Pediatric Pearls Restrung: Part 2

Sheila Friedlander, Ilona Freiden

Diaper Rashes

1984 was the introduction of a superabsorbent polymer, sodium polyacrylate. It absorbs a lot of water and converts from powder to gel. These diapers also buffer pH, they have a polyethylene film surface, are less irritant, and are better at containing fecal bacteria.

The lesions for diaper rash tend to appear as kissing lesions; in children with more chronic fecal or urinary exposure, the lesions can spread out.

When managing these children, try to address underlying cause of constant exposure to liquid stool. Barrier pastes e.g. Triple paste, Desitin, etc are often helpful. Clinicians should also consider adding an anti-yeast medication e.g. miconazole-zinc oxide paste or nystatin-HC ointment combination. If the child is not responding, re-think the diagnosis.

Pseudoverrucous Papules and Nodules

These are also known as “Granuloma gluteal infantum”. The papulo-nodular eruption is due to chronic irritation, usually with severe chronic fecal or urinary exposure. They can be difficult to treat so clinicians need to address underlying cause, if possible.

Pampers Dry-Max® are a 2010 product and claim to be two times drier and 20% thinner in order to “let them play on!” However, there was a widespread social media outburst (~12,000 members) among mothers who claimed that the diapers caused rashes and even “chemical burns”. A Consumer product safety commission investigated the issues and found that from April through August 2010, CPSC received nearly 4,700 incident reports about diaper rash. Nearly 85 percent of these complaints came in May and then dropped off significantly. The report from September 2010 stated: To date, the review has not identified any specific cause linking Dry Max diapers to diaper rash. However, if parents think Pampers DryMax are causing their child to have a rash, consult the doctor and change to a different diaper.

Vitamin D Delirium and Sunscreen Phobia

Patients are inundated with conflicting information regarding the benefits of the sun and the role of Vitamin D. Obviously, there are clear risks of the sun and there are also risks regarding the agents used for sun protection. Clearly, patients and parents are confused. It is important, as a clinician, to have a cogent message in mind. It’s important to explain the controversies and provide patients/parents with direction.

The sun is a source of Vitamin D; yet, it is also a source of harmful radiation. The spectrums for these two actions overlap and there is no way to separate them.
The AAD & AAP remain steadfast in their recommendations, i.e., vitamin D should be obtained via diet /supplements.

Vitamin D Requirements—IOM Recommendations
Assume no solar production component!

Take Home Message:

• Only clear benefit of Vitamin D relates to bone health
• Get your required amount through diet/supplements
• Things are not as bad as we thought in terms of how many people are deficient (IOM)
• There are risks to too much Vitamin D

Sunscreens

Patients are confronted with several different choices when choosing a sunscreen product. The Environmental Working Group – Watchdog has continuing concerns regarding sunscreen ingredients. Organic sunscreens have a hormonal effect and physical sunscreens have a penetration, persistence via ultramicronized nanoparticles. Their newest concern is Retinyl palmitate, a Vitamin A derivative found in many sunscreens. It is a vitamin A relative (retinyl ester) used to fortify food products such as milk, dairy, cereal. In sunscreens, it acts as antioxidant + aesthetic optimizer. In animal models, RP can generate free radicals. The National Toxicology Program selected RP for study, along with aloe vera, nano-titanium dioxide and zinc oxide.

Regarding baby sunscreen, it’s really an effort of trial and error. It is probably best that the baby is not exposed.

It is important to work with your patients and really weigh the benefits against the risks. The projected risk of melanoma in the US in 2015 is one out of fifty. One American dies of melanoma every hour. Clearly, we know that UB radiation exposure plays a role in this. If sunscreen were applied appropriately, we would be better off.

A study in Australia (Green AC, et al.) looked at patients 25 to 75 years of age to measure the effect of five years of sunscreen application and betacarotene on the incidence of BCC and SCC. The group that used the sunscreen had a lower incidence of melanoma (22 versus 11). There was some controversies around this study; however, an editorial in the Journal of Clinical Oncology stated that the P values were of borderline significance, but the hazard ratios showed a 50% reduction—in situ compared to invasive malignant melanoma and a 73% reduction in hazard related to melanoma alone.

Sunscreen Phobia-Summary

• Sun exposure – Modifiable risk factor
• Many studies – positive effect of sunscreen on mole number, some now show direct protective effect for melanoma
• Concerns raised by EWG re: ingredients; all theoretical re: humans
• If you tell people to avoid sun, they may ask you re: Vit D…. be prepared!