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Update in Pediatric Dermatology

Zachary Zinn MD

Assistant Professor

WVU Department of

Dermatology

Objectives Discuss new developments in

dermatology

Learn treatment pearls for most

common pediatric dermatologic

conditions

Acne Vulgaris

Most common skin problem in U.S.1

1: KK Kraning, GF Odland: Prevalence,

morbidity and cost of dermatological diseases. J

Invest Dermatol. 73 (Suppl):395-401 1979

AL Zaenglein, DM Thiboutot: Acne vulgaris.

JL Bolognia JL Jorizzo RP Rapini Dermatology.

2003 Mosby Edinburgh

Hurwitz Clinical Pediatric

Dermatology 5th Edition

Hurwitz Clinical Pediatric

Dermatology 5th Edition

Hurwitz Clinical Pediatric

Dermatology 5th Edition

Guidelines

American Academy of Dermatology

(AAD.org)

Practice Management Center

Quality

Clinical Guidelines

Acne Pearls

Benzoyl peroxide is recommended

for patients on topical or systemic

antibiotic therapy*

*Fulton JE Jr, Farzad-Bakshandeh A, Bradley S.

Studies on the mechanism of action to topical benzoyl

peroxide and vitamin A acid in acne vulgaris. J Cutan

Pathol. 1974;1:191-200.

Acne Pearls

Given current data, no specific

dietary changes are recommended

in the management of acne

Acne Vulgaris - Comorbidity

Decreased emotional well-being

Withdrawal from society

Depression

Decreased self-esteem

Increased suicidal ideation

Poorer academic performance

Higher unemployment rates

Acne Pearls

Oral isotretinoin is used for:

Severe Acne

Non-responsive acne

Acne that produces physical or

psychological scars

Verruca Vulgaris

Therapeutic Pearls

Consider watchful waiting

Lower expectations of treatment

Therapeutic Pearl

+

Other Treatments

Cryotherapy

Immunotherapy

Cimetidine 30-40mg/kg/day divided bid

Imiquimod

Candida antigen injection

Pulsed dye laser

Cantharidin

Verruca plantaris

Verruca Plana

Condyloma Acuminata

AL Allen, EC Siegfried: The natural history of condyloma in

children. J Am Acad Dermatol. 39:951-955 1998

Molluscum contagiosum

Hurwitz Clinical Pediatric

Dermatology 5th Edition

Molluscum contagiosum

Treatment

Observation

Cantharidin

Cryotherapy

Curettage

Cimetidine

Do Not Use

Imiquimod!

Therapeutic Pearl

Cantharidin is preferred treatment

by most pediatric dermatologists*

*Coloe J, Morrell DS. Cantharidin use among pediatric

dermatologists in the treatment of molluscum contagiosum.

Pediatr Dermatol 2009; 26: 405-408.

Cantharidin

Vigorously shake bottle before using

Apply with wooden end of cotton tip

applicator

Apply single drop

Let dry 3-5 minutes

Wash off in 2-6 hours

Therapeutic Pearl

Treat molluscum dermatitis to

reduce auto-inoculation*

*E Netchiporouk, BA Cohen: Recognizing and managing

eczematous id reactions to molluscum contagiosum virus in

children. Pediatrics. 129:e1072-5 2012

Atopic Dermatitis (AD)

Characteristics

Pruritus

Relapsing and Recurring Course

Onset in childhood

Association with atopy

4 Pillars of Atopic Dermatitis

Xerosis

Inflammation

Infection

Itch

Emollients

Anti-

Inflammatories

Mupirocin;

Bleach baths

Anti-histamines

Treatment

Cutaneous hydration*

*Eichenfield LF et al. Guidelines of care for the management of atopic

dermatitis: section 2. Management and treatment of atopic dermatitis with

topical therapies. J Am Acad Dermatol. 2014 Jul;71(1):116-32

Atopic Dermatitis Pearl

Bathing is recommended,

but no standard exists for

frequency or duration*

*Eichenfield LF et al. Guidelines of care for the management of atopic

dermatitis: section 2. Management and treatment of atopic dermatitis with

topical therapies. J Am Acad Dermatol. 2014 Jul;71(1):116-32

Atopic Dermatitis Pearl

Bleach baths may reduce AD

flares and AD severity*

*Huang JT, Abrams M, Tlougan B, Rademaker A, Paller AS. Treatment

of Staphylococcus aureus colonization in atopic dermatitis decreases

disease severity. Pediatrics 2009;123: e808-14

Bleach Bath: How To?

Add ½ cup of 6% household bleach to a full

bath of warm water and mix

¼ cup if small bath

1-2 teaspoon per gallon for bucket bath

Soak 10-20 minutes approximately twice

weekly

Rinse with normal water before exiting bath

Atopic Dermatitis

What’s New??

Topical PDE4 Inhibitor

Crisaborole (Eucrisa) 2% ointment

Approved for mild to moderate atopic dermatitis in ages 2 years or older

Boron based topical phosphodiesterase inhibitor

Application site burning most common SE

Dupilumab

Fully human monoclonal Ab targeting IL-4R

Approved for adults with mod-severe eczema

in 2017

Approved for ages 12+ with mod-severe

eczema recently

Psoriasis

Affects approximately

0.5-1.0% of children less

than age 18

Psoriasis Comorbidity

Obesity

Hyperlipidemia

Hypertension

Metabolic Syndrome

Psoriasis Pearl

Start screening earlier for arthritis, depression and anxiety

Screen for overweight/obesity using BMI starting at age 2

Screen for diabetes every 3 years starting at age 10, or at puberty if obese plus other risk factors

Most common benign soft-tissue tumor

of childhood

Affects up to 5% of children

Infantile Hemangioma (IH)

Natural History

Observation alone most commonly

Reasons to treat:

Function threatening

Disfiguring

Ulcerated

IH-Treatment

Propranolol for severe hemangiomas of infancy. Leaute-Labreze C et al. N Engl J Med. 2008 Jun 12;358(24):2649-51.

Vasoconstrictive on endothelial cells

Decrease nitric oxide

Decrease VEGF

Induce apoptosis of endothelial cells

Propranolol

Infantile Hemangiomas: What Have We Learned from Propranolol?

Hagen R, Ghareeb E, Jalali O, Zinn Z. Curr Opin Pediatr. 2018

Aug;30(4):499-504.

Side effects:

Nightmares/insomnia

Hypoglycemia

Hypotension

Bradycardia

Bronchospasm

Hypothermia

Propranolol

Propranolol Safety

Propranolol enters CSF

Propranolol impairs:

“Word/photographic recall

Reaction time

Sleep

Propranolol and central nervous system function: potential implications for

paediatric patients with infantile hemangiomas. Langley A, Pope, E. Br J

Dermatol 2015; Jan 172(1):13-23

Propranolol Safety

Vadimovich, A et al. Propranolol treatment of infantile hemangioma (IH) is not associated with developmental risk or growth impairment at age 4 years. J Am Acad Dermatol 2016;75:59-63.

Parents completed Dutch 48-months ASQ

Height and weight were collected from charts

82 Patients included in the study

No difference on ASQ from controls

Moyakine A, Koulil S, van der Vleuten C. Propranolol treatment of infantile hemangioma is not associated with psychological problems at 7 years of age. J Am Acad Dermatol. 2017; 77:105-8

Propranolol Safety

Propranolol Pearls

Excellent safety profile

Can be initiated outpatient

Best response if started early

Propranolol

Outpatient Initiation:

Greater than 8 weeks AGA

Good social support

Lack of comorbid conditions

Timolol maleate

Puttgen, K et al. Topical Timolol Maleate

Treatment of Infantile Hemangiomas.

Pediatrics. Sept 2016 Vol 138

Retrospective multi center study including 731

patients across 9 centers

Timolol maleate

IH likely to respond if thin

Excellent alternative to

watchful waiting

Macular stains with pink-red color

A capillary malformation

Lack rapid growth or proliferation

Often unilateral, favor the face

Nevus Flammeus

(Port Wine Stain (PWS))

PWS

Leptomeningeal angiomatosis

Glaucoma

Sturge-Weber Syndrome

Sturge Weber Syndrome and Port-Wine Stains

Caused by Somatic Mutation in GNAQ. Shirly et

al. NEJM. March 2013

Port-Wine Stain

Laser Treatment

Pulsed-dye laser

Port-Wine Stain Pearls

Benefit of early treatment

Better clinical response

Less risk of anesthesia

Psychological benefits

Conclusions

Acne

Always BPO if on antibiotics

No dietary changes

Isotretinoin highly effective

Warts

Wart stick plus duct tape occlusion

Lower expectations of treatment

Conclusions

Molluscum

Cantharidin highly effective

Cimetidine for immune boost

Atopic Dermatitis

Moisturize!

Consider bleach baths

Dupilumab

Conclusions

Psoriasis

Guttate flare after strep

Screen for cardiovascular

comorbidity

Conclusions

Infantile Hemangioma

Benefit of early treatment w/propranolol

Consider timolol as alternative to watchful waiting

Port Wine Stain

Benefit of early treatment w/PDL

Less risk; Better result

Questions???