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Scalp Dermoid Cyst What Lies Beneath? Skin Nodules, Lumps & Bumps Renee Howard, MD Professor of Dermatology, UCSF Director of Dermatology UCSF Benioff Children’s Hospital Oakland Renee Howard MD DISCLOSURES I have no relevant relationships with industry Objectives Learn efficient approach to diagnosis and treatment Outline differential diagnosis of skin nodules at “high risk hotspots”: nose/brow, scalp, lower back, neck 5 Facts to Know and Tell Who = Other anomalies or systemic issues What = Morphology Vascular stain, pigmentary change, pit, aplasia cutis, nodule, mass When=Congenital, at what age acquired Where= Hotspots How ➡️ high risk or low risk for deep extension How? Management Low risk Observation High Risk Imaging Referral Neurosurgery ENT Plastic Surgery Pediatric Surgery Where? Developmental hotspots = Embryological fusion From Kos and Drolet. Neonatal Dermatology 2nd Edition 10 month-old with subtle lump nasal bridge, slowing increasing in size Nasal Midline Dermoid cyst/sinus, glioma (5-7%), encephalocele High risk CNS extension Common embryologic origin Dermoid Cysts Entrapment of surface ectoderm Midline or over suture lines higher risk Can rupture, become inflamed or infected, erode bone Nasal Dermoid rare J Neurosurg Pediatr. 2017 Jul;20(1):30-34. International Journal of Pediatric Otorhinolaryngology 2015 79, 18-22 102 cases 58 superficial 38 intraosseous 10 intracranial International Journal of Pediatric Otorhinolaryngology 2015 79, 18-22DOI: (10.1016/j.ijporl.2014.10.020) Copyright © 2014 Elsevier Ireland Ltd Terms and Conditions Nasal Dermal Sinus Tract (DST) Congenital midline pit Tuft of hair Oily or clear discharge (CSF!) 10-30% extend deep +/- cyst anywhere along the tract Complications infectious or aseptic meningitis Nasal Midline Checklist Who: healthy newborn or toddler What: pit, tuft of hair, nodule When: sinus tract congenital, cyst first few years of life Where: midline glabella to nasal tip How Refer to: ENT + Neurosurgeon Imaging-MRI with contrast for soft tissue, CT for bony defects prn Lateral Brow Most common location of dermoid cysts 60-68% of craniofacial dermoids on lateral brow Lateral Brow Dermoid Cyst Who: healthy infant or toddler What: slowly growing nodule When: first few years of life Where: lateral 1/3 eyebrow How No imaging needed as no extension Observation ENT or plastic surgeon for endoscopic or simple excision J Laparoendosc Adv Surg Tech A. 2018 May;28(5):617-621. Developmental hotspots = Embryological fusion lines From Kos and Drolet. Neonatal Dermatology 2nd Edition Imagine these 2 kids come in… There are two patients in two rooms One requires quick reassurance--low risk The other needs imaging and/or surgical referral--high risk Low risk: active nonintervention Off midline Soft slow growing nodule Mobile High risk: imaging/refer Midline membranous aplasia cutis congenita Hair collar Which scalp lesion is high risk? High risk: imaging/refer Midline membranous aplasia cutis Hair collar Low risk: active nonintervention Scar like No other skin or hair changes Dias et al. Pediatrics 2015; 136:e1105-1119 Scalp Aplasia Cutis Congenita (ACC) 86% of ACC located on scalp Most sporadic though can be syndromic Presents at birth as erosion or scar like area with alopecia Hair collar sign high risk Journal of Perinatology (2018) 38, 110–117. Hair Collar Sign Bessis et al J Am Acad Dermatol 2017;76:478-487. Scalp ACC: When to MRI Midline Membranous Hair collar YES YES Vascular stain YES Which scalp nodule is high risk? Hemangioma vs. Dermoid Cyst -Natural history, skin changes, firmness -Ultrasound or refer -Active nonintervention Scalp Dermoid Cyst 2nd most common location after lateral brow (9%) Presents < 4 years, 40% congenital Usually asymptomatic, firm, fixed to underlying bone Slowly enlarge then stabilize Plast Reconstr Surg. 2020 Jan 9 Pediatr Dermatol 2013; 30:706-11. School age boy with hx of lump and alopecia for years Scalp Dermoid Cyst Retrospective studies by neurosurgeons 33-46% eroded or within bone Higher rate in patients older at time of surgery Time of surgery 33% <1 year, 49% 1-3 years; all did well Neurosurgeons: refer for excision at time of presentation World Neurosurg. 2018;120:119-124. J Neurosurg Pediatr. 2017;20:30-34. “Tip of the Iceberg” phenomenon Dias et al. Pediatrics 2015; 136:e1105-1119 Scalp Dermal Sinus Tracts (DST) Located parietooccipital With or without associated cyst Intracranial extension through midline occipital skull defect into dura Dias et al. Pediatrics 2015; 136:e1105-1119 Scalp: ACC, Pit, Nodule High risk Low risk Present at birth Later onset Midline, especially vertex, occipital Off midline Nodule, membranous ACC, pit Soft mobile nodule, scar -like ACC Multiple signs Other signs Hair collar Focal hemangioma, hyperpigmentation Vascular stain Pediatr Dermatol. 2018 Jan;35(1):e59-e61. Dias et al. Pediatrics 2015; 136:e1105-1119 8 month old with 2 skin lesions Hotspot: Lumbosacral Spine Pits Aplasia cutis Nodules and subcutaneous masses Vascular stains Segmental hemangiomas Hypertrichosis Consequences of Undiagnosed LS anomalies Infection + vascular stain, mass Aseptic meningitis Atretic cephalocele Spinal cord compression Tethered cord Dias et al Pediatrics 2015 Oct;136:e1105-19. Lumbosacral lipoma with intraspinal lipoma and tethered cord Photos courtesy of Ilona Frieden MD Hypertrichosis Dias et al Pediatrics 2015 Oct;136:e1105-19. Dermal sinus tracts Innocent coccygeal pit in presenting as a pit intergluteal cleft Pediatrics 2015 Oct;136:e1105-19. Dimple Dilemma Common, in 2-4% of newborns Blind-ended dimple/pit not necessarily innocent Location of the dimple along the craniocaudal axis? Flat part of sacrum at S2 greatest risk Neurosurgeon’s decision to treat based on presence of a pathologic dimple, regardless of imaging IF UNSURE THEN REFER Pediatrics 2015:136:e1105-19. J Neurosurg Pediatr. 2017 Feb;19(2):217-226. Ultrasound Screening Skin Signs OSD 2.2-7.2% newborns w/skin signs .5% have operable spinal lesion Prospective study 475 newborns Ultrasound abnormal in 39 MRI confirmed OSD in 12 High risk > 1 skin sign Highest risk dermal sinus Lowest simple sacral dimple 1.2% required neurosurgery Ausili E, et al Childs Nerv Syst. 2018 Feb;34(2):285-291. MRI for Occult Spinal Dysraphism (OSD) 522 patients screened due to cutaneous stigmata over 6 years Average age 6 months OSD found in 23% OSD in 20% of those with dimples In this series, dimple location did not correlated with OSD J Neurosurg Pediatr. 2017 Feb;19:217-226. Cutaneous Signs LS Spine High risk Low risk Midline mass, membranous ACC Off midline Thick tuft of terminal hair Diffuse fine hair Pit over sacrum Pit low in intergluteal crease (?) Vascular stains + Pigment changes, nevus, small Tail hemangioma Segmental hemangioma Isolated deviation crease Checklist for LS Spine Who: other GU, GI, midline defects What: pit, ACC, nodule, vascular stain, tail, hair tuft, segmental hemangioma When: at birth Where: midline, above gluteal crease How: ultrasound if first six months, MRI and… How Refer to neurosurgery if any chance high risk REGARDLESS of imaging ←Read this 11 year old with slowly enlarging neck nodule PILOMATRIXOMA Thyroglossal, Branchial Cleft ➡️ ➡️ ➡️ http://www.ghorayeb.com/branchialcleft.html OtolarynologyCurr Opin Otolaryngol Head Neck Surg. 2012 Dec;20:533-9. Neck: Developmental Anomalies Cartilaginous rest/wattle Midline anterior neck inclusion cyst (MANIAC) Thyroglossal duct cyst Branchial cleft cyst Dermoid cyst Midline cervical cleft Thymic cyst Bronchogenic cyst Figure 9-2 Neonatal Dermatology, 2nd edition Neck: Pits, Tags, Nodules High risk Low risk Present at birth Later onset Midline or just anterior to SCM Off midline, not anterior to SCM Nodule, pits, especially with Firm blue plate like nodule or milia discharge like superficial cyst even if midline Figure 1 Walsh R Pediatr Dermatol 2018 Jan;35(1):55. What Lies Beneath Remember Importance of “Where”: Illustration Textbook of Neonatal and Infant Dermatology, 3rd Edition Photos Dias et al. Pediatrics 2015;136:e1105-e1119 Many thanks to Dr. Betts and UCSF Benioff Children’s Hospital Oakland pedi derm team Pediatric trainees & colleagues UCSF Pediatric dermatology team Patients and families Photo courtesy of Ann Petru Dr. Nicole Kittler, me, Anjali Washington PA-C Sport-Related Concussion in Pediatrics Celina de Borja, MD Pediatric Musculoskeletal and Sports Medicine Assistant Clinical Professor Division of Pediatric Orthopaedics UCSF Benioff Children’s Hospitals Disclosures . I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity . I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation 2 Learning Objectives . Identify, diagnose and evaluate concussions . Discuss main principles of concussion management . Tackle common questions that parents raise regarding concussions 3 Case 1 4 Ava“is a 15 year old female cheerleader with a chief complaint of headaches for 5 days. It all started after she got kicked in the head during practice. She denies LOC, but reports headaches and balance issues immediately after the injury. She didn’t tell anyone and finished the last 10 minutes of practice. On the way home, she experienced light sensitivity from the cars on the freeway, which was followed by difficulty
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