At the most recent Skin of Color Update, we had the honor to learn about pediatric inflammatory skin conditions from the renowned Dr. Candrice Heath, triple board-certified dermatologist and Associate Professor at the Howard University Department of Dermatology and Dr. Brandi Kenner-Bell, Assistant Professor of Dermatology and Pediatrics at the Northwestern University Feinberg School of Medicine.
The panel led by Dr. Heath and Dr. Kenner-Bell provided an in-depth overview of pediatric inflammatory skin conditions, focusing on diagnostic challenges and management strategies, especially in pediatric patients with skin of color. The presentation highlighted the complexities in diagnosing conditions such as seborrheic dermatitis, pediatric psoriasis, and hidradenitis suppurativa (HS).
Seborrheic Dermatitis in Pediatric and Adolescent Patients
Seborrheic dermatitis is a common condition in pediatric and adolescent patients. Dr. Heath provided several diagnostic clues for recognizing seborrheic dermatitis, including checking for post-inflammatory hyperpigmentation (PIH) on the face, flaky scalp, and subtle erythema around the nasal alae. Additionally, she suggested assessing the patient’s tolerance to acne products, as dry skin is a common side effect, as well as assessing for signs of puberty.
An important point in the presentation was the overlap between seborrheic dermatitis and atopic dermatitis (AD). While these two conditions can coexist, causality has not been fully established. There is evidence suggesting a shared pathophysiological mechanism between AD and seborrheic dermatitis, indicating a possible predisposition to both conditions in some patients.1
Pediatric Psoriasis: Clues and Treatment Options
Pediatric psoriasis is another challenging condition for clinicians. One of the key insights provided was that a family history of psoriasis may not always be present, especially since psoriasis is underdiagnosed in adults with skin of color. Early signs of pediatric psoriasis may include scaling plaques on the upper eyelids or in the perineum, due to the Koebner phenomenon from rubbing the eyes or friction from the diaper.2,3 Nail involvement is more common in boys, however, in contrast to adult psoriasis, pediatric nail involvement is not linked with increased risk of psoriatic arthritis. 2,3 Scalp involvement is also found to be more common in girls. Dr. Heath highlighted the importance of asking pediatric patients about itchy/scaly rashes in the genital area and intergluteal cleft as this information may not be voluntarily offered by the patient.
Treatment for pediatric psoriasis includes both topical and systemic therapies. Systemic options include etanercept (approved age > 4 years), ixekizumab (approved age > 6 years), secukinumab (approved age > 2 for psoriatic arthritis and age > 6 years for psoriasis), ustekinumab (approved age > 6 years), upadacitinib (approved age > 2 years for psoriatic arthritis), and apremilast (approved age > 6 years).
Hidradenitis Suppurativa (HS) in Pediatric Patients
Dr. Kenner-Bell shared her insights in diagnosing HS in pediatric patients as well as the challenges associated with it. Dr. Kenner-Bell stressed that diagnosis is frequently delayed by up to two years, which can lead to significant disease progression with the development to a chronic, inflammatory state with fistula/sinus formation, malodorous discharge, cribriform scarring, and dermal fibrosis with contractures.4 Classically, HS is diagnosed once patient has two recurrences within 6 months or chronic/persistent lesions for more than 3 months; however, waiting for the chronic, relapsing course can lead to delays in diagnosis in pediatrics.
Pediatric HS is often associated with metabolic syndrome, making it crucial to screen for associated conditions such as obesity, insulin resistance, and hyperlipidemia. In terms of demographics, HS is more prevalent in Black and Latino patients, and up to 80% of pediatric HS patients are overweight or obese.4-6 Dr. Kenner-Bell also shares that children with HS have more frequent hormonal imbalance. Prepubertal HS is rare but may be a marker of precocious puberty. Importantly, there is a 5-fold higher risk of HS in children with Down’s syndrome.5,6
Dr. Kenner-Bell stressed that just like adult HS, pediatric HS is associated with several comorbidities including but not limited to follicular occlusion tetrad (HS, acne, dissecting cellulitis, pilonidal cyst), depression, anxiety, inflammatory bowel disease, and arthritis, making it essential to screen for these conditions in your pediatric patients with HS.7-9
Dr. Kenner-Bell shared key treatment insights, emphasizing the principle of “Do no harm!” For tetracyclines, they should be avoided in children under 8 years old but are acceptable for a short course of treatment (up to 21 days). Combined oral contraceptives (COCs) should be used only after 1-2 years of an established menstrual cycle. Finasteride can be used from age 6 and up, but caution is needed due to its teratogenic potential. Metformin’s dosing and safety remain unclear for children under 10. The only medication approved for treating hidradenitis suppurativa (HS) in children over 12 years is adalimumab. The emphasis was not just on avoiding harm, but also on doing more good with treating HS aggressively and early, as missing the “window of opportunity” for intervention can lead to a chronic, difficult-to-manage condition.
Recognizing Pigmentary Changes and Hair Loss
The presenters also discussed the importance of recognizing pigmentary changes and hair loss as indicators of ongoing inflammation. Inflammation in pediatric skin conditions can cause significant pigmentary alterations, which are often a major concern for both patients and their families. Hair loss, particularly in conditions such as seborrheic dermatitis and psoriasis, can also be a sign of active inflammation and should be addressed promptly to prevent further complications.
Shared Decision-Making and the Role of Family
An essential element of the presentation was the role of shared decision-making in pediatric dermatology. Pediatric patients require a tailored approach that involves both the child and their parents. Treatment plans should take into consideration the concerns of the family, the child’s ability to adhere to treatment, and realistic expectations. Dr. Heath and Dr. Kenner-Bell stressed the importance of engaging both the patient and their family in treatment discussions to ensure adherence and long-term success.
Conclusion: The Need for Early Diagnosis and Aggressive Treatment
In conclusion, Dr. Heath and Dr. Kenner-Bell’s presentation provided a detailed exploration of pediatric inflammatory skin conditions. The emphasis on early diagnosis, aggressive treatment, and the unique concerns of pediatric patients highlighted the complexities of managing these conditions, particularly in patients with skin of color. The presentation underscored the importance of recognizing early signs such as pigmentary changes and hair loss, considering metabolic and demographic factors in conditions like HS, and engaging in shared decision-making with patients and their families. Overall, the presentation called for a proactive, patient-centered approach to care that addresses the specific needs of pediatric dermatology patients.
References
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- Rau A, Silva GS, Margolis DJ, Chiesa Fuxench ZC. Adult and infantile seborrheic dermatitis: update on current state of evidence and potential research frontiers. Int J Dermatol. Published online June 14, 2024. doi:10.1111/ijd.17324
- Hebert AA, Browning J, Kwong PC, Duarte A, Price HN, Siegfried E. Diagnosis and Management of Pediatric Psoriasis: An Overview for Pediatricians. J Drugs Dermatol. 2023;22(8):742-753. doi:10.36849/jdd.7531
- Treat J. Tips, Tricks, and Pearls to Expertly Treat Common Pediatric Dermatologic Conditions. Dermatol Clin. 2022;40(1):95-102. doi:10.1016/j.det.2021.09.009
- Liy-Wong C, Kim M, Kirkorian AY, et al. Hidradenitis Suppurativa in the Pediatric Population: An International, Multicenter, Retrospective, Cross-sectional Study of 481 Pediatric Patients. JAMA Dermatol. 2021;157(4):385-391. doi:10.1001/jamadermatol.2020.5435
- Garg A, Wertenteil S, Baltz R, Strunk A, Finelt N. Prevalence Estimates for Hidradenitis Suppurativa among Children and Adolescents in the United States: A Gender- and Age-Adjusted Population Analysis. J Invest Dermatol. 2018;138(10):2152-2156. doi:10.1016/j.jid.2018.04.001
- Deckers IE, van der Zee HH, Boer J, Prens EP. Correlation of early-onset hidradenitis suppurativa with stronger genetic susceptibility and more widespread involvement. J Am Acad Dermatol. 2015;72(3):485-488. doi:10.1016/j.jaad.2014.11.017
- Tiri H, Jokelainen J, Timonen M, Tasanen K, Huilaja L. Somatic and psychiatric comorbidities of hidradenitis suppurativa in children and adolescents. J Am Acad Dermatol. 2018;79(3):514-519. doi:10.1016/j.jaad.2018.02.067
- Seivright JR, Collier E, Grogan T, Hogeling M, Shi VY, Hsiao JL. Physical and psychosocial comorbidities of pediatric hidradenitis suppurativa: A retrospective analysis. Pediatr Dermatol. 2021;38(5):1132-1136. doi:10.1111/pde.14765
- Cotton CH, Chen SX, Hussain SH, Lara-Corrales I, Zaenglein AL. Hidradenitis Suppurativa in Pediatric Patients. Pediatrics. 2023;151(5):e2022061049. doi:10.1542/peds.2022-061049
This information was presented by Dr. Candrice Heath and Dr. Brandi Kenner-Bell during the 2024 Skin of Color Update conference. The above session highlights were written and compiled by Dr. Nidhi Shah.
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