Download Common Dermatological Problems in the Paediatric Office

COPYRIGHT PULSUS GROUP INC. – DO NOT COPY
CANADIAN PAEDIATRIC SOCIETY – 89th Annual Conference
Common Dermatological
Problems in the Paediatric
Office
James Bergman, MD FRCPC
Clinical Assistant Professor
Department of Dermatology and Skin Science
University of British Columbia, Vancouver,
British Columbia
Miriam Weinstein, MD FRCPC
Associate Professor of Medicine and Pediatrics
University of Toronto
Co-Chief, Dermatology
Hospital For Sick Children, Toronto, Ontario
Many common dermatological problems
can safely be treated and followed up by the
paediatrician, although referral is advised
when a diagnosis is in doubt, treatment
may be complicated or the skin condition
suggests a more serious syndrome.
Numerous skin conditions encountered in everyday paediatric practice can
produce uncertainty as to diagnosis and
optimal management. Close attention
to one or two key distinguishing features
can typically help the clinician identify
the problem or distinguish a benign condition from a more serious entity that
may present with similar characteristics.
New medications and modalities can
replace or supplement classic treatments
for several common problems.
Hemangiomas
Hemangiomas are caused by vascular
proliferation. They typically grow for the
first six to 12 months of life, then stabilize and and then slowly involute. “They
may not completely go away. There may
be some residual effects such as telangiectases or fibrofatty tissue,” Dr Bergman
cautioned. Although most hemangiomas
are benign, aggressive therapy is sometimes warranted. For example, large nasal
hemangiomas may have severe cosmetic
effects through destruction of cartilage. A
hemangioma in a beard distribution may
indicate laryngeal involvement that can
effect the airway and can be life threatening if bleeding occurs. A lesion in
the groin region may be prone to breakdown, ulceration, infection and scarring.
“When they are large, perineal heman-
giomas can be associated with gastrointestinal or genitourinary abnormalities,”
noted Dr Bergman. A lesion near the eye
may impede vision or produce pressure
effects, so early treatment and/or referral
to an ophthalmologist is appropriate. A
large facial hemangioma may also raise
suspicion of PHACES (Posterior fossa
brain abnormality/Hemangioma/Arterial
cerebrovascular abnormalities/Cardiac
anomalies/Eye problems/Sternal defects)
syndrome, which requires an extensive
diagnostic workup. A patient with numerous hemangiomas has an increased
risk of systemic hemangiomatosis. The
risk of this is more significantly increased
if the patient has more than five lesions,
Dr Bergman indicated.
When the hemangioma is life threatening or has serious functional implications
then most paediatric dermatologists now
use oral propanolol instead of high dose
oral steroids. This strategy alleviates
parents’ and physicians’ anxiety over the
side effects of high-dose oral steroids.
Propanolol appears to be safe, but given
the drug’s known mechanisms of action
and reports of side effects, its use at this
point should be undertaken by someone
familiar with the treatment of hemangiomas with propanolol (1,2).
When a hemangioma engenders cosmetic, psychosocial or less serious medical concern, then treatment with topical
beta blocker can be effective (3). Timolol
is available commercially at 0.5% as an
ophthalmological
preparation.
Dr
Bergman indicated that in his practice he
has a pharmacist compound timolol into
a 2% gel which may increase the effect
and allows easier application given the
thicker consistency. In his experience,
topical 2% timolol can work quite well
but this depends on the thickness of the
hemangioma and how early the lesion is
treated. The risks of side effects are much
lower with topical beta blockers compared with oral preparations, and I have
not had any parents note any local side
effects.
Pyogenic Granuloma or Spitz Nevus?
Pyogenic granulomas are misnamed because they are neither infectious nor
granulomas. They are common benign
vascular tumours that may occur as the
result of minor trauma. They are often pedunculaed and have a tendency to bleed
easily. Parents often resort to having the
child wear a bandage constantly. Patients
often present to the office with ‘the bandaid sign’ which aids in diagnosis and differentiation from other red papules.
Recent studies indicate topical imiquimod
is an easier and less invasive treatment
option than the gold standard treatment
of curettage and electrocautery previously employed (4,5). Parents should be
counseled about the risk of irritation with
this medication. If irritation occurs, the
patient should be instructed to stop the
treatment until the irritation resolves.
Thereafter, they can reintiate treatment
but at a lower frequency. Based on the
results achieved with hemangiomas, topical timolol can be considered as an option
for pyogenic granulomas.With this treatment the patient does not experience the
irritation that can occur with imiquimod.
My experience is that topiccal timolol
may be less effective, but further research
is needed to define the best treatment.
If a paedictrician removes a pygenic granuloma (curretage) the specimen should be sent
to the lab because Spitz nevi can at times
mimic pyogneic granuloma. In the situation
where the clinician is not sure of the diagnosis
(Spitz nevi versus pyogenic granuloma versus
other) then the biopsy specimen should be
sent to an experienced dermatopathologist
because Spitz nevi can be mistaken for melanoma under the microscope. Although Spitz
nevi are considered to be benign, their true
prognosis and risk is not known and some
dermatologists prefer to remove the lesion
while others feel comfortable with close
observation of a typical spitz nevus.
Molloscum Contagiosum
This viral infection is characterized by
pearly, dome-shaped papules. Koebnerization (papules growing in a line of trauma)
may provide a clue to the papules being
molluscum because they often grow in a
line due to scratching. Secondary redness
usually indicates an inflammatory reaction rather than infection. “I like to see a
bit of inflammation (redness) in the area.
I tell my patients that this is a good sign
that the body is trying to rid itself of the
3
COPYRIGHT PULSUS GROUP INC. – DO NOT COPY
CANADIAN PAEDIATRIC SOCIETY – 89th Annual Conference
infection,” said Dr Bergman. The inflammatory response can induce a secondary
eczema that can camouflage the molluscum. Cure the molluscum and the eczema
will resolve. However, if the eczema is significant then treating the inflammation
associated with the eczema is important
even though the anti-inflammatory effects
of the medications may allow a temporary
flare of the molluscum.
There is not one preferred evidencedbased treatment for molluscum, as well,
not treating is always an option. Some
advocate curettage with good cure rates,
but this process increases patient anxiety
and may increase the risk of scarring. The
use of topical cantharidin (6) or imiquimod (7) may well be easier to perform and
be more pleasant for the patient and family,
Dr Bergman indicated; in one study of
cantharidin, the cure rate was approximately 90% with one or two treatments.
Patients using cantharidin may develop
blisters because it is an extract of blister beetle; however, if applied sparingly
and washed off after 4 h the risk is low.
Parents of patients with a greater degree
of pigment in their skin should be counselled that they will have a higher rate of
postinflammatory hyperpigmentation. I
do not recommend the use of cantharidin
on the face, neck or groin due to a higher
tendency for larger blisters in this area.
Wart or Epidermal Nevus?
A wart is caused by one of more than
200 human papillomaviruses transmitted
through direct contact or auto-inoculation.
Children most frequently develop common warts (verruca vulgaris) on the feet
or hands, or flat warts, which typically
occur on the face.
Because some warts may resolve with
time, a decision to initiate treatment
must take into account the efficacy of the
proposed treatment, side effects including pain, likelihood of compliance, convenience and cost. A recent Cochrane
analysis deemed salicylic acid the most
efficacious treatment. If over-thecounter preparations are not effective, “I
often use [a 50% concentration] in white
petrolatum. You put a small amount on
the wart and tape it up. It will induce
maceration of the tissue…you need to
warn the patient,” Dr Weinstein stated.
Liquid nitrogen is less effective and,
unless a numbing cream is administered
first, is painful for children. Adolescents
4
are often able to tolerate it. Some practitioners have employed imiquimod (offlabel) for common warts. “I would not
use it for plantar warts [because] I don’t
think that the hyperkeratosis that builds
up on the wart allows adequate penetration,” Dr Weinstein cautioned.
Based on anecdotal reports, at least
two studies have evaluated the efficacy
of duct tape versus a regular occlusive
dressing or cryotherapy for wart removal.
In one of these, said Dr Weinstein, “all
the warts that showed a response to duct
tape did so by three weeks. So if parents
want to use duct tape, I tell them use it
[replaced weekly] for three weeks; if there
is benefit, to continue until the wart is
gone. If there is no benefit [by three
weeks], it’s unlikely to be helpful.”
Epidermal nevi are papillomatous and
verrucous and can be mistaken for warts,
Dr Weinstein remarked. “The problem
is [an epidermal nevi] often has a latent
onset, so while it’s destined to be there
from birth it’s not always evident at
birth....Often times we can reassure the
family it’s not a wart, it’s a birthmark.”
They tend to grow until the child is
about school age. If bothersome, these
benign lesions can be removed with laser,
cryotherapy or excision.
Bald, Brown and White Spots
Nevi sebaceous are hairless, oval, salmoncoloured, greasy plaques that develop on
the scalp or other areas of the head or neck.
They may wax and wane (for example, are
more prominent in infancy and at puberty)
but never resolve completely on their own.
It was once believed nevi sebaceous were associated with a 10% basal cell carcinoma in
adulthood; however, most recent literature
indicates the risk is likely less than 1% (8,9).
They do have an increased risk of benign
adnexal tumours of approximately 10% (9).
Patients must be counselled to return for
evaluation of any new bump on the plaque.
For cosmetic reasons, many children with a
nevus sebaceous want it removed by adolescence, at which time the procedure can be
performed safely under local anesthesia.
Cutis aplasia is differentiated from
nevus sebaceous by its shiny, smooth, scarlike appearance. This type of lesion may
require investigation if it is large (>3 cm)
or situated on the neck/spine or midline,
posterior or anterior to the vertex. Other
signs for concern are concomitant abnormalities (hemangioma or vascular stain)
or a ‘collarette’ of hair around the lesion,
which suggests the possibility of neurocutaneous involvement.
When a patient presents with a possible café au lait macule that has a history of being irritated or swollen then
the clinician should try to elict Darier’s
sign. Darier’s sign is when a hive appears
in the brown area after rubbing frimly
and it is diagnostic of a mastocytoma
(mast cell disease). Mast cell disease
is a continuum ranging from solitary
local involvement to systemic disease.
Fortunately the most common form is
the solitary mastocytoma which presents with local lesional symptoms and
the lesion generally involutes over time.
More extensive cutaneous involvement
may produce urticaria pigmentosa which
is often isolated to the skin but can have
systemic organ involvement. Patients
should avoid known triggers that include
heat, cold, stress, and certain foods and
medications. In patients with multiple
mastocytomas (urticaria pigmentosa)
an epinephrine autoinjector should be
prescribed as a precaution because it is
possible to have a generalized degranulation of these mast cells.
Among the many causes of white spots
on the skin are tinea versicolor and vitiligo. Tinea versicolor often appears in a
shawl distribution and produces a fine,
wrinkled scale, Dr Bergman noted. Vitiligo
generally has a symmetrical distribution
and is well demarcated. In addition, vitiligo produces depigmentation while tinea
versicolor lesions are hypopigmented.
Similarly, pityriasis alba produces hypopigmented areas with fuzzy borders, he
added. Tinea versicolor can be managed
with topical or oral antifungals. A simpler
and less expensive option to eliminate
the causative pathogen, malassezia, is
antifungal shampoo. It could be applied
from the neck down, left for five minutes,
then rinsed off; the treatment should be
repeated daily for a week.
New Methods Against Lice
Head lice infestation causes embarrassment, distress, exclusion from school or
daycare, and social stigma. Local treatments now available include insecticides
(permethrin [eg, Nix (Insight Pharmaceuticals, LLC, USA)], synergized pyrethrin [eg, R&C Shampoo (Block Drug
Company, Inc, USA)] and malathion) and
noninsecticidal/physical modalities. Oral
COPYRIGHT PULSUS GROUP INC. – DO NOT COPY
CANADIAN PAEDIATRIC SOCIETY – 89th Annual Conference
ivermectin is widely used elsewhere but is
difficult to obtain in Canada.
Insecticide resistance is developing
among many lice strains (10), which in
addition to incomplete ovicidal activity
by these agents may lead to treatment
failures. Newer over-the-counter medications such as isopropyl myristate in
combination with cyclomethicone (eg,
Resultz [Nycomed Canada Inc, Canada])
or dimeticone (100cST 50% w/w, eg,
NYDA [PediaPharm Inc, Canada] –
approved by Health Canada in 2011)
kill lice by physical mechanisms (dehydration or asphyxiation) rather than
neurotoxicity, Dr Weinstein indicated,
and in comparative studies these have
been more effective than permethrin at
eradicating both adult lice and larvae.
“They may well address the resistance
issues we have encountered and concerns
about pesticides,” she added. As with
insecticides, two treatments seven to
10 days apart followed by fine-combing
help ensure complete eradication of lice
and eggs.
Home remedies, such as mayonnaise,
tea tree oil and coconut oil, are not supported by current evidence. Similarly,
given that lice need a regular blood meal,
there is little evidence that environmental decontamination with pesticides is
necessary or helpful. Washing clothes,
toys and bedding in hot water, or storing
items in an occlusive bag for several days
to weeks is likely equally effective.
If patients or parents still complain
of symptoms, clinicians should consider
several possibilities including treatment failure due to resistant lice or
poor compliance with the regimen, or
reinfestation. In addition, Dr Weinstein
commented, think about other diagnoses. “There are lots of causes of itchy
scalp, with atopic dermatitis being one
of the major ones.”
Complicated Eczema
Patients with eczema may experience
secondary infection with pathogens such
as Staphylococcus or Streptococcus (impetigo) or herpes simplex. The risk is
heightened by the loss of the skin’s barrier function in eczema.
Impetiginized eczema may have more
subtle signs and symptoms than impetigo
alone, Dr Weinstein remarked. “You can
get a thick or yellow crust, but sometimes
it’s just a worsening of the eczema. And
patients tell you their typical therapies
don’t work any more. Of course they can
be systemically unwell but that is uncommon.” Topical antibiotics and bleach
baths (1/2 cup of household bleach in
a 1/4 standard-sized tub of water, three
times weekly) can help address bacterial
infection and colonization in patients
with eczema. “I don’t use [bleach baths]
first line. I use them in kids who repeatedly get impetiginized with their eczema
and I use it in hard to control eczema,”
Dr Weinstein said.
Infection with herpes simplex virus
can cause extensive lesions in patients
with eczema. The lesions are very similar
in appearance and typically grouped. “It
can have a high degree of morbidity and
needs to be recognized and treated properly,” Dr Weinstein stressed. Depending
on the patient’s condition and the availability of follow-up, oral or intravenous
acyclovir may be considered. If the
eczema herpeticum involves the nasal tip
or the eye, an ophthalmologist referral
may be needed due to the risk of herpes
keratitis.
Barrier Repair
In addition to corticosteroids and calcineurin inhibitors, clinicians may also
consider a prescription-strength barrierrepair emulsion to help restore adequate
ceramides to the skin (eg, EpiCeram [PediaPharm Inc, Canada]). There are also
some emollients that aim to enhance ceramide content of the skin in the management of eczema (eg, CeraVe [Coria Laboratories, USA], Restoraderm [Galderma,
Switzerland]). “The calcineurin inhibitors
and the cortisones are anti-inflammatory
and anti-itch. I like to think of them as
the fire extinguisher when you have a
flare of eczema,” Dr Weinstein remarked.
“[The barrier repair emulsion – EpiCeram]
works in a different way. It’s trying to temporarily repair the barrier defect, which
is one of the main problems in eczema. If
you can repair the barrier then you don’t
get as many irritants in to incite an inflammatory response and you’ll prevent
water from getting out.” She suggested
that this product may be effective on mild
or thin eczema patches and/or as part of
a multi-agent regimen. “These classes can
all be mixed. You can, for example, use a
calcineurin inhibitor on the face and a
corticosteroid on the body. You can also
use [the barrier repair product] at the beginning of a flare, and if it doesn’t control it you can advance to a calcineurin
inhibitor.” The new therapy may be offered to patients or parents who have concerns about steroid use; however, said Dr
Weinstein, “If the patient has rip-roaring
eczema covering a lot of their body I am
probably going to push pretty hard for
them to get it under control rapidly with a
corticosteroid, and then longer term they
can look at the other agents when there is
less inflammation.”
DISCLOSURES: Dr Weinstein has acted
as a consultant and/or speaker for Pediapharm, Nycomed and Galderma.
References
1. Leaute-Labreze C, Dumas de la Roque E,
Hubiche T, et al. Propranolol for severe
hemangiomas of infancy. N Engl J Med
2008;358:2649-51.
2. Sans V, de la Roque ED, Berge J, et al.
Propranolol for severe infantile
hemangiomas: Follow-up report. Pediatrics
2009;124:e423-31.
3. Pope E. Topical timolol gel for
hemangiomas. A pilot study. Arch Dermatol
2010;146:564-5.
4. Glencoglan G, Inanir I, Gunduz K. Pyogenic
granuloma in two children successfully
treated with imiquimod 5% cream.
Pediatr Dermatol 2009;26:366-8.
5. Tritton SM, Smith S, Wong LC et al.
Pyogenic granuloma in ten children treated
with topical imiquimod. Pediatr Dermatol
2009;26:269-72.
6. Silverberg NB, Sidbury R, Mancini AJ.
Childhood molluscum contagiosum:
Experience with cantharidin therapy in
300 patients. J Am Acad Dermatol
2000;43:503-7.
7. Hanna D, Hatami A, Powell J, et al. A
prospective randomized trial comparing
the efficacy and adverse effects of four
recognized treatments of molluscum
contagiosum in children. Pediatr Dermatol
2006;23:574-9.
8. Cribier B, Scrivener Y, Grosshans E. Tumors
arising in nevus sebaceous. A review of 596
cases. J Am Acad Dermatol 2000;42:263-8.
9. Rosen H, Schmidt B, Lam HP et al.
Management of nevus sebaceous and the
risk of basal cell carcinoma: An 18-year
review. Pediatr Dermatol 2009;26:676-81.
10. Marcoux D, Palma KG, Kaul N, et al.
Pyrethroid pediculicide resistance of head
lice in Canada evaluated by serial invasive
signal amplification reaction. J Cutan Med
Surg 2010;14:115-8.
5