> Starting and Running a Practice

Always Keep Your Eyes Open for New Trends

At the time that I graduated residency and went on to a pediatric dermatology fellowship I was unaware of what my practice would look like as a new practitioner, and even more so a decade later. One of the most important things I learned in practice is that it is vitally important to keep an eye out for new trends or reappearances of old diseases. In this vein, I am going to list five things that were below my radar until recently, and are now on my mind as I practice daily.

#1: Eczema Coxsackium

Hand foot mouth disease is caused by the picornavirus Coxsackie or by enterovirus 71. Whereas I saw herpangina (ulcerations on the hard palate/ throat) as a pediatrics resident, as a pediatric dermatology fellow I had the opportunity to see cases of onychomadesis with Anthony Mancini, MD. These cases have re-appeared in force in my practice over the past three years accompanied by blistering of the extremities, localized blistering within eczema lesions, Gianotti- Crosti like lesions and a host of other appearances. 1Keeping abreast of changing trends in infectious disease manifestations is key in the practice of pediatric dermatology.

#2 Contact Dermatitis

When I was training, no self respecting 8-year-old would allow their rears to be cleaned with diaper wipes, but things have changed. Individuals ranging from infancy through senescence now use wipes to clean their derrieres, hands and surfaces in the household. Infants fare best, with many better diaper makers producing well-tested hypo-allergenic wipes. On the other hand, many wipes marketed as antibacterial for adults and parents contain a variety of allergens including fragrance and the most recently reported methylisothiazolinone (other names: Kathon CG, MCI/ MI). 2 3 4Alertness to new allergy trends both in usage patterns and in the inclusion of newer chemicals in common products is an important feature of today’s dermatology practice.

#3 Fatty Liver

Teresita Laude, MD, a personal mentor, described the usage of griseofulvin for childhood tinea capitis in the 1970s and taught me that most children did not require lab screening. Recently, I have begun to request recent liver function tests for children with tinea capitis, especially children who are obese, due to the recent rise in incidence of fatty liver in children, which has appeared at times in children who are in my practice5 6

#4 Antibiotic Resistant Staphylococcus Aureus

A broad mixture of Staphylococcus aureus species with resistance to Oxacillin/ Methicillin (MRSA) came on the radar 10 years ago. Resistant strains have become increasingly of concern as newer variants appear in my practice including Methicillin Sensitive disease with Clindamycin resistance, which has been noted cultured from a number of the severely superinfected atopic dermatitis patients who were hospitalized in our institution this past 2 years. Keeping in mind that resistance, even if not to Oxacillin, means there is a virulence factor present focuses us on the core of the issue.

Children who harbor MRSA lesions may carry bacteria in sites other than the nostrils, like the underarms. Colonization can also prompt or relate to recurrent eczematous changes in some children termed “perianal bacterial dermatitis” when localized to the groin.7 In these cases and when children with atopic dermatitis experience recurrent staphylococcal infections, the dilute bleach bath, an old remedy which has recently been proven in clinical testing, along with clinical interventions may aid in long-term reduction in dermatitis severity.8 9


#5 Bed Bugs

Whereas most people with “delusions of parasitosis” were delusional when I trained, nowadays, it may not be all in the patient’s head. “Vontz” (Yiddish for bed bug) the old scourge of immigrants and tenements from the turn of the 20th century, has returned. The old enemy is an equal opportunity biter knowing no boundaries regarding per capita income or street address, even having been reported in hospital settings.10 The rapidity of the spread of the bed bug is now well-documented.11 Good extermination is the key to recovery, and new and interesting techniques involving bug-sniffing dogs for identification and heat treatments have emerged that are less toxic than prior therapeutics. Other considerations in therapy include the recently reported potential superinfection of the bite, due to Cimex Lectularius colonization with Methicillin-Resistant Staphylococcus aureus.12 Even within a newer or recurrent trend, a new twist often arises.

Spotting the Trends

The practitioner at large should keep in mind these new trends emerge rapidly. I often use medical database searches and consultation with colleagues to help me spot emerging trends. The busy dermatologist can use grand rounds, scanning key journals, physician forums, lunch with your colleague and national meetings to identify how these trends affect your population of patients. The new and emerging trends are exciting and gratifying when identified. They are some of my favorite aspects of pediatric dermatology practice.

1 Mathes EF, Oza V, Frieden IJ, Cordoro KM, Yagi S, Howard R, Kristal L, Ginocchio CC, Schaffer J, Maguiness S, Bayliss S, Lara-Corrales I, Garcia-Romero MT, Kelly D, Salas M, Oberste MS, Nix WA, Glaser C, Antaya R. “Eczema coxsackium” and unusual cutaneous findings in an enterovirus outbreak. Pediatrics. 2013 Jul;132(1):e149-57.

2 Chang MW, Nakrani R. Six children with allergic contact dermatitis tomethylisothiazolinone in wet wipes (baby wipes). Pediatrics. 2014Feb;133(2):e434-8.

3 Aerts O, Baeck M, Constandt L, Dezfoulian B, Jacobs MC, Kerre S, Lapeere H, Pierret L, Wouters K, Goossens A. The dramatic increase in the rate ofmethylisothiazolinone contact allergy in Belgium: a multicentre study. Contact Dermatitis. 2014 Jul;71(1):41-8.

4 Hosteing S, Meyer N, Waton J, Barbaud A, Bourrain JL, Raison-Peyron N, Felix B, Milpied-Homsi B, Ferrier Le Bouedec MC, Castelain M, Vital-Durand D, Debons M, Collet E, Avenel-Audran M, Mathelier-Fusade P, Vermeulen C, Assier H, Gener G, Lartigau-Sezary I, Catelain-Lamy A, Giordano-Labadie F; REVIDAL-GERDA network. Outbreak of contact sensitization to methylisothiazolinone: an analysis of French data from the REVIDAL-GERDA network. Contact Dermatitis. 2014 May;70(5):262-9.

5 Laude TA, Shah BR, Lynfield Y. Tinea capitis in Brooklyn. Am J Dis Child. 1982 Dec;136(12):1047-50.

6 Aggarwal A, Puri K, Thangada S, Zein N, Alkhouri N1. Nonalcoholic fatty liver disease in children: recent practice guidelines, where do they take us? Curr Pediatr Rev. 2014;10(2):151-61.

7 Heath C, Desai N, Silverberg NB. Recent microbiological shifts in perianal bacterial dermatitis: Staphylococcus aureus predominance. Pediatr Dermatol. 2009 Nov-Dec;26(6):696-700.

8 Huang JT, Rademaker A, Paller AS. Dilute bleach baths for Staphylococcus aureus colonization in atopic dermatitis to decrease disease severity. Arch Dermatol. 2011 Feb;147(2):246-7.

9 Paller AS(1), Simpson EL, Eichenfield LF, Ellis CN, Mancini AJ. Treatment strategies for atopic dermatitis: optimizing the available therapeutic options. Semin Cutan Med Surg. 2012 Sep;31(3 Suppl):S10-7.

10 Sfeir M, Munoz-Price LS. Scabies and bedbugs in hospital outbreaks. Curr Infect Dis Rep. 2014 Aug;16(8):412.

11 Mabud TS, Barbarin AM, Barbu CM, Levy KH, Edinger J, Levy MZ. Spatial and temporal patterns in Cimex lectularius (Hemiptera: Cimicidae) reporting in Philadelphia, PA. J Med Entomol. 2014 Jan;51(1):50-4.

12 Barbarin AM, Hu B, Nachamkin I, Levy MZ. Colonization of Cimex lectularius with methicillin-resistant Staphylococcus aureus. Environ Microbiol. 2014 May;16(5):1222-4.