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Pediatrics (week 6): Dermatology

where can I buy pharmaceutical grade boric acid in small quantities?

DERMATOLOGY

ECZEMA
one of top 10 presenting complaints in kids
18% of kids have it
most onset in year 1, the rest btw age 2-5, sporadic later development
genetic susceptibility, runs in families, check for fhx of allergies, eczema, asthma, hayfever
distribution diff in young kids vs older
infant: little red bumps on face, chest, extensor surfaces
young: behind knees, flexoral sfcs, lower leg, butt, elbow
adults: hands, feet, scalp
sx: erythematous papular pruritic rash, lichenification, possible weeping/crusting
sx: may occur in round patches, be confused with tinea
sx: waxing and waning pattern, annoying, parents have tried lotions, steroids, etc
dx: clinical, high IgE
parents get on internet, listserves about eczema, learn lots of things to try
tx: mild soaps, don't bathe every day, no bubble baths, no soap in tub, avoid dry skin
tx: emollient lotion within 15 mins of getting out of tub, eucerin is a fave, alba's very emolient lotion
tx: emu oil, coconut (esp if staph superinfx), other oils
need system for keeping oils on skin and not rubbing off everywhere
tx: shea butter, rub it in, cerevey is another product, vaseline...
---keep trying new things
tx: calendula, comfrey salves better than vaseline but don't absorb that much
tx: ayurveda: put on oil before bath, water pushes it in
look out: sodium lauryl sulfate in detergents and soaps may cause rxns
allo tx: topical steroids 2-3wks
1% hydrocortisone is OTC, ask what they're using, aveno eczema crm is 1%
eczema may not respond to 1%, may need 2% to get response
ointments usu more potent than creams
need to know what potency kid is on
oral abx for superinfx, over 80% of eczema has some superinfx
must tx superinfx to lower inflam
pemecrolimus other crms are topical immunosuppressants
-->decr T cells in skin, v effective, short term tx
expensive, slight association with lymphoma in animals
rarely systemic steroids given
nd tx: her standard: look at food sensitivities, address skin moisture, treat gut
always: probx, efa's (cod liver oil 2 tsp/day for little ones, TBS for bigger kids)
targeted food modification, diet diary may or may not help, consider wheat, dairy
diet change works 30-50% of the time
bioflavonoids? quercetin may worsen it. zinc, vit c, beta carotene
topical chickweed (herb pharm salve), calendula, yarrow, comfrey, lavendar
wisewoman all purpose salve is a fave product
gut protocols: l glutamine, slippery elm, marshmallow
some docs recommend 1/4 cup bleach in bathtub for staph, sounds like bad idea to me
txing superinfx: goldenseal, manucha honey, heat, hygiene, potato poultice
clay poultice with goldenseal powder, herbal washes, add herbs to lotion

CRADLE CAP / SEBORRHEIC DERMATITIS
mild cases nearly universal, severe cases less common, on face more of an issue
etio: systemic yeast? doesn't think so, she thinks it's prob hormonal from mom but not sure
low grade inflam
sx: scaly yellow plaques on scalp, mb erythematous base
tx: mom take high dose cod liver oil
usu goes away by age one
younger if you pick it out it grows back
"you can't start kindergarten with cradle cap" to talk her daughter into letting her comb out
tx: efas, probx, warm oil on scalp (olive) then comb, scrub and pick scales out

DIAPER RASH
diaper area hotbed for issues due to wetness
interestingly most kids with eczema are clear in diaper area
etio: assorted, what is cause? hard to know for sure
etio: friction rash, shiny/smooth
etio: allergies, detergents, topicals, diaper additives, plastics, perfumes, even G diapers
etio: candida mb 80% of all
sx of candida: beefy red, raised sharp margins, satellite lesions, mb in creases
etio: contact derm to diarrhea, bulls eye around anus
dx: culture: fungal or bacterial, if you don't have pustules to open it's not worth culturing
tx: air drying, sunshine, hygiene
tx: boric acid salve for yeast infx
tx: vinegar wipes and rinses
tx: topicals: yogurt, GSE rinse
tx: probx
allo tx: antifungals: nystatin, etc, if thrush nystatin on mom's nipples
tx superinfx: topical abx, herbs, poultices
tx: if cloth diapers wash hot and double rinse, vinegar rinse ev few washes, hang in sun
sx: stinky urine indicates need for vinegar rinse in diaper wash

IMPETIGO
bact infx of superior layers of epidermis
honey colored crusting lesions, nonbullous and bullous, invades broken skin areas
usu around nose, mouth, quite contagious, kids get sent home from school or daycare
no need for labs
tx: topical, culture if worried about strep-->scarlet fever
tx: clean, remove crusts, apply wet dressing
tx: topical abx, bactroban is rx, mupirocin works to kill mrsa
if widespread or bullous use abx: cephalexin, etc
nd tx: moist dressings, same topical tx as for superinfx above
if recurrent or refractive consider nasopharyngeal culture: mrsa?
tx: intranasal mupirocin if mrsa carrier in nose

MOLLUSCUM CONTAGIOSUM
pox virus
umbilicated waxy papules 2-10mm in diameter, usu asx but mb itchy
usu on trunk, also in armpit, diaper area
solitary lesions
warn parents that name is stupid, don't worry so much about contagiousness
tx: usu resolves on own, can do cryo, puncture, dessicate
tx: probx, antiviral orals and topicals

LICE
the bane of many households
head, body, anogenital
average infestation is 12-24 critters, hard to find them, if you do: bad infestation
will find: eggs attached to hair shaft, round, smooth, threads down shaft when you pull on it
hatches in 8 days, itching dt feeding site irritation
allo tx mb neurotoxins, kills bugs but doesn't hurt eggs so new hatch can happen, comb out
coating hair in mayo, oil, etc to suffocate eggs does work
key is getting nits out of hair, special combs are available, hand pulling seems to be best
must tx whole family, requires cooperation of all

SCABIES
all ages
mites that burrow into stratum corneum then lay eggs
poop in skin is irritant
dx: hard to get diagnostic scraping, she dxs based on location, family spread, itching
tx: toxic crm--permethrine 5% I think

URTICARIA
comes and goes abruptly
wildly itchy hives, papules, wheals, may have light halo
usu never know trigger
amoxicillin rash is common
v bad hives-->concern re anaphylaxis in future
cold rxn also happens
URTICARIA PIGMENTOSA
brown oval flat lesions or raised, some erythematous, some itchy
tx: keep epi pen handy (and benadryl)
(tx: reduce Th2 dominance)

STRAWBERRY HEMANGIOMAS
aka cherry, capillary, etc hemangiomas
show up in first few months of life
any size, any place
generally involutes spontaneously in 5-7 years
only refer if near eye or body orifice or if multiples
prednisone injx may trigger involution

PORT WINE STAIN = NEVUS FLAMMEUS
reddish-purple flat discoloration
if in trigeminal nerve distribution (opthalmic branch) consider Sturge-weber syndrome
(S-W synd = unilat stain forehead & 1 eyelid, and neuro probs, learning disabilities, unilat paralysis, most sieze in yr 1, glaucoma, angiomas and AVM's in same side brain, developmental anomaly apparently not heritable)
laser treatments used to fade them over time
no medical need to tx, only cosmetic

MONGOLIAN SPOT
on Asian and Hispanic babies, present at birth
top of gluteal fold, sacral area, mb on flanks, shoulders, even arms-wrists
normal finding
macular blue gray pigmentation
mb mistaken for bruise, parents may hide them due to previous unpleasant experiences
may fade by 4 yrs, some residual color may last for life
(incidence in newborns per wiki: almost all East Asians, 90-95% of East Africans, 80-85% of Native Americans, 90% of Polynesians and Micronesians, 46% of Latin Americans-those c native blood, 1-10% of Caucasians)

OTHER LESIONS
insect bites
contact derm
tinea
nothing new for peds

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