Pediatric Dermatology~ A

Primary Care Approach

Terri Nagy, MPAS, PA-C

tnagy@dermatologypartners.com

Topics

Rashes Viruses Acne

Eczema

Chronic contact dermatitis

7,450,560

Atopic

dermatitis

2,912,597*

Chronic

contact

unspecified

dermatitis

6,441,403*

Chronic

allergic

dermatitis

487,000*

Chronic

irritant

dermatitis

27,000*

Acute

allergic

dermatitis

1,790,000*

*Source: PDDA, patients diagnosed and treated.

Eczema: A Prevalent Condition

Irritant Dermatitis

Phyto-photo

Dermatitis

Contact Dermatitis

Margarita Dermatitis

Allergic Contact

Dermatitis

Hand Dermatitis

•Contact/irritant

•Allergen

Allergic Contact Dermatitis25 chemicals responsible for half of all cases

• Poison Ivy (Toxicodendron

radicans)

• Nickel

• Rubber gloves

• Hair Dye and temporary tattoos

• (p-Phenylenediamine)

• Textiles

• Preservatives

• Fragrances

• Corticosteroids

• Neomycin

• Benzocaine

American Contact Dermatitis Allergen of the

Year

Bacitracin

2003

Cocamidopropylbetaine

2004

Corticosteroids

2005

Paraphenylenediamine

2006

Fragrance

2007

Nickel

2008

Mixed Dialkylthiourea

2009

Neomycin

2010

Dimethyl fumarate

2011

Acrylate

2012

Methylisothiazolinone

2013

Benzophenones

2014

Formaldehyde

2015

Cobalt

2016

2018 Allergen of the

Year

• Skin Products/cosmetics

• Coated pills

• Topical corticosteroids

• Food coloring/vanilla extract/bread

• Topical acne meds

• Brake fluid

• Nontoxic antifreeze

Propylene glycol

Atopic Dermatitis

‘Eczema’ Treatment

Avoid irritants/allergens/causative agents

Moisturize – to restore barrier

Topical steroids?

Oral steroids?

Moisturize!

1

CeraVe

2

Cetaphil

3

New Products•Cetaphil Pro Gentle

•Aveeno Eczema Balm

•Eucerin Eczema Relief

•CeraVe Therapeutic Hand Cream

First line therapy

Topical corticosteroids

• Potency

• Site

• Frequency of application

• Duration of therapy

• Risk vs benefit

• Age of patient

• Vehicle

Things to consider:

TOPICAL STEROIDS

The Chosen

Ones:

Topical

Steroids

• Desoximetasone cream/ointment (Topicort)

• Class 3/2

• Clocortolone pivalate cream (Cloderm)

• Class 5

Class C

• Fluocinolone topical (Derma- Smoothescalp and body oil)

• Desonide (Desonate)

• Both Class 6

Class B

Special Circumstances

www.expertcosultbook.com

PO steroids(based on weight/age)

• 1-2 mg/kg PO div BID X 5 days

Prelone 15/5

• 20 mg QD – BID X 5 days

Prednisone

Antibiotics

• 25-50 mg/kg/day div Q 12 hours X 7-10 days

Cephalexin 125/5; 250/5

• 8-10 mg/kg/day div Q 12 hours X 7-10 days

Septra DS

• 1 tablet bid X 10 days• (8 years and older)

Doxycycline 100 mg

Sometimes – treating the ‘itch’ helps….

Cetirizine (Zyrtec) SyrupFexofenadine (Allegra)

Liquid/MeltableTablets/Tablets

Loratadine (Claritin) Syrup/Chewables/

Reditabs

But only for contact/allergic/irritant

AAD recommendations for AD

• Non sedating antihistamines have shown no benefit

• Sedating are beneficial, but only as adjuncts to topical therapy/an aid for insomnia due to pruritus

• Hydroxyzine

• Diphenhydramine

• Chlorpheniramine

Treatment Rule:

2 week treatment regimens

If not better – re-evaluate!

Diagnosis

• Anyone itching should be suspect

• Scabies: Scrape with mineral oil and #15 blade

• Finger webs, wrists, axillae, nipples, penis, ankles

• Lice: Look behind the ears; hair line

• Treat entire area and counsel patient ad nauseum

• Treat ENTIRE household / ALL contacts

Scabies

• Permethrin (Elimite)

• PO Ivermectin .2mg/kg PO X1 –

can repeat in 2 wks

• 15 kg (33 lbs)

Lice

• New Products

• Spinosad (Natroba): >4 yrs – wash

off in 10 mins; repeat in one week

• Ivermectin topical (Sklice): > 6

months – wash off in 10 mins

Treatment

Cetaphil

Gentle

Cleanser?(no age restrictions)

Use 8 ounce bottleUse

Apply to dry hair; massage into scalpApply

Comb out excessComb

Dry with hairdryer – completelyDry

Leave in overnight/8 hoursOvernight

Shampoo out in morningShampoo

Repeat in 7 days if neededRepeat

www.medicinenet.com

Tinea

Tinea

• Dermatophyte infection

• Trychophyton

• Person to person contact

• Scaly

• Expanding

• Alopecia with tinea capitus

www.medicinenet.com

Treatment

• Ketoconazole 2% shampoo - daily

• Topical Ciclopirox – BID till clear plus 1 week

• Capitus - Griseofulvin 20-25 mg/kg/day for 6-8

weeks

• AVOID Lotrisone

Lotrisone

John Bielinski “It covers everything!”

Betamethasone .05% crm

• Steroid

• Class 1 and 2

Clotrimazole 1% crm

• “Ok” antifungal

• Better on Candida

http://dermimages.med.jhmi.edu/images/tinea_incognito_1_050103.jpg

http://dermimages.med.jhmi.edu/images/tinea_incognito_1_080902.jpg

Tinea

Incognito

Tinea corporis whose appearance has been modified by the application of high-potency topical steroids in a way that renders it no longer visually diagnostic.

Tinea incognito usually presents as nonspecific inflammatory papules and pustules without the characteristic features of tinea. In some cases, however, tinea incognito may retain the scaly appearance of tinea but be modified by local steroids so that it becomes extensive and bizarrely shaped.

The condition was first described and so named in 1968 by FA Ive and R Marks (in the British Medical Journal vol. 3, pages 149-52). It is, literally, tinea in disguise, tinea veiled by treatment.

• BMJ. 1993 September 11; 307(6905): 645–647.

• PMCID: PMC1679014

•

E G Evans, B Dodman, D M Williamson, G J Brown, and R G

Bowen

Department of Microbiology, University of Leeds and General

Infirmary.

Comparison of terbinafine

and clotrimazole in treating tinea pedis.

Conclusion

These results indicate that a one week course of terbinafine 1% cream

(Lamisil) is more effective in the treatment of tinea pedis than a four

week course of clotrimazole 1% cream (Lotrimin), both in terms of

mycological cure and effective treatment.

Quality of Dermatologic Care

Delivered by Physician Assistants:

An Analysis of Prescribing Behavior

for the Combination Antifungal Agent

Clotrimazole-Betamethasone

ARCH DERMATOL/VOL 143 (NO. 12), DEC 2007

Anita Satyaprakash, BS Rajesh Balkrishnan, PhD Fabian T. Camacho, MS

Sujata S. Jayawant, MS Alan B. Fleischer Jr, MD Steven R. Feldman, MD, PhD

Tinea Versicolor

Tinea Versicolor

Hypo or Hyper pigmented patches

and macules on chest, back, neck,

abdomen…..

Malassezia furfur

Treatment

Ketoconazole 2% shampoo as a body wash

• AND

Topical Ciclopirox gel/cream BID till clear plus 1 week

Can consider Diflucan…but with caution

• 7% of candida isolates are resistant

• 46,000 infections yearly

• 3400 resistant infections

• 220 deaths• http://www.cdc.gov/drugresistance/threat-report-2013/

Fluconazole – CDC Threat Report

Diflucan 150/200 mg(adolescents and older)

Take two tablets; wait one hour

Work out to the point of sweating

Repeat in one week

Viruses

Molluscum Contagiosum

What do we know about viruses?

Contagious

Require an immune response for resolution to

occur

www.webmd.com

Pox Virus

Dome

shaped

Umbilicated

Treatment??

American Academy of Pediatrics

• Retinoids – Tazarotene gel

• LN2

• EMLA and curettage

• Aldara (Imiquimod)

• Cantharidin (beetle juice)

Goal: stimulate immune response

“BOTE” sign

Warts

Warts

Human Papilloma Virus

• At least 100 different strains

• Probably more

Treatment

• Cryosurgery

• Laser

• Vit C/Zinc

• Topicals

• Antigen injections

Herpes Labialis

Grouped vesicles on an

erythematous base

HSV

• 90% of individuals worldwide have either HSV 1 or 2 or both

• US: approx 50% under 50 years of age have HSV 1 – cold sores

• 1 in 6 under 50 years of age have HSV 2 (approx. 16%) - genital

HSV – 8 different types

• HSV 1

• Cold sores

• HSV 2

• Genital herpes

• HSV 3

• Varicella-zoster

• HSV 4

• Epstein Barr

• Mono

• HSV 5

• Cytomegalovirus

• Mono

• HSV 6

• Roseola

• HSV 7

• Roseola

• HSV 8

• Kaposi Sarcoma

Aphthous

Ulcers

HSV 6

Recurrent and Persistent Pityriasis Rosea

HSV 6 & 7

HSV and….

• Erythema multiforme minor – recurrent

• Most commonly HSV 1

• Proceeds skin eruption by 3-14 days

• Mycoplasma pneumonia is the next most common trigger

Target lesion

Purpuric macule or urticarial plaque

Maximum of 2cm

HSV Labialis Treatment

• Resistance is developing to Acyclovir….

• Especially among HIV and transplant patients

• 2-11 years: 75mg/kg/day divided 5X daily 5-7 days

• 12 years: 1000mg/day divided 5X daily 5-7 days

• Valacyclovir 2000 mg q12hr X 1 day at onset

• 12 years and older

• Famcyclovir 1500 mg X1 at onset

• 12 years and older

• Sitavig 50mg buccal tab

• 18 years and older

• Apply within 1 hr of onset

• 6 hr application

Acne

www.acneonlineinfo.net

Components…

Hormones

Sticky oil

Dead skin

Bacteria

• normal skin flora

Inflammation

Treatment…

Retinoids – KEY TO THERAPY

• we’ll talk about this

PO antibiotics

BPO cleansers/combinations

BCP

Isotretinoin

Retinoids and

analogues

Act on retinoid receptors

Tretinoin, Adapalene, Tazarotene

Important for inflammatory and non-inflammatory acne

Nightly application ~ photoinactivation

Benzoyl peroxide inactivated by tretinoin

Tretinoin

• Tretinoin .025%/.05%/.1%

• RetinA Micro

.04%/.08%/.1%

• Atralin .05% gel

• Ziana/Veltin ( tretinoin .025%

gel/clindamycin gel 1.2%)

Adapalene

• Adapalene .1% cream/gel/lotion

• Differin .3% gel (adapalene .3%)

• Epiduo (adapalene .1% gel/benzoyl peroxide

2.5%)

• Epiduo Forte (adapalene .3% gel/benzoyl

peroxide 2.5%)

Tazarotene

• Tazorac .05% cream/gel

• Tazorac .1% cream/gel

• Fabior .1% foam

• Maybe…soon a wash/combo?

New Study

• 40% of acne patients have scars

• Can occur with any level of acne

• Topical Adapalene and Tazarotene

• Increase dermal collagen

• As effective as micro-needling for prevention and treatment of scars

PO

Antibiotics

Doxycycline 100 mg QD WITH FOOD

• Pseudotumor cerebri

TMP-SMX DS 1 PO BID X 1 month then QD X 1 month

• Stevens Johnson Syndrome/TEN

Doxycycline 40 mg (Oracea) 1 PO QD

• Currently: not FDA approved for acne

New PO acne antibiotics

Tetracycline: Seysara

Minocycline: Ximino; Minolira

BPO

Cleansers

Neutrogenia Clear Pore

Acne Free

Oxy 5Proactive

BenzeFoam Ultra (BenzePro)

Topical

AntibioticsErythromycin Clindamycin

Since 1997…

Topical Antibiotic combos

• Clindamycin/BPO

combinations

• Duac

• Benzeclin

• Acanya

• Onexton

BCP

Ortho Tri-Cyclen

Estrostep

Controversial due to potential increase in blood clots

Recently – papilledema/hepatoxicity YAZ

Spironolactone

Off label

PI – check labs

25 – 50 mg BID

Teratogenic

IsotretinoinAccutane

www.accutanesideeffects.net

Acne

Inflammatory

• Apoptosis of oil glands

• Anti-inflammatory

• Anti- bacterial

• 60-80% cure rate

• Highly regulated by FDA

• Ipledge program

Isotretinoin

Isotretinoin

• Like hundreds of meds, it is not safe for use in pregnancy

• Gained FDA approval in 1982 under brand name Accutane

• Warnings include: IBD, birth defects, depression/suicidal ideation

• Clear and open communication is key

• Monthly visits are REQUIRED

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