Pediatric Dermatology: Maui Derm 2019 Highlights

In this session, Maui Derm’s expert panel of dermatologists covered a wide range of topics in pediatric dermatology. Among those experts were Sheila Fallon-Friedlander, MD, and Ilona Frieden, MD.

Sheila Fallon-Friedlander, MD

Dr. Fallon-Friedlander began her presentation with a discussion of rare cases of Spitz nevi in children and strategies when encountering Spitz nevi in pediatric patients under the age of 12. In addition, Dr. Fallon-Friedlander discussed the incidence of melanoma in pediatric patients with congenital melanocytic nevus (CMN), including how to identify which patients with CMN are most at risk for melanoma. In addition, the role of genetic mutations in CMN was discussed, as well as a case of aggressive melanoma in an infant with congenital nevus syndrome and multiple NRAS and BRAF mutation-negative nodules. Dr. Fallon-Friedlander also reviewed screening guidelines for thyroid function in children with alopecia areata. In addition, Dr. Fallon-Friedlander discussed terbinafine therapy for pediatric onychomycosis and culture methods for the diagnosis of the condition. Dr. Fallon-Friedlander concluded her presentation with a discussion of molluscum contagiosum.

Ilona Frieden, MD

Dr. Frieden’s presentation covered such topics as infantile hemangiomas (IH) and vascular malformation updates. Dr. Frieden reviewed the clinical practice guidelines for the management of IH from the American Academy of Pediatrics, including guidelines on risk stratification, timing of referrals for IH, and the management of IH across multiple medical and surgical specialties. In addition, Dr. Frieden discussed risk factors for the degree and type of sequelae after the involution of untreated IH as well as studies on propranolol for the treatment of high-risk IH and timolol for superficial IH. Moving on to vascular malformations, Dr. Frieden discussed somatic mosaicism, new research on the cause of birthmarks, and a case of Klippel-Trenaunay syndrome treated with sirolimus. Dr. Frieden also discussed sirolimus for the treatment of lymphatic malformation.

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Pediatric Acne: Putting Best Practices into Actual Practice

By Lawrence F. Eichenfield, MD

Restaurants do it all of the time—something changes and the restaurant must understand the change, adapt to it, and make changes to its system. Changes may seem unimportant—a decrease in local foot traffic, changes in customer preferences for certain foods—but they can impact business. When the change is well managed, the restaurant recognizes it and responds accordingly. If it does this well, the consumer experience remains optimal, the restaurant retains or expands its business, costs are controlled, and outcomes remain favorable.

Why don’t we do this in healthcare? Specifically, why don’t we do this in the field of pediatric acne?


Here’s what has changed:

A great deal has been elucidated recently about the preadolescent acne microbiome. Preadolescents with acne tend to be colonized with a greater diversity of cutaneous bacteria than control patients; in particular, Streptococcus species are more prevalent. See Figure 1.



Figure 1. Preadolescent microbiome for acne for healthy controls, acne patients treated with benzoyl peroxide (BP), and those treated with tretinoin. Note that 1 and 2 indicate first visit and pretreatment while 2 indicates the second visit.1


In a study of girls between the ages of 7 and 12 with at least six acneiform lesions performed by Ahluwalia et al, patients were treated with benzoyl peroxide (BP) 4% for six weeks (range four to 8 weeks). They were administered a swab to assess the microbiome at week 0 and then at the end of their treatment. This study found that patients with more acneiform lesions were significantly more likely to have more P. acnes bacteria and there were trends toward decreased S. mitis and increased S. epidermis.  This has led to the intriguing observation that P. acnes seems to create a hostile environment for certain pathogens—but allows Staphylococcal strains like S. epidermis to flourish.1 This seems to suggest that early preadolescent acne may involve a shift from a dominant S. mitis in the microbiome to a dominant P. acnes, which is then accompanied by more acne lesions.

Another change has been the switch of BP from a prescription medication to an over-the-counter (OTC) product, as well as the introduction of OTC retinoids (adapalene). OTC products are a cornerstone of acne treatment, but patients seem somewhat less consistent at acquiring OTC products as compared to prescriptions.. In a cohort study of 84 patients (ages 12 to 45) seen in a dermatology clinic for acne, patients were contacted by phone two weeks after their appointment. All patients had been counseled by the dermatologist to purchase an OTC BP product as part of their treatment. Only 20% of the patients remembered what OTC product was recommended and about a third (36%) did not purchase any OTC products, although 93% picked up their prescriptions. Of the 64% of patients who reported that they did buy an OTC acne product as recommended, only 32% of these products contained BP.2


Here’s what we can do:

Knowing more about the microbiome, better and more targeted medications can be developed. The antimicrobial effects of BP have been shown to be equivocal.1 Nevertheless, BP is a key part of acne treatment.  BP is now available OTC and patients must be educated that it is an important element in acne treatment and that they must read labels or follow instructions to be sure to get the right OTC product. Some ideas to improve this situation are samples for patients to take home and handouts or other printed materials with product images so the patient purchases the right OTC product.

Pediatric acne guidelines are in place.3 There is a large body of evidence in the medical literature about how to treat pediatric acne. However, in medicine, there is often a time lag between the validation of medical evidence (including published clinical trials and updated guidelines) and their implementation. For example, it took over 15 years for the use of beta-blockade following myocardial infarction to translate into practice as a standard of care for the average heart attack survivor.

Pediatricians are on the frontlines of caring for pediatric acne. While patients can be referred to a dermatologist, it may be more efficient and convenient for patients if the pediatrician could manage these cases efficiently. To that end, these pearls are offered.

  • Pediatricians and the clinicians who work with them should be trained with respect to the guidelines on pediatric acne
  • Training materials for patients should be developed—it would be ideal if these could be ordered via electronic medical records
  • In particular, training materials should offer images of OTC products, if recommended, to assure patients select the right medications


  1. Coughlin CC, Swink SM, Horwinski J, et al. The preadolescent acne microbiome: A prospective, randomized, pilot study investigating characterization and effects of acne therapy. Pediatric dermatology. 2017;34(6):661-664.
  2. Huyler AH, Zaenglein AL. Adherence to over-the-counter benzoyl peroxide in patients with acne. Journal of the American Academy of Dermatology. 2017;77(4):763-764.
  3. Eichenfield LF, Krakowski AC, Piggott C, et al. Evidence-based recommendations for the diagnosis and treatment of pediatric acne. Pediatrics. 2013;131 Suppl 3:S163-186.

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.


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.

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