Kid Doc — Good Job Being the Mom!
A fun and informative podcast for all the challenges parents face in raising their brood!
Kid Doc — Good Job Being the Mom!
Skin Episode 1--Eczema, Acne, Molluscum, Warts and More!
SKIN PODCAST
SKIN VISITS
ONE OF THE MORE FREQUENT REASONS YOU HAVE FOR PATIENT ENCOUNTERS IS SKIN CONCERNS.
WE ARE GOING TO BREAK UP SKIN CONCERNS INTO THREE EPISODES
WE HAVE SO MANY TOPICS TO DISCUSS THAT WE WANT TO BREAK THEM UP INTO EASIER TO FIND SEGMENTS.
LET’S START OFF WITH ECZEMA
WHY IS IT SO COMMON IN UTAH?
WHEN IS ECZEMA THE WORST?
DOES IT GET BETTER WITH AGE?
WHAT ARE THE WAYS TO PREVENT ECZEMA?
WHAT SKIN CARE PRODUCTS CAN FAMILIES USE? PARENTS ALWAYS GET FUN LAVENDER AND BABY-SCENTED PRODUCTS FOR BABY SHOWERS BUT THOSE ARE PROBLEMATIC FOR BABY SKIN.
WHAT ABOUT OTHER PRODUCTS THAT TOUCH SKIN?
HOW DO PARENTS MANAGE FLARE-UPS?
SPEAKING OF PREVENTING BLEEDING. WHAT ABOUT MEDICATION PREVENTION WHEN SKIN IS DOING WELL?
WHAT IF THEY DO ALL THESE THINGS AND STILL HAVE PROBLEMS?
ONE OF THE COMPLICATIONS OF ECZEMA IS THE TENDENCY TO GET SOME SECONDARY INFECTIONS.
SOUNDS KIND OF LIKE A SPELL NAME FROM HARRY POTTER—mol-LUS-CUM con-TAGE-E-OSUM AND POOF —A BAD RASH
WHY DO KIDS WITH ECZEMA GET IT MORE OFTEN?
WHAT ARE TREATMENT OPTIONS?
THE LESIONS SOMETIMES GET REALLY INFLAMED AND INFECTED APPEARING
ARE THERE OTHER MORE AGGRESSIVE TREATMENT OPTIONS?
HOW ABOUT A COMMON SKIN CONDITION KERATOSIS (KARA-TOSIS) PILARIS (PIE-LAIR-US) THAT PEOPLE OFTEN CONFUSE WITH ECZEMA
AND IT OCCURS IN VERY CONSISTENT LOCATIONS
AND IT IS NORMAL ON SKIN, LIKE SOMEONE HAVING FRECKLES
IF IT BOTHERS SOMEONE ARE THERE OPTIONS TO HELP MANAGE IT?
LET’S MOVE TO EVERYONE’S FAVORITE—ACNE. WE DO HAVE A COUPLE ITEMS IN THIS PART ONE THAT ARE INFECTIONS LIKE MOLLUSCUM AND ACNE
SO AFTER GOOD SKIN HYGIENE WITH ANY NUMBER OF SKIN CLEANING PRODUCTS, WHAT ARE YOUR RECOMMENDED STEPS IN THE HIERARCHY FOR ACNE TREATMENT?
I THINK THEY GOT THE MESSAGE THAT EACH STEP REQUIRES 6 WEEKS OF PATIENCE. ONE CHALLENGE IS DOING A GOOD JOB WITH EACH STEP—THE MEDICINES DON’T WORK WELL IF THEY DON’T GET USED.
PROBABLY ANOTHER FAVORITE FOR PARENTS IS WARTS. HERE WE HAVE ANOTHER COMMON PROBLEM THAT IS ALSO A VIRAL INFECTION.
AND WARTS ALSO GO AWAY 100 PERCENT OF THE TIME—EVENTUALLY.
IF PARENTS WANT TO ACTIVELY TREAT, WHAT ARE THE OPTIONS? THERE ARE SOME CREATIVE ONES LIKE USING DUCT TAPE.
WHAT ABOUT THE OVER THE COUNTER FREEZING AGENTS?
ANY OTHER OPTIONS INCLUDING FREEZING IN THE OFFICE?
AND WHO SHOULD MAYBE GO DOWN THE PATHWAY OF HAVING WARTS FROZEN?
ARE THERE ANY WARTS THAT YOU REFER TO SPECIALISTS?
LET’S MOVE ON TO MOLES. THESE ARE ALWAYS TRICKY—WHEN DO I GET A MOLE CUT OUT VS LEAVE IT ALONE? MANY FAMILIES HAD A HISTORY OF SKIN CANCER AND WORRY ABOUT MOLES.
MAYBE WALK US THROUGH THE A-B-C-D-E MNEMONIC FOR MOLES
AND THEY CAN FIND REFERENCES FOR THIS ONLINE
AND WHILE WE ARE STILL IN THE SPACE WHERE PEOPLE MIGHT BE CONCERNED ABOUT CANCER—MANY CHILDREN COME IN WITH UNUSUAL LUMPS. I THINK THAT MOM’S IN PARTICULAR ARE ATTUNED THAT UNUSUAL LUMPS ARE BAD.
AND WE HAVE SAVED THE MOST FUN FOR LAST—HYPERHIDROSIS—EXCESSIVE SWEATING.
WHAT TREATMENT OPTIONS ARE OUT THERE?
THIS WRAPS UP PART ONE OF THE SKIN PODCASTS. NEXT WILL BE MORE ABOUT SKIN INFECTIONS AND SKIN TRAUMA.
WELL, WE ARE REALLY UTILIZING OUR ABILITY TO BE REMOTE WITH YOU IN SUN VALLEY AND ME IN PALO ALTO.
Technology is pretty great to allow us to be productive even when apart. We are having a great time in Sun Valley with paddle boarding at little redfish lake and pickleball, bike riding and hiking—really recharging the batteries—probably appropriate that we are talking about skin concerns while in Sun Valley—remember to keep up with your sun block. Your Mom and I have done a good job with our skin protection this week.
WELL LET’S TAKE THAT SEGUE AND TALK ABOUT SKIN CONDITIONS TODAY. ONE OF THE MORE FREQUENT REASONS YOU HAVE FOR PATIENT ENCOUNTERS IS SKIN CONCERNS.
The skin manifests so many things as both the largest organ in the body many things show up on the skin as well as problems with the skin specifically.
WE ARE GOING TO BREAK UP SKIN CONCERNS INTO THREE EPISODES
Kind of like Lord of the Rings started the pattern of breaking up individual books into three movies.
WE HAVE SO MANY TOPICS TO DISCUSS THAT WE WANT TO BREAK THEM UP INTO EASIER TO FIND SEGMENTS.
We will group them into stand alone problems like eczema and acne in part one and then part 2 will cover infections and trauma and part three will cover baby skin concerns
LET’S START OFF WITH ECZEMA
I talk about eczema every day in the office. It is such a common problem here in Utah.
WHY IS IT SO COMMON IN UTAH?
There is a genetic component with a high incidence of eczema among Europeans that formed the founder effect of Utah with the pioneers that settled this state and then you combine that with Utah being a desert with our low humidity and it is a perfect recipe for eczema.
WHEN IS ECZEMA THE WORST?
It is worst in the winter with the cold and dryness with furnace use, but it can also be bad in the summer with lots of swimming due to the chlorine and wetting and drying the skin with oil removal from the skin.
DOES IT GET BETTER WITH AGE?
Yes—it is the worst during the first year or two of life and then improves until about age six
WHAT ARE THE WAYS TO PREVENT ECZEMA?
Less frequent cleaning is better, warm water is better than hot water, and showers are better than baths—all this keeps the natural oils on the skin.
WHAT SKIN CARE PRODUCTS CAN FAMILIES USE? PARENTS ALWAYS GET FUN LAVENDER AND BABY-SCENTED PRODUCTS FOR BABY SHOWERS BUT THOSE ARE PROBLEMATIC FOR BABY SKIN.
It is interesting to me that the the products made for babies are the worst for babies with all the perfumes and dyes. The most important is that a product be HYPOALLERGENIC or be made for SENSITIVE SKIN. I like Aveeno and Cerave as product examples.
Can move up from daily lotion to cream to ointments if you need something stronger to hydrate skin. Can be once or twice daily. Good timing is after baths to keep the skin hydrated.
WHAT ABOUT OTHER PRODUCTS THAT TOUCH SKIN?
Make sure all products that go on patient's skin are free of perfumes or dyes (detergents, fabric softeners, soaps, shampoos, lotions, etc.)
Can use Cheer FREE or Tide FREE or Dreft or similar.
HOW DO PARENTS MANAGE FLARE-UPS?
Treating eczema is a bit like playing WHACK-A-MOLE—it is a constant endeavor to manage flares popping up and do the best we can for prevention.
I recommend either an over-the-counter steroid or prescription strength that varies based on what part of the body we are treating. I have parents apply that 2-3 times daily when the skin is flared up.
Full disclosure—this is hard work where we work to fix the skin and then it gets bad again. We had one child with bad eczema and sometimes our cue to do a better job was when his eczema was bleeding. Judgement free on my part for parents doing their best to help their kids
SPEAKING OF PREVENTING BLEEDING. WHAT ABOUT MEDICATION PREVENTION WHEN SKIN IS DOING WELL?
I will still have parents apply the steroid to problem areas 1-3 times/weekly for prevention if lotion and cream every day isn’t enough.
WHAT IF THEY DO ALL THESE THINGS AND STILL HAVE PROBLEMS?
Reach out to me if you are doing a great job with the products you have and skin is not improving--I can get a stronger prescription production for you. I will want to see them to see if there also any secondary infection that we will manage with bleach baths, topical or oral antibiotics. It is hard for skin to heal if it is infected.
ONE OF THE COMPLICATIONS OF ECZEMA IS THE TENDENCY TO GET SOME SECONDARY INFECTIONS.
One of the most common ones, and almost happens exclusively to kids with eczema is MOLLUSCUM CONTAGIOSUM.
SOUNDS KIND OF LIKE A SPELL NAME FROM HARRY POTTER—mol-LUS-CUM con-TAGE-E-OSUM AND POOF —A BAD RASH
Yes. It is definitely an evil spell with the lessons lasting from 6-18 MONTHS. So a long time and requires a lot of patience. This is a pox virus although not dangerous like small pox or cow pox.
WHY DO KIDS WITH ECZEMA GET IT MORE OFTEN?
This virus likes compromised, abraded skin which is what eczema gives us. People think that the molluscum are itchy because they are scratching those areas, but that is the whole problem. Eczema is itchy, kids get the molluscum where they have eczema then scratch other eczema areas and spread the molluscum—the molluscum themselves are not itchy, they just hang out on itchy skin.
WHAT ARE TREATMENT OPTIONS?
Prevention is great by treating the eczema before and after the molluscum occur—will minimize unhealthy skin where the molluscum thrive.
Otherwise, I have parents buy some over the counter products that have tea tree oil. My favorite is called Molluscum Blast but there is also Zymaderm or any other tea tree oil product. Apply this directly to lesions 1-2 times daily until resolved—it will take a long time still and I haven’t seen parents contract molluscum from their kids.
THE LESIONS SOMETIMES GET REALLY INFLAMED AND INFECTED APPEARING
Yes this usually happens as the body finally comes around to rejecting the virus causing the molluscum. To prevent this, when the bumps have whitehead appear in the middle, you can extrude that core and the lesion will dry up and go away.
ARE THERE OTHER MORE AGGRESSIVE TREATMENT OPTIONS?
Yes, but I always say—this problem will go away 100% of the time if we do nothing and so unless it is creating a significant problem then don’t spend money or have pain blistering these lessons with a blistering agent that we derived from blistering beatles. I would treat for excessive spread, lesions causing problems somehow like getting infected. Overall the best advice is to keep skin as healthy as possible to limit spread and to facilitate healing
HOW ABOUT A COMMON SKIN CONDITION KERATOSIS (KARA-TOSIS) PILARIS (PIE-LAIR-US) THAT PEOPLE OFTEN CONFUSE WITH ECZEMA
Keratosis pilaris is actually one of the best named conditions around because it describes exactly what is happening. Skin is made of keratin and in this condition you have little piles of keratin—keratosis pilaris—making bumps on your skin.
AND IT OCCURS IN VERY CONSISTENT LOCATIONS
It is always on the extensor surfaces of your arms and legs—over the triceps and quads—and sometimes on cheek skin on the face.
AND IT IS NORMAL ON SKIN, LIKE SOMEONE HAVING FRECKLES
This is normal skin. It is how your body makes skin in this area.
There are no symptoms, like itching that go along with it.
It is cosmetic only.
IF IT BOTHERS SOMEONE ARE THERE OPTIONS TO HELP MANAGE IT?
I joke that we should only do something about it if someone wants to become a tricep model.
It takes a lot of work for almost no reward. I would never have a busy mom try to make a child’s skin a little smoother when the child doesn’t care.
There are options to do a special acid-containing lotion that smooth the skin.
It only works while you use it as a temporary fix and the bumps will always come back if you stop using it.
I usually recommend only treating in older kids, like teenagers, if they care about it
LET’S MOVE TO EVERYONE’S FAVORITE—ACNE. WE DO HAVE A COUPLE ITEMS IN THIS PART ONE THAT ARE INFECTIONS LIKE MOLLUSCUM AND ACNE
That’s true, and warts are the same but I grouped them here because most of the time people don’t think about them as the infections that they are. Acne is caused by proprionibacterium acnes and it is helpful to view this as an infection.
SO AFTER GOOD SKIN HYGIENE WITH ANY NUMBER OF SKIN CLEANING PRODUCTS, WHAT ARE YOUR RECOMMENDED STEPS IN THE HIERARCHY FOR ACNE TREATMENT?
First, it is very important to remember that each step of treatment requires 6 weeks to evaluate effectiveness. It takes this long to get from the skin you see today to the skin that comes from the work you have done.
Stop sooner if you don't like side effects like too much dryness. May get a little worse before getting better.
I first start with over the counter adapalene gel also called Differin gel 0.025% each night for 6 weeks. If this isn’t helpful then I change to OTC benzoyl peroxide 5-10% for 6 weeks, this is known as clearacil or by other names. Then if this isn’t enough I will have them do BP at night and adapalene in the morning for 6 weeks
Then we go to prescription strength:
2. I do a combined benzoyl peroxide plus clindamycin topical medication for 6 weeks and then
3. add oral antibiotic like minocycline along with topical medication for 6 weeks then
4. refer to dermatology for Accutane as the nuclear option which is very effective.
I THINK THEY GOT THE MESSAGE THAT EACH STEP REQUIRES 6 WEEKS OF PATIENCE. ONE CHALLENGE IS DOING A GOOD JOB WITH EACH STEP—THE MEDICINES DON’T WORK WELL IF THEY DON’T GET USED.
It is always a challenge to make the decision to move up a step if there is a question of compliance on the previous step—do we need to go up OR do a better job with what we already have?
PROBABLY ANOTHER FAVORITE FOR PARENTS IS WARTS. HERE WE HAVE ANOTHER COMMON PROBLEM THAT IS ALSO A VIRAL INFECTION.
Papilloma virus is the culprit for warts. We actually have a vaccine for many strains of wart-causing papilloma virus but not for the kinds that cause regular hand warts.
AND WARTS ALSO GO AWAY 100 PERCENT OF THE TIME—EVENTUALLY.
It can also be a long time—months or years for them to resolve on their own, but this is the reason that observation is the main pathway for managing warts if they aren't causing problems--they will always resolve with time
IF PARENTS WANT TO ACTIVELY TREAT, WHAT ARE THE OPTIONS? THERE ARE SOME CREATIVE ONES LIKE USING DUCT TAPE.
I will just reiterate observation as a first step.
I actually do recommend duct tape for pain free and inexpensive treatment with demonstrated effectiveness.
Apply a piece of duct tape over wart--cut to fit the wart, keep on for a week at a time--replace tape if it falls off.
Once a week, file the wart with a nail file to remove excess tissue.
Treatment should take 4-6 weeks and the cure rate is comparable to freezing in the office with liquid nitrogen
Compound W is an option or wart / acid patches (Dr. Scholl's or similar) this takes several seeks of diligent and consistent application to be effective like you mentioned with the acne treatments.
Apply nightly to warts. Duct tape during the day. File with a nail file at least weekly.
WHAT ABOUT THE OVER THE COUNTER FREEZING AGENTS?
I never recommend these, they are not effective enough.
ANY OTHER OPTIONS INCLUDING FREEZING IN THE OFFICE?
I Can prescribe a compound to be applied nightly and covered with tape, wash off in AM. Plan 3-6 weeks to resolve. A little more effective than the OTC compounds and also more expensive.
Lastly, I can freeze them with liquid nitrogen if desired. This can be quite effective.
AND WHO SHOULD MAYBE GO DOWN THE PATHWAY OF HAVING WARTS FROZEN?
Like with the molluscum we discussed, if the warts are causing problems of pain, infection, bleeding, etc. based on where they are located then we should work on them.
ARE THERE ANY WARTS THAT YOU REFER TO SPECIALISTS?
I have learned to not freeze plantar warts—it just doesn’t work well enough where the warts are like icebergs—you only see a small amount and most is deep under the surface. I have these go to dermatology or podiatry for more aggressive burning or cutting procedures—they also make sure and do numbing beforehand.
LET’S MOVE ON TO MOLES. THESE ARE ALWAYS TRICKY—WHEN DO I GET A MOLE CUT OUT VS LEAVE IT ALONE? MANY FAMILIES HAD A HISTORY OF SKIN CANCER AND WORRY ABOUT MOLES.
In the matter of moles: Knowing what to watch for is helpful: Knowledge is Power [School House Rock].
I will help with checking moles with parents and documenting any images of their moles in the chart so we can watch them over time.
MAYBE WALK US THROUGH THE A-B-C-D-E MNEMONIC FOR MOLES
A-Asymmetry—one half is not like the other
B-Borders—irregular or blurry or blends into the skin
C-Color—color that is uneven
D-Diameter—desirable to be pencil-eraser size or smaller
E-Evolving / Elevated—changing or raising up
AND THEY CAN FIND REFERENCES FOR THIS ONLINE
I have people Google: ABCDE + mole and there will be 10 million references where they will have Picture references for what is okay and not okay with moles and when to consider having taken off—stick with the cancer institute or recognized health care institutes for the best information
AND WHILE WE ARE STILL IN THE SPACE WHERE PEOPLE MIGHT BE CONCERNED ABOUT CANCER—MANY CHILDREN COME IN WITH UNUSUAL LUMPS. I THINK THAT MOM’S IN PARTICULAR ARE ATTUNED THAT UNUSUAL LUMPS ARE BAD.
Yes. I find lumps under the skin of kids all day every day and have to go through a thought process of whether these lumps are normal or they are a sign of a deeper problem.
I go through a checklist every time:
Is there:
- daily fever
- weight loss
- unusual bruising—not just lots of kid bruising but bruising in unusual, difficult to bruise places that aren’t over bones, or,
- widespread lymph node enlargement.
If the checklist is reassuring then I can talk about normal lymph node enlargement in response to body taking care of infection as part of normal immune defense mechanisms, or something common like a small cyst or lipoma.
Because there may be a deeper concern about cancer, I always tell parents that I find no signs of leukemia or lymphoma. I will offer to do blood work to check if they are still concerned—remember that my job is to listen to their concerns and they will tell me what is wrong—even if it is their personal level of worry.
AND WE HAVE SAVED THE MOST FUN FOR LAST—HYPERHIDROSIS—EXCESSIVE SWEATING.
This is a pretty embarrassing problem for a lot of people and it is on a spectrum to mild with extra smelly shoes to severe with sweat dripping off of hands where they cannot manage a ball or a bat or a pencil.
DO YOU EVER OFFER TO HOLD OFF ON TREATMENT FOR HAND SWEATING UNTIL PARENTS ARE OKAY WITH THEIR CHILD DATING AND HOLDING HANDS?
I do offer that in jest—it has never failed to get a laugh and break the ice on talking about the disorder.
WHAT TREATMENT OPTIONS ARE OUT THERE?
I start with as much aeration as possible such as with open/breathable shoes—even having them keep some sandals at school when they are wearing more occlusive shoes in the winter or maybe year round if tennis shoes make their feet too sweaty.
First line treatment is a prescription strength anti-perspirant for hands, feet, or arm pits.
Then there are options for referral for botox or laser treatments at a later time.
THIS WRAPS UP PART ONE OF THE SKIN PODCASTS. NEXT WILL BE MORE ABOUT SKIN INFECTIONS AND SKIN TRAUMA.
