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Home , Acne, Acne conglobata, Alopecia areata, Infantile acne, Keratosis pilaris, Scarring hair loss

Pediatric and adolescent

Management and referral guidelines ICD-10 guide

• : L70.0 acne vulgaris; L70.1 ; • : B08.1 L70.4 ; L70.5 acne excoriae; L70.8 • Nevi (moles): Start with D22 and rest depends other acne; or L70.9 acne unspecified on site • : L63 alopecia; L63.0 alopecia • ( fungus): B35.1 (capitis) totalis; L63.1 ; L63.8 other alopecia areata; or L63.9 alopecia areata • : L40.0 plaque; L40.1 generalized unspecified pustular psoriasis; L40.3 palmoplantar pustulosis; L40.4 guttate; L40.54 psoriatic juvenile • Atopic (eczema): L20.82 flexural; arthropathy; L40.8 other psoriasis; or L40.9 L20.83 infantile; L20.89 other ; or psoriasis unspecified L20.9 atopic dermatitis unspecified • : B86 • of infancy: D18 hemangioma and lymphangioma any site; D18.0 hemangioma; • Seborrheic dermatitis: L21.0 capitis; L21.1 infantile; D18.00 hemangioma unspecified site; D18.01 L21.8 other seborrheic dermatitis; or L21.9 hemangioma of skin and ; seborrheic dermatitis unspecified D18.02 hemangioma of intracranial structures; • : B35.0 D18.03 hemangioma of intraabdominal structures; or D18.09 hemangioma of other sites • : B36.0

• : R61 generalized hyperhidrosis; • : L80 L74.5 focal hyperhidrosis; L74.51 primary focal • : B07.0 verruca plantaris; B07.8 verruca hyperhidrosis, rest depends on site; L74.52 vulgaris (common warts); B07.9 viral secondary focal hyperhidrosis unspecified; or A63.0 anogenital warts • pilaris: L85.8 other specified epidermal thickening

1 Acne

Treatment basics • 0.025% or 0.05% cream

• Education: often take weeks to work AND and the patient’s skin may get “worse” (dry and red) • - 1%-5% gel in the before it gets better. Patients should use oil-free, morning OR clindamycin gel/solution/cream in non-comedogenic - and skin-care products. morning, in addition to using an OTC benzoyl • Compliance: Make sure patients are using the peroxide wash in the morning. medications as prescribed before switching to another regimen. Moderate to early severe mixed acne (many comedones and inflammatory lesions) Basic • Stronger topical at night: • Wash skin gently 1-2 times per day. • Tretinoin 0.05% or 0.1% cream/gel • Apply oil-free to skin as needed • 0.05% or 0.1% cream (0.05% or for dryness. 0.1% gel if skin is very oily). This is high potency • Apply oil-free every morning. and may need to work up to this by starting with lower potency retinoid such as tretinoin cream. • When using moisturizer and/or sunscreen, medications should be applied first. AND

How to apply topical medications • Clindamycin-benzoyl peroxide 1%-5% in the morning OR clindamycin gel/solution/cream in • Skin should be clean and dry. the morning, in addition to using an OTC benzoyl • A pea-sized amount of should be used peroxide wash in the morning. to cover the entire . OR

• Consider gels for oily skin and creams for dry/ • Oral (if more severe) sensitive skin. • 50-100 mg PO daily or BID • Gentle cleansers and are often recommended to avoid excessive irritation from • 50-100 mg PO daily or BID topical acne treatments. Severe acne (, nodules, evidence of scarring)

Mild comedonal acne (mainly comedones) • is likely needed. Referral to • Mild topical retinoid at night AND an OTC benzoyl dermatology is appropriate but initiating treatment peroxide wash in the morning while appointment is pending is generally necessary. • 0.1% or cream (0.1% gel if skin is very oily) When to initiate referral • Tretinoin 0.025% gel or cream • Comedonal or inflammatory acne resistant to treatment after three months Mild mixed acne (comedones and a few inflammatory lesions) • Nodulocystic acne with or without scarring

• Mild topical retinoid at night • Acne associated with signs of excess or as part of a systemic • Adapalene 0.1% lotion or cream (0.1% or 0.3% gel if skin is very oily)

2 Product recommendations for OTC acne treatments (washes and topical medications) acne-prone skin • Clean and Clear Invisible Blemish Treatment, Maximum Strength (2% ) Gentle skin cleansers • Clearasil Daily Acne Control Cream (10% benzoyl Purpose Gentle Cleansing Bar • peroxide) • Purpose Gentle Cleansing Wash (pump) • Clearasil Maximum Strength Acne Treatment (10% • Neutrogena Fresh Foaming Cleanser (pump) benzoyl peroxide)

• Olay Foaming Face Wash (pump) • Clearasil Ultra Rapid Action Treatment Cream (10% benzoyl peroxide) • Olay Gentle Foaming Face Wash (pump) • Neutrogena Clear Pore Wash (3.5% benzoyl • Cetaphil Antibacterial Soap (bar) peroxide)

Facial moisturizers • Neutrogena Oil-Free Acne Wash (2% salicylic • Cetaphil UVA/UVB Defense Moisturizer acid) (SPF 50) • PanOxyl Acne Cleansing Bar (5% or 10% benzoyl • Neutrogena Healthy Defense (SPF 30 or 45) peroxide)

• Neutrogena Oil-Free Moisture (SPF 15) • PanOxyl Wash (4 or 10% benzoyl peroxide)

• Olay Complete (SPF 20) • Panoxyl Creamy Wash (4% benzoyl peroxide)

• Olay Complete Defense (SPF 30)

3 3 Alopecia areata

Treatment basics • Rarely, alopecia may be associated with thyroid disease or . Typically, this is a more • Education: Families should know that alopecia widespread and other symptoms areata happens in approximately 1% of the general are present. In otherwise healthy children not population. It is not caused by something they did exhibiting signs or symptoms of thyroid disease or did not do. While may exacerbate the or anemia, in whom there is not a strong family condition, it is not the primary cause. history of either, thyroid and anemia studies do • Alopecia tends to be something that “turns on” not need to be routinely checked. Use your clinical and “turns off,” meaning that even after hair has judgment as to whether this is necessary. regrown it may fall out again in the future. There • In the dermatology clinic, treatment options is not a medication that can prevent this range from topical, intralesional or intramuscular from occurring. to topical immunotherapies, • The more widespread and long-standing the hair stronger systemic medications such as loss, the more difficult it may be to treat. immunosuppressants, and more.

• No treatment is guaranteed to work for alopecia When to initiate referral areata, though there are many options they may try. • Most children with alopecia areata should be referred to dermatology as management may Isolated patches of alopecia on the be complex, and there are may be significant • If there is no scale, redness, atrophy or other emotional stress associated with the disease. skin change, and these have never occurred, the • Widespread hair loss likelihood of this being a fungal is very low. Antifungal medications will not help in • When the diagnosis is in question this case. Obtain a fungal culture if unsure. • Any

• Typically, treatment consists of application of a • When there are associated skin changes or other Class I or Class II , such as Clobetasol potentially related changes gel, applied once daily to affected areas of scalp Monday through Friday with a break on • When there is significant emotional stress related the weekends to minimize the risk of steroid to the diagnosis — we are thrilled to be able to offer atrophy. Follow-up within 6-8 weeks is important in-office pediatric psychology in most cases when to assess treatment response and any potential needed and family is interested. side effects. • It may be appropriate to initiate therapy while referral is pending.

4 Atopic dermatitis (AD)

Treatment basics • 0.03% or 0.1% ointment or 1% cream once or twice daily as • Education: Families should know that AD is a needed for flares (medications are approved for chronic and relapsing disease. Gentle skin care children 2 years or older) and medication instructions should be reviewed in detail. The skin should be moisturized immediately • You can also consider using these medications after bathing to “lock in” moisture. on steroid-free days for patients who flare during steroid breaks. • AD severity and locations determine medications used in addition to the frequency and duration Moderate to severe AD on the body: of treatments. • 0.1% ointment or similar class III-IV • Topical steroids are typically used to treat a flare topical twice daily as needed twice daily until clear, usually for 1-2 weeks, no for flares longer than 15 days per month to minimize risk of steroid side effects (striae, telangiectasias, • Wet wraps for flares or persistent areas ). After initial treatment of flare, • Apply topical steroids to affected areas; cover 2-3 applications of topical steroid per week may be entire body with bland moisturizer of choice; used to maintain. apply cotton long johns or pajamas soaked with • You should dispense enough medication when warm water and wrung out for 15 to 20 minutes prescribing topicals. Small 15 + 30 gm tubes will 1-2 times per day for flares. If localized, may use not be sufficient for most AD patients. gauze, cotton towels or cotton socks as an alternative. • Ointments are often preferable to creams due to increased and reduced irritation. Use • For associated pruritus, particularly at bedtime, creams, however, if this will increase compliance. initiate systemic as appropriate for weight/age. • 1/8 cup household in 1/2 full standard bathtub twice weekly may be helpful in patients • Diphenhydramine with recurrent skin conditions. Rinse with clear • Hydroxyzine water afterwards.

• Compliance: Make sure patients are using the When to initiate referral medications as prescribed before switching to • Moderate AD not responding to treatment after another regimen. two months

Mild AD on the face or body • Severe or poorly controlled AD despite management recommendations (topical steroids, Desonide 0.05% ointment or 2.5% • wet wrap therapy, and oral ) ointment twice daily as needed for flares

• For AD involving the , neck, axillae or inguinal folds, consider topical immunomodulators (calcineurin inhibitors).

5 Dry and sensitive skin care • Vaseline Ointment (no fragrance!) recommendations • Vaniply Ointment

Soap • Cetaphil or Cetaphil Restoraderm Cream

• Dove for Sensitive Skin (bar or liquid) • CeraVe

• CeraVe Cleanser • Vanicream

• Cetaphil Gentle Skin Cleanser or Bar (not face • Aveeno Advanced Care Cream wash); Oil of Olay for Sensitive Skin (bar or liquid); • Aveeno Eczema Cream Vanicream Cleansing Bar • Eucerin • Aveeno Advanced Care Wash Sunblock Detergent • Vanicream Sensitive Skin SPF = 30 or 60 • Tide Free • Neutrogena Sensitive Skin SPF = 60+ • Cheer Free • Neutrogena Pure & Free Baby SPF = 60+ • All Free and Clear Diaper cream • Purex Free • Triple Paste Fabric softener • Aquaphor Ointment • Bounce Free • Vaseline Ointment • Downy Free and Clear • Desitin Maximum Strength Moisturizer

• Aquaphor Ointment

6 Hemangioma

Treatment basics • While are benign, some may lead to complications. Most small, uncomplicated • Education: Families should be counseled that hemangiomas do not require a dermatology these are benign collections of blood vessels and appointment. When the majority of hemangioma endothelial cells. They occur in approximately growth and/or an ulceration has occurred, medical 5-7% of all babies. There are some known risk treatment may only be partially effective. Ideally, factors, such as prematurity; maternal high blood treatment would be initiated early to prevent pressure; multiple gestation (twin, etc.); and low these complications. birth weight, but it is still not clear what causes them. We do know they are not caused by anything • Certain hemangiomas are at an increased risk the mother did or did not do during . of causing functional or residual defects. These may include hemangiomas on or near /eye, • Some hemangiomas may be fully present at birth nose, forehead, glabella, nose, lip, ear, areola and and rapidly involute. Others may be fully present genitalia; and those that grow large quickly. at birth and never involute. However, the typical growth cycle of a hemangioma is that it is barely • Large, segmental, plaque-like hemangiomas of the noticeable or not at all present at birth; it begins to face (and rarely other areas) may be associated grow in the first few weeks of life; and continues with PHACE(S) Syndrome and require prompt until roughly 6-9 months of age when it will imaging studies and initiation of treatment. commonly stabilize. • Segmental, plaque-like hemangiomas of the sacral • After it stops growing, the body will slowly start spine, and/or genitalia may signal an to reabsorb part or all of the hemangioma. This underlying abnormality. is called involution. The color will fade and it will • Segmental, plaque-like hemangiomas in the typically get softer and smaller. This may take distribution signal an increased risk of an airway several years. hemangioma, and patients must be monitored • Sometimes, after the hemangioma reaches the for any signs of respiratory compromise. These point of maximal involution, there is residual patients should see ENT as well. discoloration or fibrofatty tissue. The skin cannot • If a child has five or more hemangiomas, always return completely to normal, particularly if particularly if they are small, this is called there has been significant vertical growth. hemangiomatosis and may be a sign that there are • While many treatments for hemangiomas exist, internal hemangiomas. The child should have an the treatment of choice for those who require abdominal ultrasound to look for hemangiomas intervention is propranolol/Hemangeol. Treatment in the liver. If these are present, they should also is usually required until approximately 9–12 months have labs to rule out effects on liver or thyroid of life. Occasionally, very superficial hemangiomas function. They must be followed closely and often may respond to Timolol gel-forming ophthalmic require medical management to ensure they do not solution applied sparingly to the hemangioma BID. experience liver failure, high output cardiac failure, or thyroid dysfunction. • If an older child with an involuted hemangioma has significant fibrofatty or other residual defects • Ulcerated hemangiomas can be painful and lead to distressing to patient/family, it is most likely more or infection. These generally require medical appropriate to refer to pediatric plastic surgery over management. Hemangiomas in the diaper area, pediatric dermatology. axilla or other areas prone to friction are at an increased risk of ulceration, and must be monitored closely.

7 When to initiate referral • If in doubt, call our office to discuss whether a patient should be worked in.

• Hemangiomas on or near eyelid/eye, nose, forehead, glabella, nose, lip, ear, areola and genitalia

• Hemangiomas that grow large quickly and/or ulcerate

• Large, segmental, plaque-like hemangiomas of the face, sacral spine, buttocks, genitalia, beard distribution, or other areas

• Five or more hemangiomas in one child

• Residual color that is distressing to patient/family. This may respond to pulsed dye .

8 Hyperhidrosis

Treatment basics • If topical therapy does not provide adequate relief, consider treatment with glycopyrrolate • Hyperhidrosis (excessive sweating) is caused by or oxybutynin by mouth, provided there are either sweat glands that respond excessively to no contraindications. normal signals, or by the body sending excessive signals to sweat to the sweat glands. It is common, • Potential side effects include dry mouth, occurring in at least 1% of the population. headaches, dizziness, blurry vision, heart palpitations, constipation. Care must be used to • Hyperhidrosis may have significant impact on a ensure patient does not overheat when taking patient’s self-esteem and quality of life. It often these medications. Medication breaks during interferes with friendships, schoolwork, jobs and periods of significant heat and/or exercise, other areas. adequate hydration, and education regarding signs • Treatment for hyperhidrosis often begins with of hyperthermia must be provided. aluminum chloride topical products. If these are not effective, the next line is often oral When to initiate referral glycopyrrolate or oxybutynin, iontophoresis and/ • Sweating that is unilateral or botulinum toxin injections, provided there are no contraindications. • Sweating that occurs on the face with certain foods/triggers Hyperhidrosis of axillae, and/or feet • Sweating that significantly interferes with patient’s • Initiate therapy with a topical product such as quality of life, self-esteem, etc. Dry-sol, Certain Dri (over-the-counter), Hypercare. • Sweating that does not respond to therapy • Topical products must be applied to dry skin. You can achieve this by using the cool air feature on blow dryer if needed. Aluminum chloride mixed with sweat may lead to irritation.

9 Molluscum contagiosum Nevi (moles)

Treatment basics Basics

• Education: This is a common virus that may last • It is normal to develop new moles in childhood many months to several years. These children and early . Moles may enlarge should not be excluded from group childcare around . settings or other activities. • It is normal to see uniform growth or thickening of • No treatment is 100% effective. moles with overall growth of a child.

• No treatment prevents spread of new molluscum. • Congenital moles (moles presenting at birth or during infancy) are typically larger than acquired • New cases of molluscum can be observed clinically moles and may thicken and/or develop hair without treatment. If treatment is desired, options over time. vary based upon location and number of lesions. • Educate families regarding the importance of Molluscum on the face, neck, axillae, inguinal folds regular applications of sunscreen, hats, sun- or genitalia protective clothing, etc. • Tretinoin 0.025% or 0.05% cream/gel to the lesions, 3-5 nights per week as tolerated. Note: When to initiate referral Topical may be irritating and should be • If a patient has had a dysplastic , a history of avoided in patients with eczema. They should not , or if there is a positive family history of be applied close to the eyes. either in first-degree relative

Molluscum on the trunk or extremities • Sudden or worrisome mole changes

• In-office treatments (cantharidin, curettage or • Size, shape or color liquid nitrogen) every 4-6 weeks if available and • Development of persistent symptoms pediatrician has experience with treatments. • Itching, pain or bleeding When to initiate referral • If a lesion has been biopsied or removed and needs • Most cases of molluscum contagiosum do not further evaluation (please include a copy of the require dermatology referral. pathology report with referral)

• Symptomatic, rapidly progressing or numerous • Large congenital nevus and/or congenital with molluscum lesions satellite nevi

• Molluscum in immunosuppressed patients

10 Onychomycosis (nail fungus)

Basics Moderate to severe onychomycosis (brittle nails, subungal debris, etc.) and fungal culture is positive for • Nails that are thickened, brittle, discolored, . separating from the nail bed, and/or have subungual debris. • Terbinafine (comes in a 250 mg tablet and is given PO once daily) is preferred if there are no • Adjacent skin involvement may be suspicious for contraindications (e.g. history of significant liver fungal infection (red, scaly or pruritic). disease or potential drug interaction). • Recurrence is common and treatment does not • If baseline CBC and LFTs are within normal limits, always guarantee a permanent cure. can dose as follows: <20 kg = 62.5 mg/day, 20- • There is often exposure via one or multiple affected 40 kg = 125 mg/day, or >40 kg = 250 mg/day. family members, and they should also be treated Fingernails: 6-week course and toenails: 12-week by their primary care provider(s) when appropriate. course.

Initial step • Repeat CBC and LFTs after 4-6 weeks on therapy prior to continuing full course. • Confirm presence of a fungal infection.

• Send an adequate nail clipping for fungal culture. When to initiate referral

• The specimen is sent to microbiology in a fungal • Failure to respond to therapies above swab tube or sterile urine cup (results can take • Symptomatic or extensive nail involvement up to four weeks). • Onychomycosis in immunosuppressed patients Mild onychomycosis (mild nail discoloration of a few nails)

• Ciclopirox 8% nail lacquer solution or topical terbinafine 1% cream nightly to the nails until clear

11 Psoriasis

Treatment basics Psoriasis on the face, ears, eyelids, axillae, inguinal folds or genitalia • Education: Families should know that psoriasis is a chronic and relapsing disease. • Tacrolimus 0.03% or 0.1% ointment or pimecrolimus 1% cream once or twice daily as • Psoriasis severity and locations determine needed for flares (medications are approved for medications used in addition to the frequency and children 2 years or older) duration of treatments. • May also require desonide or hydrocortisone • Topical steroids are typically used to treat a 2-3 times a week flare once to twice daily until as needed for flares, usually for 1-3 weeks on average. Do not Scalp psoriasis: apply steroids more than 10-15 days per month to minimize risk of steroid side effects (striae, • OTC salicylic acid, tar-containing , or telangiectasias, hypopigmentation). prescription 2% shampoo daily or at least 2-3 times per week • You should dispense enough medication when prescribing topicals. AND

• For guttate psoriasis, you should consider a throat • DermaSmoothe FS Oil (fluocinolone in or perianal bacterial swab culture to check for a hypoallergenic peanut oil) or fluocinolone 0.01% possible strep infection that can be associated with solution once or twice daily as needed for flares in a flare. mild scalp psoriasis

• Patients should moisturize several times per day OR with a bland, hypoallergenic cream or ointment. • 0.05% solution or clobetasol 0.05% • You should ask about associated joint pain, redness solution/gel/foam once or twice daily as needed or swelling. for flares in moderate to severe scalp psoriasis • Compliance: Make sure patients are using the When to initiate referral medications as prescribed before switching to another regimen. • Mild or moderate psoriasis not responding to treatment after two months Psoriasis on the trunk or extremities: • Severe psoriasis with or without systemic • Mild - Desonide 0.05% ointment or hydrocortisone symptoms 2.5% ointment to affected areas once or twice • Suspicion for psoriatic arthritis daily as needed for flares

• Moderate - Triamcinolone 0.1% ointment twice daily as needed for flares

12 Scabies

Basics Control of transmission

• Scabies is an infestation of the skin by the mite • Recently used (within several days before Sarcoptes scabiei treatment) clothing, linens, stuffed animals, etc. may be bagged for several days, machine washed, • Usually transmitted by close person-to-person and then ironed, dried in a hot dryer, or contact or by parents to children (especially dry cleaned. mother to infant) • All household members and close contacts should • Severely itchy, especially at night be treated simultaneously if no contraindications, • Usually distributed on the sides and webs of even if they do not have skin lesions/. fingers, flexor wrists, extensor elbows, folds, • Close contacts without skin lesions/rash generally peri-umbilicus and genitalia do not need a second, repeat treatment. • Infants often have palms/soles involved When to initiate referral • Skin lesions in children are typically more inflammatory, and are often vesicular or bullous. • Treatment failure in spite of proper treatment of patient and all household members First steps • Persistent scabies , especially in • Scabies is generally a clinical diagnosis. Skin immunosuppressed patients scrapings for microscopic evaluation in the clinic can be used for confirmation.

Treatment

• Permethrin 5% cream: apply to all areas of the body from the neck down to the toes and wash off after 8-14 hours. Repeat after one week.

• Permethrin appears to be safe and effective even when applied to infants less than 1 month of age. In infants, permethrin should also be applied to scalp and face, avoiding the eyes and mouth.

• Itching and lesions often persist for several weeks after successful treatment. Oral antihistamines and/or low to medium potency topical steroids are appropriate for relief.

13 Seborrheic dermatitis

Basics Face and body seborrhea

• A common, benign in infants and • Desonide 0.05% cream or hydrocortisone 2.5% young children that can be chronic cream (mild steroids) once to twice daily as needed for flares • Often occurs in adolescents, when sebaceous activity tends to increase. AND/OR

• The expected course is gradual resolution over a • Ketoconazole 2% cream or OTC clotrimazole period of months to years. cream once to twice daily as needed for flares

• It is not necessary to treat all cases of seborrhea. When to initiate referral • Treatment should be initiated for moderate to • Moderate seborrheic dermatitis not responding to severe cases and/or symptoms of pruritus/pain. therapy after two months

Scalp seborrhea • Severe or widespread eruption

• Ketoconazole 2% shampoo; OTC selenium sulfide • If the diagnosis is in doubt shampoo; or OTC Becker’s P&S shampoo/solution 2-3 times a week (shampoo should be allowed to sit for ~5 minutes before rinsing)

AND/OR

• DermaSmoothe FS Oil (fluocinolone in hypoallergenic peanut oil) or fluocinolone 0.01% solution once or twice daily as needed for flares

14 Tinea capitis Tinea versicolor

First step Basics

• A fungal swab culture should be taken prior to • Caused by the lipophilic Malassezia yeast species starting treatment. This may be obtained by (part of the normal microflora of the skin) moistening a fungal culture swab with the media • Tends to occur more frequently in tropical climates in the bottom of the culture tube followed by vigorously rubbing of the affected area (results can • Associated with activity (so more take up to four weeks) frequently seen in post-pubertal adolescents and adults) Treatments • Recurrences are common. • Griseofulvin 20-25 mg/kg/day PO dosed once or twice daily for 6-8 weeks • Skin dyspigmentation can last months after condition treated. OR Treatments include • Terbinafine is given PO once daily for 4-6 weeks. Weight-based dosing is as follows: • Ketoconazole 2% shampoo or OTC selenium sulfide shampoo applied to affected areas daily • <20 kg = 62.5 mg/day, 20-40 kg = 125 mg/day, until clear (left on for five minutes prior to rinsing) or >40 kg = 250 mg/day • Topical antifungal creams such as ketoconazole 2% AND cream or OTC clotrimazole cream once to twice • Ketoconazole 2% shampoo or OTC selenium daily until clear sulfide shampoo 2-3 times weekly When to initiate referral Points to remember • Lack of response to therapy after two months • Testing of liver function with griseofulvin or terbinafine is usually unnecessary in otherwise • Severe or widespread eruption healthy children. Testing is recommended with griseofulvin for treatment of eight weeks or longer, or terbinafine for six weeks or longer.

• It may be appropriate to initiate treatment while waiting for initial culture results in highly suspicious cases.

• If signs of bacterial infection (pustules, oozing, etc.), obtain a bacterial swab culture and treat appropriately.

• Fomites (objects which may retain and spread infection such as combs, hats, etc.) should also be disinfected.

When to initiate referral • Recalcitrant and/or severe cases, such as those with kerion, scarring, or severe alopecia

15 Vitiligo Warts

Basics Basics

• Treatment depends on the patient’s age, cultural • New cases of warts can be observed clinically beliefs, and the location and extent of the without treatment. If treatment is desired, options affected areas. vary based upon location and number of lesions.

• Consider mid- to high-potency topical steroids with • No treatment is 100% effective, and some OTC “steroid holidays”. therapies such as salicylic acid may achieve very similar results to in-office therapies. • Emphasize importance of sun protection as affected areas at-risk for the sequelae of acute and Warts on the face, neck, axillae, inguinal folds chronic sun exposure. or genitalia

• In some patients, cover-up may be • Tretinoin 0.025% or 0.05% cream/gel to the appropriate (Dermablend, Covermark). lesions, 3-5 nights per week as tolerated. Note: • An excellent resource and support group is the Topical retinoids may be irritating and should be Vitiligo Research Foundation: avoided in patients with eczema. They should not vrfoundation.org be applied close to the eyes.

Vitiligo on the face, axillae, inguinal folds or genitalia Warts on the trunk or extremities

• Tacrolimus 0.03% or 0.1% ointment or • OTC salicylic acid 17-40% (wart stick or pimecrolimus 1% cream once to twice daily until plasters) nightly clear (medications are approved for children 2 • Gentle nightly abrasion with pumice stone or nail years or older) file, not to be used on other areas. Stop at first sign of very mild bleeding and wait to reapply topical Vitiligo on the trunk or extremities medications until well healed. • Triamcinolone 0.1% ointment once or twice daily • In-office treatments (cantharidin, curettage or on the weekdays, and tacrolimus ointment or liquid nitrogen) every 4-6 weeks if available and pimecrolimus cream once or twice daily on pediatrician has experience with treatments. the weekends When to initiate referral When to initiate referral • Most warts do not require referral • Poor response to the above treatments after to dermatology. three months • Symptomatic, rapidly progressing warts • Extensive or distressing vitiligo • Warts in immunosuppressed patient

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