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AFP Journal Review: January 1, 2008

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Title: AFP Journal Review: January 1, 2008


1
AFP Journal Review January 1, 2008
  • John W. Hariadi, M.D.

2
Newborn Skin Part I. Common Rashes
  • Rashes extremely common in 1st 4 weeks of life
  • Mostly benign and self-limited
  • Transient Vascular phenomenon
  • Erythema Toxicum
  • Acne Neonatorum
  • Milia, Miliaria
  • Seborrheic Dermatitis

3
Clinical Recommendation Clinical Recommendation Clinical Recommendation
Evidence rating
Infants who appear sick and have vesiculopustular rashes should be tested for Candida, viral, and bacterial infections. C
Acne neonatorum usually resolves within four months without scarring. In severe cases, 2.5 benzoyl peroxide lotion can be used to hasten resolution. C
Miliaria rubra (also known as heat rash) responds to avoidance of overheating, removal of excess clothing, cool baths, and air conditioning. C
Infantile seborrheic dermatitis usually responds to conservative treatment, including petrolatum, soft brushes, and tar-containing shampoo. C
Resistant seborrheic dermatitis can be treated with topical antifungals or mild corticosteroids. B
A consistent, good-quality patient-oriented evidence B inconsistent or limited-quality patient-oriented evidence C consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system A consistent, good-quality patient-oriented evidence B inconsistent or limited-quality patient-oriented evidence C consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system A consistent, good-quality patient-oriented evidence B inconsistent or limited-quality patient-oriented evidence C consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system
4
Transient Vascular Phenomena
  • Normal Newborn Physiology rather than true
    rashes
  • Cutis Marmorata and Harlequin Color Change

5
Cutis Marmorata
  • Normal reticulated Mottling of skin
  • Trunks and extremities
  • Vascular response to cold
  • May persist for weeks or months
  • Generally resolves when skin is warmed

6
Harlequin Color Change
  • ?Caused by immaturity of hypothalamic center that
    controls dilation of peripheral blood vessels
  • Occurs when newborn lies on side
  • Erythema of dependent side with blanching of
    contralateral side
  • Persists for 30 seconds to 20 minutes
  • Resolves with crying or increased muscle activity
  • Up to 10 of full term infants
  • From 2nd-5th day of life, may continue up to 3
    weeks

7
Erythema Toxicum Neonatorum
  • Most common pustular eruption in newborns
    (40-70)
  • Common in term infants and those gt5.5 lbs
  • Present at birth, 2nd-3rd DOL
  • Erythematous 2-3 mm macules papules ?pustules
  • Pustule surrounded by blotchy area of erythema
    flea bitten
  • Face, trunk, proximal extremities-spares
    palms/soles

8
Erythema Toxicum Neonatorum
  • Generally clinical diagnosis
  • Cytologic exam of pustule?eosinophilia with Gram,
    Wright, Giemsa Stain
  • Etiology is unknown
  • Fade over 5-7 days, may recur for several weeks
  • No treatment needed
  • If sick appearing, need to r/o infectious cause

9
Table 1. Infectious Causes of Vesicles or Pustules in the Newborn Table 1. Infectious Causes of Vesicles or Pustules in the Newborn Table 1. Infectious Causes of Vesicles or Pustules in the Newborn
Class Cause Distinguishing features
Bacterial Group A or B Streptococcus Listeria monocytogenes Pseudomonas aeruginosa Staphylococcus aureus Other gram-negative organisms Other signs of sepsis usually present Elevated band count, positive blood culture Gram stain of intralesional contents shows polymorphic neutrophils
Fungal Candida Presents within 24 hours after birth if congenital, after one week if acquired during delivery Thrush is common Potassium hydroxide preparation of intralesional contents shows pseudohyphae and spores
Spirochetal Syphilis Rare Lesions on palms and soles Suspect if results of maternal rapid plasma reagin or venereal disease research laboratory test positive or unknown
Viral Cytomegalovirus Herpes simplex Varicella zoster Crops of vesicles and pustules appear on erythematous base For herpes simplex and varicella zoster, Tzanck test of intralesional contents shows multinucleated giant cells
10
Transient Neonatal Pustular Melanosis
  • Vesiculopustular rash
  • 5 Black, ,1 White
  • Lesions lack surrounding erythema
  • Pigmented macules within the vesiculopustules
  • Rupture easily?leave behind scales pigmented
    macules
  • All areas affected including palms/soles
  • Fade over 3-4 weeks
  • Cytology PMNs

11
Acne Neonatorum
  • 20 of newborns
  • Closed comedones on forehead, nose, cheeks
  • Open comedones, inflammatory papules
  • Stimulation of sebaceous glands by maternal
    androgens
  • Resolve within 4 months without scarring
  • Treatment usually not required can use 2.5
    benzoyl peroxide
  • Persistent/Severe? need to look for underlying
    causes

12
Milia
  • 1-2 mm pearly white/yellow papules
  • Retention of keratin within dermis
  • Up to 50 of newborns
  • Forehead, nose, cheeks, chin but can also trunk,
    penis, limbs, mucous membranes
  • Resolve within 1st month, can last till 2nd or
    3rd month

13
Miliaria
  • Sweat retention by partial closure of eccrine
    structures
  • 40 of infants-1st MOL
  • Miliaria Crystallina
  • 1-2mm vesicles without surrounding erythema
  • Hours to days
  • Miliaria Rubra-Heat Rash
  • Erythematous papules, in covered portions of skin
  • Deeper level of sweat gland obstruction
  • Avoid overheating, remove excess clothing,
    cooling baths, air conditioning

14
Seborrheic Dermatitis
  • Extremely common
  • Cradle Cap-may include face, ears, neck
  • Erythema in flexural folds, scaling on scalp
  • Often involves diaper area
  • Can be difficult to distinguish from atopic
    dermatitis

15
Table 2. Distinguishing Features of Seborrheic and Atopic Dermatitis in Infancy Table 2. Distinguishing Features of Seborrheic and Atopic Dermatitis in Infancy Table 2. Distinguishing Features of Seborrheic and Atopic Dermatitis in Infancy
Feature Seborrheic dermatitis Atopic dermatitis
Age at onset Usually within first month After three months of age
Course Self-limited, responds to treatment Responds to treatment, but frequently relapses
Distribution Scalp, face, ears, neck, diaper area Scalp, face, trunk, extremities, diaper area
Pruritus Uncommon Ubiquitous
16
Seborrheic Dermatitis
  • Etiology unknown-? Malassezia furfur, hormonal
    fluctuations
  • Self limited- resolves several weeks to months
  • Conservative approach
  • Watchful waiting
  • Soft Brush after shampooing
  • Emollient

17
Table 3. Treatment Options for Infantile Seborrheic Dermatitis Table 3. Treatment Options for Infantile Seborrheic Dermatitis Table 3. Treatment Options for Infantile Seborrheic Dermatitis Table 3. Treatment Options for Infantile Seborrheic Dermatitis
Medication Directions Cost (generic) Notes
White petrolatum Apply daily 3 for 30 g May soften scales, facilitating removal with soft brush
Tar-containing shampoo Use several times per week 13 to 15 for 240 mL Use when baby shampoo has failed Safe, but potentially irritating
Ketoconazole (Nizoral, brand no longer available in the United States), 2 cream or 2 shampoo Cream apply to scalp three times weekly Shampoo lather, leave on for three minutes, then rinse. Use three times weekly Cream (16 to 37 for 15 g) Shampoo 30 to 33 for 120 mL (16 to 38) Small trial showed no systemic drug levels or change in liver function after one month of use
Hydrocortisone 1 cream Apply every other day or daily 2 to 4 for 30 g Limit surface area to reduce risk of systemic absorption and adrenal suppression May be especially effective for rash in flexural areas
18
Newborn Skin Part II Birthmarks
  • 3 Main groups
  • Pigmented
  • Congenital melanocytic Nevi
  • Dermal Melanosis
  • Vascular
  • Hemangiomas
  • Nevus Flammeus, Nevus Simplex
  • Abnormal development
  • Most do not require immediate treatment

19
Clinical recommendation Evidence
Patients with large congenital melanocytic nevi should be referred to a surgeon and followed for recurrence. C
Uncomplicated hemangiomas that are not near the eyes, lips, nose, or perineum do not require treatment. C
Infants with port-wine stains near the eyes should be referred for glaucoma testing. C
Patients with multiple midline lumbosacral skin lesions or a single high-risk lesion should undergo magnetic resonance imaging or ultrasonography to rule out occult spinal dysraphism. C
20
Congenital Melanocytic Nevi
  • 0.2-0.4 infants at birth
  • Disrupted migration of melanocytic precursors in
    neural crest
  • Color Brown to black
  • Mostly flat, can be raised
  • Potential for malignancy-based on size
  • Nevus that changes in color, shape or thickness
    need further evaluation

21
Table 1. Management of Congenital Melanocytic Nevi by Size Table 1. Management of Congenital Melanocytic Nevi by Size Table 1. Management of Congenital Melanocytic Nevi by Size Table 1. Management of Congenital Melanocytic Nevi by Size
Size Size during infancy Projected size in adulthood Management strategy
Giant gt14 cm gt 40 cm Remove nevus, observe for recurrence in original or distal sites
Large gt 7 cm on torso, buttocks or extremities gt12 cm on head 20 to 40 cm Remove nevus, observe for recurrence in original or distal sites
Medium 0.5 to 7 cm 1.5 to 20 cm Consider referral to dermatologist for observation
Small lt 0.5 cm lt 1.5 cm Observe in primary care setting
22
Dermal Melanosis
  • Mongolian Spots
  • Flat, most often in back or buttocks
  • Arise when melanocytes trapped deep in the skin
  • Common in Non-white populations
  • Should be documented in newborn exam
  • Most fade by 2 years of age

23
Hemangiomas
  • 1.1-2.6 of newborns
  • Can develop anytime in 1st few months of life,
    10 at 1 year
  • 50 involute by 5 years, 70 by 7 years and 90
    by age 10
  • May leave scars
  • Can treat with pulse dye laserunsure long term
    cosmetic outcome
  • Eye, airway or organ compression require
    immediate treatment referral
  • Prednisone 3mg/kg x 6-12 weeks

24
Nevus Flammeus
  • Port Wine Stain
  • 0.3 of newborns
  • Flat,dark red to purple lesions
  • Do not fade over time
  • May develop varicosities, granulomas, nodules
  • Do not require treatmentPulse dye laser before
    age1
  • Opthalmic (V1) distribution associated with
    glaucoma
  • 5-8 with Sturge-Weber Syndrome
  • glaucoma/seizures/port-wine stain, angioma of
    brain/meninges
  • Mental retardation hemiplegia
  • Refer to Ophthalmology

25
Nevus Simplex
  • Stork bites ,Angel Kisses , Salmon patch
  • Flat, salmon colored lesions-telengectasias in
    dermis
  • Eyes, scalp, neckblanch when compressed
  • Occur on both sides of face in symmetric pattern
  • 40 resolve in neonatal period, most by 18 months

26
Supernumerary Nipples
  • Arise from mammary ridges along ventral body wall
  • May contain areola, nipple or both
  • May be unilateral/bilateral
  • Up to 5.6 of children
  • Mostly benign

27
Skin Markers of Spinal Dysraphism
  • Spinal dysraphism
  • diverse congenital spinal anomalies caused by
    incomplete fusion of midline elements of the
    spine
  • Tethered Cord Syndrome-need surgical release
  • Midline lumbosacral skin lesions are often
    cutaneous markers of spinal dysraphism
  • High or intermediate risk lesions should undergo
    imaging
  • MRI is most sensitive. Spinal ultrasonography
    also used

28
Table 2. Cutaneous Markers and Risk of Occult Spinal Dysraphism Table 2. Cutaneous Markers and Risk of Occult Spinal Dysraphism Table 2. Cutaneous Markers and Risk of Occult Spinal Dysraphism
Skin lesion Risk of occult spinal dysraphism Suggested evaluation
Any one of the following Dermal sinus Lipoma Tail High MRI
Any one of the following Aplasia cutis congenita Atypical dimple Deviation of gluteal furrow Intermediate MRI or ultrasonography
Any one of the following Hemangioma Hypertrichosis Mongolian spot Nevus simplex Port-wine stain Simple dimple Low No evaluation needed in most cases may consider ultrasonography depending on local standard of care
Two or more lesions of any type High MRI
29
Clavicle Fractures
  • 5-10 of all fractures
  • Most in menlt25 yrs, men gt55 women gt75
  • Allman Classification
  • Group I (midshaft/middle third) -gt75-80, young
  • Group II (lateral/distal)-gt 15-25
  • Group III (medial/proximal)-gt 5

30
Clinical recommendation Evidence
Nonoperative treatment is preferred for nearly all acute, nondisplaced midshaft clavicle fractures. B
Treatment with an arm sling is preferred over a figure-of-eight dressing for acute midshaft clavicle fractures because it is better tolerated and leads to similar outcomes. B
Displaced midshaft clavicle fractures may be managed nonoperatively, but plate fixation should be considered. B
Nonoperative treatment is preferred for distal clavicle fractures because outcomes are the same whether or not bony union is achieved. B
31
Anatomy
  • Midshaft is thinnest, least medullous area
  • AC SC joints have robust ligamentous support
  • Sternal ossification center fuses with shaft by
    age 30
  • Malunion can impair mobility to upper extremity
  • Callus formation/ displacement can lead to
    thoracic outlet obstruction

32
Evaluation
  • Mechanism of injury fall directly on shoulder
    with arm at side, often in contact sports
  • Hold affected arm adducted close, support with
    opposite hand
  • Exam ecchymosis, edema,focal tenderness and
    crepitus on palpation of clavicle
  • Need to perform neurovascular lung exam
  • Radiographs should be performed

33
Midshaft Clavicle Fractures
34
Midshaft Clavicle Fractures
  • Nondisplaced
  • Sling /Figure of eight dressing
  • Can discontinue in 1-2 weeks when pain subsides
  • Pendulum exercises as soon as pain allows, active
    ROM strengthening 4-8 weeks
  • Displaced
  • Higher rates of nonunion
  • Can consider operative treatment in patients with
    multiple risk factors

35
Table 1. Risk Factors for Nonunion of Midshaft Clavicle Fractures
Clavicle shortening gt 15-20 mm
Female sex
Fracture comminution
Fracture displacement
Greater extent of initial trauma
Older age
36
Midshaft Clavicle Fractures
  • Operative options
  • Open/closed reduction with plate fixation
  • Intramedullary fixation-gtsmaller incisions,
    avoids plate pressure but risk of device
    migration
  • Complications rare-gtpneumothorax, vascular injury
  • Long term Sequelae Pain, weakness, parasthesias
  • Displacement of gt one bone width is strongest
    radiographic risk factor for symptoms sequealea

37
Return To Activity Considerations
  • Full Range of motion
  • Normal shoulder strength
  • Clinical radiographic evidence of bone healing
  • No tenderness
  • Can return to noncontact sports in 6 weeks
  • Contact sports in 2-4 months
  • If surgical case-gtmay need removal of hardware

38
Midshaft Clavicle Fractures in Children
  • 88 percent of clavicle fractures
  • Nearly all heal well due to great periosteal
    regenerative potential
  • Often have significant callus formation
  • Healing within 4-6 weeks
  • If no history of trauma, need to consider
    malignancy, rickets, osteogenesis imperfecta and
    physical abuse

39
Distal Clavicle Fractures
  • 5 Types
  • Type I Coracoclavicular ligament intact
  • Type II Conoid (medial) torn, trapezoid intact
  • Type III Extension into AC joint
  • Type IV Disruption in periosteal sleeve
    (children)
  • Type V Avulsion of ligaments with small cortical
    fragment
  • Type I III-stable? nonoperative
  • Type II-gthigh rate of nonunion
  • Type IV-often occurs through distal physis with
    ligaments attached-gt pseudodislocation
  • Operative treatment only with sever displacement

40
Proximal Clavicle Fractures
  • Very uncommon
  • Typically nondisplaced
  • If displaced, need to evaluate for neurovascular
    compromise
  • May need CT scan for better visualization

41
Herbal and Dietary Supplement-Drug Interactions
in Patients with Chronic Diseases
  • Herbs, Vitamins and supplements may augment or
    antagonize actions of drugs
  • Deleterious effects are most pronounced with
    anticoagulants, cardiovascular medications, oral
    hypoglycemics and antiretrovirals
  • St. Johns Wort
  • Reduction in INR with warfarin, reduced levels of
    verapamil, statins, digoxin, antiretrovirals
  • Physicians should routinely ask patients about
    use of supplements
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