Name That Nubbin!Elizabeth (Lisa) Swanson, MD

Advanced Dermatology- Colorado

Rocky Mountain Hospital for Children

lisaswansonmd@gmail.com

Disclosures

• Speaker

• Valeant

• Bayer

• Aqua

• Advisory Board Representative

• Allergan

• Amgen

• Sanofi-Regeneron

Nubbin: something that is small for its kind,

stunted, undeveloped, or imperfect

Made Famous in a Friends Episode

• Chandler reveals his accessory nipple

• Joey: “I can’t believe you. You told me it was a nubbin.”

• Ross: “Joey, what did you think a nubbin was?”

• Joey: “I don’t know. You see something, you hear a word, I thought that’s what it was. Let me see it again.”

Nubbin

• I am going to use the term nubbin to mean a collection of spots in kids that represent a “miscellaneous” sort of category

Spider Angioma

• Small raised pink-red papule with radiating telangiectasia like legs on a spider

• Blanch with pressure from a glass slide

• Eventually resolve on their own

• Can be treated with vascular laser if bothersome

Pyogenic Granuloma

• “Little ball of capillaries”

• Common in kids and pregnant women

• Some people remember trauma to the area prior to its growth

• 2 Treatment Options

• Shave removal

• Topical timolol bid

• Initial study in March/April 2014 SPD journal using timolol 0.5% gel forming solution BID

• Great results with clearance after 2-3 mos

• Bleeding stopped relatively instantly

• Likely working by vasoconstriction

• Important to followup these patients to ensure improvement (spitz nevi, even melanoma in ddx)

Pyogenic Granulomas

Pyogenic Granuloma

Pyogenic Granuloma

Juvenile Xanthogranuloma

• Form of non-Langerhan’s cell histiocytosis

• Presents as an orange-yellow-brown dome shaped papule in a child

• “color of the rising sun”

• Benign; will resolve spontaneously

• Recurs if it is removed

Lichen Striatus

• Causes a linear streak of raised flat topped skin colored to pink papules, typically down an extremity

• Can affect the nail on that extremity

• 10% of cases are bilateral

• Sometimes itchy, sometimes not

• Topical steroids or calcineurin inhibitors help for the itch

• Resolves on its own; typically takes 2-3 yrs

Ring Phenomenon

• Typically associated with cantharidin

• Can happen with liquid nitrogen

• The treated wart may or may not go away and then a ring of warts develops around the initial wart

• If you continue that treatment, the ring gets bigger

• I feel it is happening more and more commonly with cantharidin these days

Warts• Countless treatment options

• Liquid nitrogen

• Cantharidin

• OTCs

• Candida

• Squaric Acid (contact sensitizers)

• Laser

• Bleomycin

• Best Thing Ever- WartPeel!• Nucara Pharmacy- Iowa

• Sal acid + 5FU

• Magic in a bottle

• Applied at bedtime under “sticky tape”

• $89 and worth every penny!

WartPeel

WartPeel

Warts- Alternative Therapies

• Zinc sulfate 10 mg/kg/day (max 600 mg) x 2 mos• Complete clearance in 75% of patients

• Nausea is really bad

• Propolis daily x 3 mos• 135 patients- 73% had clearance

• Avoid if bee allergy

• Valtrex 1 gm daily x 60 days- just 2 cases (JDD Feb 2016)

• Picato- couple case reports on using it for genital warts and epidermodysplasia verruciformis

• Just wait- 200 kids- 65% resolved by 2 yrs, 80% by 4 yrs (SPD Sept/Oct 2015)

• Mounting number of case reports showing that when pre-teens and teens are given HPV vaccine, their warts go away

• It will be interesting to see if we notice a decrease in incidence of warts over time as more and more people get immunized

Warts and HPV Vaccination

HPV Vaccines

• 3 approved HPV vaccines

• Some concern about reports of MS, optic neuritis, transverse myelitis

• 10 cases of regional pain syndrome

• 4 reports of premature ovarian failure (possibly an autoimmune reaction from vaccine)

Wart vs Callus/Corn-A Handy Trick

• Press on top of it

• If it hurts, it is a callus/corn

• Press on the sides of it (squeeze it)

• If it hurts, it is a wart

• Look like pimples/boils

• Due to body’s immune system response

• Not infected, just inflamed

• BOTE sign- Beginning Of The End

PseudofurunculoidMolluscum

PseudofurunculoidMolluscum

PF Molluscum and Id Reaction

PF Molluscum and Id Reaction

• Treat the Id Reaction with topical steroids

• Treat the PF molluscumwith oral antibiotics or bleach baths

• F/u 2-3 wks

• Usually everything is “all better”

Molluscum Contagiosum

• Caused by a poxvirus

• Very common in kids- pretty much all kids get them

• Spread by direct contact and spread like crazy in water (including swimming pools)

• Treatment is not mandatory as they will go away with time

• Can take up to 2 yrs to resolve on their own

• Recent study of 170 kids- half treated, half not treated

• Molluscum resolved in the same amount of time

Molluscum Treatment Options

• Imiquimod/Zyclara• Apply MWF at bedtime x 8 wks

• A little irritation- good; a lot of irritation-bad

• Zymaderm• All natural OTC product,

botanical based

• Applied BID

• Candida antigen injections• Injected into 1-2 of the molluscum

every 3 wks

• Tolerable; typically 3-5 treatments

• Side effect profile

• Cantharidin• Never use it in the axilla

• Blisters can be bad

• 50% resolution with each treatment is success

• Hard to get these days

• Curettage

• Liquid Nitrogen

• Topical retinoids

• Some kids will get an eczema like rash around the molluscum

• Important to treat it as it itches so kids scratch and then spread the molluscum

Molluscum Dermatitis

Accessory Tragus

• Benign, harmless

• No associated issues with hearing, kidneys, etc

• Can be removed

• My preference is to have peds ENT do it as they can be a “top of an iceberg”

• Sometimes if it is small and clearly just fleshy without cartilage, I will numb it and snip it off

Solitary Mastocytoma

• Benign collection of mast cells

• Hives up when rubbed or irritated

• Will go away

• Not scary

Urticaria Pigmentosa

Urticaria Pigmentosa

• Lots of solitary mastocytomas

• Not scary, but looks scary and parents are often freaked out

• Most kids outgrow it

• No reason to check serum tryptase

• No risk of mast cell leukemia

• Manage with topical steroids prn

• Antihistamines +/-

Dangerous Mast Cell Issues

• Bullous Mastocytosis- presents as blistering in a newborn; ddx includes EB

• Diffuse Cutaneous Mastocytosis- the skin is diffusely infiltrated by mast cells so it becomes yellowish and rubbery diffusely

• Only these 2 mast cell issues carry risk of mast cell leukemia and require systemic workup and hem/onc involvement

Aquagenic SyringealAcrokeratoderma

• Causes swelling, papules, increased wrinkling on palms following immersion in water

• If occurring in a young child, they should be screened for Cystic Fibrosis

• If occurring in an older, clearly healthy child, then there is no concern

• Sometimes kids with this are heavy sweaters-treating that can help

• Kids outgrow it

Gluteal Variant of Perioral Dermatitis

• Consists of small pink papules and pustules on buttocks

• DDx includes keratosis pilaris and staph

• I typically culture at first visit to r/o staph

• Treatment:• Clindamycin wipes

• Elidel

• Amoxicillin (azithro if PCN allergic)

• Since the chicken pox vaccine has been more regularly administered to children, cases of herpes zoster in children have been on the rise

• We don’t know why immunity seems different with the vaccine vs having the chicken pox

• Patient is contagious to people who have not had the chicken pox (can’t catch shingles from shingles)• Need to avoid unimmunized kids and pregnant women

• Treatment with Acyclovir 30-50 mg/kg/day divided TID (valtrex if old enough to take pills)

Herpes Zoster

Psoriasis

• This was a real “curbside” photo sent to me

• No other photos were sent

• Even with the limited info, this is clearly psoriasis, most likely guttate

• “Psoriasis” pink

• Koebner phenomenon

Bronchogenic Cyst

• Classically in the sternal notch

• Can look like a milia, cyst, divot

• Should be removed by a peds ENT or pedsgeneral surgeon

• “Tip of an Iceberg”

Other Neck Cysts in an Infant

• Sternal notch-bronchogenic cyst

• Midline upper neck-thyroglossal duct cyst

• Lateral neck-branchial cleft cyst

Nevus Anemicus

• Somewhat reticular hypopigmented-appearing area. Appears mottled

• Due to slight decrease in superficial cutaneous blood vessels

• Recently described as an association with NF-1

• Typically on the chest

• Very common on the scalp of children

• Frequently biopsied because of somewhat atypical coloring, large size, history of changing

• Often read out as atypical on pathology, but these are known to be completely benign

• Probably a “special site” that isn’t currently recognized as a special site

Eclipse Nevi

Eclipse Nevi

Bed Bugs

• Cause typical bug bite appearance, but often occurs in clusters of 3- “breakfast, lunch and dinner”

• Home needs to be evaluated by a professional exterminating service- no “DIY” projects

• Bed bugs know where to hide; they don’t want to be found

• Come out when CO2 levels in the air indicate that we are asleep

Pilomatricoma

• Subcutaneous firm plaque

• Skin colored and sometimes a bluish hue

• Demonstrates a positive “teeter totter” sign

• 2/3 resolve on their own

• Can be surgically excised

Tinea Corporis

• Corporis

• Ketoconazole 2% cream bid (apply to area and 1 inch around, cont treatment after clinical clearance)

• Oral meds if extensive

• Capitis (presents as redness, scaling and alopecia)

• MUST USE ORAL MEDS

• Griseofulvin 20-25 mg/kg/day divided bid for 6 wks. Must be given with fatty food.

• 2nd line- either itraconazole or lamisil

• It happens!

• Often there is family history

• Evaluate for tinea pedis

• Treat with terbinafine for 3 mos

• <20 kg- 62.5 mg daily (1/4 pill)

• 20-40 kg- 125 mg daily (1/2 pill)

• >40 kg- 250 mg daily

• Itraconazole can be used in a pinch (comes in syrup)

• Pulse dosing

• Liver function tests- to test or not to test

• Griseofulvin doesn’t work

Pediatric Onychomycosis

Pediatric Onychomycosis- Picture

Hyperkeratotic Lichenoid Papules

of the Elbows and Knees

• Very common in kids age 4-12, boys > girls

• Misdiagnosed as flat warts, molluscum, KP

• Probably a variant of KP

• Kids outgrow it

• Could treat it with AmLactin, Cerave SA, etc

Toddler (Infantile) Acne

• Kids age 6 mos- 3 yrs old

• Typically occurs on cheeks

• Small pink papules and pustules

• Sometimes comedones

• Can scar; important to treat

• 1st line- Topical clindamycin

• 2nd line- Topical adapalene

• 3rd line- Oral amoxicillin

Pigmented PurpuricDermatoses

• 5 types of pigmented purpuric dermatoses

• Most common type in kids in studies appears to be Schamberg’s Purpura

• In my clinic, most common type is definitely Lichen Aureus

Pigmented PurpuricDermatoses

• Idiopathic

• These conditions present with petechial lesions (often pediatricians will panic)

• Schaumberg’s purpura looks like specks of cayenne pepper

• Lichen Aureus looks like petechiae in a gold-brown patch

• Treatment is difficult, but it resolves on its own eventually

• Topical steroids and UV light might help

Lichen Aureus

• Lesions overlying lumbosacral spinal cord can indicate a problem underneath- tethered cord, meningocele, tumor

Pediatric Spots-Lumbosacral Dysraphism

• >2 cutaneous stigmata

• Lipoma

• Acrochordon/pseudotail/tail

• Aplasia cutis

• Dermoid cyst or dermal sinus

• Infantile hemangioma > 2.5 cm in size

• Must do an MRI

Pediatric Spots- Lumbosacral

Dysraphism- HIGH RISK

• Intermediate• Atypical dimple (> 5 mm)• Hemangioma less than 2.5 cm in size• Hypertrichosis• Can do ultrasound if child < 3mos old, MRI if older than 3

mos old

• Low• Simple dimple• Hyperpigmentation/hypopigmentation• Congenital nevus• Port wine stain• No imaging needed

Pediatric Spots- Lumbosacral Dysraphism-

Intermediate and Low Risk

A Couple of Tricky “Nubbins”

Jan 2016- Mom’s Photo

Sept 2016- 1st visit

1st Visit

• Ordered an MRI stat

• Ddx- vascular (atypical hemangioma, AVM), neoplasm

• MRI results showed findings consistent with a hemangioma

• Started the patient on Propranolol

Nov 2016

Biopsy

• Pathology revealed DFSP

• Pt underwent excision in 2 stages

• Considered pre treatment with Gleevac but the stain for the 9,22 translocation was negative

Initial History

• Rash was noticed for about 6 wks

• Asymptomatic

• OTC remedies had not been helpful

• History of episodes of constipation and diarrhea but no significant abdominal pain, no blood in stool, no hospitalizations for symptoms

• Family was using bubble baths, fab soft, dryer sheets, Gain detergent

Initial visit

• Attempted treatment for contact dermatitis with sensitive skin care and hydrocortisone 2.5 ointment

• No improvement

• Attempted treatment for yeast with econazolecream bid

• No improvement

Biopsy Under Anesthesia

• Punch biopsy showed granulomatous dermatitis c/w cutaneous Crohn’s

• Patient was referred to peds GI for GI eval which questioned the diagnosis of Crohn’s• Labs were normal

• Didn’t want to scope her

• Presented patient at Colorado Grand Rounds and every dermatologist agreed with me

• Treated with clobetasol bid x 3 wks and it cleared

• Now will just see what happens

“These people are members of a community that care about

where they live. So what I hear when I’m being yelled at is

people caring loudly at me.” –Leslie Knope, Parks and Rec

A Quick Thought on Burnout and “Mindfulness”

“Life moves pretty fast. If you don’t stop and look

around once in a while, you could miss it.”

-Ferris Bueller

• Putting down your juggling balls for a little bit

• Embrace the beauty of monotasking

• Paying attention in a particular way: on purpose, in the present moment, and nonjudgementally

Mindfulness Defined

• Take a second to notice things

• Raisin

• Fingers

• Start a “Gratitude” journal

• Write down 2 or 3 things every night that you are grateful for that day

High Yield Mindfulness Tidbits

• Anything that lets you “zone out” for a little bit

• Meditation- apps that help teach a “non-hippy” how to meditate• Headspace

• Calm

• Fly fishing

• Tai Chi

• Yoga

• Adult coloring books

Mindfulness Activities

• Breathe

• Music can change your mood quicker than anything

• Make yourself different playlists

• You can’t give what you don’t have

• Think of yourself as a car. You need to fill up your tank once in a while to keep running

• Make time for the things that refill your tank

High Yield Burnout Tips

The End

• Feel free to contact me with any questions

• lisaswansonmd@gmail.com