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 Part 2--Infections and Trauma
SKIN PART 2— INFECTIONS AND TRAUMA
IN PART 2 OF SKIN VISITS, WE TALK ABOUT INFECTIONS AND TRAUMA
LET’S START WITH THE COMMON STAPH AND STREP INFECTIONS OF SKIN—FOLLICULITIS, CELLULITIS, AND IMPETIGO. THESE ARE ALL INFECTIONS THAT USUALLY ARISE FROM THE BODY’S OWN BACTERIA THAT ARE OPPORTUNISTIC AND CAUSE INFECTIONS WHEN GIVEN THE OPPORTUNITY.
WHAT IS FOLLICULITIS?
WHAT IS THE MANAGEMENT FOR THIS?
NEOSPORIN IS GREAT FOR PREVENTION BUT NOT GREAT FOR TREATING AN INFECTION
HOW CONTAGIOUS IS THIS?
DOES ‘HOT TUB’ FOLLICULITIS FIT IN THIS CATEGORY AS WELL.
THEN WE HAVE THE FUN IMPETIGO WITH YELLOW CRUSTED SORES ON FACES.
WHAT IS THE MANAGEMENT FOR IMPETIGO
GOOD OPPORTUNITY TO MENTION ANTIBIOTIC STEWARDSHIP—THAT WE SHOULDN’T THROW ORAL ANTIBIOTICS AT EVERY INFECTION UNLESS THEY ARE TRULY NEEDED AS THIS CAN CONTRIBUTE TO ANTIBIOTIC RESISTANCE.
WITH PLAYING OUTSIDE, KIDS GET LOTS OF CUTS AND SCRAPES THAT GET INFECTED AND SHOW UP WITH CELLULITIS.
DO YOU TREAT THIS ANY DIFFERENTLY?
WITH EACH OF THESE INFECTIONS, WHEN SHOULD PARENTS CALL FOR MORE HELP?
LET’S COVER THE COMMON ANTIBIOTIC SIDE EFFECT OF ERYTHEMA MULTIFORME
LET’S FINISH THE BACTERIAL SKIN INFECTIONS BEFORE WE MOVE OVER TO VIRAL SKIN INFECTIONS. A PARONYCHIA IS CELLULITIS BUT LOCALIZED TO NAIL BEDS
DOES A PARONYCHIA GET CONFUSED WITH AN INGROWN NAIL?
LET’S MOVE TO THE VIRAL SKIN INFECTIONS NOW.
ROSEOLA IS A TOUGH ILLNESS BECAUSE IT PRESENTS WITH FEVER ONLY—AND SOMETIMES A VERY HIGH FEVER AND NO OTHER SYMPTOMS.
AND THEN WHEN THE RASH COMES ON AFTER THE FEVER GOES AWAY THEN YOU KNOW WHAT CAUSED THE FEVER.
HOW IS THIS RASH AND DISEASE DIFFERENT FROM FIFTH DISEASE?
AND FIFTH DISEASE IS MORE DANGEROUS.
LET’S TALK ABOUT HAND-FOOT-MOUTH DISEASE
WHAT DOES THE RASH LOOK LIKE WITH HAND FOOT AND MOUTH
HOW LONG IS IT CONTAGIOUS AND HOW DO WE CARE FOR THE KIDS?
AND THE OTHER COMMON MOUTH VIRUS IS HERPES VIRUS CAUSING COLD SORES
SO MANY PEOPLE GET THIS AS A SMALL CHILD AND NEVER KNOW THEY HAD IT?
AND THIS IS TOUGH TO MANAGE BECAUSE MEDICATIONS ONLY WORK WHEN THEY CAN BE GIVEN BEFORE THE COLD SORES ARISE
WHAT IS SYMPTOMATIC CARE FOR THAT FIRST BAD PRESENTATION OF MOUTH HERPES?
OKAY. NOW LET’S MOVE TO SKIN TRAUMA ITEMS. MOST COMMON IS PROBABLY INSECT BITES. FOR SOME PEOPLE THESE ARE NOT A BIG DEAL AND FOR OTHERS THEY GET BAD REACTIONS.
HOW DO WE HELP KIDS WHOSE BODIES OVERREACT TO INSECT BITES?
CAN PARENTS DO ANYTHING FOR PREVENTION OF THE HYPERSENSITIVITY?
WHEN SHOULD PARENTS CALL ABOUT MOSQUITO BITES?
LACERATIONS ARE UP NEXT. ONE OF THE BIG QUESTIONS PARENTS HAVE IS “WHEN SHOULD I COME IN AND GET STITCHES”?
BURNS ARE ALSO TOUGH TO EVALUATE AND TO KNOW WHAT TO DO WITH THEM. WHEN SHOULD PARENTS COME IN WITH BURNS?
WHAT IS THE MOST COMMON BURN YOU SEE?
What is your management for MINOR BURNS?
ARE THERE ANY BURNS THAT NEED TO GO TO SPECIALISTS?
LAST IS SLIVERS OR OTHER FOREIGN BODIES.
THIS WRAPS UP OUR EPISODE ON SKIN INFECTION AND TRAUMA. NEXT WILL BE OUR EPISODE REVIEWING BABY SKIN.
SKIN PART 2— INFECTIONS AND TRAUMA
IN PART 2 OF SKIN VISITS, WE TALK ABOUT INFECTIONS AND TRAUMA
Let’s jump right in and get through all the infections and skin trauma we see in the office.
LET’S START WITH THE COMMON STAPH AND STREP INFECTIONS OF SKIN—FOLLICULITIS, CELLULITIS, AND IMPETIGO. THESE ARE ALL INFECTIONS THAT USUALLY ARISE FROM THE BODY’S OWN BACTERIA THAT ARE OPPORTUNISTIC AND CAUSE INFECTIONS WHEN GIVEN THE OPPORTUNITY.
Yes. You don’t usually catch them from someone else, but when the wrong circumstances arise from breaks in the skin then the bacteria have a fiesta and cause infections.
WHAT IS FOLLICULITIS?
This is an infection of the hair follicles and can occur most anywhere on the body. It usually shows up with a lot of individual red dots that are the infection sites.
WHAT IS THE MANAGEMENT FOR THIS?
Soap and water and gentle scrubbing at least once daily makes a huge difference.
Topically we use prescription Mupirocin 2-3 times daily until resolved—this prescription antibiotic is much more effective than neosporin.
YOU MENTIONED THAT NEOSPORIN IS GREAT FOR PREVENTION BUT NOT GREAT FOR TREATING AN INFECTION
Right. And then I have parents call for any worsening and I will add an oral antibiotic.
HOW CONTAGIOUS IS THIS?
We talked about this being normal skin bacteria but it is now in massively higher amounts at the site of infection so it is easy to transmit to other people. It is contagious by contact until the infection is resolved but the contagiousness drops quickly with good treatment.
DOES ‘HOT TUB’ FOLLICULITIS FIT IN THIS CATEGORY AS WELL.
No, this is caused by particular pseudomonas bacteria that thrive in hot water but not in properly chlorinated hot tubs. So we see it when someone uses a hot tub that hasn’t been treated with chemicals for awhile. This infection resolves quickly and is self-limited and just needs symptom care for things like itching.
THEN WE HAVE THE FUN IMPETIGO WITH YELLOW CRUSTED SORES ON FACES.
Yes, it is a little bit scary looking on faces.
WHAT IS THE MANAGEMENT FOR IMPETIGO
Same management as for folliculitis. I should mention that with some staph infections we can see resistant bacteria in people with exposure to those in nursing homes and long-term hospital stays. So if we don’t see improvement with mupirocin and first-line oral antibiotics we may need to use different antibiotics that cover resistant staph bacteria.
MAYBE THIS IS A GOOD OPPORTUNITY TO MENTION ANTIBIOTIC STEWARDSHIP—THAT WE SHOULDN’T THROW ORAL ANTIBIOTICS AT EVERY INFECTION UNLESS THEY ARE TRULY NEEDED AS THIS CAN CONTRIBUTE TO ANTIBIOTIC RESISTANCE.
It takes me more time to explain why we DON’T need antibiotics than to just prescribe an antibiotic. Some people feel a lot of satisfaction out of receiving something like an antibiotic as part of their visit—it is satisfying that they got something from their visit. It is hard to explain why it is not needed and using it may cause side effects of diarrhea and yeast infections and create antibiotic resistance and there are some rare but dangerous reactions for some people that I have seen.
WITH PLAYING OUTSIDE, KIDS GET LOTS OF CUTS AND SCRAPES THAT GET INFECTED AND SHOW UP WITH CELLULITIS.
Whenever we see the surrounding or spreading redness around cuts and scrapes we are talking about cellulitis.
DO YOU TREAT THIS ANY DIFFERENTLY?
I probably recommend a little more massaging of this infected skin to prevent the bacteria from walling themselves off like in Fortnight and forming abscesses.
I recommend that a parent massage affected area with a warm washcloth for 10-15 minutes three times daily and then use the topical antibiotic as prescribed.
WITH EACH OF THESE INFECTIONS, WHEN SHOULD PARENTS CALL FOR MORE HELP?
Call for:
new fever
increased tenderness
any spreading redness
any worsening.
LET’S COVER THE COMMON ANTIBIOTIC SIDE EFFECT OF ERYTHEMA MULTIFORME
This common rash we will see with amoxicillin and other antibiotics shows up about 8-12 days after starting use and is called erythema multiforme MINOR to separate it from some more severe reactions.
Benign rash that some people will say is an allergy.
This rash is more correctly called a serum sickness.
No treatment necessary. Sun-sensitive.
Call for any worsening symptoms (mouth rash, eye redness).
May still have the antibiotic in question in the future.
The thought comes up to remind people to us a probiotic whenever taking an oral antibiotic to prevent diarrhea or yeast infections that will show up in a about 30% of people taking antibiotics—prevention is better than fixing the problem.
LET’S FINISH THE BACTERIAL SKIN INFECTIONS BEFORE WE MOVE OVER TO VIRAL SKIN INFECTIONS. A PARONYCHIA IS CELLULITIS BUT LOCALIZED TO NAIL BEDS
The blood flow around the nail bed is particularly sluggish capillary blood flow and prone to cellulitis when tearing off a hang nail or any loose skin and then an infection sets in.
I am really aggressive with the warm soak and massage part of managing this by doing this 2-3x/day or more at the first sign of redness or irritation and then move to medications if the symptoms worsen.
DOES A PARONYCHIA GET CONFUSED WITH AN INGROWN NAIL?
I think because the skin is red and swollen it can look like the nail is ingrown—and it may be. So I try to fix the redness and infection before sending to a podiatrist for evaluation and management.
LET’S MOVE TO THE VIRAL SKIN INFECTIONS NOW.
ROSEOLA IS A TOUGH ILLNESS BECAUSE IT PRESENTS WITH FEVER ONLY—AND SOMETIMES A VERY HIGH FEVER AND NO OTHER SYMPTOMS.
Yes. This is a tough one because I get the most worried about fevers without a reason because this might be strep or a bladder infection when we don’t have an obvious reason for the fever. And with the beginning of roseola all you have is a high fever and you don’t have the rash yet to clue you in on the reason for the fever.
AND THEN WHEN THE RASH COMES ON AFTER THE FEVER GOES AWAY THEN YOU KNOW WHAT CAUSED THE FEVER.
It is a very characteristic rash that shows up on the face and torso and generally spares the arms and legs and starts when the fever breaks. Once the rash shows up you know what you have.
It is caused by Human Herpesvirus 6 and is contagious until the rash resolves.
HOW IS THIS RASH AND DISEASE DIFFERENT FROM FIFTH DISEASE?
Fifth disease is super interesting because it is named by a number. We used to have a first and second disease etc. that were measles and scarlet fever respectively but they got their own names. Roseola was actually 6th disease
AND FIFTH DISEASE IS MORE DANGEROUS.
Fifth disease is more dangerous that Roseola. It is caused by Parvovirus B19. Main concern is for exposure to pregnant women because of potential life-threatening affect on developing fetus. There is also a concern for kids who have blood cell disorders.
Once the rash shows up on the cheeks and extremities you are not contagious any more. We don’t see this rash on the torso like we do with Roseola. There shouldn’t be any treatment needs, but for any itchiness you may use topical hydrocortisone 2-3x/day and benadryl in appropriate doses.
LET’S TALK ABOUT HAND-FOOT-MOUTH DISEASE
This is a classic warm weather disease.
It is caused by a virus called Coxsackie A16
Interesting side note: this virus is in the same family and enterovirus genus as poliovirus. When we think about how common HFM disease is..
poliovirus was every bit as common as hand foot and mouth is now but polio caused death and permanent disability— definitely one of the successes of vaccinations
Yes—great example of the importance of vaccinating.
WHAT DOES THE RASH LOOK LIKE WITH HAND FOOT AND MOUTH
Well, the name describes it all—we get individual red bumps on the palms and soles of the hands and feet—they may move quite a way up the legs as well. Then we see little ulcers at the back of the throat.
HOW LONG IS IT CONTAGIOUS AND HOW DO WE CARE FOR THE KIDS?
HFM is Contagious for a couple of weeks.
The goal of treatment is to Control pain and fever.
Alternate tylenol and ibuprofen every 3 hours for 48 hours and then as needed.
Encourage fluids--whatever patient will drink.
Use cool fluids, no carbonation, nothing acidic.
AND THE OTHER COMMON MOUTH VIRUS IS HERPES VIRUS CAUSING COLD SORES
Everyone is exposed to herpes simplex virus and tests positive by about age 18 but not everyone gets cold sores.
SO MANY PEOPLE GET THIS AS A SMALL CHILD AND NEVER KNOW THEY HAD IT?
Right. But it can be pretty bad for a little kid with their first infection causing sores all over the mouth that are pretty painful. And for the lucky few it can return again and again as cold sores, usually when sick or tired.
AND THIS IS TOUGH TO MANAGE BECAUSE MEDICATIONS ONLY WORK WHEN THEY CAN BE GIVEN BEFORE THE COLD SORES ARISE
Yes. Once the sores arise then the disease is going to take it’s course. And because most kids cannot tell you they are feeling the sensation of paresthesia or tingling pain before the sores arise we cannot prevent them. But we can use acyclovir if you can predict when the sores come out, otherwise we have to just treat symptoms when sores arise
WHAT IS SYMPTOMATIC CARE FOR THAT FIRST BAD PRESENTATION OF MOUTH HERPES?
Give any fluid patient will drink--cold, no carbonation.
Tylenol and motrin alternated every 3 hours for a few days.
Call for any concerns about dehydration--can hospitalize if necessary for IV fluids.
OKAY. NOW LET’S MOVE TO SKIN TRAUMA ITEMS. MOST COMMON IS PROBABLY INSECT BITES. FOR SOME PEOPLE THESE ARE NOT A BIG DEAL AND FOR OTHERS THEY GET BAD REACTIONS.
People who get bad reactions to mosquito bites with excessive swelling will often say they are “allergic” to mosquito bites but this is better termed a hypersensitivity to these bites.
HOW DO WE HELP KIDS WHOSE BODIES OVERREACT TO INSECT BITES?
The trifecta for helping these kids is a combination of Zyrtec AND Benadryl AND topical hydrocortisone. Zyrtec is 1 ml per for every 10 pounds of body weight every 24 hours for the next few days AND Benadryl 1 ml per 5 pounds of body weight every 6 hours to help with itch and redness AND 1% hydrocortisone to affected area 2-3x/day to help with itch.
CAN PARENTS DO ANYTHING FOR PREVENTION OF THE HYPERSENSITIVITY?
Besides the prevention for bites with clothing coverage and using insect repellant, I suggest the option for doing zyrtec every day during seasons when they are around lots of mosquitos. Because this hypersensitivity reaction is due to histamine after the bites, having an ANTI-histamine in your system ahead of time prevents the overreaction after the bite.
WHEN SHOULD PARENTS CALL ABOUT MOSQUITO BITES?
Call for any worsening and expanding redness as there may be a secondary infection.
LACERATIONS ARE UP NEXT. ONE OF THE BIG QUESTIONS PARENTS HAVE IS “WHEN SHOULD I COME IN AND GET STITCHES”?
This is a tough one because it is difficult to make a judgement call based on a description and pictures can look worse based on how a photo is taken. But in general I recommend getting stitches for any wound that is gaping open and especially in a cosmetically important area like the face or an area that moves a lot like a knee. What we are trying to accomplish is to help a wound heal together and not with a lot of scar tissue. I am happy if people text me on this for an opinion on what to do.
BURNS ARE ALSO TOUGH TO EVALUATE AND TO KNOW WHAT TO DO WITH THEM. WHEN SHOULD PARENTS COME IN WITH BURNS?
Another tough question. We get so many common burns with sunburns and mild, first-degree, burns with hot chocolate or similar. I think that any burn that rises to the degree of blistering we ought to see because there is immediate help we can give as well as prescription help for when the blisters rupture.
WHAT IS THE MOST COMMON BURN YOU SEE?
It is when kids touch the glass in front of a fire place and burn the palms of their little hands.
OUCH!!!
What is your management for MINOR BURNS?
It is similar to what most parents do—Aloe or similar burn creams. Some have lidocaine in them and that can be helpful. What is often forgotten is using pain medication like Tylenol and ibuprofen—this is very important in the pain management. Burns hurt a lot and we need to help with the pain.
ARE THERE ANY BURNS THAT NEED TO GO TO SPECIALISTS?
Yes. I send blistering and more severe burns when they cross joint spaces on hands and palms over to the burn specialists at the University. Improper management of these burns can lead to scarring that limits the use of hands and fingers. So I get them to the burn clinic for those.
LAST IS SLIVERS OR OTHER FOREIGN BODIES.
I don’t manage a lot of slivers. These are usually self-limited and come out on their own if they don’t get infected. I am happy to see any of these and some are worth removing but I don’t like to do any cutting that opens the skin more that it already is and increase the chance for infection. Other possible foreign bodies in the skin like glass pieces we will x-ray to see if something is in there that shows up on x-ray. Some of these may need to go to surgery if they need management because sedation and an operating room may be needed for really deep foreign bodies.
THIS WRAPS UP OUR EPISODE ON SKIN INFECTION AND TRAUMA. NEXT WILL BE OUR EPISODE REVIEWING BABY SKIN.
