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Download Elizabeth (Lisa) - The Kansas Association of Osteopathic Medicine
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Elizabeth (Lisa) Swanson, MD Advanced Dermatology Can be deep (look bluish) or superficial (look red) or a combination Typically not present at birth or can be a slightly pink area Grow until the age of 8-12 mos and then involute slowly by 10% per year (all of them are gone by age 10) More common in girls, more common in premies, more common in mult gestation births In most cases, they are a benign nuisance but they can cause some big problems Hemangiomas on the lip, eyelid and nose are very important to think of separately both for functional and cosmetic reasons If the hemangioma crosses the vermilion border of the lip, damages the cartilage of the nose, or occludes an eye, the consequences can be disastrous Large hemangiomas and ones in certain locations (perineum, midline) are prone to ulceration Ulceration is incredibly painful for the baby and leads to permanent scarring Hemangiomas in the “beard” distribution can have subcutaneous involvement in the larynx and can threaten the airway Pelvic and lumbosacral hemangiomas can be a sign of a tethered cord or other neurologic abnormality Always get an MRI (or ultrasound if child is less than 3 mos old) Propranolol 2 mg/kg/day divided TID with food Side effects include hypoglycemia, decreased HR and BP, inc wheezing with resp infections Prednisolone 2 mg/kg/day given in the AM Vincristine is largely outdated Vascular laser- can be used for ulceration, for residual telangiectasia Surgery can have its place Topical beta blockers- Timolol, Propranolol Must evaluate for PHACES Post fossa abnorms Hemangioma Arterial anomalies (mainly head and neck) Cardiac anomalies and coarc of the aorta Eye abnormalities Sternal clefting Do an MRI/MRA of the head and neck and an ECHO in these babies Rapidly Involuting Congen Hemangiomas and Noninvoluting Congen Hemangiomas are present at birth and typically can be big RICHes go away quickly NICHes never go away and many opt for surgical removal Flat pink-purple patches that do not blanch Present at birth If on the upper eyelid or near the eye, baby should see ophthalmology to eval for glaucoma Can be treated with pulsed dye laser (starting at 6 mos old, every 6-8 wks) Babies with extensive PWS, esp in V1 and V2 distribution, should be eval for Sturge Weber Sturge Weber is triad of PWS, glaucoma, seizures Basically ophthalmology appt is all they need MRI scanning is controversial, most wait to see if they are going to have seizures Present at birth as an orange-tan hairless patch At puberty it can become bigger and more lumpy Has a risk of benign and malignant neoplasms (BCC) within it Can choose excision or yearly visits to derm Present at birth, usually as shallow ulceration and then the ulceration heals as a scar Consider ultrasound if lesion is large, if there are multiple, and if there is the “hair collar sign” Usually people have them cut out because of the hairlessness Small congenital nevi have <1% chance of developing into malignancy Patients have option of excision vs yrly visits to derm Questionable role of laser These patients belong in a pediatric derm’s office 6% risk of melanomatends to be in nevus overlying spine and tends to occur in 1st year of life Definite risk of neurocutaneous melanosis and most would obtain MRI Autoimmune attack of hair follicles Produces circular nonscarring patches of alopecia Can affect scalp, eyebrows, eyelashes, body hair Three possible courses of disease One time event with complete recovery Complete recovery with each episode but recurrences every few years Progression of disease to alopecia totalis or universalis (rare) Family/personal history of alopecia areata History of eczema Pattern of alopecia (ophiasis has bad prognosis) Speed of alopecia (the quicker it happens, the worse it is) Minimal association with thyroid disease, diabetes…if child is otherwise healthy, no need to check Squaric acid contact therapy DPCP contact therapy Light therapy Anthralin Intralesional steroids Pulse steroids Sulfasalazine? Clobetasol solution and Rogaine? Intentional/unconscious hair pulling Islands of sparing Hair of different lengths Usually 7-13 yr olds Typically high achievers Can do shave test to differentiate from alopecia areata Red and crusty areas on scalp, usually with associated hair loss unless you see it early on Do fungal culture to diagnose Tell pt and family members to use Nizoral shampoo to help prevent spread from spores (not a treatment, just to prevent spread to other family members) MUST treat with oral antifungals Griseofulvin 20-25 mg/kg/day divided BID for 6 weeks Lamisil 125-250 mg daily for 3 weeks (bad for microsporum) Itraconazole 100-200 mg daily for 3 weeks Griseo and Itra come in a syrup Annular, erythematous, scaly lesion with raised red edge is the hallmark Kids get it from other kids or animals Very common in wrestlers, gymnasts To diagnose: KOH or fungal culture Topical antifungal- ketoconazole, spectazole, terbinafine BID. AAA and one inch around it. Once it resolves, cont treating for 1-2 weeks to ensure eradication Oral antifungal Must be used if steroids have been used previously or if there is evidence of a fungal folliculitis Griseofulvin 10-20 mg/kg divided BID for 3 weeks Terbinafine 125-250 mg daily for 1-2 weeks- doesn’t work great for microsporum species (if family dog is suspected, do not use) Itraconazole 100-200 mg daily for 1-2 weeks More common in kids than adults Typically triggered by a strep infection Ask about family history Patients usually continue to have lifelong problems with psoriasis Topical medicines Clobetasol ointment Dovonex ointment Tazarotene Protopic Scalp solutions- Clobetasol, DermaSmoothe- always recommend a salacylic acid containing shampoo (Neutrogena T Sal, Baker’s P and S) Light therapy Systemic options- Methotrexate, Enbrel Triggered by a virus Lasts up to 8-10 weeks In african americans, it looks more papular…can be tricky to identify Can treat with Erythromycin- varying reports of efficacy Topical steroids will help if it’s itchy but won’t help clear up the rash Very common, tends to run in families, can coexist with asthma/allergies Typical distributions based on the age of the child Very itchy (“the itch that rashes”) Very important to treat- can lead to weight loss, failure to thrive, sleep disturbances (for the whole family) Topical steroids are mainstay- use OINTMENTS so they don’t sting Hydrocortisone 2.5% Triamcinolone 0.1% Fluocinonide 0.05% Clobetasol 0.05% Topical steroid burst Wet dressings Protopic/Elidel are very useful Always emphasize the importance of sensitive skin care (ALL detergent, no fabric soft and dryer sheets, Dove or cetaphil soap) and moisturization (Vaseline or Vanicream) Occasionally light treatment Occasionally systemic meds- Methotrexate, Imuran, Cellcept 2 out of 3 kids grow out of it (somewhat) by age 5 Pretty common Think of it when eczema just not getting better Treat with oral antibiotics I tend to get culture If recurrently problematic, can recommend bleach baths 2-3 times weekly (1/2 cup bleach to one full tub water) Teeny blisters, often on palm or lateral sides of the fingers Pts sometimes have hyperhidrosis too Treat with topical steroids +/- drysol antiperspirant Coin shaped Can look like tinea Typically requires high potency steroidsFluocinonide or even Clobetasol Typically kids age 1-5 yrs old Classically on the ball of the foot, big toe and pinky toe Not eczema and not a fungus Improves with time No real treatment Associated with sensitive skin and eczema More noticeable in the summer because of tanning Goes away on its own Can try Hydrocortisone 2.5% oint BID or Protopic BID if patient really wants treatment Differential diagnosis: Vitiligo- PA is HYPOpigmented, vitiligo is Depigmented Tinea Versicolor- affects the face in kids (unlike in adults). Typically has areas of hypo and hyper pigmentation, tends to have a pink tone with scale, but can be difficult to tell Autoimmune destruction of pigment producing cells- produces DEpigmented patches Can be widespread or segmental Treatment is difficult, but options include: Clobetasol once daily Protopic twice daily Light therapy Excimer laser treatments Typically on trunk of teens and young adults, but frequently on the face of kids KOH can show spaghetti and meatballs appearance to prove it Treatment options Selsun Blue shamp00- leave on 10 minutes in shower Ketoconazole 2% cream BID Ketoconazole 400 mg once (then work out) and repeat in one week Itraconazole 400 mg once Fluconazole 400 mg once Recurrences are common and it takes awhile for pigment to return to normal The target consists of 3 concentric areas of discoloration- the outer red wheal, an area of blanching, and a central red-purpuric macule Almost always the result of a virus (rarely a medicine)either a viral illness or HSV Self limited, but can be uncomfortable esp because of the oral lesions I typically prescribe Prednisone 1-1.5 mg/kg/day for 7 days If triggered by HSV, can be recurrent- can be a reason for suppressive therapy Due to meds- Bactrim, antiseizure meds, PCN antibiotics Evolves rapidly Eyes and mouth tend to start having problems first Skin lesions usually not targetoid. Tend to be vague erythematous macules and patch at first. Then widespread blisters develop Can lead to permanent scarring in eyes, mouth, esophagus, GU system, skin Pts need early hospitalization with IVIG or prednisone Potentially very serious…any baby with clustered blisters on a red base should be hospitalized and started on IV acyclovir First 4 weeks of life, usually in 1st week Fetal scalp monitoring is a risk factor Can cause hepatitis, pneumonitis, meningitis Differential would include bullous impetigo, possibly candida, but HSV is most serious and should be treated while cultures are cooking Presents with red, slightly erosive and crusty rash around mouth and in folds (axilla, groin) Due to a staph (or strep) infection elsewhere- typically oropharyngeal Rash occurs due to a toxin released by the bacteria Patients have a fever, seem sick and have remarkably sensitive skin (almost like they are sunburn…it really hurts if you just touch them) Treat for staph and strep and use vaseline on the skin Only other thing that looks like this is Zinc deficiency Cause is unknown Classically around mouth, around eyes, in crease of nasal ala Consists of small pink papules, pustules, and oftentimes some pink and scaly (dermatitis-like) areas Frequently mistreated with topical steroids and topical steroids make it worse Treatment Elidel 1% cream BID in kids Metrogel 1% gel daily in adults Oral antibiotics- Minocycline, doxycycline if greater than 9 yrs old; azithromycin or amoxicillin if less than 9 yrs old Recurrences are common Interstitial infiltrate of lymphs in the dermis create an annular lesion with a raised, red border without scale Typically occurs on dorsal hands, dorsal feet, ankles Subcutaneous GA is most common in kids and presents as painless subcutaneous nodules typically on the scalp and lower extremities Tends to resolve eventually on its own. High potency steroids, IL steroids, or light therapy can be used. Frustrating for patients and doctors Treatment options are many (because no one treatment is fantastic) Liquid nitrogen- hurts Cantharadin PS- doesn’t hurt, from a blister beetle Soak, Scrape and Tape with 17% Sal Acid and duct tape Squaric Acid contact therapy Candida ag injections Bleomycin Cimetidine (in combo with other txs) Surgery? Aldara? Usually m0re frustrating than common warts Especially common in teenage girls that use tanning beds, often on the legs (shaving is a factor) Treatment options Liquid nitrogen Cantharadin PS Aldara Veregen Retin A Little balls of capillaries, typically thought to occur as result of trauma Best treatment is shave removal with cautery of the base Small lesions can be treated with Aldara MWF at bedtime with relatively good results I favor removing them with path eval because spitz nevi and even melanoma are in the differential diagnosis Dome shaped pink papule Technically benign but their histology and behavior is a bit controversial Used to be called “juvenile melanoma” Treatment is controversial Classically pink-yellow papule Goes away- typically by age 5 If excised, it frequently recurs If just one, no real associations If several, pt should have eye exam Questionable link with neurofibromatosis Very common on the face of children Most go away eventually Can be treated with vascular laser Firm white-blue subcutaneous nodule or plaque Benign cystic lesion that calcifies ½-2/3 go away Only treatment is surgical excision Look like café au lait macules but tend to be slightly raised and slightly more pink Positive darier’s sign Completely benign and will go away Internet can scare parents Avoid mast cell degranulators Autoimmune destruction of a mole producing a depigmented halo Normal in kids, abnormal in adults Associated with vitiligo
