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Pediatric News®

A SUPPLEMENT TO

CommonDermatologic Problems inthe PediatricPractice

An Overview of Rashes and Lesions

Managing Children With AtopicDermatitis

Treating Warts and Molluscum in Children

Congenital and Acquired Nevi in the Pediatric Patient

Recognizing and Treating Scabies in Children

Acne Therapy: An Overview

Tinea Capitis and Other Cutaneous Fungal Infections

Protection From Bites, Stings, and Photodamage

Jointly sponsored by Excerpta Medica, Inc., and PEDIATRIC NEWS.

Amy S. Paller, MD (Chair)Professor and Chair of Dermatology Professor of PediatricsFeinberg School of MedicineNorthwestern University, ChicagoChildren’s Memorial Hospital, Chicago

Adelaide A. Hebert, MDProfessor and Vice ChairmanDepartment of DermatologyUniversity of Texas Medical School, Houston

Moise L. Levy, MDProfessor of Dermatology and PediatricsBaylor College of Medicine, HoustonChief, Dermatology ServiceTexas Children’s Hospital, Houston

Seth J. Orlow, MD, PhDProfessor of Dermatology and PediatricsDirector of Pediatric DermatologyNew York University School of Medicine

Annette M. Wagner, MDAssistant Professor of Dermatology and PediatricsNorthwestern University Medical School, ChicagoAttending PhysicianChildren’s Memorial Hospital, Chicago

Proceedings of a Clinical Roundtable

PED-3Mderm 4/30/04 5:20 PM Page 2

Group Publisher/General ManagerAlan J. Imhoff

Vice President,Medical Education & Business DevelopmentSylvia H. Reitman

Program Manager, Medical EducationLaura I. Plemenik

Clinical EditorJoanne M. Still

National Account ManagerRory Flanagan

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Production SpecialistAnthony Draper

Pediatric News®

The roundtable discussion fromwhich this supplement was devel-oped took place in Chicago, Ill., onJanuary 30, 2004.

This educational supplement toPEDIATRIC NEWS was supported by arestricted educational grant from

It was produced by the medical edu-cation department of InternationalMedical News Group. Neither theEditor of PEDIATRIC NEWS, theEditorial Advisory Board, nor thereporting staff reviewed or con-tributed to its content. The opinionsexpressed in this supplement arethose of the faculty and do not nec-essarily reflect the views of the sup-porter or the Publisher.

Copyright © 2004 Elsevier Inc. Allrights reserved. No part of this pub-lication may be reproduced or trans-mitted in any form, by any means,without prior written permission ofthe Publisher. Elsevier Inc. will notassume responsibility for damages,loss, or claims of any kind arisingfrom or related to the informationcontained in this publication, includ-ing any claims related to the prod-ucts, drugs, or services mentionedherein.

Amy S. Paller, MD (Chair)Professor and Chair ofDermatology

Professor of PediatricsFeinberg School of MedicineNorthwestern University, ChicagoChildren’s Memorial Hospital, Chicago

Adelaide A. Hebert, MDProfessor and Vice ChairmanDepartment of DermatologyUniversity of Texas Medical School, Houston

Moise L. Levy, MDProfessor of Dermatology and Pediatrics

Baylor College of Medicine,HoustonChief, Dermatology ServiceTexas Children’s Hospital,Houston

Seth J. Orlow, MD, PhDProfessor of Dermatology and Pediatrics

Director of Pediatric Dermatology

New York University School of Medicine

Annette M. Wagner, MDAssistant Professor of Dermatology and Pediatrics

Northwestern University Medical School, Chicago

Attending PhysicianChildren’s Memorial Hospital,Chicago

Faculty AccreditationThis activity has been planned and implemented in accordance with theEssential Areas and Policies of the Accreditation Council for ContinuingMedical Education (ACCME) through the joint sponsorship of ExcerptaMedica, Inc., and PEDIATRIC NEWS. Excerpta Medica is accredited by theACCME to provide continuing medical education for physicians.

Excerpta Medica designates this educational activity for a maximum of 1.5category 1 credits toward the AMA Physician’s Recognition Award. Each physi-cian should claim only those credits that he/she actually spent in the education-al activity.

Term of Approval: June 2004-May 2005.

Estimated time to complete this educational activity: 1.5 hours.

Target AudienceThis activity has been developed for pediatricians, family physicians, and otherclinicians who provide health care for children and adolescents.

Educational NeedsAs the front-line health care providers for infants, children, and adolescents, pediatric health care providers are continually confronted with a wide variety ofdermatologic conditions. Many of these problems, if accurately diagnosed, arequite appropriately managed in the physician’s office. In other cases, recognitionof the need for prompt referral to a dermatologic specialist is the more prudentcourse, with the referring physician working in consultation with a dermatologistcolleague. Pediatric specialists must remain up-to-date on the treatment of themost common infections and other dermatologic conditions seen in children.

Learning ObjectivesBy reading and studying this supplement, participants should be able to:

• Recognize the most common lesions and rashes that are likely to occur in a pediatric population.

• Discuss the approach to diagnosis when the condition is not immediatelyidentifiable.

• Provide a rationale for referral to a dermatologic specialist.

• Summarize the treatment options for each of the diseases or conditions discussed in this supplement.

Faculty and Unapproved Use Disclosures Faculty/authors must disclose any significant financial interest or relationshipwith proprietary entities that may have a direct relationship to the subject matter.They must also disclose any discussion of investigational or unlabeled uses ofproducts.

Dr Hebert has received research support from and is a consultant to 3MPharmaceuticals. Dr Levy has received support from and is a consultant to 3M,Fujisawa Healthcare, Inc., and Novartis Pharmaceuticals Corporation. He dis-cusses the unlabeled uses of imiquimod for molluscum and warts (other thancondyloma), and ivermectin for scabies. Dr Orlow discusses the unlabeled usesof tretinoin, adapalene, tazarotene, minocycline, tetracycline, doxycycline, ben-zoyl peroxide, topical clindamycin or erythromycin, and oral isotretinoin for usebelow the lowest approved age and/or in use for acne. Dr Paller receives researchsupport from and is a consultant to 3M, Fujisawa, and Novartis. She discussesthe unlabeled use of imiquimod for molluscum/warts. She also discusses theunlabeled use of pimecrolimus and tacrolimus for eczema for infants and childrenunder the age of 2 years. Dr Wagner has nothing to disclose.

3 Introduction

3 An Overview of Rashes and Lesions

5 Managing Children With Atopic Dermatitis

7 Treating Warts and Molluscum in Children

9 Congenital and Acquired Nevi in the Pediatric Patient

10 Recognizing and Treating Scabies in Children

11 Acne Therapy: An Overview

13 Tinea Capitis and Other Cutaneous Fungal Infections

14 Protection From Bites, Stings, and Photodamage

16 CME Post-Test and Evaluation

Common Dermatologic Problems in the Pediatric Practice

INTERNATIONALMEDICAL NEWS GROUP


Common Dermatologic Problems in the Pediatric Practice 3

IntroductionAmy S. Paller, MD

An Overview of Rashes and LesionsAnnette M. Wagner, MD

ashes come in many shapes andforms. The myriad conditions,diseases, and reactions that can

affect the skin to produce these rashesmay seem overwhelming to the generalpractitioner. Dermatologists accrue abody of knowledge over the course oftheir specialty education and clinicalexperience, and this article provides abrief summary of some of the mostimportant information that would per-tain to the dermatologic problems seen inchildren. The sheer number of possibili-ties in the differential diagnoses of rashesand lesions is challenging, but a system-atic approach can be helpful in narrow-ing the list.

Detecting the Etiology of Rashes:Clues on the History and Physical

History can provide useful informa-tion in diagnosing the cause of a rash. Alist of questions is shown in Table 1, andsome clinical pearls that may be helpfulfor both diagnosis and treatment are pro-vided in Table 2 on page 4. On the skinexamination, inspect all parts of thebody, not just the area of concern to thepatient. Do not neglect the mucousmembranes, the genitalia, and the palmsof the hands and soles of the feet.

Note the extent of the rash andwhether it is symmetric. A symmetricrash distributed equally over the entirebody—including extremities—indicatesthe likelihood of an “inside job,” a sys-temic reaction. In contrast, a rash thatappears only on one part of the bodyshould lead to consideration of an “out-side job,” such as contact dermatitis, sun-burn, or other nonsystemic cause.

The shape and distribution of a rashalso help define its cause. Contact der-matitis is an obvious example: a rashunder the umbilicus or watchband sug-gests nickel dermatitis.

Color is another identifying feature.The majority of rashes seen in the prima-ry care office—perhaps 95%—have aninflammatory component and, therefore,will be red. A rash that is not red isunusual and may require referral to a der-matologist for accurate identification.

Scaly versus Nonscaly Rashes The next feature to note is whether a

red rash is scaly. Scaly rashes involveinflammation in the epidermis, and, if

the rash is diffuse, the most commondiagnosis is a form of atopic dermatitis(eczema). In general, eczematous erup-tions are poorly marginated—that is,there are no areas within the region of therash where the skin appears normal. It isthis feature that helps to distinguishbetween eczema and lesions of tinea cor-poris or psoriasis, for example, which arecharacterized by distinct and discrete red,scaly lesions separated by normal skin.

Nonscaly rashes result from injury toblood vessels in the dermis and usuallyare accompanied by some swelling.Dermal rashes are familiar to all primarycare clinicians. Those seen most fre-quently are drug rashes and maculopapu-lar eruptions that accompany viruses.Hives—also called urticaria, wheals, orwelts—occur as the result of a vascularinjury arising from immunologic or non-immunologic mechanisms. Nonscaly, reddermal rashes may be treated with anti-histamines if itching is a problem; coolcompresses and emollients also may beapplied to the skin for symptomaticrelief. Topical corticosteroids are nothelpful and should not be used becausethese are effective only for epidermalinflammation that is clinically apparentas a scale.

A viral exanthem may be clinicallyindistinguishable from a drug reaction.For this reason, it is important to avoiddiagnosing a “drug rash” in a child with aviral infection who is taking a medica-tion. Instead, that child’s chart shouldindicate that he or she “had a rash whiletaking….” In addition to symptomatictreatment, it is prudent to stop the drugand choose another medication, in case

R

1. How long has the rash or lesion been

present?

2. Is it changing rapidly (over hours or

days)?

3. Do lesions come and go, or persist?

4. Are there any systemic symptoms that

appeared at the same time as the rash?

5. Is the patient taking any medications

(including over-the-counter or herbal

remedies)? Does this coincide with

the onset of the rash?

6. What are the skin symptoms? (Does

the area of the rash itch or burn?)

7. Does anyone else in the family have

this particular rash?

Table 1. Questions to Help Diagnose theCause of a Rash or Lesion

n estimated 20% to 30% of pediatric patients

are found to have primary or secondary skin

problems when they visit their primary care

doctors. Therefore, recognition and management of

the many common cutaneous disorders are of critical

importance in pediatric and family care practices. Of

course, making the correct diagnosis is a prerequisite for

prescribing appropriate therapy or determining the

need for referral to a dermatologic specialist.

According to our faculty of premier pediatric derma-

tologists, the diagnosis of skin problems is based on a

careful history, a thorough examination, and a variety of

other diagnostic techniques. Examination of the skin

and oral mucosa should be complete, as appropriate, for

the presenting problem. The observation of individual

lesions tends to be of greatest significance. The distri-

bution of lesions, patterning, and specific morphology

should be noted.

We hope this review and update of common derma-

tologic problems will be useful to you, and we look for-

ward to reviewing your feedback on this educational

activity.

A


4 Common Dermatologic Problems in the Pediatric Practice

the drug actually is the problem. Re-member, however, that drug-relatederuptions can worsen even when the drugis withdrawn, so continued follow-up isadvisable to ensure that the child’s condi-tion is improving and not worsening.

More severe injury to the blood vesselscan result in an eruption known as ery-thema multiforme, also commonly seenin general practice. This vascular reactionproduces annular, indurated, discreteplaques (with normal skin betweenplaques) that resemble archery targets.The epidermis in the central portion ofthe plaques often is necrotic and appearsgray or purple. Erythema multiformelesions with involvement of two or moremucous membranes is a potentially life-threatening systemic reaction thatrequires immediate referral.

The most serious among the vascularinjuries to the skin is vasculitis, a non-scaling, purple rash that does not blanchto the touch. All such eruptions are clin-ically important and require referral forevaluation of the underlying etiology.

When Is Referral Indicated?Experienced pediatricians and family

practitioners will be able to identify mostskin rashes and lesions. Referral is indi-cated for any patient who has been treat-ed for what appears to be a common skindisease and who is not improving. A dermatologist also should be consultedregarding any unidentified rash in a child

who appears ill and/or who has a fever;such a rash is potentially more problem-atic than an eruption in a child whoseems otherwise healthy. The potentialfor a serious disease is even greater if theextent of the rash is progressing rapidly.

Cautious and prompt managementalso is required if a rash appears in a very young child—less than 3 months of age—or an immunocompromisedpatient. In such cases, the rash may be animportant clinical sign of a serious

1. Examine the palms, soles, and mucous membranes. A rash limited to the trunk andextremities tends to be less serious than if the palms, soles, and mucous membranes areinvolved.

2. Too many lesions? It may not be tinea. Nummular eczema involves well-defined, scaly,red lesions that may be mistaken for tinea. The distinguishing feature is number:patients with tinea typically have only between one and five papulosquamous lesions.

3. An annular plaque that looks like tinea is not tinea if there is no scale on the surface.More likely, the diagnosis of such a nonscaly plaque is granuloma annulare.

4. Systemic symptoms such as malaise, myalgias, photophobia, or joint swelling with arash that appears to be eczematous suggest an underlying systemic disease such as lupusor dermatomyositis.

5. Treat itchy rashes with counter-irritants that are refrigerated, such as phenol or menthollotions. Temperature and a tingling sensation are conducted by the same nerve pathwaysin skin as itch, so you can’t feel itch and tingle or cold at the same time.

6. Eczema is much more common than scabies, but scabies is likely if burrows are evidentin the “M” lines in the palms, if lines are seen at the edges of the fingers, if there is scal-ing between the fingers, and/or if the classic burrow lines appear in the genital region oron the wrists.

7. Milk allergy is rarely a trigger for infantile eczema (<3%). Formula should not bechanged for skin symptoms only.

8. Allergic reactions typically produce recognizable patterns. Hives, erythema multi-forme, and vasculitis are rash patterns that are recognizable as allergic reactions.

9. Topical steroids do not work on nonscaling eruptions.

Table 2. Nine Clinical Pearls From a Dermatology Practiceunderlying problem. In these situations,referral to a dermatologist—or an emer-gency room, if that seems appropriate—is warranted unless the cause of the rashcan be definitively established and theclinical picture is clear.

Erythroderma—confluent erythemaover the entire skin surface—has multi-ple causes, all of which require a derma-tologic consultation. In addition, if anyportion of a rash is nonblanchable, theunderlying etiology must be established,and this usually requires a biopsy.

A localized area of small vesicles orbullae suggests infection with herpes sim-plex virus, contact dermatitis, or bullousimpetigo and does not require a consul-tation with a dermatologist. Referral isrequired for rashes accompanied byextensive blisters, bullae, or bruises.

Finally, rashes should not be treatedempirically. If a rash is the primary prob-lem and cannot be identified accuratelyin the primary care office, referral shouldbe made for a diagnosis.

When making a referral to a dermatol-ogist, use the descriptive terminology inTable 3 to document the rash or lesionaccurately. The morphology of the rash,its color, shape, and anatomic locationshould all be documented in referral cor-respondence.

ConclusionCareful attention to lesion morpholo-

gy, distribution, and color will allowready identification of the nature ofmany common rashes. If the etiology of arash is uncertain—especially in a childwho appears ill, an immunocompro-mised child, or a neonate—prompt refer-ral to a dermatologist is critical.

Table 3. The Language of Rashes and Lesions

Bulla Large, fluid-filled elevation > 1 cm in diameter

Eczematous lesion/eruption Scaly, red, poorly-defined plaque

Erosion Destruction (shallow ulceration) of epidermis

Hive Raised, red welt

Macule Flat, nonpalpable discoloration < 1 cm in diameter

Nodule Dome-shaped, palpable lesion > 1 cm in diameter

Papule Palpable lesion < 1 cm in diameter, flat topped or

dome-shaped.

Papulosquamous lesion/eruption Scaly, red, discrete, well-marginated plaques

Patch Flat, nonpalpable discoloration > 1 cm in diameter

Plaque Flat, palpable lesion > 1 cm in diameter

Ulcer Erosion of the full thickness of the skin

Vesicle A fluid-filled, clear papule



Managing Children With Atopic DermatitisAmy S. Paller, MD

topic dermatitis, commonly knownas eczema, is among the mostcommon skin disorders seen in

infants and children (Figure 1). At least85% of children with this condition areaffected before 5 years of age, with 60%being affected by 12 months of age.1 Thecurrent prevalence of atopic dermatitis inthe pediatric population in the UnitedStates is 17.2%,2 a figure which hastripled in the past several decades. A sim-ilar increase has been seen in asthma dur-ing this same time.3,4

Although it is not possible to predictthe course of atopic dermatitis in indi-vidual patients, many children experienceclearance of eczema in early childhood—by 3 to 5 years of age—and recent stud-ies have shown that complete clearanceoccurs in 40% to 60% of patients by theage of puberty or shortly thereafter.5,6

Patients whose eczema has not cleared bythe time of puberty may still hope toexperience improvement over time.5,6

The clinical features and diagnosis ofatopic dermatitis are familiar to mostpediatricians and family practitioners.This article focuses on treatment, basedon what is currently known about thepathology of this disease and the mecha-nisms of actions of both standard andnewer therapies. Treatment includesattention to avoiding trigger factors,moisturization, application of primarilytopical antiinflammatory agents, and theuse of antistaphylococcal antibiotics whenindicated.

Trigger Factors Common irritants are sweat, saliva,

and rough clothing. Patients should min-imize exposure to irritants, includingsweat, saliva, harsh clothing (particularlywool), harsh soaps and detergents, prod-ucts with scents (including fabric soften-ers), and bubble baths. Other allergictriggers specific to an individual childmay be difficult to identify, but if theyare known, they should be avoided.

Hydration and MoisturizationIn addition to being enjoyable for

infants and children, daily baths are anexcellent means of hydrating the skin andremoving surface bacteria and desqua-mated tissue. To prevent loss of lipids inthe skin, baths should be limited to about10 minutes, and only mild soaps or soap-less washes should be used.

To maintain hydration of the skin afterbathing, a thick emollient should beapplied before water on the skin evapo-

rates—that is, within a few minutes ofremoving the child from the water. Themost effective emollients for decreasingskin dryness are those with the highestcontent of oil relative to water; thicker andgreasier emollients meet this definition.

Enhancing Symptomatic Relief To decrease pruritus and the sensation

of burning at night, topical antiinflam-matory agents may be applied. In addi-tion, “wet wraps” applied either after abath and emolliation or following theapplication of a topical antiinflammato-ry, can be soothing and promote comfortand sleep.7 In hospitals, wet gauze ban-dages are typically used; at home, thesame effect can be achieved by dressing ayoung child in pajamas and socks moist-ened in plain water (and covered by a drylayer to prevent excess cooling of bodytemperature).

In general, oral antihistamines arethought to have little direct effect on pru-ritus, but sedating doses of antihista-mines such as hydroxyzine, diphenhy-dramine, and doxepin may be helpful in children who have pruritus severeenough to interrupt sleep.

Topical Corticosteroids Topical corticosteroids have been the

mainstay of treatment for atopic dermati-tis and are available in a wide range ofpotencies, from weak (class VII agents,such as hydrocortisone acetate) to ultra-potent (class I). Agents in ointment vehi-cles offer several advantages over creamor lotion formulations. These includeocclusion, more effective penetration,and generally greater efficacy. Cortico-steroid ointments are particularly effec-tive in the management of dry, licheni-fied, or plaquelike areas of dermatitis.The disadvantages of ointments are that

they are messier than creams and lotionsand are not as well tolerated in warmertemperatures. Oil preparations are mostcommonly used for scalp dermatitis,although they may be effective on otherareas of the body.8

Potent corticosteroids are the mosteffective in managing atopic dermatitis,but they also are associated with the great-est risk for local and systemic side effects.Therefore, a corticosteroid that has theleast potency but adequately controlssymptoms should be chosen.

The first-line therapy for treating chil-dren with exacerbations of eczema—par-ticularly when the disease is mild to mod-erate—includes low- and mid-potencyagents. In general, these topical agentsshould be applied twice daily to controlinflammation. No studies have shownthat more frequent application increasesefficacy.

Concern about the use of cortico-steroids in general has led to “steroid phobia” among some families and evensome physicians.9 This fear may causedecreased compliance on the part of care-givers and a reluctance on the part ofphysicians to prescribe topical cortico-steroids at a strength that is adequate tocontrol an eczema flare.

If potent corticosteroids are applied tolarge body surface areas, used underocclusion, or used chronically, the poten-tial side effects may be local (most com-monly, atrophy and telangiectasia) or sys-temic. However, considering the wide-spread use of topical corticosteroids, fewadverse reactions occur when these agentsare carefully chosen and used appropri-ately, based on the site of application andthe severity of the dermatitis.

Once the eczematous flare is controlled,therapy can be tapered to a less potent cor-ticosteroid agent, and/or the patient canbe gradually weaned off the corticosteroidand only resume this therapy intermittent-ly, to control future flares.10

Calcineurin InhibitorsTopical calcineurin inhibitors—tacro-

limus and pimecrolimus—are alternativeagents for treating atopic dermatitis. Themechanism of action of these drugsinvolves blocking the production ofinflammatory mediators—that is, thenuclear transcription of cytokines.

Tacrolimus ointment, 0.03%, andpimecrolimus cream, 1.0%, currently areapproved by the US Food and DrugAdministration for the treatment ofatopic dermatitis in children 2 years of

The type of flare experienced by this childrequires aggressive management with topicalantiinflammatory agents to control intensepruritus and resolve erythema and scaling.

Photo courtesy of Dr Amy S. Paller.

Figure 1. Atopic Flare in AntecubitalFossae

A



age and older. However, studies suggestthat these agents are safe in children asyoung as 3 months of age.11 Tacrolimusointment is often used in children withmoderate to severe atopic dermatitis,12 andpimecrolimus is more commonly used inthose with milder eczematous disease.13

These agents have not been associatedwith the local or systemic side effects seenwith corticosteroids, presumably becauseof the more targeted action of the cal-cineurin inhibitors. Assays of systemicabsorption of tacrolimus and pime-crolimus have shown that, at most, thesedrugs achieve transient, low blood lev-els.12,14 The lack of demonstrated sideeffects has led many clinicians to feelconfident in using tacrolimus and pime-crolimus on the face (including the peri-orbital areas) and intertriginous areas.

No increase in cutaneous or systemicinfections has been reported with the useof the calcineurin inhibitors.15 A burningor stinging sensation may occur duringthe first several days of application, par-ticularly in children with more severesymptoms. If this reaction does occur, itusually subsides with continued use andthe improvement of the dermatitis. Todecrease the child’s discomfort, someclinicians mix topical corticosteroidswith the calcineurin-inhibiting agent ortry to achieve some control of the diseasebefore beginning treatment with eithertacrolimus or pimecrolimus alone.

There is no evidence that the use oftopical calcineurin inhibitors increasesthe risk for nonmelanoma skin cancers(NMSCs), but an increase in NMSCshas been reported in organ transplantrecipients receiving cyclosporine andoral tacrolimus. Therefore, it is prudentto caution parents and patients about theneed for sun protection while using thesedrugs.

Calcineurin inhibitors may offer a par-ticular advantage over topical cortico-steroids in three main areas: (1) whenpatients have an inadequate response tocorticosteroids, (2) when parents orpatients have “steroid phobia” despiteefforts at education, (3) for the treatmentof dermatitis of the head and neck whenlow-potency corticosteroids fail to con-trol symptoms.

Antistaphylococcal Antibiotics Children with atopic dermatitis also

have an increased risk of developing cuta-neous Staphylococcus aureus infections(Figure 2). Because S. aureus overgrowthplays a role in dermatitis, antistaphylo-coccal antibiotics are important in themanagement of patients with heavy colo-nization or infection with S. aureus. Themost commonly used agents are first-

generation cephalosporins, as the resis-tance of S. aureus to erythromycin isincreasing. Methicillin-resistant S. aureus(MRSA) is not yet a problem for patientswith eczema, but community-acquiredMRSA is increasing rapidly and chronicantistaphylococcal therapy should beavoided whenever possible. Adding 1/8to 1/4 cup of chlorine bleach to bathwater, if tolerated, can be helpful inreducing the risk of chronic infections.

Postinflammatory Pigment Changes Regardless of the phase of atopic der-

matitis postinflammatory hypopigmen-tation or hyperpigmentation may beseen. Hyperpigmentation often occurson lichenified skin, particularly in dark-er-skinned children, because thicker epi-dermis tends to accumulate epidermalmelanin pigment. Pigmentary changesare transient and usually resolve sponta-neously when the underlying inflamma-tion is controlled. However, this processmay take 6 months or longer, and expo-sure to sunlight tends to highlight thedifference between dyspigmented anduninvolved areas. Parents should be reas-sured that postinflammatory pigmentchanges are not scars. Unless secondaryinfection occurs or lesions are deeplygouged, atopic dermatitis is not a scar-ring disorder.

Conclusion Parents should be reminded that atop-

ic dermatitis is a chronic disease and thattopical immunosuppressive therapy isnot a cure. If a child has an active, under-lying tendency toward cutaneous inflam-mation and comes into contact with atrigger, a flare will occur. Control of thatflare requires aggressive management

Staphylococcus aureus was the causativeorganism in the cutaneous infection on thischild’s knee.

Photo courtesy of Dr Amy S. Paller.

Figure 2. Secondary Infection of the Knee with a topical antiinflammatory agent.For some children—particularly thosewho have moderate to severe atopic der-matitis—maintenance of control mayrequire daily or twice-daily use of a topi-cal immunosuppressive agent. In chil-dren with milder disease, control may beachieved by daily hydration and moistur-ization, with intermittent use of topicalcorticosteroids to control flares.

The observation that patients withatopic dermatitis have an increased riskfor other atopic disorders—particularlyasthma and allergic rhinitis—has led toresearch exploring the possible mecha-nisms for such a connection. Studies inthe mouse model have demonstrated thatdisruption of the stratum corneum andexposure to allergens early in life canincrease the risk for the subsequent devel-opment of asthma. These lines of inquiryhave resulted in a theory called the “atopicmarch,” suggesting that patients beginwith atopic dermatitis and later have othermanifestations of atopy, especially asthma.

Continuing studies are exploring thistheory, and seeking to evaluate whetherearly, aggressive treatment will reduce achild’s risk for the later development ofother atopic conditions. Support groups(www.nationaleczema.org) and othersources of information (eg, www.skincare-physicians.com/eczemanet) may be help-ful to families who must cope with theissues involved in caring for a child withatopic dermatitis.

References 1. Kay J, Gawkrodger DJ, Mortimer MJ, Jaron

AG. The prevalence of childhood atopic eczemain a general population. J Am Acad Dermatol.1994;30:35-39.

2. Laughter D, Istvan JA, Tofte SJ, Hanifin JM.The prevalence of atopic dermatitis in Oregonschoolchildren. J Am Acad Dermatol. 2000;43:649-655.

3. Schultz Larsen F, Hanifin JM. Secular changein the occurrence of atopic dermatitis. ActaDerm Venereol Suppl (Stockh). 1992;176:7-12.

4. Eichenfield LF, Hanifin JM, Beck LA, et al.Atopic dermatitis and asthma: Parallels in theevolution of treatment. Pediatrics. 2003;111:608-616.

5. Williams HC, Strachan DP. The natural histo-ry of childhood eczema: Observations from theBritish 1958 birth cohort study. Br J Dermatol.1998;139:834-839.

6. Wuthrich B. Clinical aspects, epidemiology,and prognosis of atopic dermatitis. Ann AllergyAsthma Immunol. 1999;83:464-470.

7. Goodyear HM, Harper JI. “Wet wrap” dress-ings for eczema: An effective treatment but notto be misused. Br J Dermatol. 2002;146:159.

8. Paller AS, Nimmagadda S, Schachner L, et al.Fluocinolone acetonide 0.01% in peanut oil:Therapy for childhood atopic dermatitis, evenin patients who are peanut sensitive. J Am AcadDermatol. 2003;48:569-577.

Continued on page 8



Treating Warts and Molluscum in ChildrenMoise L. Levy, MD

arts represent a usually benigninfection of skin and mucousmembranes caused by the human

papillomavirus (HPV). More than 100types of HPV have been identified, andrelationships exist between the HPVtypes and the variety of warts that areseen clinically. For example, verruca vul-garis (the common wart) can be seenwith HPV types 1, 2, and 4, with type 2predominating. Verruca plana (flat warts)usually are caused by HPV types 2 and 3.Types 1, 3, and 6 are the most commoncauses of verruca plantaris (plantarwarts). Finally, condylomata acuminata(genital warts) usually are associated withHPV types 6 and 11, although types 16and 18 also may cause genital warts.Types 16 and 18 are associated with cer-vical and anogenital carcinoma.

Unless the presentation is unusual, fewphysicians would fail to recognize thesetypes of warts. When the clinical presen-tation of verruca vulgaris is atypical, thesewarts may be confused with molluscumcontagiosum, foreign body reactions inthe skin, a variety of insect bite reactions,or, in immunocompromised patients,malignancy. Atypical verruca plana occa-sionally may be confused with eithermolluscum, a variety of benign adnexaltumors, or with epidermodysplasia verru-ciformis, another HPV-related infection.Verruca plantaris may be clinically con-fused with a simple callus, a foreign bodyreaction, or any of a number of benigntumors. Finally, very occasionally, condy-lomata acuminata may be confused withthe syphilitic lesion, condyloma latum,molluscum, developmental skin tags, asmall epidermal nevus, or lymphatic orother vascular malformations.

Treatment of Warts In more than 50% of cases, warts

resolve spontaneously.1-3 Although theperiod of resolution is variable, mostwarts will take about 2 years to resolvewithout treatment. Multiple treatmentoptions are available, but before under-taking any therapy, clinicians shouldadvise parents honestly that no particulartreatment is totally effective, and, in fact,that many remedies can be painful.

Treatments range from observationalone, to tape occlusion, to a variety of destructive or surgical modalities,chemical or cytotoxic treatments, andimmunotherapies. No treatment forwarts is uniformly effective, and so clini-cians should be familiar with the optionscurrently available. These will not be

completely addressed, but some com-mentary on certain modalities may behelpful here.

Cryosurgery is a common technique inthe dermatologist’s office, but pediatri-cians and family practitioners should beaware that some cryofreeze units beingmarketed today do not provide sufficientfreezing to eliminate viral tissue. Forcryosurgery to be effective, liquid nitro-gen must be used and is painful.

Topical cantharidin is an option forchildren with recalcitrant warts. Whenusing cantharidin on the plantar aspect ofthe feet, we first pare or curette the sur-

face of the wart. For stubborn lesions, atechnique that we have found to be use-ful in our practice is a combination ofmodalities, using cantharidin or liquidnitrogen first, followed by the immuneresponse modifier imiquimod, then sali-cylic acid under tape occlusion. The“sandwich” should be removed andreplaced every 2 to 3 days or once week-ly, depending on the age of the patientand the site of the lesion.

Imiquimod alone, under occlusion,may be helpful for flat warts, particularlyfor smaller lesions. Other agents that maybe helpful for flat warts include salicylicacid and retinoids. Regardless of theagent used, effects tend to be enhanced ifthe keratotic surface is abraded beforeapplication of the medication. Occlusionmay be accomplished with any occlusivetape, including—but not limited to—duct tape. The major advantage of ducttape is that its adhesive properties arelong-lived, even in water.

Immunotherapy also is an option fordifficult cases (and is especially helpfulfor difficult anatomic sites, such as thefeet). One method is to sensitize thepatient with a 2% solution of squaric

acid by placing a small amount on theforearm. In 2 weeks, apply squaric acid,0.6% - 0.8%, to the surface of the warts.Hydrating and abrading the warts beforeapplying the squaric acid solutionenhances the efficacy of this method. Animmunologic reaction should occurwithin 6 to 8 weeks. Mumps andCandida antigen have been studied fortheir efficacy in clearing warts, but anindividual patient’s response to theimmunologic challenge must be substan-tial for a therapeutic benefit to be seen.

Molluscum Contagiosum Molluscum contagiosum (Figure) is a

viral infection that involves the skin andmucous membranes. The viral culprit isknown by the genus name Mollusci-poxvirus. The molluscum virus prolifer-ates in the follicular epithelium and replicates within the cytoplasm.

As with warts, molluscum are acquiredby direct contact with hosts or, in somecases, a variety of fomites; an element ofautoinoculation also must be considered.A number of theories persist regardingmethods of transmission of both wartsand molluscum. One that is plausibleconcerns traumatized skin as the site ofvirus infection. This would explain, forexample, why molluscum lesions report-ed in public swimming pool users tend tooccur most frequently on the trunk: aschildren pull themselves up out of thewater over the side of a concrete pool,they can abrade the skin, presenting a siteof entry for any organisms that are pre-sent. Nevertheless, not enough is knownabout transmission of molluscum orHPV via fomites to make reasonablepublic health recommendations at thistime.

Recognizing Molluscum Molluscum infection generally is seen

in preadolescent children, and particular-ly in immunocompromised children andadolescents. (The infection also is notuncommon in immunocompromisedadults.) The molluscum virus has beenfound to elaborate a number of protec-tive proteins that seem to block normalhuman host responses. This is importantto keep in mind when considering poten-tial therapeutic options.

Most of the papules of molluscumoccur on the trunk, but about 25% ofpatients will present with involvement of the scalp and face.4 Intertriginousfolds—the axillae, antecubital andpopliteal fossae, and crural folds—seem

W

Molluscum contagiosum, caused by theMolluscipoxvirus, is most commonly seen inchildren prior to adolescence and in immuno-compromised children.

Photo courtesy of Dr Moise L. Levy.

Figure. Molluscum Contagiosum



to be particularly common sites ofinvolvement in many patients.

Traditional teaching holds that mol-luscum can be identified by the classicpresentation of umbilicated papules.However, although it may be possible toidentify some lesions that have this char-acteristic morphology, many more mol-luscum lesions are simply dome-shaped,firm, translucent papules. The differen-tial diagnosis of molluscum includes anumber of other viral infections, includ-ing varicella and, in immunocompro-mised patients, individual lesions ofcryptococcus. In addition, small epider-mal cysts, or milia, might be mistaken formolluscum; inflamed, isolated, largermolluscum lesions might be confusedwith pyogenic granuloma.

Biopsies are rarely indicated in thediagnosis of molluscum. Instead, thediagnosis is made clinically.

Treatment Options for MolluscumThe majority of patients—about 60%

of children and adolescents—presentwith fewer than 15 lesions.4 Spontaneousinvolution of molluscum occurs at anytime between 6 months and 5 years aftertheir appearance in immunocompetenthosts. Unless only a few lesions are pre-sent, most parents elect to have theirchild treated.

One argument in favor of treatment,regardless of the number of lesions, is thepossible prevention of autoinoculationand the prevention of transmission of thevirus to others. However, similar to thetreatment options with warts, a numberof the therapies may work—althoughwithout universal efficacy—and somecan cause discomfort or pain. In addi-tion, some treatments may result in scar-ring, although parents should understandthat, even without treatment, normalinvolution of the molluscum lesions mayleave pitted scars or dyspigmentation.

If a patient has a small number oflesions on the trunk, axillae, or otherareas that are not cosmetically sensitive,

curettage is an option. Curettage shouldnever be done without first applying atopical anesthetic. However, even over-the-counter topical anesthetics can beoverapplied and result in systemicabsorption and a risk for side effects.

One form of nonsurgical treatmentthat seems to work in many cases is can-tharidin. Children and their parentsshould understand that a blisteringresponse is possible with this agent, butthis is transient and, in lighter-skinnedchildren, the blister will not leave a scar.However, dyspigmentation—beyond thepostinflammatory hyperpigmentationcommonly seen after resolution of themolluscum lesions—is more common indarker-skinned patients.

Studies using the immune responsemodifier imiquimod in patients withmolluscum have demonstrated promisingresults. In one double-blind, placebo-con-trolled study,5 100 males between 9 and27 years of age used imiquimod twicedaily, 5 days a week for 1 month. At theend of that time, molluscum lesions hadcleared in 80% of patients who usedimiquimod versus 16% with placebo. In asecond study, an open-label trial,2 15 chil-dren between 4 and 11 years of age weretreated with imiquimod three times week-ly. Two patients left the study because oflocal irritation. Of the 13 who completedthe study, 9 had either complete or partialresponses. (A partial response was definedas a decrease in lesion count from base-line.) Through its known immunologicmechanism, imiquimod may prove usefulfor the treatment of molluscum.Controlled studies will define its true util-ity in this regard.

Because imiquimod does not causeblistering the way cantharidin does,imiquimod may be preferred for treatinglesions on the face and in the groin area,particularly near the orifices.

A 3-month course of treatment withcimetidine is an option that may be triedin selected cases. It is occasionally usefulwhen other treatments fail. Cimetidine

also may be useful for patients withatopic dermatitis, or in a child with alarge number of lesions for whom curet-ting or topical treatment with can-tharidin or imiquimod is impractical.6

ConclusionWhether patients have warts or mol-

luscum, it is important to emphasize toparents that no treatment is universallyeffective, and elimination of lesions—particularly warts—may take severaltreatment attempts with more than onemodality. In addition, parents shouldunderstand that the appearance of newlesions does not necessarily indicate arecurrence of a previous outbreak, butmay be the result of a clinical manifesta-tion of lesions that had been incubatingin the same area. Both warts and mollus-cum, while benign conditions, representtherapeutic challenges for generalists anddermatologists alike. Because of the pos-sibility for autoinoculation and spread toother individuals, effective treatment isoften required. Physicians must be awareof a variety of management options whenevaluating such patients.

References 1. Massing AM, Epstein WL. Natural history of

warts: A two-year study. Arch Dermatol. 1963;87:306-310.

2. Cobb MW. Human papillomavirus infection. J Am Acad Dermatol. 1990;22:547-566.

3. Sanfilippo AM, Barrio V, Kulp-Shorten C,Callen JP. Common pediatric and adolescentskin conditions. J Pediatr Adolesc Gynecol.2003;16:269-283.

4. Dohil M, Paller A, Lucky A, Lee J, EichenfieldL. Molluscum contagiosum in children: Whogets them? J Am Acad Dermatol. 2004;50:134.

5. Syed TA, Goswani J, Ahmadpour OA, AhmadSA. Treatment of molluscum contagiosum inmales with an analog of imiquimod 1% incream: A placebo-controlled, double-blindstudy. J Dermatol. 1998; 25:309-313.

6. Dohil M, Prendiville JS. Treatment of molluscumcontagiosum with oral cimetidine: Clinical experience in 13 patients. Pediatr Dermatol. 1996;13:310-312.

9. Charman CR, Morris AD, Williams HC. Topicalcorticosteroid phobia in patients with atopiceczema. Br J Dermatol. 2000;142:931-936.

10. Hanifin J, Gupta AK, Rajagopalan R.Intermittent dosing of fluticasone propionatecream for reducing the risk of relapse in atopic dermatitis patients. Br J Dermatol.2002;147:528-537.

11. Paller AS. Use of nonsteroidal topical im-munomodulators for the treatment of atopic

dermatitis in the pediatric population. J Pediatr.2001;138:163-168.

12. Paller A, Eichenfield LF, Leung DY, Stewart D,Appell M. A 12-week study of tacrolimus ointment for the treatment of atopic dermatitisin pediatric patients. J Am Acad Dermatol.2001;44(suppl 1):S47-S57.

13. Eichenfield LF, Lucky AW, Boguniewicz M, et al. Safety and efficacy of pimecrolimus (ASM 981) cream 1% in the treatment of mild

and moderate atopic dermatitis in children andadolescents. J Am Acad Dermatol. 2002;46:495-504.

14. Harper J, Green A, Scott G, et al. First experienceof topical SDZ ASM 981 in children with atopicdermatitis. Br J Dermatol. 2001;144:781-787.

15. Fleischer AB Jr, Ling M, Eichenfield L, et al.Tacrolimus ointment for the treatment ofatopic dermatitis is not associated with anincrease in cutaneous infections. J Am AcadDermatol. 2002;47:562-570.

Managing Children With Atopic DermatitisContinued from page 6



Congenital and Acquired Nevi in the Pediatric PatientAnnette M. Wagner, MD

wo types of nevi, or moles, areseen in the pediatric patient: thecongenital nevus, which appears

in the first year of life (although not nec-essarily present at birth) and the acquirednevus, which appears after 18 months,with peaks of incidence in the preschoolyears and during adolescence.

Evaluation and Management of Congenital Nevi

The issue of when congenital nevishould be excised is controversial in pedi-atric dermatology.1 Congenital nevi areassociated with an increased risk formalignancy. If a nevus is less than 1 cm indiameter, the risk for malignant conver-sion is small—less than 1% over the life-time of the patient.2 Nevertheless, anycongenital mole should be monitoredthroughout the patient’s lifetime. Insome cases, small nevi present cosmeticissues, and despite the limited risk formalignancy, such factors must be consid-ered in decisions about removal (Figure).

Congenital moles that are larger than 1cm and have a benign appearance also donot require removal, but the larger themole, the greater the risk for malignancyto occur, and the greater the need formonitoring these nevi for suspiciouschanges.3 When a child has a congenitalnevus between 1 and 3 cm in diameter,consider the anatomic location in anydecision about whether to remove orobserve the nevus. If the nevus is in alocation that will make it hard to moni-tor over time, such as on the scalp, I mayrecommend to the parents that the lesionbe removed, only because the chances ofsafely following any changes in that moleare reduced. Other difficult locationsinclude the groin, the bottom of the foot,and the middle of the back.

Any mole that has atypical features—such as multiple colors, irregular borders,

or rapid growth—warrants an evaluation.In such cases, removal is probably pru-dent. The removal of very large congeni-tal nevi—so-called garment moles—isprobably less controversial. These rarenevi cover a large portion of the body andoccur in approximately 1 in 20,000 chil-dren.4 Garment nevi are associated withan increased risk for malignancy in therange of 10% to 15%.5-7 Surgery toremove these lesions involves serial exci-sion or tissue expansion to remove asmuch of the nevus as possible to mini-mize the risk for malignancy.

Acquired Nevi Acquired nevi, commonly referred to

as moles, generally appear for the firsttime in Caucasian children between 18months and 2 years of age. They initiallyappear to be, and frequently are mistakenfor, freckles.

Three types of nevi are recognized.Junctional moles are flat, nonpalpable,brown skin lesions. Compound nevi areusually brown and elevated. Intradermalnevi are moles that are skin-colored andelevated. The appearance of more nevi onsun-exposed areas of the body, comparedwith nonexposed areas, suggests thatultraviolet light exposure may influencethe site of mole development.

The appearance of new moles and slowgrowth of moles with a gradual increasein thickness are normal changes duringchildhood. The layperson’s perception isincorrect that elevation of a mole or hairgrowing from a nevus is abnormal.Approximately 20% to 30% of molesprogress from being lentiginous (or flat)to being elevated. Such changes areexpected, particularly during puberty.Moles may continue to be acquired upthrough about age 30; approximately 20to 30 moles appear in the averageCaucasian by age 30.

Caveats About the ABCD Rules The ABCD guidelines were developed

for adults for self-examination of nevi.According to this mnemonic, a nevusshould be considered suspicious if itbecomes asymmetrical (A), developsirregular borders (B), changes color (C),or increases in diameter (D) beyond 6mm, or the size of a pencil eraser.

In examining color in moles, physi-cians and parents should understand thatthis feature is individual. Mole color dif-fers from person to person.

However, both physicians and parentsshould recognize that even if a mole

meets all the ABCD criteria for beingnormal, it is abnormal if it does notmatch all the other moles on an individ-ual’s body. In addition, parents who havelearned the ABCDs should be advisedthat these rules do not necessarily applyto nevi in children, particularly con-genital nevi. For example, congenital nevi often are asymmetric and larger than6 mm. Finally, changes in nevi in childrenare more significant if they are focal. If anentire mole darkens or gets uniformly larg-er, this is of less concern than if one por-tion of a mole undergoes these changes.

Melanoma Risk The general population risk of

melanoma in Caucasians is currently esti-mated to be 1 in 70.8 Melanoma is theleading cause of cancer-related death inindividuals between 20 and 40 years of age.

Pediatricians and family practitionersshould be aware that family history hassignificance for evaluating nevi in chil-dren. A child with a first-degree relativewho had or has melanoma is at increasedrisk for malignancy, but a relationshipmore distant than this confers no greaterrisk.9 If a child has a parent who has mul-tiple atypical nevi, the child may have anincreased lifetime risk for melanoma,compared to the general population;atypical nevus syndrome is heritable andconveys an increased risk for melanoma.10

Parents who are concerned about theirfamily history of atypical moles or a fam-ily history of melanoma frequently askhow often their child should be seen fora physical examination to evaluate nevi.These parents can be reassured thatmelanoma is quite rare in the childhoodyears, and—unless some changes occurin these lesions—examinations by a der-matologist can be performed once in theelementary school years (prepuberty),once in the middle school grades (aroundthe time of puberty), and once in highschool.

In addition to being alert for possiblemalignant conversions in nevi, all physi-cians can contribute to controlling themelanoma epidemic by impressing onparents the importance of using sun-screens on their children from very earlyin life. Although no relationship has beendefinitively demonstrated yet betweenchronic sun exposure and melanoma,blistering sunburns have been shown toincrease the frequency of this type of skincancer.11

T

Large nevi with a benign appearance, suchas the one shown here, do not requireimmediate removal but should be moni-tored for suspicious changes. However,removal to improve cosmetic appearancemay be a consideration.

Photo courtesy of Dr Annette M. Wagner.

Figure. Congenital Nevus

Continued on page 12



cabies is a contagious infestationcaused by the mite Sarcoptes sca-biei. Patients become sympto-

matic within 2 to 4 weeks after close per-sonal contact with an infested individual;the onset of symptoms coincides with thepatient’s sensitization to the infestation.

The infestation often presents with a variety of lesions, including papules,nodules, vesicles, pustules, and evenlarge bullae. Crusting may be promi-nent, particularly (although not exclu-sively) with smaller lesions. The classiclesion, erythematous, slightly vesicularlinear burrows, may be evident but arenot always present. When burrowsappear, they may be no more than a fewmillimeters long and may appear any-where on a patient’s body.

Diagnosing ScabiesThe diagnosis is made clinically, based

on the appearance and distribution of thelesions. The distribution of scabies tendsto vary with the patient’s age. In infants,evidence of infestation typically is seenon the trunk, palms, soles (Figure), and,sometimes, the face (especially if a moth-er with scabies is breast feeding thechild). In older children, adolescents, andadults, scabies lesions are more common-ly seen in the flexural areas, interdigitalweb spaces, wrists, and axillae. However,involvement of the trunk, breasts, andgenitalia is not uncommon.

The differential diagnosis may includeany condition that can present with der-matitis, papules, crusting, or vesicula-tion, so it is not unusual for the diagno-sis of scabies to be missed occasionally,even by experienced dermatologists.Conditions to be ruled out include atopicdermatitis, dyshidrotic eczema (becauseof vesicles or bullae on the hands andfeet), contact dermatitis, an isolated bac-terial infection (such as impetigo or folli-culitis), insect bites, and the congenitalpustular eruption known as infantileacropustolosis, which may involve thepalms and back of the hands and/or thesoles and dorsa of the feet.

Confirmation of the diagnosis may bemade by microscopic examination ofscrapings from burrows of fresh vesicles.This material is mounted on a slide andmineral oil or potassium hydroxide(KOH) is added. A mineral oil prepara-tion allows visualization of active, livemites, whereas KOH kills scabies; however, KOH is less messy than oil andstill allows identification of mites, eggs,or feces.

Biopsies usually are performed only ifanother diagnosis is being considered forwhich a biopsy is indicated.

Finally, scabies is a diagnosis of exclu-sion, and it is important to avoid over-diagnosis. Treatment for scabies shouldnot be prescribed unless the diagnosis isdefinitive. Agents used to eliminate mitestend to dry the skin and can be irritating,so if the problem actually is dermatitis oreczema, therapy can exacerbate thoseother conditions.

Treatment Considerations and Options

Families should be advised that treat-ment involves both the patient and allpotential contacts, whether or not thosecontacts have symptoms or other evi-dence of scabies infestation. Such indi-viduals may be bringing the mites intothe home and may be the source of rein-festation even if the patient is successful-ly treated. In addition to other residentsin the household, babysitters, a friend orfamily member who spends time in thehome, or an attendant who cares for adisabled family member, for instance, areexamples of potential sources of infesta-tion. The decision to treat depends onhow close the contact is. Close contacts(family members and others, such ascaregivers) should be treated. Casual con-tacts can be advised to seek treatment ifsymptoms of scabies infestation appear.

A traditional treatment for scabies thatis still used occasionally is 5% to 10%precipitated sulfur in petrolatum, applieddaily for 3 to 4 days. Because of the odorfrom the sulfur and the messiness owingto the petrolatum base, this is not themost convenient or attractive treatment,but it should be considered for patientsin whom other treatments may not bemost desirable, such as very young chil-dren or pregnant women.

Currently, the standard of care for sca-bies therapy is 5% permethrin cream,which should be applied to all exposedskin surfaces—not just affected areas—from the neck down. It is important to work this product under finger-nails because mites can be picked upwhile scratching. The cream is appliedovernight and washed in the morning. Inaddition, on the morning following treat-ment, bed linens should be removed andlaundered.

In cases in which permethrin is ineffective, oral ivermectin, at a singledose of 200 �g/kg, may be considered.Unfortunately, ivermectin can be diffi-cult to obtain in many locations. In addi-tion, because it is available only in 3- and 6-mg tablets and no liquid formu-lation exists, dosing may be a problem.

Crotamiton, available in cream orlotion, is a scabicide and antipruriticagent. It is applied for two consecutivedays. Unfortunately, this product is not aparticularly effective agent for killingmites.1 Lindane, another topical pesti-cide, was once widely used to treat sca-bies and lice, but the neurologic compli-cations and environmental concerns asso-ciated with this agent have caused manyclinicians to avoid it. Nevertheless, whenused as directed on unbroken skin, lin-dane should not be automatically elimi-nated as an option, particularly becausethis agent is considerably less expensivethan permethrin in most areas, and costis an important consideration for somefamilies.

None of these scabicidal agents is uni-formly effective in every patient. For thisreason, re-treatment should be consid-ered within 7 to 10 days.

In addition to therapy to eliminate thescabies mite, symptomatic therapy forpruritus and inflammation should beprescribed. Topical corticosteroids or oralantihistamines often are useful.

Conclusion Scabies remains an infestation that

must be considered when evaluating apatient with a pruritic papular or vesicu-lar skin eruption. The eruption, asdescribed, can be easily missed and, iron-ically, is often overdiagnosed as well.Most traditional therapies are effective ifappropriately used.

Reference1. Prendiville JS. Scabies and lice. In: Harper J, Oranje

A, Prose N, eds. Textbook of Pediatric Dermatology.

Oxford, UK; Blackwell Science; 2000:555-569.

Recognizing and Treating Scabies in ChildrenMoise L. Levy, MD

S

The sole of the foot is a typical site of sca-bies infestation in infants. The diagnosis isconfirmed by microscopic examination ofscrapings from burrows.

Photo courtesy of Dr Moise L. Levy.

Figure. Scabies on the Plantar Surfaces



Teenage AcneAcne in teenagers is a disease of pilose-

baceous glands. Because these glands arefound in highest concentration on theface, forehead, cheeks, chin, chest, andback, these are the sites at which acnetypically occurs.

Treatment of teenage acne is influ-enced by the pathogenesis of the condi-tion in this age group. It is believed thatthe same hormones that regulate theonset of puberty cause increased sebumproduction in the pilosebaceous glands.In addition, the same pubertal hormonesadversely affect the shedding of the skincells at the neck of the gland where itopens to the surface of the skin. Theopening becomes more easily clogged,and the result is a more active gland withcontents that are “trapped” in place.

The initial consequence of this pro-cess is a microscopic lesion—a micro-comedone. As the lesion enlarges, itbecomes visible and is known as a come-done, either closed (commonly known asa whitehead) or open (a blackhead). Ablackhead results when melanin accumu-lates and oxidizes in the opening.

Inflammatory acne lesions are causedby the proliferation of Propionibacteriumacnes in response to the increase insebum. The metabolic byproducts ofP. acnes cause the release of proinflamma-tory fatty acids and materials chemotacticfor neutrophils. In addition, acne lesionsmay break, releasing their contents intothe dermis and provoking what is, essen-tially, a foreign-body reaction.

Topical Therapy (Table) Because the initial lesion in acne is

always a microcomedone, the ideal acneregimen for patients with mild to moder-ate acne might contain an agent withanticomedonal properties. At this time,the best comedolytic agents available aretopical retinoids. The three types current-ly available—tretinoin, adapalene, andtazarotene—are available dispensed in avariety of formulations. Irritation is themain side effect associated with topicalretinoids. However, this problem usuallycan be managed by trying differentagents and/or by manipulating the fre-quency of application and amount used.

Azelaic acid has antibacterial activityand also seems to have anticomedonaland antiinflammatory properties. Azelaicacid may be a reasonable alternative forpatients for whom retinoid therapy fails.Mild stinging is a side effect of this agent,but tends to resolve with continued use.

Benzoyl peroxide, the most commonlyused agent to treat acne, is available bothby prescription and over-the-counter(OTC) and in a variety of formulations(gels, ointments, liquids) and concentra-tions (ranging from 2.5% to 10.0%).

Benzoyl peroxide has some comedolyt-ic properties, is known to be helpful fortreating inflammatory lesions, and hasantibacterial properties. Thus, this agentcan be helpful for treating both come-donal and inflammatory acne. Benzoylperoxide can be irritating and can causean allergic reaction in some patients. Inaddition, patients who use this agentshould be cautioned to wash their handsafter applying the medication because itcan discolor fabrics.

Salicylic acid is an ingredient in many OTC acne washes. Although salicylicacid has comedolytic properties, mostother agents available are far superior forthis purpose.

Topical antibiotics—most commonly,clindamycin and erythromycin—alsohave a role in the treatment of inflamma-tory acne. Formulations are available withthese agents as monotherapy or in combi-nation with benzoyl peroxide. The advan-tage of combining the topical antibioticwith benzoyl peroxide is that the latteragent may decrease the ability of P. acnes tobecome resistant to the antibiotic.

A reasonable amount of time isrequired to determine whether an anti-acne regimen is effective. Substantialchange should be seen in approximately6 weeks.

Oral Medications Oral medications are indicated for

patients who do not respond to topicaltherapy or for those with moderate tosevere inflammatory or comedonal acne.These fall into three main categories: oralantibiotics, isotretinoin, and, for females,oral contraceptives (OCs).

The agents in the tetracycline familytypically are the first-line oral antibioticmedications, but erythromycin and otherbroad-spectrum agents also are used fre-quently. The most difficult issue withtetracycline is that it must be taken 1hour before or 2 hours after a meal—aschedule that proves problematic formost teenagers. In addition, because themolecule binds to calcium, special caremust be taken to avoid interactions withcalcium-containing foods.

Doxycycline and minocycline are notassociated with these problems. Patientsusing doxycycline, however, should becautioned about the potential for height-ened photosensitivity while using thisdrug. In addition, doxycycline can beirritating to the esophagus and stomachand so should be taken with a full glass ofwater and not immediately before lyingdown. Minocycline is extremely well tol-erated, but some patients experience sideeffects such as dizziness, tinnitus, or nau-sea. If these occur, the medication shouldbe discontinued and another antibioticshould be used instead. A lupuslike syn-drome is a very rare side effect withchronic use of minocycline.

Misconceptions about the use of oral antibiotics in patients with acneoften result in their being discontinuedtoo soon. These agents work because oftheir antibiotic action, but they alsoappear to have antiinflammatory proper-ties. Generally, these medications shouldbe used in blocks of therapy lasting aminimum of several months. Medicationmay be withdrawn periodically to deter-mine whether the disease remains undergood control with topical therapy alone.

Gastrointestinal (GI) upset is a com-mon side effect of oral erythromycin,making this drug a less popular choice.Although derivatives of this agent are lesslikely to be associated with GI symp-toms, these drugs tend to be more expen-sive than the parent compound.

Treatment with other oral antibioticsmay be considered for patients who fail to respond to tetracyclines or ery-thromycin drugs. These include cephalo-sporins and trimethoprim-sulfa-methox-azole.

Isotretinoin has been used for morethan 20 years for the treatment of resistantnodular acne in teenagers and olderpatients. It is an extremely effective med-ication, even for those with the mostsevere, cystic, or scarring types of acnelesions. Ninety percent or more of patientstreated with this drug have excellent

Acne Therapy: An OverviewSeth J. Orlow, MD, PhD

■ Retinoids (tretinoin, adapalene,tazarotene)

■ Azelaic acid

■ Benzoyl peroxide

■ Salicylic acid

■ Topical antibiotics (eg, clindamycinand erythromycin), alone or in combination with benzoyl peroxide

Table. Topical Agents for Acne



responses after a typical 4- to 5-monthcourse of isotretinoin at approximately 1mg/kg body weight per day.1,2 Approx-imately 65% to 80% of patients either donot experience a recurrence of their diseaseafter treatment or, if lesions do recur, theoutbreak is not nearly as severe as beforetreatment. After a second course of treat-ment, if required, the response rateincreases to more than 85%.1,2 Isotre-tinoin is a potent teratogen and cliniciansmust be registered to prescribe this med-ication; female patients of childbearingage must have monthly pregnancy tests,and treatment with this drug must be discontinued if pregnancy is detected.

The most common side effects of oralisotretinoin are dryness of the mucousmembranes (the lips, in particular), face,and eyes. Muscle aches have been report-ed in teenagers more commonly than inany other group. The question ofwhether isotretinoin causes depressivesymptoms remains open,2-4 although thelabel for this medication carries a warn-ing concerning this possibility.

Several OCs are now approved specifi-cally for the treatment of acne and areeffective for both comedonal and inflam-matory acne. These agents work by mod-ulating hormonal levels. Efficacy withOCs is approximately the same as for oralantibiotics, but not all patients whorespond to one class of drugs will neces-sarily respond to the other.

Other Types of Acne TreatmentPrior to the availability of effective

oral agents, intralesional injection oflesions was the mainstay treatment ofnodular acne. It remains a viable option,especially for the patient who has just a few nodules—too few to warrantthe use of oral isotretinoin.

Comedone extraction is a procedureperformed in the dermatologist’s office.Although this technique can temporarilyeliminate visible lesions, it does nothingto prevent new comedones from formingand, thus, should never be considered themainstay of an acne regimen.

One experimental treatment for acneis the use of intense blue light, which ispurportedly absorbed by compoundswithin the P. acnes organism, causing bac-terial death. Another line of researchinvolves the use of photodynamic thera-py to treat resistant nodular acne.

Neonatal Acne Neonatal acne is a condition character-

ized by small, inflammatory lesions, oncethought to result from the effect ofmaternal hormones on the neonatal seba-ceous glands. Newer evidence suggeststhat in some cases, children with theselesions actually may have a Pityrosporuminfection.5 Such infections may be appro-priately treated with observation alone orwith a topical antifungal agent.

No data are available regarding thesafety of benzoyl peroxide or other topi-cal agents in the neonates. However, suchagents have been used to treat neonatalacne, and there have been no reports ofserious side effects.

Acne in Older Infants In children older than 3 years of age,

lesions that appear to be acne may be apresenting sign of precocious puberty.However, most infants and young chil-dren with acne are otherwise healthy, andin the absence of any other clinical signs,an endocrine workup is not warranted.

The most common problem with acnein older infants, toddlers, and young chil-dren is the lesions may be severe, but the

treatments available are the same as forteenagers and adults. Unfortunately, someof the most effective treatments—such astetracycline and its derivatives—are notappropriate for this age group. Topicalagents can be tried, but some childrenrespond poorly; some cases have beenreported in the literature of children asyoung as 3 or 4 years of age with severe andeven scarring acne who respond to nothingbut isotretinoin.6

ConclusionPediatricians and family practitioners

may wish to limit their treatment to top-ical medications, or they may choose tobecome familiar with the details ofantibiotic therapy. However, in cases ofmoderate to severe or resistant acne inwhich OCs or isotretinoin are possibletherapies, referral to a dermatologist isappropriate.

References 1. Layton AM, Knaggs H, Taylor J, Cunliffe WJ.

Isotretinoin for acne vulgaris—10 years later: Asafe and successful treatment. Br J Dermatol.1993;129:292-296.

2. Brecher AR, Orlow SJ. Oral retinoid therapy fordermatologic conditions in children and adoles-cents. J Am Acad Dermatol. 2003;49:171-182.

3. O’Donnell J. Overview of existing research andinformation linking isotretinoin (Accutane),depression, psychosis, and suicide. Am J Ther.2003;10:148-159.

4. Jacobs DG, Deutsch NL, Brewer M. Suicide,depression, and isotretinoin: Is there a causallink? J Am Acad Dermatol. 2001;45:S168-S175.

5. Bernier V, Weill FX, Hirigoyen V, et al. Skin colonization by Malassezia species in neonates: A prospective study and relationship with neo-natal cephalic pustolosis. Arch Dermatol.2002;138:215-218.

6. Sarazin F, Dompmartin A, Nivot S, Letessier D,Leroy D. Treatment of an infantile acne with oralisotretinoin. Eur J Dermatol. 2004;14:71-72.

ConclusionNot every congenital nevus necessarily

requires evaluation by a dermatologist.However, regardless of the age of thepatient, and whether the mole is congenitalor acquired, any nevus that is undergoing asuspicious-looking change should be evalu-ated promptly and, if necessary, removed.

References1. Marghoob AA. Congenital melanocytic nevi

evaluation and management. Dermatol Clin.2002;20:607-616.

2. Ceballos PI, Ruiz-Maldonado R, Mihn MC Jr.Melanoma in children. N Engl J Med.1995;332:656-662.

3. Makkar HS, Frieden IJ. Congenital melanocyt-ic nevi: An update for the pediatrician. CurrOpin Pediatr. 2002;14:397-403.

4. Castilla EE, da Graca Dutra M, Orioli-ParreirasIM. Epidemiology of congenital pigmentednaevi: Incidence rates and relative frequencies.Br J Dermatol. 1981;104:307-315.

5. Egan CL, Oliveria SA, Elenitsas SR, Hanson J,Halpern AC. Cutaneous melanoma risk andphenotypic changes in large congenital nevi: Afollow-up study of 46 patients. J Am AcadDermatol. 1998;39:923-932.

6. Bittencourt FV, Marghoob AA, Kopf AW,Koenig KL, Bart RS. Large congenitalmelanocytic nevi and the risk for development

of malignant melanoma and neurocutaneousmelanocutosis. Pediatrics. 2000;106:736-741.

7. Ruiz-Maldonado R, Orozco-Covarrubias ML.Malignant melanoma in children: A review.Arch Dermatol. 1997;133:363-371.

8. Johnson TM, Bradford CR, Gruber SB, SondakVK, Schwartz JL. Staging workup, sentinelnode biopsy and follow-up tests for melanoma:Update of current concepts. Arch Dermatol.2004;140:107-113.

9. Pappo AS. Melanoma in children and adoles-cents. Eur J Cancer. 2003;39:2651-2661.

10. Naeyaert JM, Brochez L. Clinical practice:Dysplastic nevi. N Engl J Med. 2003;349:2233-2240.

11. Beddengfield FC 3rd. The melanoma epidemic:Res ipsa loquitur. Oncologist. 2003;8:459-465.

Congenital and Acquired NeviContinued from page 9



inea, the ring-shaped cutaneousfungal infections commonlyknown as ringworm, may affect

any part of the body (Figure and Table).These infections may be divided into thosethat affect the soft keratin of the skin andthose that affect the hard keratin in the hairand nails. Treatment options differ accord-ing to these classifications. Soft keratininfections can be treated with topicalagents; hard keratin infections—tineaunguium (onychomycosis) and tinea capi-tis—must be treated with oral agents.

Children with primary and secondaryimmunodeficiency are among the mostsusceptible populations for acquiring fun-gal infections of the skin. Among theimmunocompetent populations, tineacapitis tends to be a problem among chil-dren in day care centers and elementaryschools. Tinea corporis should be suspect-ed in teenagers who engage in close contactsports, such as wrestling, and who presentwith round, scaly lesions of the trunk andextremities.

Tinea capitis, in particular, is a commonproblem in children, especially in urbanpopulations. The most common cause oftinea capitis in the United States isTrichophyton tonsurans. However, the dogand cat ringworm, Microsporum canis, alsomay cause tinea and may be one of themore challenging fungal infections to treat,often requiring higher dosages and longertreatment regimens.

Treatment Options Tinea of the body, hands, face, feet, and

groin areas is usually effectively treatedwith one month of a topical antifungalagent. The clearance of tinea capitis mayrequire oral medication for 2 months ormore. Onychomycosis usually requireslonger oral dosing regimens.

Oral griseofulvin has a long history ofsafe and effective use. The disadvantageof therapy with this antifungal agent isthat it must be taken for a minimum of 2months. Failure to clear tinea capitis withgriseofulvin may result from underdos-ing. The dosage regimen for micronizedgriseofulvin is 20 to 25 mg/kg/day for atleast 2 months. For ultramicronizedgriseofulvin, 15 mg/kg/day for 2 monthsshould be prescribed.

For patients who do not respond togriseofulvin, treatment with oral terbin-afine is an alternative medication. Someclinicians consider using itraconazole inchildren, but I prefer to avoid this agent.My experience is that the liquid formula-tion of itraconazole may cause diarrhea,and, more importantly, the labeling of thisdrug in capsule carries a warning that it

may cause congestive heart failure. In thefuture, fluconazole liquid may become anoption; this agent is currently under inves-tigation for tinea capitis and onychomyco-sis in pediatric patients.

In addition to oral therapy, a sporicidalshampoo should be used twice weekly forthe duration of treatment. The shampooshould be left on the scalp for 10 minutesand then rinsed off. As these shampoostend to be drying, advise the parent orpatient that they may also use a cream rinseor conditioner. Like topical antifungalmedications, sporicidal or antiseborrheicshampoos are ineffective as monotherapyfor tinea capitis.

Managing FomitesOrganisms that cause cutaneous fungal

infections may persist for some time onfomites. Transmission via fomites shouldbe suspected when children experiencechronic reinfections, but, unfortunately,information is lacking to guide cliniciansand parents in the management of fomites.As a result, it is not possible to advise par-ents or patients about the elimination offungal organisms or to issue public healthrecommendations regarding cutaneousfungal infections with the feasibility oftreating fomites effectively.

Until evidence is available, the best aclinician can do is advise parents to usecommon sense. Children should notshare headwear, grooming tools (combs,brushes), or other objects that come intocontact with the head (headbands,“scrunchies,” and so forth). In addition,parents should be alert to the habits prac-ticed in barber shops and beauty salons,and ensure that combs, brushes, and clippers are always cleaned in a germici-dal/fungicidal agent between customers.Although these are not proven sources ofinfection, they certainly are potentialavenues of fomite transmission.

ConclusionFungal infections are an ongoing public

health problem in pediatric populations.School-age children and those who attendday care are particularly likely to acquirefungal infections of the hair, nails, andskin. Clinicians and caregivers must under-stand that fungal infections of thehair/scalp (tinea capitis) and nails (ony-chomycosis) cannot be successfully treatedwith topical agents because the currentlyavailable products do not penetrate hardkeratin. These infections require treatmentwith systemic agents, given for an adequateduration and in sufficient dosages.

Tinea Capitis and Other Cutaneous Fungal InfectionsAdelaide A. Hebert, MD

T

Tinea capitisScalp/hair

Tinea pedis (athlete’s foot)Foot

Tinea facieiNonhairy areas of the face

Tinea corporisBody

Tinea manuumInterdigital spaces and palmar surfaces

of the hand

Tinea crurisGroin

Tinea unguium (onychomycosis)Nails

Table. Fungal Infections by AffectedAnatomic Site

Tinea capitis (A) is a particularly commonproblem in children. Tinea corporis (B) pre-sents as round, scaly lesions of the trunk andextremities. Tinea cruris (C) and tinea pedis(D) occur in the groin and between the toes,respectively, where moist skin provides anattractive host environment for these fungalinfections.

Photos courtesy of Dr Adelaide A. Hebert.

Figure. Common Sites of Tinea Infection

A

B

C

D



Protection From Bites, Stings, and PhotodamageAdelaide A. Hebert, MD

ites from insects and spiders usually are readily identifiable.Among the most common, de-

pending on the region of the UnitedStates, are bites from mosquitoes, ticks,fleas, chiggers, and fire ants, and stingsfrom wasps, bees, and hornets. Spiderbites are less common but not unusual.

In most cases, bites and stings do notrepresent serious medical problems.However, in certain regions of the US,Lyme disease and Rocky Mountain spot-ted fever are endemic, tick-borne dis-eases. A recent concern is the transmis-sion of West Nile virus from mosquitoes.In addition, some individuals are suscep-tible to acute anaphylactic reactions frombites and stings.

Repellents: What’s Safe forChildren?

N, N-Diethyl-meta-toluamide (DEET),the most popular insecticide ingredientin use in the world today, was developedby the United States Army in 1946 andfirst sold to the general population in1957. Seventy manufacturers makeapproximately 230 DEET-containingproducts. DEET provides protectionfrom a number of insects and is particu-larly effective against mosquitoes.

The Environmental Protection Agencycurrently prohibits child safety claimson insecticide labels. The wording “gen-erally recognized as safe” is permittedfor products that qualify, however; tox-icity is not known to be a problem forproducts so designated if they are usedaccording to the directions on the label.In studies with rats and mice,1 it hasbeen established that DEET is not aspecific neurotoxin. There is no evi-dence that children less than 6 years ofage are at greater risk to develop adverseevents than older children.

DEET-containing products should beapplied to the skin or clothing beforeexposure to outdoor areas where mosqui-toes are likely to bite. Application shouldoccur in well-ventilated areas, and careshould be taken to avoid the mucousmembranes. Additional applications tothe skin are not required if insects are notbiting. Protection lasts for weeks onclothing stored in plastic bags after beingsprayed with DEET.2 It is helpful to spraythe clothing of children bound for sum-mer camp, for example, to reduce theirrisk for insect bites.

Permethrin, another common insectrepellent, is a plant-based product derivedfrom chrysanthemums. Unlike other

insect repellents, permethrin is uniquebecause it also has insecticidal action andis lethal for ticks, preventing tick attach-ment and reducing the risk for tick-bornediseases. Therefore, in areas where suchdiseases are endemic, permethrin is theagent of choice.

Permethrin is applied to clothing, out-doors, and the clothing should beallowed to dry before it is worn. Theproduct should be reapplied after everyfifth laundering. Like DEET, permethrinis considered to be safe for children if it isused according to the manufacturers’guidelines. Permethrin is poorly absorbedby the skin and has been shown to havelow toxicity in mammals; in addition, itis rapidly inactivated by ester hydrolysis.3

Permethrin cream, used for the treat-ment of scabies, is approved by the USFood and Drug Administration for directapplication to the skin in children asyoung as 2 months of age and in a con-centration of 5%. No studies have beenconducted to date using topical prescrip-tion permethrin-based products as insectrepellents or insecticides.

Parents frequently ask about insectrepellents made from botanical products.One such product, containing the activeingredient p-methane-3,8,diol, at a 10%concentration, is effective against mosqui-toes, black flies, gnats, and no-see-ums.

In addition, some recent evidence hasdemonstrated that plant-based productsmay be highly effective. For example, onestudy of the mosquito-repellent activitiesof thyme indicates essential oil from thisherb has a protection rate of 91% at aconcentration of 0.05%, and that it is arich source of insect-repellent moleculesknown as monoterpenes.4 The potency ofthis repellent is stronger than that seenwith DEET.

Citronella is less effective than otherinsect repellents against mosquitoes. Itprovides a protection time of 30 to 120minutes. Citronella is safe for topical usebut can cause aspiration pneumonia ifswallowed.

Devices for repelling mosquitoes maybe considered, but the efficacy and mech-anism of action of most is questionable.So-called “zappers” have the goal ofreducing the mosquito population in agiven area, but because they work byattracting insects to them, they actuallymay increase the risk for insect bites. Adoughnut shaped device placed in watermay be useful to reduce mosquito popu-lations in areas with a pond or otherstanding water. This device is a larvaekiller that treats up to 100 square feet ofsurface water for up to 30 days. It is EPA-registered in all 50 states and has beendetermined to be environmentally sound.

For further information on these top-ics, several Web sites are useful. These areprovided in Table 1.

Sun Protection for Children Many of the consequences of exposure

to ultraviolet (UV) radiation have beenrecognized for many years, but the exactmechanisms of sun damage—or photo-damage—continue to be studied anddescribed. For example, it is well knownthat photodamage is a cumulative processthat begins in childhood, and that severesunburns early in life increase the risk forboth melanoma and nonmelanoma skincancer. In addition to the acute andchronic consequences of UV light expo-sure that are seen on the skin (Table 2),the epithelial tissue of the eyes also suffersdamage, a fact that has not been empha-sized in the past.

Physicians and laypersons are familiarwith the sun protection factor (SPF) pho-

Pesticide and insecticide ingredients

National Pesticide Information Center:

(800) 858-7378

E-mail: [email protected]

http://www.npic.orst.edu

Insect/spider/bee/wasp bites, for children

American Academy of Dermatology

Kids’ Connection Page

http://www.aad.org/Kids/bugbites.html

Sun protection

Oregon Health & Science University

http://www.ohsu.edu/dermatology/patients

Click on “Sunscreen facts.”

American Academy of Dermatology

Public Resources Page

http://www.aad.org/pamphlets

Click on any of several

“Sun Protection” topics.

Table 1. Sources of Further Information

B



toprotection ratings. SPF was developedspecifically to rate sunscreens and indi-cates the amount of time protection lastscompared with the exposure time thatwould result in a sunburn without sun-screen. Remember, however, that SPFprimarily designates the ultraviolet-Bspectrum of photoprotection, and it isimportant that children and adults haveprotection from the entire spectrum ofultraviolet light.

The methods of sun protection for theskin include physical shading, wearingtight-weave clothing, and chemicaland/or physical sunscreens and sun-blocks. The least reliable of these is shade,as from an umbrella or tree. Shade isthought to provide the equivalent of SPF15, but light reflected from surroundingareas would decrease that protection.

Clothing Denim is a good example of tight-

weave clothing that provides photopro-tection equivalent to approximately SPF8. In addition, a number of companiesmanufacture clothing specifically for sunprotection, including gloves, hats, andscarves. As an alternative, parents maywant to wash regular clothes in a photo-protective laundry additive that is avail-able in grocery stores. The protectionlasts for a number of subsequent wash-ings and is a low-cost way to enhance thephotoprotective value of clothing.

Sunscreens and BlocksPhysical sunscreens work by reflecting

light. This class of photoprotective agentsincludes the classic product known aszinc oxide as well as titanium dioxide.Today’s formulations of these productsare more cosmetically elegant than thoseavailable in the past (recall the whitenoses on lifeguards, for example); thezinc and titanium are contained in small-er particles that can be rubbed into theskin. Products containing iron oxide andother physical blocking agents also areavailable.

The choice of product is individual,but children, in particular, should use asunscreen or sunblock with at least anSPF of 30. My personal recommendationis to avoid combination sunscreen andinsect-repellent products. Patients shouldreapply sunscreens throughout the day,especially if they are swimming or inwind, but insect repellents—particularlythose containing DEET—should not bereapplied frequently.

A problem that has been identifiedwith sunscreens is that most consumersuse an insufficient amount—usually farless than what is indicated on the label.One way to achieve adequate coverage is

to instruct parents and patients to “layer”products. First, apply a sunscreen prod-uct containing a chemical sunscreen suchas parsol, oxycinnamates, or oxyben-zones. Next, apply a second layer, using aphysical sunscreen containing zinc oxideor titanium dioxide. This method resultsin the application of more sunscreen andreduces the chance that areas of the skinwill be missed. In addition, let parentsand patients know that products labeledas “water-resistant” lose their SPF after40 minutes in the water; those labeled“waterproof” lose SPF after 90 minutesof exposure to water.

In acne-prone patients, a gel-basedsunscreen may be the least comedogenic,although it is difficult to predict an indi-vidual patient’s response to specific prod-ucts. It is helpful to provide samples topatients with eczema or sensitive skin andhave them try these products on theirforearms (not the face) to determine theirskin’s reaction. As a general rule, remem-ber that the more “runny” the emollientproducts are the more likely they are tocontain an ingredient (such as propyleneglycol or alcohol) that can cause burningor stinging in sensitive individuals. Forpatients with sensitive skin, consider rec-ommending a generic zinc oxide or tita-nium dioxide sunscreen. Because theseproducts contain nothing but zinc oxideand/or titanium dioxide in petrolatum,they rarely cause burning or stinging, andthey have an SPF of 45 or greater.

For teenagers who consider a tan a“must-have,” advise the use of artificialtanning products. However, also cautionteenagers that these products do not con-tain sunscreens, so photodamage can stilloccur. Instruct them to apply the sun-screen and allow it to dry before applyingthe artificial tanning product.

Eye ProtectionBefore age 10, children’s ocular lenses

are clear, regardless of their eye color.Thus, younger children are most suscep-tible to eye injury from UV light. Afterthis age, the lens becomes cloudier, filter-ing out some UV light and providingsome natural protection. It should be agoal of every clinician who deals withchildren to teach and encourage eye pro-tection early, as part of an entire programof sun protection.

The ideal sunglasses have polycarbon-ate plastic lenses and fit close to the eyes,wrapping around the face. Polycarbonateis a relatively inexpensive material thatprovides good protection against bothUVA and UVB radiation. In addition,this plastic provides excellent protectionfrom impact injury (from a small projec-tile such as a BB, for example).

ConclusionCaring for the pediatric patient

involves providing education on the pre-vention of common problems such asinsect bites and sunburn. A clear under-standing of the products available to helppatients and their parents will ensure thata specific regimen to protect both theskin and the eyes will be discussed in theoutpatient setting. The overview provid-ed here covers anticipatory guidance tipsthat will help caregivers avoid some ofthe most common and troublesome skinconditions that may affect children. Inaddition, attention to measures that pre-vent photodamage to the skin and eyes inchildhood will have an effect on protec-tion against long-term health problemssuch as skin cancers and ocular disease.

References1. Schoenig GP, Hartnagel RE Jr, Osimitz TG,

Llanso S. Absorption, distribution, metabolism,

and excretion of N,N-diethyl-M-toluamide in

the rat. Drug Metab Dispos. 1996;24:156-163.

2. Curtis CF, Lines JD, Ijumba J, Callaghan A, Hill

N, Karimzad MA. The relative efficacy of repel-

lents against mosquito vectors of disease. Med Vet

Entomol. 1987;1:109-119.

3. Insect repellents. Med Lett Drugs Ther. 1989;

31:45-47.

4. Choi WS, Park BS, Ku SK, Lee SE. Repellent

activities of essential oils and monoterpenes

against Culex pipiens pallens. J Am Mosq Control

Assoc. 2002;18:348-351.

Acute■ Suntan

■ Sunburn

■ Increase in nevi

Chronic■ Cosmetic changes

• Wrinkles

• Telangiectasias

• Lentigines

• Multiple nevi

• Loss of elasticity

■ Sebaceous hyperplasia

■ Increase in nevi

■ Premalignant lesions

■ Skin cancer

■ Eye damage

• Pterygia

• Cataracts

• Macular degeneration

Table 2. Acute and ChronicConsequences of Photodamage


There is no fee to participate in this activity. Please forward the Test Answer Sheet and Evaluation Form to: Excerpta Medica/Elsevier – Office of Continuing Medical Education, Department PEDI-DERM, 105 Raider Blvd., Suite 101, Hillsborough, NJ 08844-1528. Fax: 908-874-5633Release Date of Activity: June 2004 – Expiration Date of Activity: May 31, 2005. A certificate of course completion will be mailed to you.

Pediatric News®

Common Dermatologic Problems in the Pediatric PracticeCME Post-Test and Evaluation

Instructions: For each question or incomplete statement, one answer or completion is correct. Seven of 10 correct responses are required for credit.Circle the most appropriate response.

1. Which one of the following agents is lethal for ticks?a. Citronella c. Monoterpenesb. DEET d. Permethrin

2. By the age of puberty, or shortly thereafter, complete clearance of atopic dermatitis occurs in ___ of patients.a. 20% to 40% c. 40% to 60%b. 30% to 50% d. 70% to 90%

3. Blockade of the production of inflammatory mediators isthe mechanism of action of pimecrolimus and tacrolimus,two agents in a class of drugs known as:a. Calcineurin inhibitors c. Class IV corticosteroidsb. Monoterpenes d. Immune response modifiers

4. All of the following are topical retinoids that are effectivecomedolytic agents except:a. Adapalene c. Tazaroteneb. Azelaic acid d. Tretinoin

5. A new immunologic approach for the treatment of molluscum contagiosum involves the topical use of:a. Cantharidin c. Imiquimodb. Cimetidine d. Tazarotene

6. The current standard of care for scabies is:a. Crotamitonb. Ivermectin, a single oral dose of 200 �g/kgc. Permethrin cream, 5%d. Precipitated sulfur in petrolatum, 5% to 10%

7. Topical treatments for flat warts in children include all ofthe following except:a. Cimetidine c. Retinoidsb. Imiquimod d. Salicylic acid

8. The clearance of tinea capitis:a. Is often spontaneousb. May be achieved with a topical antifungalc. May be achieved with daily use of a sporicidal

shampood. Requires the use of an effective oral medication

9. Garment nevi are associated with an increased risk formalignancy in the range of:a. 1% to 5%b. Between 10% and 15%c. Between 20% and 35%d. Greater than 35%

10. Scaly rashes involve inflammation in the:a. Epidermisb. Dermal-epidermal junctionc. Dermisd. Stratum corneum

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