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?!

Pre-Test: What is…

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

• Newborn – Milia – Dermal melanocytosis – Hemangioma – Erythema Toxicum Neonatorum

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!

Milia

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

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

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)

Hemangioma

• Multiple cutaneous hemangiomas should cue

imaging to look for hemangiomas in solid organs

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

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

Are you still showing baby pictures?!

Srsly… Next slide, dude!!

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

• Infants – Diaper dermatitis – Viral exanthem

• Roseola • Parvovirus B-19 • Measles • Varicella

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!

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

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

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

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

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

• Children – Contact dermatitis – Drug eruptions

• Urticaria • Erythema multiforme • SJS • TEN • DRESS (bit of a stretch!)

– Warts – Traction alopecia – Mycoplasma pneumonia associated mucositis

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

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

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

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

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

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

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

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

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

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

MPAM

Meyer Sauteur et al. (2012).

https://doi.org/10.1016/j.jtumed.2016.12.002

https://doi.org/10.1177/1203475419874444

MPAM

• Treatment – Abx – Steroids – Occasionally IVIg – Early specialist involvement if ocular involvement

• Adolescents – Acne – Tinea versicolor – Tinea corporis – Keratosis pilaris

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/

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

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

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

Wrap-Up Nevi are gone but the crazy remains!

• 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