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Pityriasis Rosea lotion

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					General Pediatrics, the University of Chicago
Yingshan Shi, MD (773) 702-6169 05/2002, 03/2003, 02/2004

                                                 Common Skin Problems
 Disease                 Etiology                               S&S                                                     Tx
Molluscum         A common viral                 Small, benign, white, pink, or flesh-         Chemical destruction (patient applied)
Contagiosum       infection of the skin’s        colored, umbilicated, raised papules          Salicylic acid or 5% sodium nitrate
                  epithelial layer               or nodules                                    to non-facial under occlusive dressing qhs
                  (poxvirus)                                                                   75% clear in 7weeks, 25% irritation
                                                 Tx                                            35% sodium nitrate can cause brown staining
                  Transmission                   Debate- treat or let the disease              Retinoic acid
                  direct bodily contact          spontaneously resolve                         Imiquimod 5% cream- immune modifier.
                                                                                               Leave it on for 3 days , then wash off with soap
                  Incubation period              Physical destruction                          and water 3 or qhs 5day per week for 4-16 weeks
                  14-50d                         Liquid nitrogen-light 2-3 second              (max 60 topical applications)6 with 80% of
                                                 application to each individual                complete clearance.
                  Generally resolves in          lesion-pain less, no scarring, in             1-3% topical cidofovir bid
                  6-12 months, may take          resolution of most lesions with 2-3           Clear within 4-6 weeks, with minimal or no
                  5 years                        applications at intervals of 2 to 4 wk        recurrence, need to be compounded , very
                                                 Gentle curettage with a small                 irritating and expensive.
                                                 needle and expression of the plug
                                                 under aseptic technique                       Chemical destruction (physician applied)
                                                 Electrosurgery-electric needle,               Cantharidin /compounded liquid (0.7% in
                                                 laser                                         collodion) Put very small drop on each of the
                                                                                               lesions. a small blister will form and the lesions
                                                                                               will usually go away. Side effects: 92% blistering
                                                                                               40% discomfort, erythema, pain or itching,
                                                                                               Lymphangitis. Not applied to >3 lesions initially

Pityriasis        Self limited                   Rash: Usually starts with a single            No special treatment.
Rosea             inflammatory disorder          round or oval, 1/2-3 inch scaling             If has itch, dry, and scaling
                  Harmless                       patch with a raised edge (herald                Moisturizing cream for dry skin
                  Non-contagious                 patch). 5-10 days later, the                    Oral Benadryl for itchiness
                  Unknown cause                  widespread, symmetric smaller                   Topical corticosteroid for itchiness such as
                  probably caused by a           patches on chest, back, abdomen                 1% hydrocortisone cream
                  virus.                         and proximal arms/legs. The rash              Severe forms- oral steroid or dapsone
                  1st reported in 1860           may be itchy.                                 In a recent study, oral erythromycin found to be
                  75% occur between              Clears up spontaneously in about              effective with a complete response in 73% of
                  age 10-35yr                    2-12 wks, no scars left.                      patients3
                                                 10-15% atypical                               You child can attend school, daycare or camp
Warts             Skin reaction to               Common warts- verrucae vulgaris               Destructive Tx
                  Human papillomavirus            Common on the dorsal of hands                Remove top firm skin - soak the lesion with
                  (HPV) infection                Plantar warts- verrucae plantaris             lukewarm water for 10 minutes, then gently take
                                                 Flat warts- verrucae planataris               off the top firm skin by clean scissors, emery
                  Estimated 79%                   Common on the face, neck, and                board or pumice stone
                  lifetime risk of                extremities, 2-5mm in diameter               Apply a piece duct tape for 6days, left off
                  acquiring HPV                   Color: flesh, erythematous, brown,           overnight and reapplied the next morning.
                  Annual incidence of             or hyperpigmented                            Apply a drop of Salicylic Acid (17%) solution
                  8%                             Condyloma acuminata- genital/                 to the lesion and cover the lesion by round shape
                  Peak incidence:                 venereal warts                               bandage for 3 days, reapplied the next morning.
                  Age 13 for girls               Diagnosis:                                    Need 2-3 weeks to see the improvement
                  Age 14.5 for boys              Usually made clinically                       40%-84% complete remission within 7 weeks
                                                 Can be confirmed with a biopsy,               SE: erythma, burning, peeling, & itching
                  2/3 of warts will              PCR, in situ hybridization, southern          Liquid nitrogen: 2nd line Tx, more expensive,
                  regress spontaneously          blot analysis, blot hybridization, or         painful. 60-80% cure rates.
                  within 2 years, may            hybrid capture                                Other Txs
                  not need Tx                    Differentiate diagnosis:                      Cantharidin, Podophyllotoxin, retinoid (flat
                                                 Seborrheic keratoses, callosities,            warts), excision, carbon dioxide, laser ablation.
                                                 corns, lichen planus, epidermal               Chemotherapeutic and virucidal therapies
                                                 nevi, molluscum contagiosum, and              Immunologic therapies cimetidine, imiquimod
                                                 squamous cell carcinoma                       (genital warts)
Herpes                                           Primary infection: 7-10days of                Topical acyclovir- questionable value, expensive
Simplex                                          painful blistering                            Oral acyclovir for severe primary infections or
                                                 Recurrent infection: mild                     for prophylaxis of severe recurrences
Ref: 1. AAP 60th Annual Meeting 02/2002, New Orleans;          4. Cutis 2003;71:213-222                    7. Cutis. 2004;73:379-383
     2. Cutis 2002; 70:121                                     5. Inf. Disease in Children 2003;16(3):46
     3. Inf. Disease in Children 2003;16(1):6.                 6. Cutis. 2004;73:202-206
General Pediatrics, The University of Chicago
Yingshan Shi, MD (773) 702-6169 05/2002, 04/2003, 08-7/03

                                             Common Skin Problems
     Disease             Etiology                     S & S/Dx                                        Tx

Tinea            Trichophyton                 KOH test                     Griseofulvin against TT
Capitis          tonsurans                    Scraping scale patches       20-25mg/kg/d microsized formulation qd to bid
With             (TT)                         with a #15 scalpel           15mg/kg/d ultramicrosized form qd 6-12 weeks
kerions          Microsporum Canis            blade. Place the             % ketoconazole shampoo (Nizoral) daily shorten time for
                 (fluorescent, pick up        specimen on a glass          oral griseofulvin Tx and increase cure rate.
                 from dogs and cats)          slide with a drop of         Terbinafine(Lamisil) against TT only
                                              KOH and a cover slip,        not approved by FDA, widely prescribed by American
                 Tx                           and examine it under         dermatologists for its short treatment times and excellent
                 Caution against              low power.                   tolerability.
                 sharing hair-brushes,                                     Slightly more than 4.5mg/kg per day3 or
                 hats, combs, and other       Fungal cx-gold               Wt <20kg 1/4 of a 250mg tablet/day
                 fomites, which may be        standard                     20-40kg 1/2 tab           >40kg        1 tab
                 a source of reinfection      Scrapings by a               2-3 weeks, children seem to tolerate it well
                                              moistened cotton swab        not included in many HMO formularis, no peds forms
                 No reason to keep            or sterile plastic plate     Itraconazole (Sporanox) against TT & M. Canis
                 children from going to                                    4-6mg/kg/d 3-4 weeks, susp is not a pediatric formulation
                 school.                                                   Fluconazole (Diflucan)
                 About 20% children                                        6mg/kg/d 3-4 weeks
                 are asymptomatic                                          not FDA approved for tinea but for candida now
                 carriers                                                  works well for fungal nail infections
Tinea                                         Superficial                  Topical antifungal for 2-3 weeks
Coporis/                                      Often with scale             Oral antifungal treatment for unresponsive to topical Tx
Facial                                        Located anywhere             Differentiate diagnosis - granuloma annulare
                                              Asymp to itchy               Deeper ring and intact skin lines, no scale. Most at feet,
                                                                           hands, knees & elbows, asymptomatic to painful
Tinea            Uncommon in                  Dx: look between the         Topical antifungal medication
Pubis            children <age10              4th and 5th toe              Recurrent infection: use powder in the shoes
                                              Moccasin distribution        Prevention: keep skin clean and dry, avoiding walking
                                              or vesicular rash            barefoot in public areas, and wearing moist socks for long
                                                                           periods in warm weather. Wear shoes that fit properly.
Tinea            0.3% in children,            Confirm Dx with a             Oral griseofulvin won't clear up in adults, but in
Onycho-          increasing to a 48%by        culture under age 12              children< age12, 20mg/kg 2-4-12 month may work
mycosis          age 70                                                     Older child and the closer to adulthood
                                              The crusty nail                   Fluconazole 3-6mg/kg once weekly for 3month-hand
                                              thickening may not                     6mo-foot
                                              require use of any of             Itraconazole 5mg/kg/day, up to 200mg bid 1wk per
                                              the oral agents                        Month, finger-2 pulses; toenail-3 pulses
                                                                                Terbinafine 20-40kg 125mg/day>40kg 250mg/day
                                                                               For 6-12weeks-fingers or toenails
Tinea            Fungus- Malassezia           Slightly scaling patches      2.5% Selenium sulfide lotion/shampoo applied as a
Versicolor       furfur                       on the trunk, neck, or            thin coating to the affected skin daily, max 28 days.
                 More common in hot ,         arms                          Monistat , clotrimazole, ketoconazole nightly
                 humid climates               Untanned skin- pink to        Terbinafime cream or gel
                 Dx:                          coppery patches               Double -strength Whitfield's oint at bed time for 10 to
                 KOH of skin scraping         On tanned skin-lighter            14 days
                 Wood's lamp:                 patches                       Widespread lesion- ketoconazole adult 200mg/d
                 yellowish to yellow-         Not contagious                Cleaner medication is 50% propylene glycol in water
                 green fluorescence           DD                                nightly for several wks
                                              Vitiligo, pityriasis alba,
                                                                            Weekly washing with benzoyl peroxide or zinc
                                              psoriasis, seborrheic
                                                                                pyrithione soap to prevent recurrence.
                                              dermatitis, erythrasma,
                                              and dermatophytosis
Candida
1.    AAD 60th Annual Meeting 02/2002, New Orleans;
2.    Cutis 2002;70(8):121
3.    Pediatric News 2003; 37(2):38
4.    Inf. Dis. In Children 2003; 16(3):41-46
5.    Cutis 2004;73(6):425-428
General Pediatrics, The University of Chicago
Yingshan Shi, MD (773) 702-6169 5/02; 09/02, 03/03
                                                 Dry Skin, Eczema
 Disease                   Etiology                      S&S                                          Tx
Dry skin         Exacerbating factors:          Flaking, irritation, and   Mild soap, such as Dove,
                 sunburn, dust, pollen,         itchiness                  Don't bathe > twice daily
                 chlorinated pools, harsh                                  Moisturize at least twice a day
                 exfoliation, severe climates                              Humidifier in the winter

Lichen                                                                     Lac Hydrin 12% cream twice a day
Nitidus                                                                    Other moisturize

Perioral         Cold air, dry skin                                        Metronidazole cream/gel/lotion-gold standard
dermatitis       Use inhaled steroid 2.9%                                  Erythromycin oint- standard
                 Asian and AA children are                                 Clindamycin- if not sure acne or perioral dermatitis
                 more prone to                                             Tacrolimus 0.03%

Eczema           Etiology uncertain             Red, blistering,           Antihistamines are not generally recommended unless
                 Children with atopic           oozing, brownish,          let the child sleep through the night
                 dermatitis often suffer        scaling, and itching       Moisturizers
                 from asthma and hay fever                                 at least twice a day, within 3 minutes after bathing
                 Prevalence has increased,                                 Triceram (Sephora) helps draw topical steroids into
                 10-20% in children                                        skin
                 Exacerbating factors:          Tx                         Topical steroids
                 Allergens in the air and in    Avoid those things         Hydrocortisone
                 food, scratchy or tight        that can irritate skin     Tridesilon-Desonide cream .05% low
                 clothing, rapid temperature    Controlling the            Fluocinolone-Synalar cream .025%medium, .2%high
                 changes, sweating              environment - avoid        Fluticasone- Cutivate oint. was safe for age 3m0
                                                getting too hot            Elocon 0.1% oint moderate
                 Watch for MRSA with            or sweaty                  Wet wrap dressings over topical steroids works well
                 severe eczema- Pediatric                                  Antifungals as needed
                 News 6/02                                                 Topical immunomodulators FDA approve for age2
                                                                           Anti-inflammation &not inhibit normal growth of skin
                 www.nationaleczema.org                                    Appear safe for <2yr, only used on limited body areas
                                                                           Tacrolimus-Protopic 0.03% oint., 0.1%- for adults
                                                                           Pimecrolimus-Elidel 1% cream
                                                                           Cyclosporines for severe eczema. Switch to ultraviolet
                                                                           therapy and taper off cyclosporines
Contact          Common allergens:              Acute: vesicular, red,     Avoid the allergen
Dematitis        Nickel, rubber,                swelling, blistering       Soothing lotions
                 dyes,cosmetics, fragrances,    Chronic: red, scale,       Cold wet compresses or soaking in cool water
                 poison ivy, oak, cold air,     darken, crack,             Topical corticosteroids, begins within a few hours
                 over-the-counter               lichenification, can       Severe case: prednisone (1mg/kg/day) for 7 days, then
                 medications                    last for 14-2odays         gradually tapering over the next 7 days

Psoriasis        Chronic genetic disorder       Silvery scaly red          Moisturize
                 Abnormal functioning of        rash-often scalp,          Vitamin D - calcipotriene
                 white blood cells may          elbows, knees, lower       Plus UVA radiation
                 cause the skin to regenerate   back
                 too quickly                    Scalp and nail pits

                                                71% with positive
                                                Fhx
Vitiligo         Autoimmune disorder?           Hypopigmentation           Topical immunomodulator Tacrolimus oint 0.1% bid
                 Selective destruction of                                  for a minimum of 45 days, 87% experienced partial
                 melanocytes                                               improvement.*

Infections Dis in Children 2003:2:31
Infections Dis in Children 2003:3:40
* Tanghetti, Emil A. Cutis 2003; 71:158-162
General Pediatrics, The University of Chicago
Yingshan Shi, MD (773) 702-6169 05/02; 09/02, 08/03
                                                       Skin Problems
   Disease                Etiology                                S&&                                         Treament
Sunbern              Overexposure to        Painful red, swollen, sometimes blistered skin      Wet compresses, tub baths, soothing
                     the ultraviolet                                                            lotions
                     rays of the sun                                                            High-protection sunscreen

Keloids              Unknown                A greatly enlarged scar that projects above the     Inject a long-acting cortisone into the
                     Never become           skin surface, firm                                  keloid. Usually become less noticeable
                     malignant                                                                  and flattens in 2-3 months. The
                                                                                                injection can be repeat in 2-3 months if
                                                                                                necessary
Keratosis                                                                                       Little evidence that any Tx works
pilaris                                                                                         Ammonium lactate may achieve some
                                                                                                desquamation and lubricants soften and
                                                                                                hydrate the scale, making less visible
Granuloma            <10% early                                                                 Intralesional steroids
annulare             childhood cases
                     need biopsies
Scabies              Caused by a            Initial infestation: Symps may occur up to 3 wks       Treat all household contacts,
                     mite, Sarcoptes        Subsequent infection with symps in 1-3 days             involved healthcare workers, and
                     scabiei var            S&S                                                     their families simultaneously
                     hominis                Intensely itching with nocturnal predominance          Washing clothing and linens in
                                            Burrows (mm long) only in < 10% patients                soap and hot water or placing items
                                            Erythematous papules                                    in a closed container for 5-7 days
                                            Adults: typically on the wrists, fingers, axilary      Permethrin 5% cream applied to
                                            and genital areas, and around the belly button          the whole body, including the scalp
                                            and breasts.                                            and face but avoiding contact with
                                            Children: face, neck, and body                          the eyes and mouth, repeat in 1 wk
                                            Diagnosis:                                              to catch emerging larval forms.
                                            Clinically: Intense itching lesions                    Other topical scabicides- Lindane
                                            Confirmed by the presence of the mite, eggs, or         1% lotion- not used after a bath
                                            scybala                                                 which increased absorption. Not
                                            Mite may be visible at the leading end of a             for age 3 and younger
                                            burrow                                                 Itching may be managed with
                                            Skin scrapings with direct microscopic exam             topical steroids, oral antihistamines
                                            with KOH, saline, or mineral oil preparation           Ivermectin approved by FDA only
                                                                                                    for age >=6yr
                                            Itching continues after 2 week of treatment            1% solution of Ivermectin 2
                                            may suggest:                                            doses a week apart-100% cure rate
                                             Skin irritation from over-treatment or from           by researchers
                                                severe eczematous scabies
                                                                                                   Crusted scabies- ivermectin oral
                                             Contact dermatitis                                    two dose (wt 15kg or >= age 5)
                                             Treatment failure (whole body application,           Antibiotics for 2nd infection. "
                                                treatment of contacts, resistance)                  There have been epidemics of
                                             Treat all contacts in the day care setting            acute glomerulonephritis following
                                                                                                    2nd strep infection of scabies."
                                                                                                   Return to day care or school the
                                                                                                    day of following treatment
Raynaud's                                   Principally affects girls
Phenomenon                                  Frequently free of with connective tissue disease
                                            Antinuclear antibody positive and abnormal
                                            nailfold capillaries correlate with 2nd disease
                                            Antiphospholipid antibodies are common2
Facial               Hyperpigmentati                                                            Combined (adult)
Melasma              on disorder                                                                0.05% tretinoin, hydroquinone 4% and
                                                                                                dexamethasone 0.01% in a hydrophilic
                                                                                                cream qhs 8wks
                                                                                                SE: erythma, peeling, burning, deyness,
                                                                                                and pruritus
Ref.
1. Cutis 2003; 71:193-196
2. Pediatrics 2003; 111:715-721
3. Infectious Diseases in Children. 2003;16(6):55
General Pediatrics, The University of Chicago
Yingshan Shi, MD (773) 702-6169 05/02; 09/02
                                     Rash on the Palms & Soles
 Disease                    Cause                                     S&S                         Tx
Bacterial   Group A streptococcus                    Don't cause discrete lesions
            Staphylococcus aureus                    Can generate erythema by toxin

            Disseminated Neisseria- Gonorrhoeae,     Pustular or erythematous vesicular lesions
            Meningitidis                             On hands, feet, fingers and toes
                                                     Petechiae- doesn't blanch when put
                                                     pressure on then, or darker, black
                                                     infarcted and died areas
            Streptobacillus moniliformis- rat bite
            fever                                    Animal contacts, rare
                                                     Faverm arthritis and pustularlike lesions
            Leptospirosis
                                                     Contact with soil or water contaminated
            Spirochetes                              by an animal's urine
            Lyme disease- Borrelia burgdorferi
            Syphilis- Treponema pallidum

            Rickettsia- Rocky Mountain Spotted
            Fever                                    Start on the wrists/ ankles-spreading
                                                     centrally and to the palms & soles
            Ehrlichia
                                                     Less commonly, look like RMSF
Viral       Herpes
            Herpes simplex, Cytomegalovirus
            Epstein-Barr, Varicella zoster

            Parvovirus B19, Coxsackie B6,            Papular purpuric gloves and socks
            measles, EBV, CMV, Herpes 6,             syndrome
            Hepatitis B and mercury intoxication

            Adenovirus, enteroviruses                Hand-food mouth disease- summer time,
            Less common- Rubella, Rubeola and        not too ill, has lesions in the mouth-
            dengue virus                             enteroviruses
Non         Drugs- amoxicillin, sulfomamides,        Stevens-Johnson syndrome - specific
infection   anticonvulsants                          erythma multiforme type rash with
                                                     involvement of mucous membranes in the
            Vasculitic disorder                      mouth, eyes, genitalia, or rectum.
            Systemic Lupus Erythmatosus
            Kawasaki disease
            Dermatomyositis

            Mercury poisoning                        Tachycardia, hypertension , emotional
                                                     instability and rash
General Pediatrics, The University of Chicago
Yingshan Shi, MD (773) 702-6169 05/02; 09/02
                                              Painful, Red Feet
   Disease                    Cause                                S&S                                     Tx
Erythromelalgia   Increase in blood flow and            Hot, tingling, burning pain          Topical capsaicin and lidocaine
                  temp in the extremities                of both feet and/or hands,            - temporarily helpful
                  strangely corresponds to a             more severe at night and             Nitroprussider infusion-
                  decrease in tissue oxygenation         when exposure to heat                 effective in some patients
                  due to dysfunction of the pre-        Skin appears red and feels           Comprehensive support over
                  capillary sphincters and AV            warm to the touch                     the long term
                  shunts
Acrodynia         Chronic exposure to mercury           Needle-like pain, puffy, &           Blood or urine mercury levels
                  which block the enzyme that            pink in hands and feet               Removing the source or using
                  converts epinephrine to               Weight loss, night sweats             chelating agents to reduce
                  norepinephrine.                       Personality changes:                  mercury levels
                  Source of mercury: pre-1991            restlessness, withdrawal,            Adequate hydration
                  latex paint, alkaline batteries,       depression, and personality          Carbamazepine to treat pain
                  thermometers, barometers,              change
                  industrial preservatives, and
                  bleaching creams
Pernio            Exposed to chilly, wet weather        Tender, purple-red                   Better fabrics to protest against
(Chilblains)                                             inflammatory papules and              the cold and dampness
                                                         nodules on the toes or hands         Ibuprofen, and Nifedipine for
                                                                                               pain
Fabry's disease   X-linked lysosomal storage            Insidious onset in childhood or      Dx: clinical suspicion and
                  disease leads to an                    the early teen years                  confirmed by low activity of
                  accumulation of glyco-                Temp sensitive aching in              alpha galactosidase A in
                  phospholipids in cells of body         hands and feet                        plasma
                                                        Small angiokeratomas on the          Carbamazepine for pain
                                                         extremities or groin                 Enzyme replacement therapy
Reflex                                                  Intensive burning pain, edema        Intensive physical therapy
neurovascular                                            and mottled discoloration of         Compressive bandages
dystrophy, or                                            an extremity                         Discontinuation of the use of
amplified                                               Often following a minor injury        crutches
musculoskeletal                                         Cool to the touch
pain syndrome                                           Psychological distress
type 1
Palmer Plantar    Pseudomonas hot foot                  Red, tender modules on               Tends to resolve spontaneously
Hidradenitis      syndrome                               bilateral extremities, esp. on        in a few days.
                  A very dense infiltrate of             the soles
                  neutrophils around the eccrine        Sometimes with a mid, low
                  glands and blood vessels               grade fever

Pediatric News. 2003; 27

				
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Description: Pityriasis Rosea lotion