1. Eczematous skin disorders
Dr. Ravneet Sekhon, PGY3 Pediatrics
Telehealth Rounds
January 27, 2017
Thanks to Dr. Ramien for her feedback and support in preparation of this presentation!

2. Objectives Describe the functions of skin Description of skin lesions
Eczema and other dermatides
Outpatient management of eczema

3. Functions of the skin Protection Sensation: receptors Thermoregulation
Protective barrier
Radiation shield from UV light
Mechanical, chemical, thermal insults
Relatively impermeable to water
Microbes
Sensation: receptors
Thermoregulation
Insulates from heat loss
Heat loss through evaporation of sweat
Metabolic function
Subcutaneous fat stores energy
Vitamin D synthesized in epidermis in presence of UV light

4. Normal skin anatomy Reference: Zitelli’s visual diagnosis EPIDERMIS
Stratum corneum: barrier layer (keeps irritants OUT), moisture IN, and protects
DERMIS
Lots of fibroblasts and collagen
Tough, leathery
Structural support for hair
Sebaceous glands: produce oil, again a barrier for skin
SUBCUT TISSUE
Fat helps store energy and acts as a soft cushion

5. Careful and detailed history should be gathered regarding onset, inciting factors, evolution of skin lesions, pruritus, medications/immunizations, family hx

6. Describing skin lesions
Describe:
Size
Shape
Color
Texture
Configuration (relation to each other)
Distribution (where on the body)

7. Reference: American academy of dermatology web module

8. Review of common skin lesions
Macule; flat and <1 cm
Patch; flat and >1 cm
Papule; raised and <1 cm
Plaque; raised and >1 cm
EPIDERMIS: macule, patch
EPI and DERMIS: papule, plaque
Vesico-bullous lesions are ALMOST ALWAYS clinically significant
Nodule; raised with more
deep component, <1 cm
Tumor is > 1 cm
Vesicle: small bubble, fluid filled, <0.5 cm
Bulla: >0.5 cm
Pustule: pus containing bubble; can be related to hair follicles

9. Acrodermatitis: involvement of distal extremities

10. Great resource with modules - https://www. aad
Great resource with modules - (American Academy of Derm)

11. Eczematous disorders Erythema, edema, pruritus, weeping
Chronic: thick, dry, scaly lesions with lichenification and changed pigmentation
Includes:
Eczema or atopic dermatitis
Seborrheic dermatitis
Allergic and irritant contact dermatitis
Nummular eczema
Acute dyshidrotic eczema

12. Diagnosis?
Nickel contact dermatitis.

13. Nickel dermatitis A type of allergic contact dermatitis
Due to prolonged or repetitive exposure
Improves after removal of stimulus but recurs quickly on re-exposure
Temporary treatment with topical or oral corticosteroids - what steroid, how much, and for how long?
Education of parents about cause
Can recur within 48 hours (shorter time period) with re-exposure
If mild reaction, just remove the cause. Ask them to use mild soap like Vaseline, Dove if not sure of the cause.
For mod but localized reactions: Betamethasone valerate 0.1% ointment BID until resolved.
For severe or generalized reactions (ie. poison ivy, which is also a type of ACD): prednisone mg/kg/d with a taper that should cover at least 3 weeks because shorter courses will cause rebound (ie. if you give 5 days of treatment, the rash gets better but comes right back).
Education of parents about cause - especially important in case of poison ivy

14. Contact dermatitis Irritant contact dermatitis:
Dry skin dermatitis: from repetitive wet-to-dry like lip licking, thumb sucking, etc.
Juvenile plantar dermatosis: red scaly lesions on weight bearing aspects of foot due to wearing occlusive footwear
Diaper dermatitis: irritant, infection (Candida)
Allergic contact dermatitis: poison ivy, poison oak, nickel
Juvenile plantar dermatosis: treat with thick emollient; if severe, 1-2 week medium-high potency steroid
Diaper dermatitis: loose stools, friction, occlusion, diaper wipes
Tx:
period of rest free of diaper; if not super realistic then can instead do frequent diaper changes (like q1h), disposable/super absorbent diapers, face cloth+water or wipes (wipes used to be allergenic but the problem component has been removed
cleanse skin with soft cloth and lukewarm water and pat dry,
avoid overwashing
Zinc oxide ointment; thick layer (like icing, should not be able to see the skin underneath), ideally 30+% Desitin. Don’t need to wipe it all off every time, just remove soil and re-apply
add 1% hydrocortisone powder in clotrimazole cream or nystatin cream if > 3days duration (this is when candida set in)
Poison ivy, poison oak: in response to plant allergens, linear streaks
Spontaneous resolution in 1-3 weeks with exposure avoidance
What can we apply on it in the meantime? Topical steroid ointments – betamethasone valerate 0.1% BID, maximize antihistamines (sedating ie. benadryl + non-sedating ie. reactine)
Nickel: jewelery, metal  many sources including cell phones and iPads!!

15. Diagnosis?
Lip licking eczema or lip licking dermatitis.

16. Diagnosis?
Juvenile plantar dermatosis. Usually looks a bit more shiny in the red areas with peeling.

17. Diagnosis?
Poison ivy dermatitis. Notice the linear patterns.

18. Diagnosis? Pityriasis alba
Multiple hypopigmented areas on the face which are not well circumscribed, mostly round/oval, not raised, no scale/roughness, no erythema; also peri-oral hypopigmentation as well. Darker/tan skin.

19. Pityriasis alba Mainly in kids 3-16 yo, M=F
Hypopigmented, ill defined, round or oval patches
Can be mildly erythematous and have fine scales
Location: face, neck, upper trunk, prox arms
Frequently misdiagnosed: vitiligo, tinea versicolor, tinea corporis
Treatment: emollient, low potency topical steroid or calicineurin inhibitor
PITYRIASIS: scale
ALBA: white (hypopigmented)
“white eczema”
Common in atopic dermatitis
More noticeable in spring/summer because don’t tan like surrounding skin Pityriasis alba improves when you get acne (ie. teen years)
If scaling: use steroid or Calc inhibitor. 5-7 days of Desonide or hydrocortisone would work.

20. Diagnosis? Seborrheic dermatitis
Multiple yellow small scales on the scalp with some dryness, raised, some dry skin/erythema to the forehead as well.

21. Seborrheic dermatitis
Also called cradle cap in infants
Greasy scaling of scalp, axillae, groin folds; in adults face, eyebrows, upper trunk
Salmon pink patches that can flake or peel
Not itchy
Infants<3 mo
Associated with proliferation of various Malassezia species
Treatment: keratolytics, topical antifungals, mild corticosteroids.
Resolve by 6-12 mo age
Keratinolytics: salicylic acid, lactic acid, etc
Topical antifungals: ketoconazole, shampoo/cream (selenium sulfide, zinc pyrithione, tar); use up to indefinitely
Mild topical steroids for 1-3 weeks in acute flare: hydrocortisone, can apply BID
Calcineurin inhibitors cause burning/stinging sensation and can be uncomfortable so generally NOT recommended
Nizoral/ketoconazole shampoo or cream is usually enough…

22. Diagnosis?
Atopic dermatitis
Erythema, scaling, crusting

23. Atopic dermatitis 10-30% of kids worldwide
Most common relapsing-remitting skin condition
Occurs with other atopic dz like: asthma, allergic rhinitis, food allergy

24. Etiology Genetic mutations in filaggrin in up to 50%
Defective skin barrier
Reduced skin innate immune responses
Exaggerated T cell response to environmental allergens and microbes
Chronic skin inflammation
Filaggrin: structural protein in epidermis which is critical to skin barrier function

25. Toddlers Infants School kids Adults ECZEMA AT VARIOUS AGES:
Infants: 1-6 mo age, lasts 2-3 years. Red itchy papules and plaques which ooze and crust on cheeks, forehead, scalp, trunk, extensor surfaces of extremities in symmetrical fashion.
Children: 4-10 yo. Dry, papular, pruritic circumscribed scaly patches on the wrists, ankles, antecubital/popliteal fossae (flexor surfaces). ¾ improve between yo, rest get chronic dermatitis.
Adults: age 12+. Can have persistent eczema from childhood which becomes more localized and lichenified. Flexural areas of arms, neck, legs with lichenification. Usually persistent localized eczema.
NOTE: Infants: diaper areas are spared! If it is in the diaper area, it is NOT eczema.
Reference for photos: New Zealand DermNet
School kids
Adults

27. Reference: AAP article on eczema Nov 2014
These are the technical criteria, although no one really uses them strictly.

28. Many have Staph aureus colonization at time of flare and may have altered cellular immunity
Higher risk of developing generalized eczema herpeticum

29. Differential diagnosis
Differentiating features
Seborrheic dermatitis
Contact dermatitis
Nummular eczema
Psoriasis
Icthyoses
Scabies
HIV-associated dermatitis
Insect bites
Cutaneous lymphoma
LCH
Dermatitis herpetiformis
Wiscott-Aldrich
SCID
Hyper IgE syndrome
Zinc deficiency
Vitamin B6 and niacin def
PKU
Tinea corporis
Salmon pink patches with greasy scale, scalp involved, min itch
Location to specific skin area, exposure history
Coin shaped itchy eczematous plaques on extensors, buttocks, shoulders; face sparing
Koebner phenomenon, red patches with little scale, diaper area affected
Dry thick fish scale ski, acquired or inherited
Involvement of skin folds, diaper area, vesico-pustules on palms/soles
Impetigo and cellulitis (Staph), recurrent herpetic gingivostomatitis, scabies, severe atopic dermatitis, drug eruptions, leukocystoclastic vasculitis
Single large lesions, rust brown spots on bedding, blisters could develop and ooze on scratching
Telangiectasias in early cases, LNs, skin biopsy
Crusted atrophic rash, chronic draining ears, hsm, LNs
Bullous lesions, blisters can erode, serpiginous clusters, can initially present with petechiae; located on scalp, shoulders, buttocks, elbows and knees
Associated thrombocytopenia
Facial, dental, and skeletal abnormalities, fail to lose their primary teeth, specific facial features; recurrent staphylococcal and candidal infections, pneumonias
Stomatitis, oral ulcers, angular cheilitis, disturbed smell/taste, night blindness, resp/GI infections from impaired immune function, anorexia, cognitive function decline, growth
Atrophic glossitis with ulcers, conjunctivitis, somnolence, confusion, neuropathy
Seizures, “musty odor”, microcephaly
Single lesion often, steroids make it worse
Koebner: lesions develop in areas of skin injury like from a scratch

30. Management Prevention
Bathing: lukewarm baths or showers; mild skin cleanser (unscented); pat skin dry
Moisturize: traps water in the skin and improves barrier function. Can be applied throughout the day PRN. Aveeno, Glaxal base, Cliniderm, Vaseline, etc.
Clothing: avoid wool, rough clothes; prefer cotton. Loose, light clothes in warm weather.
Bedroom:
Vacuum bedroom carpet daily
Use special mattress and pillow covers under cotton liner or mattress cover
Change furnace filters q3-4 months
Wash sheets and mattress cover weekly
Humidifier
Reference: recommendations by local dermatologists
Moisturize: No fragrance, urea, and alpha hydroxyl acids.
If all these things are too much to do, then focus on humidifier and moisturizing as key! Anything in addition to that is great.

31. Replace scratching with moisturizing, etc.
Wet wrap overnight, after moisturizing or medicated creams are applied (for flares)
WET WRAP VIDEO:
Wet wraps increase penetration of topical steroids into the skin, decrease the itch, and are effective in preventing scratching
Technique:
After soaking bath, apply topical steroid to affected areas -> then apply moisturizer to the rest of the skin -> then put on moist clothing dampened with warm water -> cover the wet layer with a dry layer
Keep room warm for comfort
Leave dressings in place for 3-8 hours then change them (ie. can sleep in them overnight for example)
Wet dressings can be used continuously for hours or overnight for up to 1 week at a time.
Watch wet wrap video from 3:22 onwards. They use a Tubifast material, but can just use moist damp clothing with a dry layer on top.

32. Treatment Topical corticosteroids: what can you apply and where?
Treat the itch!: antihistamines orally, also has sedative effect for sleep
Antibiotics for superinfections
More on this on the next few slides…

33. What kind of topical preparation to use?
The various preparations:
Ointment:
Less likely to produce burning/stinging (no preservatives)
More effect with the same active ingredient and concentration bc of their occlusive effect
Need only to apply a thin layer to affected areas until they are smooth to touch
Cream: more cosmetically acceptable
Lotion: good for hair-bearing areas
Oil based: easier to spread (esp useful in large areas of skin are involved) and are not too strong (useful for mild-mod eczema); Ex. Dermasmooth
Foam
Dermasmooth can be safely used in patients allergic to peanuts (common question).
Ointment:
Has NO water and doesn’t need a preservative; is OILY
Greasy, sticky, retains sweat
Occlusive effect makes medication more penetrable
Strong emollient
Cream:
WATER+OIL
Spreads easily
Doesn’t leave skin greasy
Contains preservatives which can cause contact allergy
Lotion
HIGH water content
More liquidy
Non sticky and tend to dry out skin (contain small amounts of alcohol which help evaporation)
Easy to apply to large areas
Gel
Tend to be more drying
Leave a thin film of active medication

34. Higher potency = closer to class I
Class 1 meds are 1800X more potent than least potent medication in class 7

35. Topical corticosteroids
Mild: hydrocortisone 1% ointment to red raised itchy areas on face or folds BID PRN
Mild-mod: Desonide 0.05% ointment on face or body BID PRN
Moderate: Betaderm 0.1% ointment to body BID PRN
Severe: Clobetasol propionate 0.05% to palms and soles BID PRN; not on body usually
Advice:
Remember 2-3 meds from low potency (6,7) and from medium potency (3,4,5)
Do not apply topical steroids to skin more than BID when using

36. Risks of steroid use: Cutaneous atrophy Striae Telangiectasias
Systemic absorption -> adrenal suppression
Around mouth: peri-orificial dermatitis
Around eyes: intraocular HTN, cataracts
Higher risks with higher potency medications and large surface areas
Overall risks are VERY low especially if patients only on topical steroids intermittently
Systemic absorption is very low; patients who get adrenal suppression are more so those who are on additional steroids for other reasons ex. asthma etc.

37. Common questions
Which steroid can be used for daily prevention use (proactive use)?
None
How to manage acute flares?
Treat red, raised, rough areas with topical steroids for up to 1-2 weeks at a time; if not improving by then seek MD
How much steroid is safe to prescribe in the clinic?
Limit prescribing to low potency steroids for face/neck/skin folds and moderate to trunk/extremities
If red, raised rough areas not resolved in 1-2 weeks, then reassess and consider other diagnoses. If still convinced pt has eczema, step up to next level potency steroids and reassess. If eczema, should resolve.
If a particular steroid in a particular class doesn’t improve symptoms, is there any evidence that an alternate steroid from the same class might work better?
Not usually unless the patient has been using the same one for a LONG time and has tachyphylaxis
How frequently can higher potency steroids be used for flares? (ex. in one year)
1-2x/month but if they are flaring this often, they might need better baseline or maintenance treatment to avoid flares ie. 1-2x/week application of BMV/calcineurin inhibitor to recurrent areas.
When to consult Dermatology?
Lack of response to routine treatment
Features not compatible with eczema
Needing to use treatment cream every day continuously
Needing better eczema education/reinforcement of general measures
If would like a one-time consultation to confirm diagnosis, make it clear on consultation that you would like to continue following the patient after consultation performed
No studies looking at proactive use of steroids when patients are not in flares so cannot be recommended at this time.
Many derms advocate 1-2x/week application of corticosteroids to recurrent areas.
3. Would recommend max betaderm to the face (no higher potency) and up to desonide->betaderm->clobetasol (max to body)
4. If patient has allergy to a particular steroid, would use another one in the same potency range with a different MOA

38. Sample action plan from 2014 AAP Article on Eczema
Regarding #1:
There is various literature regarding frequency of bathing
Essentially, there is no harm from bathing daily (if you prefer) as it cleanses the skin
If patient seems to not want to bathe daily, then every few days is alright as well
Most important to their eczema management is using MOISTURIZER daily regardless of whether there is bathing
We’re developing an illustrated eczema action plan and it is in a validation phase right now. Hopefully will be ready by the end of the year!

39. Topical calcineurin inhibitors
Topical immuno-suppressants
Inhibit T cell activation
2 forms:
Tacrolimus (Protopic) 0.03% and 0.1% ointment; only 0.03% approved for 2-15 yo kids
Pimecrolimus 1% cream
Second line therapy for recurrent areas
Adverse effect profile is different from steroids
More costly
Adverse effects:
Stinging/burning, pruritus – tend to be brief (few days)
Rare cases of skin malignancy and lymphoma reported; continuous long term use not recommended and limit application to affected areas only
Prolonged systemic exposure associated with inc risk of infections
Unknown if interferes with skin response to UV damage; minimize/avoid sun
Health Canada recommends if sx do not improve in 6 weeks of BID treatment, then discontinue and reassess diagnosis
Safety and efficacy in <2 yo has not been established
Adults can use both 0.03% and 0.1%
Not nec useful for med-severe eczema because they will cause stinging sensation which can be quite uncomfortable on more dry raw skin.
For treatment they're BID but protopic also has a maintenance indication (if recurs can apply 2X per week as maintenance)
Adverse effects notes:
Long term safety not established; rare cases of malignancy reported
Absolutely contraindicated in immunosuppressed patients
Caution with renal impairment; if using in large amounts, can be absorbed and cause acute renal failure
Hasn’t been studied with infections
Have been used in kids for >15 years and no report describing malignancy and little-none systemic absorption or immunosuppression
Safe for use around eyes (steroids are not)
There are recent studies showing the safety of these agents; often we do prescribe them for chronic/maintenance therapy

40. Treat that itch! DAYTIME (all PRN):
6-12 mo: Cetirizine 2.5 mg PO daily
12 mo – 2 yo: Cetirizine 2.5 mg PO daily, can increase to 2.5 mg q12h PRN
2-5 yo: Cetirizine 2.5 mg PO daily, can increase to 2.5 mg q12h or 5 mg PO daily PRN
6+ years: Cetirizine 5-10 mg PO daily
Reference: Handout from Dermatologists

41. NIGHT TIME (all PRN) Benadryl 0.5 mg/kg/dose PO qhs
Hydroxyzine (Atarax) mg/kg/dose PO qhs, max mg single dose

42. Antibiotics Crusty areas where infection suspected:
Cephalexin 50 mg/kg/day PO divided TID or QID, max 1500 mg/day for 7-10 days
If febrile or suspect systemic illness, may need admission
If febrile but look well, can be treated as outpatient
If look unwell or suspect systemic illness, then admit

43. Decolonizing Staph aureus
Dilute bleach bath once weekly x 3 months
Mix ½ cup bleach in full tub of water; or ¼ cup in ½ tub of water
More dilute than chlorine exposure in a swimming pool
Topical mupirocin 2% ointment to nares BID x 5-10 days if colonized with MRSA/recurrent impetigo
If patient has mild eczema that seems to be persistent despite therapy, dilute bleach baths can be tried

44. Thank-you!

45. References Nelson’s textbook of Pediatrics
Zitelli’s atlas of pediatric physical diagnoses: 5th edition
New Zealand website on Dermatology
AAP Article on Eczema Nov