This presentation covers acute skin issues in children that often panic parents and puzzle pediatricians, with a focus on problems that increased during quarantine. UCSF dermatologist Renee Howard, MD, provides tips for these conditions – from “COVID toes” and space-heater reactions to follicular cysts and bug bites – to help with determining diagnoses, treatment plans and referral needs.
mm. So I get a lot of referrals from the community, which I absolutely love. Some of them are by email, some by text, some by official consult. Um Come through the clinic and over the years I've been here now for five years back at Children's full time, I noticed certain trends in certain entities that tend to come back over and over again. And these are the cases I try to choose is the ones that are confusing for our fabulous pediatric community. Certain rashes and certain lesions tend to be confusing and lead people astray and there's some examples of what you feel like when you see the rash and some of the rashes will be looking at today. I'm going to start by just reviewing the current status of our pediatric Dermatology clinic at Oakland in the Covid era. And then we'll move on to present six common puzzling rashes and lesions. I want to give you some diagnostic clues. Some primary care management. Um got help and then review indications for dermatology referral. So this is our road map. This is me taking a picture of the path ahead up in point race. So as you all know a year ago, almost a year ago, our lives changed completely. Who knew that I would be hanged drawing cloth masks um by the way, which have in 95 filters in them to wear to the grocery store on my deck. Who knew that I would have to convert the entire pediatric dermatology service to virtual in March of last year. And then over the summer as we started to come back in person, um we had to limit our volume of family so they didn't have so they could social work and social distance. So at this point we have one provider in clinic, five days a week, we have to alternate which providers in clinic so that we don't have crowding. Um dr Kettler, anjali Washington and I alternate different days being on call and being in clinic. Um And now at this point Dr Hitler is the only one going to walnut Creek. I'm just in Oakland and I have a marine practice too. So we are triaging very heavily more than usual whether we want to do a video, we all have video clinics and in person and what the timing should be on that. We're triaging the urgent through 800 you see child or through the division. Um And we do have tele dermatology available every day for urgent consult. You can mark your referral is urgent. For example a two week old baby with the hemangioma that's growing. Those get priority over an eight year old with award. And I have to admit those patients have a hard time getting in right now. The older kids with monarchy problems. I will admit that because of the limitation in person. And then if you're unsure, I do a lot of triage by email, by inbox staff messaging. If you're on the UCSF instance of epic, I love doing triage. I'm happy to help you. If you have a minor question, you can email me. I don't mind at all and don't feel like you shouldn't do it. Um that you'll be bothering me. This is part of my job and I really enjoy it. Please don't send us a patient with active covid. We just aren't equipped for that in our clinic. So if there's any covid exposure, any fever symptoms. Marcus video. Is it only we do screen the families both on the phone and in the lobby. But a couple of escaped through our providers are vaccinated that our whole staff is not vaccinated. Even with the PPE. Which has been very effective. We haven't had an outbreak in our clinic, it still makes me nervous. I don't want to see sick kids in the clinic at this point. So I thought I would start with a case that was covid related. So all of you may recall last spring when these types of toes started showing up on social media and in the medical literature. And this is a patient of a marine patient of Susan Dabs who sent me set dr corda. Are these photos um of what we would call in dermatology? Pernia Asus. But what was called last spring and social media and in the lurch is covid toes. So what is covid toes? And why are we seeing a whole bunch of these cases again in the last month or two? So we saw a bunch last spring and then not much over the summer and then a bunch in the last couple of months. Getting a lot of these consults in person and on video. So the email from the pediatrician said to Dr Cordaro sent you a message regarding this boy, another one to send your complaints. Purple Iquitos do derm this term. So I want to see these patients. How do we manage it? I instructed wear socks, which is the number one thing you tell these people move around more. Very important and hydrate. So why are we seeing so much per neurosis? This is another case from Yasmin Corinne. This child had purple toes. Last spring was worked up for Covid was negative, was tested just with PcR not with antibody. Um and then in the last month started having the purple toes again. Then they became dry and scaly and even a little bit blistery at this point. Our opinion is that some of these cases are not covid related that there's a behavioral component to this covid pandemic, um which involves number one kids rolling out of bed and going to school on zoom. So not putting shoes on, walking around the house barefoot, number two, they're being very um inactive. So they're standing at a computer, sitting at a computer and not moving around, they go to school, they're running around between classes, etcetera. They're standing and sitting and running around at home. They're sitting in mobile now for hours at times. And so their circulation slowing down and they're getting cold injury to their hands and feet. So we do not want to see every case of Perdio, you can manage most of them and just basic pediatric approach, um, to screen the ones that have might have something more serious second vasculitis. But the main problem with these covid toeses kelly says here and um is that the main question is whether they have active covid and if they're contagious. Most cases of Parnassus associated with covid infection were post covid. So they were after the active covid infection. The patient had symptoms in september and then came in in november with tuberculosis. So most of time they're not gonna change is when they get the covid toes. But obviously if you're worried or there's an exposure concern it's just easier to do the pcr then we get the question. Should we do antibodies? Should we be doing mayonnaise? Another room tests. Our advice is if it's very painful and very very very dark purple or there's any associated systemic symptoms. So you just do your rheumatology, reviews, systems, joint paying fever, fatigue, hair loss, etcetera. Then you can decide if you want to do screening rheumatology labs, look for inflammatory markers. Crp and said rate and get both. The pcr and the antibodies is what we usually advise um terms of treatment Clovis, all korean B. I. D. Works for the severe cases. That's a class one really potent topical steroid. If it's a milder case you can just use trying to stand alone. And I do recommend a cream because when you're hands and feet are cold and flaky it's easier to rub in a cream than use appointment. And then if you if you're concerned about any associated systemic symptoms, you can put in a referral for Durham or rheumatology and we can do any consult for this. And then if they're not that severe and you think it's just regular cold injury called um uh cold vasculitis. Cold induced vasculitis. Just tell a child to keep the core temperature warm to try to stay active when they're on zoom school to keep moving, they have a five minute break right up and down the stairs where socks wear slippers um, and you don't need to refer them. So what exactly is per neurosis? It is um, an inflammation of the blood vessels. So it's a, it's a vasculitis. It's nondestructive vasculitis. It's induced by temperatures. So we saw these last spring because it was cold weather and the things I talked about in terms of the lifestyle changes we're seeing again now because the weather is cold again, specifically cold, damp triggers this type of inflammation. And by the way, this is a teenage issue, We don't see this in tiny little kids usually. Um, So if I had like a three year old who had this, I would be more concerned. So this is another rash I'm seeing a lot now. Um You can see here there's reticulated hyperpigmentation of the lower leg, this is the lower leg and this is both legs. You can see it here and here. It was, nowhere else in the body was asymptomatic, very alarming looking. I had a similar case come into the clinic at Children's having been to the er twice and the doctor up in value where this child lived three times. My guess is that the lab work up of that other child was up to about $18,000. Um and it took me about 25 minutes of calming the mom down to convince her that this child had a benign diagnosis. So does anybody know the name of this? Since I can't listen to you, I'll give you the answer. So this history is that this showed up pretty quickly about 4-5 days ago, pretty suddenly. And it's been fading a bit since it appeared. It's flat. So there's no lumps or bumps. There is absolutely no covid symptoms or signs or exposures. The child was schooled at home, just on the bilateral ankle, no leg. So in the old days we used to see this on the belly because people use hot water bottles. So I just gave you a cold induced skin problem. Covid toes or per neurosis. And now I'm talking about a heat induced dermatitis which is erythema ab agni, it's got a great name. It's inflamed skin, which is due to contact with heat. And um for some reason the skin gets inflamed and articulated manner. So it can look really scary like libido vasculitis and that's why people get so alarmed or libido race. Samosas, another type of libido that could be associated vasculitis, but this is not associated vasculitis. Um What you need to ask in the history is are you using a radiant heater or space heater? So again, people are home there immobile, they're getting cold, they're using space heaters, they're standing up against a um a fireplace, they're putting heating pads on their thighs to keep themselves warm. Or they've got their laptop on their thighs for hours on end and it's warming up their legs and they're getting it on their thighs. So, when the pediatrician texting me these photos, I asked her to took all the family and see if they were using a space here. And indeed this child had a space heater at her feet at her desk. And this is erythema ab Big me. I got an email about two weeks later from the rheumatologist which the child had already seen saying, you know, it hasn't faded. The labs were all normal and this doesn't fade quickly because there's an element of post inflammatory hyperpigmentation, which is a temporary scarring process. You don't get permanent scarring from this, but you can't get a temporary color change at last four weeks or even months. So what is the treatment? Stop the space heater or move it away from being in close proximity to the skin. So moving on to our next case, this is something I see a lot of and the issue with this Dermot o sis is it can look like just about anything and it can be very alarming looking. This might meet the criteria for most dramatic of this spectrum of skin rash that I've ever seen, which is saying something that I've been doing this for a long time. So here you see this target, toyed red dramatist plaque with a central paypal and there might be to Paypal's there in the middle and then there's some fine populace up in the more approximately thigh and a little bit of an exam in this patch there. And then you see on the other leg, there's also a bunch of appeals. This child also had a more disseminated popular rash on the hands and feet. It almost looks like hives a little bit with that blanching halo and that was quite symmetric on the arms, hands, feet, ankles and legs. So this is a six year old with impressive rash with a history of mollusc. Um, so first I thought it was infected mollusc, um, squeezed some cheesy stuff out of the center. This is the email from the pediatrician, the rash in the knees getting much bigger tender in the center if you push on it now there's rash showing off the hands, feet, and legs, No tick bites. So they were thinking about Lyme disease. Everything that chronicle migrants. Any thoughts. So the main thing is to get out your magnifying glass and look at the center and then look around the body for molesting and hiding in this rash. So dermatologists call this an eruption. Don't ask me where that term came from. Something we just learned in Durham training. But I think it makes more sense. And actually an epic the diagnosis as auto examine Ization. So when your immune system is stimulated by finally seeing um Alaskan infection, it overshoots and it causes a generalist rash and also too much inflammation around them lost them. So if you see a super inflamed in Los come anywhere in the body that child's gonna be more at risk for auto examine Ization. So there's the inflamed mollusk. um and then that causes the auto summarization. So there's two things going on here. This is the more typical localized examine this reaction to Matlock skin that we see. And we try to reassure families that this is the beginning of the end. But honestly, this process where there's examine ization around the mollusk, um, can wax and wane for weeks or even months before the moleskine actually go away. But I try to tell the family this is a good sign. This means the immune system is fighting them, Alaska. Um it's going to go away. It's going to go away. You have to keep repeating yourself. Um, So the email on this one was four year old melissa behind the knee, three months of ple plaque. So this is a very persistent now, it's three months, um, flares after bath. So this does tend to happen more in kids who have underlying eczema. Mp cultured. Some staff grew no change with me pierson. So it's probably colonized. It's probably not impetigo. Um and these folks do a little better with can theron treatment or sometimes I'll cure it or freeze if they're older. Um So if this is going on for three months, usually the kids are pretty uncomfortable. This is an appropriate referral to drum. We don't have to see all the last government. They're un inflamed. Absolutely. Tell the family it's going to go away on its own, don't worry. But if the child has an uncomfortable examine its reaction or an auto examine ization or examine its reaction that's uncomfortable. It does help for us to treat it. Um and kind of get rid of the ones that are inflamed. So they don't go through this process here. You can see more classic examine this rash on the anti cubes. But you also see the tomb Alaskan there that are inflamed. My friend Elaine stick figure a really nice article called the beginning of the end or B O. T. E. Sign for this process and sometimes I'll refer families to that article. The boat sign bot again. This is something you see all the time, your practice, this kid has mollusk. Um they're getting inflamed, are getting examine ties and then the eczema starting to move away from the Alaska and just generalizing it's if you think about it it's almost an auto examine Ization variant and the good news is all these are treated the same way. So all you have to remember is to use a mid potency topical steroid like try and sit alone anti histamines for itch you can do cool compresses if it's like the knee super inflamed and then if they're really miserable, if the auto examine. Ization is super itchy, you can do a predniSONE poison oak dose taper for two weeks. Um It can come back if it's still um immune system still cranked up at least the kid will get a break and the auto exempt organization rash doesn't usually come back. But the inflame Alaskan can continue for some time and then this is an appropriate referral. So again, most of these kids who get the examine its reaction of underlying a topic dermatitis. This more inflamed with the ed any kid can get but most kids melissa to go away with no drama. What's confusing is sometimes I'll see a kid like this so lots of paypal's scattered on the body. Um Here's one with surrounding era theme and a little bit of crusting. You can see underneath that scabbed lesion. There's a intact postural and um there actually is a hair coming out of it. So that gives you the clue that the issue is in the hair follicle and this is follicle. Itis also an extremely common rash. It's very persistent and recurrent. Some of the kids have a topic dermatitis and others are just colonized with staff and it's really hard to get rid of. I used to be housed and I did and I worked a lot with charlotte and and brian at the time to help de colonize these patients. It is not easy. So this kid had so many lesions and the problem was with his dark pigmented skin every time there was a like a lettuce leaves and it left post inflammatory pigmentation. So again, like I said with the earth Mad big me that can last for months. So you have to explain to the family, we're going to treat the active infection in this car and will fade over time. It's gonna take a long time. So how do we approach follicle itis. If it's this bad and you're getting this post inflammatory pigmentation scarring then I do treat orally. If it's more mild I try to avoid oral treatment I'll give you some tricks for that. But 14 days of Catholics, most of the staff and the community now is M. S. A. So we just use Catholics. We don't have to use Splenda International New Pearson twice a day for seven days and I often will do the whole family Um and then we'll do something to reduce the risk of recolonization. So either bleach fast 2-3 days a week for two months. And those of you have access to our instance of epic, we have some smart phrases for this to put into your A. V. S. Or you can have the family, get closure exiting for the shower. So what about this kid? Are we going to give everybody with mild flu colitis two weeks of complex? No, because what happens, the colitis comes right back and then you're still kind of trying to figure out how to get rid of the colonization. If you have a buttock follicle itis. The bleach baths are really great for that because most of these kids are colonized in their groin. Their parental skin, their inner glow real creepy Greece has colonized and then it goes out and makes the inter follicular infection or follicle itis. So my routine is to do those bleach baths every other day for usually two weeks or that's typo and then twice a week for two months. So I tell the residents just remember to Every two days for two weeks, then two times a week for two months. Is that a scientific paper that came up with that? No, that's just easy to remember and effective. And then you want to de colonize the, knows where you carried in the anterior vestibules. Same as the other kid I showed you. This is another trick. Um Now that we're not running low on pure L you can put 6% alcohol gel or pure L right on the buttock if that's the only place they get it. And I've had a couple of kids with really stubborn butterfly colitis that did really well with just a little bit of Purell. It is irritating you have to watch for dry skin. Okay. So we're moving away from bumpy rashes into bumps and lumps. So this year to patients that came into my clinic two weeks ago, 1-2 weeks, I think it's about two weeks ago now with the same thing and they were in adjoining rooms. So this child had this um stable in size firm. And when you felt this, it felt like somebody had put a stick under his skin, like a oblong firm. And when you push on one end of the stick, the other end went up obviously kind of an alarming color, this sort of gray brown. And then this kid next door had a blue nodule with a central sort of pink scar. This is the number one nodule in kids and it comes in so many different flavors and colors. There's so many variants of it that if you refer one of me one of these and you don't know what it is. I totally don't blame you. Here's another one. This is more skin colored Again, very firm. So very alarming to families because their firm in their dark colored and when the family comes in they're worried about skin cancer and eye explicitly will tell them it's not a skin cancer from sure that it's a pile of Tacoma. So what's the difference between a pilot matrix? Soma assist and the kind of cyst that you see in adults and teenagers that are more spaciousness? Um The difference is the depth. So in kids, the follicular benign growth comes from the bottom of the poor. That's called the matrix. That's where the hair matrix where the hair is formed at the bottom of the poor, the bottom of the follicle. And so these lesions are deep and they don't always have a visible poor above them and they don't always drain, they'll just sit there for years even um stable in size are slowly growing. So you don't have that overlying poor that you see with regular assists, which is the number one growth and adults. And um what we find is pediatric dermatologist, we schedule these kids for surgery. If it's less than a centimeter a lot of times is that thing's gone away so it does self resolve and this is the magic number. If it's greater than a centimeter, refer it because I'm going to think about talking to family about taking it out. So this one we're going to take out because we want to confirm this on path because it is a little weird color. Um if it's less than a centimeter, you can watch it if it's greater than a centimeter or it's symptomatic, so painful draining or it's been there more than a year. Then go ahead and refer to us and we can talk to the family about excision. We can't take these out without a scar. So you can imagine if you cut this out, you're going to give the kid a scar right in the middle of the face so you don't want to do surgery unless you have to. There's no such thing as surgery without a scar, even including plastic surgeons. There's just no way to check this out with a scar. So this is a really challenging case. Um This kid had been followed for quite some time and seeing a lot of doctors and carried the diagnosis of bug bites. So we do see a ton of bug bites in dermatology clinic because these patients are extremely uncomfortable and it's very aggravating. It's really hard to prevent kids from getting bit and once they get allergic to fleas, usually they will have reactions like this for a couple of years before they get tolerant, sometimes longer. And when you look at armpit like this, you don't even know where to begin. I mean there's so many different things going on and this was her back. But the primary relations in article real popular plaque. So I think all of you will look at this and worry about bedbugs or fleas. But this kid had been down this road so many times and this is what her feet look like. So she had a sub epidermal or a deep blistering problem in associated with this burger carol plaques. So now you're wandering into the very far end of the bell curve for bug bite reaction. And then you have to start thinking about a differential diagnosis. I looked at this and I'm like, this is fully by allergy. They're vesicular, they're grouped, you've got all these different phases of the game there on the waistline where the fleas love to bite there on the side of the chest where they love to bite the ankles, they love to bite. But this child is so allergic to whatever bid her in the first place that her body started to go off the rails and she just started getting spontaneous blistering 14 medical counters, 7 80 visits, 2.5 years from age 1 to 4 before I saw her. And these are all the diagnoses. She had, some of which are absolutely the differential. She had so many courses of antibiotics without a single culture done. So you know if you want to be a good antibiotic Stewart at some point you got to do a culture, improve what you're treating. Um When she got to the chobe d. Finally she lived a little bit far away. They did a culture, it was negative. They sent to me and I did a skin biopsy because again, this kid's way on the end of the normal curve for bug bite and it came back blistering bug bite reaction. So we went through this whole thing with the mom saying, you know, this could be a blistering immune disease. Here's another patient who has a flea bite allergy and you can see it looks really similar to the case. I just showed you there's this blister the ankles, there's one on the face, the side of the chest. They just love to bite where the clothing is touching. So you can see why everybody thought that my patient had bug bites. But this is the differential that you have to at least think of immune bowls disease. They're all extremely rare bowls. Pantelides really rare in kids, chronic bulls disease of childhood a little less. So this is a biopsy diagnosis as a pediatrician, you're not going to make this diagnosis. This is extremely rare in kids that there's an associated cancer driving it. And then this is an S. And I feel like um Dermott Asus caldwell's which I've seen a few times and kids exquisitely predniSONE sensitive. Um I tried one particular apprentice on for this patient and she didn't do do well. I checked a cbc and she didn't have hypertensive ophelia. But that's something to worry about. And we had another case last year of a boy who came in with hybrid a set of values syndrome ended up having leukemia, older kid. So the moral of the story with this patient is, most of these patients have bug bite allergy. You have to get the fleas exposure controlled um and you can treat them with try and sit alone and kind of similar the way you treat the reaction and his means try and settle. Um but remember there's a differential diagnosis and if you start seeing blisters, it's time to refer. So blisters is really the indication for referral. I'm thinking of this is another covid associated rash. I'm seeing so much of this these days and some of the cases come in and they have no idea what they have. The family has no idea, and they don't believe me. So, I want you to notice the streaky nature of this rash, the linear aspect. This is poison oak. So people are home, they're taking walks there there, home with their pets, they're struggling with their pets who are in and out of the house and getting poison oak oil on there for um The classic poison oak morphology where you kind of have this individual lesions that look like bug bites, but then they're running together over days, they turn into more plaques. And then this linear morphology where the kids scratched and you look for occult sources like cast and also cats. So I had a couple of cases, two cases in the last week that the pet was in and out of house and the kid was getting it from the pet, here's the extreme end of the bell curve for poison oak. I had to do dressing changes on this kid for a month. She was on predniSONE for five weeks. So this is on the far end of severe for poison oak, but this is poison oak. So again, if it's blistering you refer, that's an urgent referral. So the take home is that they start bumpy like poison oak. I'm sorry, like bug bites and then they evolve into the plaques and some will be linear can be blistering and obviously you don't have to refer to me if you know it's poison oak and blistering, you want to start predniSONE. I'm totally fine with your treating this. It's so common you don't have to refer poison to a dermatologist. Um, it's almost always itchy. And then remember that it's an oil on the plant that can get on film rights, including pets, wash Fido and that it cross reacts with mango.