Batches of Scratches: Pediatric Skin Patches

Batches of Scratches:
Pediatric Skin Patches
Adapted for the
Pediatric Nurse Practitioner
and Advanced Practice Nurse
Pediatric Focus Conference
November 5, 2014
By Dr. Jane Chevako
Cutaneous Fungal Infections:
1. Dermatophytes: Tinea
2. Candida
Tinea
Corporis:
Ringworm
Tinea Pedis:
Athlete’s Foot
“Sweaty Sock
Dermatitis”
Tinea Cruris:
Jock Itch
Tinea Skin Infections
Apply topical antifungal BID:
 Clortrimazole Cream (Lotrimin®)
 Miconazole (Monostat®, Lotrimin® Spray)
 Terbenafine (Lamisil®)
 Tolnaftate (Tinactin ®)
 RX: Ketoconazole, Spectazole
 Do NOT use Nystatin
***TREAT FOR 2-3 WEEKS***
Patient & Family Instructions:
Apply an antifungal until
the rash is completely gone
PLUS 3-7 more days.
Tinea Scalp Infections
Needs oral antifungals for
tinea capitis and adult face:
 Griseofulvin®
• 20-25 mg/kg/d for 6-8 weeks
 Fluconazole (Diflucan®)
TREAT FOR 6-8+ WEEKS
Kerion:
 Marked inflammatory response
 Can lead to scarring alopecia
 Add oral corticosteroids:
•
0.5-1 mg/kg/d for 2-4 weeks, wean
 Add oral antibiotics if significant
crusting or positive skin culture
Candida Infection
Candidiasis in diaper area:
Widespread vivid red erythema
Raised edge, sharp margins
White scales at the boarders
Pinpoint satellite lesions
Spares intertriginous areas
Topical antifungal:
 OTC antifungal lotrimin or miconazole: 2 times a day

Do NOT use terbinafine or tolnaftate

Nystatin Rx: effective, must be applied 3-4 times/day

Ketoconazole Rx: 2 times a day helps compliance
Viral Exanthum: Treat Symptoms
Coxsackie:
Hand, Foot and Mouth
Symptomatic Treatment:
 Antihistamine, like
Diphenhydramine (Benadryl®)
mixed 1:1 with an oral antacid
• 1 mg/kg/dose diphenhydramine
divided every 6-8 hours.
• More Sleepy: Swish and swallow.
• Less Sleepy: Swish and spit.
Analgesics for pain.
Eczematous Eruptions
Atopic Dermatitis
Nummular Eczema
Seborrheic Dermatitis
Contact Dermatitis
Primary Irritant Dermatitis
Allergic Contact Dermatitis
Atopic Dermatitis:
The most common cause
of eczema in children
PRURITIS
Dryness
Sites of predilection
 Infant: face
 8-10 m/o: extensor surfaces
of arms and legs
 Children, teens and adults:
face; neck; antecubital and
popliteal fossae
Atopic Dermatitis
Atopic Pleats
 extra grooves to
lower eye lids
Long, luxurious
eyelashes
Pallor of buccal and
paranasal areas
Atopic Dermatitis
Pruritis, the feeling of “itch,” leads to scratching
Scratching leads to skin trauma and “spreading” itch
“Itch-scratch-itch” cycle
Atopic Dermatitis:
Itch Comes First
Reduce the ITCH: Antihistamine
 Loratadine, cetirizine, fexofenadine
• Only need to give every 12-24 hours
 Diphenhydramine (Benadryl®)
• 1 mg/kg/dose every 6-8 hours but best
at night to help child sleep
 Hydroxyzine (Atarax®)
• 2 mg/kg/day divided every 6-8 hours
 Sarna Lotion® (camphor and menthol)
 Eucerin® Itch-Relief Moisturizing
Spray
Atopic
Dermatitis
Moisturize the SKIN:
 Bathe frequently as directed
 Soak in tepid water for 20
minutes (add 1 cup salt to
water, if needed for stinging
 Apply topical corticosteroids
while the skin is still damp
 Cover with petroleum jelly
(Vaseline®) or Aquaphor®
Atopic Dermatitis
Use topical corticosteroids
Ointments = good penetration;
 Occlusion is good, except in hot weather
 Great in dry or plaque-like areas
Creams and lotions = less penetration
 “More convenient”
 Good in hot weather
 Intertriginous areas
 Hairy areas
Atopic Dermatitis
Avoid irritants to the SKIN:
 Wear soft cotton clothing
 Avoid wool, harsh materials
 Avoid cigarette smoke
 Avoid feather pillows, fuzzy toys,
stuffed animals
 Don’t use carpeting in bedrooms
 Minimize exposure to dogs and cats
 Reduce perspiration
 Avoid foods that worsen the rash
• Treat secondary infection
(usually staphylococci)
Nummular Eczema
Much Thicker Lesions
Potent topical steroids in
an ointment base
Frequent lubrication
Avoid irritants (wool,
harsh or drying soap)
Treat secondary infection
(staphylococci)
Corticosteroids
Use the least potent for the shortest time
IV. Medium Potency
 Fluocinolone (Synalar®) Ointment 0.025%
 Hydrocortisone Valerate (Westcort®) Ointment 0.2%
V. Lower-Mid Potency
 Triamcinolone (Kenalog ®) Ointment 0.1%
 Fluticasone (Cutivate®) Cream/Lotion 0.05%
 Hydrocortisone Valerate (Westcort®) Cream 0.2%
VI. Mild Potency
 Aclometasone (Aclovate®) Ointment 0.05%
VII. Low Potency
 Hydrocortisone 2.5% Ointment, Cream
 Hydrocortisone 1% Ointment, Cream (OTC)
When You Write Muliple Rx’s
Fluocinolone Ointment 0.025%
SMALL TUBE
Use on BAD eczema 2 times a day until better.
TEACH BACK: Where are you going to put this one…
Triamcinolone Ointment 0.1%
BIG TUBE
Use on MEDIUM eczema 2 times a day until better.
Remind family NOT to look at the percentages on the medications!
Hydrocortisone Ointment 2.5%
454 gms (One Pound Jar)
Use on MILD eczema and dry skin 2 times a day.
Seborrheic Dermatitis:
Dry patches of thick, yellowbrown and greasy crusts
Mile topical steroids reduce:
 Inflammation
 Scaling
 Number of lesions
Seborrheic Dermatitis:
Cradle Cap
Best Treatment: May be the lack of treatment
Frequent shampoo:
 Baby shampoo if mild
 Head and Shoulders™ if moderate
Scales: may be removed manually
 Loosen first with warm mineral oil
Seborrheic Dermatitis:
May present in adolescents as dandruff
Shampoos for the scales:
 Salicylic acid (Neutrogena® T/Sal)
 Salicylic + tar (Neutrogena® T/Gel)
 Zinc pyrithione (Head and
Shoulders® or DHS™ Zinc Shampoo)
 Selenium (Selsun Blue®)
For pruritis
 Steroid solution can help, but sting
(Lidex® or Synalar®)
Seborrheic Dermatitis:
In diaper area
Salmon-colored, scaly lesions
Greasy
Intertriginous and flexural
areas are heavily involved
Candidiasis:
Seborrheic Dermatitis:
May get secondary infections
Topical antibacterial agent:
 Bactoban®
• Apply BID with good hand washing
If widespread, add oral antibiotic:
 Augmentin®
• 90 mg/kg/day divided BID
 Keflex®
• 25-100 mg/kg/day divided TID
 Culture if not responding or MRSA?
If candida, add anticandidal agent:
 Nystatin® or Lotrimin®
• Apply until clear PLUS 3-7 more days
Refer to a Pediatric Dermatologist
Contact Dermatitis
Shoe Dermatitis: Rubber adhesives; Tanning
“Sweaty Sock Dermatitis”: Hyperhidrosis
Fiberglass Dermatitis: Fiberglass particles
Video Display Terminal Dermatitis
Lip Licker’s
Dermatitis:
Saliva
“Dr. Jane’s Medicine”
Low Potency Topical Corticosteroid
Nickel Dermatitis
Contact Dermatitis
Avoid offending metal:
•
•
•
•
•
•
Earrings and jewelry
Belt buckles
Buttons on blue jeans
Zippers
Clothing fasteners, snaps
Guitar strings
Coat the offending metal
• Clear nail polish
• Moleskin
• Topical aerosol dexamethasone
(Decaspray®) to both surfaces
Potent topical steroids
Rhus Dermatitis
Poison Ivy:
Delayed Contact
Hypersensitivity
Oleoresin (Urushiol)
 Resin: Wash off ASAP after exposure
 Clothes and shoes must be removed
 Clothing: Wash in soap and water
or cold water and alcohol
Treatment:
 Topical antipruritic: Calamine®
 Potent topical corticosteriods
 Systemic antihistamine/antipruritic
 Systemic corticosteroids when needed

Hypersensitivity Reaction
to an Insect/Mosquito Bite
• Super high potency steroid will drastically
reduce swelling, redness, and itching.
• Class 1 Steroid
• Clobetasol 0.05% Ointment Sig: Apply ONLY 1 -2 times.
• If it doesn’t work RIGHT AWAY, it likely won’t.
• Consider 2° Infection
Head Lice: Don’t Freak Out!
Head Lice: Don’t Freak Out!
 Make sure there are LIVE LICE!
 Lice die if off humans for 24-55 hours
 Eggs die if not at temp near scalp
 Many treatments kill lice but not eggs
 Lice can hold their breath for hours!
 Most pediculocides need to be repeated
 Day 9 may be optimal
 Three treatments: 0, 7 and 13-15 days
 Rinse pediculocides:
 Over a sink to avoid skin contact
 In warm, not hot, water to  absorption
Head Lice Treatments
1% Permethrin Cream Rinse: Nix® OTC
Pyrethrins: RID® OTC
5% Permethrin Cream: Elimite® Rx
Malathion Lotion (Ovide®)
Home remedies:




Petroleum jelly; mayonnaise; margarine
Olive oil
Herbal oils
Kerosene
A Bit Nit Picky?


“Treat and return” policy
AAP Clinical Report 2011
Head Lice Treatments
•
•
•
•
•
•
•
•
•
•
Nit comb
Lice MD ®
Lice Shield®
LiceFreee® and Vamouse®
Ivermectin (Sklice®) Rx
Benzyl Alcohol (Ulesfia®) Rx
Spinosad (Natroba®)
LouseBusterTM
Ivermectin (Stromectol®)
Nit Picking Service
 Physical removal
 Dimethicone
 Oils
 Natrum Muriaticum
 Parayzes lice + eggs
 Asphyxiation of lice
 Insecticide
 Hot air desiccation
 Anthelmintic PILL!
 National Association
of Lice Treatment
Professionals
An untreated head louse standing on a hair (from Speare et al,33 with permission)
A Nuvo-treated head louse coated with dried-on DSP lotion
Copyright ©2004 American
Academy of Pediatrics
www.nuvoforheadlice.com
Cleaning Personal Items
Scabies
Scabies
• 5% Permethrin: Elimite®
 Treat everyone in the house
 Repeat in 1 week
 Emphasize: Do NOT use more
than 2 applications, which must
be one week apart
 Itching will continue for 3+weeks
• Antipruritics:
 AM: Loratadine, Cetrizine
 HS: Benadryl® or Atarax®
 Low potency steroid:
hydrocortisone 1 or 2.5%
• Antibiotics: if infected
Bed Bug Bites
Bed Bug
What To Do About Bed Bugs:
Getting rid of them is not easy!
Good advice:
• Don’t bring them home!
• Look for them when travelling and on your luggage.
• Don’t put anything on the floor of a hotel room.
• Don’t pick up mattresses or furniture from the curb!
• Run clothes through a dryer on high heat.
• There are poisons, but they are poisons.
• There are professional exterminators, but they may
not solve the problem in one, expensive trip.
What To Do About
Bed Bug Bites:
• Give treatment for itchiness so bites don’t get infected.
 Antihistamines orally.
 Topical steroids of low to mild potency.
• Give antibiotics if bites are infected.
• Give the family pictures of bed bugs.
• 91% Isopropyl Alcohol: Spray liberally, spray often!
Strawberry Tongue
Raspberry Tongue
Strep Throat:
Scarlet Fever Rash
Group A Beta Hemolytic Strep
Antibiotics are required:
 Penicillin
 Erythromycin
Alternatives to consider:
 Amoxicillin:
• 40-60mg/kg/day divided BID
 Azithromycin (Zithromax®):
• 12mg/kg/day for 5 days
Perianal Strep:
Antibiotics: Patient may need
20 days of amoxicillin or a
stronger antibiotic for
perianal strep.
Impetigo
Small areas: topically
 Bactoban®
• Apply BID with good hand washing
Large areas: orally
 Augmentin® ES
• 90 mg/kg/day divided BID
 Keflex®
• 50 mg/kg/day divided TID
Clindaycin if MRSA suspected
Can the lesions be covered?
Let’s Review
SA: Staphylococcus Aureus
MSSA: Methicillin Sensitive Staph Aureus
MRSA: Methicillin Resistant Staph Aureus
MRSA-HA: MRSA-Hospital Acquired
MRSA-MDR: MRSA-Multiple Drug Resistant
MRSA-CA: MRSA-Community Acquired
MRSA-CS: MRSA-Clindamycin Sensitive
MRSA-CA: MRSA-Clindamycin Resistant
MSSA-CA: MSSA PVL+
Recommendations:
MSSA: Keflex or Augmentin
MRSA: Clindamycin
MRSA MDR: TMP/SMX
Add Rifampin (never use alone)
Topical Mupirocin
Linezolid in severe infections
Vancomycin, if inpatient
In Your Handouts
Additional Information about:
• Staphylococcus
• MRSA
• Common Causes of
Contact Dermatitis
• Acne
And that is a
very good place
to End!
Staphylococcus Aureus:
“Staph for Short”
• Gram positive bacteria.
• Humans are colonized:
• Skin.
• Nose.
• Throat.
• GI tract.
Staphylococcus Aureus:
Before Antibiotics
• Caused severe infections, disfiguring
scars, disabling chronic infections, and
death.
• Mortality rates ~30%.
• Therapy was surgical drainage,
cauterization or amputation.
Chusid, MJ, Grand Rounds: MRSA, 2007
1928: Fleming Discovers
Penicillin
• The first antibiotic is discovered.
• Produced by molds of the genus Penicillium.
• Difficult to isolate bacteria-killing
component.
• 1941: First use in a human.
• Extensive use saved lives of WWII soldiers.
Penicillin: Resistance
• We made penicillin.
• Staph produced β-lactamase.
• Resistance occurred within one year of
using penicillin.
Methicillin:
Semi-synthetic Penicillin
• We made semi-synthetic penicillins
that were more effective against
β-lactamase.
• We made Methicillin (1961).
• Resistance to methicillin in 1961.
Resistance to Multiple
Drugs
• We start treated Staph with more drugs.
• Staph developed multiple drug resistance
(MDR).
• These are called MRSA-MDR.
Staphylococcus Aureus:
Why are they such a bugger?
• Have surface proteins that allow for
attachment and damage.
• Produce enzymes that cause local
damage.
• Secrete toxins.
• Survive by developing resistance.
Chusid, MJ, Grand Rounds: MRSA, 2007
MRSA MDR:
Acquired in Hospitals:
MRSA-HA
• Staph with resistance to multiple drugs
were first acquired in hospitals.
• Associated with risk factors such as ICUs,
post-op, dialysis, immune-compromised
state, and prolonged antibiotic use.
• Limited cases in community, except with
recent exposure to health care setting.
Chusid, MJ, Grand Rounds: MRSA, 2007
MRSA:
Acquired in Communities:
MRSA-CA
• Staph with different susceptibilities start to appear in
large numbers in the community from:
 Schools;
 Daycares;
 Sports teams;
 Recreational centers;
 Emergency Departments.
• These MRSA-CA organisms are more pathogenic
than hospital acquired despite being sensitive to
more antibiotics.
Chusid, MJ, Grand Rounds: MRSA, 2007
Compare
At-Risk Populations
MRSA HA


•

•
Patients in a hospital.
Patients in health care
settings or long-term care.
Patients with invasive
medical devices.
MRSA CA
•
•
•
•
Infants in diapers.
Athletes.
Prisoners.
Military recruits.
Chusid, MJ, Grand Rounds: MRSA, 2007
Compare Risks Factors
MRSA HA






ICU.
Post-operative.
Dialysis.
Tracheostomy.
Immune-compromised.
Prolonged antibiotic use.
MRSA CA





Prior MRSA infection.
Multiple infected family
members.
Young age (Birth-5 yrs).
Abnormal skin:
eczema, trauma.
History of “spider bite”.
Chusid, MJ, Grand Rounds: MRSA, 2007
Compare Genetic Coding
SCC = Staph Cassette Chromosome, the DNA carrier.
mec = is the genetic locus for PBP2a production.
MRSA HA
SCCmec I, II, III.
MRSA CA
SCCmec IV, not seen before.
The genetic structure coding for The mecIV codes only for MRSA
MRSA and MDR.
not other drugs.
Large chromosomes that don’t
transmit easily to other Staph.
SCCmec IV is small and
transmits easily to other MSSA.
Chusid, MJ, Grand Rounds: MRSA, 2007
Losing Clindamycin Susceptibility
While on Therapy or at Relapse
• Clindamycin is still the drug of choice for MRSA-CA
infections because of the high rate of clindamycin
susceptibility.
• HOWEVER: there is a small but significant failure
rate after initial therapy.
• Organisms originally Clindamycin S/Erythromycin R
are developing clindamycin resistance.
• Some MRSA-CA have a second resistance factor which
induces clindamycin resistance during therapy!
Chusid, MJ, Grand Rounds: MRSA, 2007
MRSA-CA/MRSA-CS
The “D” or Double Diffusion Test

Erythromycin resistant MRSA strain
lawn placed on plate

Erythromycin and clindamycin disks
are placed adjacently.


Cut off (‘D’ shape) of clinda zone
demonstrates organism will develop
resistance on Rx.
At CHW, organism will be reported
resistant on initial report only after D
testing.
Chusid, MJ, Grand Rounds: MRSA, 2007
New Toxicity Factors?
Panton Valentine Leukocidin (PVL)
• A more potent toxin, creating more invasive diseases.
• Now showing up in both MRSA & MSSA.
• In some cases:
• The PVL came in with MRSA-CS genes →
• The MRSA gene was lost →
• Leaving aggressive MSSA PVL+ .
• The PVL is transforming the “wimpy” strains that are
PCN sensitive into very aggressive strains.
Chusid, MJ, Grand Rounds: MRSA, 2007
GERMS: WE vs. THEM
•
•
•
•
•
•
We need them.
They need us.
We have barriers to keep them “out”.
They cause problems when they get “in”.
We try to kill them.
They become more resistant.
Patient Education:
Critical Component of Management
1.
2.
3.
4.
5.
6.
7.
Wash hands regularly.
Keep draining wounds covered.
Maintain good general hygiene.
Do not share potentially contaminated items.
Wash clothing exposed to wound drainage.
Do not participate in activities involving skin
contact until the wound is healed.
Clean equipment and other environmental
surfaces.
Adapted from Gorwitz R, et al. Strategies for Clinical Management of MRSA in the Community: Summary of an Experts’
Meeting Convened by the Centers for Disease Control and Prevention. March,2006.
The Importance of Follow-Up in
Out-Patient Management
•
•
•
•
Drain the pus!
Schedule a follow-up visit in 24-48°.
Return if symptoms do not improve.
Return for worsening local symptoms
• Return promptly if systemic symptoms.
MRSA Key Points:
• Hand-washing is still best defense.
• Find out what you are treating.
• Use antibiotics wisely.
• Resistance comes from exposure.
• Follow-up!
Contact Dermatitis
PRIMARY IRRITANT:
•
•
•
•
Harsh Soaps, Bubble baths, Bleach
Detergent, Solvents, Talcum Powder
Foods
Saliva, Urine, Feces, Intestinal Secretions
ALLERGIC CONTACT:
•
•
•
•
Nickel, Vinyl, Lanolin(Wool), Adhesive Tape
Medications (Neosporin)
Perfumes, Hair Dyes, Lipstick, Antiperspirants
Poison ivy, Plants, Pollen (Ragweed)
Acne
BLACKHEADS
WHITEHEADS
Papules and pustules
Acne
Pilosebaceous unit:
 Abnormal keratinization
 Follicular canal obstruction
 Androgenic stimulation
 Sebum formation
 Propionibacterium acnes
hydrolyzes sebum into
irritating free fatty acids
 Intradermal explosion with
inflammation in the skin
1
3
2
4
1.
2.
3.
4.
Open comedo: “blackhead”
Closed comedo: “whitehead”
Papule or pustule:”zits”
Nodule: “undergrounder”
Acne:
Don’t PICK
Prevent follicular
hyperkeratosis
Reduce P. acnes
Reduce free fatty acids
Eliminate comedos
 papules
 pustules
 nodules
 cysts
Acne: Don’t PICK
Topical therapy:
 Dove Fragrance Free
 2% Salicylic acid
• Neutrogena® Oil-Free Acne
Wash
 Benzoyl Peroxide 2.5 to 10%
• Bar, wash, lotion, cream, gel
• Lots of OTC preparations
 Vitamin A Acid
• Retin-A® 0.025%
 Adapalene (retinoid receptor)
• Differin® 0.1% cream, gel
Acne Antibiotics:
Only for inflammatory lesions
 Topical
• Clindamycin

Cleocin®; Clindagel®;
Clindets®
• Erythromycin

T-Stat®
 Systemic
• Tetracycline 500 mg BID
• Minocycline 50-100mg BID
 Minocin Pellets®
Acne: Don’t PICK
Vitamin A Acid and Benzoyl Peroxide
The results are more dramatic
when they are used in combination:
 There is less irritation than Vitamin A alone
 Systemic antibiotics can often be reduced
 Use one in the morning, one at night
 Differin® is less irritating than Retin-A®
 Use Vitamin A Acid on DRY skin so need to
wait 30 minutes after washing face to apply
 A little dab will do it!
Acne Management
Teach patient about acne
Stress NO PICKING, gentle washing
Try benzoyl peroxide in the morning
Add Retin-A or Differin at night
Use antibiotics for inflammatory lesions
and wean as tolerated
Adjust treatment as needed for patient
satisfaction
Unresponsive Acne Vulgaris:
Cysts and nodules
Scarring
Isotretinoin: Accutane
Refer to a dermatologist