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New Treatments for Common Skin Problems in Children

Let’s start by talking about hemangiomas, vascular birthmarks. Two main categories now. In the past there was a lot of errors in terminology in terms of vascular birthmarks. This is a new nomenclature system - actually, not that new, it’s about ten years old - that we use. Hemangiomas, by definition, are benign tumors of endothelial cells.

This is a salmon patch, and we are going to go through each of these areas individually. You guys have never seen a neonatal tooth; there’s one up there also, and port wine stains which are important primarily because they are disfiguring.

Okay, let’s start with hemangiomas. Again, benign tumors of endothelial tissue that have a growth potential. We see them in about 10% of all infants. They are more common in females than they are in males and about half of them are present at birth. But by definition they have to be present by about two to three months of age. If you are six-years-old and you suddenly develop a lesion, it’s not a hemangioma. It has to arise in the neonatal period.

Residual skin changes. We used to say that almost all hemangiomas got better and that there weren’t any problems associated with them. Probably anywhere from 10-30% have significant residual skin changes. Now that we are a little more cosmetically aware. Changes can range anywhere from - this is actually one involuting, just to show you how it involutes.

Treatment options. In most cases what we do is we just reassure the family because, again, 70% at least are going to clear without any residual. So most of the time we just kind of watch them and reassure the family. One area that you do need to know about nowadays, and this is relatively new, we are pretty aggressive now at treating hemangiomas on three parts of the face; the nose, the lip and the ear lobe, or the ear. Anywhere around there. Those areas typically heal very very poorly. In fact this is a girl who is out at five years of age.

Ulcerations. This is a little kid who came into our emergency room with an ulceration over his hemangioma. This usually occurs when they are going through the stage of rapid growth, so we typically see it out at around 6-9 months of age.

Treatment. They are almost always secondarily infected. If they are wet, as a rough rule of thumb in derm, if it is wet it’s probably infected. So these kids go on oral anti-staph, anti-strep antibiotics. We put on some type of cream to cover the surface; either a zinc oxide or if you want to get fancy you can do a DuoDerm or a Vigilon.

Associated syndromes. I don’t have a picture of Kasabach-Merritt. This is one they might very well test you on. It is incredibly rare. This is basically a child who comes in with … well, for the test purposes of hemangiomas, it is actually not a hemangioma. We now know it’s a more complicated lesion called a hemangioendothelioma, but they are not going to test you on that.

A couple of other associated syndromes. Remember, almost anything over the lumbar sacral area, short of a Mongolian spot, is potentially an indicator that you’ve got spinal dysraphism. That you’ve got a tethered cord underneath especially, or other lesions. This is a real trivial looking hemangioma. You can barely even see it. But this kid requires an ultrasound in the neonatal period to make sure there is not a tethered cord or part of the hemangioma.

Okay, let’s talk about salmon patches. Salmon patches, these are pretty trivial. These are seen in 50-70% of all kids. These are the "angel kisses" on the front of the face, the "stork bites" on the back of the neck. Typically the key thing for making this diagnosis is they are roughly symmetrical around the midline. They like to go to the glabella, both eyelids, around the corner of the nose, down the filtrum, down the middle of the chin. Depending on your skin color they can be light or dark. This is one over the nape of the neck, this is the "stork bite".

Syndromes. This they can actually ask you about. Sturge-Weber. If you see a child with a port wine stain in the V1 distribution of the trigeminal nerve. So that means forehead, upper eyelid or possibly lower eyelid, because there is some dual nerve innervation there in some kids. You need to worry about Sturge-Weber. And the three components are the port wine stain.

Klippel-Trénaunay-Weber. I don’t have a picture of. This is massive soft tissue overgrowth. Related to the port wine stain. This is usually isolated to an extremity and these things become horribly, horribly deformed. Because this is a port wine stain - this is a vascular malformation, not a hemangioma - steroids are not helpful and in fact we have no real good treatment for Klippel-Trénaunay.

Pyogenic granuloma. If somebody looks like they have a hemangioma but they didn’t have it, and now they are five-years-old and it’s been there for a month, think of this. This is a total misnomer. It’s not pyogenic, it’s not bacterial, it’s not a granuloma.

The next lesion is the Spitz nevus and this one sometimes is confused with hemangiomas, because when it’s on the face it’s often bright red. But it gives you this smooth, dome-shaped appearance. It’s usually solitary and it is a benign melanocytic nevus.

Let’s talk about some neonatal skin disorders real quickly. E. toxicum, you guys have all seen. Key thing on this in terms of making a differential. It’s not present at birth. It comes up at the end of the first 24 hours but it’s usually not there when the child pops out. Classically, the real key thing here is patchy areas of erythema and what looks like a little insect bite in the center with a big urticarial wheal around it. This is a close-up of that lesion.

The other one that people sometimes confuse with this, and it’s really quite different, transient neonatal pustular melanosis. A big mouthful for something that’s totally, totally benign. But important to know because it presents as pustules and you don’t want to confuse it with herpes or with a staph infection or something like that. The key to this; first of all, it occurs most commonly in African-Americans, in about 4% of black babies.

Cutis marmorata. This is the normal mottling that we see in newborns. It goes away by the time you are about a month old. It’s a problem with vasomotor control of your surface cutaneous vessels, your capillaries. It sometimes persists beyond a month, usually in kids, some of the trisomy’s such as Down syndrome, trisomy 18 and in Cornelia de Lange’s.

Subcutaneous fat necrosis. This one is going to be a little hard to see because you really had to be there to feel it, to be honest. But this kid has got some patchy areas of erythema here and here and here. Then he had this really hard, woody, indurated plaque. I mean, this thing was hard. It felt like a tabletop.

Neonatal acne. It comes up around 2-4 weeks of age, usually not before that. It peaks when they are about a month to six weeks out and then usually goes away by three months. You can see comedones, you can see pustules.

Seborrheic dermatitis. This is cradle cap. They might ask you a question about how to differentiate eczema from seborrheic dermatitis, in which case it should be an easy question for you. Seborrheic dermatitis starts earlier, 2-4 weeks. Eczema doesn’t start until you are about three months of age. Seborrheic dermatitis doesn’t itch, although sometimes you can’t tell at this age. Eczema should itch.

Neonatal lupus. From the derm point of view, it gives you a skin rash that starts up about 2-4 weeks out, usually with exposure to sun and usually on sun-exposed parts of the body. So you usually see it on the arms, maybe part of the chest, and typically on the face and scalp. If you see anything that kind of looks like ringworm.

Atopic derm. We talked about differentiation between atopic derm and eczema. Let’s look at a couple of pictures. Okay, classic atopic derm on the cheeks, spares the mid-face. Seb-derm remember likes to go to the corners of the nose, atopic derm likes to spare that area. This again is a disease of childhood with 95% of it appearing by five years of age. Typically infants tend to have a little more widespread disease.

A couple of things about topical steroids. The side effects you are going to get depend on a few things. Obviously the potency of the steroid and how much you put on, but also the location. Remember that areas where there is thin skin - the groin, the face, the axilla - you don’t want to use that strong of a steroid. If you have eczema on the hand in an adolescent, where your skin is very very thick, or on the soles of your feet, you need to use a very potent steroid. Occlusion; very importantly. We occlude steroids by putting them on then putting an emollient over the surface. That will occlude and increase the absorption. But on an infant, the easiest way to occlude a steroid is to put it in the diaper area and then put the diaper on. That’s another reason why you can’t use high potency steroids in the diaper area. What are the complications that you get that they might ask you about? Localized atrophy. That gives you skin that looks kind of smooth, a little depressed, and when you push on the edges it kind of crinkles up like parchment. Telangiectasias, stria, acne, perioral dermatitis - this is very common in people who don’t have eczema but who get some type of contact dermatitis on the face and they put a fairly high powered steroid there and every time they try to wean the steroid off it burns and stings and they have to put the steroid back on. It can be very miserable trying to get them off of it. Increased hair, granuloma gluteale. This is a nodular lesion that develops in the groin in response to high powered steroids in the diaper area. Systemic effects; we really don’t see glaucoma or growth failure very often.

Some of the other things that are associated with dry skin; pityriasis alba. These are these little hypopigmented, poorly demarcated patches that you see usually on the face, but also on the arms. Most apparent during the summer because that’s when the rest of the skin is tanning and they don’t itch. Tinea versicolor could look like this except they are usually smaller.

This is keratosis pilaris. This is hard to see but what you are seeing are little teeny bumps throughout here, little hard papules and this appears in a characteristic area; on the cheeks, on the outside of the arms and the tops of the thighs. This is a girl with it on the thighs. In this area here she’s got some little papules. These are basically another manifestation of dry skin.