Pediatric Dermatology Updates & Common Curbsides

EMILY CROCE, MSN, APRN, CPNP-PC, PHD STUDENT PEDIATRIC & ADOLESCENT DERMATOLOGY DELL CHILDREN’S MEDICAL CENTER, AUSTIN, TEXAS THE UNIVERSITY OF TEXAS AT AUSTIN No relevant conflict of interest

DISCLOSURES: Some off-label discussion, but commonly used indications Case 1: 5 y/o male with few month hx molluscum contagiosum. In the last week they have become red, tender, and “angry.” Do we:

A. Begin mupirocin B. Begin oral antibiotic with staph coverage C. I&D D. Reassurance B.O.T.E. Sign

 Beginning of the end  Inflammation is a sign that there is an immune response and, often, impending resolution  Comfort measures such as warm compresses  Discuss signs infection and reasons to return  Reassurance Warts & Molluscum Update:

 No definitive therapy…nothing new about this!  Tretinoin or OTC Differin gel may be useful every 1-2 nights  Wart Stick - strongest OTC salicylic acid product  Efudex every 2 nights x 12 wks  Compounded topical such as Wart Peel  Cimetidine 2—40 mg/kg/day x 2-3 months (or longer if helping)  Molluscum dermatitis – treat like eczema  Liquid nitrogen, cantharidin, candida antigen injections all still work…but only about 40% of the time Case 2: Parents of 2 y/o female with atopic dermatitis are worried about steroid s/e and black box warning on topical calcineurin inhibitors, but Eucrisa is not helping and patient is miserable. How we will treat and reassure:

A. Steroid s/e and how to use B. Topical calcineurin inhibitor discussion C. To Eucrisa or not to Eucrisa D. Reinforce skin care routine How we will treat and reassure:

A. Steroid s/e and how to use B. Topical calcineurin inhibitor discussion C. To Eucrisa or not to Eucrisa D. Reinforce skin care routine Topical Steroid Potency Chart

• Low potency for face • Medium to high for extremities/torso depending on thickness of plaques, response to steroids, age • BID x 1-2 wks for flare then 2-3x/wk when needed on “hot spots” to maintain Topical steroid safety profile:

 Tacrolimus (Protopic) & Pimecrolimus (Elidel)

 Black box warning: animals in trials developed lymphomas

 PEER – long-term Pimecrolimus registry has not documented increased risk malignancy in normal topical use in children

 Crisabarole (Eucrisa)

 Benefits: do not cause atrophy, okay on thin-skinned areas, good for maintenance, Eucrisa approved to 3 mos, Protopic/Elidel approved to 2 yrs (but studied down to 3 mos)

 Cons: $$$, insurance coverage Topical calcineurin inhibitors & Eucrisa:

 Tacrolimus (Protopic) & Pimecrolimus (Elidel)

 Black box warning: animals in trials developed lymphomas

 PEER – long-term Pimecrolimus registry has not documented increased risk malignancy in normal topical use in children

 Crisabarole (Eucrisa)

 Benefits: do not cause atrophy, okay on thin-skinned areas, good for maintenance, Eucrisa approved to 3 mos, Protopic/Elidel approved to 2 yrs (but studied down to 3 mos)

 Cons: $$$, insurance coverage Case 3: 7 y/o male with few month hx scaly plaques and hair loss on scalp. No significant medical history, topical terbinafine is not helping. Tinea capitis treatment tips:

 Palpate for lymph nodes  Culture (but probably okay to start treatment) to confirm dx and determine microsporum vs trichophyton  Affected family members and fomites should be addressed  Griseofulvin or terbinafine…but give enough med for long enough duration! 20 mg/kg/day x 6-8 wks griseofulvin or weight-based dosing terbinafine po x 4-6 wks  Risk is low in otherwise healthy child, labs studies not indicated unless prolonged course  If kerion, may need oral antibiotic and or oral/topical steroid Case 4: 14 y/o female with few year hx acne on face and back. No improvement with OTC products or rx benzoyl peroxide-clindamycin gel Acne plan of attack:

 Type

 Comedonal needs a retinoid

 Inflammatory probably needs benzoyl peroxide +/- antibiotic

 Most need both!  Distribution

 Chest/back may require wash and/or PO

 Beard distribution in girls – ask about menstrual hx, consider PCOS  Severity  Scarring

 Response to therapy  Impact on patient

 Cost  Complexity of treatment regimen Acne treatment:

 Topical retinoid  Tretinoin, adapalene, tazorac

 Start slow, advance as tolerated, moisturize, educate  Topical antibiotic and/or antimicrobial

 Clindamycin  Benzoyl peroxide  Combo clinda/bpo  Oral antibiotic

 Doxycycline  minocycline  Isotretinoin (Accutane)  OCP, spironolactone  Clascoterone

Case 5: 6 wk old male with small red papules on back and arm. Started to appear around 2 weeks of age. Baby is otherwise healthy. What is your workup, if any? Hemangiomas:

 Benign vascular growths with some potential complications

 Cosmetic

 Glabella, eyelid, nose, lip, areola genitalia

 Ulceration

 Especially if friction such as diaper area, axilla or fast growing

 Syndromic or signifying underlying issues

 Superficial & plaque-like on face, midline spine, beard distribution

 5+ hemangiomas = hemangiomatosis, obtain liver u/s early

 Functional

 If in doubt, refer early to dermatology Case 6: 9 month-old male with itchy red papules and nodules scattered on torso and extremities, concentrated on axillae. He has been treated x 1 with permethrin without improvement. No affected family members. Scabies:

 The main reason we see treatment failure in our clinic is inadequate treatment of household members and close contacts.

 All household members must be treated, even if they are not symptomatic

 Ask, ask, ask again if they all treated

 Standard of care is permethrin 5% cream applied (neck down if over 1 year or head to toes if under 1 year) at bedtime, rinse in morning, repeat in 14 days

 The itch may persist for up to a month due to hypersensitivity but new burrows/pustules should not be appearing after 2nd treatment

 Consider PO ivermectin for difficult cases or crusted scabies References BUTALA, N., SIEGFRIED, E., & WEISSLER, A. (2013). MOLLUSCUM BOTE SIGN: A PREDICTOR OF IMMINENT RESOLUTION. PEDIATRICS, 131(5), E1650-E1653; DOI: 10.1542/PEDS.2012-2933 DIAMANTIS, S. A., MORRELL, D. S., & BURKHART, C. N. (2009). PEDIATRIC INFESTATIONS. PEDIATRIC ANNALS, 38(6), 326–332. HTTPS://DOI-ORG.EZPROXY.LIB.UTEXAS.EDU/10.3928/00904481-20090521-05 EICHENFIELD, L. ET AL. (2013). EVIDENCE-BASED RECOMMENDATIONS FOR THE DIAGNOSIS AND TREATMENT OF PEDIATRIC ACNE. PEDIATRICS, 131(SUPPL3), S163-S186. MARGOLIS, D. J., ABUABARA, K., HOFFSTAD, O. J., WAN, J., RAIMONDO, D., & BILKER, W. B. (2015). ASSOCIATION BETWEEN MALIGNANCY AND TOPICAL USE OF PIMECROLIMUS. JAMA DERMATOLOGY, 151(6), 594–599. HTTPS://DOI-ORG.EZPROXY.LIB.UTEXAS.EDU/10.1001/JAMADERMATOL.2014.4305 PAPIER, A., & STROWD, L. C. (2018). ATOPIC DERMATITIS: A REVIEW OF TOPICAL NONSTEROID THERAPY. DRUGS IN CONTEXT, 7, 212521. HTTPS://DOI-ORG.EZPROXY.LIB.UTEXAS.EDU/10.7573/DIC.212521 SIEGFRIED, E. C., JAWORSKI, J. C., KAISER, J. D., & HEBERT, A. A. (2016). SYSTEMATIC REVIEW OF PUBLISHED TRIALS: LONG-TERM SAFETY OF TOPICAL CORTICOSTEROIDS AND TOPICAL CALCINEURIN INHIBITORS IN PEDIATRIC PATIENTS WITH ATOPIC DERMATITIS. BMC PEDIATRICS, 16, 75. HTTPS://DOI-ORG.EZPROXY.LIB.UTEXAS.EDU/10.1186/S12887-016- 0607-9 SMITH, C., FRIEDLANDER, S. F., GUMA, M., KAVANAUGH, A., & CHAMBERS, C. D. (2017). INFANTILE HEMANGIOMAS: AN UPDATED REVIEW ON RISK FACTORS, PATHOGENESIS, AND TREATMENT. BIRTH DEFECTS RESEARCH, 109(11), 809– 815. HTTPS://DOI-ORG.EZPROXY.LIB.UTEXAS.EDU/10.1002/BDR2.1023