Common Dermatologic Conditions in School Age Children

Size: px

Start display at page:

Download "Common Dermatologic Conditions in School Age Children"

Hector Farmer
5 years ago
Views:

Common Dermatologic Conditions in School Age Children Kimberly Dempsey, MPA, PA-C Eastern Virginia Medical School Children s Specialty

canis Highest prevalence in the inner-city Grade-school age children, especially AA Rising incidence in adult black women 30%

and clinics - 16-44% in household contacts - Can persist for months to years - Viable spores on household fomites: combs/brushes,

-Papules/patches -Pustules with or without scale -Impetigo crusted papules (occiput) TINEA CAPITIS WHAT I DO TINEA CAPITIS WHAT I DO

treatment if suspicion high Griseofulvin still first-line therapy Once daily dosing helps with compliance After dinner, with milk or

1 Common Dermatologic Conditions in School Age Children Kimberly Dempsey, MPA, PA-C Eastern Virginia Medical School Children s Specialty Group TINEA CAPITIS: EPIDEMIOLOGY #1 dermatophyte infection in childhood Trichophyton tonsurans, M. canis Highest prevalence in the inner-city Grade-school age children, especially AA Rising incidence in adult black women 30% asymptomatic carriers in adult relatives of index cases TINEA CAPITIS UNDETECTED Asymptomatic Carriers - 15% in inner-city classrooms and clinics % in household contacts - Can persist for months to years - Viable spores on household fomites: combs/brushes, hats, pillows, blankets, toys - spores can live up to 2 yrs in lab (dry/dark) TINEA CAPITIS UNRECOGNIZED Varied appearance: -Dry scalp -Papules/patches -Pustules with or without scale -Impetigo crusted papules (occiput) TINEA CAPITIS WHAT I DO TINEA CAPITIS WHAT I DO Look for scale (localized/generalized), adenopathy, alopecia Culture with cotton swab and plate on DTM or send to lab Start empiric treatment if suspicion high Griseofulvin still first-line therapy Once daily dosing helps with compliance After dinner, with milk or ice cream (fat absorption) 6 to 8 weeks of treatment No lab work is required Adjunctive shampoo 2 3 x/wk: decrease spore count 1% or 2½% selenium sulfide 1% or 2% ketoconazole (Nizoral) 1

HOW TO INCREASE CURE RATES Evaluate family members or close contacts and culture if needed Wash hats and pillowcases in hot soapy water Wash

them to refill the medicine after 1 month Reculture after treatment to verify cure Continue sporicidal shampoo to prevent recurrence/carrier

Tinea Corporis Fungal Infection on skin + Pruritic May initially resemble a bug bite Spreads with central clearing Scale at periphery TINEA

tonsurans Skin-to-skin transmission (head, neck, arms), not matto-skin Excluded from competition if lesions on exposed skin Tinea Corporis/Tinea

2 HOW TO INCREASE CURE RATES Evaluate family members or close contacts and culture if needed Wash hats and pillowcases in hot soapy water Wash combs and brushes in medicated shampoo Make sure hair clippers sterilized HOW TO INCREASE CURE RATES Stress compliance with medication Remind them to refill the medicine after 1 month Reculture after treatment to verify cure Continue sporicidal shampoo to prevent recurrence/carrier state? Tinea Corporis Fungal Infection on skin + Pruritic May initially resemble a bug bite Spreads with central clearing Scale at periphery TINEA GLADIATORUM Tinea corporis in wrestlers Large outbreaks may occur Usually T. tonsurans Skin-to-skin transmission (head, neck, arms), not matto-skin Excluded from competition if lesions on exposed skin Tinea Corporis/Tinea Gladiatorum Treatment Topical Antifungal Oral Antifungal for extensive infections Transmission is person to person Less common from animals Not from sandboxes or playing outside TINEA GLADIATORUM - TX Systemic if multiple or large lesions Fluconazole 200 mg weekly x 4 Itraconazole 100 mg qd x 2 wks or 200 mg qd x 1 wk Beller and Gessneer JAAD 1994:31;

Tinea Incognito Results from improper treatment of a tinea infection May have varied

treatement one week past resolution May not be able to be detected by microscopy

more frequent at home No nit school policies may result in unnecessary treatment and

months Viable eggs brown - found closer to scalp NITS LOUSY LIFE CYCLE Females lay 3

host Lindane Kwell 1% shampoo Neurotoxicity and widespread resistance Not used

3 Tinea Incognito Results from improper treatment of a tinea infection May have varied appearances Tinea Incognito Treatment Taper off Steroid Taper on Antifungal Continue treatement one week past resolution May not be able to be detected by microscopy (KOH) PEDICULOSIS CAPITIS 6-12 million schoolchildren affected each year Transmission more frequent at home No nit school policies may result in unnecessary treatment and possibly increased resistance Empty nits (white) can adhere to hair shaft for 6 months Viable eggs brown - found closer to scalp NITS LOUSY LIFE CYCLE Females lay 3 5 eggs/day Eggs hatch in 6 9 days Adult lice live 7 10 days Survive 1 2 d off human host Lindane Kwell 1% shampoo Neurotoxicity and widespread resistance Not used Pyrethrins - RID, A200, Pronto Derived from chrysanthemums Low toxicity Fair ovicidal and residual activity 3

4 Permethrin (Nix 1%) - synthetic pyrethroid Prescription strength (5%) Respiratory muscle paralysis, louse dies Safe: poor absorption, rapid metabolism & excretion Use in children over 2 y.o. Apply to washed, towel-dried hair and scalp for 10 minutes, rinse out Re-treat in 10 days Least expensive Benzyl Alcohol (5% lotion Ulesfia) Use in ages over 2 y.o. Mechanism of action is asphyxiation of lice Apply for 10 minutes saturating hair and scalp, then rinse with water. Side effects: irritation of skin and eyes, transient numbness at application site Use in children over 6 mos. Spinosad (Natroba) Compromises CNS of lice causing paralysis Lotion is applied to entire scalp and hair for 10 minutes then rinsed thoroughly with warm water Re-treat in 7 days Expensive Use in children over 4 y.o. Ivermectin (topical) Induces paralysis and death of lice Single application to dry hair Sit for 10 minutes and rinse Side effects: ocular irritation, dry scalp, burning sensation on skin Ovicidal and pediculicidal Expensive Use in children over 6 mos. Malathion Ovide 0.5% lotion Irreversibly inhibits acetylcholinesterase Very ovicidal and pediculocidal Binds to hair shaft for up to 4 wks Flammable/irritating 78% alcohol, terpineol/dipentene, pine needle oil Don t use in neonates, infants, pregnant or nursing ALTERNATIVE THERAPY Suffocate Lice and Eggs Greases: petrolatum, mayonnaise, butter, margarine, Crisco, hair pomades Oils: olive, corn, sunflower, soy Need liberal quantities for over 12 hours Messy and difficult to remove Dawn dish detergent 4

COMING SOON, NEW TOPICAL TREATMENT Resultz -50% Isopropyl Myristate (surfactant found in products such as soap) Dissolves the waxy exoskeleton of the lice which leads to dehydration.

5 COMING SOON, NEW TOPICAL TREATMENT Resultz -50% Isopropyl Myristate (surfactant found in products such as soap) Dissolves the waxy exoskeleton of the lice which leads to dehydration. Toxin free treatment Currently in phase III trials in the US Eliminated 100% of live lice with in 24 hours. Requires repeat treatment in one week. ALTERNATIVE THERAPY Hair Clear Anise, coconut, ylang-ylang oils Apply to dry hair for 15 mins, wash, repeat in 1 wk 100% (36/36) lice killed after 2 nd application and 94% of eggs after 3 rd application in vivo (Meinking) Health food stores NIT PICKING Combs with closely-spaced teeth Lice Meister comb dog-grooming comb Hair casts (scale, etc) slide off easily Products that dissolve egg/nit cement Acetic acid (white vinegar) 1:1 with water Formic acid 8% (Step 2) Hydrolase and lyase (Clear Rinse) Dental plaque remover, bleach, vodka BUG-BUSTING Rid live eggs from all sources!!! Examine all household members daily Vacuum floors and furniture daily to remove shed hairs and viable eggs Wash all washable clothing, hats, bed linens in hot, soapy water and dry in dryer Non-washables to drycleaner or place in plastic bags in warm place for 2 wks or freezer for 48 hrs R & D spray (permethrin) OPTIONS FOR TREATMENT FAILURES Most common cause of treatment failure is lack of compliance Oral Ivermectin 1% permethrin plus TMP/SMX 10 mg/kg/d for 10 days If live lice noted after 2 wks, repeat tx SCABIES Mite (tiny arachnids) S. scabiei Attach themselves or burrow under the human epidermis Mites deposit feces and Females lay eggs in the burrows Transmission via direct contact with an infected individual or acquisition from fomites 5

MITE LIFE CYCLE Female mite life span 15-30 days

10-14 days until maturity Complete life cycle 30-60

burrows located in webbing between fingers and toes,

Intense itching, usually at night Initial case of

after infestation DIAGNOSING SCABIES Evidence of

mites, eggs, or mite fecal matter MEDICAL THERAPIES

8-14 hrs Re-treat in 10 days Treat entire household

Post-scabetic dermatitis Insect Bites Extremities

repellants ok if over 2 months old 10-20% DEET

6 MITE LIFE CYCLE Female mite life span days Female mites lay 1-4 eggs a day Incubation 3-4 days days until maturity Complete life cycle days CLINICAL PRESENTATION Irritated papules, and burrows located in webbing between fingers and toes, wrists, skin folds, and genital areas. Excoriations! Intense itching, usually at night Initial case of scabies can take 4-6 weeks for symptoms to begin after infestation DIAGNOSING SCABIES Evidence of burrows on exam Skin scrapping and KOH looking for mites, eggs, or mite fecal matter MEDICAL THERAPIES Permethrin Cream 5% applied to the neck down, rinse 8-14 hrs Re-treat in 10 days Treat entire household Wash fomites Pruritus can continue for months Post-scabetic dermatitis Insect Bites Extremities Breakfast, Lunch, Dinner, Snack Distribution Insect repellants ok if over 2 months old 10-20% DEET Picaridin Allergy to insect bites Improves over years oral antihistamines topical steroids Papular Urticaria 6

Bullous Arthropod Bites Common with pet fleas, sand fleas,

dinner pattern is a clue Bedbug Bites Larger and more pruritic

pattern Topical steroids Antihistamines Remove infestation

hotel rooms including furniture Atopic Dermatitis A Big Problem

in 30 years Over half of AD patients will continue to have some

Wallets 50% of children with moderate AD and 80% with severe AD

stomach aches, sleep disorders Up to 75% of AD children sleep

8 billion annuallyº *Br J Dermatol 1997;137:241-5.

Major Clinical Features of AD (Should have Three) Pruritus

7 Bullous Arthropod Bites Common with pet fleas, sand fleas, chiggers (mites) Often lower legs or ankles Breakfast, lunch, dinner pattern is a clue Bedbug Bites Larger and more pruritic than other insect bites Face, neck, hands, arms, trunk Linear pattern Topical steroids Antihistamines Remove infestation Bedbug Detection Seams of mattress New mattresses and old Check hotel rooms including furniture Atopic Dermatitis A Big Problem Getting Bigger Affects >17% of children in US Prevalence up 30% in 30 years Over half of AD patients will continue to have some type of eczema in adulthood AD Straining Families and Draining Wallets 50% of children with moderate AD and 80% with severe AD show psychological disturbances* Excessive worrying, crying, stomach aches, sleep disorders Up to 75% of AD children sleep with parents Third-party payer costs range from $0.9 to $3.8 billion annuallyº *Br J Dermatol 1997;137: ºJAAD 2002;46(3): Major Clinical Features of AD (Should have Three) Pruritus Typical Distribution Facial/extensor infant Flexural child/adult Chronic/Relapsing Personal or family history of atopic disease 7

Moisturizing Regimen Thick emollient applied to skin within 3

every diaper change) Petroleum jelly works best and cheapest!

petrolatum Best if applied throughout the day Mainstays of AD

Wool clothing Avoidance of Allergens Mainstays of AD Treatment

application Decrease itching with topical steroids and

necessary AD Therapy Pitfalls Medication efficacy Only 44% of

for atopic dermatitis are effective* Fears of local or systemic

8 Varying severity Chronic vs. Acute Atopic Dermatitis Mainstays of AD Treatment Adequate skin hydration Daily bath or shower is good! No longer than 10 or 15 minutes Soap-free cleanser Tepid water Moisturizing Regimen Thick emollient applied to skin within 3 minutes of bathing and several other times during the day (infants every diaper change) Petroleum jelly works best and cheapest! Thick creams water plus petrolatum Lotions - more water than petrolatum Best if applied throughout the day Mainstays of AD Treatment Avoidance of Irritants Harsh soaps, detergents Fragrances Wool clothing Avoidance of Allergens Mainstays of AD Treatment Reduce local inflammation with topical steroids Twice daily application Decrease itching with topical steroids and antihistamines Topical and oral antibiotics for superinfection when necessary AD Therapy Pitfalls Medication efficacy Only 44% of physicians and 19% of patients/parents think prescription products for atopic dermatitis are effective* Fears of local or systemic effects of chronic steroid use Skin atrophy, HP axis suppression, growth and development Fears of chronic use of antihistamines *NEASE (National Eczema Association for Science and Education) Survey, AAD Mtg, March

Molluscum Contagiosum Poxvirus family Viral volcanoes Pearly flesh to pink colored papules, often translucent, can become inflamed with host

Frequently seen on the face, neck, arm pits, groin, arms and hands MOLLUSCUM Can have associated dermatitis from scratching and inflammation.

Who? School age children between 1-10 years of age Immune compromised ( HIV, Chemotherapy patients) Increased incidence in number of cases since

Autoinoculation (picking, scratching) most common mode of spreading.

skin covered if possible During contact sports/ water activities keep affected areas covered with water tight bandages Do not share clothing or

9 Molluscum Contagiosum Poxvirus family Viral volcanoes Pearly flesh to pink colored papules, often translucent, can become inflamed with host immune response. Often puritic. Frequently seen on the face, neck, arm pits, groin, arms and hands MOLLUSCUM Can have associated dermatitis from scratching and inflammation. Can be confused with chicken pox, moles, warts, acne Resolution in 6-12 months but can take up to 2 years MOLLUSCUM CONTAGIOSUM: EPIDEMIOLOGY Who? School age children between 1-10 years of age Immune compromised ( HIV, Chemotherapy patients) Increased incidence in number of cases since 1966 TRANSMISSION Transmitted skin to skin contact and fomites (clothing, towels, sports equipment) as well as pool and bath water. Autoinoculation (picking, scratching) most common mode of spreading. HOW TO AVOID SPREADING/INFECTION Good hygiene habits Hand washing Do not touch, pick, or scratch any skin with active molluscum Keep affected skin covered if possible During contact sports/ water activities keep affected areas covered with water tight bandages Do not share clothing or towels TREATMENT FOR MOLLUSCUM Cantharidin- extract from blister beetle Catharis vesicatoria. Droplets placed on active molluscum, rinsed 4-6 hours after application in office. Can develop a blister or redness. Cryotherapy Curettage Cimetidine (Tagamet) Topical retinoids (Retin-A, Differin) painted to the tops of molluscum each night. Watchful waiting 9

What the CDC recomends There should be no reason to keep a child with molluscum infection

MRSA Growths not covered by clothing should be covered with a watertight bandage.

If a child with bumps in the underwear/diaper area needs assistance going to the bathroom

Covering the bumps will protect other children and adults from getting molluscum and will

other parts of his/her body or cause secondary (bacterial) infections. http://www.cdc.

htm Community Acquired 1990s emerged in community 86% MRSA infection Hospital Acquired

infections MRSA MRSA High Risk Settings Daycares Schools Sports Teams Military Dorms

10 What the CDC recomends There should be no reason to keep a child with molluscum infection home from day care or school. MRSA Growths not covered by clothing should be covered with a watertight bandage. Change the bandage daily or when obviously soiled. If a child with bumps in the underwear/diaper area needs assistance going to the bathroom or needs diaper changes, then growths in this area should be bandaged too if possible. Covering the bumps will protect other children and adults from getting molluscum and will also keep the child from touching and scratching the bumps, which could spread the bumps to other parts of his/her body or cause secondary (bacterial) infections. Community Acquired 1990s emerged in community 86% MRSA infection Hospital Acquired Healthcare related Chronic conditions requiring frequent hospitalization Skin and systemic infections MRSA MRSA High Risk Settings Daycares Schools Sports Teams Military Dorms Jails/Prisons Tattoo recipients MRSA MRSA Factors that facilitate Transmission Crowding Compromised Skin Shared Items Contaminated Surfaces Cleanliness Inappropriate Antibiotic Use Cellulitis Distribution Treatment Oral Antibiotics IV Antibiotics Culture Lesion Nasal Swab 10

Management of MRSA Antibiotics Clindamycin TMP/SMX Tetracyclines Vancomycin I & D Patient Education critical Follow-Up Keep wounds covered If unable to cover, remove from activities and school

, Dinulos, J.G., Zug, K.A (2005). Skin Disease: Diagnosis and Treatment (Second Edition). Philadelphia: Elsevier Mosby. Paller, A.S., & Mancini, A.J. (2006).

11 Management of MRSA Antibiotics Clindamycin TMP/SMX Tetracyclines Vancomycin I & D Patient Education critical Follow-Up Keep wounds covered If unable to cover, remove from activities and school References Goldstein, A. O., & Goldstein, B. G. (2013). Pediculosis capitis. Retrieved from Habif, T.P., Campbell, J.L., Chapman, M.S., Dinulos, J.G., Zug, K.A (2005). Skin Disease: Diagnosis and Treatment (Second Edition). Philadelphia: Elsevier Mosby. Paller, A.S., & Mancini, A.J. (2006). Hurwitz Clinical Pediatric Dermatology (Third Edition). Philadelphia: Elsevier Saunders. Wolff, K., & Johnson, R. A. (2009). Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology (Sixth Edition). New York: McGraw Hill Medical. 11

3/27/2017. Head Lice. Learning Objectives. Disclosures

3/27/2017. Head Lice. Learning Objectives. Disclosures Head Lice Andi L. Shane, MD, MPH, MSc Associate Professor and Interim Division Director, Division of Pediatric Infectious Disease Marcus Professor of Hospital Epidemiology and Infection Control Learning