DERMATOLOGIC DISEASE
From Current Clinical Pediatrics, presented by Boston University School of Medicine and the Department of
Pediatrics at Boston Medical Center, Boston, MA
Peter Lio, MD, Instructor in Dermatology, Harvard Medical School, Boston, MA
| Focus of talk: atopic dermatitis
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| Etiology: unclear, but genetics play role; hygiene hypothesis (environment “too clean,” leads to abnormal development of
immune system); pollution probably plays role; abnormal neurogenic responses to histamine injection (eg, white dermatographism)
and vasogenic responses; altered immune function; disruption of epidermal barrier function
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| Topical steroids: safe when used correctly; in general, ointments more efficacious than creams; patients often prefer
creams, but propylene glycol and preservatives can cause irritation and dryness; hydrocortisone—start at 2.5% (safe,
even for youngest infants); 1% hydrocortisone often does more harm than good, unless condition mild; consider hydrocortisone
(Westcort) or triamcinolone (0.1%; inexpensive and works well); safe to use up to 2 wk/mo; side effects of
overuse—stretch marks; striae; atrophy of skin; depigmentation; summary—“because newer methods of treatment
good, it does not follow that old ones bad”
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| Antibiotics: often, skin heavily colonized by Staphylococcus; mupirocin (Bactroban)—resistance rare; calming properties
of emollient; use generic formulation in ointment base; oral antibiotics—even if patient not impetiginized, consider
course of cephalexin (Keflex), dicloxacillin, or amoxicillin; even children colonized with methicillin-resistant
Staphylococcus aureus (MRSA) improve on antibiotic therapy; safer than prednisone; chlorine bleach (eg, Clorox)—
effective antibiotic and antimicrobial agent; mix capful (not cupful) into bath water; soak few minutes, then rinse with
clean water; resistance not issue; safe and nonirritating at low concentration; helpful adjunctive therapy for MRSA
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 | Hydrolated or hydrated petrolatum: works well; moisturizing, soothing, and inexpensive; Eucerin and Aquaphor not
cheap; problem of compliance with greasy, sticky moisturizers; if indicated, greasy moisturizer best at bedtime (for
daytime, less greasy products available)
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| CeraVe: mimics ceramides in skin (correct ratio of ceramides, free fatty acids, and cholesterol restores epidermal barrier
function); not occlusive like white petrolatum (Vaseline); Nouriva Repair (emollient)—similar
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| Olay Complete Body Wash: liquid soap used in shower; contains 17% Vaseline; after shower, pleasant residue on skin;
Olay Moisturinse (emollient)—conditioner for skin; used in shower (leave on few minutes, then rinse)
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| Sarna Anti-Itch Lotion (pramoxine, camphor, menthol): cooling and soothing; strong medicinal scent; Sarna Sensitive
Anti-Itch Lotion—does not contain camphor or menthol
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| LidaMantle (lidocaine, glycerine, parabens): topical therapy; for small areas, can eliminate itch rapidly
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| Aveeno Anti-Itch (pramoxine, calamine, camphor): available as cream or lotion
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| Systemic antihistamines: hydroxyzine (Atarax); cetirizine (Zyrtec); diphenhydramine (Benadryl); helpful in some patients;
not first-line therapy (beware paradoxical stimulant effect)
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| MimyXT: newer nonsteroidal anti-inflammatory cream; aggressively marketed; approved by Food and Drug Administration
(FDA) as prescription device
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| Biafine: soothing but bland water-based topical emulsion; used for radiation dermatitis; similar to MimyXT; probably not
worth expense, but offers alternative to tacrolimus (Protopic) and pimecrolimus (Elidel)
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| Atopiclair: nonsteroidal anti-inflammatory cream; contains glycoretinic acid; eczema product approved by FDA as prescription
device; “stinky” (problem of compliance); MimyXT may be worth trying in patients with extremely sensitive skin
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| More about moisturizers: Cetaphil Daily Facial Moisturizer—speaker’s favorite facial moisturizer; gentle (good
choice for patients with acne); CeraVe—also noncomedogenic; soothing; well tolerated by patients with rosacea; Vaseline
exacerbates oily skin in patients with acne
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| Unna’s boot: gauze wrap impregnated with zinc oxide and calamine; calamine stains (absent from pediatric formulation);
soothing, protective, and helps healing; prevents “digit toxicity” (digging and scratching); parents change dressing every
1 or 2 days (if preferred, can be used just at night)
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| Antibiotics: sometimes necessary; consider oral formulation
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| Balnetar (tar-containing bath preparation): tar products old remedies for psoriasis and eczema; helpful for children with
eczematous skin in groin/diaper area; soothing, gentle, moisturizing, and safe; nonsteroidal
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| Aluminum acetate solution (Domeboro): drying and astringent agent; apply compress to weepy, scaly areas (eg, antecubital
fossa)
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| Allergy testing: in speaker’s experience, rarely clinically helpful in severe eczema; these children often hypersensitive
to wide variety of allergens; even after elimination of suspected triggers in diet, eczema often worse than ever;
disclaimer—positive response to elimination diet may not come to attention of dermatologist
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| Eczema action plan: given to patients as handouts; guidelines work well (although not evidence-based); face and body
handled separately; 3 columns (clear; mild-to-moderate; severe); speaker circles prescribed treatment at each visit; initially,
follow-up for patients with severe eczema frequent (every 1-3 wk)
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| Occlusive therapy: patients tolerate Unna’s boot well; wet wraps to prevent epidermal water loss out of favor (efficacy
not supported in literature); polyvinylidene wrap (Saran Wrap)—can be used, but markedly increases cortisone absorption;
used with sauna suit in patients with erythrodermic eczema or psoriasis; otherwise, speaker avoids occlusive application
of corticosteroids
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| Probiotics: eg, Lactobacillus, Acidophilus; prevention (clinical trial)—half of women received lactobacillus during
pregnancy; children supplemented after birth; result decreased incidence of atopic dermatitis; also helps children with established
atopic dermatitis; data promising but not conclusive; Culturelle—contains Lactobacillus; well-studied adjunctive
therapy; for children <3 or 4 yr of age, administered once daily (for grade school-aged children, dosing up to 1
tablet with meals)
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| Bathing frequency (study): bathing every day fine if moisturizer applied while skin still moist; group that bathed less
often had insignificant improvement in water barrier function; daily bath helps control bacteria and promotes overall
compliance
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| Lidocaine: potential for systemic toxicity (restrict use to small areas of body)
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| Chronic thick lichenification: problem often chronic scratching (consider Unna’s boot)
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| Urea cream (carbamide; Carmol): generally too strong (often causes burning sensation); 20% formulation tolerated by
some patients; thick lichenified skin may respond
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| Most patients outgrow disease: worse severity, longer course; counseling parents—each patient unique
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| Difficulty discontinuing cortisone: assess compliance with moisturization; investigate possible bacterial component; systemic
prednisone—contraindicated for chronic inflammatory dermatosis (when discontinued, some patients hospitalized
with erythroderma); short course reasonable for localized contact dermatitis (eg, poison ivy reaction)
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| Hand eczema: because of alcohol content, waterless hand sanitizers drying and irritating; wash with moisturizing synthetic
detergent (eg, Cetaphil Gentle Skin Cleanser or Olay Body Wash) and rinse; apply moisturizer after each hand
washing (consider CeraVe or Cetaphil)
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| Moisturizing wash for body and hair: Olay Body Wash lathers well; Cetaphil cleanser less expensive (gentle, but does not
lather as well)
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| Pityriasis alba: white spots on back; history of vitiligo in aunt; no fluorescence on Wood’s lamp examination; postinflammatory
hypopigmentation of atopic dermatitis; mild case (faintly scaly); potassium hydroxide (KOH) stain negative;
treatment—frequent administration of bland emollients; clearing took few months
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| “Give Western medicine a chance” (case): despite homeopathic therapy, patient miserable and digging into skin to point
of bleeding; eczema terrible (weepy, oozy, crusty, and itchy); during examination, patient given cookie to hold to ease
aggressive scratching; parent refused antibiotics or topical cortisone; treatment—Domeboro; Unna’s boot; moisturizer;
patient not completely cleared but improved
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| Nummular eczema: initially, ringworm suspected; patient previously treated with butenafine (Lotrimin), then terbinafine
(Lamisil), then naftifine (Naftin); presentation—nipple involvement; yellowish crusting impetigo; antifungals not effective
against bacteria (exception ciclopirox [Loprox]); treatment—condition cleared quickly on Bactroban and triamcinolone;
if diagnosis uncertain, consider KOH
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| Behavioral issues: patient observed aggressively scratching own face in office; background skin red and dry; problem of
self-mutilatory habits; difficult to treat; mild-to-moderate eczema exacerbated by scratching; initially, burn suspected;
in office, scratching observed with nail marks; psychologic or psychiatric counseling may be indicated; treatment—
Bactroban ointment; liberal application of gentle moisturizer (eg, hydrolated petrolatum); Unna’s boot applied to arm;
soothing medications for face (if skin sensitive to “everything,” consider MimyXT)
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| Erythrodermic atopic dermatitis: more difficult to see rashes or redness in darker skin types; patient erythrodermic (skin
hot to touch); patient hospitalized directly from clinic; ichthyosiform pattern on arms; dry skin; history of treatment
with prednisone, then discontinuation; blood cultures positive; treatment—fluocinonide (Synalar) for face and fluocinolone
(Lidex [class II topical steroid]) for body; earlier treatment with prednisone made subsequent management
more difficult
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| Dyshidrotic eczema: hand dermatitis; deep-seated blisters (often between fingers); itchy and difficult to treat; tinea
manuum—history of treatment with ultrapotent (class I) steroids; on physical examination, skin on feet abnormal;
floridly positive on KOH; fungal infection on hands and feet; with treatment, skin cleared
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| More management tips: over-the-counter antibiotic ointment—eg, bacitracin or Neosporin (bacitracin, polymyxin,
and neomycin) should be avoided (common source of contact allergy that exacerbates atopic dermatitis); rate of developing
sensitization greatly increased if applied to inflamed skin; Bactroban (mupirocin) almost never causes contact dermatitis;
Unna’s boot—if tolerated, can be left on up to 1 wk (or wrap at bedtime and remove next morning)
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Scabies
| Introduction: every case of refractory “scabies” that speaker has seen actually misdiagnosis; can see prolonged itch/
scratch cycle from initial scabies infestation (confirm diagnosis with scrape)
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| Natural history: Sarcoptes scabiei completes life cycle on human host; without treatment, infection could persist indefinitely;
65% of hosts develop some evidence of immune resistance to reinfestation; adult female burrows through epidermis
and superficial dermis; areas of involvement—webspaces between fingers; axilla, genital/groin area
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| Differential diagnosis: Langerhans cell histiocytosis; bullous pemphigoid (autoimmune blistering disease; same pattern
on immunofluorescence microscopy)
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| Lindane (Kwell; no longer available): FDA warning (neurologic toxicity; causes seizures and aplastic anemia in some
children); resistant strains reported
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| Permethrin (Elimite): 5% cream first-line treatment; safe in small children and immunosuppressed patients; well studied;
side effects minimal
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| Ivermectin (Stromectol): oral formulation can be used for mass infection; main use for onchocerciasis (African river
blindness); effective for other parasitic infections, including scabies; can be used in immunosuppressed patients and to
augment topical therapy in patients with crusted scabies; resistance reported
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| Regimen: for patients >2 or 3 yr of age, treat with permethrin from jaw to toes overnight, then shower next morning; repeat
in 7 to 14 days (not effective against ova); treat whole family
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| Summary: fomites (wash all bedding and towels in hot water; in general, condition not contagious after hosts cleared);
precipitated sulfur (5%) and petrolatum older remedy used for outbreaks in Romanian nurseries (less expensive than
permethrin); permethrin resistance low (<1%-2%; may be reinfections); children treated as young as 2 mo of age (topical
preferred to oral medication); 5% precipitated sulfur has been used in first 30 days after birth (safe and effective)
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Head Lice (Pediculosis Capitis)
| Diagnosis: pubic lice look like crabs (head louse more elongated)
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| Cure rates (study): some resistance to permethrin (Elimite) and malathion; impressive resistance to lindane
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| Nuvo method (Pearlman’s technique): 2 open clinical trials—93 subjects; Cetaphil cleanser applied, then hair
blow dried; lice combed out; 97% cure rate (at 6-mo follow-up, 94% remained clear); regimen—start with dry hair;
cover scalp with Cetaphil cleanser; and massage through scalp; leave on ≈2 min; comb out nits using fine comb; blow dry
hair and leave residue on overnight; repeat once weekly for 3 wk; chemical-free, inexpensive, and avoids problem of resistance
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Educational Objectives
| The goal of this program is to educate the listener about dermatologic disease. After hearing and assimilating this program,
the clinician will be better able to:
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| 1. Recommend effective moisturization products for managing atopic dermatitis in children.
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| 2. Select anti-inflammatory agents for atopic dermatitis.
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| 3. Prescribe appropriate antibiotics for patients with atopic dermatitis.
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| 4. Diagnose and manage scabies.
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| 5. Diagnose and manage head lice.
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Discussed on This Program
Aluminum acetate solution (Burow’s or modified Burow’s solution) [Bluboro Powder, Boropak Powder, Domeboro
Powder and Tablets, Pedi-Boro Soak Paks, Buro-Sol]
Amoxicillin [Amoxil, Amoxil Pediatric Drops, Trimox, Trimox Pediatric Drops]
Aquaphor Natural Healing (ointment containing petrolatum, mineral oil, lanolin, alcohol, panthenol, and glycerin)
Aveeno Cleansing (soap-free therapeutic cleanser)
Bacitracin [AK-Tracin, Altracin, Baci-IM]
Butenafine HCL [Lotrimin Ultra, Mentax]
Cephalexin [Biocef, Keflex]
Cetaphil (soap-free therapeutic cleanser)
Cetirizine HCl [Zyrtec]
Ciclopirox [Loprox, Penlac Nail Lacquer]
Crotamiton [Eurax]
Dicloxacillin sodium
Diphenhydramine HCl (several formulations and trade names)
Eucerin (petrolatum, mineral oil, mineral wax, woolwax alcohol)
Fluocinolone acetonide [Fluonid, Flurosyn, FS Shampoo, Synalar, Synalar-HP]
Hydrocortisone (cortisol) (several formulations and trade names)
Hydrocortisone valerate [Westcort]
Hydroxyzine [Atarax, Atarax 100, Vistaril]
Ivermectin [Stromectol]
Lidocaine HCl (several formulations and trade names)
Lindane (gamma benzene hexachloride) [Kwell; discontinued]
Malathion [Ovide]
Mupirocin (pseudomonic acid A) [Bactroban, Bactroban Cream, Bactroban Nasal]
Naftifine HCl [Naftin]
Permethrin [Acticin, Elimite, Nix Crème Rinse]
Pimecrolimus [Elidel]
Polymyxin B sulfate, neomycin, and bacitracin (several formulations and trade names)
Pramoxine HCl [-X, PrameGel, Prax, Sarna Sensitive Anti-Itch Lotion, Tronothane HCl]
Prednisone (several formulations and trade names)
Tacrolimus (FK506) [Prograf, Protopic]
Terbinafine HCl [Lamisil, Lamisil DermGel 1%]
Triamcinolone (oral) [Aristocort, Atolone, Kenacort]
Urea (carbamide), topical [Aquacare, Carmol 10, Carmol 20, Gordon’s Urea 40%, Gormel Creme, Lanaphilic, Nutraplus,
Ultra Mide 25, Ureacin-10, Ureacin-20]
White petrolatum [Vaseline]
Resources
www.nuvoforheadlice.com
Suggested Reading
Adkis CA et al: Diagnosis and treatment of atopic dermatitis in children and adults: European Academy of Allergology
and Clinical Immunology/American Academy of Allergy, Asthma and Immunology/PRACTALL Consensus Report. J Allergy
Clin Immunol 118:152, 2006; Devillers, AC, Oranje AP: Efficacy and safety of ‘wet wrap’ dressings as an intervention
treatment in children with severe and/or refractory atopic dermatitis: a critical review of the literature. Br J
Dermatol 154:579, 2006; Eichenfield LF et al: Consensus conference on pediatric atopic dermatitis. J Am Acad Dermatol
49:1088, 2003; Foti C et al: Contact allergy to topical corticosteroids in children with atopic dermatitis. Contact
Dermatitis 52:162, 2005; Jones KN, English JC 3rd : Review of common therapeutic options in the United States for
the treatment of pediculosis capitis. Clin Infect Dis 36:1355, 2003; Leung AK et al: Pediculosis capitis. J Pediatr
Health Care 19:369, 2005; Lio PA, Kaye ET: Topical antibacterial agents. Infect Dis Clin North Am 18:717, 2004;
Meinking TL: Clinical update on resistance and treatment of Pediculosis capitis. Am J Manag Care 10:S264, 2004;
Roffe C: Treatment of pediculosis capitis by dry combing. Lancet 355:1724, 2000; Tidman MJ et al: Childhood scabies
mistaken for Langerhans cell histiocytosis. Clin Exp Dermatol 28:111, 2003.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship
with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Dr. Lio was recorded at Current Clinical Pediatrics, presented April 17-21, 2006, at Hilton Head, SC, by Boston University
School of Medicine and the Department of Pediatrics at Boston Medical Center. The Audio-Digest Foundation
thanks Dr. Lio and the sponsors for their cooperation in the production of this program.
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