Dr. Sheila Fallon-Friedlander

Infectious Disease 2016: Pediatric Infected Atopic Dermatitis

Dr. Sheila Fallon-Friedlander

Dr. Sheila Fallon-Friedlander

Dr. Sheila Fallon-Friedlander

A major aggravating factor associated with atopic dermatitis is the presence of microorganisms on the patient’s skin surface. S aureus and Streptococcus pyogenes can exacerbate chronic skin inflammation. S aureus can colonize the skin or the respiratory tract in healthy patients and become pathogenic under conditions such as skin barrier breakdown and diminished immunity. Atopic dermatitis patients are highly susceptible to staphylococcal skin infections. Studies have shown that between 80% and 100% of patients with atopic dermatitis have nasal or skin colonization by S aureus vs 5% to 30% in individuals without atopic dermatitis. First and second generation cephalosporins are suitable for treatment of patients infected with methicillin-susceptible S aureus and MRSA is best treated with clindamycin and trimethoprim/sulfamethoxazole. Antimicrobial therapy should be tailored on the basis of local resistance patterns. Streptococcal infections may be treated with clindamycin and cephalexin.

Eczema herpeticum, also known as a form of Kaposi varicelliform eruption caused by viral infection, usually with the herpes simplex virus (HSV), is an extensive cutaneous vesicular eruption that arises from pre-existing skin disease, usually atopic dermatitis. Children with atopic dermatitis have a higher risk of developing eczema herpeticum, in which HSV type 1 is the most common pathogen. Patients with this condition may be treated with acyclovir.

Eczema cocksackium may also occur in patients with atopic dermatitis. In one case series, 51% of patients diagnosed with Eczema cocksackium had a history of atopic dermatitis. This enterovirus-associated exanthem is characterized by fever, stomatitis of the oral mucosa, and a vesicular rash affecting the hands, feet, and occasionally the buttocks. About one-third of infants <1 year of age may also present with bullae. Symptoms are strikingly similar to eczema herpeticum caused by HSV type 1. Patients with eczema cocksackium have been successfully treated with wet wrap therapy and low-dose corticosteroids. Bleach baths are also effective for both killing of pathogens and decreasing inflammation.

 

Dr. Sheila Fallon-Friedlander

Infectious Disease 2016: Pemphigus Syphiliticus

Dr. Sheila Fallon-Friedlander

Dr. Sheila Fallon-Friedlander

Dr. Sheila Fallon-Friedlander

Persistent sniffles and a rash? Pemphigus syphiliticus is a possible answer.

Congenital syphilis is increasing and it is important to be aware of symptoms in neonates. Mucosal features may include rhinitis that develops at 1 week and worsens. Mucus is initially clear then progressively purulent and blood stained. Mucous ‘patches’ are seen on palate and lips along with perioral and perianal condylomata. Cutaneous features include maculopapular eruption over buttocks and lower torso, palms, and soles; and bullous eruptions that mimic staphylococcal infection.

Maui Derm 2016 Highlights: Pediatric Dermatology

S. Fallon-Friedlander, MD
I. Frieden, MD
L. Eichenfield, MD
J. Treat, MD

Our faculty presented some fantastic insights into pediatric dermatology including:

Neonatal Herpes Simplex Virus – The Dark Side of the Force?

Neonatal herpes simplex virus (HSV) infection is rare occurring in 1/2000 – 1/5000 live births. HSV encephalitis and disseminated HSV are most concerning and difficult to detect clinically. Because of this, and the significant associated morbidity and mortality, we must have high index of suspicion these infections. HSV is the “Darth Vader” of pediatric dermatology. If there is any suspicion that a child is infected HSV, scrape, culture, and cover.

Eczema Coxsackium or Herpes Zoster?

Eczema “coxsackium” is a frequent reason for presentation of children in the dermatologist’s office. Be careful that it may mimic herpes zoster. Diagnosis may be made by polymerase chain-reaction (PCR) of blister fluid, or pharyngeal, or rectal swabs. Patients also have a high rate of onychomadesis (nail shedding).

Urticaria Multiforme (UM)

Patients with UM can be usually be effectively managed with antihistamines and do not require hospitalization or other therapy. UM occurs most often in infants and toddlers and it is characterized by annular urticarial and polycyclic morphology and a duration of individual lesions <24 hours. There are no mucosal blisters or erosions, but angioedema may be present.

Allergic Contact Derm. Is it Nickel?

Nickel is the most common cause of allergic contact dermatitis that we test for in our patients. Patients may be exposure to nickel via earrings, belts, snaps on pants, jewelry and even their laptop computers or iPads. Nickel reactions may also occur in patients with orthopedic devices. The American Academy of Dermatology (AAD) has noted that allergic contact dermatitis is on the rise and have emphasized that nickel should be avoided in the parts of piercings that are in contact with open skin. The rate of nickel release from a given alloy is the most important risk factor for nickel-associated allergic contact dermatitis.

The benefit of patch testing in patients undergoing arthroplasty is not clear. We are not sure what metals to test for or whether a positive patch test is a significant predictor of failure of the implanted device.

Atopic Derm. New Therapies, Communication Tips…And Peanuts?

We need to change our messaging to parents about treatment of their children with atopic dermatitis. Children need to be treated and many new therapies are becoming available. New agents are focused on blocking inflammation associated with activation of the TH2 pathway (e.g., interleukin [IL]-4, IL-5, and IL-13). It is now clear that atopic dermatitis is a disease of TH2-driven inflammation and impaired barrier function.

Peanuts? Recent studies suggest exposure of at-risk infants (positive for atopic dermatitis) to infants to peanuts decreases the probability of developing peanut allergy. These results may lead to a recommendation for peanut exposure to infants at elevated risk for development of this allergy.

Dupilumab, in particular, is viewed as a milestone in the treatment of atopic dermatitis, and it is being evaluated in children in studies being carried out in Europe. Other emerging therapies for pediatric atopic dermatitis include apremilast, crisaborole, OPA-15406 (phosphodiesterase type 4 inhibitor), dupilumab, and lebrikizumab.

Lesions and Port Wine Stains?

Some benign vascular lesions that will fade with time can look “scary” and should be managed conservatively. The International Society for the Study of Vascular Anomalies (ISSVA) classification will help you determine causes and even genetic mutations associated with uncommon/difficult-to-diagnose lesions.   http://www.issva.org/

The most important intervention of a child with Sturge-Weber syndrome is an ophthalmology examination. Recent data suggest that port wine stains without forehead involvement are not associated with glaucoma or evidence of central nervous system involvement. Early studies suggested that earlier laser treatment of port wine stains results in greater improvement, but more recent information has suggested that anesthesia in young children may result in impaired neural development. Results addressing this issue are conflicting, but there is still reason for concern.

Beware of “acquired” port wine stains. These are very rare and may actually be morphea.

Pediatric Dermatology Update: Clinical Pearls from Albert Yan, MD

  • Treatment of molluscum can result in stereotypical ID reactions resembling Gianotti-Crosti syndrome
  • Papular-purpuric gloves and socks eruption resembles RMSF, but is painful and caused by a virus
  • Candidal diaper dermatitis can be treated with mupirocin
  • Kerions may become less symptomatic with oral corticosteroid
  • Atypical mongolian spots may indicate mucopolysaccharidosis
  • Multiple satellites are associated with neurocutaneous melanosis
  • Segmental pigmentation can occasionally be associated with underlying syndromes
  • Forehead port wine stains indicate a risk for Sturge-Weber syndrome
  • The site of the hemangioma dictates its associated risks

Pediatric Dermatology: Clinical Pearls

James Treat, MD

3 points to remember about pediatric dermatology:

  • It may be possible to prevent atopic dermatitis with emolliation started before 3 weeks of age
  • Excess Hair around congenital scalp lesions may indicate ectopic brain tissue
  • Topical timolol can be very effective for early superficial hemangiomas.

Acne: Clinical Pearls

James Treat, MD

5 things to remember about treating acne in pediatric patients:

  • Children who develop acne between the ages of 1 and 7 should have an endocrine workup
  • When needed oral erythromicin can be used off-label as a systemic antibiotic in children under 8.
  • Neonatal acne is in part caused by malassezia yeasts.
  • Pre-adolescent acne can be treated similarly to adolescent acne except that doxycycline should not be used in children under 9 or those who have not developed their secondary teeth
  • Isotretinoin MUST be given with food

Infectious Disease: Clinical Pearls

James Treat, MD

5 pearls for treating infectious disease in children:

  • Gianotti Crosti can be induced by molluscum contagiosum and may mark the end of the infection
  • Tonsillectomy should be considered in children with severe psoriasis that correlates with GRoup A Streptococcal infection
  • ‪If you see Guttate psoriasis in children under 5, look at their perianal area for the Strep infection
  • Leishmaniasis can present as a non-healing ulcer in patients who have traveled to Central AMerica or Middle East
  • Exuberant hand foot and mouth is caused by coxackie A6

Clinical Pearls: Pediatric Infectious Disease

Albert Yan, MD

A few clinical pearls from Dr. Albert Yan’s presentation on Pediatric Infectious Disease at the 2015 Fall NPPA conference:

  • Interrupted skin integrity in premies and infants may indicate infection first and foremost
  • Epidermolysis bullosa-like neonatal presentations may indicate widespread HSV infection
  • Eczema herpeticum may recur and should be monitored for recurrences to determine if prophylaxis is needed
  • Superinfection of atopic dermatitis with fever, grouped pustules, cellulitis, facial infection can suggest group A strep infection
  • Itchy papules and blisters at sites of exposure can indicate carpet beetle dermatitis
  • Head lice infestations resistant to conventional otc agents may respond to newer pediculicide

Advanced Systemic and Topical Therapy in Pediatrics

A few clinical pearls from Dr. Albert Yan’s presentation on Advanced Systemic and Topical Therapy in Pediatrics at the 2015 Fall NPPA conference:

  • N-acetylcysteine compounded into a topical formulation may inhibit keratinocyte proliferation and help with keratinizing disorders (ichthyosis, and possibly epidermal nevi and PPK)
  • N-acetylcysteine administered systemically can be help in mediating glutamate metabolism and help with neuropsychiatric disorders such as trichotillomania and neurodermatitis
Dr. Sheila Fallon-Friedlander

New Drugs-Pediatric Style

Sheila Fallon-Friedlander, MD

Dr Friedlander provides us with her clinical pearls on new drugs–pediatric style…

  • Propranolol has revolutionized the treatment of problematic infantile hemangiomas
    • The most common side effect is sleep disturbance; next acral cyanosis
    • Hypoglycemia can occur but unlikely if baby is eating appropriately
    • The drug can be given BID
    • Infants with large segmental hemangiomas should be evaluated for PHACES prior to instituting propranolol therapy
  • Timolol is highly effective for superficial hemangiomas & can obviate the need for systemic therapy
  • Nadolol is a beta blocker which does not cross the blood-brain barrier; it can be useful in kids with CNS effects (e.g severe sleep disturbance)
  • Rapamycin is useful both systemically & topically in the treatment of disorders involving the mTor pathway
  • This includes Tuberous Sclerosis, Lymphatic malformations, and some mixed veno-lymphatic abnormalities