Things that make you go hmmmmm
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Things that make you go Hmmmmm ……. Or It is what it is!. Objectives. Identify benign skin lesions with confidence Identify resources for dermatology education AND one new thing about management of Hemangiomas. Lichen Striatus. Primary phase.

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Things that make you go Hmmmmm ……

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Things that make you go Hmmmmm……


It is what it is!


  • Identify benign skin lesions with confidence

  • Identify resources for dermatology education

  • AND one new thing about management of Hemangiomas

Lichen Striatus

  • Primary phase

Secondary Phase

Fading and Flattening

-Common 9months to 6 years but can occur earlier or later

-Last 1-3 years

-Relapses of short duration have been noted after complete clearing

Nevus Depigmentosis

  • Generally present at birth or within several months, sometimes not obvious until sun exposure in fairer skin

  • Borders can be regular or irregular

  • Can have whorled appearance

PigmentaryMosacism/Hypomelanosis of ito

  • Follows blashkos lines

  • Can be associated with neurologic, skeletal, and/or ocular abnormalities

  • The hypopigmentation is secondary to hypofunctioning of melanocytes and is thought that mishap ear in embryogenesis is responsible for the mosaicism.

  • No consistent genetic defect.

  • Follow up depends on associated abnormalities.

Beckers Nevus

Large dermal nevi commonly shoulder but not exclusively

  • Large, pigmented, hairy nevus

  • Most commonly noted in adolescence

  • Benign

Melan0nychia StriataLongitudinal Melanonychia

  • Most commonly seen in individuals with darker skin- especially African-Americans in whom up to 90% may have at least one such streak

  • The pigmentation extends from the proximal nail fold to the distal margin of the digit

  • The width may vary from less than 1mm to several mm

  • But……. (there is always a but) 

Nail Matrix Melanoma should be considered

  • Worrisome features may include very dark, broad bands AND

  • Extension of the pigmentation onto the proximal or lateral nail folds (aka Hutchinson’s Sign)

  • Any patient with this presentation should be referred for nail matrix biopsy which can cause permanent damage to the nail plate

Confluent and Reticulated Papillomatosis

CRPEtiology: Unknown

  • Minocin 100mg BID x30 days then qd x 30 days

Terre Firma FormeorDuncans Dirty Dermatosis

First described by Dr. Duncan in Houston in 1987

At fist glance these patients may appear to have confluent and reticulated papillomatosis (CARP) or acanthosisnigricans

In contrast to derma neglecta soap and water will not wash this off, isopropyl alcohol is necessary

When this condition is suspected, firm, persistent pressure should be applied while rubbing the skin with alcohol.

The cause of terra firma-formedermatosis is unknown.

Pityriasis Alba (again)

This a variant of dry skin

It is usually asymptomatic

Appears worse in summer, better during school year

Treatment is sunscreen and moisturizer

If you mom think it is fungal…..

Do a culture

Keratosis Pilaris

Very common!!

Become more extensive in drier climate.

Individual lesions represent plugs of stratum corneum in individual follicular openings

ie: Skin Trash

Moisturizer with urea of lactic, salycylic acid

May help but is not curative.


Autosensitization Dermatitis


Hypopigmented thickened papules often on elbows , knees

Can be eczematous and very itchy

  • -found in up to 50% of patients with nickel dermatitis

  • -nearly always symmetrical

  • -may also be seen in response to infectious agents, particularly in bacterial and dermatophyte infections.

  • In the case of tineacapitis the id reaction is usually seen on the head and neck and is often after initial of oral antifungal agent and is erroneously diagnosed as drug reaction

  • Clearance occurs with resolving of the originial cause- nickel avoidance, clearance of tinea, etc.

Knuckle PADS

Knuckle pads were medically first described by Garrod in 1893 and are also named Garrod's pads

There is no known established, generally successful therapy.

Injection of corticosteroids (triamcinolone) can soften and sometimes even shrink the pads. Radiation therapy has also been reported to be successful in some cases but not consistently.

Knuckle pads can be surgically removed in the case of pain associated with them. .


Aplasia Cutis Congenita

Developmental defect rather than birthmark

Occurs in about 1 in 5000 births

Ulcerated defects may heal with scar.

Although usually benign, the hair collar sign may be associated with other physical anomalies and malformation syndromes.

No specific laboratory tests are required, although a hair collar sign signals the possibility of a CNS malformation and thus may warrant an MRI scan to rule out an underlying pathology

Nevus Sebaceous

Appears at birth as slightly raised yellow orange nevus

At puberty become raised and warty

Basal cell carcinoma and other benign tumors occur in 15-50% of the tumors

Excision recommended prior to puberty.




  • Hereditary Form

  • Seen in less than 2% of children

  • Often onset is after 12 months of age

  • More lesions accumulate slowly with age and lesions do not spontaneously resolve.

  • System symptoms develop with time in 2% of the children with this form (flushing, tachycardia, hypotension, hepatosplenomegaly


  • Solitary lesion

  • Will not develop more

  • Topical steroids for treatment of symptoms

  • Non Hereditary Form of Mastocytosisis much more common

  • Blotchy macular and nodular pigmented lesions which appear in the first 8 months of life starts with one or 2 and then develop numerous lesions over months.

  • The hyperpigmented appearance may not appear until 6 months after onset

  • Darriers sign- stroking the lesion will cause tense edema and redness

  • Spontaneous clearing by 6 or 7 years of age is usual

Essential that children with any type of Mastocytosis not be given the following medications:

Opiates (codeine, demerol, morphine)

Polymixin B

Acetylsalicylic Acid

In the case of surgery very important that perioperative medications carefully


Treatment options

  • Nonsedating Antihistamine (zyrtec, Allegra, etc)

  • Regular daily dosing

  • Can try every 6 months to stop and if starts flaring then resume medication

  • Topical Steroids for itching in individual lesions BID

  • For body Triamcinolone 0.025% or 0.1%

  • For face/neck/groin/axilla/head Hydrocortisone 2.5% or Desonide 0.05%.

Which hemangiomas warrant this Treatment?

Propranolol Protocol at CMC Dermatology

  • Prior to initiation of therapy needs :

  • BP

  • Pulse

  • Chest Xray

  • ECG

  • Propranolol 1mg/kg/dose administer BID (20mg/5ml solution)


  • Propranolol 1mg/kg/dose administer BID 20mg/5ml solution

  • Taper Schedule:

  • Days 1-4 0.25mg/kg/dose BID

  • Days 5-9 0.5mg/kg/dose BID

  • Days 10-13 0.75mg/kg/dose BID

  • Day 14 and on 1mg/kg/dose BID

  • Can also divide the above doses to TID (.025mg/kg x2)

  • 3

Follow up Schedule

  • Follow up is weekly x 3,then q2w x 4, then montly. BP q visit.

  • Infants younger than 3 months should have CBG monitored each visit.

  • Parents should be instructed how to count pulse and recognize low heart rate

  • They should watch for somnolence, perioral pallor, cold hands and feet.

  • Patients must be fed q4h while on this medication due to hypoglycemia possibility

11/17/12 baseline










Dermatology information resources

  • Textbooks:

  • Color Textbook of Pediatric Dermatology- Weston, Lane, and Morelli

  • Pediatric Dermatology- Bernard A Cohen

  • Great for pictures and information that is clinically helpful.

  • DermNet NZ. Facts about the skin.

  • Skin Advocate App- available for free in app store- has information on parent and patient support organizations and is set up for you to email the address directly to the patient with a share line. (Developed by UTSW Resident and received national award !)

Some things can be fixed and some cannot…..

However we do know that education and information

is just as valuable as cures can be.

The goal is always………….

Happy Pt., Happy Momma, Happy Grandma!!

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