8/29/14 Pediatric Dermatology Overview - From Head to Toe Joanna Guenther, PhD, RN, FNP-BC, CNE September 2014 Objecves • Discuss a systemac approach to common dermatologic condiMons of children encountered in primary care. • Describe the clinical manifestaons of common dermatologic condiMons of children. • Review therapeuMc and pharmacologic treatments for each dermatologic condiMon. History Taking • Age, race, and sex • Onset/duraon • Locaon on body • Evoluon of lesions • Treatment aempted • Associated symptoms – Pruritus, fever, headache, GI, etc – Think infecMon with rash + fever 1 8/29/14 AddiMonal Aspects of History • Family history • Known personal contacts • Trauma • Travel & play • Environmental exposure – Insects, plants, toxins, sun, etc • Season Primary Skin Lesions Atopic DermaMs Eczema Treatment: • Inherited predisposiMon - • Rehydraon of skin, oen hx. Asthma, allergic anMhistamines, topical low rhiniMs, food allergies potency steroid creams, • Usually affects cheeks, face, Elidel or Protopic cream bid trunk, extremiMes • Erythematous papules to scaly plaques • Intense pruritus >> scratching >> risk of impego 2 8/29/14 Seborrheic DermaMs Cradle Cap Treatment: • Common during first several • Emollient – baby oil months of life • Baby shampoo + soZ brush • OZen on face & scalp, but can extend to other areas • Well circumscribed plaques with scaling • Resolves by 6-12 months ImpeMgo Characteriscs: Treatment: • InfecMon usually caused by • Bactroban (mupirocin) oint d X 7 days; Altabax oint bid X 5 days + staph aureus; contagious warm compresses and gentle • Red papules >>> fragile washing vesicles >>> honey-colored • Oral anMbx - dicloxacillin, cephalexin, clindamycin X 7 days crusted papules • Recurrence: check for nasal carrier of MRSA with C&S swab (Bactroban intranasally) MRSA • Methicillin-resistant staphylococcus aureus • Only responds to certain anMbioMcs – local anMbioMc suscepMbility (clindamycin 40 mg/kg in 3-4 daily doses or, bactrim 8-12 mg trimethoprim/kg in 2 daily doses) • Enters through cuts and wounds • OZen starts as small bumps that resemble pimples and quickly turn to painful, deep abscesses • Risk factors: contact sports, sharing towels, weakened immune system • PrevenMon: Good handwashing 3 8/29/14 Cellulis Characteriscs: Treatment: • Erythema, edema, warmth, taut shiny skin, tender • Cause staph or strep, • Erisypelas – superficial erythematous complicaon of wound or trauma patch >>> fiery red, indurated, tense (dog/cat bite) • CelluliMs – deep infecMon, usually caused by beta-hemolyMc Strep or Staph aureus, • The borders are well defined and or complicaon of wound or trauma (dog/ change rapidly cat bite) • Immediate aenMon – C&S if draining; CBC; IV anMbioMcs followed by oral • Facial celluliMs can cause visual damage if spreads to eyes • Elevate & heat 4 8/29/14 Trauma • Animal Bite vs. Scratch – Cat & Dog Bite: Pasteurella species most common – also staph and strep – Txment: Wound care, AnMbioMcs • Amoxicillin-clavulanate, doxycycline > 8 yrs old • Oral vs. parenteral depends on wound depth & severity • Tetanus/Rabies prophylaxis – Cat Scratch: Bartonella pathogen most common • Azithromycin or clarithromycin most effecMve Candidal Diaper DermaMs Characteriscs: Treatment: • Confluent bright red papules and • Frequent diaper changes; plaques with scaered pustulo- expose skin to air vesicular satellite lesions • Topical pastes and ointments • Caused by moist environment, urine/ to serve as a barrier – zinc stool increase the pH, fricMon from oxide (Desin, A&D Ointment) diaper • AnMfungal creams (nystan, • Candida albicans invade clotrimazole, miconazole) • Severely inflamed – 1% hydrocorMsone sparingly bid for 5-7 days • Mupirocin ointment only if infecMon present Hand-Foot-and -Mouth Characteriscs: Treatment: • Caused by Coxsackie virus • SupporMve; oral ulcers A16 tender – Anbesol, Orajel • Abrupt onset of scaered • Lasts < 1 week papular & 3-6 mm elongated vesicular lesions on palms, soles & mouth • Sxs: fever, malaise, joint aches, sore throat 5 8/29/14 Erythema InfecMosum Fi6h Disease Treatment: • Caused by parvovirus B19; • Supporve (fever, common in late winter & hydraon); Good early spring; spread by resp. handwashing droplets • Fever, malaise, h/a, sore throat, coryza >>> slapped cheek rash appears aer 48 hrs >>> diffuse, lacy pink rash on body X 1-2 wks • Contagious before rash Pityriasis Rosea Characteriscs: Treatment: • Prodrome sxs: malaise, headache, • Control pruritus: calamine, sore throat topical steroids, oral • Diffuse raised red patches with anMhistamines central scales in Christmas tree • Rash will subside without paern; first lesion is herald treatment – may last 6 weeks patch (large oval plaque) with more lesions 5-10 days later • ? Viral eMology Roseola Characteriscs: Treatment: • Caused by Human • SupporMve: Control fever herpesvirus 6 (HHV-6) and increased hydraon • Common age 7-13 months • High fever (oZen >104⁰ F) and irritability for 3-5 days • Blanching maculopapular rash develops as fever decreases 6 8/29/14 Measles Characteriscs: Treatment: • Rubeola – Paramyxovirus • Highly contagious 4 days • Prodrome: fever, malaise, dry before and aer rash cough, conjuncvis, photophobia >> 3-4 days rash • SupporMve care: control develops fever; increase fluids • NonpuriMc maculopapular, blanching rash starts on face and spreads to trunk & extremiMes • Koplik spots on buccal mucosa • Incubaon period 8-12 days Varicella Chicken Pox Treatment • Fever, sore throat, malaise • Symptomac: Cool compresses, X 2 D >>> rash starts on face oatmeal baths; RX. or trunk and spreads diphenhydramine, hydroxyzine, downward fexofenadrine, loratadine • Rash progresses from red • Watch for secondary impeMgo macules >> papules >> due to scratching vesicles >> umbilicated pustules >>> crusMng • Less common since varicella vaccine • Incubaon 7-21 days Verruca Warts Treatment • Caused by HPV - > 150 • No rouMnely effecMve treatment subtypes – may spontaneously resolve – Cryotherapy q wk X3 • Lesions raised, pink, rough – Podofilox (Condylox) topical growths 0.5% soln bid for 3 consecuMve days/wk up to 4 weeks – Aldara topical thin layer 3 X per week – alternang days – Laser ablaon 7 8/29/14 Molluscum Contagiosum Molluscum Treatment • Caused by pox virus – more • May treat to prevent spread to common in pedi; others: – Cryotherapy considered contagious – Laser ablaon • Clusters of 3-5 mm flesh colored papules with umbilicated center; usually < 30 lesions • Resolve spontaneously over months to yrs Herpes Simplex Virus Fever blister; genital herpes Treatment: • Either Type I or II • Acyclovir topical q 3 h X 7 D • Clear papules with superficial • > 2 yrs – acyclovir susp ulceraons/erosions 20mg/kg qid X 5 D • OZen preceded by burning pain • Genital herpes – child abuse • Contagious GuUate Psoriasis Characteriscs: Treatment: • Inflammatory changes occur • Rash usually resolves on own within the epidermis & (weeks to months) dermis; increased turnover rate of dermal cells • Numerous salmon-pink, scaling, small plaques on trunk and extremiMes (usually 2-4 weeks aer strep pharyngiMs or URI) 8 8/29/14 Adolescent Acne Characteriscs: Treatment: • ObstrucMon of oil glands • Avoid oil based cosmeMcs • Mild: topical clindamycin and • Open comedones or closed erythromycin in AM & benzoyl peroxide 2.5-5% @ hs or topical comedones; pustules, renoids (Differin, ReMn-A) .025-. nodules, cysts 05% @ hs • Moderate: above regimen + minocycline or doxycycline 50-100 mg bid, tapering to 50 mg/d as acne improves; OCP (progesMn & estrogen) • Severe: Accutane – refer to dermatologist (labs & pregnancy test, contracepMon, informed consent) Tinea CapiMs/Tinea Corporis Characteriscs: Treatment: • Well defined circular patches with • Topical anMfungals scaly borders – Terbinafine (lamisil), • Occurs aer contact with person/ Miconazole, ketoconazole, animal that has fungus not nystan (for candida) • Use oral anMfungals if creams fail Tinea Pedis Athlete’s Foot Treatment: • Lesions are pruriMc and • KOH examinaon of scales – clusters of scaly with raised border; hyphae may become fissured • Keep feet dry • Contagious • Extensive – oral terbinafine, itraconazole • AnMfungal cream/powders (1-4 wks) – OTC -Miconazole, clotrimazole 9 8/29/14 Keratosis Pilaris Characteriscs: Treatment • Excess keran forms plugs in the • Emollients and mild hair follicles exfoliaon • Symmetric sandpaper like follicular papules • Considered a normal skin variant ParasiMc - Pediculosis Lice Treatment: • Nit (egg) adheres to hair >>> • Spread by shared hats, clothing, develops into louse in 3-4 D >>> able towels, combs, etc. to reproduce in 12 D >>> single • ferMlizaon needed to lay 10 eggs/ OTC pyrethrin (RID) and day for 30 day life span permethrin (Nix) – usually 2 • Louse pierce the skin and secrete txments 7-10 days apart; RX saliva which causes intense itching malathion loMon; benzyl alcohol; ivermecn • Fine tooth comb • Wash clothing/bedding in very hot water; place nonwashable items in a sealed plasMc bag for 2 weeks ParasiMc - Scabies Scabies Treatment • Wash clothing/bedding in very hot • Papular linear rash primarily on water hands, feet, & body folds; pruritus; • 5% Permethrin (Elimite) cream spreading rash applied from neck to feet – wash off • Female mites burrow under skin and aer 8-14 hrs; may retreat aer 10 lay eggs days • Can survive off human host up to 4 • AnMhistamine for pruritus days • Skin scrapings – microscope 10 8/29/14 Henoch-Schonlein Purpura Characteriscs: Treatment: • IgA vasculiMs, oZen occurs • SupporMve care: Adequate post viral hydraon,