Dr. Lisa Swanson shares tips for treating children with common skin conditions, including updates on options for chronic skin problems.
Lisa Swanson, MD, Ada West Dermatology, Boise, Idaho
“I started my talk with some rapid-fire peds derm tips and began with using topical timolol to treat pyogenic granulomas. It’s very effective, very easy, and very painless,” said Lisa Swanson, MD, who presented “What’s New and Hot in Pediatric Dermatology” at the 2022 Fall Clinical Conference®.
“So, it is a nice alternative to numbing them up and shaving them off if you’re dealing with a patient that has one in a challenging location or is of an age where they’re not going to tolerate an in-office shave biopsy very well.”
Moles
Eclipse moles are among the moles that can be safely left alone in pediatric patients, said Dr. Swanson.
“They’re common on the scalps of blonde-haired children. And they tend to be two-toned, with either a darker center and lighter rim or a lighter center and darker rim. Both patterns are normal.”
Eclipse moles can occur in bunches and seem to come out of nowhere. Still, they’re completely benign and can be left alone, she said.
“When you see these on the scalp of a young person, you can reassure the family that they’re normal and you don’t have to worry about doing a biopsy of an eclipse nevus.”
Dermatologists should also leave Spitz nevi alone, said Dr. Swanson.
“For years we would recommend removing the Spitz nevi. Over the past 10 to 15 years, we have learned we don’t have to do that. Spitz nevi—as long as they’re not an atypical Spitz—are benign and harmless and can be safely observed.”
Most Spitz nevi—about 80% according to a recent study—go away without treatment, according to Dr. Swanson.1
Tinea Manuum
“We’ve seen a ton of tinea manuum since COVID-19 because of some new ‘family members’ that people have welcomed into their homes—things like guinea pigs, pet rats, and hamsters. The children will hold the cute little critters in their hands and, lo and behold, a few weeks later they have fungus on their hands. So, if you see fungus on the hand of a child, always ask about a little fury critter at home. Chances are that is the source.”
Teenage Boys Post Biopsy
Teenage boys have a tendency to pass out after in-office biopsies, so give them a snack before they leave, said Dr. Swanson.
“The passing out often doesn’t happen in the exam room. It typically happens in the waiting room or parking lot as they exit the practice, and it freaks everybody out. So, years ago I instituted a mandatory snack policy for all teenage boys having biopsies. We give the boys a little juice, a little snack before they get up and go. And since instituting the policy, I haven’t had a single teenage boy pass out.”
Atopic Dermatitis
It’s an exciting time in atopic dermatitis (AD), said Dr. Swanson.
“The Aron Regimen is a compounded mix of a mild topical steroid (betamethasone valerate) and a topical antibiotic (mupirocin), and it’s mixed up in a moisturizing base, either Vanicream or plastibase, depending on if you want cream or ointment.”
The Aron Regimen is dilute enough and safe enough that it can be applied to any body area, up to 5 times a day for flares. It can be used at night for prevention and maintenance, said Dr. Swanson.
“I have found it to be very effective, especially in toddlers that have persistent face eczema.”
Kids with AD don’t sleep well, which affects growth rate, said Dr. Swanson.
“They don’t enter REM sleep as long or as often, and it’s during REM sleep that growth hormone is secreted.”
A recent article2 about the effects of excess interleukin (IL)-4 on the developing brain could help explain the link between increased incidences of things like attention deficit hyperactivity disorder (ADHD), anxiety, depression, learning disabilities, and autism spectrum disorder in patients with bad atopic dermatitis, she said.
Dr. Swanson discussed dupilumab (Dupixent, Sanofi, Regeneron), which is approved for children 6 months of age and older with severe AD.
“For the shot, I recommend taking it out of the refrigerator about an hour before giving it. It hurts less at room temperature.”
Then, to give the shot, Dr. Swanson tells parents about the HELP approach—an acronym they can remember because Dupixent is going to “help” them, she said.
“H stands for hug; E for electronic device; L for lollipop; and P for prize. When it’s time to do the shot, I have the child sit in the parent’s lap, facing the parent in a hug. That exposes the upper lateral arm and the lateral thigh, making it convenient for the shot. We then get an electronic device playing something they like (Paw Patrol or Frozen, something they enjoy), and we put a lollipop in their mouth. We know the child is going to cry but that’s ok because we have that prize box right in front of them, to help make that negative into a positive.”
As for live vaccines, the FDA recommends avoiding live vaccines while on the drug, said Dr. Swanson.
“The two most common are MMR and chickenpox, which are typically given between the ages of 1 and 2 and 4 and 5. In the trials, they gave Dupixent then held Dupixent for 12 weeks and gave the vaccination, waited 4 weeks, then restarted the Dupixent. That’s what I intend to do in practice.”
Psoriasis
Pediatric psoriasis is increasing in prevalence, it’s misdiagnosed all the time, and it’s important to treat kids with pediatric psoriasis because of the “psoriatic march of inflammation” that leads to associated comorbidities with psoriasis, according to Dr. Swanson.
“We believe with good treatment, we can help thwart those comorbidities. You’re not just treating that child’s skin, you’re treating their general health as well.”
“Psoriasis is associated with numerous comorbidities like heart disease, hypertension, hyperlipidemia, obesity, psoriatic arthritis, anxiety, and depression. We really believe that all that inflammation is not just in the skin. It’s a systemic process that has an impact over time.”
Children don’t outgrow psoriasis, so their risk for comorbidities is a legitimate concern, said Dr. Swanson.
“If we can prevent or reduce that, that’s definitely something I want to do.”
The Black Box Warning
Janus kinase (JAK) inhibitors are revolutionizing the treatment of autoimmune processes, including alopecia areata and vitiligo, said Dr. Swanson. So it is important to put the Black Box warning in perspective, she said.
“Do not let it overshadow the wellness that these medicines can provide for patients and their families. Don’t let concerns over the Black Box warning remove these medications as an option for you and your patients. They’re too valuable.”
References:
- Emiroglu N, Yıldız P, Biyik Ozkaya D, et al. Evolution of Spitz Nevi. Pediatr Dermatol. 2017;34(4):438-445. doi:10.1111/pde.13184.
- Jackson-Cowan L, Cole EF, Arbiser JL, et al. TH2 sensitization in the skin-gut-brain axis: How early-life Th2-mediated inflammation may negatively perpetuate developmental and psychologic abnormalities. Pediatr Dermatol. 2021;38(5):1032-1039. doi:10.1111/pde.14657.
Disclosures: Dr. Swanson is a speaker for Abbvie, Almirall, Amgen, Incyte, Janssen, Lilly, Novartis, Ortho Dermatologics, Pfizer, and Sanofi-Regeneron, and an advisory board member at Janssen, Lilly, Ortho Dermatologics and Sanofi-Regeneron.