1. Pediatric Dermatology Dr. Jerald E. Hurdle Kennebec Medical Consultants Dr. Jerald E. Hurdle Kennebec Medical Consultants

2. Learning Objectives  To review common congenital & acquired skin lesions,  To recognize rashes that present in childhood, and  To manage the kids and their parents.

3. Vascular Lesions  Commonly seen in pediatric population  Need to distinguish hemangioma from vascular malformation  Commonly seen in pediatric population  Need to distinguish hemangioma from vascular malformation

4. Hemangioma  Normally not present at birth  Grows rapidly in first few months  Then involute  Rx: nothing, steroids, laser & surgery  Normally not present at birth  Grows rapidly in first few months  Then involute  Rx: nothing, steroids, laser & surgery

5. Hemangioma  Gradual Involution

6. Vascular Malformation  Present at birth  Abnormal size & number of vascular structures  Salmon patch or stork bite  Present at birth  Abnormal size & number of vascular structures  Salmon patch or stork bite

7. Vascular Malformation Port Wine Stains  Much less common  Hypertrophy with time  If V1/V2 rule out Sturge Weber Syndrome  Rx: laser Port Wine Stains  Much less common  Hypertrophy with time  If V1/V2 rule out Sturge Weber Syndrome  Rx: laser

8. Pigmented Lesions  Congenital vs. Acquired  Congenital nevomelanocytic nevus (syn. congenital hairy nevus)  Small, medium or large  50% hairy  Have verrucous surface  Small: No increased risk of melanoma  Congenital vs. Acquired  Congenital nevomelanocytic nevus (syn. congenital hairy nevus)  Small, medium or large  50% hairy  Have verrucous surface  Small: No increased risk of melanoma

9. Giant Congenital Nevi  >5% BSA in infants  8.5% MM risk in 1 st 15 years  Rx: surgical excision, tissue expanders, flaps & grafts  >5% BSA in infants  8.5% MM risk in 1 st 15 years  Rx: surgical excision, tissue expanders, flaps & grafts

10. Case 1  9/12 old baby  3/7 of fever  Febrile fit  Fever defervesces with this rash Diagnosis?  9/12 old baby  3/7 of fever  Febrile fit  Fever defervesces with this rash Diagnosis?

11. Case 1: Roseola  HHV6  2/3 of patients get erythematous papules mucosa of soft palate (Nagayama spots)  HHV6  2/3 of patients get erythematous papules mucosa of soft palate (Nagayama spots)

12. Case 2  3 yr old girl  Slightly irritable for a few days  Presents with this rash! Diagnosis?  3 yr old girl  Slightly irritable for a few days  Presents with this rash! Diagnosis?

13. Case 2: Fifth Disease or Erythema Infectiosum  Classical Slapped cheeks appearance  Caused by Parvovirus B19  Aplastic Anemia  Arthritis  Hydrops Fetalis  Classical Slapped cheeks appearance  Caused by Parvovirus B19  Aplastic Anemia  Arthritis  Hydrops Fetalis

14. Case 2: Fifth Disease or Erythema Infectiosum  Classical Slapped cheeks appearance  Caused by Parvovirus B19  Aplastic Anemia  Arthritis  Hydrops Fetalis  Classical Slapped cheeks appearance  Caused by Parvovirus B19  Aplastic Anemia  Arthritis  Hydrops Fetalis

15. Case 3:  10 year old boy  Sore throat, myalgia for 3 days before presentation with this rash  Rash feels like sandpaper  10 year old boy  Sore throat, myalgia for 3 days before presentation with this rash  Rash feels like sandpaper

16. Case 3:  10 year old boy  Sore throat, myalgia for 3 days before presentation with this rash  Rash feels like sandpaper  10 year old boy  Sore throat, myalgia for 3 days before presentation with this rash  Rash feels like sandpaper

17. Case 3: Scarlet Fever  Group A Strep  Erythrogenic toxin  Culture potential bacterial reservoirs (throat commonest)  Rx: penicillin  Watch out for post- streptococcal glomerulonephritis  Group A Strep  Erythrogenic toxin  Culture potential bacterial reservoirs (throat commonest)  Rx: penicillin  Watch out for post- streptococcal glomerulonephritis

18. Case 4  7 yr old girl  Ring like lesions on the back of her hands for 3 months  PCP tried antifungals Diagnosis?  7 yr old girl  Ring like lesions on the back of her hands for 3 months  PCP tried antifungals Diagnosis?

19. Case 4

20. Case 4: Granuloma Annulare (GA)  Localized GA  Self limiting  Tends to spontaneously resolve  Can try potent topical steroids  Link with DM (controversial)  Localized GA  Self limiting  Tends to spontaneously resolve  Can try potent topical steroids  Link with DM (controversial)

21. Case 5  2 yr old boy presents with 2/7 of this non- itchy rash  Affects his hands & feet  Had diarrhea 1/52 ago

22. Case 5: Gianotti-Crosti Syndrome  Originally described in conjunction with Hep B in 1955  Other associations: EBV, RSV, Coxsackie, echo, Parainfluenzae, CMV etc etc.  Originally described in conjunction with Hep B in 1955  Other associations: EBV, RSV, Coxsackie, echo, Parainfluenzae, CMV etc etc.

23. Case 6  4/12 baby girl  Febrile & irritable for 2/7  Developed rash on face yesterday  Now red all over  Father noticed some blistering  4/12 baby girl  Febrile & irritable for 2/7  Developed rash on face yesterday  Now red all over  Father noticed some blistering

24. Case 6: Staphylococcal scalded skin syndrome (SSSS)  Occurs in kids <6 yrs  Staph producing exotoxin disrupts barrier at granular layer  Rx: admit patients with generalized disease for IVABs & minimize trauma to skin with emollients  Occurs in kids <6 yrs  Staph producing exotoxin disrupts barrier at granular layer  Rx: admit patients with generalized disease for IVABs & minimize trauma to skin with emollients

25. Atopic Dermatitis: Causes  Genetics (filaggrin gene)  Staph acting as super antigen  Extremes of climate  Food as allergen controversial  Aeroallergens & house dust mite  Genetics (filaggrin gene)  Staph acting as super antigen  Extremes of climate  Food as allergen controversial  Aeroallergens & house dust mite

26. Atopic dermatitis  Itch & scratch  Sleep deprivation for the whole family  Worsening weeping eczema think Staph  Sudden painful eczema think herpes  Itch & scratch  Sleep deprivation for the whole family  Worsening weeping eczema think Staph  Sudden painful eczema think herpes

27. Atopic Dermatitis

28. Atopic dermatitis

29. Secondarily Infected Eczema with Staph

30. Atopic dermatitis Secondarily Infected Eczema with Herpes: Eczema herpeticum

31. Treatment  Educate parents about what is known about AD  Encourage emollients (point to diaper area to show that moist environment helpful)  500g per week or more  Educate parents about what is known about AD  Encourage emollients (point to diaper area to show that moist environment helpful)  500g per week or more

32. Treatment: Steroids  Tackle Steroid phobia head on!  Atrophy rarely seen when appropriate steroid is used for appropriate time  No increased risk of cancer  Use potent steroid to induce quick remission & get family on your side  Tackle Steroid phobia head on!  Atrophy rarely seen when appropriate steroid is used for appropriate time  No increased risk of cancer  Use potent steroid to induce quick remission & get family on your side

33. Treatment: Steroids Finger Tip Units (FTU)  Squeeze ointment DIP crease = 1 FTU  Covers 2 hands of skin  2FTUs = 1g  (http://www.patient.co.uk/ showdoc/27000762/)  Squeeze ointment DIP crease = 1 FTU  Covers 2 hands of skin  2FTUs = 1g  (http://www.patient.co.uk/ showdoc/27000762/)

34. Treatment: calcineurin inhibitors  Pimecrolimus cream limited efficacy  Tacrolimus ointment 0.1 & 0.03%  No atrophy  Pimecrolimus cream limited efficacy  Tacrolimus ointment 0.1 & 0.03%  No atrophy

35. Treatment: Antihistamines  No role for non- sedating  Use benadryl, atarax will make patient more drowsy  No role for non- sedating  Use benadryl, atarax will make patient more drowsy

36. Treatment: Antibiotics  Take cultures, lesion & nares  Culture other members of family if recurrent  Treat for likely Staph  Review patient when cultures are back  Take cultures, lesion & nares  Culture other members of family if recurrent  Treat for likely Staph  Review patient when cultures are back

37. Treatment: Eczema herpeticum  Acyclovir p.o.  Analgesia  May need Staph coverage as well  Acyclovir p.o.  Analgesia  May need Staph coverage as well

38. Pitryriasis Alba (PA)  1/3 of kids in USA may have PA  Occurs in all races  ♂ > ♀  More problematic in darker skin  1/3 of kids in USA may have PA  Occurs in all races  ♂ > ♀  More problematic in darker skin

39. Pitryriasis Alba (PA)  Associated with Atopic Dermatitis 3 stages  Papular erythematous  Papular hypochromic  Smooth hypochromic  Associated with Atopic Dermatitis 3 stages  Papular erythematous  Papular hypochromic  Smooth hypochromic

40. Pitryriasis Alba (PA): Rx  Gentle Skin care  1% Hydrocortisone Cream  Sunscreen  Reassurance  Gentle Skin care  1% Hydrocortisone Cream  Sunscreen  Reassurance

41. Learning Objectives  To review common congenital & acquired skin lesions,  To recognize rashes that present in childhood, and  To manage the kids and their parents.