THIN

GS THAT

MAKE YOU G

O

HMMMMM……

OR

IT IS

WHAT IT

IS!

OBJECTIVES

Identify benign skin lesions with confidence

Identify resources for dermatology education

AND one new thing about management of Hemangiomas

LICHEN STRIATUS

Primary phase

SECONDARY PHASE

Fading and Flattening

-Common 9months to 6 years but can occur earlier or later

-Last 1-3 years

-Relapses of short duration have been noted after complete clearing

NEVUS DEPIGMENTOSIS

Generally present at birth or within several months, sometimes not obvious until sun exposure in fairer skin

Borders can be regular or irregular

Can have whorled appearance

PIGMENTARY MOSACISM /HYPOMELANOSIS OF ITO

Follows blashkos lines

Can be associated with neurologic, skeletal, and/or ocular abnormalities

The hypopigmentation is secondary to hypofunctioning of melanocytes and is thought that mishap ear in embryogenesis is responsible for the mosaicism.

No consistent genetic defect.

Follow up depends on associated abnormalities.

BECKERS

NEVUS

Large, pigmented, hairy nevus

Most commonly noted in adolescence

Benign

Larg

e der

mal

nev

i com

mon

ly s

hould

er b

ut

not e

xclu

sive

ly

MELAN0NYCHIA STRIATALONGITUDINAL MELANONYCHIA

Most commonly seen in individuals with darker skin- especially African-Americans in whom up to 90% may have at least one such streak

The pigmentation extends from the proximal nail fold to the distal margin of the digit

The width may vary from less than 1mm to several mm

But……. (there is always a but)

NAIL MATRIX MELANOMA SHOULD BE CONSIDERED

Worrisome features may include very dark, broad bands AND

Extension of the pigmentation onto the proximal or lateral nail folds (aka Hutchinson’s Sign)

Any patient with this presentation should be referred for nail matrix biopsy which can cause permanent damage to the nail plate

CONFLUENT AND RETICULATED PAPILLOMATOSIS

CRPETIOLOGY: UNKNOWN

Minocin 100mg BID x30 days then qd x 30 days

TERRE FIRMA FORME OR

DUNCANS DIRTY DERMATOSIS

First described by Dr. Duncan in Houston in 1987

At fist glance these patients may appear to have confluent and reticulated papillomatosis (CARP) or acanthosis nigricans

In contrast to derma neglecta soap and water will not wash this off, isopropyl alcohol is necessary

When this condition is suspected, firm, persistent pressure should be applied while rubbing the skin with alcohol.

The cause of terra firma-forme dermatosis is unknown.

PITYRIASIS ALBA (AGAIN)

If you mom think it is fungal…..Do a culture

This a variant of dry skinIt is usually asymptomaticAppears worse in summer, better during school yearTreatment is sunscreen and moisturizer

KERATOSIS PILARIS

Very common!!

Become more extensive in drier climate.

Individual lesions represent plugs of stratum corneum in individual follicular openings

ie: Skin Trash

Moisturizer with urea of lactic, salycylic acid May help but is not curative.

ID REACTI

ON

Autose

nsitiz

atio

n Der

mat

itis

auto

ecze

mat

izat

ion

Hypopigmented thickened papules often on elbows , knees

Can be eczematous and very itchy

-found in up to 50% of patients with nickel dermatitis

-nearly always symmetrical

-may also be seen in response to infectious agents, particularly in bacterial and dermatophyte infections.

- In the case of tinea capitis the id reaction is usually seen on the head and neck and is often after initial of oral antifungal agent and is erroneously diagnosed as drug reaction

- Clearance occurs with resolving of the originial cause- nickel avoidance, clearance of tinea, etc.

KNUCKLE PADS

Knuckle pads were medically first described by Garrod in 1893 and are also named Garrod's pads

.

There is no known established, generally successful therapy.

Injection of corticosteroids (triamcinolone) can soften and sometimes even shrink the pads. Radiation therapy has also been reported to be successful in some cases but not consistently.

Knuckle pads can be surgically removed in the case of pain associated with them. .

Aplasia Cutis Congenita

Developmental defect rather than birthmarkOccurs in about 1 in 5000 birthsUlcerated defects may heal with scar.

Although usually benign, the hair collar sign may be associated with other physical anomalies and malformation syndromes.

No specific laboratory tests are required, although a hair collar sign signals the possibility of a CNS malformation and thus may warrant an MRI scan to rule out an underlying pathology

NEVUS SEBACEOUS

Appears at birth as slightly raised yellow orange nevus

At puberty become raised and warty

Basal cell carcinoma and other benign tumors occur in 15-50% of the tumors

Excision recommended prior to puberty.

MASTOCYT

OMA

MASTOCYT

OSIS

URT I C

AR

I A P

I GM

E NT O

SA

Seen in less than 2% of children

Often onset is after 12 months of age

More lesions accumulate slowly with age and lesions do not spontaneously resolve.

System symptoms develop with time in 2% of the children with this form (flushing, tachycardia, hypotension, hepatosplenomegaly

Hereditary Form

URTICARIA PIGMENTOSA

MASTOCYTOMA

Solitary lesionWill not develop more Topical steroids for treatment

of symptoms

Non Hereditary Form of Mastocytosis is much more common

Blotchy macular and nodular pigmented lesions which appear in the first 8 months of life starts with one or 2 and then develop numerous lesions over months.

The hyperpigmented appearance may not appear until 6 months after onset

Darriers sign- stroking the lesion will cause tense edema and redness

Spontaneous clearing by 6 or 7 years of age is usual

Essential that children with any type of Mastocytosis not be given the following medications:

Opiates (codeine, demerol, morphine)Polymixin BAcetylsalicylic Acid

In the case of surgery very important that perioperative medications carefullySelected.

TREATMENT OPTIONS

Nonsedating Antihistamine (zyrtec, Allegra, etc)

Regular daily dosing

Can try every 6 months to stop and if starts flaring then resume medication

Topical Steroids for itching in individual lesions BID

For body Triamcinolone 0.025% or 0.1%

For face/neck/groin/axilla/head Hydrocortisone 2.5% or Desonide 0.05%.

WHICH HEMANGIOMAS WARRANT THIS TREATMENT?

PROPRANOLOL PROTOCOL AT CMC DERMATOLOGY

Prior to initiation of therapy needs :

BP

Pulse

Chest Xray

ECG

Propranolol 1mg/kg/dose administer BID (20mg/5ml solution)

PROPRANOLOL

Propranolol 1mg/kg/dose administer BID 20mg/5ml solution

Taper Schedule:

Days 1-4 0.25mg/kg/dose BID

Days 5-9 0.5mg/kg/dose BID

Days 10-13 0.75mg/kg/dose BID

Day 14 and on 1mg/kg/dose BID

Can also divide the above doses to TID (.025mg/kg x2)

3

FOLLOW UP SCHEDULE

Follow up is weekly x 3,then q2w x 4, then montly. BP q visit.

Infants younger than 3 months should have CBG monitored each visit.

Parents should be instructed how to count pulse and recognize low heart rate

They should watch for somnolence, perioral pallor, cold hands and feet.

Patients must be fed q4h while on this medication due to hypoglycemia possibility

11/17/12 baseline

11/26/12

12/3/12

12/10/12

12/17/13

12/31/13

01/17/13

3/5/13

9/13/13

3/17/14

DERMATOLOGY INFORMATION RESOURCESTextbooks:

Color Textbook of Pediatric Dermatology- Weston, Lane, and Morelli

Pediatric Dermatology- Bernard A Cohen

Great for pictures and information that is clinically helpful.

DermNet NZ. Facts about the skin. www.dermnetnz.org

Skin Advocate App- available for free in app store- has information on parent and patient support organizations and is set up for you to email the address directly to the patient with a share line. (Developed by UTSW Resident and received national award !)

Some things can be fixed and some cannot…..

However we do know that education and information is just as valuable as cures can be.

The goal is always………….

HAPPY PT., HAPPY MOMMA, HAPPY GRANDMA!!