Seborrheic Dermatitis

Since I was on a roll with Dr. Jafarian (MCH Dermatology), I decided to tap into her expertise for one other common problem we encounter in the ED and oftentimes likely manage sub optimally, and that is seborrheic dermatitis.

While I won't go into how you diagnose seborrheic dermatitis, she wanted me to emphasize that this is a problem found exclusively in young infants within the first couple of months of life.

The reason seborrheic dermatitis is often not treated appropriately, is that people tend to forget that even though there is inflammation present, it is commonly associated with a fungal infection as well (M. Furfur).

If the family does not have private insurance, ie. has to pay out of pocket (because the government plan does not cover mixtures), then prescribe (the less expensive alternative):

• a custom mixture of 1% hydrocortisone cream in Loprox cream, mixed 1:1, applied BID for 1-2 weeks (most often effective).

If the family does have private insurance, this mixture is ideal because it does not reduce the concentration of either component used (apparently costs about $30-40):

• a custom mixture of 1% hydrocortisone powder in Loprox cream, applied BID for 1-2 weeks (apparently this tends to be more reliably effective).

Thank you to Dr. Jafarian, MCH Dermatology for her advice.

Warts

As we likely all know, Dermatology no longer accepts routine consults for warts.

If you have a patient who has any of the following scenarios, they will agree to see them, but these factors have to be very clearly indicated on the consult:

• warts on the face
• warts on the genitals
• the patient is immunocompromised

Otherwise, they say that topical Soluver Plus for plantar warts, and regular Soluver for warts elsewhere has been definitively proven to be as effective as cryotherapy, provided it is done properly. This is what they recommend:

• the wart cannot be properly treated unless it properly exposed (i.e. it is often covered by too many layers of thick skin for the therapy to penetrate effectively)
• the area of skin first needs to be well soaked, and then exfoliated aggressively (especially for plantar warts) with a pumice stone, ideally removing all of the overlying scale
• the therapy oftentimes needs to be done daily for a duration of 2-3 months

This preparation does not require a prescription. Note that in general any of the salicylic acid preparations are very effective, the Soluver happens to be our Dermatologist's preference.

Note that the above is the recommended therapy if the family decides they want to treat the wart, otherwise, simple warts are generally self-limited, and will resolve on their own with time.

Thank you to Dr. Jafarian, MCH Dermatology for her advice.

Tinea Capitis (& Corporis)

Doing results recently I noted numerous scalp scrapings coming back positive for tinea, and the physician who initially saw the patient had not started the patient on treatment. Therefore, I decided to check with dermatology as to their recommended approach.

If you have a patient who you think has tinea capitis:

1. Culturing the lesion is important because sometimes it can be a more unusual, difficult to treat fungal pathogen.
2. If the lesions are scaly, take a scraping (scrape off as many flakes as you can, and put them between 2 glass slides, tape up the edges of the glass slide, and label it). Send this to microbiology for KOH stain and fungal culture. 
3. If the scalp lesion is boggy and wet (as can happen with a kerion), use a regular culture swab (like for strep) and culture as much of the oozing stuff as possible. Send this for fungal culture (KOH cannot be done on this sample). 
4. Draw off a baseline CBC and LFTs (even though the risk of problems with Lamisil treatment is very low in children, Dermatology recommends this). Needs to be done in all cases (whether you are sure or unsure of the diagnosis), so that if we have to call the patient back to start the therapy after a positive culture, we don't have to bring them back to get this done. 
5. If you are not sure of the diagnosis, then just start the patient on Loprox cream for the lesion, and Nizoral shampoo for the rest of the family, pending the culture results. Keep in mind that tinea capitis can only be treated with oral therapy, therefore this is just a temporizing measure hoping to limit spread of the infection pending the culture result. 
6. If you are sure you are dealing with tinea capitis, then start the patient on oral Lamisil:

• Griseofulvin no longer exists
• Lamisil only comes in pill form, but it can be crushed and given in a puree or other food, and Dermatology uses the following dosing guideline in all patients
• < 20 kg, 62.5mg (1/4 pill) qday x 6 weeks
• 20-40 kg, 125mg (1/2 pill) qday x 6 weeks
• > 40 kg, 250mg (1 pill) qday x 6 weeks

1. Follow-up CBC and LFTs are recommended 4 weeks into the therapy, Follow-up can with be done through the primary care physician, or the patient can be referred to Dermatology. If you send them to Dermatology, indicated that follow-up is requested in 4 weeks, and give the family a requisition to get the CBC and LFTs done prior to the appointment. 

As an added note, tinea corporis is much easier to treat. If the lesion is scaly and can easily be cultured, do so as above for tinea capitis. If it is not easily cultured, do not worry, it is not as critical. Tinea corporis responds easily to topical therapy. Dermatology recommends Loprox cream BID for 2-4 weeks (they say better than Lamisil cream), and that it works every time!

Thank you to Dr. Jafarian, MCH Dermatology for her advice.