Pediatric Dermatology~ A Primary Care Approach

Terri Nagy, MPAS, PA-C [email protected] Topics

Rashes Viruses Acne Eczema: A Prevalent Condition Eczema Atopic Chronic Chronic Chronic Acute dermatitis contact irritant allergic allergic 2,912,597* unspecified dermatitis dermatitis dermatitis dermatitis 27,000* 487,000* 1,790,000* 6,441,403*

Chronic contact dermatitis 7,450,560

*Source: PDDA, patients diagnosed and treated. Irritant Dermatitis Phyto-photo Dermatitis

Contact Dermatitis Margarita Dermatitis Allergic Contact Dermatitis Hand Dermatitis

•Contact/irritant •Allergen Allergic Contact Dermatitis 25 chemicals responsible for half of all cases

• Poison Ivy (Toxicodendron • Preservatives radicans) • Fragrances • Nickel • • Rubber gloves • Neomycin • Hair Dye and temporary tattoos • Benzocaine • (p-Phenylenediamine) • Textiles 2003 2005 2007 2009 2011 2013 2015

Corticosteroids Fragrance Mixed Dimethyl fumarate Methylisothiazolin Formaldehyde Bacitracin Dialkylthiourea one

Cocamidopropyl Paraphenylenediami Nickel betaine ne Neomycin Acrylate Benzophenones Cobalt 2004 2006 2008 2010 2012 2014 2016

American Contact Dermatitis Allergen of the Year • Skin Products/cosmetics 2018 Allergen of the Year • Coated pills • Topical corticosteroids Propylene glycol • Food coloring/vanilla extract/bread • Topical acne meds • Brake fluid • Nontoxic antifreeze Atopic Dermatitis

‘Eczema’ Treatment

Avoid irritants/allergens/causative agents Moisturize – to restore barrier Topical ? Oral steroids? 1 2 3 Moisturize! CeraVe Cetaphil New Products •Cetaphil Pro Gentle •Aveeno Eczema Balm •Eucerin Eczema Relief •CeraVe Therapeutic Hand Cream First line therapy

Topical corticosteroids

Things to consider: • Potency • Site • Frequency of application • Duration of therapy • Risk vs benefit • Age of patient • Vehicle

TOPICAL STEROIDS Class C

• cream/ointment The Chosen (Topicort) • Class 3/2 Ones: • pivalate cream (Cloderm) • Class 5 Topical Steroids Class B • topical (Derma- Smoothe scalp and body oil) • (Desonate) • Both Class 6

Special Circumstances www.expertcosultbook.com Prelone 15/5

• 1-2 mg/kg PO div BID X PO steroids 5 days (based on weight/age)

• 20 mg QD – BID X 5 days Cephalexin 125/5; 250/5

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

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

Doxycycline 100 mg

• 1 tablet bid X 10 days • (8 years and older) Sometimes – treating the ‘itch’ helps….

Fexofenadine (Allegra) Loratadine (Claritin) Cetirizine (Zyrtec) Syrup Liquid/Meltable Syrup/Chewables/ Tablets/Tablets 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 Treatment

Scabies Lice • Permethrin (Elimite) • New Products • PO Ivermectin .2mg/kg PO X1 – • Spinosad (Natroba): >4 yrs – wash can repeat in 2 wks off in 10 mins; repeat in one week • 15 kg (33 lbs) • Ivermectin topical (Sklice): > 6 months – wash off in 10 mins Use Use 8 ounce bottle

Apply Apply to dry hair; massage into scalp

Cetaphil Comb Comb out excess

Gentle Dry Dry with hairdryer – completely Cleanser? Overnight Leave in overnight/8 hours (no age restrictions)

Shampoo Shampoo out in morning

Repeat Repeat in 7 days if needed Tinea

www.medicinenet.com Tinea

• Dermatophyte infection • Trychophyton • Person to person contact • Scaly • Expanding • Alopecia with tinea capitus www.medicinenet.com Treatment

• 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 Clotrimazole 1% crm • • “Ok” antifungal • Class 1 and 2 • Better on Candida

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 Tinea 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 Incognito 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. Comparison of terbinafine and clotrimazole in treating tinea pedis.

• 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. 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-

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, Malassezia furfur back, neck, abdomen….. 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 Fluconazole – CDC Threat Report

• 7% of candida isolates are resistant • 46,000 infections yearly • 3400 resistant infections • 220 deaths Diflucan 150/200 mg • http://www.cdc.gov/drugresistance/threat-report(adolescents-2013/ 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?

Require an immune response Contagious for resolution to occur Dome shaped

Pox Virus Umbilicated

www.webmd.com American Academy of Pediatrics

Goal: stimulate immune response Treatment?? • Retinoids – Tazarotene gel • LN2 • EMLA and curettage • Aldara (Imiquimod) • Cantharidin (beetle juice)

“BOTE” sign Warts

Human Papilloma Virus • At least 100 different strains • Probably more Treatment Warts • 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 • HSV 5 • Cold sores • Cytomegalovirus • HSV 2 • Mono • Genital herpes • HSV 6 • HSV 3 • Roseola • Varicella-zoster • HSV 7 • HSV 4 • Roseola • Epstein Barr • HSV 8 • Mono • 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…. • Famcyclovir 1500 mg X1 at onset • Especially among HIV and transplant • 12 years and older patients • 2-11 years: 75mg/kg/day divided 5X daily 5-7 days • Sitavig 50mg buccal tab • 12 years: 1000mg/day divided 5X daily 5-7 • 18 years and older days • Apply within 1 hr of onset • Valacyclovir 2000 mg q12hr X 1 day at • 6 hr application onset • 12 years and older Acne www.acneonlineinfo.net Hormones

Sticky oil

Dead skin Components… Bacteria • normal skin flora Inflammation Retinoids – KEY TO THERAPY

PO antibiotics

• we’ll talk about this

Treatment… BPO cleansers/combinations

BCP

Isotretinoin Act on retinoid receptors

Tretinoin, Adapalene, Tazarotene

Retinoids and Important for inflammatory and non- analogues inflammatory acne Nightly application ~ photoinactivation Benzoyl peroxide inactivated by tretinoin Tretinoin Tazarotene • Tretinoin .025%/.05%/.1% • RetinA Micro • Tazorac .05% cream/gel .04%/.08%/.1% • Tazorac .1% cream/gel • Atralin .05% gel • Fabior .1% foam • Ziana/Veltin ( tretinoin .025% • Maybe…soon a wash/combo? 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%) 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 Doxycycline 100 mg QD WITH FOOD • Pseudotumor cerebri TMP-SMX DS 1 PO BID X 1 PO month then QD X 1 month Antibiotics • 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

Neutrogenia Clear Pore

BenzeFoam Acne Free BPO Ultra (BenzePro) Cleansers

Proactive Oxy 5 Topical Erythromycin Clindamycin Antibiotics 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 YAZ Recently – papilledema/hepatoxicity Spironolactone

Off label PI – check labs 25 – 50 mg BID Teratogenic

Isotretinoin Accutane

www.accutanesideeffects.net

Inflammatory

Acne • Apoptosis of oil glands • Anti-inflammatory • Anti- bacterial Isotretinoin • 60-80% cure rate • Highly regulated by FDA • Ipledge program 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

DERM EXPRESS