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Daily Dose

Brown Spots on Your Baby?

1:30 to read

I was examining a 4 month old baby the other day when I noticed that she had several light brown spots on her skin. When I asked the mother how long they had been there, she noted that she had started seeing them in the last month or so, or maybe a couple even before that.  She then started to point a few out to me on both her infant’s arm, leg and on her back.

These “caramel colored” flat spots are called cafe au lait macules, (CALMs) and are relatively common. They occur in up to 3% of infants and about 25% of children.  They occur in both males and females and are more common in children of color.  While children may have a few CALMs, more than 3 CALMS are found in only 0.2 to 0.3% of children who otherwise do not have any evidence of an underlying disorder.  

Of course this mother had googled brown spots in a baby and was worried that her baby had neurofibromatosis (NF).  She started pointing out every little speckle or spot on her precious blue eyed daughter’s skin, some of which I couldn’t even see with my glasses on. I knew she was concerned and I had to quickly remember some of the findings of NF type 1.

Cafe au lait spots in NF-1 occur randomly on the body and are anywhere from 5mm to 30 mm in diameter. They are brown in color and have a smooth border, referred to as “the coast of California”. In order to make the suspected diagnosis of NF-1 a child needs to have 6 or more cafe au lait spots before puberty, and most will present by 6 -8 years of age.

For children who present for a routine exam with several CALMs ( like this infant), the recommendation is simply to follow and look for the development of more cafe au lait macules. That is a hard prescription for a parents…watch and wait, but unfortunately that is often what parenting is about.

Neurofibromatosis - 1 is an autosomal disorder which involves a mutation on chromosome 17 and may affect numerous organ systems including not only skin, but eyes, bones, blood vessels and the nervous system. Half of patients inherit the mutation while another half have no known family history.  NF-1 may also be associated with neurocognitive deficits and of course this causes a great deal of parental concern. About 40% of children with NF-1 will have a learning disability ( some minor, others more severe).

For a child who has multiple CALMs it is recommended that they be seen by an ophthalmologist and a dermatologist yearly,  as well as being followed by their pediatrician.  If criteria for NF-1 is not met by the time a child is 10 years of age,  it is less likely that they will be affected, despite having more than 6 CALMs.

The biggest issue is truly the parental anxiety of watching for more cafe au lait spots and trying to remain CALM…easier said than done for anyone who is a parent. 

Daily Dose

Ringworm

1:30 to read

The last patient of the day last week was a mother with her 3 adorable little girls…who were actually en route to the local high school football game but swung by my office first. While the mother had been dressing her daughters’ in their “mini-cheerleader” outfits, she noticed a rash on her oldest daughter’s trunk and kind of “freaked out” that she had ringworm. 

 

Ringworm is a common fungal skin infection and the medical term is tinea corporis (fungus of body). You can also get tinea on your feet ( athlete’s foot) in the groin area and on the scalp. Fungal infections are easy to acquire and they are nothing to be “too” alarmed about as they are typically fairly easy to treat. As I remind many a parent….this is not life threatening.

 

This sweet mother had not noticed the rash until that day and she assured me that she bathed her daughter every night.  Having ringworm has nothing to do with cleanliness as it is easily acquired by direct contact with other people and clothes, as well as from contaminated surfaces (locker rooms, pool decks) and for many kids from a family pet.  A new kitten or puppy may often be the source of the infection. Trying to track down the “source” is typically not necessary….it is just one of those common childhood issues.

 

The typical lesion of ringworm is easy to diagnose and rarely requires a trip to the dermatologist.  It is described as a circular lesion with a raised red rim and will often have decreased pigmentation in the central area of the skin lesion.  It may be itchy and scaly.  At times the edge of the lesion may form an “irregular” circular that looks like the wavy outline of a worm - and so the name. If your doctor has a Wood’s lamp they may shine the light on the lesion as it will “glow” in the black light. If the lesion is “atypical” a scraping may be obtained and prepared and can be looked at under the microscope.

 

Most infections of the skin may be treated with a topical over the counter anti-fungal cream or ointment.  It may take several weeks to a month or more to treat the infection and I usually recommend longer rather than shorter topical treatment.  In some cases an over the counter cream may not work as the fungus may be resistant and you may need a broader spectrum anti- fungal that will be prescribed by your pediatrician.

During elementary school one of my sons had gotten a new watch that he wore day and night. When he finally took it off I noticed what I thought to be a LARGE ringworm beneath the watch face….oh well. A few weeks of an anti-fungal cream on his wrist and he had that watch back on!!  

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Daily Dose

When Bug Bites Get Infected

1.00 to read

It is the season for bug bites and and I am seeing a lot of parents who are bringing their children in for me to look at all sorts of insect bites. I am not always sure if the bite is due to a mosquito, flea or biting flies, but some of them can cause fairly large reactions. 

The immediate reaction to an insect bite usually occurs in 10-15 minutes after bitten, with local swelling and itching and may disappear in an hour or less. A delayed reaction may appear in 12-24 hours with the development of an itchy red bump which may persist for days to weeks.  This is the reason that some people do not always remember being bitten while they were outside, but the following day may show up with bites all over their arms, legs or chest, depending on what part of the body had been exposed. 

Large local reactions to mosquito bites are very common in children. For some reason, it seems to me that “baby fat” reacts with larger reactions than those bites on older kids and adults. (no science, just anecdote). Toddlers often have itchy, red, warm swellings which occur within minutes of the bites. 

Some of these will go on to develop bruising and even spontaneous blistering 2-6 hours after being bitten. These bites may persist for days to weeks, so in theory, those little chubby legs may be affected for most of the summer. 

Severe local reactions are called “skeeter syndrome” and occur within hours of being bitten and may involve swelling of an entire body part such as the hand, face or an extremity. These are often misdiagnosed as cellulitis, but with a good history of the symptoms  (the rapidity with which the area developed redness, swelling, warmth to touch and tenderness) you can distinguish large local reactions from infection.

Systemic reactions to mosquito bites including generalized hives, swelling of the lips and mouth, nausea, vomiting and wheezing have been reported due to a true allergy to the mosquito salivary proteins, but are extremely rare. 

The treatment of local reactions to bites involves the use of topical anti-itching preparations like Calamine lotion, Sarna lotion and Dommeboro soaks.  This may be supplemented by topical steroid creams (either over the counter of prescription) to help with itching and discomfort. 

An oral antihistamine (Benadryl) may also reduce some of the swelling and itching. Do not use topical antihistamines. Try to prevent secondary infection (from scratching and picking) by using antibacterial soaps, trimming fingernails and applying an antibiotic cream (polysporin) to open bites. 

Due to an exceptionally warm winter throughout the country the mosquito population seems to be especially prolific. The best treatment is prevention!! Before going outside use a DEET preparation in children over the age of six months, and use the lowest concentration that is effective.  Mosquito netting may be used for infants in strollers.  Remember, do not reapply bug spray like you would sunscreen. 

Daily Dose

Acne Problems

Adolescents and acne….the two often go together. With so many options, both over the counter and prescription available, most teens who are interested in treating their acne can achieve clear skin.  The first step is typically making sure that the tween-teen is washing their face every morning and before bed…which proves to be difficult for some.

 

Interestingly, diet may also play a role in acne. While we were told years ago that french fries and greasy hamburgers may cause acne a new study suggests that milk may actually be the culprit and contribute to the development of acne. I can even remember the dermatologist many years ago asking my sons (who unfortunately all dealt with acne) if they were big milk drinkers.  

 

There have been earlier studies (2005 - 2008) which showed a correlation between milk intake and acne…and the risk seemed to be greater in those that drank non fat milk over whole milk.  The newest study published in 2016 looked at teens with acne compared to controls who did not have acne and found “positive associations with total dairy and non-fat dairy, but not with whole-fat or low -fat dairy. In other words it seemed that skim milk might be involved in the pathogenesis of acne??  There have been proposed mechanisms as to why this might occur, but much of it is speculative.

 

At the same time that teens are developing acne they are also growing and building healthy bones, which means more calcium is needed in their diets. Nutritional guidelines recommend 1,300 mg of calcium every day for adolescents. Much of the dietary calcium intake comes from dairy products including milk, yogurt, and cheese.  It is often very hard for adolescents to meet the daily calcium and vitamin D requirements and stopping dairy may put them at risk nutritionally.

 

But, with that being said….in cases of teenage acne that do not seem to be improving on a well prescribed skin care regimen, it may be prudent to do a dairy free trial to see if this makes a difference in their acne. During the trial you can easily offer a calcium supplement.   If the teen’s face does not seem to improve with a 2-4 week dairy free trial I would recommend to resume normal dairy intake - but maybe use whole-fat or low-fat dairy rather than non fat.

 

This would be a good topic for discussion with your own dermatologist.

Daily Dose

Teens, Sun and Acne

Teens using acne medication need to take extra care of their skin during the sunny months.With the sun beating down on many us, this seems like the beginning of  a long, hot summer. I am already seeing kids with sunburned shoulders and noses, and this brings to mind all of my teenage patients who are using products, both OTC and prescription, for treatment of their acne.

Although I discuss sun protection with teens throughout the year, summer is an especially important time to re-iterate the risk of sunburn and sun damage, especially for those who are using acne products. While I was growing up (many moons ago), we all thought that baking our faces in the sun helped with pimples and acne. In fact, you may see some improvement in a teens “pimply” skin after they have been in the sun, but at what cost? According to the American Academy of Dermatology, 80% of lifetime sun exposure occurs before the age of 18.  Blistering sunburns before the age of twelve (think about those peeling noses) and freckles before age 12 are both signs that too much sun exposure has happened. Many teens use over the counter products containing glycolics, lactic acids and salicylic acid products.  These products promote exfoliation (peeling) of the skin which results in more sun sensitivity. Teens are also often prescribed a group of drugs called retinoids that are applied topically to control acne.  The most common names are Retin-A, Differin (a retinoid analog), Tretinoin (generic), Renova, Tazorac, and combination products like Ziana, and Epiduo. These products cause exfoliation of the top layer of the skin which initially causes increased sun sensitivity, but after about the first 30 days of using these products you actually get thickening of the skin and therefore will have minimal to no increase in sun sensitivity as long as you are not getting red, dry or irritated from these products. I typically do not begin a teen on a retinoid product during the summer months if they are planning significant sun exposure. Procedures such as micro-dermabrasion and peels will also cause increased sensitivity early on. Due to the above statements it  is important that teens using topical ( as well as oral) acne products apply a daily facial sunscreen.   Products such as Oil of Olay Complete 15 or Complete Defense 30, or Neutrogena Dry Touch #30 are both inexpensive and well tolerated. When buying a facial sunscreen you want to make sure that the product says “non-comedogenic, non-greasy, non-irritating and broad-spectrum (UVA/UVB) coverage. For sun exposure at the pool/beach/sporting activities etc. I would use a higher sunscreen product like Neutrogena Dry Touch 55. You want to apply these to the face 30 minutes prior to sun exposure.  Make sure that you are using more than enough sunscreen on the face, squirt out enough that it looks like you have too much and just keep rubbing it on until it disappears. We are all guilty of applying too little sunscreen when using these products. Rule of thumb is a shot glass full of sunscreen can cover the whole body, but also needs to be reapplied every 2 hours. Lastly, hats and sun protective clothing definitely have a place in preventing sun damage to teens faces. These are especially useful for teens who may be lifeguarding, working on outdoor projects, or spending long hours with continuous sun exposure. Do not allow your teens to tan in a tanning booth either as this is even WORSE than tanning outdoors. If you do get a facial sunburn try mixing 1 part vinegar to 4-6 parts water to make a solution. Chill the solution and use a well soaked washcloth to apply to affected areas. Ibuprofen is also more effective for pain relief and inflammation than acetaminophen. Frequent moisturization as well as the use of a OTC topical steroid cream may also ease the symptoms, but the skin damage has already been done. With good sun protection, and a little planning a head, most teens can continue to use their acne treatment products. That's your daily dose for today.  We'll chat again tomorrow. Send your question or comment to Dr. Sue now!

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Daily Dose

When Bug Bites Get Infected

1.00 to read

It is the season for bug bites and and I am seeing a lot of parents who are bringing their children in for me to look at all sorts of insect bites. I am not always sure if the bite is due to a mosquito, flea or biting flies, but some of them can cause fairly large reactions. 

The immediate reaction to an insect bite usually occurs in 10-15 minutes after bitten, with local swelling and itching and may disappear in an hour or less. A delayed reaction may appear in 12-24 hours with the development of an itchy red bump which may persist for days to weeks.  This is the reason that some people do not always remember being bitten while they were outside, but the following day may show up with bites all over their arms, legs or chest, depending on what part of the body had been exposed. 

Large local reactions to mosquito bites are very common in children. For some reason, it seems to me that “baby fat” reacts with larger reactions than those bites on older kids and adults. (no science, just anecdote). Toddlers often have itchy, red, warm swellings which occur within minutes of the bites. 

Some of these will go on to develop bruising and even spontaneous blistering 2-6 hours after being bitten. These bites may persist for days to weeks, so in theory, those little chubby legs may be affected for most of the summer. 

Severe local reactions are called “skeeter syndrome” and occur within hours of being bitten and may involve swelling of an entire body part such as the hand, face or an extremity. These are often misdiagnosed as cellulitis, but with a good history of the symptoms  (the rapidity with which the area developed redness, swelling, warmth to touch and tenderness) you can distinguish large local reactions from infection.

Systemic reactions to mosquito bites including generalized hives, swelling of the lips and mouth, nausea, vomiting and wheezing have been reported due to a true allergy to the mosquito salivary proteins, but are extremely rare. 

The treatment of local reactions to bites involves the use of topical anti-itching preparations like Calamine lotion, Sarna lotion and Dommeboro soaks.  This may be supplemented by topical steroid creams (either over the counter of prescription) to help with itching and discomfort. 

An oral antihistamine (Benadryl) may also reduce some of the swelling and itching. Do not use topical antihistamines. Try to prevent secondary infection (from scratching and picking) by using antibacterial soaps, trimming fingernails and applying an antibiotic cream (polysporin) to open bites. 

Due to an exceptionally warm winter throughout the country the mosquito population seems to be especially prolific. The best treatment is prevention!! Before going outside use a DEET preparation in children over the age of six months, and use the lowest concentration that is effective.  Mosquito netting may be used for infants in strollers.  Remember, do not reapply bug spray like you would sunscreen. 

Daily Dose

Winter Season & Eczema

1.30 to read

I received these nice pictures and a question via email the other day. The mother was concerned as she had found this “spot” on her 6 year old son’s back. He was otherwise well and she did not see any other “spots” or rash.   

Her son complained that the “spot” was itchy so being the good mother she applied some over the counter cortisone cream for several days (which I always tell patients to try). After 2 days of it not improving, but not worsening, she thought it might be ringworm (also a good thought) and she applied an OTC anti-fungal cream.  Again, the rash was not better, but really not worsening or spreading.  That is an important part of the history. 

Now in medicine you learn about red herrings, which are part of a patient’s history that may not really have any bearing to their current problem....but one has to consider it. In this case, her dog developed a lesion and was taken to the vet and was diagnosed with a staph infection, but the vet told the mom that the dog was not contagious to humans.  Red herring or is that the problem? 

After looking at all of the pictures (which is never as good as seeing a rash in person), I am thinking that this may be nummular eczema, (nummular means coin shaped, hence the round)  The history is right as is was not bothersome other than being itchy, and eczema is often called the “itch that scratches”.   

With all of this cold dry weather and heaters on full blast all over the country eczema is having a heyday.  I have seen a ton of these little inflamed patches on skin of all ages (my own hands are a mess).   The treatment of choice is to moisturize the skin and also the use of a topical steroid. But, it takes a long time to see an improvement in the spots and they may change on a daily basis depending  on the weather, bathing and how much lubrication and moisturizing you are doing.  

I would use an OTC moisturizer that contains ceramides (Cetaphil Restoraderm, Cerave, Aveeno for eczema) and use it liberally and frequently.  I would also apply an OTC steroid several times a day (under the moisturizer). Eczema also sometimes requires a stronger topical steroid that is prescription. 

Hope that helps.....but if not improving after 7-10 days it may be worth a visit to your pedi for up close and personal diagnosis.

Daily Dose

Summer Skin Infections

1:30 to read

I have been seeing a lot of skin infections and many of these are due to community acquired methicillin resistant staph areus (caMRSA). The typical patient may be a teen involved in sports, but I also see this infection in young children in day care, or summer camp. The typical history is “I think I have a spider bite” and that makes your ears perk up because that is one of the most common complaints with a staph infection, which is typically not due to a bite at all.

The poor spider keeps getting blamed, and how many spiders have you seen lurking around your house waiting to pounce? The caMRSA bacteria is ubiquitous and penetrates small micro abrasions in the skin without any of us every knowing it. The typical caMRSA infection presents with a boil or pustule that grows rapidly and is very tender, red and warm to the touch. The patient will often say that they “thought it was a bite” but the lesion gets angry and red and tender very quickly and typically has a pustular center.

For most of us pediatricians, you can see a lesion and you know that it is staph. It is most common to see these lesions in athletes on exposed skin surfaces such as arms and legs, but lesions are also common on the buttocks of children who are in diapers in day care. The area is angry looking and tender and the teenage boy I saw the other day would not sit on the chair, but laid on the table on his side as he was so uncomfortable. If the lesion is pustular the doctor should obtain a culture to determine which bacteria is causing the infection, but in most cases in my office the culture of these lesions comes back as caMRSA or in the jargon Mersa. When I say Mersa, I often cause widespread panic among my patients, but in most cases to date these infections may still be treated with an oral antibiotic that covers caMRSA, such as clindamycin or trimethoprim-sulfa. Many of the lesions improve dramatically once the site is drained and cultured. I will reiterate that if possible you want your doctor to obtain a culture to identify the bacteria that is causing the infection.

To prevent caMRSA remind your student athlete not to share towels, clothing or other items. Make sure that common areas are disinfected and once again encourage good hand washing. The closure of schools or disinfecting an entire football field or area with turf is not recommended. Lastly, this is a good reminder that you only want to take an antibiotic for a bacterial infection and that overuse of antibiotics leads to resistance. That’s your daily dose, we’ll chat again tomorrow.

Daily Dose

Viral Skin Rashes

We often see in kids are viral rashes (exanthems) that seem to appear as the other viral symptoms are resolving.While on the topic of skin, let's talk about viral rashes in kids. As every parent knows, your child will get several 100 or is it 1,000 viruses during their 18 years at home with you. Most of these viral infections present with typical fever, runny nose, cough and are more common during the winter months, and more frequent in the younger child. We are in the thick of these now.

What we also often see in kids are viral rashes (exanthems) that seem to appear as the other viral symptoms are resolving. It is not unusual to see a child who has had several days of fever develop a blotchy, red, flat rash on their body (not purple or bruise like) which doesn't seem to bother the child at all. The rash is not itchy, and may even come and go. This is often concerning to a parent as people say, "maybe it is the measles or chickenpox." The biggest distinguishing factor with a post viral rash is just that, it is later in the course of the illness and is actually appearing as you child is improving, all the more confusing for a parent. Measles and chickenpox are still present in the U.S. and worldwide. Unfortunately, due to decreasing immunization rates in some areas, outbreaks of chickenpox and measles have recently been reported. But in the case of these illnesses the rash occurs early in the course of the illness, along with the other symptoms. Children with both measles and chickenpox appear ill and the rash starts early and continues throughout. If your child has a fever and a rash at the beginning of an illness give your doctor a call to discuss the symptoms and appearance of the rash and whether they should be seen. But a rash that occurs late in the illness is often just the tale end of the virus and by then your child should be feeling better, not worse. In most cases of a post viral rash, the rash will disappear over the next several days and the child is good to go (until the next virus finds their prey!) That's your daily dose, we'll chat again tomorrow.

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