Transcript Things that make you go Hmmmmm**

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.
Large, pigmented,
hairy nevus
Most commonly
noted in
adolescence
Benign
MELAN0NYCHIA STRIATA
LONGITUDINAL MELANONYCHIA
Most commonly seen in individuals with darker skinespecially 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
CRP
ETIOLOGY: 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)
This a variant of dry skin
It is usually asymptomatic
Appears worse in summer, better during school year
Treatment 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.
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 birthmark
Occurs in about 1 in 5000 births
Ulcerated 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.
URTICARIA PIGMENTOSA
Hereditary Form
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
MASTOCYTOMA
Solitary lesion
Will 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 B
Acetylsalicylic Acid
In the case of surgery very important that perioperative
medications carefully
Selected.
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 RESOURCES
Textbooks:
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!!