The Management of Persistent Pediatric Skin Problems

Symposium on Persistent Signs and Symptoms

The Management of Persistent Pediatric Skin Problems

Arthur L. Norins, M.D.* and Patricia A. Treadwell, M.D. t

The emphasis of this paper will be on the management of persistent skin problems in children. Descriptions of the conditions and their diagnosis may be found in pediatric dermatology texts. 9 •26 Skin disease poses an additional problem not usually found in diseases of other systems - the skin is visible. At the time of the intitial examination, therefore, one should discuss with the parents the fact that other adults and children will often notice the skin condition. There may be staring and occasionally, someone will inquire as to the nature of the condition. We have found it best to tell the parents and the child that this is the natural curiosity most of us have, that it should be expected and that they should try not to be disturbed or defensive. It often helps to have a short phrase for the condition such as, "That's a birth mark." Since the condition can be seen, well-meaning family and friends often remember "just such a case" that was magically "cured" by one treatment. Parents are cautioned about this and are told to check with the physician before any suggested remedies are instituted. Support of the parents whose child has a persistent skin disease is as important as it is with other diseases. Often marriages are placed in increased jeopardy by such situations. The need for involvement of both parents is helpful. The primary caretaker should also be encouraged to have at least a few hours "off' each week, just to get out and away from the routine.

FUNGUS INFECTIONS OF THE SCALP Patchy hair loss with scaling in the scalp is a signal of possible tinea infection. The infection seen in past years was frequently caused by the fungus Microsporum audouini and Microsporum canis. The diseased patches were round and quite noticeable, and patients sought early advice. In the last few years, the

*Chairman and Professor, Department of Dermatology, Indiana University School of Medicine, Indianapolis, Indiana tDepartments of Dermatology and Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana

Pediatric Clinics of North America-Val. 29, No. 1, February 1982

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fimgus causing the infection has changed to Trichophyton tonsurans. 20 The infection caused by this organism is often subtle with irregular patches and less dramatic scaling. Furthermore, with Trichophyton tonsurans infection, the hair does not fluoresce under the \Vood' s light, and scraping of scale alone for a potassium hydroxide mount will often not uncover the fungus. In suspicious cases, the small broken hairs should be plucked for the examination by potassium hydroxide mount and for culture. If several inexpensive toothbrushes are kept at hand, one may gently brush the area with a toothbrush and then press the bristles onto the Sabouraud's culture plate. When the diagnosis is established, the child is treated with oral micronized griseofulvin (Grifulvin V suspension, 125 mg per 5 ml), 10 mg per kg per day divided into two doses and given with milk or ice cream to help absorption. This is continued for a minimum of six weeks, and then the area is rechecked with a repeat potassium hydroxide mount. When starting therapy, shampooing the hair twice a week with Selsun shampoo for two weeks has been found helpful. A topical antifungal such as micronazole cream 2 per cent (Monistat-Derm) is applied to the scalp twice daily. Topical medication alone is not sufficient to clear the infection, but may help to decrease transmission to others. The hair is not shaved off. Kerion, a complication of scalp fungal infections, is a peculiar immune response in which a boggy swollen area with pustules occur. This lesion is destructive and, if severe, can leave a scarred area of alopecia when it eventually resolves. This can be cleared by giving oral steroids (prednisone, l mg per kg per day in a single morning dose) for about three weeks in addition to the antifungal regimen.

EPIDERMOLYSIS BULLOSA A number of chronic skin conditions with various inheritance patterns are manifested primarily by easy blistering. They are referred to as epidermolysis bullosa and are included in the group of mechanicobullous diseases. Accurate diagnosis is important because it helps in genetic counseling, in determining prognosis, and in recognizing associated complications in some of the types. Electron microscopy is a great aid in diagnosis. Of great importance is the recognition that the dystrophic type may be helped by phenytoin (Dilantin). 1 The general concepts of care which apply to the conditions as a group will be focused upon here. These children often exhibit blistering at birth. Other diseases that cause infantile blisters have to be considered in the differential diagnosis, such as congenital syphilis, candidiasis, and epidermolytic hyperkeratosis. When epidermolysis bullosa is diagnosed, several measures should be included in the child's care. An attempt should be made to prevent new blisters by gentle handling. Since friction trauma as well as pressure can cause blistering, the child's skin should not be compressed or rubbed. It generally helps to put several layers of clothing on the baby as padding, including thin cotton socks on the hands and feet. A small piece of tape placed over the material but not on the skin, helps to keep the socks in place. To protect the fingers from suction trauma, it is preferable to keep them out of the mouth by substituting a pacifier. Unfortunately, sucking on any object (finger or pacifier) can cause blisters in the mouth. If parenteral fluids are needed during hospitalization, taping should be avoided; soft roller dressings of cloth can often be used to hold tubing in place.

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Blisters around the anus erode and become painful with the result that the child often withholds stools. Application of a thin layer of plain petrolatum to the surrounding skin and just into the anal opening can be protective and aid stool passage. Oral blisters are frequently present and interfere with feeding. A premie nipple or a soft lamb's nipple (as used in children with cleft palates) may help avoid mouth trauma. Compressible plastic bottles that can be gently squeezed minimize sucking pressure. If the mother is nursing, some gentle breast compression helps. If the mother has problems with a vaginal yeast infection, the child is more likely to acquire thrush and aggravate the underlying condition. In that event, the baby is treated by allowing him to suck on several cotton-tipped applicators soaked in nystatin suspension four times a day for four days. The mother should also be treated for her candida infection. To prevent the blisters from extending, it is recommended that all blisters be opened. The mother is instructed in the way to do this, both morning and night. The small disposable sterile lancets used for finger sticks work well, and the mother is reassured that the procedure is painless. Complete trimming away of the roof of the blister may be more effective than simply opening it. Surgical tenotomy scissors can be used for this purpose. Blistered areas are left open, covered only by the child's clean cotton clothing. In general, these areas heal well. With denuded skin, bacterial colonization and infection can occur. Although from the appearance of erosions and crusts, the physician is tempted to keep the child on antibiotics indefinitely, in general this is not necessary. Gentle cleansing with soapy water followed by rinsing with clear water is all that is required. This may have to be repeated several times a day. If an area of skin is repeatedly blistered, the child should be watched carefully to ascertain what action or movement may be causing the irritation. The resultant trauma can often be avoided with some form of padding or shift in positioning. We try to avoid complicated bandaging with yards of gauze; it is often simpler, less expensive, and less irritating to use a sock or a once-around wrap with a cloth diaper. Waterbeds which help distribute the child's weight evenly during sleep have helped some children. Since the child's hair acts as a cushion, it should not be cut too short. As the child develops, standing or walking begin to cause problems since new stress is placed on the skin of the feet. Shoes of the tennis shoe type which are soft are preferred. The technique of double-socking with two dissimilar materials, as used hy basketball players, pads the feet. Special attention should be paid to the web spaces of the toes and fingers. Infection in these areas is common and in the scarring forms of epidermolysis bullosa, the ensuing scars can be incapacitating. In the severe forms of this condition, blistering can occur in the esophagus as well as in the mouth. With these children, food should be served in small pieces or pureed, if necessary. Rough foods, such as crackers and crusts, should be avoided. Since meats such as hamburger and hot dogs often break into very small particles which get caught in erosions in the esophagus, they should also be avoided. It is important to consult a pediatric dentist from the time the teeth erupt. Early instruction in gentle cleansing of teeth twice daily with a soft washcloth or extra soft natural bristle · toothbrush is important. In dystrophic epidermolysis bullosa, scarring leads to a smaller sized mouth, and tooth extractions may be necessary in order to provide room to accommodate the teeth. Denuded skin areas with secondary infection can sometimes be helped by the application of silver sulfadiazine cream (Silvadene). This should be used in limited

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areas and only when necessary. It should not he used as a routine lubricant since, like many other topical preparations, it can he absorbed through the skin and cause problems. The affected area is soapy washed, and rinsed, and then a thin covering of silver sulfadiazine cream is applied. This is covered with a cloth dressing. Dressing material can become very expensive. Old sheets laundered and then torn in strips is an excellent dressing material. After the cream is applied in a very thin layer to the cloth with a tongue blade, the cloth with the cream is applied to the skin. Because of chronic infection, these children have to be checked for anemia. Phenytoin (Dilantin) is used for therapy in the dystrophic type of epidermolysis bullosa in sufficient close to produce levels similar to those considered therapeutic in anticonvulsant therapy. The initial close required is 5 mg per kg per clay given in divided closes. We find that the crushed tablet form (Dilantin Infatabs) produces more reliable levels than the suspension form. Serum levels are drawn at regular intervals and the close adjusted to achieve levels of about lO p,g per ml. 3 . As with other chronically ill children, the parents need frequent counseling and reassurance. They have to be told frequently of the good work they are doing. They should recognize that the condition is so severe that no matter what they did, the child would still develop blisters. Older children are encouraged to carry out much of their own care. It is better for them to walk, go to school and participate in various events, even if such activity results in a blister.

ACNE Acne has always been recognized as a persistent problem of a few years duration. 21 Now we appreciate that for many patients the condition can continue into adult life. The face should be washed once or twice a clay with soap. The cleansing should be clone gently with the hands, not a vigorous scrubbing. A skin brush, washcloth, or other abrasive object should be avoided. The hair should be shampooed several times a week. With many adolescents the vogue is to shampoo daily; this does not seem to be harmful to the hair. A hairstyle should be used that does not require hair spray to be held in place. The hair can be a difficult problem for black patients whose hairstyles often requires the application of oil or petrolatum. These children are cautioned to use as little of the oil as possible and to cover their hair at night with a scarf or cap. It is of great importance to help the child avoid developing the habits of leaning on and touching the face. vVhile studying and reading, students often lean on their faces for hours. Patients are admonished to "keep hands off and do not squeeze pimples." Should a pimple come out, it is best to leave it alone. Second best is to use a warm cloth for five or ten minutes to soften the skin, then place the fingers on either side of the pimple and pull gently outward. If the pimple opens, fine; if not, leave it alone. If not so instructed, the patients will squeeze and pick. Diet has not been found specifically to alter acne. 8 In general, we try to encourage a regular diet and adequate sleep and exercise. vVe point out that frequently during examination time acne becomes worse. It is not known whether

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this is caused by the stress of the examinations, loss of sleep, or fingering of the face. \Vith young men who have begun to shave, a blade razor is preferable to the electric razor. It should not be used as television commercials suggest. The heard should be prepared with a soapy water wash, the face left wet while the teeth are brushed, a foam type shaving cream then applied, and the beard shaved "once over," not against the grain of the beard. This avoids a real close shave. The cream is then rinsed off. After-shave lotion is not recommended. A small amount of dry powder can be used if desired. For the girl, some cosmetics can be used which do not aggravate acne. A "blush" of the powder type, but not a gel or crea~ variety, can be used. Lipstick and eye makeup do not cause acne problems. If a powder is desired, a loose one is suggested. A water base foundation can also be used. The girl is cautioned that since the water base will often layer out in the bottle, it has to be shaken, and while it will not go on quite as nicely as the creamy ones, it is the one to use. They are also advised not to use makeup bases, even if labeled for acne or nonallergenic. Anything that can "goo up" and close the pores can be a problem. The wide variety of astringents available also do not seem to be helpful. For many youngsters the above general regimen alone will keep them reasonably clear and no further treatment is required. \Vhile many young people will do just the opposite of what has been outlined, they still have beautiful skin. But for the person having trouble, it seems best to follow the regimen discussed. For the youngster presenting primarily with open comedones (blackheads) and closed comedones (whiteheads), the use of topically applied tretinoin cream 0.05 per cent (Retin A cream) is suggested. If not used properly, this can be initating to the skin. The irritation can be avoided or minimized by starting slowly and cautiously. The medication is applied after evening dinner at least half an hour after washing the face. A small amount of cream, only that which sticks to the finger when it is touched to the tube opening, is used. This amount is put on an area the size of a cheek. The skin just adjacent to the eyes, nose, and mouth is avoided. The medication is left on for two hours and then washed off. This is done each evening for one week. The next week, the cream is left on for about four hours. From then on it is applied at bedtime and left overnight. The patient is told that this will help prevent comedones, but the results will often not be evident for at least six to eight weeks. If the condition consists mainly of small papules and pustules and there are not too many, a benzoyl peroxide preparation is used. This is put on after evening dinner at least half an hour after washing. Only a small amount is used. It is left on two hours the first week, then washed off; then four hours the second week. After that, it is applied at bedtime and washed off the next morning. The patient should be advised that benzoyl peroxide is an oxidant that will cause bleaching of colored fabiics. After a month of therapy, twice a day application is used. If the papules and pustules are more numerous, oral tetracycline is prescribed. In order to prevent interference with absorption, pharmaceutical instructions recommend that tetracycline be taken one hour before or two hours after meals. For this reason, it is helpful to take the medication about an hour before breakfast and at bedtime. An hour before breakfast is often too early for many children, so better compliance is achieved when a compromise is made to take the tetracycline as long before breakfast as possible. Generally, the patient is started

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on 500 mg of tetracycline twice daily. Because of "drug problems," many schools frown on taking medicine at school, so often a nurse has to dispense it. This inconvenient and embarrassing arrangement is avoided by the twice daily at-home schedule. The patient is kept on this dose until clearing occurs, usually in about two to three weeks. During this period we generally avoid applying any medication to the skin. This helps establish a baseline of response which allows us to judge more accurately the effect of topical preparations when they are eventually added. After clearing has occurred, the dose of tetracycline is decreased to 250 mg three times daily for the next month. At this time, topical benxoyl peroxide is started as described above. The tetracycline dose is decreased at about monthly intervals. Mter the acne is brought under control, the patient will be able to stop the tetracycline and continue on only topical medication. In some severe cases the tetracycline has to be continued for a year or more. Several other oral antibiotics, such as erythromycin, are occasionally used when response has not been adequate. Recently, erythromycin and clindamycin have been incorporated into special vehicles designed for topical use. 25 We use them when the other topical medications have not worked satisfactorily. In our opinion, topical antibiotics have not been sufficiently effective to warrant their use as standard initial therapy. In some patients multiple tiny pustules develop which do not respond to tetracycline. Culture of the pustules is suggested. Frequently, gram-negative organisms are found. 15 There is often a history of using "hot tubs." In these cases, a several week course of trimethoprim and sulfamethoxazole (Septra or Bactrim) is often helpful. In an occasional patient, ordinary mild acne will develop in a matter of weeks into severe, cystic, painful acne. Constitutional symptoms may occur. This type of acne is characterized by lesions which leave severe scars and expert care is required. Often intralesional and, occasionally, even systemic steroids, are needed to control the condition. Another group of drugs, the retinoids, now being investigated for oral use, appear to be promising in the treatment of severe acne. They are not yet available for general use in the United States.

URTICARIA There are two general presentations of urticaria in children. The most common is acute urticaria. The problem often has been present for only several hours when the child is seen by the physician. A less frequent presentation is chronic urticaria, present for several weeks and, at times, months. The diagnosis of urticaria is usually not difficult. Individual lesions characteristically appear within minutes, change size, and resolve in hours. New lesions may be evolving while others are fading. Most lesions of urticaria have a circular or ring shape. They are generally distributed symmetrically about the body, and can be few to many in number. They are pruritic. Lesions can occur on the mucous membranes and can become a significant problem if they obstruct the airway. Airway obstruction usually occurs early in the development of the condition, namely, in the first few hours after the onset of urticaria. The child should be watched for this complication and, when noted, epinephrine solution should be administered on an emergency basis. On rare occasion, intubation is required.

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Most children respond well so that subsequent doses of epinephrine are not required. An intramuscular injection of an antihistamine, such as diphenhydramine (Benadryl), is given following the injection of epinephrine or is given initially in milder cases when epinephrine is not required. The antihistamine should be continued orally on a regular dosage schedule for two days after the last hive is noted. It is not given on a "when necessary" basis. When the child has been clear of hives for two days, the dosage is reduced in half for two more days and discontinued if the condition remains clear at the reduced dosage. Several groups of antihistamines can be used alternatively. Finding the cause of urticaria is important in an attempt to terminate the current bout and to prevent recurrences. In general, five factors are considered to be possible causes of urticaria: ingestants (food and drugs), injectables (from the doctor or dentist, or self-administered), infections, inhalants (an uncommon cause), and "tissue breakdown" as seen in neoplastic and connective tissue diseases. These etiologic groups can be remembered as the 5 'Ts" (using tissue as the fifth 'T'). Commonly, the cause of acute urticaria can be determined by a careful history of the preceding few hours. lngestants, such as food or drugs, are the most common etiologic agents. 6 When several potential agents are suspected, keeping a record often makes it possible to determine the correct agent at the time of a future attack. Skin testing has not been effective in isolating the agent. It is generally not recommended that a patient be given a trial dose to test whether a specific medication causes urticaria. The patient should also be given instructions to inform other physicians about possible drug sensitivities. If a specific agent is identified, obviously it should be avoided. Finding the etiology of chronic urticaria is more of a challenge. The causative agent is still present but often is not apparent from the history. The patient is managed by the use of antihistamines in a dose sufficient to suppress the condition. Drowiness, a common side effect of antihistamines, often makes adequate therapy difficult. Hydroxyzine has been a helpful drug when given in a dose of 2 mg per kg per day. When the patient remains free of the urticaria for two days, the dose is halved and continued for two more days. Antihistamines alone are usually not sufficient to relieve chronic urticaria. A detailed history is taken, being alert to all medications used, including items not considered by some to be medicines, such as vitamins, headache tablets, "stomach" medications, eyedrops, and laxatives. All unnecessary medications are stopped. If the urticaria persists, one attempts to substitute alternative medications for ~edical conditions that require continuing therapy. The patient is evaluated by looking for chronic infections, such as tinea, sinusitis, otitis, and urinary tract infections. 23 Evidence of connective tissue or malignant disease is sought. In the absence of history or examination "leads," only a minimal laboratory workup seems necessary. This includes a complete blood count, urinalysis, and chest and sinus x-rays. 11 If the urticaria still persists, attempts are made to identify and eliminate the causative agent. Salicylates, yellow food dye, and artificial sweeteners have been incriminated in a number of cases, so elimination of foods containing these items is attempted. The patient is instructed to avoid aspirin, anything with a minty flavor, foods that have yellow food dye listed on the label, and artificial sweeteners as found in soft drinks and some other food products. A two week trial of this avoidance is carried out. Occasionally a person can tolerate a low level of a

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substance, such as salicylate, without any problem, but a higher level will cause hives. If the hives resolve, during these trial periods, the eliminated items are reintroduced, one at a time. If the hives still persist, then a very strict elimination diet may be helpful. 6 Such diets are not easily followed and the aid of a dietitian may be necessary. In severe problems, the child is sometimes hospitalized. In general, it is better to prescribe a strict elimination diet allowing the patient only a few specified foods than a less strict diet avoiding one food at a time. The patient is told that nothing should go into the mouth except steamed rice, broiled lamb (without seasoning), broccoli, green beans, fresh pears, sugar, salt, and water. This is certainly not a very appetizing diet, but can be handled by most patients for about five days. If the hives resolve during this period, then additional foods are added, one at a time, beginning with those foods which have been the most difficult to avoid. The added foods should be easily identifiable, not mixtures. A recurrence of urticaria when a specific food is reintroduced can be diagnostically helpful. If this diet does not disclose the offending agent, a broadspectrum antibiotic is given and the effect on the urticaria is noted. In this way, a low-grade infection may be implicated. If the patient does not respond to these measures, further workup is usually fruitless. The child should be reexamined at about three month intervals for additional clues. In the meantime, the child is kept as comfortable as possible on the least dosage of antihistamine necessary. It is sometimes advisable to give a single large dose of hydroxyzine at bedtime, and additional dosages may not be required during the day. The patient who has experienced an acute bout of urticaria with respiratory involvement should carry a kit with an antihistamine and syringe with epinephrine. Those involved should be instructed regarding the use of a hypodermic injection. We like to have each parent or patient actually administer a small injection of saline so they overcome the initial fear of giving an injection.

STAPHYLOCOCCAL INFECTIONS Recurrent skin infections, such as folliculitis and stys, can be a troublesome problem in children. At any specific time, the child will have one or two lesions with a history of new lesions occurring about every 10 days. Staphylococcus aureus can be cultured from the lesion. There is usually no indication of immune problems. It seems that the child has become colonized by the organism and with some minimal insult an infection occurs. A course of antibiotics often clears a specific lesion, but the cycle soon recurs. Local care is often more important than antibiotics in treating such cases. One successful regimen is as follows: The child is bathed with a chlorhexidine preparation (Hibiclens). This is most easily done in the shower. The child is totally wetted, and the shower is turned off. Hibiclens is applied sparingly to the body and lathered in the same way one scrubs hands prior to surgery. A clean wash cloth is used to help apply it to the face and scalp. Care is taken not to get the material in the ears. The whole procedure usually takes about three to five minutes. The shower is again turned on, and the body is rinsed off. After the child is dried, clean pajamas are put on. The regimen is repeated two days in a row each week for a month. The same two days the child is washed in this manner, Bacitracin ointment is applied with a cotton tip applicator to each nares,

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twice daily. The child is bathed with ordinary bar soap the other days of the week. Many children with recurrent skin infections have crusting of the eyelashes, and Staphylococcus aureus can often be cultured from the lashes. A few drops of a mild shampoo (Johnson's Baby Shampoo) are applied to a washcloth and used to gently wash the eyelids and eyelashes. The shampoo is then rinsed off with clear water. This is repeated twice daily. Special attention is also given to keep the fingernails clean and trimmed. Handwashing with regular soap is encouraged several times a day. Fresh cotton underwear is put on daily. 4 The child should sleep in pajamas and not in the underwear worn during the day. It is best to avoid irritating occlusive double knit polyester clothing. Underarm antiperspirants are avoided since they act by occluding sweat ducts and, thereby, aggravate axillary folliculitis. If there has been a prolonged problem, a course of dicloxacillin for 10 days is given at the outset of the program. Information should be sought about the possibility of other family members currently experiencing the same problem. 24 If so, they should receive similar treatment. On occasion, a pet, such as a Siamese cat, will be a carrier. A family member may also be a carrier of Staphylococcus aureus yet not develop lesions. If a problem is persistent, it may be necesary to obtain nose cultures from the members of the family to find the s·ource. If this is contemplated, the laboratory should be consulted in order to minimize the expense involved in obtaining multiple cultures. If the child is developing abscesses in addition to other types of infections, an immune disorder must be considered.

HEMANGIOMAS The most common type of hemangioma in childhood is the strawberry type. This is present at birth, but may not develop its red color or stand out until after the first few days of life. Nothing has to be done for the small hemangioma 1 to 2 em in diameter. The natural course of such a lesion should be discussed with the parents. The lesion will often become larger during the first six to 12 months of life, then remain stationary in size. Gray areas wiU then begin to develop within the tumor, and it will regress over the next few years. Most hemangiomas are almost completely resolved by school age. After resolution, the skin in the involved area will show some puckering, but often this is not noticeable. The parents are encouraged to allow the natural evolution to occur rather than subject the child to aggressive therapy . 10 Unfortunately, some hemangiomas are larger and occur in problem areas. A strawberry hemangioma can cause difficulty with vision, interfere with feeding, occlude the external auditory meatus, or obstruct the anal or urethral opening. In such special situations, systemic steroids should be considered since they are capable of causing resolution of the hemangioma. 12 Oral prednisone (2 mg per kg per day) is given daily in a single morning dose for several weeks until adequate resolution has occurred. The medication is then tapered over the next month. On occasion, reenlargement of the lesion may occur when the steroids are reduced. If necessary, the dose may be temporarily increased. Several such episodes of enlargement and retreatment may occur during the first year of life. After that

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time the hemangioma may still be present, but usually does not pose the same threat. Again, the long-term prognosis for such lesions is good. Resolution can be expected. The scarring which remains after the resolution of any hemangioma will be more noticeable with large lesions. These areas can often be revised by the plastic surgeon. On occasion, if a lesion interferes with vision and is not responsive to systemic steroid therapy, a surgical procedure should be considered. Some local measures can be of help in the everyday care of hemangiomas. Parents always worry about possible bleeding. They are reassured that this is not a frequent problem. If the lesion is injured, gentle pressure over the bleeding area with a clean handkerchief is all that is necessary. Pressure should be applied for about five minutes by the clock before any "peeking." In the event of a more severe laceration, suturing is occasionally necessary. With larger or multiple hemangiomas, platelet trapping may occur. Excessive bleeding may occur from the hemangioma as well as from other sites owing to a dysfunction of the clotting mechanism. Bleeding can also be a problem if surgery is required for other reasons. With larger hemangiomas of the extremities, gentle pressure to the lesion by wrapping with an elastic type (Ace) bandage may effect quicker resolution. The bandage should be applied carefully so as to avoid constriction. With some of the larger facial lesions, specially fitted Jobst type elastic bandages can be made and worn. These help protect the area from trauma, seem to hasten resolution, and conceal the lesion. They are a nuisance because they are uncomfortable, are warm in the summer, and have to be washed frequently because of soiling. Hemangiomas around the anal opening require special care since they have a tendency to ulcerate. Frequent cleansing of the area is necessary. A nasal bulb syringe is helpful in squirting water over the surface to remove debris. A light coating of plain petrolatum can then be placed over the lesion. If ulceration occurs, more frequent water cleansing is encouraged and the open area is treated with topical silver sulfadiazine cream several times daily. A non-laxative stool softener (Maltsupex or Colace) is recommended to avoid the hard stools and straining which traumatize the hemangioma. Hemangiomas around the face, especially around the mouth, seem more susceptible to infection following minor trauma. A relatively small cut which might become secondarily infected yet heal quite well on normal skin can lead to extensive destruction in a hemangioma. Such complications can occur in just a day or two. When they finally heal, a significant scar may remain. For this reason, routine wound care should be discussed with the parents. Generally, a good soapy water cleansing at the time of injury is most important. This is followed by gentle cleansing several times a day. The lesion is kept dry and protected. The use of an occlusive dressing, such as Telfa, is discouraged. If such a lesion does not respond quickly and there is an indication of infection, oral antibiotics are started. In general, antibiotics are used more promptly if there is a problem with a hemangioma than with a similar problem involving normal skin.

STOMAL CARE Nurses trained in ostomy care can be a great aid in counseling parents of children with stomas. We have found that prevention of problems is quite important.

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irritation. 7

The method of pouch .application is important in preventing In general, the normal skin around a stoma is cared for. by gentle cleansing with water, with only an occasional need for mild soap. The area is then rinsed well with water and allowed to dry. Gentle drying with a hand held hair dryer can be of help. Wet skin is avoided since it allows easier penetration of irritants. A "blanket" (4 X 4 inches) of special adhesive (Stomadhesive, Rolli Hesive) with a hole cut in the center the size of the stoma is placed around the stoma with the adhesive side in contact with the skin. The stoma pouch is then attached to the adhesive material by a ring of karaya gum which comes already attached to the stoma pouch. The body discharge then flows from the stoma into the pouch without contacting the skin. It will touch the special adhesive, the karaya ring, and the pouch, but is prevented from running underneath the adhesive onto the skin. A pouch can be changed by removing it from the adhesive as frequently as desired, since the removal does not involve the skin. The special adhesive "blanket" is changed about every three or four days. As can be imagined, each patient or parent devises his own special techniques for care of the appliance. Several variations will be described. A small circle of the special adhesive can be cut with a diameter about 3 em larger than the diameter of the stoma. A hole is cut in the center the size of the stoma. This is placed on the skin first, then the larger "blanket" piece of special adhesive is attached. It is easier to seal the small piece to the skin than the large "blanket." The small piece also builds up the skin level near the stoma and helps material run "away from" the stoma. With a biliostomy, it often helps to remove the karaya gum ring since it will frequently be digested by the bile and small pieces of the karaya gum may work their way back into the stomal opening, If the special adhesive does not stick to the skin, a thin application of compound tincture of Benzoin is carefully applied with a cotton applicator. This may sting for a minute but results in good adhesion. Occasionally, the Benzoin becomes an allergen and, therefore, cannot be used. Young children often finger and pull off the special adhesive. A layer of paper tape applied over the special adhesive and extended onto the skin usually cannot be removed by the child. With improper care and, occasionally, even with good care, the skin will become irritated. 16 A variety of conditions result from the drainage of saliva, gastric contents, bile, urine and feces from a stomal opening directly onto the skin. 22 The most common problem is a direct irritation of the skin causing a primary irritant dermatitis. Further irritation is caused by the removal of layers of epidermal cells sticking to adhesive materials which are frequently applied and removed. These materials include tape as well as the adhesives used on the pouches and attachment devices. Over-the-counter remedies and prescribed topical medications can be additional sources of irritation or allergic sensitization. These various forms of dermatitis can be further complicated by secondary Candida albicans infections. 14 When a dermatitis develops, the appliance material is removed and the area is gently compressed for about five minutes with clear water using a handkerchief or diaper as the compress materiaL "Four by four" sponges or "Lightdays" sanitary pads can be used to absorb the discharge so as not to contaminate the skin during the compress period. The area is dried with the blow dryer. A small amount of steroid cream is placed on the skin and allowed to dry. Then a small amount of nystatin powder (Mycostatin Powder, 100,000 units per gram) is dusted on the involved skin. Only a thin coat is used so as not to interfere with adhesion

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of the special adhesive. The special adhesive is then reapplied. This may have to be repeated twice daily but as soon as possible the frequency of removal is decreased. It is generally best to keep the bag on at all times. Since tincture of Benzoin and aerosol steroids cause discomfort when applied to irritated skin, they should be avoided. When Candida albicans is found on the skin, nystatin (Nilstat Oral Suspension) is given orally to reduce the candida in the bowel and, thereby, decrease skin contamination. In children with stomas who have had major gastrointestinal surgery, long periods of parenteral nutrition may be required. In these cases it is necessary to be certain the child receives adequate supplements of such nutritional components as zinc, lipid, and biotin. 13 A deficiency of these nutrients can result in dermatitis. On numerous occasions stomal dermatitis persists until these needs are recognized.

FOOT DERMATITIS Foot dermatitis in childhood can be difficult to cure. Tinea infections of the feet in children are unusual, but certainly occur. Therefore, any child with foot dermatitis should have scrapings of their skin examined by potassium hydroxide mount and culture. If the condition proves to be a tinea infection, it is treated appropriately. Relatively small patches of tinea are treated topically with miconazole cream 2 per cent (Monistat-Derm Cream) applied twice daily for several weeks. If there is a significant inflammatory component, hydrocortisone cream 1 per cent can be used in addition to the antifungal medication. In extensive or resistant cases, oral griseofulvin can be used. Generally the suspension (Grifulvin V, 125 mg per 5 ml) is given in a dose of 10 mg per kg per day. The medication is taken with a small amount of milk or ice cream to enhance absorption. The griseofulvin is given for about four weeks after which a rescraping of the area for potassium hydroxide mount should be performed. Children with tinea infections of the feet should follow similar general foot care instructions as will be described for other types of foot dermatitis. Foot dermatitis unrelated to tinea is often difficult to diagnose specifically. When the dermatitis involves the top of the toes, allergic contact dermatitis should be suspected. Patch testing to the common ingredients used in shoe manufacture should be performed only after the acute episode has been cleared. If a positive test defines an allergy, the parent should be advised as to which ingredient should be avoided when purchasing shoes. Avoidance is often difficult. Special shoes can be a problem to find and are expensive. Some general rules have been found to be helpful in most types of foot dermatitis regardless of cause. If the child is allergic to some shoe material, the allergen must travel from the shoe to the foot through the sock and this requires moisture. Therefore, the first rule is to try to keep the feet as dry as possible. Since it takes a pair of shoes about two days to dry out after they have been worn, it is important to have several pairs of shoes even though this can involve a significant initial expense. In general, thin leather-soled shoes are less hot to the feet than rubber-soled sneakers. In most shoes the inside is not leather and tends to be occlusive. 5 It is suggested that a thin piece ofleather be obtained, cut out to the shape of an insole and glued into the shoe. Cotton socks (of any color) should

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PERSISTENT PEDIAtRIC SKIN PROBLEMS

be worn and changed several times during the day. Shoes should be of proper size. A laced shoe will fit better than a nonlaced boot or moccasin. The lining of shoes should be inspected frequently to be sure it is not worn since a torn lining will rub and irritate. Compliance with these suggestions often makes a great difference in preventing dyshidrotic dermatitis, allergic contact dermatitis, sweat occlusion plantar dermatitis, and recurrent tinea pedis infection (when the tinea infection has been treated properly). 27 Children with atopic dermatitis will often rub their feet on the carpet or on the bed sheets, causing sufficient irritation to keep the dermatitis active. It is important not to allow such rubbing to become a habit. To disrupt this tendency, the feet should be protected day and night. At night, this can be done by wrapping elastic type (Ace) bandages over a pair of socks. Topical hydrocortisone cream 1 per cent is applied to the feet before the sock and bandage are put on. On arising in the morning, the bandage is removed, hydrocortisone cream is reapplied, and fresh socks and shoes are put on in order to prevent bouts of rubbing. Once the dermatitis on the feet has cleared, the itching is reduced, and the stimulus to rub is removed. A number of children have been seen who have applied potent topical steroid preparations to the sole of the foot for excessively long periods of time. Often the preparation has been used with extra occlusion in the form of "Baggies" or "Saran Wrap." This can cause atrophy of the skin which further complicates the original problem. When an attempt is made to stop this practice, one can anticipate some Hare of the condition. Nevertheless, the potent steroids should be stopped and the dermatitis treated using the methods outlined above. Occasionally a child seen with one of the conditions described above also has the complication of secondary infection. The feet are not only dermatitic but are macerated, tender, and pustular. These children have to be off of their feet for several days until the condition is brought under control. The feet should be soaked in soapy water for 10 minutes, then rinsed in clear water for a few minutes. While soaking, the skin should be rubbed softly with a cloth. The purpose of the soak is to gently debride the skin. On completing the soak, topical hydrocortisone 1 per cent cream is applied. Oral erythromycin is given for 10 days. In some children, secondary infection recurs frequently. The slightest irritation causes dermatitis, which then becomes easily secondarily infected, further augmenting the dermatitis. An immune sensitization to the bacteria and to the breakdown of products of the involved skin seems to occur and trigger the subsequent dermatitic reaction. Children subject to this cycle of events are instructed to soak their feet twice daily in clear water as a routine measure. Only five minutes is needed. The purpose of the soak is to remove debris, including the remnants left from sweat. It is also important that these children curtail active sports during bouts of dermatitis and for a short time after the feet clear. Once the condition becomes chronic, it is difficult to clear and can cause considerable disability.

SCABIES Frequently scabies is needlessly a long-term problem. Often, at the time the child is evaluated by a physician, the pruritic eruption has been present for

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months. Sometimes the diagnosis of scabies has not even been considered. 2 In other instances the diagnosis has been accurately made, but treatment details have not been followed. It is most important to confirm the diagnosis with a direct mount scraping demonstrating the organism, eggs, or feces. These can be clone on almost all children with the condition. When the diagnosis is absolutely established, treatment can be carried out with confidence. At this time lindane l per cent lotion (Kwell) is still the agent of choice for treating scabies. Lindane l per cent lotion is applied to the skin from the neck clown. Only a thin application of the medication is necessary, but it is important that all surfaces be treated. It is necessary to get the medication between fingers and toes, and around the genitalia, in the axilla, and on the rest of the skin. The medication is left on overnight and washed off the next morning. It is left on for a total of eight hours. After the lotion is showered off, the child is dressed in clean laundered clothing. This procedure is repeated in one week. The parent should personally carefully apply the medication to the child. The parent is fully instructed that the medication is a poison and should be used only topically as instructed and only on those two occasions. Itching will not stop immediately after application; rather it often takes a week to two weeks before the itching begins to subside. Patients are made aware that this is an allergic phenomenon which takes time to resolve. During this time, topical steroid preparations are prescribed. All persons who live together and have reasonably close contact are treated. It is best to treat everyone on the same night. In this way, "ping-ponging" of the infestation back and forth is minimized. The bed linens are all changed and need only be washed in the regular manner. Unless laundered, all other clothing should not be worn for two clays. This makes it unlikely that an organism will remain alive and able to reinfest others. Generally, no other precautions or further decontamination procedures are recommended. In prescribing the medication, about half an ounce of lindane l per cent lotion is needed to cover a child for one application and about one ounce is needed for an adult. The amount of medication prescribed should be close to what will be required. Any medication left over should be disposed of and not left in the medicine cabinet. Special precautions are needed in treating very young children, especially those under one year of age. Children in this very young age group certainly get scabies, and when the diagnosis is confirmed, the child should be treated. Medications other than lindane do not seem to work as effectively, yet it seems prudent to prescribe an alternative because of reports of toxicity.l 9 Crotamiton cream (Eurax Cream) is used in these situations. It is applied to the body surface (except the face) at night, reapplied the next night (without taking a bath), and then washed off the following night (48 hours after the first application). This procedure is repeated in one week. Children infested with scabies are subject to the development of impetigo because of excoriations. These children should be treated appropriately with oral antibiotics in addition to the anitscabetic regimen.

ATOPIC DERMATITIS Some children with severe atopic dermatitis are difficult to manage. 1 7.1 8 The etiology of atopic dermatitis is not known; therefore, the emphasis is on management, and the methods used are those found to work and which result in minimal

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problems over the long haul. Fortunately, in most children, atopic dermatitis tends to resolve by the third or fourth year of life. The everyday care of the skin is quite important. In this condition itching is primary. Minimal irritation aggravates itching, the itching causes scratching, which causes the skin to eczematize, which causes more itching. Dry skin is easily irritated. It is helpful to keep the skin hydrated. This is done by short baths of about five minutes duration twice daily. Soap is avoided but, if needed, is rinsed off thoroughly. The bath is immediately followed by the application of a lubricant such as Eucerin. Eucerin is applied to the skin immediately after the child is removed from the tub while the skin is still wet. Then the child is dressed. One hundred per cent cotton clothing has generally been found to be the least irritating. Today cotton clothing is difficult to find and expensive, but we believe it is important. Usually someone in the family will take on the chore of making cotton clothes. Cotton underwear, socks, and tee shirts are still generally available in stores. Bedding is also important. Well worn cotton sheets and pillow cases are very soft. Blankets should also be made of cotton, such as the "receiving type" blankets or quilts. The play area should be a non-carpeted floor. Since many homes are carpeted, this often is not possible. Spreading a quilt on the floor helps. This can also be done in the area where the child views television. Likewise, chair coverings in the house and in the automobile should be checked. If they are rough, a soft terry cloth towel can be used to sit on. If possible, it is best to have a pet-free house. This is suggested because many of the children also have asthma. Pets often make the asthma worse and, in the process, the skin usually suffers. Individual children may respond better to an alternative regimen of local therapy, namely, one in which the child is kept from bathing for long periods. In this regimen, the skin is cleansed and lubricated with the same substanceCetaphil Lotion. Cetaphil is a nonlipid lotion which can be applied to the skin as a lubricant or cleanser. If applied liberally and rubbed, lathering occurs. It is then gently wiped off. This procedure cleanses the skin. Another application of the Cetaphil using a smaller amount is then applied as a lubricant. The lotion is used as a lubricant at least four times during the day. Patches of dermatitis are treated with a topical hydrocortisone 1 per cent preparation four times daily. In the winter, an ointment base is used; in the warmer summer months, a cream base is used. In the more severe forms of the disease, therapy will be initiated with a more potent topical steroid. Triamcinolone cream, 0.1 per cent, is generally used. This is applied to the involved areas about four times daily. When resolution occurs, lubrication alone is used. With severe atopic dermatitis there is often significant secondary infection with Staphylococcus aureus. Generally, the patient with severe disease will be started on systemic antibiotic therapy for two weeks. Erythromycin is a frequent choice. Topical antibiotic preparations have not been found to be satisfactory in these cases. Food restriction has not been found to help the child with atopic dermatitis directly. There are a few children who do start to itch following ingestion of certain foods. Usually these children are found to develop hives from the foods, the hives then itch and this, in turn, stimulates scratching, which worsens the atopic dermatitis. Occasionally animal dander will cause contact urticaria and

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itching in a similar manner; avoidance of pets is helpful. Sweating also aggravates itching. The practice of giving habies warm bottles causes scalp sweating and itching. The itching is often misinterpreted as an allergy to milk. The scalp will often be scaly in atopic dermatitis. this is not a true seborrheic dermatitis and should not be treated with strong antiseborrheic shampoos which can irritate the atopic scalp. Often, only clear water is necessary for cleansing. Occasionally, a mild tar shampoo (Polytar) can be used but should be rinsed off well. A steroid lotion can be made in the palm by mixing triamcinolone cream (Aristocort) with a little water, and this can easily be applied to the scalp. Antihistamine type drugs are often given to help the child sleep at night. Hydroxyzine syrup, 0.5 mg per kg, can be given an hour before bedtime. Parents have often heard that a medicine exists which will clear the condition in a few clays. Oral prednisone, indeed, will do this, but it should be strongly avoided. Invariably, the child placed on prednisone will have to be kept on it in order to stay clear, and this will be accompanied by all the problems of chronic steroid administration. The availability of such medications and the hazards of their use should be reviewed with parents so they can properly evaluate information they might hear from family or neighbors about "magic medicines." Psychological stress also aggravates atopic dermatitis. It is not felt, however, that it is a primary etiologic factor. This concept is discussed with parents. If there are family situations which are stressful to the child, they should be recognized and efforts made for their resolution. A situation not uncommon is to have the young child coerce the mother into the child's bed at night. This situation is also discussed with the parents. There is need to comfort the child, but it is important that normal discipline be maintained. The children can quickly learn to use their skin problem to manipulate the family. It has always been of interest that most children with severe atopic dermatitis admitted to the hospital do much better. This is accomplished on the same diet and medications that are given at home. It is not known why this occurs. There are certainly many things to be learned about this condition.

REFERENCES 1. Bauer, E. A., Cooper, T. W., Tucker, D.R., et a!.: Phenytoin therapy of recessive dystrophic epidermolysis bullosa. N. Engl. J. Med., 303:776, 1980. 2. Burns, B., Lampe, R., and Hansen, G.: Neonatal scabies. Am. J. Dis. Child., 133:1031, 1979. 3. Chiba, K., Ishizaki, T., Miura, H., eta!.: Michaelis-Menten pharmacokinetics of diphenylhydantoin and application in the pediatric age patient. J. Pediatr., 96:479, 1980. 4. Eickhoff, T.: Therapy of staphylococcal infection. In Cohen, J. (ed.): The Staphylococci. New York, Wiley-lnterscience, 1972, p. 517. 5. Enta, T.: Peridigital dermatitis in children. Int. J. Derm., 19:390, 1980. Gibson, A., and Clancy, R.: Management of chronic idiopathic urticaria by the identification and 6. exclusion of dietary factors. Clin. Allergy, 10:699, 1980. 7. Gross, E., and Irving, M.,: Protection of the skin around intestinal fistulas. Br. J. Surg., 64:258, 1977. 8. Hurn'itz, S.: Acne vulgaris: Current concepts of pathogenesis and treatment. Am. J. Dis. Child., 133:536. 1979. 9. Hurwitz, S.: Clinical Pediatric Dermatology. Philadelphia, W.B. Saunders Co., 1981. 10. Jacobs, A.: Birthmarks: I. Vascular nevi. Pediatr. Rev., 1:21, 1979. 11. Jacobson, K.W., Branch, L.B., and Nelson, H.S.: Laboratory tests in chronic urticaria. J.A.M.A., 243:1644, 1980. 12. Lasser, A., and Stein, A.: Steroid treatment of hemangiomas in children. Arch. Dermatol., 108:565, 1973. 13. Latimer, J.S., McClain, C.J., and Sharp, H.L.: Clinical zinc deficiency during zinc-supplemented parenteral nutrition. J. Pediatr., 97:434, 1980. I•

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14. Leyden, J., and Kligman, A.: The role of microorganisms in diaper dermatitis. Arch. Dermatol., 114:56, 1978. 15. Leyden, J.J., McGinley, K.J., and Mills, O.H.: Pseudomonas aeruginosa gram-negative folliculitis. Arch. Dermatol., 115:1203, 1979. 16. Mollitt, D., Malangoni, M., Ballantine, T., eta!.: Colostomy complications in children. Arch. Surg., 115:455. 1980. 17. Moss, E.: Atopic dermatitis. PEDIATR. CLIN. NORTH AM., 25:225, 1978. 18. Norins, A.: Atopic dermatitis. PEDIATR. CLIN. NORTH AM. 18:801,. 1971. 19. Pramanik, A., and Hansen, R.: Transcutaneous gamma benzene hexachloride absorption and toxicity in infants and children. Arch. Dermatol., 15:1224, 1979. 20. Prevost, E.: Nonfluorescent tinea capitis in Charleston, S.C.: a diagnostic problem. J.A.M.A., 242:1765, 1979. 21. Rasmussen, J.: Acne. Major Probl. Clin. Pediatr., 19:54, 1978. 22. Rothstein, M.: Ostomy skin care. Curtis, 26:200, 1980. 23. Schuller, D.E., and Elvey, S.M.: Acute urticaria associated with streptococcal infection. Pediatrics, 65:592, 1980. 24. Steele, R.W.: Recurrent staphylococcal infection in families. Arch. Dermatol., 1i6:189, 1980. 25. Stoughton, R.B.: Topical antibiotics for acne vulgaris. Arch. Dermatol., 115:486, 1979. 26. Weston, W.L.: Practical Pediatric Dermatology. Boston, Little, Brown and Company, 1979. 27. Zaias, N., Battistini, F., Gomez-Urcuyo, F., eta!: Treatment of "tinea pedis" with griseofulvin and topical antifungal cream. Cutis, 22:196, 1978. Department of Dermatology Indiana University School of Medicine llOO West Michigan Street Indianapolis, Indiana 46223