Update in Pediatric Dermatology
Zachary Zinn MD Assistant Professor WVU Department of Dermatology Objectives
Discuss new developments in dermatology Learn treatment pearls for most common pediatric dermatologic conditions Acne Vulgaris
Most common skin problem in U.S.1
1: KK Kraning, GF Odland: Prevalence, morbidity and cost of dermatological diseases. J Invest Dermatol. 73 (Suppl):395-401 1979 AL Zaenglein, DM Thiboutot: Acne vulgaris. JL Bolognia JL Jorizzo RP Rapini Dermatology. 2003 Mosby Edinburgh Hurwitz Clinical Pediatric Dermatology 5th Edition Hurwitz Clinical Pediatric Dermatology 5th Edition Hurwitz Clinical Pediatric Dermatology 5th Edition Guidelines
American Academy of Dermatology (AAD.org) Practice Management Center Quality Clinical Guidelines Acne Pearls
Benzoyl peroxide is recommended for patients on topical or systemic antibiotic therapy*
*Fulton JE Jr, Farzad-Bakshandeh A, Bradley S. Studies on the mechanism of action to topical benzoyl peroxide and vitamin A acid in acne vulgaris. J Cutan Pathol. 1974;1:191-200.
Acne Pearls
Given current data, no specific dietary changes are recommended in the management of acne Acne Vulgaris - Comorbidity
Decreased Increased emotional well- suicidal ideation being Poorer Withdrawal academic from society performance Depression Higher Decreased self- unemployment esteem rates Acne Pearls
Oral isotretinoin is used for: Severe Acne Non-responsive acne Acne that produces physical or psychological scars Verruca Vulgaris Therapeutic Pearls
Consider watchful waiting Lower expectations of treatment Therapeutic Pearl
+ Other Treatments Cryotherapy Immunotherapy Cimetidine 30-40mg/kg/day divided bid Imiquimod Candida antigen injection Pulsed dye laser Cantharidin Verruca plantaris Verruca Plana Condyloma Acuminata
AL Allen, EC Siegfried: The natural history of condyloma in children. J Am Acad Dermatol. 39:951-955 1998
Molluscum contagiosum
Hurwitz Clinical Pediatric Dermatology 5th Edition Molluscum contagiosum Treatment Observation Cantharidin Cryotherapy Do Not Use Curettage Imiquimod! Cimetidine Therapeutic Pearl
Cantharidin is preferred treatment by most pediatric dermatologists*
*Coloe J, Morrell DS. Cantharidin use among pediatric dermatologists in the treatment of molluscum contagiosum. Pediatr Dermatol 2009; 26: 405-408. Cantharidin
Vigorously shake bottle before using Apply with wooden end of cotton tip applicator Apply single drop Let dry 3-5 minutes Wash off in 2-6 hours
Therapeutic Pearl
Treat molluscum dermatitis to reduce auto-inoculation*
*E Netchiporouk, BA Cohen: Recognizing and managing eczematous id reactions to molluscum contagiosum virus in children. Pediatrics. 129:e1072-5 2012
Atopic Dermatitis (AD)
Characteristics Pruritus Relapsing and Recurring Course Onset in childhood Association with atopy
4 Pillars of Atopic Dermatitis
Xerosis Emollients Inflammation Anti- Inflammatories Infection Mupirocin; Itch Bleach baths Anti-histamines Treatment
Cutaneous hydration*
*Eichenfield LF et al. Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies. J Am Acad Dermatol. 2014 Jul;71(1):116-32 Atopic Dermatitis Pearl
Bathing is recommended, but no standard exists for frequency or duration*
*Eichenfield LF et al. Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies. J Am Acad Dermatol. 2014 Jul;71(1):116-32 Atopic Dermatitis Pearl
Bleach baths may reduce AD flares and AD severity*
*Huang JT, Abrams M, Tlougan B, Rademaker A, Paller AS. Treatment of Staphylococcus aureus colonization in atopic dermatitis decreases disease severity. Pediatrics 2009;123: e808-14 Bleach Bath: How To?
Add ½ cup of 6% household bleach to a full bath of warm water and mix ¼ cup if small bath 1-2 teaspoon per gallon for bucket bath Soak 10-20 minutes approximately twice weekly Rinse with normal water before exiting bath Atopic Dermatitis
What’s New?? Topical PDE4 Inhibitor
Crisaborole (Eucrisa) 2% ointment Approved for mild to moderate atopic dermatitis in ages 2 years or older Boron based topical phosphodiesterase inhibitor Application site burning most common SE Dupilumab
Fully human monoclonal Ab targeting IL-4R Approved for adults with mod-severe eczema in 2017 Approved for ages 12+ with mod-severe eczema recently
Psoriasis
Affects approximately 0.5-1.0% of children less than age 18
Psoriasis Comorbidity
Obesity Hyperlipidemia Hypertension Metabolic Syndrome Psoriasis Pearl
Start screening earlier for arthritis, depression and anxiety Screen for overweight/obesity using BMI starting at age 2 Screen for diabetes every 3 years starting at age 10, or at puberty if obese plus other risk factors
Infantile Hemangioma (IH)
Most common benign soft-tissue tumor of childhood
Affects up to 5% of children Natural History IH-Treatment
Observation alone most commonly
Reasons to treat: Function threatening Disfiguring Ulcerated Propranolol for severe hemangiomas of infancy. Leaute-Labreze C et al. N Engl J Med. 2008 Jun 12;358(24):2649-51. Propranolol
Vasoconstrictive on endothelial cells Decrease nitric oxide Decrease VEGF Induce apoptosis of endothelial cells
Infantile Hemangiomas: What Have We Learned from Propranolol? Hagen R, Ghareeb E, Jalali O, Zinn Z. Curr Opin Pediatr. 2018 Aug;30(4):499-504. Propranolol
Side effects: Nightmares/insomnia Hypoglycemia Hypotension Bradycardia Bronchospasm Hypothermia Propranolol Safety
Propranolol enters CSF Propranolol impairs: “Word/photographic recall Reaction time Sleep Propranolol and central nervous system function: potential implications for paediatric patients with infantile hemangiomas. Langley A, Pope, E. Br J Dermatol 2015; Jan 172(1):13-23 Propranolol Safety
Vadimovich, A et al. Propranolol treatment of infantile hemangioma (IH) is not associated with developmental risk or growth impairment at age 4 years. J Am Acad Dermatol 2016;75:59-63. Parents completed Dutch 48-months ASQ Height and weight were collected from charts 82 Patients included in the study No difference on ASQ from controls Propranolol Safety
Moyakine A, Koulil S, van der Vleuten C. Propranolol treatment of infantile hemangioma is not associated with psychological problems at 7 years of age. J Am Acad Dermatol. 2017; 77:105-8 Propranolol Pearls
Excellent safety profile Can be initiated outpatient Best response if started early Propranolol
Outpatient Initiation: Greater than 8 weeks AGA Good social support Lack of comorbid conditions
Timolol maleate
Puttgen, K et al. Topical Timolol Maleate Treatment of Infantile Hemangiomas. Pediatrics. Sept 2016 Vol 138
Retrospective multi center study including 731 patients across 9 centers Timolol maleate
IH likely to respond if thin
Excellent alternative to watchful waiting
Nevus Flammeus (Port Wine Stain (PWS))
Macular stains with pink-red color A capillary malformation Lack rapid growth or proliferation Often unilateral, favor the face Sturge-Weber Syndrome
PWS Leptomeningeal angiomatosis Glaucoma Sturge Weber Syndrome and Port-Wine Stains Caused by Somatic Mutation in GNAQ. Shirly et al. NEJM. March 2013
Port-Wine Stain
Laser Treatment Pulsed-dye laser Port-Wine Stain Pearls
Benefit of early treatment Better clinical response Less risk of anesthesia Psychological benefits
Conclusions Acne Always BPO if on antibiotics No dietary changes Isotretinoin highly effective Warts Wart stick plus duct tape occlusion Lower expectations of treatment Conclusions
Molluscum Cantharidin highly effective Cimetidine for immune boost Atopic Dermatitis Moisturize! Consider bleach baths Dupilumab Conclusions
Psoriasis Guttate flare after strep Screen for cardiovascular comorbidity Conclusions
Infantile Hemangioma Benefit of early treatment w/propranolol Consider timolol as alternative to watchful waiting Port Wine Stain Benefit of early treatment w/PDL Less risk; Better result Questions???