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4Th Annual Texas Children's Hospital Advanced Practice Provider A Potpourri of Pediatric Dermatology 4th Annual Texas Children’s Hospital Advanced Practice Provider Conference April 2017 MOISE L. LEVY, M.D. DELL CHILDREN’S MEDICAL CENTER DELL MEDICAL SCHOOL/UT, AUSTIN AUSTIN, TX Conflicts of Interest Ø Anacor Ø Scioderm Ø Castle Creek Pharmaceuticals Ø Up to Date None Should Apply For This Presentation One way we are viewed… It’s just a birthmark 9 month old with asymptomatic scalp lesion noted in NICU; increases in size with straining But maybe something else… Sinus Pericranii Ø Communication between intra- and extracranial venous drainage pathways Ø Most are midline and non.pulsatile Ø Connect pericranial veins with superior sagittal sinus Ø TX depends on flow pattern/direction -Dominant; main flow via SP -Accessory; small flow via SP Neuroradiology 2007;49:505 Neurology 2009;72:e66 Case History 5 y/o girl w celiac disease Seen for evaluation of perianal growth Present, by hx, x 2 yrs No prior tx Case History Was seen by pediatric surgery Excised Condyloma - HPV 6, 16 Management? ARS – Pediatric Anogenital Warts When seeing a 5 yo with anogenital warts A. HPV testing should be done B. All cases are due to abuse C. All cases should be treated with imiquimod D. History and physical examination are key for suspicion of abuse E. Call Dr Eichenfield; he’ll know what to do Pediatric Anogenital Warts Age of onset and abuse - 6.5 ± 3.8 yrs (5.3 yrs) - 37% 2-12 yrs; 70% > 8 yrs - 4 yrs 8 months (83% female) HPV testing felt not of use… high subclinical History and PE key - physical findings abuse rare Arch Dermatol 1990;126:1575 Pediatrics 2005;116:815 Arch Dis Child 2006;91:696 Pediatr Dermatol 2006;23:199 J Pediatr Adolesc Gynecol 2013;26:e121 Age of Onset and Abuse Pediatr Dermatol 2006;23:199 ARS – Pediatric Anogenital Warts When seeing a 5 yo with anogenital warts A. HPV testing should be done B. All cases are due to abuse C. All cases should be treated with imiquimod D. History and physical examination are key for suspicion of abuse E. Call Drs Hunt or Metry; they’ll know what to do Oops!!! -14 y/o female -Chronic abd pain -Exploratory lap -Cholecystectomy -Recurrent painful erythema Case History/Factitious n Dermatographia n Photographed n Severe behavioral disorder n Psychotherapy Lessons Learned Listen to the trainees… Reason for being in teaching environments is to be challenged by everyone Hand-Foot-and-Mouth Disease Hand Foot and Mouth Sausage shaped vesicles palms/soles Oral erosions - Can see feeding problems Erythematous papules on buttocks “Eczema coxsackium” Mild gastroenteritis Etiologies -Coxsackie A16, A2, A5, A6, A9, A10, B2… -Enterovirus 71 -Others… Pediatrics 2013;132:e149 Severe HFM and Coxsackie A6 MMWR 2012;61:213 Exanthem and fever more Mathes, et al: SPD, July 2012 severe JAAD 2013;69:736 Hospitalization more Pediatrics 2013;132:e149 common… - dehydration, pain Atopic Dermatitis: The Disease Increasing prevalence1 ¡ 15%-30% of general population ¡ 80%-90% diagnosed by 5 years of age Pathogenesis1-3 ¡ Genetic; filaggrin other biomarkers ¡ Increased transepidermal water loss; possible lipids and barrier? ¡ Biochemical immunologic ÷ Potential food hypersensitivity? ÷ Hygiene hypothesis? ÷ Defective innate immunity Management Atopic Dermatitis: AAD Diagnostic Criteria1,2 20 Essential Features Important Features Associated Features Both of the following must be present Add support to the diagnosis, Suggestive of AD, but too nonspecific observed in most cases of AD to be used for defining or detecting AD in research or epidemiologic studies 1. Pruritus 1. Early age of onset 1. Atypical vascular responses (eg, 2. Eczema (acute, subacute, chronic) 2. Atopy facial pallor, white dermographism, delayed blanch response) a. Typical morphology and age- a. Personal or family history 2. Keratosis pilaris/pityriasis alba/ specific patterns b. Immunoglobulin E (IgE) hyperlinear palms/ichthyosis • Infants/children: facial, neck, and reactivity exterior involvement 3. Xerosis 3. Ocular/periorbital changes • Any age group: current or 4. Other regional findings (eg, perioral previous, flexural lesions changes/periauricular lesions) • Sparing of the groin and axillary 5. Perifollicular accentuation, regions lichenification, or prurigo lesions b. Chronic or relapsing history Exclusionary Conditions Diagnosis of AD depends on excluding conditions • Scabies • Seborrheic dermatitis • Photosensitivity dermatoses • Psoriasis • Contact dermatitis • Immune deficiency diseases • Ichthyoses (irritant or allergic) • Erythroderma of other causes • Cutaneous T-cell lymphoma J Am Acad Dermatol 2014;70:338 Atopic Dermatitis: Distribution 21 Weidinger S et al. Lancet. Published online ahead of print September 14, 2015. Lancet 2016;387:1109 “Eczema Coxsackium” Pediatrics 2013;132:e149 Atopic Dermatitis: Treatment Guidelines Mild Disease 23 Moderate to Severe Disease Basic Management for All patients at All times (add maintenance and/or acute treatment as needed) Basic Management Maintenance TCI Maintenance Topical Corticosteroids 1. Skin care (pimecrolimus or tacrolimus) Medium-potency topical corticosteroids a. Moisturizera (choice depends on patient (class III-IV, see Table 3) once to twice 19-22 preference) liberal and frequent TCI 2 to 3 times weekly weekly (except for face/eyes)23 OR b. Warm baths or showers using nonsoap (if patient is AND/OR (depending on patient/physician cleansers or mild soaps generally once daily nonresponsive) preference and lesion location) 22,24,25 followed by application of moisturizera (even to TCI once to twice daily “uninvolved” skin) Low-potency topical corticosteroids (class V-VII, see Table 3) once to twice 2. Antiseptic measures daily (including face and eyes) Diluted bleach bathsb (or equivalent) twice weekly or more (daily for more severely affected children), especially for patients with recurrent skin infections 3. Trigger avoidance For relapsing course (frequent/persistent flares despite treatment) Avoid common irritants (eg, soaps, wool), Topical anti-inflammatory medication applied at first signs/symptoms temperature extremes, and proven allergens or to flare-prone areas Flare not resolved within 7 days Acute Treatment Acute Treatment Topical anti-inflammatory medication Consider Topical anti-inflammatory medication applied to inflamed skin nonadherence, applied to inflamed skin Medium-potency topical corticosteroids (class III-IV, infection, Low-potency topical corticosteroids (class VII) twice daily see Table 3) twice daily for up to 3 days beyond clearance misdiagnosis, for up to 3 days beyond clearance Consider possible secondary infection that may referral require oral antibiotic “Flare” (acute worsening of symptoms, necessitating escalation in treatment) Eichenfield LF et al. Pediatrics. 2015;136:554-565. Psychology Referral… early, as needed! Moisturizer Size Cost (Avg) Vaseline 13 oz $4.51 Eucerin Cream 16 oz $12.88 Cetaphil Lotion 16 oz $10.45 Cetaphil 10 oz $14.88 Restoraderm Aquaphor 14 oz $15.44 Aveeno Ecz Care 7.3 oz $12.42 Cerave Cream 16 oz $15.10 Vanicream 16 oz $13.19 Epiceram 90 g $175.30 Mycoplasma pneumoniae-Induced Rash and Mucositis (MIRM) Difference from drug or viral induced SJS/EM Generally w more limited skin involvement - vesiculobullous Oral>Ocular>GU mucosal involvement - mucositis alone seen in 34% Most with excellent recovery; ATB (!), IVIG, steroids - resistance (TCN or fluoroquinolone) Recurrence rarely J Am Acad Dermatol 2015;72: 239 Pediatrics 2011;127:e1605 Photos from: J Am Acad Dermatol 2105;72:239 Case History Ø A child is seen with rapidly developing morbilliform erythema, facial edema, and fever. These findings were noted approximately 21 days after starting carbamazepine. Laboratory studies show 13% eosinophilia and elevated liver functions. Case 1. Stevens-Johnson syndrome 2. Serum sickness – like eruption 3. Urticaria multiforme/Giant urticaria 4. Drug reaction with eosinophilia and systemic symptoms (DRESS) 5. Presidential fever Case 1. Stevens-Johnson syndrome 2. Serum sickness – like eruption 3. Urticaria multiforme/Giant urticaria 4. Drug reaction with eosinophilia and systemic symptoms (DRESS) 5. Presidential fever Case Which of the following viral conditions is associated with DRESS? A – Echovirus 8 infection B – Hepatitis A infection C – HHV-6 reactivation D – Influenza A E – Parvovirus infection Case Case Ø A – Echovirus 8 infection; has not been reported Ø B – Hepatitis A infection; has not been reported Ø C – HHV-6 reactivation; multiple reports of such; ? Due to cytotoxic T cell activation w cross reaction with drug and organ toxicity (also EBV, CMV) Ø D – Influenza A; has not been reported Ø E – Parvovirus infection; has not been reported DRESS – Associated Medications Anti- Anti- Anti- Biologics NSAIDs Misc infectives convulsa hypertens nts ives Dapsone Carbemazepin Amlodipin Imatinib Celecoxib Allopurino e e l Ampicillin Lamotrigin Captopril Vismodegi Ibuprofen Ranitidine e b Linezolid PBS Vemurafen ib Minocycline Phenytoin TMP/SMX Valproate Vancomycin INH DRESS – Systemic Concerns Autoimmune disease – - Grave’s - Type 1 DM - AA - Autoimmune hemolytic anemia End organ disease… most commonly renal Semin Cutan Med Surg 2014;33:2 DRESS - Management Stop the suspected medication Steroids… systemic v topical Retrospective study - 50 consecutive pts with d/c Dx: 38 prob or confirmed Potent topical steroids v Systemic steroids - Systemic tx not felt nec for mild disease - Systemic use felt to be assoc with viral reactivation (HHV6) and more severe/prolonged course
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