Staying A-’Head’ in Pediatric Dermatology: Common Scalp and Hair Diagnoses
Matt Grisham, MD Greenville Health System Post-Graduate Seminar April 20, 2016 I have no financial disclosures or conflicts of interest.
Objectives • Discuss common pediatric dermatologic diagnoses affecting the scalp and hair
• Identify key features on history and exam to help narrow the differential diagnosis
• Generate appropriate therapeutic plans for these conditions
• Born at term gestation by C/S without complication
• No maternal medications or infections
• Prenatal US and quad screening were both normal
Cutis Aplasia Congenita • Born at term gestation by C/S without complication
• No maternal medications or infections
• Prenatal US and quad screening were both normal
Cutis Aplasia Congenita • 80% occur at the vertex o Can occur on face, trunk, and extremities
• Majority are single lesions
• Healing over weeks to months, forming a hairless scar
• Larger lesions may warrant plastic surgery
Trisomy 13 (Patau Syndrome) • Midline cleft palate/lip
• Holoprosencephaly
• Omphalocoele
• Polydactyly
• Cardiac anomalies
• Renal anomalies Nevus Sebaceous
Congenital lesion that grows with the child and eventually thickens in adolescence Basal Cell Carcinoma
• Began on the scalp and is now spreading onto forehead • Using baby shampoo daily without improvement
Seborrheic Dermatitis
• Began on the scalp and is now spreading onto forehead • Using baby shampoo daily without improvement
Seborrheic Dermatitis • Occurs in areas with highest concentration of sebaceous glands
• Controversial fungal etiology
• Self-limiting (8-12 mos) o Mineral/baby oil o Selenium sulfide shampoo o Zinc pyrithione shampoo o Topical steroids o Topical antifungal
6 Months Later… • Scalp issues have persisted despite anti- seborrheic shampoo
• Cheeks and chin are now involved
• Loves to eat
• Beginning to teethe
Atopic Dermatitis
• Commonly affects the infant scalp
• Dry appearance vs. greasy scale
• Predictable involvement of other sites
• Positive family history of atopy
• Mom worried about a ‘knot’ on the back of his head
• Recent haircut and noticed this spot as well
• She wants to know if she needs to get rid of the family pet.
Tinea Capitis • Mom worried about a ‘knot’ on the back of his head
• Recent haircut and noticed this spot as well
• She wants to know if she needs to get rid of the family pet.
Tinea Capitis
• Black Dots = Fractured Hair
• Dermatophyte infection o Trichophyton tonsurans o Microsporum canis
• Kerion
Tinea Capitis
Tinea Capitis
• Black Dots = Fractured Hair
• Dermatophyte infection o Trichophyton tonsurans o Microsporum canis
• Kerion
Tinea Capitis
Drug Dosage Duration Griseofulvin microsize 20–25 mg/kg/day ≥6 wk; continue until (liquid 125 mg/5 mL) clinically clear Griseofulvin ultramicros 10–15 mg/kg/day ≥6 wk; continue until ize (tablets of varying clinically clear size) Terbinafine tablets (250 4–6 mg/kg/day T tonsurans: 2–6 wk mg) 10–20 kg: 62.5 mg M canis: 8–12 wk 20–40 kg: 125 mg >40 kg: 250 mg Terbinafine granules <25 kg: 125 mg FDA approved for (125 mg and 187.5 mg) 25–35 kg: 187.5 mg children ≥4 y >35 kg: 250 mg 6-wk duration for all species Fluconazole 6 mg/kg/day 3–6 wk FDA approved for children >2 y Id Reaction
• Widespread papular rash
• Pruritic
• Treatment o Oral antihistamines o Topical corticosteroids Traction Alopecia • Hair loss along lines of tension
• Regional adenopathy is common
• Treatment o Discontinue hairstyling
• Complication o Traction folliculitis Traction Folliculitis Late Childhood/Early Adolescence • This middle school female is being teased Now refusing to attend school o
• Closer inspection of her scalp reveals…
Trichotillomania
• This middle school female is being teased Now refusing to attend school o
• Closer inspection of her scalp reveals…
Trichotillomania • dsafsdf • Association with OCD and anxiety • Treatment o Address the underlying psychiatric disorder • Appendectomy 3 months ago… Telogen Effluvium • Appendectomy 3 months ago… Telogen Effluvium • Diffuse thinning of the hair seen 6-16 weeks after a stressful event o Thyroid disorders o SLE o Fe-deficiency anemia o Oral contraceptives
• Treatment: address any underlying cause + time
• Single patch of hair loss over the last few days
• No recent stressful events or prior tinea infections
• Never noted scaling, pustules
• Anxious because dad is bald
• Single patch of hair loss over the last few days
• No recent stressful events or prior tinea infections
• Never noted scaling, pustules
• Anxious because dad is bald
Alopecia Areata • Single patch of hair loss over the last few days
• No recent stressful events or prior tinea infections
• Never noted scaling, pustules
• Anxious because dad is bald
Alopecia Areata • New patches of hair loss may appear for 4-6 weeks (or months) o Alopecia universalis
• Scotch-plaid nails
• Treatment • Complete resolution in Topical steroids (Class I/II) o 95% within one year if o Intralesional steroid injections o Anthralin 1% cream mildly affected 2% minoxidil solution o o 30% experience relapse o Psychological support
Dandruff that is not improving with selenium sulfide or pyrithione zinc shampoo
Psoriasis
Dandruff that is not improving with selenium sulfide or pyrithione zinc shampoo
Psoriasis
Auspitz sign Psoriasis • Knees and elbows commonly affected
• Positive family history
Scalp Psoriasis: Management • Topical corticosteroids o Fluocinolone 0.01% in peanut oil base • Shampoo options o Coar-tar based o Zinc-based o Keratinolytic
• Look for an occult Streptococcus pyogenes infection • Avoid vigorous brushing, combing, scratching of the scalp Pediatric Dermatology Resources • Hurwitz Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence by Paller and Mancini (~$185)
• Atlas of Pediatric Physical Diagnosis by Zitelli and Davis (~$90)
• Pediatric Dermatology: A Quick Reference Guide by Krowchuk and Mancini (~$90 – new edition coming in May 2016)
• VisualDx (online and app format- iOS and Android) Thank you for your time and attention.
Any Questions?