Pri-Med Southwest: Common Pediatric Dermatologic Cases in Primary Care

Session at Pri-Med Southwest focuses on diagnosing and treating atopic dermatitis and other conditions in children.

Friday at the 2011 Southwest Pri-Med conference, Denise Metry, MD, chief of dermatology at Texas Children’s Hospital in Houston, TX, offered her recommendations for managing common pediatric dermatologic problems. During her presentation, “Treatment of Common Dermatologic Problems,” Metry discussed key points in the identification, diagnosis, and management of complicated hemangioma, atopic dermatitis, tinea capitis, and other dermatologic problems seen in pediatric and adolescent patients in the primary care setting.

Complicated hemangioma

Oral propranolol is a recent addition to the armamentarium for treating complicated hemangiomas. Dr. Metry has seen dramatic improvements with oral propranolol, sometimes within 24—48 hours of the first dose. Metry recommended a dose of 1 mg/kg/dose two or three times per day and suggests starting with one-fourth the final dose and tapering up. Treatment often needs to be continued until 12-18 months of age. Optimal dose and duration of treatment, monitoring practices, and candidates have not been elucidated yet. The exact mechanism of action of propranolol is also unknown.

Topical propranolol is also available and recommended for thin lesions. Patients should apply it twice a day; treatment will likely need to be continued for six months or longer.

Although it is believed to be safe, known safety risks with oral propranolol include: hypotension, bradycardia, hypoglycemia, hypothermia, nightmares, and lethargy. To avoid problems with hypoglycemia, Metry recommends that the drug not be given with food and that it be discontinued during illness if the child is not eating.

Atopic Dermatitis

Education is a key strategy for management of atopic dermatitis. Parents need to be advised that there is no cure and should be regularly reminded of the importance of daily skin care and avoidance of triggers. Therapy should be tailored for each patient.

Emollients are critically important components of therapy and the choice of product matters. In general, Metry recommends ointments and creams available in a jar, as opposed to a pump dispenser. Apply emollients twice a day to the entire body, after bath and after topical therapy has been applied.

Topical steroids are the standard of care for acute dermatitis, but it is important to take breaks from therapy to avoid side effects. Topical imiquimod is also beneficial, especially for the facial periorbital area.

Metry strongly recommends wet wraps in combination with topical therapy. Although it is a simple concept, she finds it to be one of the most effective tools for eczema flares and lichenified acute dermatitis. It can easily be done at home. After applying topical medication, wet a onesie or pajamas with warm water, then layer on a dry onesie or towels and leave on for 10—15 minutes, or overnight. The time, duration, and extent of wrapping can be modified. Warm, moist socks can be used for older children with affected hands, arms, legs, or feet.

Molluscum Contagiosum

Observation is the ideal treatment, especially for lesions around the eye.

According to Metry, plain cantharidin (Paladin Labs, Montreal, Canada) is the most effective and least traumatic therapy for molluscum. It can be applied easily and painlessly in the office. There are no known systemic side effects; however, blistering should be expected. Transient dyschromia may occur, especially in children of color. Treatment should be repeated every 3—4 weeks, as needed.

Tinea Capitis

This is a fungal infection that needs to be treated systemically. First-line therapy should be 20 mg/kg/d of griseofulvin given with fatty food for 8—12 weeks. Griseofulvin is approved for use in infants as young as 3 months of age. Measures should be taken to prevent spread, including weekly ketoconazole 2% or selenium sulfide shampoo for all household members. Monitoring of liver function is unnecessary in otherwise health children. Swab fungal cultures are useful for verifying clinically subtle cases, for documenting clearance or recurrence of infection, and for identifying fungal species.

More details on any of these treatments can be found here.