Pediatric Dermatology Updates & Common Curbsides EMILY CROCE, MSN, APRN, CPNP-PC, PHD STUDENT PEDIATRIC & ADOLESCENT DERMATOLOGY DELL CHILDREN’S MEDICAL CENTER, AUSTIN, TEXAS THE UNIVERSITY OF TEXAS AT AUSTIN No relevant conflict of interest DISCLOSURES: Some off-label discussion, but commonly used indications Case 1: 5 y/o male with few month hx molluscum contagiosum. In the last week they have become red, tender, and “angry.” Do we: A. Begin mupirocin B. Begin oral antibiotic with staph coverage C. I&D D. Reassurance B.O.T.E. Sign Beginning of the end Inflammation is a sign that there is an immune response and, often, impending resolution Comfort measures such as warm compresses Discuss signs infection and reasons to return Reassurance Warts & Molluscum Update: No definitive therapy…nothing new about this! Tretinoin or OTC Differin gel may be useful every 1-2 nights Wart Stick - strongest OTC salicylic acid product Efudex every 2 nights x 12 wks Compounded topical such as Wart Peel Cimetidine 2—40 mg/kg/day x 2-3 months (or longer if helping) Molluscum dermatitis – treat like eczema Liquid nitrogen, cantharidin, candida antigen injections all still work…but only about 40% of the time Case 2: Parents of 2 y/o female with atopic dermatitis are worried about steroid s/e and black box warning on topical calcineurin inhibitors, but Eucrisa is not helping and patient is miserable. How we will treat and reassure: A. Steroid s/e and how to use B. Topical calcineurin inhibitor discussion C. To Eucrisa or not to Eucrisa D. Reinforce skin care routine How we will treat and reassure: A. Steroid s/e and how to use B. Topical calcineurin inhibitor discussion C. To Eucrisa or not to Eucrisa D. Reinforce skin care routine Topical Steroid Potency Chart • Low potency for face • Medium to high for extremities/torso depending on thickness of plaques, response to steroids, age • BID x 1-2 wks for flare then 2-3x/wk when needed on “hot spots” to maintain Topical steroid safety profile: Tacrolimus (Protopic) & Pimecrolimus (Elidel) Black box warning: animals in trials developed lymphomas PEER – long-term Pimecrolimus registry has not documented increased risk malignancy in normal topical use in children Crisabarole (Eucrisa) Benefits: do not cause atrophy, okay on thin-skinned areas, good for maintenance, Eucrisa approved to 3 mos, Protopic/Elidel approved to 2 yrs (but studied down to 3 mos) Cons: $$$, insurance coverage Topical calcineurin inhibitors & Eucrisa: Tacrolimus (Protopic) & Pimecrolimus (Elidel) Black box warning: animals in trials developed lymphomas PEER – long-term Pimecrolimus registry has not documented increased risk malignancy in normal topical use in children Crisabarole (Eucrisa) Benefits: do not cause atrophy, okay on thin-skinned areas, good for maintenance, Eucrisa approved to 3 mos, Protopic/Elidel approved to 2 yrs (but studied down to 3 mos) Cons: $$$, insurance coverage Case 3: 7 y/o male with few month hx scaly plaques and hair loss on scalp. No significant medical history, topical terbinafine is not helping. Tinea capitis treatment tips: Palpate for lymph nodes Culture (but probably okay to start treatment) to confirm dx and determine microsporum vs trichophyton Affected family members and fomites should be addressed Griseofulvin or terbinafine…but give enough med for long enough duration! 20 mg/kg/day x 6-8 wks griseofulvin or weight-based dosing terbinafine po x 4-6 wks Risk is low in otherwise healthy child, labs studies not indicated unless prolonged course If kerion, may need oral antibiotic and or oral/topical steroid Case 4: 14 y/o female with few year hx acne on face and back. No improvement with OTC products or rx benzoyl peroxide-clindamycin gel Acne plan of attack: Type Comedonal needs a retinoid Inflammatory probably needs benzoyl peroxide +/- antibiotic Most need both! Distribution Chest/back may require wash and/or PO Beard distribution in girls – ask about menstrual hx, consider PCOS Severity Scarring Response to therapy Impact on patient Cost Complexity of treatment regimen Acne treatment: Topical retinoid Tretinoin, adapalene, tazorac Start slow, advance as tolerated, moisturize, educate Topical antibiotic and/or antimicrobial Clindamycin Benzoyl peroxide Combo clinda/bpo Oral antibiotic Doxycycline minocycline Isotretinoin (Accutane) OCP, spironolactone Clascoterone Case 5: 6 wk old male with small red papules on back and arm. Started to appear around 2 weeks of age. Baby is otherwise healthy. What is your workup, if any? Hemangiomas: Benign vascular growths with some potential complications Cosmetic Glabella, eyelid, nose, lip, areola genitalia Ulceration Especially if friction such as diaper area, axilla or fast growing Syndromic or signifying underlying issues Superficial & plaque-like on face, midline spine, beard distribution 5+ hemangiomas = hemangiomatosis, obtain liver u/s early Functional If in doubt, refer early to dermatology Case 6: 9 month-old male with itchy red papules and nodules scattered on torso and extremities, concentrated on axillae. He has been treated x 1 with permethrin without improvement. No affected family members. Scabies: The main reason we see treatment failure in our clinic is inadequate treatment of household members and close contacts. All household members must be treated, even if they are not symptomatic Ask, ask, ask again if they all treated Standard of care is permethrin 5% cream applied (neck down if over 1 year or head to toes if under 1 year) at bedtime, rinse in morning, repeat in 14 days The itch may persist for up to a month due to hypersensitivity but new burrows/pustules should not be appearing after 2nd treatment Consider PO ivermectin for difficult cases or crusted scabies References BUTALA, N., SIEGFRIED, E., & WEISSLER, A. (2013). MOLLUSCUM BOTE SIGN: A PREDICTOR OF IMMINENT RESOLUTION. PEDIATRICS, 131(5), E1650-E1653; DOI: 10.1542/PEDS.2012-2933 DIAMANTIS, S. A., MORRELL, D. S., & BURKHART, C. N. (2009). PEDIATRIC INFESTATIONS. PEDIATRIC ANNALS, 38(6), 326–332. HTTPS://DOI-ORG.EZPROXY.LIB.UTEXAS.EDU/10.3928/00904481-20090521-05 EICHENFIELD, L. ET AL. (2013). EVIDENCE-BASED RECOMMENDATIONS FOR THE DIAGNOSIS AND TREATMENT OF PEDIATRIC ACNE. PEDIATRICS, 131(SUPPL3), S163-S186. MARGOLIS, D. J., ABUABARA, K., HOFFSTAD, O. J., WAN, J., RAIMONDO, D., & BILKER, W. B. (2015). ASSOCIATION BETWEEN MALIGNANCY AND TOPICAL USE OF PIMECROLIMUS. JAMA DERMATOLOGY, 151(6), 594–599. HTTPS://DOI-ORG.EZPROXY.LIB.UTEXAS.EDU/10.1001/JAMADERMATOL.2014.4305 PAPIER, A., & STROWD, L. C. (2018). ATOPIC DERMATITIS: A REVIEW OF TOPICAL NONSTEROID THERAPY. DRUGS IN CONTEXT, 7, 212521. HTTPS://DOI-ORG.EZPROXY.LIB.UTEXAS.EDU/10.7573/DIC.212521 SIEGFRIED, E. C., JAWORSKI, J. C., KAISER, J. D., & HEBERT, A. A. (2016). SYSTEMATIC REVIEW OF PUBLISHED TRIALS: LONG-TERM SAFETY OF TOPICAL CORTICOSTEROIDS AND TOPICAL CALCINEURIN INHIBITORS IN PEDIATRIC PATIENTS WITH ATOPIC DERMATITIS. BMC PEDIATRICS, 16, 75. HTTPS://DOI-ORG.EZPROXY.LIB.UTEXAS.EDU/10.1186/S12887-016- 0607-9 SMITH, C., FRIEDLANDER, S. F., GUMA, M., KAVANAUGH, A., & CHAMBERS, C. D. (2017). INFANTILE HEMANGIOMAS: AN UPDATED REVIEW ON RISK FACTORS, PATHOGENESIS, AND TREATMENT. BIRTH DEFECTS RESEARCH, 109(11), 809– 815. 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