AFP Journal Review: January 1, 2008

1. AFP Journal Review:January 1, 2008 John W. Hariadi, M.D.

2. Newborn Skin: Part I.Common Rashes • Rashes extremely common in 1st 4 weeks of life • Mostly benign and self-limited • Transient Vascular phenomenon • Erythema Toxicum • Acne Neonatorum • Milia, Miliaria • Seborrheic Dermatitis

4. Transient Vascular Phenomena • Normal Newborn Physiology rather than true “rashes” • Cutis Marmorata and Harlequin Color Change

5. Cutis Marmorata • Normal reticulated Mottling of skin • Trunks and extremities • Vascular response to cold • May persist for weeks or months • Generally resolves when skin is warmed

6. Harlequin Color Change • ?Caused by immaturity of hypothalamic center that controls dilation of peripheral blood vessels • Occurs when newborn lies on side • Erythema of dependent side with blanching of contralateral side • Persists for 30 seconds to 20 minutes • Resolves with crying or increased muscle activity • Up to 10% of full term infants • From 2nd-5th day of life, may continue up to 3 weeks

7. Erythema Toxicum Neonatorum • Most common pustular eruption in newborns (40-70%) • Common in term infants and those >5.5 lbs • Present at birth, 2nd-3rd DOL • Erythematous 2-3 mm macules & papules pustules • Pustule surrounded by blotchy area of erythema –”flea bitten” • Face, trunk, proximal extremities-spares palms/soles

8. Erythema Toxicum Neonatorum • Generally clinical diagnosis • Cytologic exam of pustuleeosinophilia with Gram, Wright, Giemsa Stain • Etiology is unknown • Fade over 5-7 days, may recur for several weeks • No treatment needed • If sick appearing, need to r/o infectious cause

10. Transient Neonatal Pustular Melanosis • Vesiculopustular rash • 5% Black, ,1% White • Lesions lack surrounding erythema • Pigmented macules within the vesiculopustules • Rupture easilyleave behind scales & pigmented macules • All areas affected including palms/soles • Fade over 3-4 weeks • Cytology: PMNs

11. Acne Neonatorum • 20% of newborns • Closed comedones on forehead, nose, cheeks • Open comedones, inflammatory papules • Stimulation of sebaceous glands by maternal androgens • Resolve within 4 months without scarring • Treatment usually not required; can use 2.5% benzoyl peroxide • Persistent/Severe need to look for underlying causes

12. Milia • 1-2 mm pearly white/yellow papules • Retention of keratin within dermis • Up to 50% of newborns • Forehead, nose, cheeks, chin but can also: trunk, penis, limbs, mucous membranes • Resolve within 1st month, can last till 2nd or 3rd month

13. Miliaria • Sweat retention by partial closure of eccrine structures • 40% of infants-1st MOL • Miliaria Crystallina • 1-2mm vesicles without surrounding erythema • Hours to days • Miliaria Rubra-”Heat Rash” • Erythematous papules, in covered portions of skin • Deeper level of sweat gland obstruction • Avoid overheating, remove excess clothing, cooling baths, air conditioning

14. Seborrheic Dermatitis • Extremely common • “Cradle Cap”-may include face, ears, neck • Erythema in flexural folds, scaling on scalp • Often involves diaper area • Can be difficult to distinguish from atopic dermatitis

16. Seborrheic Dermatitis • Etiology unknown-? Malassezia furfur, hormonal fluctuations • Self limited- resolves several weeks to months • Conservative approach • Watchful waiting • Soft Brush after shampooing • Emollient

18. Newborn Skin: Part IIBirthmarks • 3 Main groups • Pigmented • Congenital melanocytic Nevi • Dermal Melanosis • Vascular • Hemangiomas • Nevus Flammeus, Nevus Simplex • Abnormal development • Most do not require immediate treatment

20. Congenital Melanocytic Nevi • 0.2-0.4% infants at birth • Disrupted migration of melanocytic precursors in neural crest • Color: Brown to black • Mostly flat, can be raised • Potential for malignancy-based on size • Nevus that changes in color, shape or thickness need further evaluation

22. Dermal Melanosis • “Mongolian Spots” • Flat, most often in back or buttocks • Arise when melanocytes trapped deep in the skin • Common in Non-white populations • Should be documented in newborn exam • Most fade by 2 years of age

23. Hemangiomas • 1.1-2.6% of newborns • Can develop anytime in 1st few months of life, 10% at 1 year • 50% involute by 5 years, 70% by 7 years and 90% by age 10 • May leave scars • Can treat with pulse dye laser—unsure long term cosmetic outcome • Eye, airway or organ compression require immediate treatment & referral • Prednisone 3mg/kg x 6-12 weeks

24. Nevus Flammeus • “Port Wine Stain” • 0.3% of newborns • Flat,dark red to purple lesions • Do not fade over time • May develop varicosities, granulomas, nodules • Do not require treatment—Pulse dye laser before age1 • Opthalmic (V1) distribution associated with glaucoma • 5-8% with Sturge-Weber Syndrome • glaucoma/seizures/port-wine stain, angioma of brain/meninges • Mental retardation & hemiplegia • Refer to Ophthalmology

25. Nevus Simplex • “Stork bites” ,“Angel Kisses” , “Salmon patch” • Flat, salmon colored lesions-telengectasias in dermis • Eyes, scalp, neck—blanch when compressed • Occur on both sides of face in symmetric pattern • 40% resolve in neonatal period, most by 18 months

26. Supernumerary Nipples • Arise from mammary ridges along ventral body wall • May contain areola, nipple or both • May be unilateral/bilateral • Up to 5.6% of children • Mostly benign

27. Skin Markers of Spinal Dysraphism • Spinal dysraphism: • diverse congenital spinal anomalies caused by incomplete fusion of midline elements of the spine • Tethered Cord Syndrome-need surgical release • Midline lumbosacral skin lesions are often cutaneous markers of spinal dysraphism • High or intermediate risk lesions should undergo imaging • MRI is most sensitive. Spinal ultrasonography also used

29. Clavicle Fractures • 5-10% of all fractures • Most in men<25 yrs, men >55 & women >75 • Allman Classification • Group I (midshaft/middle third) ->75-80%, young • Group II (lateral/distal)-> 15-25% • Group III (medial/proximal)-> 5%

31. Anatomy • Midshaft is thinnest, least medullous area • AC & SC joints have robust ligamentous support • Sternal ossification center fuses with shaft by age 30 • Malunion can impair mobility to upper extremity • Callus formation/ displacement can lead to thoracic outlet obstruction

32. Evaluation • Mechanism of injury: fall directly on shoulder with arm at side, often in contact sports • Hold affected arm adducted close, support with opposite hand • Exam: ecchymosis, edema,focal tenderness and crepitus on palpation of clavicle • Need to perform neurovascular & lung exam • Radiographs should be performed

33. Midshaft Clavicle Fractures

34. Midshaft Clavicle Fractures • Nondisplaced • Sling /Figure of eight dressing • Can discontinue in 1-2 weeks when pain subsides • Pendulum exercises as soon as pain allows, active ROM & strengthening 4-8 weeks • Displaced • Higher rates of nonunion • Can consider operative treatment in patients with multiple risk factors

36. Midshaft Clavicle Fractures • Operative options: • Open/closed reduction with plate fixation • Intramedullary fixation->smaller incisions, avoids plate pressure but risk of device migration • Complications rare->pneumothorax, vascular injury • Long term Sequelae: Pain, weakness, parasthesias • Displacement of > one bone width is strongest radiographic risk factor for symptoms & sequealea

37. Return To Activity Considerations • Full Range of motion • Normal shoulder strength • Clinical & radiographic evidence of bone healing • No tenderness • Can return to noncontact sports in 6 weeks • Contact sports in 2-4 months • If surgical case->may need removal of hardware

38. Midshaft Clavicle Fractures in Children • 88 percent of clavicle fractures • Nearly all heal well due to great periosteal regenerative potential • Often have significant callus formation • Healing within 4-6 weeks • If no history of trauma, need to consider malignancy, rickets, osteogenesis imperfecta and physical abuse

39. Distal Clavicle Fractures • 5 Types: • Type I Coracoclavicular ligament intact • Type II Conoid (medial) torn, trapezoid intact • Type III Extension into AC joint • Type IV Disruption in periosteal sleeve (children) • Type V Avulsion of ligaments with small cortical fragment • Type I & III-stable nonoperative • Type II->high rate of nonunion • Type IV-often occurs through distal physis with ligaments attached-> “pseudodislocation” • Operative treatment only with sever displacement

40. Proximal Clavicle Fractures • Very uncommon • Typically nondisplaced • If displaced, need to evaluate for neurovascular compromise • May need CT scan for better visualization

41. Herbal and Dietary Supplement-Drug Interactions in Patients with Chronic Diseases • Herbs, Vitamins and supplements may augment or antagonize actions of drugs • Deleterious effects are most pronounced with anticoagulants, cardiovascular medications, oral hypoglycemics and antiretrovirals • St. John’s Wort • Reduction in INR with warfarin, reduced levels of verapamil, statins, digoxin, antiretrovirals • Physicians should routinely ask patients about use of supplements