9/18/2019 Pediatric Dermatology Jennifer Abrahams, MD, FAAD, DTM&H Collaborators: Kate Oberlin, MD; Nayoung Lee MD September 27th, 2019 1 Disclosures • Nothing to disclose 2 1 9/18/2019 Disclaimer *Pediatric dermatology is taught over 3 years of derm-specific residency training and there is an additional year of subspecialized fellowship! *We won’t cover all of pediatric derm in an hour but I hope to give you some common highlights 3 A 9 month old infant presents with the following skin lesions. Which of the following is most likely true of this disease? A.) Asthma generally precedes skin findings B.) The majority of affected children will outgrow the skin disease C.) There is no way to avoid or decrease risk of progression of the disease D.) Genetic factors account for approx 1% of susceptibility to early onset of this disease 4 2 9/18/2019 A 9 month old infant presents with the following skin lesions. Which of the following is most likely true of this disease? A.) Asthma generally precedes skin findings B.) The majority of affected children will outgrow the skin disease C.) There is no way to avoid or decrease risk of progression of the disease D.) Genetic factors account for approx 1% of susceptibility to early onset of this disease 5 6 3 9/18/2019 Atopic Dermatitis (Eczema) •Chronic inflammatory skin disease that begins during infancy or early childhood •Often associated with other “atopic” disorders • Asthma • Allergic rhinitis (seasonal allergies) • Food allergies •Characterized by intense itch and a chronic relapsing course •Prevalence almost 30% in developed countries 7 Table courtesy of Bolognia, et al. Triad of atopy: atopic dermatitis, asthma, allergic rhinitis AD has a predilection for infants and young children, asthma favors older children and allergic rhinitis predominates in adolescents/adults 8 4 9/18/2019 Epidemiology: Three main stages based on age of onset Early onset type: – Begins in the first two years of life with 60% presenting prior to age 1 – Most common type – Most go into remission by age 12 Late onset type – AD that starts after puberty Senile onset type: – Unusual subset that begins after age 60 9 Pathogenesis Complex genetic disease with both gene-gene and gene- environmental interactions Parental history of AD is a stronger risk factor than asthma or allergic rhinitis Two major sets of genes implicated in AD: – Epidermal proteins – Proteins with immunologic function 10 5 9/18/2019 Rundle CW, Bergman D, Goldenberg A, Jacob SE. Contact dermatitis considerations in atopic dermatitis. Clin Dermatol. 2017. Jul‐Aug;35(4):367‐374. 11 Morphology of Lesions Acute Subacute Chronic courtesy of Fitzpatrick, et al. •Acute lesions: edematous, erythematous plaques with oozing & serous crusting •Subacute eczematous lesions: erythema, scaling and variable crusting •Chronic lesions: thickened plaques with lichenification, scale, prurigo nodules •Perifollicular accentuation and papular eczema: common in individuals with darker skin •Any stage can evolvegeneralized exfoliative erythroderma 12 6 9/18/2019 13 Distribution of lesions Infantile Childhood Adulthood <2 years of age 2‐12 years >12 years Edematous papules on Lesions become more Lichenification cheeks with oozing lichenified, + xerosis Face & neck*, scalp, Antecubital and popliteal Flexors, hand dermatitis, extensors, trunk fossa (flexural) eyelid involvement 14 7 9/18/2019 Associated clinical features Table courtesy of Bolognia, et al. 15 Keratosis Pilaris •Discrete perifollicular papules with central keratotic core •Seen in >40% of patients with AD •Upper arms, thighs and lateral cheeks (children) •Keratosis pilaris rubra: features numerous tiny, follicular papules superimposed on confluent erythema. •Tx: exfoliation with pumice stone, urea, salicylic acid, alpha‐hydroxy acids, topical retinoids 16 8 9/18/2019 Dennie-Morgan folds & Allergic shiners courtesy of Fitzpatrick, et al. • Symmetric, prominent horizontal fold • Skin around the eyes appears gray to originating at the medial canthus violet–brown • Also see central facial pallor “headlight sign” [perioral, perinasal and periorbital pallor] 17 Palmar hyperlinearity • Accentuation of the palmar creases • Also seen in ichthyosis vulgaris 18 9 9/18/2019 Pityriasis alba courtesy of Bolognia, et al. • Hypopigmented patches with minimal scale • Etiology: Low grade eczematous dermatitis that disrupts the transfer of melanosomes to keratinocytes 19 Common allergens in atopic patients? Nickel Cobalt Thimerosal CAPB (detergent) Quaternium-15 – All formaldehyde releasing preservatives Lanolin (Aquaphor) Atopics are predisposed to sensitization of chemical allergies of topical medications and personal care products Rundle CW, Bergman D, Goldenberg A, Jacob SE. Contact dermatitis considerations in atopic dermatitis. Clin Dermatol. 2017. Jul‐Aug;35(4):367‐374. 20 10 9/18/2019 An 8yo girl has had abrupt worsening of her long-standing eczema. Which organism is most likely involved? A.) Streptococcus B) Herpes Simplex Virus C.) Varicella D.) Staphylococcus 21 An 8yo girl has had abrupt worsening of her long-standing eczema. Which organism is most likely involved? A.) Streptococcus B) Herpes Simplex Virus C.) Varicella D.) Staphylococcus 22 11 9/18/2019 Impetiginization •Staph! •Staph!! •Staph!!! • Predisposed to skin infections due to their impaired skin barrier • Reduced amount of innate antimicrobial peptides: • human β defensin • cathelicidins • S. aureus colonizes the skin of the vast majority of patients with AD • Bacterial infections exacerbate AD by stimulating the inflammatory cascade via S. aureus exotoxins that act as superantigens (exotoxin B IL4, IL5, IgE) 23 courtesy of Fitzpatrick, et al. A 4 year old male with a history of atopic dermatitis presents with the following skin lesions. Which of the following therapies would be most essential for treatment? - Corticosteroids - Antiviral - Antibiotic - Emollients and observation 24 12 9/18/2019 courtesy of Fitzpatrick, et al. A 4 year old male with a history of atopic dermatitis presents with the following skin lesions. Which of the following therapies would be most essential for treatment? - Corticosteroids - Antiviral - Antibiotic - Emollients and observation 25 Eczema herpeticum •Rapid dissemination of HSV •Numerous monomorphic, punched- out erosions with hemorrhagic crusting •Watch for: courtesy of Bolognia, et al. – Keratoconjunctiviti – Meningoencephalitis 26 13 9/18/2019 Molluscum contagiosum •Poxvirus; typically self-limited in children •Multiple pearly umbilicated papules •Intertriginous areas, face, genitals, buttocks • propensity to contract molluscum contagiosum in AD and with a more widespread distribution 27 Molluscum dermatitis Inflammation of MC lesions May herald the development of a host immune response Id reaction-like eruptions can occur manifesting with pruritic erythematous papules favoring elbows, knees + molluscum dermatitis What is an id reaction? • “Autosensitization reaction” • Disseminated secondary dermatitis, in response to a primary localized dermatitis 28 14 9/18/2019 Dupixent courtesy of Bolognia, et al. • Adjunctive therapies: bleach baths (1/4 cup bleach in tub), PO antihistamines, probiotics, sensitive skin care 29 Targeted molecular therapy •Dupilumab (Dupixent) • Human monoclonal IgG4 Ab binds IL‐4Rα, thus blocks IL‐4 and IL‐13 – JAAD article (June 2016) demonstrates early and sustained improvements in sleep, mental health, and quality of life in adults with AD – FDA granted Breakthrough Therapy designation for Dupixent for the treatment of moderate‐to‐severe (adolescents 12 to 17 years of age) and severe (children 6 months to 11 years of age) atopic dermatitis not well controlled on topical prescription medications. – Dosing: 600 mg SQ once, then 300 mg SQ every other week – AE’s: injection site reactions, conjunctivitis (10%), HSV (2‐4%) – Need to fail topical corticosteroids and TCIs 30 15 9/18/2019 Prevention Prolonged breastfeeding (>4-6 months) Vitamin D3 supplementation – May help reduce Staph colonization through vitamin D‐stimulated in cathelicidin LL‐37 (innate antimicrobial peptide) Use of emollients once daily within 3 weeks after birth may reduce the incidence of atopic dermatitis at 6 months by 50%!1 1Simpson EL, Chalmers JR, Hanifin JM, et al. Emollient enhancement of the skin barrier from birth offers effective atopic dermatitis prevention. J Allergy Clin Immunol. 2014;134(4):818‐823. 31 Other Eczematous Eruptions 32 16 9/18/2019 Infantile seborrheic dermatitis (Cradle Cap) Self-limited Common chronic dermatitis confined to skin regions with high sebum production first 3 months of life, usually starts 1 week after birth Mild greasy scale adherent to scalp (“cradle cap”) and in intertriginous areas – Acutely inflamed, oozing, sharply demarcated, superimposed with Candida May also appear psoriasisiform 33 Other Eczematous Eruptions 34 17 9/18/2019 DDx seborrheic dermatitis Infant: – Atopic dermatitis • Later onset, distribution, +pruritus – Irritant diaper dermatitis – Infantile psoriasis – Langerhans cell histiocytosis – Wiskott‐Aldrich syndrome – Tinea capitis 35 Treatment Infantile: – Self‐limited – Emollients, 2% ketoconazole cream, low potency corticosteroids, keratolytic shampoos 36 18 9/18/2019 Lumps and bumps… 37 courtesy of Habif, et al. A 12 yo boy presents with a bump on his elbow for 8 months that he picks at, but otherwise is asymptomatic. Which of the following is true of this lesion? A.) pinpoint black dots are common findings in this lesion B.) Once the lesion resolves, he is