Staying A-’Head’ in Pediatric...

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 Mineral/baby oil o Selenium sulfide shampoo o Zinc pyrithione shampoo o Topical steroids o Topical antifungal

6 Months Later… • Scalp issues have

persisted despite anti-seborrheic 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)

20–25 mg/kg/day ≥6 wk; continue until clinically clear

Griseofulvin ultramicrosize (tablets of varying size)

10–15 mg/kg/day ≥6 wk; continue until clinically clear

Terbinafine tablets (250 mg)

4–6 mg/kg/day 10–20 kg: 62.5 mg 20–40 kg: 125 mg >40 kg: 250 mg

T tonsurans: 2–6 wk M canis: 8–12 wk

Terbinafine granules (125 mg and 187.5 mg)

<25 kg: 125 mg 25–35 kg: 187.5 mg >35 kg: 250 mg

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

Psoriasis • Knees and elbows

commonly affected

• 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?