pediatric dermatology dr. jerald e. hurdle kennebec medical consultants dr. jerald e. hurdle...

Pediatric DermatologyPediatric Dermatology

Dr. Jerald E. Hurdle

Kennebec Medical Consultants

Dr. Jerald E. Hurdle

Kennebec Medical Consultants

Learning ObjectivesLearning Objectives

To review common congenital & acquired skin lesions,

To recognize rashes that present in childhood, and

To manage the kids and their parents.

Vascular LesionsVascular Lesions

Commonly seen in pediatric population

Need to distinguish hemangioma from vascular malformation

Commonly seen in pediatric population

Need to distinguish hemangioma from vascular malformation

HemangiomaHemangioma

Normally not present at birth

Grows rapidly in first few months

Then involute

Rx: nothing, steroids, laser & surgery

Normally not present at birth

Grows rapidly in first few months

Then involute

Rx: nothing, steroids, laser & surgery

HemangiomaHemangioma

Gradual Involution Gradual Involution

Vascular MalformationVascular Malformation

Present at birth

Abnormal size & number of vascular structures

Salmon patch or stork bite

Present at birth

Abnormal size & number of vascular structures

Salmon patch or stork bite

Vascular MalformationVascular Malformation

Port Wine Stains

Much less common

Hypertrophy with time

If V1/V2 rule out Sturge Weber Syndrome

Rx: laser

Port Wine Stains

Much less common

Hypertrophy with time

If V1/V2 rule out Sturge Weber Syndrome

Rx: laser

Pigmented LesionsPigmented Lesions

Congenital vs. Acquired

Congenital nevomelanocytic nevus (syn. congenital hairy nevus)

Small, medium or large

50% hairy

Have verrucous surface

Small: No increased risk of melanoma

Congenital vs. Acquired

Congenital nevomelanocytic nevus (syn. congenital hairy nevus)

Small, medium or large

50% hairy

Have verrucous surface

Small: No increased risk of melanoma

Giant Congenital NeviGiant Congenital Nevi

>5% BSA in infants

8.5% MM risk in 1st 15 years

Rx: surgical excision, tissue expanders, flaps & grafts

>5% BSA in infants

8.5% MM risk in 1st 15 years

Rx: surgical excision, tissue expanders, flaps & grafts

Case 1Case 1

9/12 old baby 3/7 of fever Febrile fit Fever defervesces with

this rash

Diagnosis?

9/12 old baby 3/7 of fever Febrile fit Fever defervesces with

this rash

Diagnosis?

Case 1: RoseolaCase 1: Roseola

HHV6

2/3 of patients get erythematous papules mucosa of soft palate (Nagayama spots)

HHV6

2/3 of patients get erythematous papules mucosa of soft palate (Nagayama spots)

Case 2Case 2

3 yr old girl

Slightly irritable for a few days

Presents with this rash!

Diagnosis?

3 yr old girl

Slightly irritable for a few days

Presents with this rash!

Diagnosis?

Case 2: Fifth Disease or Erythema Infectiosum

Case 2: Fifth Disease or Erythema Infectiosum

Classical Slapped cheeks appearance

Caused by Parvovirus B19

Aplastic Anemia

Arthritis

Hydrops Fetalis

Classical Slapped cheeks appearance

Caused by Parvovirus B19

Aplastic Anemia

Arthritis

Hydrops Fetalis

Case 2: Fifth Disease or Erythema Infectiosum

Case 2: Fifth Disease or Erythema Infectiosum

Classical Slapped cheeks appearance

Caused by Parvovirus B19

Aplastic Anemia

Arthritis

Hydrops Fetalis

Classical Slapped cheeks appearance

Caused by Parvovirus B19

Aplastic Anemia

Arthritis

Hydrops Fetalis

Case 3:Case 3:

10 year old boy

Sore throat , myalgia for 3 days before presentation with this rash

Rash feels like sandpaper

10 year old boy

Sore throat , myalgia for 3 days before presentation with this rash

Rash feels like sandpaper

Case 3:Case 3:

10 year old boy

Sore throat , myalgia for 3 days before presentation with this rash

Rash feels like sandpaper

10 year old boy

Sore throat , myalgia for 3 days before presentation with this rash

Rash feels like sandpaper

Case 3: Scarlet FeverCase 3: Scarlet Fever

Group A Strep

Erythrogenic toxin

Culture potential bacterial reservoirs (throat commonest)

Rx: penicillin

Watch out for post-streptococcal glomerulonephritis

Group A Strep

Erythrogenic toxin

Culture potential bacterial reservoirs (throat commonest)

Rx: penicillin

Watch out for post-streptococcal glomerulonephritis

Case 4Case 4

7 yr old girl

Ring like lesions on the back of her hands for 3 months

PCP tried antifungals

Diagnosis?

7 yr old girl

Ring like lesions on the back of her hands for 3 months

PCP tried antifungals

Diagnosis?

Case 4Case 4

Case 4: Granuloma Annulare (GA)Case 4: Granuloma Annulare (GA)

Localized GA

Self limiting

Tends to spontaneously resolve

Can try potent topical steroids

Link with DM (controversial)

Localized GA

Self limiting

Tends to spontaneously resolve

Can try potent topical steroids

Link with DM (controversial)

Case 5Case 5

2 yr old boy presents with 2/7 of this non- itchy rash

Affects his hands & feet

Had diarrhea 1/52 ago

2 yr old boy presents with 2/7 of this non- itchy rash

Affects his hands & feet

Had diarrhea 1/52 ago

Case 5: Gianotti-Crosti SyndromeCase 5: Gianotti-Crosti Syndrome

Originally described in conjunction with Hep B in 1955

Other associations: EBV, RSV, Coxsackie, echo, Parainfluenzae, CMV etc etc.

Originally described in conjunction with Hep B in 1955

Other associations: EBV, RSV, Coxsackie, echo, Parainfluenzae, CMV etc etc.

Case 6Case 6

4/12 baby girl Febrile & irritable for

2/7 Developed rash on

face yesterday Now red all over Father noticed some

blistering

4/12 baby girl Febrile & irritable for

2/7 Developed rash on

face yesterday Now red all over Father noticed some

blistering

Case 6: Staphylococcal scalded skin syndrome (SSSS)

Case 6: Staphylococcal scalded skin syndrome (SSSS)

Occurs in kids <6 yrs

Staph producing exotoxin disrupts barrier at granular layer

Rx: admit patients with generalized disease for IVABs & minimize trauma to skin with emollients

Occurs in kids <6 yrs

Staph producing exotoxin disrupts barrier at granular layer

Rx: admit patients with generalized disease for IVABs & minimize trauma to skin with emollients

Atopic Dermatitis: CausesAtopic Dermatitis: Causes

Genetics (filaggrin gene)

Staph acting as super antigen

Extremes of climate

Food as allergen controversial

Aeroallergens & house dust mite

Genetics (filaggrin gene)

Staph acting as super antigen

Extremes of climate

Food as allergen controversial

Aeroallergens & house dust mite

Atopic dermatitisAtopic dermatitis

Itch & scratch

Sleep deprivation for the whole family

Worsening weeping eczema think Staph

Sudden painful eczema think herpes

Itch & scratch

Sleep deprivation for the whole family

Worsening weeping eczema think Staph

Sudden painful eczema think herpes

Atopic DermatitisAtopic Dermatitis

Atopic dermatitisAtopic dermatitis

Atopic dermatitisAtopic dermatitis

Secondarily Infected Eczema with Staph

Atopic dermatitisAtopic dermatitis

Secondarily Infected Eczema with Herpes: Eczema

herpeticum

TreatmentTreatment

Educate parents about what is known about AD

Encourage emollients (point to diaper area to show that moist environment helpful)

500g per week or more

Educate parents about what is known about AD

Encourage emollients (point to diaper area to show that moist environment helpful)

500g per week or more

Treatment: SteroidsTreatment: Steroids

Tackle Steroid phobia head on!

Atrophy rarely seen when appropriate steroid is used for appropriate time

No increased risk of cancer

Use potent steroid to induce quick remission & get family on your side

Tackle Steroid phobia head on!

Atrophy rarely seen when appropriate steroid is used for appropriate time

No increased risk of cancer

Use potent steroid to induce quick remission & get family on your side

Treatment: SteroidsFinger Tip Units (FTU)

Treatment: SteroidsFinger Tip Units (FTU)

Squeeze ointment DIP crease = 1 FTU

Covers 2 hands of skin

2FTUs = 1g

(http://www.patient.co.uk/showdoc/27000762/)

Squeeze ointment DIP crease = 1 FTU

Covers 2 hands of skin

2FTUs = 1g

(http://www.patient.co.uk/showdoc/27000762/)

Treatment: calcineurin inhibitorsTreatment: calcineurin inhibitors

Pimecrolimus cream limited efficacy

Tacrolimus ointment 0.1 & 0.03%

No atrophy

Pimecrolimus cream limited efficacy

Tacrolimus ointment 0.1 & 0.03%

No atrophy

Treatment: AntihistaminesTreatment: Antihistamines

No role for non-sedating

Use benadryl, atarax will make patient more drowsy

No role for non-sedating

Use benadryl, atarax will make patient more drowsy

Treatment: AntibioticsTreatment: Antibiotics

Take cultures, lesion & nares

Culture other members of family if recurrent

Treat for likely Staph

Review patient when cultures are back

Take cultures, lesion & nares

Culture other members of family if recurrent

Treat for likely Staph

Review patient when cultures are back

Treatment: Eczema herpeticumTreatment: Eczema herpeticum

Acyclovir p.o.

Analgesia

May need Staph coverage as well

Acyclovir p.o.

Analgesia

May need Staph coverage as well

Pitryriasis Alba (PA)Pitryriasis Alba (PA)

1/3 of kids in USA may have PA

Occurs in all races

♂ > ♀

More problematic in darker skin

1/3 of kids in USA may have PA

Occurs in all races

♂ > ♀

More problematic in darker skin

Pitryriasis Alba (PA)Pitryriasis Alba (PA)

Associated with Atopic Dermatitis

3 stages Papular erythematous Papular hypochromic Smooth hypochromic

Associated with Atopic Dermatitis

3 stages Papular erythematous Papular hypochromic Smooth hypochromic

Pitryriasis Alba (PA): RxPitryriasis Alba (PA): Rx

Gentle Skin care

1% Hydrocortisone Cream

Sunscreen

Reassurance

Gentle Skin care

1% Hydrocortisone Cream

Sunscreen

Reassurance

Learning ObjectivesLearning Objectives

To review common congenital & acquired skin lesions,

To recognize rashes that present in childhood, and

To manage the kids and their parents.