Staying A-’Head’ in Pediatric Dermatology · • Hurwitz Clinical Pediatric Dermatology: A...
Transcript of Staying A-’Head’ in Pediatric Dermatology · • Hurwitz Clinical Pediatric Dermatology: A...
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Staying A-’Head’ in Pediatric Dermatology:
Common Scalp and Hair Diagnoses
Matt Grisham, MD Greenville Health System Post-Graduate Seminar
April 20, 2016
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I have no financial disclosures or conflicts of interest.
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Objectives • Discuss common pediatric dermatologic diagnoses
affecting the scalp and hair • Identify key features on history and exam to help
narrow the differential diagnosis • Generate appropriate therapeutic plans for these
conditions
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• Born at term gestation by C/S without complication
• No maternal
medications or infections
• Prenatal US and quad
screening were both normal
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Cutis Aplasia Congenita • Born at term gestation
by C/S without complication
• No maternal
medications or infections
• Prenatal US and quad
screening were both normal
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Cutis Aplasia Congenita • 80% occur at the vertex
o Can occur on face, trunk, and extremities
• Majority are single lesions
• Healing over weeks to
months, forming a hairless scar
• Larger lesions may warrant plastic surgery
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Trisomy 13 (Patau Syndrome) • Midline cleft palate/lip
• Holoprosencephaly
• Omphalocoele
• Polydactyly
• Cardiac anomalies
• Renal anomalies
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Nevus Sebaceous
Congenital lesion that grows with the child and eventually thickens in adolescence
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Basal Cell Carcinoma
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• Began on the scalp and is now spreading onto
forehead • Using baby shampoo daily without improvement
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Seborrheic Dermatitis • Began on the scalp and is now spreading onto
forehead • Using baby shampoo daily without improvement
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Seborrheic Dermatitis • Occurs in areas with
highest concentration of sebaceous glands
• Controversial fungal etiology
• Self-limiting (8-12 mos) o Mineral/baby oil o Selenium sulfide shampoo o Zinc pyrithione shampoo o Topical steroids o Topical antifungal
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6 Months Later… • Scalp issues have
persisted despite anti-seborrheic shampoo
• Cheeks and chin are now involved
• Loves to eat
• Beginning to teethe
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Atopic Dermatitis
• Commonly affects the infant scalp
• Dry appearance vs. greasy scale
• Predictable involvement of other sites
• Positive family history of atopy
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• Mom worried about a ‘knot’ on the back of his head
• Recent haircut and
noticed this spot as well
• She wants to know if she needs to get rid of the family pet.
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Tinea Capitis • Mom worried about a
‘knot’ on the back of his head
• Recent haircut and
noticed this spot as well
• She wants to know if she needs to get rid of the family pet.
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Tinea Capitis • Black Dots = Fractured
Hair
• Dermatophyte infection o Trichophyton tonsurans o Microsporum canis
• Kerion
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Tinea Capitis
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Tinea Capitis • Black Dots = Fractured
Hair
• Dermatophyte infection o Trichophyton tonsurans o Microsporum canis
• Kerion
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Tinea Capitis Drug Dosage Duration
Griseofulvin microsize (liquid 125 mg/5 mL)
20–25 mg/kg/day ≥6 wk; continue until clinically clear
Griseofulvin ultramicrosize (tablets of varying size)
10–15 mg/kg/day ≥6 wk; continue until clinically clear
Terbinafine tablets (250 mg)
4–6 mg/kg/day 10–20 kg: 62.5 mg 20–40 kg: 125 mg >40 kg: 250 mg
T tonsurans: 2–6 wk M canis: 8–12 wk
Terbinafine granules (125 mg and 187.5 mg)
35 kg: 250 mg
FDA approved for children ≥4 y 6-wk duration for all species
Fluconazole 6 mg/kg/day 3–6 wk FDA approved for children >2 y
http://redbook.solutions.aap.org/drug.aspx?gbosId=171197http://redbook.solutions.aap.org/drug.aspx?gbosId=171197http://redbook.solutions.aap.org/drug.aspx?gbosId=170923http://redbook.solutions.aap.org/drug.aspx?gbosId=170923http://redbook.solutions.aap.org/drug.aspx?gbosId=171188
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Id Reaction • Widespread papular
rash
• Pruritic
• Treatment o Oral antihistamines o Topical corticosteroids
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Traction Alopecia • Hair loss along lines of
tension
• Regional adenopathy is common
• Treatment o Discontinue hairstyling
• Complication
o Traction folliculitis
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Traction Folliculitis
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Late Childhood/Early Adolescence
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• This middle school female is being teased o Now refusing to attend school
• Closer inspection of her scalp reveals…
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Trichotillomania
• This middle school female is being teased o Now refusing to attend school
• Closer inspection of her scalp reveals…
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Trichotillomania • dsafsdf • Association with OCD
and anxiety • Treatment
o Address the underlying psychiatric disorder
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• Appendectomy 3 months ago…
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Telogen Effluvium • Appendectomy 3
months ago…
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Telogen Effluvium • Diffuse thinning of the hair seen 6-16 weeks after
a stressful event o Thyroid disorders o SLE o Fe-deficiency anemia o Oral contraceptives
• Treatment: address any underlying cause + time
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• Single patch of hair loss over the last few days
• No recent stressful events or prior tinea infections
• Never noted scaling, pustules
• Anxious because dad is bald
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• Single patch of hair loss over the last few days
• No recent stressful events or prior tinea infections
• Never noted scaling, pustules
• Anxious because dad is bald
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Alopecia Areata • Single patch of hair loss over
the last few days
• No recent stressful events or prior tinea infections
• Never noted scaling, pustules
• Anxious because dad is bald
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Alopecia Areata • New patches of hair loss
may appear for 4-6 weeks (or months) o Alopecia universalis
• Scotch-plaid nails
• Treatment o Topical steroids (Class I/II) o Intralesional steroid injections o Anthralin 1% cream o 2% minoxidil solution o Psychological support
• Complete resolution in 95% within one year if mildly affected o 30% experience relapse
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Dandruff that is not improving with selenium sulfide or pyrithione zinc shampoo
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Psoriasis
Dandruff that is not improving with selenium sulfide or pyrithione zinc shampoo
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Psoriasis
Auspitz sign
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Psoriasis • Knees and elbows
commonly affected
• Positive family history
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Scalp Psoriasis: Management • Topical corticosteroids
o Fluocinolone 0.01% in peanut oil base
• Shampoo options o Coar-tar based o Zinc-based o Keratinolytic
• Look for an occult Streptococcus pyogenes
infection • Avoid vigorous brushing, combing, scratching of the
scalp
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Pediatric Dermatology Resources
• Hurwitz Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence by Paller and Mancini (~$185)
• Atlas of Pediatric Physical Diagnosis by Zitelli and
Davis (~$90)
• Pediatric Dermatology: A Quick Reference Guide by Krowchuk and Mancini (~$90 – new edition coming in May 2016)
• VisualDx (online and app format- iOS and Android)
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Thank you for your time and attention.
Any Questions?
Staying A-’Head’ in Pediatric Dermatology:�Common Scalp and Hair DiagnosesSlide Number 2ObjectivesSlide Number 4Slide Number 5Cutis Aplasia CongenitaCutis Aplasia CongenitaTrisomy 13 (Patau Syndrome)Nevus SebaceousBasal Cell CarcinomaSlide Number 11Slide Number 12Seborrheic DermatitisSeborrheic Dermatitis6 Months Later…Atopic DermatitisSlide Number 17Slide Number 18Tinea CapitisTinea CapitisTinea CapitisTinea CapitisTinea Capitis Id ReactionTraction AlopeciaTraction FolliculitisLate Childhood/Early AdolescenceSlide Number 28TrichotillomaniaTrichotillomaniaSlide Number 31Telogen EffluviumTelogen EffluviumSlide Number 34Slide Number 35Slide Number 36Alopecia AreataAlopecia AreataSlide Number 39PsoriasisPsoriasisPsoriasisScalp Psoriasis: ManagementPediatric Dermatology ResourcesThank you for your time and attention.