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Pediatric Dermatology: Not Child’s Play
Mary Ann Maurer, DO WVU School of Medicine, Charleston Campus
CAMC Family Medicine Residency
Warning! Cute Kids Ahead!
Are you itching to
learn?!
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Pre-Test: What is…
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Common Pediatric Derm Issues • Newborn
– Milia – Dermal melanocytosis – Hemangioma – Erythema toxicum neonatorum
• Infants – Diaper dermatitis – Cradle cap – Viral exanthem
• Roseola • Parvovirus B-19 • Measles • Varicella
• Children – Contact dermatitis – Drug eruptions
• Hives • Erythema multiforme • SJS • TEN
– Warts – Traction alopecia – Mycoplasma pneumonia associated mucositis
• Adolescents – Acne – Tinea versicolor – Tinea corporis – Keratosis pilaris
Just a roadmap, don’t panic
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• Newborn – Milia – Dermal melanocytosis – Hemangioma – Erythema Toxicum Neonatorum
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Milia
• Tiny white bumps • Typically on face • Small follicular plugs • Often seen 3-5 days
after birth • Spontaneously resolve /
self-limited
http://www.dermnetnz.org/site-age-specific/neonate.html Don’t
pick!
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Milia
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Dermal Melanocytosis • Benign • Seen in pts with darker
skin – Asian – Hispanic – Black – Native American
• aka Mongolian Spot • Often at sacrum • Size can vary • Typically resolve by pre-
school
http://newborns.stanford.edu/PhotoGallery/SlateGrey1.html
http://www.skinsight.com/infant/blue-GraySpotMongolianSpot.htm
http://www.intermix.org.uk/health/health_bluespots.asp
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Hemangiomas
• Vascular tumors / lesions
• Often has a period of growth followed by period of involution
• Propranolol – Till age 12-15 mos
• Laser tx or excisional • Usually much improved
by age 5-10
http://www.whattoexpect.com/first-year/baby-care/baby-skin-care/hemangioma.aspx
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Hemangiomas • Systematic review (2013)
– n = 1264 • 74% female • 30% w other tx prior to propranolol • Mean age of intiation 6.6 mos • Mean duration of tx 6.4 mos • Mean dose 2.1 mg / kg / day • 98% response rate
– *any* response to propranolol • Rebound growth in 17% • ADRs n=371
– Changes in sleep (136) – Acrocyanosis (61) – Symptomatic hypotension (6) – Hypoglycemia (4) – Symptomatic bradycardia (1)
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Hemangioma
• Multiple cutaneous hemangiomas should cue
imaging to look for hemangiomas in solid organs
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Nevus Flammeus • Port Wine Stain
• Sturge-Weber Syndrome
– V1-V2 – Seizures
• Klippel-Trénaunay Syndrome – Vascular malformations – Varicosities – Unilateral hypertrophy
http://www.childrenshospital.org/az/Site2944/mainpageS2944P6.html
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Nevus Flammeus Nuchae
• Stork bite – Around 40% of kids,
though may be up to 70%
– Mostly Caucasian kids – Often at neck – Can also be on eyelids
and between eyes /on forehead
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Are you still showing baby pictures?!
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Srsly… Next slide, dude!!
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Erythema Toxicum Neonatorum • Benign • Self-limited • Small pustules with
surrounding erythema • Face, trunk, buttocks, limbs
– If palmar / plantar, consider other dxs
• Not seen in preterm babies • Typically within 48 hrs of
age but may be delayed up to two weeks
• Eosinophils
http://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/articles/image_article_collections/mcgraw_hill_skin_atlases/childhood_skin_problems/CAPD_erythema_toxicum_neonatorum.jpg
http://www.skinsight.com/images/dx/webInfant/erythemaToxicumNeonatorum_17955_lg.jpg
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• Infants – Diaper dermatitis – Viral exanthem
• Roseola • Parvovirus B-19 • Measles • Varicella
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Diaper Dermatitis • Often due to contact irritant
(feces / urine) • May be related to dietary
changes • Fungal a possibility • Myriad tx based on etiology
– Steroid vs antifungal vs both! – Consider thrush – Prevention w/ barrier cream – Wipes can be irritating – Spray Maalox on it!
http://dermis.net/bilder/CD050/550px/img0040.jpg
Ouch!
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Cradle Cap • Seborrheic dermatitis • Usu in the first 3 mos • Can also see behind ears,
at eyebrows • Overactive sebaceous
glands • Occasionally fungal • Tx with baby oil, gentle
brushing to loosen • No olive / coconut oils as
can worsen fungal
http://www.cheekymaidensoap.com/_blog/Cheeky_Maiden_Blog/post/Treating_Cradle_Cap/
http://upload.wikimedia.org/wikipedia/commons/5/50/Baby_With_Cradle_Cap.jpg
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Viral Exanthem: Roseola
• HHV-6 • aka Roseola Infantum • Typical hx is fever x 72
hrs without other etiology (eg ears, teething)
• When defervesce, a rash appears
• Self-limited
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Viral Exanthem: Parvovirus-B19
• aka 5th Disease or Erythema Infectiosum
• “Slapped cheek rash with lacy reticular pattern on trunk” after URI symptoms
• May also have arthralgias w/ rash
• Careful—can cause SAB in pregnant women
http://health.allrefer.com/health/fifth-disease-fifth-disease.html
http://www.cixip.com/index.php/page/content/id/939
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Viral Exanthem--Measles • Increasing #s due to
poor vaccination rates • Prodrome 2-4 days
– Stepwise fever to Tm 103-105
– 4Cs • Rash
https://jdc325.files.wordpress.com/2011/04/measles_2.jpg
http://upload.wikimedia.org/wikipedia/commons/e/e0/Measles_enanthema.jpg
http://www.atsu.edu/faculty/chamberlain/images/koplik_spots2.jpg
http://bchdmi.org/uploaded_images/measles1.jpg
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Viral Exanthem--Varicella
• Crops of lesions – Prodrome of fever,
anorexia, malaise (1-2d) – Lesions in varying states
simultaneously – Starts centrally then
moves peripherally
http://research.fuseink.com/artifactimg/MTMxOTc5NjQ3ODMyMjFfMg.jpg
http://socialhealthboxx.com/wp-content/uploads/2014/04/chicken.jpg
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• Children – Contact dermatitis – Drug eruptions
• Urticaria • Erythema multiforme • SJS • TEN • DRESS (bit of a stretch!)
– Warts – Traction alopecia – Mycoplasma pneumonia associated mucositis
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Contact Dermatitis
• Allergic or Irritant • Remove the source
– Or try to control it (!) • Mild topical
corticosteroid may help
http://blog.saintsabrinas.com/wp-content/uploads/2011/01/belt-buckle-allergy.jpg
http://eso-cdn.bestpractice.bmj.com/best-practice/images/bp/en-gb/90-3_default.jpg
http://www.skinsight.com/infant/irritantContactDermatitis.htm
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Drug Eruption: Urticaria
• Look for – Wheal = edema, and – Flare = erythema
• History is most helpful
• NB: Of course one can have urticaria for other reasons! http://allergyasthmamichigan.com/web%20site%20contents/hives.jpg
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Drug Eruption: Erythema Multiforme
• History is key – Penicillins – Sulfa – Anti-epileptics (eg Dilantin)
• Look for well-circumscribed lesions w/ central clearing
• No oral lesions!
http://www.huidziekten.nl/afbeeldingen/erythema-exsudativum-multiforme-7.jpg
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Drug Eruption: SJS
• History • Offending agent • Fever, fatigue • Skin lesions and mucous
membrane involvement – Including eyes!
• May require ICU admission
www.rightdiagnosis.com/phil/images/4650.jpg
http://syndromepictures.com/wp-content/uploads/2011/10/Steven-Johnson-Syndrome-rash.jpg
http://www.portalesmedicos.com/imagenes/publicaciones/0803_Sindrome_Stevens_Johnson/lesiones_eritemato_papulo_bullosas.jpg
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SJS: Treatment • Removal of offending agent • Analgesia • Topical steroids
– Eyes – Skin
• No real role for systemic steroids • Occasionally IVIg • Also of interest
– Cyclosporine – Tacrolimus – NAC – Biologics – Plasmapheresis
• Tincture of time • Specialty consult
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Drug Eruption--TEN • Occurs in response to
infection or drugs • Spectrum is
EMSJSthis – TEN >30% BSA
• Apoptosis of keratinocytes leads to skin sloughing – Nikolsky sign
• Admission to burn unit • Mortality 30-50%
– SCORTEN
http://www.skincareguide.ca/images/glossary/toxic_epidermal_necrolysis.jpg
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Drug Eruption--DRESS • Drug Reaction with Eosinophilia and
Systemic Symptoms – Delayed reaction – High fever – Morbiliform (measles) rash – Rash and lymphadenopathy – Eosinophila and lymphocytosis – Elevated LFTs – Rare renal involvement – Myocarditis / pericarditis – HHV6 activation also implicated
• Offending agents – AEDs – Sulfa – Ziprasidone (Geodon) – Allopurinol – Atenolol! http://archderm.jamanetwork.com/article.aspx?articleid=1733354
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Warts
• Verrucae • Varied morphology • Location = anywhere! • Tx varies
– Cryo – TCA – Curettage – Excision
http://medicalpicturesinfo.com/wp-content/uploads/2011/10/Verruca-Vulgaris-3.jpg
http://0.tqn.com/d/foothealth/1/0/-/2/-/-/DSC_3339.JPG
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Traction Alopecia • Tension from tight braids,
ponytails, weaves / extensions
• No loss of eyebrows / body hair
• Areas usually not circumferential
• Can be permanent • Treatment in peds is scalp
rest – Occ Rogaine in adults
http://hairlossgeeks.com/traction-alopecia-causes-and-treatment/
http://dermnetnz.org/common/image.php?path=/hair-nails-sweat/img/traction.jpg
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MPAM (Mycoplasma Pneumonia Associated Mucositis)
• Mucosal-only – Oral – Ocular – Urogenital
• If skin involved, MASJS (Mp-associated SJS) • MPAM has better prognosis • Auto-antibodies against Mp attack mucosal
cells
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MPAM
Meyer Sauteur et al. (2012).
https://doi.org/10.1016/j.jtumed.2016.12.002
https://doi.org/10.1177/1203475419874444
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MPAM
• Treatment – Abx – Steroids – Occasionally IVIg – Early specialist involvement if ocular involvement
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• Adolescents – Acne – Tinea versicolor – Tinea corporis – Keratosis pilaris
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Acne • Open comedones =
blackheads • Closed comedones =
whiteheads • Cystic acne
– Oral abx – Accutane
• Must be on OCP
• Topicals – Salicylic acid – Benzoyl peroxide – Retinoids
http://www.skinfoto.com/skin-facts/acne.html
http://www.skinsight.com/child/acneVulgaris.htm
http://www.dermnet.com/topics/acne/physical-findings/
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Tinea Versicolor
• Aka Pityriasis Versicolor • Malassezia furfur • Fungal • Often see in
summertime • Topical selsun blue /
nizoral • Oral tx not
recommended currently http://www.health-writings.com/img/mi/tinea-versicolor-treatment/Tinea-Versicolor.jpg
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Tinea Corporis
• Fungal • Topical anti-fungal (eg
Lamisil) • Extend tx just past
borders of lesion • Use for several days
after lesion resolves
http://medicalpictures.net/wp-content/uploads/2011/10/tinea-corporis-pictures-2.jpg
http://www.skinsight.com/images/dx/webAdult/tineaCorporisRingwormofBody_852_lg.jpg
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Keratosis Pilaris
• “chicken skin” • Often at upper arms,
thighs • Excessive keratin • Topical exfoliant like
Ammonium lactate to remove keratin plugs – Retinoids can work, too,
but often very drying – Need sunscreen!
http://www.dermnetnz.org/acne/img/keratosis-pilaris/source/image/3024.jpg
http://www.atlasdermatologico.com.br/ListaImagens/Keratosis_Pilaris4.JPG
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Wrap-Up Nevi are gone but the crazy remains!
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• http://www.cdc.gov/parvovirusb19/fifth-disease.html. Accessed 08/20/13.
• http://www.mayoclinic.com/health/keratosis-pilaris/DS00769/DSECTION=treatments-and-drugs. Accessed 08/20/13.
• http://www.drgreene.com/articles/cradle-cap/ • Patient sheet on hemangioma
https://pedsderm.net/site/assets/files/1028/12_spd_propranolol_color_web-final.pdf
• Hemangioma and propranolol: https://doi.org/10.1111/pde.12022 • Systematic review of propranolol:
https://doi.org/10.1111/pde.12089 • SJS / TENS treatments : doi: 10.4103/ijd.IJD_583_17
http://www.cdc.gov/parvovirusb19/fifth-disease.htmlhttp://www.mayoclinic.com/health/keratosis-pilaris/DS00769/DSECTION=treatments-and-drugshttp://www.mayoclinic.com/health/keratosis-pilaris/DS00769/DSECTION=treatments-and-drugshttp://www.drgreene.com/articles/cradle-cap/https://pedsderm.net/site/assets/files/1028/12_spd_propranolol_color_web-final.pdfhttps://pedsderm.net/site/assets/files/1028/12_spd_propranolol_color_web-final.pdfhttps://doi.org/10.1111/pde.12022https://doi.org/10.1111/pde.12089https://dx.doi.org/10.4103/ijd.IJD_583_17
Pediatric Dermatology:�Not Child’s Play Pre-Test:�What is…Common Pediatric Derm IssuesSlide Number 4MiliaMiliaDermal MelanocytosisHemangiomasHemangiomasHemangiomaNevus FlammeusNevus Flammeus NuchaeSlide Number 13Slide Number 14Slide Number 15Erythema Toxicum NeonatorumSlide Number 17Diaper DermatitisCradle CapViral Exanthem: RoseolaViral Exanthem: Parvovirus-B19Viral Exanthem--MeaslesViral Exanthem--VaricellaSlide Number 24Contact DermatitisDrug Eruption: UrticariaDrug Eruption: Erythema MultiformeDrug Eruption: SJSSJS: TreatmentDrug Eruption--TENDrug Eruption--DRESSWartsTraction AlopeciaMPAM�(Mycoplasma Pneumonia Associated Mucositis)MPAMMPAMSlide Number 37AcneTinea VersicolorTinea CorporisKeratosis PilarisWrap-UpSlide Number 43