Pediatric Dermatology: Clinical Pearls

Sheila Fallon-Friedlander, MD

  • Beware the midline congenital lesion! Worrisome areas include
    • 1) glabella
    • 2) vertex, occipital scalp
    • 3) lumbosacral area spine
  • Associated signs which raise concern in bumps
    • 1) surrounding/underlying vascular stain or hemangioma
    • 2) hair collar sign
    • 3) Pits
    • 4) gluteal cleft asymmetry
    • 5) tufts of hairs, polyps
  • 3)   Signs which increase concern for infantile bumps:
    • 1) Congenital
    • 2)   Abrupt, rapid growth
    • 3)   Adherent to underlying tissue
    • 4)   Rock hard /firm consistency
  • 4) Although rare, rhabdomyosarcomas are a concern, as they frequently present in the facial area, may appear vascular, & are frequently miss-diagnosed as infantile hemangiomas
  • 5) When hair loss is noted in a child, look for
    • Scale, lymphadenopathy, pustules, exclamation point hairs
    • The pattern of loss- is it “Friar Tuck”? Unilateral?

Your differential includes:

  • Tinea capitis
  • Alopecia areata
  • Trichotillomania
  • 6) When treating warts in children, remember
    • The treatment should not be worse than the disease
    • You must take into account the family’s desire to treat, but… no harm to the child.
    • Home therapy is the place to start
    • IL candida really helps a lot of patients
    • When trying to buy time, remember cimetidine & zinc

Psoriatic Arthritis: Key Developments and Future Directions

Arthur Kavanaugh, MD

Dr Kavanaugh provides us with his clinical pearls on psoriatic arthritis (PsA)…

  • There is increasing evidence that early diagnosis and treatment of PsA results in improved outcomes
  • There exists a large gap and unmet need in PsA, with many patients not being evaluated by doctors or receiving appropriate therapy
  • Because skin manifestations usually precede joint involvement, often by years, Dermatologists play a key role in PsA diagnosis. However, this can present challenges.
  • New guidelines for PsA treatment are under development, and may provide some assistance to clinicians.
  • TNF inhibitors have allowed improved outcomes in PsA, and there continues to be great interest in optimizing therapy with these agents.
  • There is great interest in new targets and agents for the treatment of PsA. Recently revealed data with IL-17 inhibition show promise for treatment of all the various domains of PsA, including peripheral arthritis, skin and nail disease, enthesitis and dactylitis, and axial/spinal arthritis.
  • The IL-12/23 inhibitor ustekinumab was approved last year in PsA and has been shown to be effective across domains of disease.
  • The PDE4 inhibitor apremilast received FDA approval for PsA 3/21/14 and for psoriasis 9/23/14. Its use is increasing in the clinic, for diverse PsA patients. Safety is a particularly attractive feature of this drug.
  • Additional agents are in development for PsA.
  • Optimal management of PsA depends on the levels of activity and severity across the various domains of disease.

Infectious Disease Update: Clinical Pearls

Ted Rosen, MD

What’s new in infectious diseases? Here are some key takeaway points from Dr Rosen…

  1. New rapid, cheap syphilis diagnostics use cell phone and disposable analytic equipment
  1. Gardasil 9: New HPV vaccine with five more oncogenic viruses added; However, there is no official statement regarding re-treatment of those previously vaccinated with bivalent type
  1. Genital HPV can be treated by daily application of 5% KOH and by a single application of ingenol mebutate (either concentration)
  1. In cases of recurrent MRSA (likely MRSA 300 strain): Clean environment; especially landline, faucet handles in kitchen and bathroom, toilet seat, and television remote
  1. Three new IV drugs for MRSA have long half-lives and less frequent dosing
  1. Watch out for atypical mycobacteria and nocardia infections following invasive cosmetic procedures
  1. Isavuconazole: New antifungal drug just approved for mucormycosis
  1. Consider using ozone cabinet or UVC shoe inserts to prevent recurrence of onychomycosis (kill fungi in shoes)
  1. Chikungunya virus: Dengue like illness; Endogenous cases in Florida; over 2000 US cases
  1. Muco-adhesive acyclovir 50mg
    1. One application is entire course of Rx for HSV-1
    2. May actually alter disease course by increasing interval between outbreaks
  1. Tungiasis: pour pure dimethicone on several times

Skin Manifestations of Systemic Malignancy and Disease

Seemal Desai, MD

What do we need to consider when our patient’s diagnosis is: pyoderma gangrenosum, erythema nodosum, NLD, Sweet’s and Bazex syndrome and many more?? Dr Desai provides us with his clinical pearls…

  1. Acanthosis Nigricans in combination tripe palms is highly linked to an underlying gastric carcinoma, typically an adenocarcinoma
  2. Sweet’s syndrome is increasingly being seen as a result of myeloid malignancies, in particular Acute Myelogenous Leukemia (AML). Check a blood count, and do a detailed history and physical
  3. On biopsy, Bazex’s Syndrome (Acrokeratosis Paraneoplastica) cannot be distinguished from Psoriasis. You need a detailed history and malignancy work-up for diagnosis
  4. Vascular nodules on the head and neck that appear suddenly without other systemic associations should be biopsied to rule out cutaneous metastases, in particular renal cell carcinoma
  5. Inflammatory bowel disease is commonly linked to multiple cutaneous findings, including erythema nodosum, pustular skin eruptions, and pyoderma gangrenosum.

Psoriasis 2015: Clinical Pearls

Bruce Strober, MD, PhD

Dr Strober provides us with some important takeaway points from his psoriasis lecture…

  • Apremilast achieves PASI 75 in approximately 30% of patients after 16 weeks of therapy.
  • Apremilast has FDA-approval for the treatment of both psoriasis and psoriatic arthritis.
  • Apremilast also has been shown to provide improvement for nail and scalp psoriasis, and the reduction of pruritus.
  • Apremilast is associated with a >5% weight loss in between 10-20% of treated patients.
  • Secukinumab is the FDA-approved biologic medication with currently the highest level of clinical efficacy of all the self-injectable medications.
  • A side effect of secukinumab is oral candidiasis, which is usually mild and occurs in up to 5% of patients.
  • IL-23 inhibition is a future mechanism of action for psoriasis therapy that shows very high efficacy in early clinical trials.
  • Tofacitinib inhibits JAK kinases and will be an oral drug approved for psoriasis.
  • Tofacitinib increases the risk for varicella-zoster.
  • Both secukinumab, apremilast and tofacitinib are all drugs that variably treat psoriatic arthritis.

Year In Review: Clinical Pearls

Ted Rosen, MD; James Treat, MD; Matthew Zirwas, MD

What’s new in dermatology? Here are some important clinical pearls that may help you in clinical practice…

  1. Younger patients with NMSC and melanoma at increased risk internal cancer
  1. Women with GU malignancies at increased risk of SCCA of the skin
  1. Four cups of coffee may contain enough caffeine to lower risk of new BCC in patient with prior occurrence of BCC
  1. Sildenafil use increases risk of melanoma?
  1. Freshwater injury: wound not improving with antibiotics, think algae!
  1. Acne: leads to stress, fatigue and reduced sexual activity
  1. Spironolactoneis an effective “add on” to retinoid in adult women with acne
  1. Dapsone gel reported to lead to methemoglobinemia (blue fingers, toes, lips, SOB): rare but serious potential adverse effect
  1. Adalimumab: acne conglobata (and hidradenitis supprativa)
  1. Lindioil (extract of Indigo naturalis plant) may help psoriatic nail dystrophy; AVAILABLE AT:
  1. Vitamin D3 at high dose (~4000IU daily) may help refractory chronic idiopathic urticarial
  1. AFTER successful repigmentation of vitiligo: maintain on topical tacrolimus 0.1% BIW
  1. Vitiligo may be associated with auditory dysfunction
  1. Weekend only dosing of cyclosporine can be used as long term maintenance therapy in some atopics
  1. Oral Glucosamine increases efficacy of cyclosporine without increasing side effects, allowing lower doses to be effective
  1. Oral magnesium is worth trying in patients with difficult to control Hailey-Hailey
  1. Simvastatin helps venous stasis ulcers to heal
  1. Antihistamines make isotretinoin work better
  1. Nitroglycerin works for chondrodermatitis Nodularis Helicis
  1. It may be possible to prevent atopic dermatitis with emolliation started before 3 weeks of age
  2. Tonsillectomy should be considered in children with severe psoriasis that correlates with GRoup A Streptococcal infection
  3. Topical timolol can be very effective for early superficial hemangiomas.


10 Pearls from Dermatopathology

Whitney A. High, MD, JD, MEng

  1. Dermatopathology is one of two ABMS-recognized subspecialties in dermatology, and one may become fellowship-trained after first being a board-certified dermatogist or general pathologist.
  1. Biopsy use is increasing. In nine geographic areas of the USA, over the time period 1986-2001, the biopsy rate among those >65 years of age rose 5-fold and the melanoma rate rose 2.4-fold.
  1. There are mulitple steps involved in taking a specimen from a piece of “wet” tissue, in formalin, to an interpretable slide and to a typewritten report. These steps include:

Biopsy performed & fixed in formalin            Accessioned

Grossed                                                                Processed

Embedded                                                            Cut

Stained and coverslipped                                  Analyzed

Transcribed/typed/signed                                Transmitted back to the provider

  1. The dermatopathologist is examining but a small portion of your original sampling, and this must always be considered when one assesses the “representative nature” of the results.
  1. There is an old mantra in pathology: crap in = crap out. No dermatopathologist, regardless of skill or expertise, can weave a poor sample into an outstanding result.
  1. It is the clinician responsibility to secure a “representative biopsy,” and if this is not done, eventually this inadequacy will be discovered. Over the period of 1998-2005, the number of shaves increased, but the volume of a typical shaves decreased.
  1. The technique employed (shave, punch, excision) must be adapted to the clinical situation – there are no fixed rules that may be applied to every situation. This is why the clinician is being paid an “evaluation/management” code; to select a biopsy that is appropriate for the circumstances.
  1. A recent study of pigmented lesions showed the odds of misdiagnosis (overall and that associated with adverse outcome) were higher with a punch biopsy than with an excisional biopsy, whereas a shave biopsy was only weakly associated with misdiagnosis. (Ng et al. 2010)
  1. Situations where the biopsy technique should be carefully considered include suspected:

Verrucous carcinoma              Mycosis fungoides

bullous pemphigoid                 Immunofluorescence studies

Panniculitis                               Alopecia

Lymphoid proliferations        Pigmented lesions

  1. The pathology report itself should be carefully read and scrutinized to understand precisely what the dermatopathologist is trying to convey. Demographic data should be confirmed. The technique and specimen size should be verified. Data used by the dermatopathologist to formulate the diagnosis should be noted (i.e. step levels, immunostains, special stains, etc.). If questions still exist, a phone call should be placed to the dermatopathologist for expanded dialog.

Contact Dermatitis and Eczema Clinical Pearls

Matthew Zirwas, MD

Dr Zirwas provides us with important clinical pearls from his presentation on contact dermatitis and eczema…

  1. If a patient with facial dermatitis is patch tested with the TRUE Test, the likelihood that patch testing will get them better is 1%. (30% chance they have contact dermatitis x 20% chance it will accurately diagnose them x 50% chance they will remember their allergies x 50% chance they will be able to avoid them if they remember them = 1.5% chance they will get better).
  1. TRUE Test is great for diagnosing allergic contact dermatitis to common metals, rubber, and active ingredients in OTC and Rx products. It is very bad at diagnosing ACD to personal care products.
  1. If there isn’t somebody in your area who does comprehensive patch testing, at the very least you should add these ten allergens to the TRUE Test: Methylisothiazolinone 2000 ppm, Formaldehyde 2%, Propylene Glycol 100%, Fragrance Mix 2, Cocamidopropyl Betaine, Amidoaminde, Dimethylaminopropylamine, Hydroxyethyl methacrylate, Mixed dialkyl thioureas, Chloroxylenol.
  1. Patients can be accurately patch tested while on 10 mg of prednisone.
  1. Every allergen you tell someone they are allergic to decreases they chances they will remember what they’re allergic to by 50%. (Allergic to 0 allergens à100% chance of remembering, Allergic to 1 à50% likelihood of remembering, Allergic to 2 à 25% likelihood of remembering, Allergic to 3 à 12% chance of remembering what they are allergic to).

Neuromodulators for Skin of Color: Maui Derm 2015

Valerie D. Callender, MD

In this presentation at Maui Derm 2015, Dr Callender reviews the use of neuromodulators in skin of color. When we think about neuromodulators in skin of color, we need to think about how these aesthetic patients present in our office.

The concept of global beauty is the desire to maintain a beautiful, youthful appearance. This concept crosses all racial, cultural, and economic barriers. It’s more than just symmetry, size, and shape of facial features. So what is global beauty? It’s the appearance of smooth, even skin complexion, as well as the absence of rhytids, volume loss, and skin laxity. Remember that the amount and type of melanin determines one’s skin color. When estimating a person’s age, skin color uniformity was amongst the most important feature.

When we think about race, ethnicity and culture the definitions are very important.

  • Race: an objective term that includes people of the same heritage who may or may not share genetic similarities but possess similar physical qualities.
  • Ethnicity: a subjective term, that is self-assigned, each person determines the group that they most readily identify with & feel most connected to.
  • Culture: refers to a set of patterned beliefs, values, conventions, or social practices of a group & may or may not take into account the concepts of race or ethnicity.

Often times we interchange these terms and it’s important for us to understand that the “Face of America” is changing. Our current population is over 301 million with people of color being the fastest growing segment. Skin lightness is a global concern. Skin color is a sign of health, attractiveness and youthfulness; it also affects job and marital prospects as well as earning potential.

What really changes things is the media as it depicts beauty and youth almost simultaneously. Dr Callender feels that it important for all of our patients, among a variety of ages and skin types, that beauty is really skin deep.

Cosmetic Concerns Among Women of Color

A survey was conducted regarding cosmetic concerns in 100 women (81 African American, 16 Hispanic, and 3 Asian). The mean age was 41 years old. 86% of the women were concerned with hyperpigmentation or dark spots; 80% were concerned with blotchy, uneven skin; 77% found combination oily or oily skin was of concern; 49% claimed sensitive skin; and 40% found that rough skin was an issue. (Grimes PE, Dermatol Clinics. 2000)

Cosmetic Procedures in 2013

Screen Shot 2015-06-16 at 5.13.59 AM

Reference: ASAPS.Cosmetic surgery national data bank statistics. Accessed Sept 2014.

Facial skin again is common across all ethnic and racial groups and varies in severity, age of onset and cultural impact. Skin of color patients demonstrate signs of rhytids at a later age than do individuals with fair skin and signs of facial aging in darker skin occurs 10 to 20 years later than in Caucasians. This is due to the photoprotective properties of epidermal melanin. The mean protective factor from UVB in skin of color is 13.4 versus 3.4 for white skin. Remember that mid-facial volume loss and prominent tear troughs are striking features of skin aging in African Americans and perioral rhytids are less common. Photo-aging differences in Hispanics and Latinos are less characterized, but vary considerably due to the broad range of skin types in this population. As dermatologists, we must be aware of nuances surrounding facial rejuvenation for patients with diverse racial and ethnic backgrounds.

Botulinum Toxin-A in African Americans

There are several published studies looking at neuromodulators in skin of color. One of the early studies of onobotulinum toxin by Grimes and colleagues found that there was really no difference in terms of adverse events in skin of color patients and maximal response was observed on day 30 with 92.4% and 100% response, respectively. (Grimes, Shabazz.Derm Surg 2009;35(3):429-436) Kane and colleagues studied abobotulinum toxin with different dosing and also found no significant racial or ethnic differences in safety. African American subjects had a slightly higher rate ocular adverse events and a lower rate of injection site reactions. The response rates and duration were slightly higher in African American subjects (177 days in AA versus 109 in overall population), the reason for this is unknown. (Kane, et al. Plastic & Reconstructive Surg 2009;124(5):1619-1629.)

When we look at neuromodulators in Asian patients, we see differences in response rates with 10 units versus 20 units; however, there were no differences in adverse events. (Harii & Kawashima. Aesth PS 2008;32(5):724-730.) What are we really looking for among all of these studies is safety issues and that’s what’s important across all of these studies. A study of onobotulinum toxin in Brazilian patients, followed by TCA 35% peel and manual dermabrasion 7 days post-injection resulted in transient PIH in 33% of the subjects. Additionally, significantly less wrinkles were seen from 90 days to three years in subjects treated with onobotulinum toxin versus placebo. (Kadunc et al. Dermatol Surg 2007;33(9):1066-1072.)

Clinical Pearls for Skin of Color Patients

  • Appropriate lighting and close examination is needed in identifying and avoiding blood vessels in darker skin
  • Post-inflammatory hyperpigmentation (PIH) is uncommon but may occur from needle injection points
  • Many Eastern Asian patients desire to have wider & rounded appearance of the eyes. BTX-A treatment using 2u lower eyelid & 12u crows feet is a nonsurgical option for these patients (Flynn, et al. Derm Surg 2001;27(8):703-708.)
  • In Eastern Asian patients, the dose should be a six-point injection to the masseter (three-points per side for a total of 50-60 units). (Ahn BK, Kim YS, Kim HJ, Rho NK, Kim HS. Consensus recommendations on the aesthetic usage of botulinum toxin type A in Asians. Dermatol Surg 2013 Dec;39(12):1843-60.)


In general, there are no racial or ethnic differences in the treatment of facial lines with botulinum toxin-A. Safety and efficacy in all skin types has been demonstrated in many published clinical studies. As with any aesthetic procedure, understanding and consideration of cultural diversity must be given to each patient’s individual aesthetic ideals.

Judy L. Seraphine, MSc-Maui Derm News Editor







TNF-a Inhibition and the Treatment of Hidradenitis Suppurativa

Bruce Strober, MD, PhD

In this presentation, Dr Strober provides us with new data on TNF alpha inhibition in the treatment of hidradenitis suppurativa (HS). HS is sometimes referred to as acne inversa; however, Dr Strober feels it is a different disease based upon a lot of lines of evidence.

Based on recent insights into the pathogenesis of this disease, TNF inhibition has found to be an effective treatment. Essentially, it’s phenomenological, because if you look at lesional skin, there is more TNF alpha as compared to peri-lesional as compared to control skin. This isn’t to say that TNF is the only relevant cytokine; in fact, it may be the first of many which will be targeted over the next decade. Just like in psoriasis, TNF will be the first cytokine studied for targeting in HS.

Screen Shot 2015-06-01 at 9.12.04 AM


Overall, etanercept (ETN), at the doses that have been studied, does not appear to be effective treatment for HS. The prospective, double-blind, placebo-controlled trial of 20 subjects were randomized 1:1 for ETN 50mg BIW versus placebo for 24 weeks. The primary efficacy endpoint assessed the Physician Global Assessment (clear or mild). Secondary endpoints included change in Patient Global Assessment and quality of life (DLQI). The results demonstrated that there was no statistically significant difference in benefit between ETN and placebo. There are some case reports that also verify this phenomenon.


The case reports for infliximab, which were published several years ago, showed efficacy in the treatment of HS; however, many patients had concomitant IBD, which is not uncommon among patients with HS.

A prospective, double-blind, placebo-controlled trial of infliximab IFX) included 38 subjects randomized to either IFX or placebo. The study’s primary endpoint was a 50 percent reduction in HS Severity Index (HSSI) at week 8 and secondary endpoints included change in Visual Analog Scale (VAS) and DLQI.

Screen Shot 2015-06-01 at 9.12.16 AM

As noted in the table above, the HSSI score takes into account a variety of features, including dressing changes and pain—which are aspects of the HS experience that should be queried with each patient.

Screen Shot 2015-06-01 at 9.12.38 AM

As we can see, about 25%-30% of patients on IFX have a reduction in HSSI score versus the placebo group. If you look at the 25%-50% reduction range, you can still see a bias towards IFX. Dr Strober feels that these are good data substantiating the value of IFX for the treatment of HS.

The VAS score as well as DLQI also show that IFX did better than placebo.

Dr Strober has used IFX on at least forty patients and feels that it really is the best drug out there, if you can access it. He also recommends using it with methotrexate to sustain the effect of IFX.


Adalimumab (ADA) represents the best set of studies done to date for the treatment of HS. The PIONEER II study looked at the safety and efficacy of ADA versus placebo in patients with moderate-to-severe HS after treatment for the first 12 weeks. The endpoint involved counting abscesses and inflammatory nodules. The HiSCR score, which Dr Strober feels is a valid score, is not dissimilar from other endpoints, in that it measures relevant issues in HS.

The study design was rigorous, in that they did a randomized, placebo-controlled approach. They key point here is that ADA will be dosed weekly, not every other week as it is when treating psoriasis. The phase II studies showed that ADA every other week did not perform as well.

Screen Shot 2015-06-01 at 9.13.00 AM

Interestingly, many more women were enrolled in this study than men. Also of note, is that two thirds of the patients in the study were smokers. Remember that HS is a systemic, inflammatory disease. Much like psoriasis, we should think of it as a systemic syndrome of inflammation.

When we look at the data (below), we can see the numerical improvement in the rating scale of skin pain is biased towards ADA versus placebo and we can see more people achieving a HiSCR on ADA versus patients on placebo.

Screen Shot 2015-06-01 at 9.13.12 AM

The ADA group also does better with regard to inflammatory lesion count reduction as well as the Sartorius Score reduction.

The safety data are remarkably clean in these studies, particularly focusing on infection, serious infection and malignancy. If anything, there were more events in the placebo group.

Clinical Pearls

What do we need to remember about HS?

  • HS is a chronic, negatively life-impacting disease.
    • Associated with metabolic syndrome (obesity, DM, HTN, dyslipidemia)
  • Pathogenesis multifactorial; primarily inflammatory and not infectious, and our understanding is evolving
  • Phase II/III studies with adalimumab are the best studies, to date, and convincing of efficacy and good safety
  • Infliximab also is very effective


MauiDerm News Editor-Judy L. Seraphine, MSc