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Dermatologic Nuances in Children with Skin of Color

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Dermatologic Nuances in Children with Skin of Color 5/21/2019 Dermatologic Nuances in Children with Skin of Color Candrice R. Heath, MD, FAAP, FAAD Director, Pediatric Dermatology LKSOM Temple University @DrCandriceHeath Advisory Board – Pfizer, Regeneron-Sanofi Consultant –Marketing – Unilever, Proctor & Gamble Speaker’s Bureau - Pfizer I do not intend to discuss on-FDA approved or investigational use of products in my presentation. • Recognize common hair, scalp and skin disorders that may present differently in children with skin of color • Select appropriate treatment options based upon common cultural preferences to increase adherence • Establish treatment algorithm for challenging cases 1 5/21/2019 • 2050 : Over half of the United States population will be people of color • 2050 : 1 in 3 US residents will be Hispanic • 2023 : Over half of the children in the US will be people of color • Focuses on ethnic and racial groups who have – similar skin characteristics – similar skin diseases – similar reaction patterns to those skin diseases Taylor SC et al. (2016) Defining Skin of Color. In Taylor & Kelly’s Dermatology for Skin of Color. 2016 Type I always burns, never tans (palest) Type II usually burns, tans minimally Type III sometimes mild burn, tans uniformly Type IV burns minimally, always tans well (moderate brown) Type V very rarely burns, tans very easily (dark brown) Type VI Never burns (deeply pigmented dark brown to darkest brown) 2 5/21/2019 • Black • Asian • Hispanic • Other Not so fast… • Darker skin hues • The term “race” is faulty – Race may not equal biological or genetic inheritance – There is not one gene or characteristic that separates every person of one race from another Taylor SC et al. (2016) Defining Skin of Color. In Taylor & Kelly’s Dermatology for Skin of Color. 2016 RACIAL GROUPS Black African-American, Afro-Caribbean/African Caribbean, African Hispanic/Latino Black or White Asian East: Han Chinese, Korean, Japanese South: Indian, Pakastani, Bangladesh, Sri Lankan Southeast: Thai, Cambodian, Vietnamese, Loatians Pacific Islanders / Native Hawaiians American Indian / Alaska Native White 3 5/21/2019 Caucasian descent African descent Asian Descent Stratum Corneum Same Same ? Thickness Stratum Corneum Less More Less Layers Concentrations of High Low High Ceramides Melanin Low High Intermediate Number of Same Same Same Melanocytes Melanosomes Small, aggregated Large, dispersed Mixed Dermis Thin, less compact Thick, compact Fibroblasts Few Large, numerous Superficial Blood Sparse to Numerous, mainly Vessels Moderate dilated Remove current style (30 min – 3 hrs depending on style) Wash Condition Detangle (15 min with large tooth comb) Rinse leave-in-conditionerDetangle (1 hr)Style (1-3+ hrs) 4 5/21/2019 Same Disease – 4 presentations Variety of Clinical Presentations Diffuse Scale Annular plaques of scale Black Dot Inflammatory Tinea Capitis Tinea • Seborrheic dermatitis-like variant – Addition of oil or grease to the scalp to camouflage Photo Courtesy Dr. B.Cohen • Applications of oils, grease, braids, ponytails, natural hair – Does NOT increase rate of tinea capitis – If oil/grease applied within 1 week of culture, may produce false negative result Sharma V et al. Arch Ped Adolesc Med. 2001 5 5/21/2019 • Tinea Corporis – thighs or arms – child sitting on the floor in front of adult for hair styling Differential Diagnosis for the pediatric scaly scalp • Tinea Capitis • Seborrheic Dermatitis • Atopic Dermatitis Photo Courtesy Dr. S. Taylor • Psoriasis • Sebopsoriasis Coley MK et al. J Drugs Dermatol. 2011 Silverberg NB. Cutis. 2015 6 5/21/2019 • 100 consecutive children (98 Black) – Scalp alopecia, scaling, pruritus, occipital lymphadenopathy • 68 had positive fungal cultures – 55 had alopecia and occipital LAD = 100% positive culture – 60/62 with scaling and occipital LAD = 96.7% positive culture Hubbard TW. The predictive value of symptoms in diagnosing childhood tinea capitis. Arch Pediatr Adolesc Med 1999 • Options: – Check the griseofulvin dose – Extend the course of griseofulvin – Review optimal foods to give • griseofulvin with fatty foods – Divide the dosing – Change the drug (terbinafine) Photo Courtesy Dr. B.Cohen – Check the siblings – Re-check the culture result (t. tonsurans vs. m. canis) • Check griseofulvin dosing (approved for kids over 2 years old) – Epocrates: give for “4-6 weeks” • Microsize (500mg tab or 125mg/5mL) 10-20mg/kg/day • Ultramicrosize (125mg or 250mg tab) 5-15mg/kg/day – Pediatric Red Book: “greater than 6 weeks until clear” • Microsize (125mg/5mL) 20-25mg/kg/day • Ultramicrosize 10-15 mg/kg/day – Peds Derms use microsize dose of 20-25mg/kg/day x 8-12 weeks Griseofulvin. (2016). In Epocrates Plus Apple iOS (Version 16.4) [Mobile application software]. Retrieved from http://www.epocrates.com/mobile/iphone/essentials. Tinea capitis (2015) in David Kimberlin, Red Book. American Academy of Pediatrics. Kakourou T, Uksal U. Guidelines for the management of tinea capitis in children. Pediatric Dermatology. 2010;27:226-228. 7 5/21/2019 • Re-check positive fungal culture report – Terbinafine is very efficacious for t. tonsurans (Most common culprit in United States) • Approved for kids 2+ years (onychomycosis) • Approved for kids 4+ years (tinea capitis) Dose -2-4 weeks for trichophyton 10-20 kg : 62.5 mg/day -8-12 weeks for microsporum 20-40 kg: 125 mg/day >40 kg: 250mg/day – Griseofulvin still first line for M. canis Gupta AK. Drummond-Main C. Meta-Analysis of Randomized, Controlled Trials Comparing Particular Doses of Griseofulvin and Terbinafine for the Treatment of Tinea Capitis. Pediatr Dermatol 2013;30:1-6. Chen X, Jiang X, Yang M, González U Lin X, Hua X, Xue S, Zhang M Bennett C. Systemic antifungal therapy for tinea capitis in children. Cochrane Database Syst Rev. 2016 • It’s a kerion! • Inflammatory tinea capitis • Oral antifungal plus oral prednisone/prednisolone Photo Courtesy Dr. B.Cohen • Kerion may lead to scalp scarring • M. canis Heath CR et al. Pediatric Dermatology in Skin of Color. AP Kelly and SC Taylor (Ed.), Dermatology in Skin of Color Textbook 2nd edition Columbus, OH. McGraw-Hill. 2016. Chen X et al. Systemic antifungal therapy for tinea capitis in children. Cochrane Database Syst Rev. 2016 • Antifungal shampoos – May help with household spread – decrease transmissible fungal spores • Conditioners – May help with household spread – Household should use it as well • Watch out for hair dryness breakage Greer DL. Successful treatment of tinea capitis with 2% ketoconazole shampoo. Int J Dermatol 2000; 39:302-304. Sharma V et al. Do hair care practices affect the acquisition of tinea capitis? A case-control study. Arch Pediatric Adolesc Med. 2001;155:818-821. 8 5/21/2019 Parent may apply antifungal shampoo directly to scalp wait 5-10 minutes rinse shampoo scalp & hair with moisturizing shampoo condition with moisturizing conditioner • Toss the grease jar • Barrettes, Combs, hair accessories – Soapy water – Dishwasher 9 5/21/2019 Photo Courtesy B. Cohen • All hair loss in Black children should not only be attributed to tinea infection or traction alopecia from tight hairstyles Traction Alopecia Alopecia Areata at risk for Traction Alopecia Photo Courtesy Dr. S. Taylor 10 5/21/2019 • Very common • May be preceded by bacterial folliculitis when hairs pulled tightly – Pustules at the areas of tension – Point it out to parents – What if the child in the room is not your patient? • Compliment, then correct. • “save edges” • Limit hair pulling and tight styles Kids may not dictate hairstyles, but they do yell OUCH!! Haskin A, Aguh C. All hairstyles are not created equal: What the dermatologist needs to know about black hairstyling practices and the risk of traction alopecia (TA). J Am Acad Dermatol. 2016 Apr 21. “No matter what I do, her hair just will NOT grow” Hair extensions grasping “catching” short, dry hair 11 5/21/2019 • Hair is likely breaking off faster than it is growing Lewallen et al. Hair care practices and structural evaluation of scalp and hair shaft parameters in African American and Caucasian women. Journal of Cosmetic Dermatology.2015;14:216-223. • Guidance provided: – Limit traction – Moisturizing shampoo and Conditioner – Time – Avoid traction, extensions – I have not seen a middle school aged child with this complaint that was un-related to another cause – Typically, these patients are toddlers, pre-schoolers, or rarely school aged children • I have given examples to refute, biologically, why this is probably not an accurate observation….. But sometimes, the parent IS RIGHT. 12 5/21/2019 • Monilethrix • Loose Anagen Syndrome • Beaded hair, autosomal dominant • Classically: blonde-haired, blue-eyed girls, few haircuts as a child • KRT81 and KRT86 mutations • “rumpled sock” = ruffled cuticle Agi et al. A case of Loose Anagen Syndrome in an African American Girl. Pediatric Dermatol. 2015; 32. Bindurani S et al. Monilethrix with variable expressivity. 2013; 5: 53-55.Photo Arif T et al. Monilethrix Case Report of a Rare Disease . Our Dermatology Online 2015. Photo • Our natural hair revolution today is saving the hair follicles of tomorrow 13 5/21/2019 • 2 year old with a very itchy rash on the hands and feet • No one else at home is itching What are your immediate thoughts? -could this be scabies? -treat entire household for scabies 2 months post treatment, the rash is STILL there, now what? Acropustulosis of Infancy Most common in Black males . Infancy to 2 years old Primarily affects palms and soles Lesions . Very pruritic . 1mm – 2mm microvesicles and micropustules 14 5/21/2019 AcropustulosisAcropustulosis
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