. Saunders; 2011.

3. Shah KN, Honig PJ, Yan AC. "Urticaria multiforme": a case series and review of acute annular urticarial hypersensitivity syndromes in children. Pediatrics. 2007 May;119(5):e1177-83. Review. PMID: 17470565 .

4. Mathes et al. “Eczema Coxsackium” and unusual cutaneous findings in an enterovirus outbreak. Pediatr 2013 Jul:132(1)e149-57.

5. Eichenfield et al. Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies. J Am Acad Dermatol 2014 Jul:71(1):116-32. Also section 1,3,4.