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MYTHBUSTERS:Dermatology Style

Rebecca Flynn, APRN, CPNP

Children’s Mercy Department of Dermatology

Myth #1

Imiquimod (Aldara) 5% cream when applied 3 x weekly to affected areas will accelerate resolution of molluscum contagiosum.

Molluscum Contagiosum

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Molluscum Contagiosum - Epidemiology Common viral disease of childhood Caused by the molluscum

contagiosum virus (MCV), a poxvirus Benign and self-limited Spontaneous resolution within 6 p

months to several years

Molluscum Contagiosum - Epidemiology Incubation period ranges from 2 weeks to 6 months Transmission occurs from skin to skin contact, fomites

or autoinoculation Clothing, bath sponges, towels, gymnastics equipment,

swimming pools, public bathsg p , p Increased susceptibility: Atopic dermatitis or

immunodeficiency

Molluscum Contagiosum - Identification 1-5 mm smooth, firm, dome-shaped papules with central

umbilication – may need magnification to improve visualization Pearly white, pink, or skin colored Average number of papules is 10-20, range from 1 to several

hundred Can affect any part of the skin, but most common on trunk, y p , ,

antecubital and popliteal fossae, axillae Inflammation of lesions usually precedes resolution

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Molluscum Dermatitis

Imiquimod 5% cream and Molluscum Contagiosum

FDA Clinical Executive Summary 9/3/2008: Limitations to use: Aldara Cream has been evaluated in

children ages 2 to 12 years with molluscum contagiosum and these studies failed to demonstrate efficacy.

Two unpublished studies failing to demonstrate efficacy

Aldara Package labeling http://www.accessdata.fda.gov/drugsatfda_docs/label/2010/0207

23s022lbl.pdf

Katz, K.A. (2015). Dermatologists, Imiquimod, and Treatment of Molluscum Contagiosum in Children: Righting Wrongs. Journal of American Medical Association 151 (2). 125-126.

Myth #1

Imiquimod (Aldara) 5% cream when applied 3 x weekly to affected areas will accelerate resolution of molluscum contagiosum.

BUSTED

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Molluscum Contagiosum Treatment Options Watchful waiting Cantharadin (Cantharone) topical treatment

Blistering agent

Cryotherapy

K l ( T l R d) Keratolytics (i.e. Topical Retinoid)

What is Cantharidin (cantharone)?

Originally derived from the blister beetle; now synthetically derived

Causes blistering of the skin (epidermal layer) – this leads to extrusion of the

ll b d d molluscum body and resolution of lesion

Retrospective study by Silverberg et al: 90% of 300 patients cleared

and 8% improved in an average of 2.1 treatments

Myth #2

Using Duct tape will make a wart go away.

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Verruca Vulgaris (Wart)

Verruca Vulgaris

Caused by human papillomavirus (HPV) Over 150 distinct subtypes of HPV The virus infects squamous epithelial cells most

commonly in acral areas Occur most commonly in children and young adults Occur most commonly in children and young adults,

peaking between 12-16 years of age Warts account for 8% of visits to dermatologists

Verruca Vulgaris Predisposing conditions for more extensive warts or

recalcitrant warts: Atopic Dermatitis Conditions with decreased cell-mediated immunity

(immunocompromised hosts)

T i i f HPV Transmission of HPV: Skin to skin contact Can transmit from people with subclinical infection Inoculation more common in sites of trauma or macerated skin Incubation period usually 2-6 months Latent infection can occur in normal skin

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Verruca Vulgaris Treatment Topical- Salicyclic Acid 40% (Wart Stick) Cryotherapy Candida Antigen Injections

Irritants

Myth #2

Using Duct tape will make a wart go away.Busted

Kwok, C.S., Gibbs, S., Bennett, C., Holland, R., Abbott, R. (2012). Topical Treatments for Cutaneous Warts. The Cochrane Library (9)

Myth #3

Eating Pizza and sugary foods will make my acne worse.

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Acne Vulgaris

Acne Vulgaris

Etiology Increased Sebum-

Sebaceous gland Comedones- open/ closed

B t i P A Bacteria- P. Acnes Inflammatory papules/

Nodules

Acne Vulgaris-Treatment 1st Line Treatment- Benzoyl Peroxide Wash (OTC) Antimicrobial & reduces bacterial resistance

Retinoid- Comedonal Acne Targets comedones Mainstay of treatment Causes Dryness, irritation

Antibiotic- Inflammatory Acne Topical

Benzamycin, BenzaClin, Clindamycin Lotion Requires BPO agent to decrease bacterial resistance

Oral Doxycycline, Minocycline, Azithromycin *Sun Sensitizing*

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Acne Vulgaris-Treatment Severe Cystic Acne Vulgaris Isotretinoin (formerly Accutane)

Pregnancy Category X Requires iPledge Program Highly Recommend management by Dermatologist Potential AE: Potential AE: Dryness Elevated Liver Enzymes Hyperlipidemia Depression/ Suicide Inflammatory Bowel Disease

Acne Vulgaris Ideal: 50% improvement within 2-3 months of new

therapy Prevent Acne Scarring

Acne Vulgaris - Diet Low Glycemic Index Diet Multiple randomized controlled trials to support low glycemic

index diet will aid in improving acne. Recommend treatment

Decreased dairy products Well described biochemical and physiologic mechanism

support milk ingestion and formation of acne. No randomized controlled trials currently. Promising data! Cannot currently recommend treatment.

Bronsnick, T., Murzaku, E.C., & Rao, B.K. (2014). Diet in Dermatology. Journal of American Academy of Dermatology.

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Myth #3

Eating Pizza and sugary foods will make my acne worse.Confirmed

Myth #4

Patient with Hand, Foot and Mouth disease will only have lesions on their hands, feet and mouth.

Hand, foot, and mouth

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Hand foot and mouth Coxsackie Virus Presents with fever, malaise, poor appetite, ST x 1-2 days Vesicles or erosions begin as small red spots in palate,

tongue, uvula, gingiva and tonsills. Advance to ulcers, painful.

Small red spots, some with blisters on palms, soles, hands, feet, or random other locations

Transmitted through nose and throat secretions, blister fluid, and feces.

Supportive treatment .

Hand, Foot, and Mouth

Hand Food Mouth Differential DX

Coxsackie Virus- Hand, Foot, mouth Eczema Herpeticum

CULTURE!

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Eczema Herpeticum

Eczema Herpeticum Herpes Simplex Virus- HSV superimposed on skin HSV-1 or HSV-2

Risk for development: Skin with poor barrier Atopic Dermatitis

History: y Close contact with recent cold sore Rapid spreading of lesions Fever, malaise, irritability, lymphadenopathy

Eczema Herpeticum Skin findings: Vesicles Erosions Pustules Crust PAIN!

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Eczema Herpeticum Treatment Viral Culture Bacterial Culture- optional

Oral acyclovir 40-80 mg/kg/day divided 3-4 x daily IV acyclovir 10mg/kg/dose q8h y g g q Get an ophthalmology consult if near the eyes Do not use topical steroids on suspected HSV Topical ointment Emollients-Vaseline or Aquaphor Consult Dermatology

Myth #4

Patients with Hand, Foot and Mouth disease will only have lesions on their hands, feet and mouth.Busted

Myth #5 Moisturizing my child with emollient will help prevent

eczema from forming.

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Atopic Dermatitis Dry, rough, itchy skin Waxes and Wanes Begins <2 years of age Commonly exists with atopy Allergies, Asthma, Atopic Dermatitisg , , p Strong Family History

Responds to Moisture and Topical Steroids Distribution of dermatitis Infant- face, scalp, trunk, back, elbows, knees Child- neck, B AC, B pop fossa, B ankles/ feet Adult- Hands, feet

Atopic Dermatitis- Differential Dx

Atopic Dermatitis Psoriasis

Atopic Dermatitis- Differential Dx

Scabies Atopic Dermatitis

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Atopic Dermatitis- Treatment Sensitive Products Dye-free, Scent-free products: soap, laundry detergent, dryer

sheet

Moisture Bland ointment/ cream emollient

Vaseline ointment, Aquaphor ointment, q p Vanicream, Cetaphil cream

Daily bathing

Topical Steroid- BID Ointments! Mild- Hydrocortisone 2.5% ointment, Desonide ointment Moderate Strong

Atopic Dermatitis- Treatment Antihistamines Daily non-sedating- Zyrtec

As needed for Allergy control to prevent flares Sedation effect to aid sleep

Benadryl Hydroxyzine Doxepin

Bleach Baths ¼ cup unscented bleach to ½ tub of water

Topical Antibiotics Mupirocin 2% ointment

Wet Wraps

Atopic Dermatitis- Wet Wraps

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Emollient Enhancement of Skin Barrier Atopic Dermatitis – Disrupted skin barrier (epidermal defect in filaggrin) Influx of allergens and irritants into epidermis Inflammatory response

Moisturization to protect skin barrier Prevent skin dryness and cracking Reduce introduction of allergen and irritant

Simpson, E.L, Chalmers, J.R., Hanifin, J.M., Thomas, K.S., Cork, M.J., McLean, W.H., et al. (2014). Emollient Enhancement of the Skin Barrier from Birth Offers Effective Atopic Dermatitis Prevention. Journal of Allergy and Clinical Immunology.

Emollient Enhancement of Skin Barrier 2014 Study Daily emollient therapy from birth significantly reduced AD at

6 months (43 % vs. 22%) in population with family history of atopy.

EmollientsC hil C Cetaphil Cream

Aquaphor ointment Sunflower seed oil

Increased family history- Emollients!

Simpson, E.L, Chalmers, J.R., Hanifin, J.M., Thomas, K.S., Cork, M.J., McLean, W.H., et al. (2014). Emollient Enhancement of the Skin Barrier from Birth Offers Effective Atopic Dermatitis Prevention. Journal of Allergy and Clinical Immunology.

Myth #5 Moisturizing my child with emollients will help prevent

eczema from forming.

Confirmed

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Myth #6 The best products I can use on my newborn with

sensitive skin is Dreft laundry detergent and Johnson & Johnson head to toe body wash.

Atopic Dermatitis Guidelines Dye-free, fragrance-free detergent, fabric softener, dryer

sheets All Free & Clear, Tide Free & Clear, Purex Free & Clear

Mild fragrance free cleanser Dove Sensitive Skin, Cetaphil Cleanser, Vanicream cleansing bar

Dye-free, fragrance-free emollients Aquaphor ointment, Vaseline ointment, Vaniply ointment Vanicream, Cetaphil cream, Cereve cream

Tollefson, M., Bruckner, A. and Dermatology Section (2014). Atopic Dermatitis: Skin- Directed Management. Pediatrics (134) 6.

Myth #6 The best products I can use on my newborn with

sensitive skin is Dreft laundry detergent and Johnson & Johnson head to toe body wash.Busted

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References Bronsnick, T., Murzaku, E.C., & Rao, B.K. (2014). Diet in Dermatology. Journal of American Academy of

Dermatology. Bruggink, S. C., Gussekloo, J., Berger, M. Y., Zaaijer, K., Assendelft, W. J., de Waal, M. W., Vavinck, J. N., Koes, B. W.

& Eekhof, J. A. (2010). Cryotherapy with liquid nitrogen versus topical salicylic acid application for cutaneous warts in primary care: randomized controlled trial. Canadian Medical Association Journal, 182 (15), 1624-1630.

Clifton, M. M., Johnson, S. M., Roberson, P. K., Kincannon, J. & Horn, T. D. (2003).Immunotherapy for recalcitrant warts in children using intralesional mumps or candida antigens. Pediatric Dermatology, 20 (3), 268-271.

Dasher, D. A., Burkhart, C. N. & Morrell, D. S. (2009). Immunotherapy for childhood warts. Pediatric Annals, 38 (7), 373-379.

Goldstein, B. G. & Goldstein, A. O. (2010). Cutaneous warts. Up to date, 18.3. Horn, T. D., Johnson, S. M., Helm, R. M. & Roberson, P. K. (2005). Intralesional immunotherapy of warts with

mumps, candida, and trichophyton skin test antigens. Archives of Dermatology, 141, 589-594. Johnson, S. M. & Horn, T. D. (2004). Intralesional immunotherapy for warts using a combination of skin test

antigens: a safe and effective therapy. Journal of Drugs in Dermatology, 3 (3), 263-265. Katz, K.A. (2015). Dermatologists, Imiquimod, and Treatment of Molluscum Contagiosum in Children:

Righting Wrongs. JAMA Dermatology151 (2). 125-126. Kim, K. H., Horn, T. D., Pharis, J., Kincannon, J., Jones, R., O'Bryan, K., Myers, J. & Nakagawa, M. (2010).

Phase 1 clinical trial of intralesional injection of candida antigen for the treatment of warts. Archives of Dermatology, 146 (12), 1431-1433.

References Kwok, C.S., Gibbs, S., Bennett, C., Holland, R., Abbott, R. (2012). Topical Treatments for

Cutaneous Warts. The Cochrane Library (9). Lee, R. & Schwartz, R. A. (2010). Pediatric molluscum contagiosum: reflections on the last

challenging poxvirus infection, part 1. Cutis, 86, 230-236. Maronn, M., Salm, C., Lyon, V. & Galbraith, S. (2008). One-year experience with candida antigen

immunotherapy for warts and molluscum. Pediatric Dermatology, 25 (2), 189-192. Mathes, E. F. & Frieden, I. J. (2010). Treatment of molluscum contagiosum with cantharidin: a practical

approach. Pediatric Annals, 39 (3), 124-129. Signore, R. J. (2002). Candida albicans intralesional injection immunotherapy for warts.

Cutis 70 185 192 Cutis, 70, 185-192. Silverberg, N. B., Sidbury, R. & Mancini, A. J. (2000). Childhood molluscum contagiosum: experience

with cantharidin therapy in 300 patients. Journal of American Academy of Dermatology, 43 (3), 503-507.

Summers, P., Richards-Altmon, P. & Halder, R. (2009). Treatment of recalcitrant verruca vulgaris with candida antigen in patient with human immunodeficiency virus. Journal of Drugs in Dermatology, 8 (3), 268-269.

Simpson, E.L, Chalmers, J.R., Hanifin, J.M., Thomas, K.S., Cork, M.J., McLean, W.H., et al. (2014). Emollient Enhancement of the Skin Barrier from Birth Offers Effective Atopic Dermatitis Prevention. Journal of Allergy and Clinical Immunology.

Tollefson, M., Bruckner, A. and Dermatology Section (2014). Atopic Dermatitis: Skin- Directed Management. Pediatrics (134) 6.