Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center San Antonio School of Medicine –June 10-12, 2011 This presentation is the intellectual property of the author/presenter. Contact them for permission to reprint and/or distribute. Pediatric Dermatology Pearls Chad Hivnor, M.D. John C. Browning, M.D. June 11, 2011 John C. Browning, M.D. has no relevant financial relationships with commercial interests to disclose. Camp Dermadillo • Summer camp for children with chronic skin problems, Ages 8-16 • Located at Camp For All in Burton, Texas • Part of the AAD’s Camp Discovery Program • Other Camps: Little Pine & Big Trout (Minnesota), Horizon (Pennsylvania), Reflection (Washington), Liberty (Connecticut) • August 7-12, 2011 -- Free for all campers • www.campdiscovery.org
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Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Pediatric Dermatology Pearls
Chad Hivnor, M.D.John C. Browning, M.D.
June 11, 2011
John C. Browning, M.D. has no relevant financial relationships with commercial interests to
disclose.
Camp Dermadillo
• Summer camp for children with chronic skin problems, Ages 8-16
• Located at Camp For All in Burton, Texas
• Part of the AAD’s Camp Discovery Program
• Other Camps: Little Pine & Big Trout (Minnesota), Horizon (Pennsylvania), Reflection (Washington), Liberty (Connecticut)
• August 7-12, 2011 -- Free for all campers
• www.campdiscovery.org
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Objectives
• Identify common dermatologic conditions seen in children.
• Develop a treatment strategy for affected patients.
• Know when referral to a pediatric dermatologist is needed.
Conflicts of Interest
– Speaker for Galderma (Cetaphil Restoraderm)
– Consultant for ViroXis
Atopic Dermatitis
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
What is eczema?
• Chronic, relapsing dermatitis associated with dry skin and intense pruritus
• It results from a complex interplay of genetic, immune, infectious, and environmental factors
Eczema Subtypes
• Infantile eczema
• Childhood eczema
• Adulthood eczema
• Dyshidrotic eczema
• Nummular eczema
• Follicular eczema
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
• Acute
• Sub-acute
• Chronic
Intense pruritus is the hallmark of atopic dermatitis.
Pathophysiology
• Impaired skin barrier function
• Abnormal immune response
• Environmental and genetic factors (polygenic)
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Barrier DefectLesional and Non-lesional Skin
• Increased trans epidermal water loss (TEWL)
• Reduced irritancy threshold
• Increased percutaneous absorption of substances
• Dry skin
Impaired Skin Barrier
• The epidermal differentiation complex (EDC) on chromosome 1q21 encodes filaggrin, loricrin, and other proteins involved in terminal differentiation in the epidermis
• Filaggrin has recently emerged as playing an important role in eczema and ichthyosis vulgaris AND asthma and allergic rhinitis
• Probably other genes involved as well (polygenic)
“Bricks and Mortar” Structure of the Stratum Corneum
Covalently
bound lipid
Cornified
cell envelope
Intracellular humectants
(NMFs)
Intracellular
lamellar lipids
Keratin macrofibrils
Corneodesmosome
Corneocyte
20
Layers
LipidsChol
Chol S
Ceramide
Harding CR. Dermatol Therapy. 2004;17:6-15.
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Stratum Corneum Disruption in Atopic Dermatitis
J Allergy Clin Immunol., 2006 118:3-21.
Immunodysregulation
• Langerhans cells may be associated with a state of heightened antigen presentation activity for autoreactive T-cells
• Monocytes have increased expression of the high affinity IgE receptor
• T lymphocytes show increased levels of activation
Immunodysregulation
• Eosinophilia is often seen but is neither sensitive nor specific enough to be of diagnostic utility
• Relationship between elevated IgE levels to foods, pollens, and dust mites and the aggravation of atopic skin is controversial
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
• Nearly 80% of patients with eczema will develop allergic rhinitis or asthma later in childhood (atopic march)
• Many of these patients report improvement in their eczema as they are developing respiratory allergies
Infantile Eczema
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Infantile Eczema
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Dyshidrotic Eczema = Pompholyx
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Nummular Eczema
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Follicular Eczema
• Pruritic, perifollicular papules
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
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reprint and/or distribute.
Lichen Simplex Chronicus
Associated Findings
• Xerosis
• Keratosis pilaris
• Ichthyosis vulgaris
• Dennie-Morgan Lines
• Palmoplantar hyperlinearity
• Pityriasis alba
• Lichen simplex Chronicus
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Associated Infections
• Over 90% of patients with severe, acute atopic dermatitis will grow S. Aureus from swab cultures taken from exudative skin
• Cathelicidins and β-Defensins produced by keratinocytes
• Expressed by injury/inflammation
• High levels seen in psoriatic skin
• Negligible levels in atopic skin
• Lack of these peptides may provide explanation for unusually high number of skin infections in AD (bacterial, viral, and fungal)NEJM 2002;347:1151
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Evaluation
• History
• Physical Exam
• Consider patch testing
• RAST and skin prick tests can be used to support the diagnosis of an atopic state but are seldom useful in counseling eczema patients regarding avoidance procedures
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to