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  • retapamulin oint 1% (Altabax) bid for 5 days
  • 50% of affected children have a solitary lesion.
  • Visual inspection of the hair and scalp is widely practiced, but this approach may miss three quarters of infestations detectable by combing hair with a fine-toothed "nit," or detection, comb; this type of comb was also twice as fast as visual inspection in detecting live lice in one study.8 Combing wet hair has also been advocated16 and may be more sensitive than combing dry hair. Although this approach is too impractical for routine clinical use,17 it may facilitate diagnosis in people with long, thick hair.
    After the hair is combed or brushed to remove tangles, the fine-toothed comb should be inserted near the crown until it gently touches the scalp, and then it should be drawn firmly down. The teeth of the comb should be 0.2 to 0.3 mm apart to trap lice. The entire head of hair should be combed systematically at least twice; the comb should be examined for lice after each stroke. It usually takes approximately one minute to find the first louse.8
  • Benzyl Alcohol Lotion, 5%, has been approval as a prescription medication, for use in patients 6 months of age and older.
    Benzyl alcohol lotion, 5%, has been shown to be an effective first line treatment to eliminate head lice infestation. The safety and effectiveness of Benzyl Alcohol Lotion, 5%, was demonstrated in two studies of 628 people, 6 months of age and older, with active head lice infestation. The subjects received two, 10-minute treatments of either Benzyl Alcohol Lotion or a topical placebo, one week apart. Fourteen days after the final treatment, more than 75 percent of the subjects treated with Benzyl Alcohol Lotion, 5%, were lice free.
    Common side effects of the medication include irritations of the skin, scalp, and eyes, and numbness at the site of application. The product should be applied only to the scalp or the hair attached to the scalp. It is not approved for use in children younger than six months. Use in premature infants could lead to serious respiratory, heart- or brain-related adverse events such as seizure, coma, or death.
    Benzyl Alcohol Lotion, 5%, is distributed by Sciele Pharma Inc., a subsidiary of Atlanta-based Shionogi Company.
  • Is Exclusion from School Necessary?
    Transmission certainly occurs between pupils at school,38 and exclusion from school for head lice is an almost universal practice in the United States.1 However, the lice have probably been present for weeks before detection, and a few extra hours will make no significant difference to the risk of transmission. Three quarters of children with nits alone are not infested, and no-nit policies are therefore excessive.14 Exclusion from school based on the presence of lice or nits is not recommended by the American Public Health Association.11
    1998, half the school nurses in the United States would not allow a child with nits back into school
  • An Pediatr (Barc). 2005 Nov;63(5):448-52.Related Articles, Links
      [Risks of black henna tattoos][Article in Spanish]Arranz Sanchez DM, Corral de la Calle M, Vidaurrazaga Diaz de Arcaya C, de Lucas Laguna R, Diaz Diaz R.
    Servicio de Dermatologia, Hospital Universitario La Paz, Madrid, Espana. dalmazia@wanadoo.esTemporary henna tattoos have become increasingly popular in the last few years, because of their apparent harmlessness and disappearance in few weeks. Black henna contains paraphenylenediamine (PPD), a synthetic colorant which is used in hair dyes and can cause sensitization. Many cases of allergic contact dermatitis occurring after tattooing have been reported, especially in children and teenagers during the summer time, since there are many tattoo-painters at holiday places and the parents are unaware of the risks of these tattoos. Clinicians, particularly pediatricians, primary care physicians and dermatologists should seek to remedy this misinformation. We can be the first person to be consulted before the tattoo painting and we will treat patients with lesions. We present our experience of eight cases of allergic contact dermatitis after tattooing and briefly review the literature on the risks of black henna tattoos.
  • Sharma V. Beyer DJ. Paruthi S. Nopper AJ.Institution Section of Dermatology, Children's Mercy Hospital, Missouri 64108, USA. vsharma@cmh.eduTitle Prominent pruritic periumbilical papules: allergic contact dermatitis to nickel.Source Pediatric Dermatology. 19(2):106-9, 2002 Mar-Apr.AbstractWe report a case series of 38 children with suspected allergic contact dermatitis (ACD) to nickel who presented with prominent subumbilical and periumbilical papules and a generalized, lichenoid papular dermatitis resembling an id reaction. We speculated that this was an ACD to nickel and performed patch tests in 9 (24%) of these patients. All 9 (100%) patients had positive patch test results for nickel, thus confirming the diagnosis.
  • Nickel is the most ubiquitous contact allergen among children and adolescents. Metal blue jeans buttons and belts have been noted to cause nickel dermatitis around the umbilicus. For these children, traditional teaching is strict avoidance of all pants with metal snaps/buttons, particularly blue jeans. In this study we tested 90 pairs of blue jeans and 47 belts for nickel using the dimethylglyoxime spot test. Only 10% of blue jeans tested positive, while 53% of belts tested positive. Furthermore, 10 pairs of nickel-negative blue jeans remained negative after 10 washings. Overall we found no resistance to testing in clothing stores. From these results, we recommend that patients with allergic contact dermatitis secondary to nickel need not strictly avoid blue jeans and metal belt buckles. Rather, families should be encouraged to use the dimethylglyoxime spot test to test these items for nickel prior to purchase.
  • I started a Pediatric Vascular Anomalies clinic in 1998 and it has grown to become the referral clinic for the evaluation and treatment of
    Infantile hemangiomas
    Other vascular neoplasms
    Capillary malformations
    Lymphatic malformations
  • response rate due to depth of vessels
    recurrences increase longer away from Rx. Due to sick dermatome theory.
    Touch up treatments
  • 3% of visits to pediatric dermatologists are for hair disorders. These are common and sometimes vexing problems for patients, families and their physicians.
  • Among the numerous causes of hair loss in children, three types account for the great majority of visits to the clinician: they are all acquired and localized forms of alopecia areata, traumatic alopecia, and tinea capitis
  • Farrier S. Morgan M.
    Department of Pathology, University of South Florida College of Medicine, Tampa, USA.
    bcl-2 expression in pilomatricoma.
    American Journal of Dermatopathology. 19(3):254-7, 1997 Jun.
    Pilomatricoma is a distinctive tumor characterized by a dual population of proliferating basophilic cells and diagnostic shadow cells, believed to arise from the hair matrix. The normal hair matrix undergoes defined cycles of growth (anagen), regression (catagen), and resting (telogen) that are regulated by programmed cell death (apoptosis). bcl-2 is a proto-oncogene that helps to suppress apoptosis in both benign and malignant tumors. In addition, both apoptosis and bcl-2 are critical factors in normal hair follicle development. In order to clarify the role of bcl-1, we used immunohistochemical means to study 10 cases of histologically proven pilomatricoma for bcl-2 expression. The study design included both positive and negative controls. All of the pilomatricomas in our series were strongly
    decorated by bcl-2 immunostaining. Based on our findings of increased bcl-2 staining, we concluded that the faulty suppression of apoptosis contributes to the
    pathogenesis of pilomatricoma.
  • Transcript

    • 1. Starting From Scratch:Starting From Scratch: Common Pediatric DermatosesCommon Pediatric Dermatoses Richard J. Antaya, M.D.Richard J. Antaya, M.D. Associate Professor, Dermatology & PediatricsAssociate Professor, Dermatology & Pediatrics Yale University School of MedicineYale University School of Medicine
    • 2. IMPETIGO CONTAGIOSAIMPETIGO CONTAGIOSA • Both Staph aureus and Strep pyogenes • Humid climates and summer months • Secondary to trauma and insect bites • Treatment – Oral - cephalexin. dicloxacillin, amoxicillin- clavulanate, erythromycin, cefaclor – Topical - mupirocin (Bactroban), retapamulin oint 1% (Altabax), soak off crusts
    • 3. Bullous Impetigo • Always Staph aureus • Epidermolytic toxin cleaves stratum granulosum • Phage group II • Same toxin as Staph Scalded Skin Syndrome • Rx: Oral anti-Staph antibiotics
    • 4. Lyme DiseaseLyme Disease • multi-stage, multi-system disease • agent:Borrelia burgdorferi, vector: Ixodes ticks • late spring to mid fall • Erythema Migrans (previouslyECM) in 80% – expanding, erythematous, round or oval areas – solitary or multiple, concentric rings – variable induration, pain, pruritus • untreated cases - arthritis, neurologic, cardiac, ophthalmic complications
    • 5. Lyme DiseaseLyme Disease TreatmentTreatment • young children – amoxicillin • older children/adults - doxycycline
    • 6. Tinea Corporis Pearls • Fungal infection of the superficial epidermis • KOH wet prep for diagnosis – Scrape with edge of glass slide; not scalpel – Apply one drop Chlorazol Black E fungal stain – Place coverslip – Scan on low power with condenser at lowest point • “If it’s scaly…scrape it!” • Don’t get CLIAphobia
    • 7. Tinea Corporis Treatment Pearls • Topical azole* unless widespread • Treat b.i.d. for 2 to 4 weeks • Terbinafine, naftifine, butenafine, ciclopirox – Fungicidal – $econd line • Look for source * clotrimazole, ketoconazole, miconazole, econazole
    • 8. Granuloma Annulare • Small, firm papules form annular plaque • Skin-colored, dusky to violaceous • No scale (- epidermal, + dermal inflammation) • Acral locations • Necrobiosis (destruction) of dermal collagen • Subcutaneous - deep nodules • Periosteal – “bony” hard; over scalp, tibia • No treatment, no associations, reassurance
    • 9. TINEA CAPITISTINEA CAPITIS • Dermatophyte infection of the hair shaft • Presentation – hair loss and/or multiple “black dots” – patchy areas of scale – lymphadenopathy • Common in African-American children • Usually caused by Trichophyton tonsurans (does not fluoresce)
    • 10. TINEA CAPITISTINEA CAPITIS • Oral griseofulvin 20-25 mg/kg/day in a single dose with fatty food • Treat for 6 - 12 weeks • Adjunctive use of selenium sulfide (Selsun Blue), ketoconazole, or ciclopirox shampoo may decrease fungal shedding
    • 11. TINEA CAPITIS Alternative Therapies • Terbinafine (Lamisil) 5-8 mg/kg/d, 4-6 wk – Oral granules FDA approved • Itraconazole (Sporonox) – 5-6 mg/kg/d – Liquid contains cyclodextrin • diarrhea, pancreatic adenomas in rats • Fluconazole (Diflucan) – 6 mg/kg/d – no more effective than griseofulvin* Br J Dermatol 1996;135:86-88 AAD poster New Orleans, LA 2005*
    • 12. KERIONKERION • Boggy, highly inflammatory reaction • Bacteria may be cultured (Staph) • Treatment Griseofulvin Prednisone (1-2mg/kg/day) for ~5 days +/- Oral antibiotics
    • 13. Id Reaction Distinguish from Drug hypersensitivity Urticaria • Edematous, erythematous papules • Lineup along hairline, postauricular, • Atopic dermatitis distribution
    • 14. TINEA VERSICOLORTINEA VERSICOLOR • Malassezia furfur(Pityrosporum orbiculare) • More common in adolescents and adults Treatment • Overnight selenium sulfide solution/ shampoo (1% OTC and 2.5% Rx) • Ketoconazole 400 mg P.O. in a single dose, may repeat in one week
    • 15. SCABIESSCABIES DIAGNOSISDIAGNOSIS 1. Hx of intractable itching 2. Hx of possible exposure 3. Character and distribution of lesions 4. Microscopic exam of skin scrappings
    • 16. SCABIESSCABIES In Older ChildrenIn Older Children Distribution anterior axillary lines inner aspect of upper arms areolae penis wrists and interdigital webs ankles
    • 17. SCABIESSCABIES InfantsInfants • Diffuse eczematous dermatitis • Frequently involves entire cutaneous surface (face, palms, soles) • Inflammatory nodular lesions of axillae / diaper area of very young • Burrows, papules, vesicles and pustules
    • 18. SCABIESSCABIES TREATMENTTREATMENT • 5% permethrin cream (Elimite) – Total body in infants and older children – Don’t recommend neck to toes – 8-14 hour (overnight); repeat in 7 days • Ivermectin (Stromectol) – 2nd line, 200 mcg/kg, repeat 1 week • Wash clothing / bedding >120o F next a.m. • Treat all close contacts • Treat the “patient” – Moderate potency topical steroids
    • 19. Louse: 6-legged, wingless,Louse: 6-legged, wingless, translucent, 2-3 mmtranslucent, 2-3 mm
    • 20. Head Lice Myths vs Facts • Don’t affect only “dirty” individuals • Not linked to poor hygiene or living conditions • Don’t jump or fly • Location of nit varies with temperature and humidity (1/4 – 6 inches)
    • 21. Pediculosis Capitis Head Lice • Symptoms – nocturnal pruritus – red macules on nape of neck and scalp • Don’t spread any other disease, rare impetigo, malaise • Transmission: head-to-head contact
    • 22. Head Lice Diagnosis • Combing vs Visual inspection – 4x more effective – 2x faster • Combing hair with nit comb – Teeth spacing 0.2-0.3 mm – Wet hair may be more effective • Procedure – Routine comb or brush – Insert louse comb at crown – Gently touches scalp – Draw firmly down, angle distally – Comb systematically at least twice – Examine comb after each pass – Usually 1 minute to find first louse • Nurses out-perform MDs Mumcuoglu KY et al. Pediatr Dermatol 2001;18:9-12 Head lice/nit combs
    • 23. Pediculosis Capitis First-line Treatment • FDA-approved OTC – 0.3% pyrethrins (RID), permethrin 1% (Nix) – Apply to scalp 10 min and rinse – Repeat 8-10 days – Apply 1:1 vinegar:H20, enzyme solution to enhance combing – Comb with metal nit comb • Re-examination for live lice (nurse preferably) after another 8-10 days • Cost ~$20 for 1-2 treatments Adapted from Guidelines for the Treatment of Resistant Pediculosis; 6/14/99
    • 24. Pediculosis Capitis Second Line Treatment • If live lice present after 2 OTC treatments • malathion lotion 0.5% (Ovide®) • Side effects: scalp irritation, dandruff, conjunctivitis, flammable until dries • 7 days after the treatment 90% were lice free • Application – To dry hair-thoroughly wet hair and scalp – Allow to dry uncovered – Shampoo hair after 20 min – 8 hr, nit combing – Only repeat in 7-9 days if lice still present • Supplied 2 oz bottles (1 application = $206) Adapted from Guidelines for the Treatment of Resistant Pediculosis; 6/14/99
    • 25. 5% Benzyl Alcohol Lotion Ulesfia • NEW FDA approved April 2009 • Kills head lice by asphyxiation w/o potential neurotoxic SE • > 6 months of age • 2 PC studies for FDA approval – 628 pts – Two 10-minute treatments, 1 week apart – 14 days after the treatment 75% were lice free – SE - irritation of the skin, scalp, and eyes, application site numbness – Avoid in premature infants - serious respiratory, heart- or brain- related adverse events • Now available
    • 26. Ulesfia Lotion Usage Guidelines Hair Length • Short – 0-2 inches – 2-4 inches • Medium – 4-8 inches – 8-16 inches • Long – 16-22 inches – > 22 inches Amount of Ulesfia Lotion/ Tx – 4-6 oz (½-¾ bottle) – 6-8 oz (¾-1 bottle) – 8-12 oz (1-1½ bottles) – 12-24 oz (1½-3 bottles) – 24-32 oz (3-4 bottles) – 32-48 oz (4-6 bottles) $41.59/8oz bottle Girl w/ long hair 3 bottles x 2 =$249.54
    • 27. Pediculosis Capitis Third-line Treatments • Oral Bactrim – Gram neg bacteria in lice GI tract – 10 day course p.o. (dose for A.O.M) • Nuvo lotion* Cetaphil Cleanser ® – Apply to scalp, dry with hair dryer – Rinse out next day, repeat qwk x 3 – Nit removal unnecessary – 96% cure – Suffocate the lice with hair drier • Ivermectin – P.O.- 200 mcg/kg x 1 on days 1 and 10 – 0.8% topical solution/shampoo * Pearlman, D. L. Pediatrics 2004;114:e275-e279 Copyright ©2004 American Academy of Pediatrics untreated louse (Speare et al) Nuvo-treated louse coated with dried-on lotion
    • 28. School Exclusion • In 1998, 50% of US school nurses would not allow a child with nits back into school • Infestation present weeks before detection • 75% with nits alone are not infested • School exclusion not recommended by American Public Health Association • “No nit” policy is questionable ($367 million/yr lost)
    • 29. WARTSWARTS • Human papilloma virus (HPV) • Verrucae vulgaris, plana, plantaris, and condyloma acuminata • Highest incidence in 10-19 y/o • 25% disappear in 3-6 months • 65% disappear in 2 years
    • 30. WART THERAPYWART THERAPY • Topical salicylic acid in collodion hs with paring • Cryotherapy with liquid nitrogen • Duct tape – apply for 6.5 days/week • Heat therapy • Pulsed Dye Laser * • Aldara (imiquimod 5% cream) • Immunotherapy (SADBE, skin test antigens) • Oral cimetidine x 2-3 months still controversial * Adapted from Tan OT, Lasers in Surg and Medicine,1993, 13:127-37
    • 31. Molluscum Contagiosum • Poxvirus infection of the epidermis • Mistaken for varicella or vesicles • Infectious (pools, fomites)… but benign • Inflamed, itchy, infected • Untreated lasts 2-48 months (avg 18 mo) • STD in adolescents and adults • Severe in HIV infected patients
    • 32. Molluscum Contagiosum Treatment • Tincture of time • Office-based therapy (q 2 weeks) – Cantharidin (Blister beetle juice) application – Liquid nitrogen cryotherapy – Curettage – Lacerate or lance with needle – Candida Antigen intralesional injection • Home treatments – Tretinoin (Retin-A) 0.025% gel with Q-tip qhs – Imiquimod 5% cream (Aldara) q.d. to b.i.d.
    • 33. ALLERGIC CONTACTALLERGIC CONTACT DERMATITISDERMATITIS Acute lesions - erythema, vesiculation, oozing Chronic lesions - dry and lichenified Most common offenders Toxicodendrons - Poison ivy, oak, sumac (~80%) Metals (Ni) (10-15%) Neomycin Preservatives and fragrances Shoes (chromates and rubber) Black henna tatoos (ppd)
    • 34. Prominent Pruritic Periumbilical Papules: Allergic Contact Dermatitis (ACD) to Nickel • 38 children with suspected ACD to nickel • prominent subumbilical and periumbilical papules • generalized, lichenoid papular dermatitis resembling an id reaction • patch testing performed in 9 (24%) • all 9 (100%) patients had positive patch test results for nickel, confirming the diagnosis Adapted from Sharma V. Pediatric Dermatology. 19(2):106-9, 2002 Mar-Apr.
    • 35. Cellphone Contact Dermatitis with Nickel Allergy • Tested numerous brands of cell phones • Most common sites with nickel – menu buttons – decorative logos on the headsets – metallic frames around the LCD screens Berkovitch L, Luo J. CMAJ 2008;178(1):23-4.
    • 36. Results of nickel spot testing of 23 wireless communication devices • CELLPHONE • BlackBerry 8700c Speakerphone (back of phone) • BlackBerry Pearl None • Kyocera KX444 None • LG Verizon VX8300 None • Motorola L2 Headset (decorative logo) • Motorola Razr Headset (decorative logo) • Motorola SLVR Headset (decorative logo) • Motorola Q Headset (decorative logo) • Motorola i580 None • Motorola i870 None • Nokia 6061 None • Nokia 6062 None • Nokia 6820 None • Nokia 6230 None • Nokia 6682 None • Palm Treo 650 None • Samsung e105 Metal around the screen, menu button • Samsung d807 Menu button • Sony Ericsson W600i Menu button • Sony Ericsson W810i Menu button • Sony Ericsson T610 Handset (if paint is chipped) • Sony Z520a None • BLUETOOTH HEADSET • Plantronics Explorer 320 None Berkovitch L, Luo J. CMAJ 2008;178(1):23-4.
    • 37. Dimethylglyoxime Positive test for Ni+ Metal jean clasps 10% Belt buckles 53% Byer TT. Periumbilical allergic contact dermatitis: blue jeans or belt buckles?. Pediatric Dermatology. 21(3):223-6, 2004 May-Jun.
    • 38. Dimethylglyoxime Nickel Test Kit Allertest Ni • Allerderm PO Box 2070 Petaluma CA 94953 • $12.50 + $6 S&H • • 800-365-6868
    • 39. CONTACT DERMATITISCONTACT DERMATITIS TREATMENTTREATMENT • Topical steroids - moderate potency • 2 week course of oral prednisone if widespread/facial • May last for 1 to 3 weeks after exposure • Identify allergen and avoid
    • 40. PORT-WINE STAINSPORT-WINE STAINS Capillary Malformation • Will not involute, does not proliferate/spread • May darken and thicken • May become nodular w/ age • May become significant, lifelong cosmetic and psychosocial problem • Laser may be effective
    • 41. Yale Vascular Anomalies Clinic (VAC) •Infantile hemangiomas •Other vascular neoplasms •Capillary malformations •Lymphatic and other malformations •Other vascular lesions – PG, angiokeratomas
    • 42. Capillary Malformation“Port Wine Stain” Pulsed Dye Laser Treatment • response rate – variable – 65% - 75% complete to considerable response – multiple treatments (5-20 average) – child versus adult – improved response • anatomical site - forehead, lateral face, temple • geographic • recurrences can occur
    • 43. SUN PROTECTIONSUN PROTECTION STATISTICSSTATISTICS • skin cancer - most common malignancy in cancer - most common malignancy in U.S. • 1 million new skin cancers diagnosed in 19971 million new skin cancers diagnosed in 1997 • about 7,300 skin cancer deaths in 1996about 7,300 skin cancer deaths in 1996 • malignant melanoma in U.S.malignant melanoma in U.S. – 1973 - cases 5.7 /100,000; mortality of 1.6/100,0001973 - cases 5.7 /100,000; mortality of 1.6/100,000 – 1994 - cases 12.5/100,000; mortality of 2.2/100,0001994 - cases 12.5/100,000; mortality of 2.2/100,000 – 41,600 new cases diagnosed in 199841,600 new cases diagnosed in 1998 • sun is the cause of at least 90% of all skin cancerssun is the cause of at least 90% of all skin cancers
    • 44. SUN PROTECTIONSUN PROTECTION • BCC / SCC associated with cumulative exposureBCC / SCC associated with cumulative exposure • melanoma associated with short, intense exposure,melanoma associated with short, intense exposure, possibly UVApossibly UVA • blistering sunburns in childhood more than doubleblistering sunburns in childhood more than double the risk of melanomathe risk of melanoma • significant amount of lifetime sun exposure occurssignificant amount of lifetime sun exposure occurs before age 18before age 18 • anticipatory guidance early is essentialanticipatory guidance early is essential
    • 45. Good Sun Sense • broad-rimmed hats • tightly woven clothing • sunscreens SPF 15 or more (> 6mo) • sun Guard by Rit ® in wash (UPF 5→30) • UV protective sunglasses • nature shade, limit midday exposure • avoid tanning beds!
    • 46. Evaluating Hair Loss in Children Localized or Diffuse Congenital or Acquired
    • 47. Acquired & Localized Hair Loss 1. Alopecia areata 2. Trauma – Trichotillomania / Hair pulling – Traction alopecia 1. Tinea capitis
    • 48. Alopecia Areata
    • 49. Alopecia Areata HISTORY Worse prognosis associated with • disease present > 1 year or young age at onset • positive family history of AA or atopy • extensive involvement – especially ophiasis pattern or alopecia totalis • Down syndrome
    • 50. Angular/geometric shapes or borders Linear lesions Incomplete loss Perifollicular petechiae and excoriations No scale TRICHOTILLOMANIA Hairs of varying length Broken / twisted hairs
    • 51. Hair Pulling “Splitting Hairs” 1. Acute hair pulling associated with stress 2. Trichotillomania (OCD) 3. Hair pulling associated with other psychiatric disorders
    • 52. Traction AlopeciaHair thinning in particular areas Very few fractured hairs Hair shafts smaller in diameter Hair care / style R/O child abuse RX: education , discontinue trauma Follicular papules
    • 53. Pilomatricoma Calcifying Epithelioma of Malherebe • Benign adnexal tumor from hair cortex • Rock-hard, bluish, “tent sign” 2 mm -1 cm nodule • Face > extremities • 10% of all skin nodules/tumors in childhood • Most asymptomatic, inflammation in some • Spontaneous regression not reported • Surgical excision, recurrence < 5% • Familial 13.3% occurrences* • Multiple 26.7% – Rubinstein-Taybi, Turner, Gardner syndromes * Adapted from Pediatric Dermatology. 14(6):430-2, 1997 Nov-Dec.