Name That Nubbin! Elizabeth (Lisa) Swanson, MD Advanced - Colorado Rocky Mountain Hospital for Children [email protected] Disclosures

• Speaker • Valeant • Bayer • Aqua

• Advisory Board Representative • Allergan • Amgen • Sanofi-Regeneron Nubbin: something that is small for its kind, stunted, undeveloped, or imperfect Made Famous in a Friends Episode • Chandler reveals his accessory nipple • Joey: “I can’t believe you. You told me it was a nubbin.” • Ross: “Joey, what did you think a nubbin was?” • Joey: “I don’t know. You see something, you hear a word, I thought that’s what it was. Let me see it again.” Nubbin

• I am going to use the term nubbin to mean a collection of spots in kids that represent a “miscellaneous” sort of category

Spider Angioma

• Small raised pink-red papule with radiating telangiectasia like legs on a spider

• Blanch with pressure from a glass slide

• Eventually resolve on their own

• Can be treated with vascular laser if bothersome

Pyogenic Granuloma

• “Little ball of capillaries”

• Common in kids and pregnant women

• Some people remember trauma to the area prior to its growth

• 2 Treatment Options • Shave removal • Topical timolol bid Pyogenic Granulomas

• Initial study in March/April 2014 SPD journal using timolol 0.5% gel forming solution BID

• Great results with clearance after 2-3 mos

• Bleeding stopped relatively instantly

• Likely working by vasoconstriction

• Important to followup these patients to ensure improvement (spitz nevi, even melanoma in ddx) Pyogenic Granuloma Pyogenic Granuloma

Juvenile Xanthogranuloma

• Form of non-Langerhan’s cell histiocytosis

• Presents as an orange-yellow-brown dome shaped papule in a child • “color of the rising sun”

• Benign; will resolve spontaneously

• Recurs if it is removed

Lichen Striatus

• Causes a linear streak of raised flat topped skin colored to pink papules, typically down an extremity

• Can affect the nail on that extremity

• 10% of cases are bilateral

• Sometimes itchy, sometimes not

• Topical steroids or calcineurin inhibitors help for the

• Resolves on its own; typically takes 2-3 yrs

Ring Phenomenon

• Typically associated with cantharidin • Can happen with liquid nitrogen • The treated wart may or may not go away and then a ring of warts develops around the initial wart • If you continue that treatment, the ring gets bigger • I feel it is happening more and more commonly with cantharidin these days Warts

• Countless treatment options • Liquid nitrogen • Cantharidin • OTCs • Candida • Squaric Acid (contact sensitizers) • Laser • Bleomycin

• Best Thing Ever- WartPeel! • Nucara Pharmacy- Iowa • Sal acid + 5FU • Magic in a bottle • Applied at bedtime under “sticky tape” • $89 and worth every penny!

WartPeel WartPeel Warts- Alternative Therapies

• Zinc sulfate 10 mg/kg/day (max 600 mg) x 2 mos • Complete clearance in 75% of patients • Nausea is really bad

• Propolis daily x 3 mos • 135 patients- 73% had clearance • Avoid if bee allergy

• Valtrex 1 gm daily x 60 days- just 2 cases (JDD Feb 2016)

• Picato- couple case reports on using it for genital warts and epidermodysplasia verruciformis

• Just wait- 200 kids- 65% resolved by 2 yrs, 80% by 4 yrs (SPD Sept/Oct 2015) Warts and HPV Vaccination

• Mounting number of case reports showing that when pre-teens and teens are given HPV vaccine, their warts go away

• It will be interesting to see if we notice a decrease in incidence of warts over time as more and more people get immunized HPV Vaccines

• 3 approved HPV vaccines

• Some concern about reports of MS, optic neuritis, transverse myelitis

• 10 cases of regional pain syndrome

• 4 reports of premature ovarian failure (possibly an autoimmune reaction from vaccine) Wart vs Callus/Corn- A Handy Trick

• Press on top of it • If it hurts, it is a callus/corn

• Press on the sides of it (squeeze it) • If it hurts, it is a wart

Pseudofurunculoid Molluscum • Look like pimples/boils

• Due to body’s immune system response

• Not infected, just inflamed

• BOTE sign- Beginning Of The End Pseudofurunculoid Molluscum PF Molluscum and PF Molluscum and Id Reaction

• Treat the Id Reaction with topical steroids

• Treat the PF molluscum with oral antibiotics or bleach baths

• F/u 2-3 wks

• Usually everything is “all better”

• Caused by a poxvirus

• Very common in kids- pretty much all kids get them

• Spread by direct contact and spread like crazy in water (including swimming pools)

• Treatment is not mandatory as they will go away with time • Can take up to 2 yrs to resolve on their own • Recent study of 170 kids- half treated, half not treated • Molluscum resolved in the same amount of time Molluscum Treatment Options

• Imiquimod/Zyclara • Cantharidin • Apply MWF at bedtime x 8 wks • Never use it in the axilla • A little irritation- good; a lot of • Blisters can be bad irritation-bad • 50% resolution with each treatment is success • Zymaderm • Hard to get these days • All natural OTC product, botanical based • Curettage • Applied BID • Liquid Nitrogen • Candida antigen injections • Injected into 1-2 of the molluscum • Topical retinoids every 3 wks • Tolerable; typically 3-5 treatments • Side effect profile Molluscum

• Some kids will get an eczema like rash around the molluscum

• Important to treat it as it so kids scratch and then spread the molluscum

Accessory Tragus

• Benign, harmless • No associated issues with hearing, kidneys, etc • Can be removed • My preference is to have peds ENT do it as they can be a “top of an iceberg” • Sometimes if it is small and clearly just fleshy without cartilage, I will numb it and snip it off

Solitary Mastocytoma

• Benign collection of mast cells

• Hives up when rubbed or irritated

• Will go away

• Not scary Urticaria Pigmentosa Urticaria Pigmentosa

• Lots of solitary mastocytomas • Not scary, but looks scary and parents are often freaked out • Most kids outgrow it • No reason to check serum tryptase • No risk of mast cell leukemia • Manage with topical steroids prn • Antihistamines +/- Dangerous Mast Cell Issues

• Bullous Mastocytosis- presents as blistering in a newborn; ddx includes EB

• Diffuse Cutaneous Mastocytosis- the skin is diffusely infiltrated by mast cells so it becomes yellowish and rubbery diffusely

• Only these 2 mast cell issues carry risk of mast cell leukemia and require systemic workup and hem/onc involvement

Aquagenic Syringeal Acrokeratoderma • Causes swelling, papules, increased wrinkling on palms following immersion in water • If occurring in a young child, they should be screened for Cystic Fibrosis • If occurring in an older, clearly healthy child, then there is no concern • Sometimes kids with this are heavy sweaters- treating that can help • Kids outgrow it

Gluteal Variant of Perioral Dermatitis • Consists of small pink papules and pustules on buttocks • DDx includes keratosis pilaris and staph • I typically culture at first visit to r/o staph • Treatment: • Clindamycin wipes • Elidel • Amoxicillin (azithro if PCN allergic)

Herpes Zoster

• Since the chicken pox vaccine has been more regularly administered to children, cases of herpes zoster in children have been on the rise • We don’t know why immunity seems different with the vaccine vs having the chicken pox • Patient is contagious to people who have not had the chicken pox (can’t catch shingles from shingles) • Need to avoid unimmunized kids and pregnant women • Treatment with Acyclovir 30-50 mg/kg/day divided TID (valtrex if old enough to take pills)

Psoriasis

• This was a real “curbside” photo sent to me

• No other photos were sent

• Even with the limited info, this is clearly psoriasis, most likely guttate

• “Psoriasis” pink

• Koebner phenomenon

Bronchogenic Cyst

• Classically in the sternal notch

• Can look like a milia, cyst, divot

• Should be removed by a peds ENT or peds general surgeon

• “Tip of an Iceberg” Other Neck Cysts in an Infant

• Sternal notch- bronchogenic cyst

• Midline upper neck- thyroglossal duct cyst

• Lateral neck- branchial cleft cyst

Nevus Anemicus

• Somewhat reticular hypopigmented-appearing area. Appears mottled

• Due to slight decrease in superficial cutaneous blood vessels

• Recently described as an association with NF-1 • Typically on the chest

Eclipse Nevi

• Very common on the scalp of children • Frequently biopsied because of somewhat atypical coloring, large size, history of changing • Often read out as atypical on pathology, but these are known to be completely benign • Probably a “special site” that isn’t currently recognized as a special site Eclipse Nevi

Bed Bugs

• Cause typical bug bite appearance, but often occurs in clusters of 3- “breakfast, lunch and dinner”

• Home needs to be evaluated by a professional exterminating service- no “DIY” projects • Bed bugs know where to hide; they don’t want to be found • Come out when CO2 levels in the air indicate that we are asleep

Pilomatricoma

• Subcutaneous firm plaque

• Skin colored and sometimes a bluish hue

• Demonstrates a positive “teeter totter” sign

• 2/3 resolve on their own

• Can be surgically excised

Tinea Corporis

• Corporis • Ketoconazole 2% cream bid (apply to area and 1 inch around, cont treatment after clinical clearance) • Oral meds if extensive

• Capitis (presents as redness, scaling and alopecia) • MUST USE ORAL MEDS • Griseofulvin 20-25 mg/kg/day divided bid for 6 wks. Must be given with fatty food. • 2nd line- either itraconazole or lamisil Pediatric Onychomycosis

• It happens!

• Often there is family history

• Evaluate for tinea pedis

• Treat with terbinafine for 3 mos • <20 kg- 62.5 mg daily (1/4 pill) • 20-40 kg- 125 mg daily (1/2 pill) • >40 kg- 250 mg daily

• Itraconazole can be used in a pinch (comes in syrup) • Pulse dosing

• Liver function tests- to test or not to test

• Griseofulvin doesn’t work Pediatric Onychomycosis- Picture

Hyperkeratotic Lichenoid Papules of the Elbows and Knees

• Very common in kids age 4-12, boys > girls

• Misdiagnosed as flat warts, molluscum, KP

• Probably a variant of KP

• Kids outgrow it

• Could treat it with AmLactin, Cerave SA, etc

Toddler (Infantile) Acne

• Kids age 6 mos- 3 yrs old

• Typically occurs on cheeks

• Small pink papules and pustules

• Sometimes comedones

• Can scar; important to treat

• 1st line- Topical clindamycin

• 2nd line- Topical adapalene

• 3rd line- Oral amoxicillin

Pigmented Purpuric Dermatoses

• 5 types of pigmented purpuric dermatoses

• Most common type in kids in studies appears to be Schamberg’s Purpura

• In my clinic, most common type is definitely Pigmented Purpuric Dermatoses

• Idiopathic

• These conditions present with petechial lesions (often pediatricians will panic)

• Schaumberg’s purpura looks like specks of cayenne pepper

• Lichen Aureus looks like petechiae in a gold-brown patch

• Treatment is difficult, but it resolves on its own eventually

• Topical steroids and UV light might help Lichen Aureus Pediatric Spots- Lumbosacral Dysraphism

• Lesions overlying lumbosacral spinal cord can indicate a problem underneath- tethered cord, meningocele, tumor Pediatric Spots- Lumbosacral Dysraphism- HIGH RISK • >2 cutaneous stigmata

• Lipoma

• Acrochordon/pseudotail/tail

• Aplasia cutis

• Dermoid cyst or dermal sinus

• Infantile hemangioma > 2.5 cm in size

• Must do an MRI Pediatric Spots- Lumbosacral Dysraphism-

Intermediate and Low Risk • Intermediate • Atypical dimple (> 5 mm) • Hemangioma less than 2.5 cm in size • Hypertrichosis • Can do ultrasound if child < 3mos old, MRI if older than 3 mos old • Low • Simple dimple • / • Congenital • Port wine stain • No imaging needed A Couple of Tricky “Nubbins” Jan 2016- Mom’s Photo Sept 2016- 1st visit 1st Visit

• Ordered an MRI stat

• Ddx- vascular (atypical hemangioma, AVM), neoplasm

• MRI results showed findings consistent with a hemangioma

• Started the patient on Propranolol Nov 2016 Biopsy

• Pathology revealed DFSP

• Pt underwent excision in 2 stages

• Considered pre treatment with Gleevac but the stain for the 9,22 translocation was negative

Initial History

• Rash was noticed for about 6 wks • Asymptomatic

• OTC remedies had not been helpful • History of episodes of constipation and diarrhea but no significant abdominal pain, no blood in stool, no hospitalizations for symptoms • Family was using bubble baths, fab soft, dryer sheets, Gain detergent Initial visit

• Attempted treatment for with sensitive skin care and hydrocortisone 2.5 ointment

• No improvement

• Attempted treatment for yeast with econazole cream bid

• No improvement Biopsy Under Anesthesia

• Punch biopsy showed granulomatous dermatitis c/w cutaneous Crohn’s

• Patient was referred to peds GI for GI eval which questioned the diagnosis of Crohn’s • Labs were normal • Didn’t want to scope her

• Presented patient at Colorado Grand Rounds and every dermatologist agreed with me

• Treated with clobetasol bid x 3 wks and it cleared

• Now will just see what happens “These people are members of a community that care about where they live. So what I hear when I’m being yelled at is people caring loudly at me.” – Leslie Knope, Parks and Rec

A Quick Thought on Burnout and “Mindfulness”

“Life moves pretty fast. If you don’t stop and look around once in a while, you could miss it.” -Ferris Bueller Mindfulness Defined

• Putting down your juggling balls for a little bit

• Embrace the beauty of monotasking

• Paying attention in a particular way: on purpose, in the present moment, and nonjudgementally High Yield Mindfulness Tidbits

• Take a second to notice things • Raisin • Fingers

• Start a “Gratitude” journal • Write down 2 or 3 things every night that you are grateful for that day Mindfulness Activities

• Anything that lets you “zone out” for a little bit

• Meditation- apps that help teach a “non-hippy” how to meditate • Headspace • Calm

• Fly fishing

• Tai Chi

• Yoga

• Adult coloring books High Yield Burnout Tips

• Breathe

• Music can change your mood quicker than anything • Make yourself different playlists

• You can’t give what you don’t have • Think of yourself as a car. You need to fill up your tank once in a while to keep running • Make time for the things that refill your tank

The End

• Feel free to contact me with any questions

• [email protected]