CME in pediatric dermatology

oh i um foreign [Laughter] foreign tell you foreign yeah what elective

oh please hello sir oh yes sir yeah okay uh good evening to everybody on

because uh welcome uh for this cme on pediatric dermatology uh i welcome our president dr ramirez pablo

and dr cobalt subramaniam treasurer and program convener dr rv [Music] i welcome all these

pp members and as well as state tv members i welcome dr haram sindhilsar who is here with me and i welcome joined secretary dr

paul subramany also and this now i uh i welcome doctor i am uh

good evening to all respected president ramirez babur our evil dynamic secretary who has been continuously

doing a great academic work during this time and still continuing president rajendra and he was smiling youngster professor nashville

who is arranging very good program to all our practicing pediatrician and all the members of central ap and all the delegates the speakers of today's

dermatology the topics are so designed in such a way that the practicing pediatrician however many times we hear about skin

infection in children especially fungal infections and other atopic dermatitis several meeting every conference we discuss

still we have confusions and this time the topics are aligned in such a way that it will be very useful for next step two hours all of us can have a very good academic

feast about day-to-day practicing dermatological problems the topics are very well and the speakers are known to

me very well dr cartigan one of the pioneer who is doing extensive work with medical college

and dr madhu and others all very good speakers we welcome our behalf of our iap and i thank our team for giving me this opportunity to

share this program thank you we will see as the program goes on you all will be benefited much about it thank you sir

thank you for thank you sir now i requested a certain ep member dr aram said to tell viewers uh

this topic is uh really uh going to be uh the breadwinner for most pediatricians because the first contact

for anyone is the pediatrician so we will learn from our pediatric dermatologist colleagues today let us have a wonderful learning

experience thank you for all the convener the faculty and doctor singer available thank you very much thanks for the opportunity i requested dr

dashani to state and foreign hello can you hear me so am i honorable sir yes no audible my brother yes sir thank you

so sir the outset i would like to thank iap tamilnadu state chapter the office bearers for this uh opportunity and uh for entrusting me with this job of

convening this uh cme and uh to start with uh i thought it would be very uh

kind of easy to get things done but uh the work wasn't all that easy um and my heartbeat thanks to our chairperson doctor singer

who immediately uh obliged every time i asked him for some favor he uh promptly says this i've never gotten a no from him thank you so much and um hearty

thanks to our president uh ramish babasa [Music] they've always trusted me and they've always let me go with whatever i have wanted to and special thanks to dr

thirusa so uh for making all these arrangements in a very short span of time and i my heartfelt thanks to all the speakers

for having uh agreed to do this at this busy uh sunday because uh it's been like always match meets and uh this meet or the other happening every time even our

chat person said he had uh see me to attend this between seven and nine and all that so in this bc uh time and this this period of the year they've

agreed to do such a um useful cme for the pediatricians and it is always like uh dermatology has always been a part of uh

practicing pediatricians we always think it is uh i mean it might as well uh go along with our management but it is not that all the time so it is always the

specialist that we look up to when we end up in a crisis or even at the start of uh diagnosing and treating difficult conditions so

dermatologists have always been in close liars and with the pediatricians so this topic i think would definitely benefit all the pediatricians and we have chosen topics in such a way that it covers all

the practical aspects of dermatology and without much further ado i would like to invite the first speaker

um my teacher professor dr madhu madam who's the associate professor of dermatology at the uh [Music] yes ma'am

professor dr madhu has a pg teacher and she's got lots of publications through her credit and she's a reviewer of indian journal of

dermatology and the indian journal of practical paediatrics and she's reviewed many articles her interest special interests include medical mycology and pediatric

dermatology she's a pediatrician herself and presently she holds the post of secretary of iap dermatology chapter and she was formerly the chairperson of

iadvl task force against recalcitrant teenia she's been awarded the best doctor award uh when she was working in garmin shanley uh medical college as an associate professor of the department of

dermatology she's very close to all of us she's got a very sweet demeanor so she never says no to whatever we ask her for i'm so happy and personally feel uh

uh delighted to uh have madame amidstress thank you ma'am over to you for the talk good evening everyone respected senior

members and dear friends now uh thank you for your kind words of appreciation of that it's always been very nice to be in close association with all of you it pleasure is mine too uh well yeah and at the outset i would

like to thank uh for the opportunity and the organizing committee of this particular cme and the communion and the chairperson and uh for giving a talk on yet another topic which

is very close to my heart fungal infections now just to begin let us recapitulate about our classification of fungal infections we all know that it can be classified as superficial indeed and the deep mycosis

get classified as circulating is and systemic with systemic becomes endemic and opportunity conventions what is relevant for us when we talk about fungal infections in

children is most often we see supervision fungal infections and among the superficial fungal infections again it is dermatophytosis which tops the list followed by petraeus is versatile and candidiasis now candidates again can

be localized and we know that it's an optional fungal infection as well and in those immunocompromised children we will be seeing the disseminated candiasis

and among the superficial bengal infections the d fungal infections we have the subcutaneous vitamin infections and these two residual microbes and pure hyper microbes is something which we might see we will talk about it a little

later actually and these days when we have more and more number of children with with the who get admitted in ic for a long time or it could be again because of

connective tissue disorders or it could be because of leukemias we do see invasive fungal infections like mocha mycosis and aspergillosis and in hiv children cryptococcuses as well but for

want of time i will focus on the most common portfolio fungal infections now the dermatophytosis as i already told you talks a list that we say i mean see in our day-to-day office

practice actually and these are caused by dermatophytes which can be anthropophilic that is you know human to human transmission and zoophilic is from animal to human transmission and geophilic is when the children of course

play in the soil and then acquire the infection and of course it all gets transmitted through direct contact or through formides as well and uh normally when we talk about

dermatophytosis in children couple of years back maybe seven to eight years back when you say dermatophytosis with children it was synonymous almost with the word linear capitals because pineal capitis that is the infection of the

scalp and the scalp hair was the most common fungal infection seen in children and occasionally we might see a patch or two of pineal coppers over the waist region of the groin of the

children because when these infants get carried by the mother or the grandmother who tend to have a pineal copper is in the waist so that was all it was about but last seven years i would say probably

almost six to seven years now there's been an increase in the incidence of the amount of isophytous of the global skin among the adults in india and there will be multiple factors

related to this starting from a global warming to the steroid abuse and this steroid abuse practically what is being used by the others themselves they were using it for

the children as well and so we do see an increase in incidence of dermatophytosis among the children as well and it is just not children it is even the neonates and infants and young

toddlers also and just an infection a dermatophytosis which is going to be increased will not be you know in fact happy to treat because it's one infection which is a very easily

uh diagnosable infection and all it takes is just you look at it you know it's senior cooperatives and you like you write the prescription patient gets all right and patient is happy too but the present scenario is entirely

different infections are not that easily treated because you know there is a difference in the strain i will talk about it later so the infections have become widespread and the patients have started getting chronic infection

chronic infection means which can be more than six months over a period of six months there can be a continuous infection or you could have infections that come and go infections that come

after within four weeks after treatment or within six weeks after treatment and the infection of the face the linear facial is becoming very common and uh most importantly the steroid

modification abuse of topical particle steroids resistant steroid modified kidney ester years when you commonly talk about the predisposing factor for dermatophytas they say overcrowding low

socioeconomic status and poor hygiene and these were the reasons well known for predisposing to dermatology but the present scenario you have additionally other factors also as i told you earlier

years if it was dermatophytosis it would be only present by annually it would be may june july again probably free monsoon it can be in october november but then now you have dermatophytosis

cases throughout the year you all must have been experiencing it also not only in tamil nadu it is across the country from you know kashmir to kanyakumari and this side from the east west from gujarat to assam this is the

same story derby fighters is seen across india throughout the year and apart from global warming what other factors could be related to probably that there is a change definitely in our

lifestyle also jeans have become almost like the national costumes so starting from your metro worker to the ceos and i.t fans everyone you know wears games

i.t fans everyone you know wears games and the leggings again which is not definitely the dress for our hot and humid weather that is prevalent in our part of the country or even elsewhere

and most importantly what we have to note is i would like to bring your attention to this point of the rampant abuse of the irrational combinations of tropical particle steroids anti-fungal antibacterial creams that is available

in our country you have the triple combinations the portable combination and even five in it you know there's a famous brand dash five which is being used it is available over the counter

and all that this deal is a patient walks up to the pharmacist and you know he asked for a dream for the fungal infection and the pharmacist happily hands over to this hands over the screen and this when it is applied the

anti-inflammatory property of topical particles gives an instant relief patient applies it for four to five days and with a relief stops applying by the time there is enough local immunosuppression the

dermatophytes multiply all the more and there is a flare of the lesion so this cycle vicious cycle goes on and on and on and the parents unknowingly i mean

it is ignorance is bliss for them so they apply these topical corticosteroid fungal free anti-fungal combination themes on their children as well so it is the family members so when you

see a child with dermatophytosis especially an infant a neonate and toddler you have to ask for an index case as we do for those children with leprosy we always have to spot the index

case because there is someone else who is always giving this infection to the child so it is important that we treat the index case as well and of course immunosuppressive states increase in dominophytus is something really well

understandable the other point which i would like to tell you is that throughout the easter years it was like the common most common organism causing development was striking but then there has been a shift in the

ecological agent and now what is more prevalent is try to put on mental graphite species complex this is supposed to be very virulent so that is one of the reasons why we are finding it difficult to treat the infection and not

enough anti-fungal resistance for fluconazole has been known well known and occasionally to grazier filming also but terminofilm which is a fungicidal drug now there has been an increase in the

incidence of anti-fungal resistance of turbinating a fungicidal drug so turbulence does not work well for a nail i mean for steroid modification for a

chronic kenya probably when you have nothing applied it works there is not much of literature available for dermatophytosis and children now these few papers if you

have a look at it you are able to see that history of family contact or closed contact members not now available is a tropical propanate is a super potent particle steroid which

has no way to be used in children we say only in children beyond 12 years they use global disorder or if your child has probably a palmer plantar psoriasis from eight years ten years and you tend to use chlorophyll otherwise

this particular molecule is not to be used in children but then unfortunately all these combination creams contain either chlorovitas or or the other potent corticosteroid called momentosome which is again used in children only

beyond two years so you can easily see that eight to six percent had applied flow beta subtropic in this paper and they had extensive disease as well just to show you a couple of cases

again steroid modified chemia eczematostemia copper corporis this child again had chronic democrats with more than one year duration when all the family members were affected with dermatophytosis this is steroid modified

kenya if you have residents now steroid modified teenia then you say this term will uh refers to lesions which is still recognizable as the amount of phytosis in spite of topical

particle steroid use whereas when i say tamiya in cognitive it there'll be only papules there won't be any border normally we know that dermatophytosis has a clear-cut border populous in the periphery active periphery and central

clearing but when you say kenya and cognitive there could be popular there will not be any scales and so you need to have a high degree of suspicion and probably we have to go for a potassium hydroxide mass now this is the steroid modified king

again in steroid modified kenya we say this female pseudo-indicator you would have come across this term quite often female pseudo imbricator is double weight you have ring within ring appearance actually that is because of

the intermittent use of topical particle steroids here we see a tenure manual again a good border scene so here again this is the border scene kenya manuel and this is senior peters this is a small blister scene this is a recycler

bullet type of kenya fetus and this is a mukasan's type of females so this child had this post i mean renal transplant recipient you were able to make out the eight difficult

manifestations of dermatophytosis you're not able to see the central clearing that much it is only a diffuse scaly pattern or psoriasis form pattern another child with hyper ig syndrome

having kenya coppers this child has just seen him recently some two months ago i think he was such a leukemia al case and he was on treatment and you can see the psoriasis form near

and not enough he had kenya facial we were able to make out the border here and apart from temer facial he had tenure capitals as well actually so multiple sites being affected

so normally what should be the differential diagnosis that we considered for kenya corporal now that depends upon the presentation if you're just seeing a single nation or lesions like this herald patch of patriarchal is

one differential diagnosis which is very common in children is also a differential diagnosis but here you will see that there'll be little ethymeters in the periphery but we do not see any scales it's a non-itchy

condition and you will have a single clearing it is an annular lesion no doubt but then there is no central clearing and absolutely no etching and patient is asymptomatic and that is how it is actually and this will not

progress further and this is an amulet eczema or a dysphoric exam or a coin shaped eczema we are able to make all the papules and the cycles actually so much of crusting and intensity change so that is again a close differential

diagnosis for dermatophytosis so when we are in doubt this is a simple very simple test we just have to take the scales from the patient and then they know add 20 potassium hydroxide they'll be seeing the characteristic

dermatophytes which look like this highly long branching septet and academic interest we see the culture so that is rubrum and this is practical mental graphites

so having seen the glamorous type of phenomenal phytosis this is female capitalist in kenya capital is the most important history that we would ask for is any history of taunt sure or harker

three weeks prior to the onset of the lesions that is the incubation period for them to fight invariably they'd say they would have had a torture in a religious place and that's how the infection starts because of transmission

through the barber's instruments and sometimes it can be from play mats also so we have to ask for similar history in the play mats or siblings issue of sharing of toys instead of playing with

better animals like cats that is also an important history for a tenure capitalist actually so here we see the gray patch is the most common type here again in the capitals you have non-inflammatory inflammatory this is a

non-inflammatory type you're able to make out the air which is lusterless and brittle and scales patchy loss of hair and this is black dot type of female capitals actually

and this is innate another type you were able to see some patchy hair loss with not obvious case but if you scratch you might be able to make a discernable scale this is one of the most important differential diagnosis for alopecia

areata and this type is very common in adolescents so whenever you see a child with female capitalist please look at whether you know there is an extension from the neck to the scalp because that is the elaborate type of pineal

capitalist from the phase again you have to see there is an extension into the hairy area and that is called as the laborous type of female capitalist and this is the inflammatory type of pineal capitals which is part of the therion

normally we see a swelling which will be boggy to touch and we will be seeing pustules stuttered on the surface and these broken bits of hair will be removable like a pin on a cushion so

because we need to differentiate it from bacterial axis in bacterial lapses obviously there's not going to be any patchy loss of hair and if you try to pull the hair from that area it's definitely going to be painful and the

child will be screaming but here you know you can just gently remove the hair and the child is quiet and that is one of those very easy signs to differentiate the fungal abscess from a

bacterial abscess so this is a cardio normally we say children with long hair girls with long hair do not get female capitalists because you know the males are more prone to developing kenya capitals but these days

i mean this child again i think recently two or three months back siblings who had the tenure capitals they were able to see the absence type of premier capitalists here first use

first use is again one another inflammatory type and sometimes you can have mixed patch also this child makes a type behaves gray patch first use and patchy loss of hair actually so

differential diagonal capitals i already mentioned about allocation areata which is an outer indian condition so differentiating between alopecia areata and the smooth patch called this type of kenya capitals we have to do a potassium

hydroxide examination or a thermoscopy so thermoscope is again a tool which is available these days which can easily help us to differentiate between these two conditions and battery loss of hair again another differential diagram is a

trichotillomania these children can have other and anxiety behaviors also could be bed wetting or thumb sucking nail biting and things like that and trichotillomania will be in the most

accessible site and the hair will be a varying lengths that is some one important point it will be an accessible site actually and sometimes of course the braiding style the traction alopecia also can be considered as a defensive

diagram so whereas in psoriasis and seborrheic dermatitis we do not talk about any loss of air and this is how we confirm the etiology of kenya capitus so this potassium hydroxide vector and this is the

dermascopic picture of kenya capitals we see kama hairs and foil hairs and zigzag hairs and in the western countries food slam is used as a screening tool for senior capitalists because the most

common organisms like microsporum can is and what only and all they fluoresce under the wood slam but here the most common causative organisms are trigonal violation and toxins which do not fluoresce

coming to the nail infection in children this is very uncommon actually because why is it less common in children unless until you have a child who's been playing in water for a long time or who has hyperhidrosis or there is some other

immunosuppressive conditions like uh chronic candidiasis chronic munich candida so that is the time we talk about microsoft children but otherwise normally it is less common in children because the surface area is small

another thing is they are not that prone to trauma and more than that is the rate of growth of the nail it's a faster growth of nail compared to the others actually so the dermatophytes does not

really get time to settle down there actually so having seen the three types of the skin hair and male dermatophytosis let us see how do we treat them the present scenario what is

most important is to give counseling to the patients regarding the general measures in case of young children of course to the parents and the adolescents to make the patient understand that the adherence to general

measures is very very important you can always ask for a review at the end of second week or third week and here the treatment regimens that have been mentioned in our standard textbooks of two weeks for turbination or one week

for intravenous does not hold good anymore you might have to continue the treatment until the child becomes altered so the duration is going to be much longer and it has to be individualized according to the clinical

response and only topical antifungal can be used in localized infection or when the child has hepatic failure or a very young infants but if it's going to be steroid

modified democratic chronic infection we definitely have to go for a systemic and topical antifungal combination and it has to be continued for a longer time and what are the general measures that

we have to advise the patients patients we have to importantly tell them that the child has to take bath twice daily in cold water white dry immediately after taking back and emollient

application is very important because per se dermatophytosis and steroid modified temia there is dry barrier dysfunction there is a dry skin so you

need an emollient to make the skin smooth and it will definitely give a good symptom relief to the patients so application of thin layer of coconut oil is very good immediately after drying

the skin that can be applied and the next antifungal cream can be applied at least 20 minutes to 30 minutes after application of the coconut oil and the clothes have to be washed in hot water

and dried in good sunlight inside out and the infected clothes have to be washed separately and dried separately and definitely a big no to all these leggings we always have to invade them

to wear loose potty clothing and those of them who do not have access to sunlight probably we could ask them to iron their clothes and in the case of rainy season the clothes could be probably put over the boiling water

vessel or lid and then you know it can be dried also and these hostel students they have a peculiar problem because they are not allowed to dry their inner garments outside the room they have to dry it only inside the room then you can

imagine if it's going to be hot and humid weather children most often tend to wear the damp garments so we have to tell them that you know those that get washed on monday can be owned on thursday or friday fully making [ __ ]

well sure that the children wear only dry garments another problem is the sports the daily wear that people use most of the times these students use the sports gear and that is going to be synthetic so we

have to advise them to use only cotton clothing and that is very very important and again after their gym or sports whatever activities they participate they have to take that immediately after

sweating so they if they're very tired they tend to you know sleep or just take rest for one or two hours and only later they go and take bath and that duration of one or two hours is good enough for the dermatophytes to multiply in the

fertile millio that is the sweat and obese children again obesity is a very common problem that we face today so these children should not wear v-shaped inner garments they should be asked to wear the boxer type of inner garments

very important and if it is there is senior feeders again open footwear and cotton socks only should be increased most important sharing of permits among the family members be towels soaps or

among the students or the i mean hospital students they could always share it with their friends so it's very important that we ask them not to share the personal belongings and this habit of wearing the waistband

or a wristband again this should be removed because now these organisms both trichometon rubrum or metagraphics they stay in the environment rubrum stays for at least three months

and metagraphite stays for at least 20 weeks five months so we have to make sure that there it will be there in the formats and it can again come back to the individual so that is why it is

important that we keep the beddings and the other belongings also clean very important and the most important is these the parents might get addicted to the potential of the anti-inflammatory

property of the corticosteroids so they might continue to use the topical particle steroid from the combination streams even with our prescription of our system mechanic fungal so we have to make sure that that is not being done and they should be always stopped

abruptly there is no question of you know stopping it gradually so particular combination things do not have any role to play in the management of dermatophytos and even if it is for one

day so as i already told you environment cleaning is also very important so vacuum cleaning or washing the detergent should be done and apart from that we have a polyclinic

setup or it's always night in the clinic set up to put up some posters also for these fungal infections because in who study they say that fifty percent of the patients they walk out of the physicians

chamber without understanding what is being told to them so it is worthwhile to have some sort of an uh pamphlet or something to re reinstate whatever was being told to

them actually so some what suppliers can also be shared so that will help you because all these will definitely contribute to the success of the therapeutic outcome in the patients i already mentioned about when we use only

topical antibodies so when there is an apinion without any application or a localized steno which is going to be only two to five centimeters when you have an infant or hepatic failure only tropical antifungal should do taking

care of the general measures and now what are the topical antifungals that are available we have all these as those are well known to all of you these are the newer results silicon as well as reconnaissance but if you really have to

go buy the fba approval setup on us all and amerolefin they get you know the recognition approved for use beyond 12 years in the case of luliconazole if the

child has senior coppers it can be approved two years and older children can be used and in the case of pineapples and pineapples it is approved for children age 12 years and above

and the cycloperox solomon is approved for children aged 10 years and above now it does not mean that these i mean these as those are not being used in younger children just that we do not have any studies for it actually and turmeric and

cream of course is used in children beyond two years of age so any of these azoles or cycloproduct soluble termine can be used accordingly but what is most important is when you choose and topical

antifungal here the cost effective option is very important because if the child is going to have 30 40 percent body surface area so we have to prescribe something which is going to be affordable for the patient and where

there'll be compliance and they have to continue for a longer time and if we see the individual property if there is a steroid abuse probably you could use one of these assaults because these resources they also have an anti-inflammatory property so though

anti-inflammatory property of corticosteroids and this may not match but when we want to stop the corticosteroids and then apply some azole antifungals it would be worthwhile to use ketoconazole aberconozola or

ceterborough and luliconazole is the one which has the minimum i mean the lowest minimum inhibitory concentration again very effective drug but of course little costly has a

reservoir effect also and we would not want to use aquaturism b definitely not and these are anti-fungus which had the sporicidal action and the yesteryears we were using whitfield oil mint which means ointment has an additional point

of keratolytic action because of the sulfuric acid but it should never be used in the flexures or in the case of young children or paste because it can have an irritant potential actually emollients are already mentioned it can

be the coconut oil or sometimes the moisturizers if the child does not want up like coconut oil in the morning but of course in the night or in the evenings when i come back i always tell them you know you have to use a coconut oil because it has a good relief coconut

oil contains lauric acid and capric acid which is supposed to have antifungal property also the next question of do we use anti-fungal soaps anti-fungal powders

can we use that is very important to address this issue because we do not have to spend money on these antifungal soaps and powders because this problem of antifungal resistance is promoted because of this because these contain

very low concentration of the antifungal and any low concentration of antifungal can always breed antifungal resistance so it is better not to spend money on anti fungal soaps and antifungal powders

instead if there is a child who is obese who would want to use some antifungal anti-fungal powders i mean want to use some powders in the area of friction they intertwine with the groin or

the inter mammary area probably we can only ask them to use a non-medicated powder which is much better actually and i already mentioned about this how you know steroids will pass the barrier dysfunction because it is increasing the

transactional water loss making the skin dry again it reduces the ceramic again making decreasing the fat content of the skin also and how should the topical antifungal be applied it should be

applied two centimeters beyond from the normal skin it should be started applying towards the area and it should be applied twice daily most of them are twice daily except gluconazole and

oxycontin griffin is all and it should be applied for two weeks beyond clinical resolution because we know that the fungi is staying there probably we do not want any residual fungi there in the border so at least for two weeks beyond

clinical resolution we definitely have to apply topical corticosteroids and this has been agreed by all the guidelines also we've been having recent guideline recommendations for the management of dermatophytosis and

these are the indications for systemic therapy anything i mean apart from whatever i mentioned the localized therapy for i mean indication for topical therapy all these are indications for systemic therapy

whenever we have hair infection male infection excellence infection and immunosuppressant stage yes systemic therapy has to be given and the dosing the most important thing is gluconosal

is a very safe option which can be given in children there are two dosage options either it is given twice weekly or size weekly and the other option is given daily dosage so daily dosage we give for four weeks and

twice weekly we give it for eight weeks and terminology this it goes according to the weight of the child between 10 to 20 we give 62.5 milligram 20 to 40 it is 125 but terminus in these days is most

often kept only for children with kenya capitals actually grazio filming again for tenure capitals and or for chronic dermatophytosis also there are some people who do give rise

to filament intercontinental is one option again uh capsule five milligram per kilogram per day is again given three weeks should be this is the minimum duration in fact i already mentioned how the individualized station

is very important for the duration of therapy depending on the clinical response and the interior capitalist terminology is definitely the drug of choice the disadvantage with is it is it definitely effective in

pineal capitals but the problem is you have to give it for a much longer duration at least eight to twelve weeks here probably we could go for four to six weeks so it's very economical also one tablet bought and you can use it for

four days so it is something which is economical and cost effective also onychomycosis is very uh it's less common in children so we do use the dosage that pulse therapy is given

actually so pulse therapy we give two pulses for fingernails and three pulses for toenails and you give it in a dosage of three to seven milligram per kilogram per day so the child this is you know

this is a very uh uncommon situation i suppose i just wanted to bring your attention to it that you know yes we do get anika microsoft children but not regularly and there are people who give continuous therapy also with

cervinophthal for two to three months and uh normally therapy systemic therapy of antifungals is going to be supplemented by when you use a nade lacquer nail

lacquers we have topical cycloproducts cycloperoxologists the amero orphan gets used weekly twice and cycloperoxology gets used every day and this is for 12 years and above and uh if

anybody is interested in the normal ones something new options to look for if unicornosol and overall of course they are available in the united states of america and approved for six

years an hour but not as yet in india so if we see the safety profile fluconazole is one drug which we can start using from neonate onwards

actually and uh brazil turbines and nitrogenous beyond two years of course we do have studies for beyond six months in the case of nitrogenous oil and glycerin the oral granules of turbination is only beyond four years of

age actually so having seen dermatophytosis we move on to the less common the next common infection the pitrius versicolor here we see hypopigmented

well-defined hypopigmented patches molecules and patches with fine brand like skates you can see in the paranasal area and the young infants sometimes we do see these well-defined hyperpigmented lesions and

it's always important that you stretch the skin and see whether the borders are well defined and you can just scratch and see if there are brand like scales because materials means brand like busy color means it can

have chromic or a chromie so that fine brand like scales and well-defined lesions will help us to differentiate it from the tyrias's alba so here again we see the chromic petriesis versicolor actually

so this is a very close differential diagnosis but you see that relation is totally ill-defined an ill-defined hyperpigmented patch is going to be heterous alba if there's going to be polymorphic light adoption the child

will complain of itching after exposure to sunlight actually in the case of early which lego there is no scaling so these three conditions which is versatile features alba and polymorphic light reception the boric dermatitis are

scaly hypopigmented patches whereas indeterminate hansen and early earlier non-scaly hyperpigmented patches action so when we are in doubt we do a potassium hydroxide mould and this is

the famous spaghetti meatball or banana grapes appearance and treatment again general measures here again importance of avoidance of sweating is not possible means they have

to take back twice daily and use only cotton clothing if there are only localized lesions this topical antifungal should do but when we have extensive lesions recurrent lesions or pre-op

that is the time when we are both tropical and systemic antifungals together actually so all these [ __ ] are very effective in the treatment of malassetia infection this is the picturesque versicolor and

the duration here it is not as like as we see in dermatophytosis even just two to four weeks of paper should be good enough actually but the problem is with a chromic bitterness versicolor the

hypopigmentation takes a little longer to disappear so that is one cause of concern and again the recurrence is the main problem if it most of the times which is expensive in adolescence

because we know it is present especially in the seborrheic areas the chest the trunk the back so and the adolescents are pretty worried about this particular infection so whenever we see an infection which is

extensive we ask for short contact tropical antiphonal therapy so either academic one is a lotion or a selenium sulfide or a zinc pyritone can be applied we have to ask the child to

apply it from the behind the years detroit area down to the trunk four arms and uh just 15 minutes before about 10 to 15 minutes before bath and then after bath child can apply one of the topical

antifungals as these sauzos or cyclobarox solomon this can go on for a period of two to two weeks actually and systematic we give gluconeogene it's a single dose which is you know eight milligram per

kilogram per boost so in young adolescent probably you can almost anything who's going to be more than 50 kg can receive at least 400 milligrams a single dose and sometimes people do repeat it after one week that's the

pulse therapy of gluconeogene for extensor petrius is versatile hydroconazole 600 milligrams single dose is also one of those therapeutic options for extensive addresses versatile in the case of recurrence this is again a

problem in those individuals who have hyperhidrosis so recurrence we always advise them to use gluconosal once a month 400 milligrams once a month and this can go on for four to five months

or retrograde 400 milligrams 200 milligrams twice daily once a month for six months and there are even options for using ketoconazola shampoo for only three days a month or one day a month

for continuously six months so these are options for expensive and recurrent fitness of course this is very well known to all of you in this you know meaning young infants of course we can see this

neonates and infants they can see oral thrush so we have to look at the other options and uh just a cloatum is all mouth pain should be good enough and

in the indigenous areas like neck and brine clotures and proteins all clean should be good again the inter drink of groin and intertwine sub memory inter memory area is one of those common

problems these days in obese children so we have to ask them to keep the area dry use spartan clothing and use one of these topical [ __ ] for a period of two to three weeks so having seen the superficial fungal

infections i thought i would take you to the subconscious fungal infection this is supposed to be little rare but you do see this once in a while in your clinical practice there will be a child who has an asymptomatic swelling which

is going to be present over the lawn and this is a typical finding you will have selling the sperm and consistency and will be able to easily lift the swelling you

will be able to insulate your fingers beneath the smelly most often it gets identified as an abscess and you will have multiple inds done and sometimes when they do instant pathology they might say this is going to be a foreign

body granuloma but then this is a substituting this fungal infection called as basically ebola mycosis and this is something which we can see in children especially in the groin on the

lawn and in the limbs actually so this is the fungus which is seen so you have to mention whenever you have an asymptomatic swelling which can be easily uh lifted and where we can insulate our fingers with an indian

rubber consistency we call the firm consistency please when you ask for a biopsy you'll have to mention whether it could be vestibular microbes then the pathologist will be able to see these fungal hyphae otherwise it gets just

reported as a foreign body granuloma and potassium iodide is the gold standard for this particular infection again cotrimoxal is also one of those good options apart from hydrogen as well and we continued for at least three months

after complete resolution this potassium iodide we administer 40 to 60 milligrams per kilogram body weight we take it as 2 grams 100 ml and according to the dosage we calculate and then give it to the

child in empty stomach along with fruit juice or milk or cold water so to conclude fungal infections in children supervision fungal infections are more common and these days it is every other

day we've been seeing loads and loads of children with dermatophytosis wherein the counselling is most important we have to tell them that the adherence to general measures is

very very important and in the case of neonates infants and young children yes we have to spot the index case and the duration has to be individualized according to the clinical response and topical therapy we have to follow the

rule of two and definitely there is no role for particle steroid combination creams in the case of dermatophytosis and in the case of supervision and the subunit is an optional microsis of course we need to have a high degree of

clinical suspicion and potassium hydroxide mount itself is a good very simple and easy tool to easily identify the fungus at an early

stage itself so thank you all for your patient listening thank you wonderful presentation madam that's up to you

it's very practical and very useful thank you thank you for your respect resume thank you so much i think there's a question sir has asked about the posters i can always

share it sir uh lindsay can share the number with dr dakshini and i will definitely share the posters with you you can always put it up in the posters put it up in your clinic

thank you ma'am thank you and others also in between you can put your questions in the chat box so that subsequent uh discussion later on

also it can be taken thank you ma'am thank you thank you that shiny hello i think we can move we can move on to

that next speaker excuse me sir so because i have another meeting to attend shall i take lee is there any questions yes you are horrible man yes yes

madam is going for a meeting so that yes any other questions thank you so much ma'am uh so i think there are no questions in the chat box or the questions

okay okay so it's a very very practical and useful yes that we should be giving the patients the counseling is all what that matters

in dermatological practice thank you thank you so much thank you thank you man thank you so we now have the next speaker

uh dr s murugu sundaram founder and medical director of chennai skin foundation and yesterday on research institute he is the founder secretary of the hair

research society of india and a fellow of the american academy of dermatology member of the international society of dermatology and he's been the reviewer reviewer for various

international and national journals in dermatology uh he's a member of the ia dvl academic council and he's got more than 250 national and international

publications to his credits author textbook and atlas of trichology and his area of interest include the periodic dermatology and

psychology um so he's been awarded the best doctor award by the tamilnadu dr mg medical university in the year 2012 and he's invented novel accessories like

fixer accelerator and the list is endless so um i would now uh like to invite our next speaker doctors murugu sundaram for

his talk on hair problems in children over to you sir welcome sir welcome sir thank you sir thank you is my

screen visible snap yes sir yes sir visible sir you are very well knowledgeable yes sir at the outset i would like to thank dr devi and dr nakshani and all the extreme

members of the aap for giving me this wonderful opportunity uh to speak in front of this august gathering i was asked to talk on hair problems in children

hand disorders in pediatric age group are predominantly congenital immunological and nutritional and due to infections and infestations compared to disorders in the adolescent and adult

populations which are predominantly andro and genetic androgen and genetic but it's also important to note that the fact that androgenetic officials also becoming increasingly common in the

pediatric age group most probably due to the genetic hormonal and lifestyle influences and why pediatric psychology and whom are the

uh patients affected mainly the atopic children obese children uh children born out of consumers parentage malnourished children children with endocrine

disorders children with genetic syndromes and children especially who are under stress so i developed a simple working classification which was published in

the indian journal of pediatric dermatology 2010 because there is no uh proper classification of hair disorders in children available so far so the

disorders can be classified as developmental alopecias alopecias are hair loss due to infections and infestations autoimmune alopecias psychogenic alopecias malnutritional electricians

miscellaneous aeropressus and pigmentary disorders and pediatric hypertrichosis or historicism in the developmental alopecia we have um

various categories like no hair in alopecia congenital care with papillary lesions which is a very close differential diagnosis for electricity total is an alopecia in your cells sparse hair where you get an trick who's

a simplex hypothyroid causes an ectodermal displacers abnormal hair as in monolithics pilate tricholexis nodosa triforces

only hair loss in syndrome uh in um congenitally in a place yeah cuteness also the pressure of the newborn uh various knee bi and triangular fishes

are colored hair in poliosis warden books in rome and many other syndromes and infections in the stations we had a very elaborative and extensive

uh informative talk by dr madhu about this trichomycosis and we have seborrheic dermatitis and created is the most common autoimmune alopecia

in children is arabic areata which is the second most common cause of alopecia in children and alopecia associated with the other autoimmune disorders especially silly is also quite common in children psychological patients like

trichotillomania and draco till which we're all i will see uh in detail in a little later and the nutritional alopecias we have this telogen effluvium tri-colored hair

diffuse hair loss making pattern hair loss these are all due to the nutritional deficiencies and the miscellaneous alopecias like has traction electricians acquired partial curly hair hydro genetic location in

children which is becoming very common and uh pigmentation is a genetic hypovolem the hair is completely white it's diffuse whitening and you can have you

can also have circumscribed poliosis a tuft of weight in the hair on the way there and premature kinetics which is not due to acute fever or graves disease

which is uh due to rapid which causes rapid grain and pernicious anemia malnutrition and malignancies gradual grain it's called can it is

subita which is overnight grain uh which is acute diffusion appreciated after severe emotional stress you have overnight grain because the alopecia does not affect the gray hairs it

affects only the pigmented hairs so the it appears that the gray hairs and pediatric processes so this is alopecia congenita which is also called atrocious it's an autosomal dominance

present there are associated rare associations are only present because it is not usually associated with any other anomaly it is usually an isolated

anomaly um with popular relations is very common in patients from iran pakistan it is mistaken for rapid shariat and efficient totalism

starts losing air after six months there are also along with the patchy hair loss there are popular lesions in the elbows knees and cheeks

but these are very rare and we found lot of this hypotrichosis simplex this is called congenital hypotrichosis simplex which is very common in the south indian population south indian children and we

also found the gene for this this map to the p2 p2 ry5 gene mutations and also the lipase h gene and we also

along with the group from germany we published this and we see a lot of these kanye lymphotricosis which is also treatable i will show you some slides

how this is easily treatable this is the case of congenital hypothyroid causes which runs in the family it is autosomal recession so only one is affected only hair is also similar to valentine's

hypocritical you may have only had levels sometimes without any evidence you may have only had only hair sometimes may also occur have you would have seen some children

feeling that the hair has become wavy and curly suddenly because it could be an early stage of androgenic pressure but that is different from this continental

air you see the only hair and this is very commonly associated with the hypotrichosis ectodermal dysplasias would have in many cases with the anomalies and

the saddle nose and the features are very clear you have this monolithics with a trichoscope trichoscope the

common thermoscope can be used as a trichoscope which is the magic land of the harry potter hdier harry potter and you can see many hashtag defects with that microscope so you can easily

diagnose the mini ascent effects of the trichoscope this is the beaded hair of monoliths hair breaks at the side of the nose and dry core excess imaginator as if two

hairs are attached to each other at the broken end recorex is imaginator and pilot these are all congenital nerve disorders where you have this twisted

hairs we uh presented a few ah series of case of this uh spangled hair it looks like this child has done some straightening of hair but

it is not straight in here it is a convenient lab disorder with the ectopic diaphysis most of the atopic children may have this and this is a condition called pile anulite

where you see this alternating light and dark bands with spangled appearance of the hair and you see the azure defects of the microscope itself and we also do the polarized light microscopy where you see

this alternating light and dark bands which confirm this pilot this is a normal hair which is a very unique feature of this south indian hair for women

this kind of bushy hair have seen many patients from kerala kanyakumari and nagarka these kind of bushy hair this is

sometimes these hairs may have a sharp effect called pilate triangular canal but this is normal and this is uh we have many uh patients commonly uh

walking in with this kind of hair then they also deliver pressure of the newborn which is a bacterial pressure due to the asynchrony of the when the synchrony is complete when all

the hairs are terminal then it disappears on its own because when they put the child on the floor uh it easily rubs and then because the friction the hair is easily removed this is the oxygen

pressure pressure and usually no treatment is required and the hair goes by itself and this is congenital triangular lupusia are also called broad levers they continue it is

called temporal triangular pressure usually the triangles appear on the temporal area the triangles can appear in all the areas sometimes inverse vertex but also in the outside area this

is a convenient temporal triangular shape it is very important to identify this type of hair loss because it is not like alopecia you don't you can't regrow hair with any sort of

treatment there's no need to apply a steroid no need to use an inflation steroid because the hair will never go it's a conventional hair loss and it will appear only when the child becomes older

and develops an android genetical official only then you will see the patch so it is they only need a reassurance for this

and as dr madhu explained we have a lot of uh infections and infestations uh of which the most common is the dermatophytos or the trichomycosis of the trichomycosis we have tener capitis

then the seborrheic dermatitis and pietra of the tenear capitis you have various uh types of dna cavities like kirian we have uh the kirian itself you have abscess type

foster type flowers type you have gray patch your black dot and your very uh varied uh morphological presentations of artemia capitis very common after this

uh taunturing in uh pilgrimage centers because of the contaminated blades and baba's knives and formates like towels homes and headrests and sometimes the power scans

also and it is very common in children and even now it is still common in many parts of india and you have seborrheic dermatitis

and sometimes you have a like trichomycosis and the most common agents have breakaway down violation it is namely conscious because it

follows foreign violation is also very common in india this is the carry on you see the buggy swirling exuding bus

the hair can be easily removed like as if you are removing a pin from a pushing and it becomes ends up in a scarring alopecia so it's very important to identify this theory and treat with an

antifungal which very quickly responds to treatment and you can save the hair and you can also prevent this thyroid this is a gray patch

you can see the dermatophytosis of the skin also this is a glabrous type of corporas this is the black dot linear cavities

this is the seborrheic dermatitis you can see the borders and you can see the patches normally when the the hair is not removed

it is very difficult to identify the separator between this but with the thermoscope of the trichoscope you can easily see the scales and you can easily differentiate the separators from

psoriasis because the scales from sugary tomatoes are oily and they are very greasy when i say psoriasis they are very dry

and powdery this is a bacterial infection of the scalp folliculate is the kelvins

and which leads to scarring alopecia so this also can be easily treated but is identified properly you can see already the scars sitting in the sky this is also sometimes very common in

children from chronic folliculate is leading to follicles is the infestations the most common is the pediculosis capitis pediclosis capitis can affect all the hair bearing

areas sometimes even the eyebrows very common in school children especially the female children and it is very very easily treatable and with one

tablet of fiber uh all the lives can be killed so it has become a very easily treatable problem and we don't see infestations very commonly as we see as

we saw when we're doing our post graduation the most common alopecia in children is alopecia data autoimmune it is a genetically determined

autoimmune patchy hair loss on any hard bearing site with methamonic exclamation marks these exclamation mark hairs can be very easily seen with the trichoscope on their patches

the uh when the alopecia usually starts in childhood uh it has got a very bad prognosis it is usually recurrent and most of the uh allocation occurs in atopic children 50 to 75

percent and also it is very common in down syndrome syndrome when it occurs and uh appears in childhood it easily progresses to alopecia total is an unofficial universalist and it has

got a little worse uh it is also the common cause of brain in children is associated with the autoimmune paradigm sometimes

uh there is uh increased occurrence of anti-therapy antibodies uh many changes are common when you see lot of male changes in an unappreciated child uh the

produce is going to be little uh guarded and oofy assist is the uh alopecia data occurring in the margins of the scalp and roofies also is not a sign of

so these are the patches of alopecia data you can see the exclamation mark hairs even without a trichoscopy with a good amount of

macro photography there digital photography or the photographs that you take with your mobile phone itself when you enlarge it and when you zoom it you can see the exclamation point

markers it's a classical appreciator most of these cases of unappreciated are mistreated or

treated by the by the friends and family at home by some irritant application like onion juice garlic and some herbal applications and it ends up

becoming a scarring aloe vera we found a lot of uh we found a series of cases in a quackery center where this area

by applying a seed of this proton pigglium it is in terminal it is called nirvana it is available for this tool because it's supposed to be a very poisonous seed

and it is used as for this irritating yellow fish patches it is just rubbed on the floor and the oil is applied on the scalp it produces

severe muscular reaction and it produces a scarring pressure sometimes when it is applied in very minimal quantities it regrows here that is why it has gained some

popularity but most of the cases it leads to starving officials this is the lupita which usually follows an articulate pattern two round patches

and many round patches joined together and they form a reticulate pattern but it becomes slowly becomes it involves the entire scalp it becomes alopecia totalis then it involves the eyebrows

and the body hair when where all the hair is lost the very close differential diagnosis for leprechauns trichotillomania trichotillomania is a

obsessive compulsive disorder where it is also listed in the diagnostics statistical manual of mental disorders where the child repeatedly rules and

then suddenly pulls the hair and to create a patch like this so this is a very interesting uh condition it is very common in children and children who are especially a distress

we uh did a study of about 37 children we found that most of these children are very severe stress and most of these children are put into stress by their mother

the mothers were putting a lot of pressure uh to get the first track in the school or to study well and these children um this is the kind of uh frustration they do not

know how to express the anger and they start pulling the hair this is what we observed in our study and most of them had this

focused pulling and they were pulling automatically while watching tv and reading some books although they even pretend to read some books and sometimes they keep on pulling the hair you can

see lot of hairs around the place of their seating you have to take a detailed history and you have to talk to the patient talk to the child

separately and along with their parents to elicit the history of this sometimes the children may not reveal or accept that they are putting the hair uh those cases we may have to do a biopsy

to prove that these are patterns of patches can appear and the these children can pull their hair not only from the scalp also from the

eyebrows and eyelashes you can uh even in alopecia when these children have alopecia after the alopecia it is resolving or when this regrowing they keep on

examining the patch and in that process they also start pulling their hair so sometimes trichotillomania is associated with alopecia and they also this child has

pulled all the eyelashes she has already pulled the eyebrows and now she's pulling the eyelashes this is a symmetrical pattern of trichoglomelia this child has created a symmetrical

pattern most of these children having this tricholuminia are very perfect in their pulling and they create a very symmetrical and bizarre or very figurative patterns like a triangular

pattern or a square pattern and some bizarre patterns this child lost her lost his father and he was very close to

the father and he started imitating the father's hairstyle by pulling the hair he's just a eight-year-old boy he started pulling the hair in a typical pattern so that he could resemble his

father at least in the picture because he was missing their father this is a very severe form of trichotillomania it's called friar tuck sign

and this also can be easily treated with proper counseling uh in this child i have to do a biopsy where i could see this follicle of plugging and the pigment class which are very important

for the diagnosis of this you can see the pigment gas in the estrogen this is a new condition called trichotillomania trichotillomania is to

pull the hair but trichotillomania is to rub and remove the hair children they rub with the palmar surface of the index finger or sometimes the form and

they constantly keep rubbing it and then they remove the hair like this this is a very typical linear pattern of this tricot romania this is the first asian case report we

published in 2005.

this is trichotemnomania temno means to cut this child has playfully cut with the scissors and he has used some sharp instruments like blades to create a patch

of baldness over here sometimes they also try to imitate the film stars and they start putting it in that pattern to create a pattern

of their favorite film stars hairstyle sometimes it's called trichotill there is no mania children playfully start pulling the hair it gives a sort of pleasure because in trichotillomania there is an impulse

to pull the hair but here there is a pleasure after pulling the hair this is a smile kind of a mild sensation which gives them an excitement they start pulling

the hair so this is trichotill this is a habitual playful pulling of hair very easy to treat when you explain the patients and caution the parents

they easily stop that they respond very well to counseling then the malnutritional officials these are the third most common cause of alopecia in children most of the

children uh that we see in our practice have this nutritional fishes children come with the diffuse thinning of hair all over the scalp there is a profound air shedding they are often

present as acute and chronic telogenic phobia and most of when they have this anxious and panic mothers and most of them have more nutrition or more absorption and industrialized small

absorption like eating junk food and crash dieting most of them have iron deficiency which is very common still in children calcium deficiency protein energy malnutrition zinc deficiency

biotin deficiency vitamin b12 and vitamin d deficiency these children have thinning of hair not only have thinning of hair but also have lightening of the hair and most of the children are under

severe stress so you could have seen many children coming with a head full of hair also handful of hair this is the typical presentation of chronic telogen effluvium you just have to reassure them

that that all the hair will regrow because it is only a nutritional deficiency or a slight hair cycle alteration or maybe a slight hormonal imbalance which is

sitting in because of the puberty and this all the hair which is fallen will grow back because once the telogen hair is fallen is pushed out that is the anagen hair which is pushing it out so

there is a growing hair which is pushing out the resting here so this reassurance will definitely bring in chair on the patient's face so this is a classical sign of chronic

telogen effort by temporal thinning even in female patients like the androgenetic pressure of a temporal thinning this is the sign of telogen epidemium

see this is mainly because the nutrition deficiency you can also see there is lightening of color the hair has become mostly brown and lighter brown golden brown in color there are various colors

of hair because of the protein deficiency and vitamin deficiency and deficiency of minerals this is a traction location many

children we have seen the mothers and even children are fond of this traction hard style because of this type traction which is put for a very long time more than 12 hours in a

day then this area becomes a scar simple traction itself can lead to attract scarring molecule you can see the scarring of pressure is developed over here and also in the occipital area

and also in the sides of the scalp wherever the attraction is applied for a very long time so we have to advise them to have a loose hairstyle

these are the cast some children who are having very severe seborrheic dermatitis and inflammatory scalp provisions may develop this peripolar gas we have a custom of not washing the hair

very regularly and the children usually wash it once uh once a week or twice a week because they have to get up and go to the school in the early morning most of the children don't wash the hair so we

have to ask them to wash the hair very regularly and repeatedly at least once the hair wash should be advised or at least for once in two days the hair should be advanced these scans can

appear on the hair these should be differentiated from the mids because gas can be easily removed from the hair but this cannot be removed easily from the hair this is a new condition called acquired

partial curly hair the localized condition we would have seen some children complaining that some hairs are becoming uh very rough for baby and curly well the rest of the hair is normal

this is also due to hair shaft weathering and sometimes due to unknown causes but usually it returns to normal by itself and the androgenetic alopecia is

becoming very common in children and we have seen many cases of hydrogen even under the age of 12 and 10 and this is a very strong family history more than androgen there is a genetic factor and

very common in female children than in male children and more of female pattern have lost than male pattern and hair loss because it doesn't follow a particular pattern there is increased

levels of vhts because the the androgen stimulations from the adrenals are not from the ovaries or the uh distance it is important to remember the androgenic blood pressure also can occur

in appearing young children and to identify this this will be useful for us to practice then we come to the pigmentary disorders

of the scalp we have this grisly and prunera syndrome which is the genetic condition which is very rare and you can see the complete silvery hair from this child

this can be differentiated from the shadiac syndrome only by polarized microscopy these are very rare

even simple seborrheic dermatitis can lead to grain of hair so washing of hair every day with the ketogenic oil shampoo or an antifungal shampoo or even with a normal shampoo

can reduce the dandruff and control the dandruff and reduce the pre-follicular micro inflammation which could be the first pathogenic event for the androgen dignification as well as

so we'll see how protein energy malnutrition leads to hair color change so these are some

older children who are going for this bariatric surgery we had a series of cases and after the bariatric surgery they develop this hair color change and also diffuse hair loss

this because in the melanin cycle melanin pathway you need this lc stream to convert you few melanin into human animal you know that

there are two types of melanin melanin which gives the black color the female in which gives red color so in the absence of cysteine the absence of cysteine due to protein

energy malnutrition the melanin pathway shifts to female 11 instead of human so the hair becomes reddish brown and finally they end up becoming a blonde

so this is a post bariatric surgery uh hair color change which teaches us that protein is very important to keep the hair color intact

then the pediatric is suitable if suitability is very common because many children are obese now and they have insulin resistance and we have this hipstitism even in children even under

the age of 12 and sometimes even the age of 16 we have seen pediatrics most of the children have pcos and acanthus and greek hands and girls born

with low birth weight are more prone for pcos and increased hydrogen hyper androgenism hyperinsulinine is very common and

intake of anabolic steroids is also very common in western children and cocaine addiction is very common in western children so this has to be identified and this could be approved for the

abdominal ovarian tumors also sometimes so it's all okay but when you can we all grow hair on the scalp that is what is the question of patients

the little patients yes even congenital hypothyroidism can be treated and you can regrow hair to some extent with the steam supplementation and oxidative topical knoxville up to

two percent can be used and it definitely gives very good results sometimes oral retinoids also help and you can see the results of this child which we saw a solidly earlier

again this at least to some extent they have thickness improves high density improves the hair color changes so their confidence improves

the hair care for this fragile hair for the children having this like portrait courses and the tv hair should be like this they have to wash the hair at least twice a week and

they have to use the shampoo with the double conditioners and they have to use some separate conditioners also after washing the shampoo and they have to use a leave-in conditioners and like oils like

vegetable oil should be applied after wash because we have a strange habit of applying the oil and then taking wash so the oil should be applied only after air wash and vigorous rubbing of the hair

should be avoided with the towel to dry the hair because 50 percent of the moisture on the hair should be absorbed by the hair shaft then only the hair will be uh having the moisture here we're having

the retained washer no andreas and no hot combs and no pressure should be advised and the headphones should be wide toothed and we have to avoid all the hairdressing procedures we have to

protect the hair from which is exposure to sunlight by wearing a scarf and loose hair style should we have advice and no clips and tight plates should be advised and

it is always better to advise them to use a satin blue to ease the reduction of friction for sleeping because that can easily remove the hair treatment of linear capitals has been

very well elaborated by dr madhu and terbinafin is very helpful in trichomycosis sometimes also and sometimes in resistant cases we use crystal from them

and most of these cases we have to always combine with the ketogenic shampoo even in androgenic pressure or linea cavities or any type of hair loss washing the hair every day with a

two percent ketogenic shampoo is definitely a value addition to the treatment so alopecia data most of the patches single patches spontaneously resolve you

just have to give reassurance and give supportive therapy like vitamins and minerals and give some nutritional supplementation topical poors cell also really helps playing a

uh photosynthetic exposure to exposing to sunlight topical midpoint and steroids without three percent salicylic acid tropical tacrolimus is also very useful

but i often use this liquid nitrogen most of the children with uh multiple patches of aloe vera do very well with liquidation therapy which is very safe and

very uh it gives very promising results and uh systemic poor sometimes is useful in extensive electricity interrelational terms alone can be given in older children but we have to restrict to 2.5

to 5 milligrams per minute we should not use the 10 milligram per ml and now the world too fast remember tuberculosis and contact immunotherapy is very useful with

different symptoms dpcp which is very useful for in order to share it of older children oral steroids should never be given we always tend to give many

dermatologists and other general practitioners tend to be more steroids for alopecia we all know that it is a recurrent problem it is going to be recurrent even if you give overall steroids so it is

better not to load with our steroids and spoil the system and treat only with the non-steroidal medications and oral cyclosporine is also not very useful and not recommended in children

this is a patch of phases which is very safe this is a case of alopecia totalis complete loss of air over the scalp a little bit on the eyebrows left this boy was about 15 years when he saw

me so we decided to do the dpcp therapy create a window or first on the obstacle area sensitize by applying two percent

dpc predictions and from after two weeks you start applying dpcp concentrations starting from point zero zero one percent uh for about

one year every two weeks you have to keep applying all over the stem this works by providing contracting immunity to the lymphocytic infiltrate

around the hair valve it removes the lymphocytic infiltrate by the counteracting immunities that is why it is called immunotherapy

this boy has started regrowing the hair after three months after six months about one year he was almost completely the official total

this is with capacity this child is very very uh done extremely well with uh fascinating i just gave 5 milligrams per

day for 3 months and we are just following it up and it does not record so far i showed you a freya tech sign of trichotomy a very severe and tough uh

case of trichotillomania where the child was simulating the father's androgenetic pressure by putting the hair all over the scalp follow the vertex the simple uh counseling

and the selective circuit and we have taken us to control his depression for all the hair within a few months

so counselling is very important in uh treating children with hair loss this is a trichotill or trichotillomania

without any mania habitual hair pulling just simple counseling as a result here premature can it is due to nutritional deficiency iron deficiency vitamin d

deficiency and calcium deficiency with just supplements is completely reversed thank you

indian academy of pediatrics and chapter thank you so much thank you so much sir thank you sir that was a very elaborate presentation and all these problems

uh i think they belong to both adults and the children and there were new uh entities that you introduced to us um so there's one question from one of

the participants who wants to know the reason behind uh exclamatory mark sign and the codability sign in alopecia aerators yeah i'll appreciate the

lymphocytic infiltrate specifically affects the hair bulb area so it just affects the hair root just about a few millimeters above

the hair root so the inflammatory infiltrate first damages that area that is where you get the good ability sign the uh just above the root you get the thinning

of the hair or the narrowing of the hair at that point it breaks so you get the this plastic as when you do a trichoscopic trichogram you can see the good ability and then the hair breaks just above the root and it is not

completely gone appreciated that is why it is reversible the hair root is the hair follicle or the hair bulb it is not completely affected is the lymphocytic infiltrate which affects the hair root

or the hair bulb it affects it makes the hair cut off from just above the root so the remaining portion of the hair follicle

or the step of the hair is seen as the exclamation mark here so that is why alopecia areata when you give anti-inflammatory treatment it is reversible

again when the inflammation comes it is it requires thank you sir you were very clear it also specifically affects the anagen hairs in antigen two and three it

affects only the pigmented hairs the gray hairs are spanned okay sir thank you sir so another participant wants to know the treatment for head lice in a three month old child

is that that common sir if the mother has lies then the child also can have and you know it is very common in the lower social economic

conditions but if it is the if the child is only three months old then you can only give topical uh perimeter emotions either cannot be i don't think it can be given

but you you are the best just to so if that is the case what percentage can be used like um what percentage of permethrin one

percent perimeter can be used even in young infants even even simple washing of the hair every day that can remove the

life's infestation very actually it is very common in our country in our place because they don't wash the hair yes thank you sir sir another question

uh um is it true that climatic conditions do play a role in hair fall and all that stuff when it's a common belief is that so

normally hair growth is more in summer and less in winter but in summer when you have a lot of sweating and dandruff then androgenetic alopecia and fungal infections

these are all common so in summer there is a increase in hair loss than in the winter but it is uh completely the reverse in the western countries

but that is essentially reversible so this hair falls due to climate if you find out if you know the cause and the type of the hair loss and the causes can be uh

if you can find out the cause and treat the cause most of them also like i just showed you even connect like requests thank you so much sir you have given us

lots of practical tips also and uh thank you so much the audience must have had a very good time uh thank you sir thank you for uh accepting our invite and uh

giving us a very valuable topic thank you sir um we'll now move to the next speaker professor dr karthik inser to deliver his talk on

skin disorders in newborn professor doctor carlton is the head of the department of dermatology and std at the sri manakulavinagar medical college

and he's the dean of academics too he is gypma right and he's published more than 200 papers in national and international journals and has delivered

lots of lectures in zonal and national conferences he's other chapters on scabies in iadvl uh textbook of dermatology and his articles

have been referenced in many prominent dermatology textbooks and he's a member of the research committee of gibmer and the core member of the meu and his areas of interest include

pediatric dermatology and tropical dermatology and he is presently the associate editor of international journal of trichology reviewer for the european journal of

dermatology venereology and post dermatology pg manual past president of pondicherry branch of indian academy of dermatology and neurology and leprosy

over to you sir thank you so much for accepting the invite sir a pleasant good evening to everyone i think after two eminent speakers

it is a good job to start with the type of dermatosis which is very unique those neonates who are very susceptible to

dermatological infections i'll be talking today on neonatal skin physiology and certain common neonatal dermatosis and certain interesting points to

differentiate these dermatosis so mind will be addressed primarily to a pediatrician level i am not going into too much of pathogenesis and other

features i'm primarily talking about the clinical features the hints and important points for diagnosis and basics in management

so a neonatal skin is a different type of skin from that of an adult and even for that matter different from that of a child it's a sudden transition from the

sterile environment to a dry one with pathogens the they are in the amniotic fluid floating the amniotic fluid nourished by amniotic fluid and from the nutrition derived from the mother

so from that environment suddenly you come into the external environment which is very dry and filled with pathogens and allergens so it's a dramatic challenge to the

newborn to adapt to the normal environment and what happens the skin is also not mature enough the skin is very thin and the basement layer is not well matured

and so what happens all these things predispose the neonatal skin to mechanical damage as well as chemical irritation and most of the time we see these neonates are subjected to the

soaps or the environmental challenges like an adult so they can absolutely not withstand that and many of them develop skin disorders and so the intact epidermal barrier is

very very important we have to maintain the barrier to prevent physical injury and to prevent trans epidermal water loss and protect it from infection because this skin the trans epidermal

water loss or what we call as an insensible water loss is very very high and this we never bother about or think about this type of water loss and moreover the physical injury due to

friction handling so-called massaging all these things can damage the skin of a neonate so the skin is when the child is born

the skin is filled with vernix casiosa and vernix queso is you see it's a good mixture of water proteins and lipids and usually we don't our was ask them to

wash it immediately allow it to remain for some time and then slowly remove it because it has a hydrating property it has uh antimicrobial property and also has

prevents it from being get skin getting dry so the the general practices immediately they remove oneness user completely and

give a bath is not advised it's better to leave it for some time then we go on to the disorders uh we classify these disorders in a different way that is transient

disorders which are self-limiting and they disappear within a short span of one to two weeks and the other group common is infections because we i already told you the

neonatal skin is highly susceptible for infections so we'll talk about the viral bacterial fungal and parasitic infections which can occur on skin and how do they manifest there are some

basic principles you should understand in neonatal skin i already told you that the neonatal skin is immature and not very well developed so when it's under developed the skin is under developed

what happens the basement layer is not very well formed so any lesion on this neonatal skin it will form only blister because then your little skin is the dermis and epidermis

are not attached very tightly so any lesion will produce only a blister so the most common type of lesions you see in neonates are blistering disorders or

what we call vesicles and pustules so first we'll talk about what are the cause of this pastel eruption because we find it very commonly in children first use sudden eruption of pustules and we

are at laws to find out what it could be it could be a bacterial cause it could be most commonly staff cephalococcus a fungal etiology

like candidiasis a viral etiology like herpes simplex or varicella a parasitic like that of scabies or it can be rare disorders like

osteocytosis and continental pigmentation is usually present in localized areas and is a very rare condition while incontinence of pigment is genetically inherited condition where

you find leaners linear streaks of vesicles and these vesicles which later heal and typically this is seen in male infants only

so the reactive phenomenon like malaria transient neonatal pustular melanosis erythema toxicum isophilic folliculitis neonatal acne as well as acropusculosis

they are reactive phenomenon and many of them are transient and they may subside on their own and what are the causes of vesicular bullets eruptions i've given a detail of

it about the infections there are hereditary causes like epidermolysis bullosa we not go to the details of epidermalosa usually it presents with bullet in the palms and souls and there

are various variants of it internal international pigment i just now told you gal syndrome and certain portfolios similarly in immune mediator like dermatitis separate formulas

epidermolyzes iga dermatosis bula swamp figure and fierce vulgaris all of them if the mother has these disorders it's a very high chance of the neonate developing it

probably one of the most commonly uh seen neonatal dermatosis erythema toxic neonatorum it's benign and self-limiting all of us know about that immunological

cutaneous reaction to probable microbial colonization of the hair follicles and the rash usually starts within two to three days after birth it starts with arithmetic macules with central papule

or pestilent multiple lesions they occur at a crops phase trunk and proximal extremities are seen by their revenues and crops they

wax and vein and resolve in a few days actually no treatment is required but if the mother is very anxious you can give them mild emollients to the skin

but we always know it is a transient and a lesion will subside on its own and usually asymptomatic the other one is a neonatal muscular dermatosis

this is a vesicular posterior rash what happens here very typically when it ruptures it forms brown macules with color at off scales and heals with

brown pigmented molecules it affects the neck face palms and soles even this type of lesions usually heal with three to four weeks probably the only

problem in neonatal fuscular dermatosis is the pigmentation we see it is less common than the erythema toxic amnionator the

lesions are like this on the face you have these regions and they are very typically seen as postules if you want you can do a

smear out of it and find out what are the types of inflammatory cells so here we typically find neutrophils in case of transient neonatal pastelodomatosis

then the infections which you are going to discuss about the surface cytomegalovirus varicella enteroviral infections as well as staphylococcal and neonatal impetigo cellulitis omphalitis

and urinate lapses candidiasis petraeus versicolor and scabies purpose simplex infection it's due to perinatal infection in first four to six

weeks of life you find vesicles or petique and dissemination with high mortality obviously you find lesions in the mother's external genitalia so it's

paramount importance for the gynecologist when they observe herpet solutions just before the delivery to make adequate precautions and most of the time the infection or easily spreads to

the child and you have to treat the child accordingly if there are active lesions in the mother at the time of delivery the neonate invariably develops surplus

simplex infection and it is disseminated so it has to be treated with parental acyclovir you can have this photograph of a disseminated herpes simplex infection you can do a smear of this

vesicle which is seen on the face and the trunk and you find the giant cells at this point of mother point i have certain points to remember

particularly with regard to the gestational i'm talking here about herpes zoster or what we call varicella i'm not talking about therapist simplex infection herpes simplex infection

occurs only at the time of delivery here we are talking about herpes zoster which is a disseminated infection or what you all vary

so sorry to interrupt sir your screen is not visible is it visible now excuse me is it visible now so it's not visible sir

all right one minute yes yeah so it's visible now okay okay thank you thank you so um

can it be made in the slide share mods slide show is it visible now yes okay this is a disseminated herpes

exhaust purpose simplex infection and now i'll go to the next topic that is about uh chicken box

and this is a very important point to remember about chickenpox the period of registration of the infected mother if it is between 7 to 28 weeks the outcome and fetus is a fetal varys

allah syndrome so i'll be talking about it bit later the fetal varicella syndrome if the period of gestation is between 1 to 28 weeks the outcome is a neonatal or childhood

hepa zoster if the infection is between two weeks before delivery it is neonatal chicken pox and five days before or after delivery

you get neonatal disseminated chicken pox with septicemia and there is an increased mortality so this is a very important point when should remember when the mother develops varicella or chickenpox

so the earlier the infection we know the virus can be teratogenic and it can produce features such as the fetal varicella syndrome

otherwise late in the pregnancy they develop neonatal chickenpox so this is a very interesting case of scar the child presence with the scar at

birth there are various differential diagnosis for the scar at birth you can see the scar on the leg and this is a very interesting case of fetal varicella syndrome

and what are the other causes of this type of skin hypoplasia or scars a plastic acute is congenita epidermolysis bullosa

neonatal le focal dermal hypoplasia antenatal procedures like amniosynthesis forceps delivery etc congenital erosion and vesicular dermatosis which heal with

reticulate scarring so these are the conditions should be remembered with when the child presents with scar and fetal varicella syndrome is very important cause like a place equities congenita so these are the other

conditions where you find the scar or congenital absence of skin they remember resemble the same in a neonate about varys i just now told you it's

perinatal transmission and hematogenous our airborne root the mother gets infected as well as the child protrum fever upper respiratory symptoms one week later small red

macules to papules vesicles and pustules on erythematous base they are polymorphous in morphology and they crust in one to three days and treatment is within seventy two hours you can give varys allows us to

immunoglobulin and then para enter lay cycle over depending upon the weight of the child and this is a case of the we had a case of neonatal varicella you can see the

lesions the vesicles and the hands the trunk and this is the neonatal varicella so the next another important condition

which presents as personal eruption is due to staph aureus infection it presents the second or third day of life it manifests as vesicles to pustules on arithmetic base

sometimes you find even large bulla that is when it becomes more of a bullets lesion and honeycomb crust forms when these bula rupture and heal and you find

that in interdigenous areas also the cytology will give the diagnosis you do a gram strain you see positive cocky in clusters and many a time topical mucorosin is

good but if the infection is disseminated or extensive or with fever and lymphadenopathy then you can start on systemic antibiotics this is a photograph which shows the

pustular lesions in case of staph infection and another important condition uh a condition which can be sometimes lethal is staphylococcus scalloped skin syndrome also called as

returns disease it is due to the exfoliative exotoxin which is produced by the staphylococcus aureus organism and spreads through circulation and

involves entire skin usually second to third day of life starts as a pustule becomes a flaccid bula with a low fluid and erosions then with cholera at of scales

and what happens the whole skin can take involved but the classical feature is skin tenderness which is a hallmark of scalded skin syndrome the child has an

incessant and painful cry when you touch the skin so that skin tenderness and a positive nikolsky sign are two important hallmarks of staphylococcus caldecon syndrome so the

skin peels off because of the exfoliative toxin and you get a positive nikolsky sign along with pain the fluid and electrolyte balance is very important topical mucosa and systemic

antibiotics cephalosporin or vancomycin depending upon the organisms so this is a condition where you find the staphylococcal scarlet skin syndrome child

neonate where the skin just peels off and nikolski sign is positive child is very irritable and sick and so it has to be managed appropriately we have various

degrees some people have very localized or few areas only you have streptococcal skeleton syndrome some children have flora it depends upon the amount of toxin produced and this is a disease

exclusively seen in neonates young children because they are not able to excrete the exfoliative toxin from their body and because the kidney is not mature enough to excrete

the toxin that's why they are developed adults usually do not develop staphylococcus syndrome if adults develop then probably they have a renal disease

candidates is another important condition caused by candida albicans within one to two weeks of life the most important manifestation of candida is oral thrush and perianal napkin dermatitis

so napkin dermatitis is a very common problem presence as pus tubes vesicles on erythematous base surrounded by satellite lesions the hallmark of cutaneous can the napkin dermatitis

produced by candidiasis is satellite lesions so you find multiple pustules around the lesions and interdigenous and perianal area are involved koh moun show soda hyphen sports anti-fungal therapy

for 7 to 10 days will be useful and you can see this very typically multiple lesions and you can see the satellite pustules here

here also you can see the satellite nostrils satellite lesions and oral thrush a pseudomembrane formation white plaques over the buccal mucosa and tongue

uh it is usually a benign condition and it self-limiting condition uh old time tested therapy is in violet paint and clatter muscle mount paint

mostly they are enough to treat oral thrush topical nistatin is also effective in management of oral thrush neonatal candida is one condition which is you find disseminated pustules all

over the body and to differentiate this from congenital candidiasis is a very important point congenital candidiasis is rare nearer to candidates is more common most of the time if you find a

candidate it's due to neonatal candidiasis acquisition is in neutral in case of congenital candidiasis and neonatal candida has anti-partum or postpartum

cord may show yellowish plaques in case of congenital candidiasis and cord is normal in neonatal candidiasis onset within six days of life and neonatal candidiasis more than six days after

birth so the sites are back skin folds palms soles and oral and napkin area are commonly spared in congenital candidiasis coral napkin

area are typically involved in neonatal candida cells because the primary set of involved site of involvement and congenital candidiasis produce generalized erythematous molecules papua's postures on erythematous base

here in neonatal candy ashes it's more of a beefy red color with moist appearance scalloped outlines and satellite pustules are seen in neonatal candles so both of them are candidiasis

with a better prognosis in case of a neonatal candidiasis when compared to congenital antigenesis which can have a poorer prognosis and the another important topic probably

very important condition which all of us should know is scabies sarcoptes kbi the mite which causes scabies you find multiple papules vesicles vesicular burrows and typically

palms souls and phase are involved this is very very important in children because palm is involved and phase is also involved and most of the time they are misdiagnosed as atopic dermatitis or

sometimes papular arctic area eczematization is very common in children because they rub it and skin is also very sensitive so in neonates you find an eczematized skin with lesions

and palms and soles you should think of scabies and the most important clues are genitalia is always involved so you always check the genitalia and see the

genitalia it's a male child is very easy to diagnose the scrotum and penis has multiple lesions and palms and souls are also involved and always ask the mother

has kb so invariably in most of the conditions the if you suspect scabies the mother also has kbs you can see the lesions in the mother or at least history of itching in the mother

you can demonstrate the might egg feces in the koh man from the scraping and five percent permethrin can be used two applications one week apart if you feel the child is too young less

than one week or just newborn very young you can use one person permethrin also and that is also useful for treating scabies sulphur ointment is the recommended agent but many a time

sulfur alignment is not available and is very tough to get self-awareness but never forget to treat the mother the most important mistake done by a lot of people is they treat the child and never

treat the mother obviously a ping pong infection is going to occur again from the mother and the child is going to present with scabies again and again so most of the time when they you can you think it is not responding to permatron

and it will be a big problem when we people apply steroids it becomes steroid incognito and it becomes a complicated uh infection here you can find uh neonatal scabies you can find that

typical skeptic lesions okay the phase the trunk and it can be managed and you find the palms and souls also the skepe articulations thank you i will

like to thank the tamilnada association of pediatricians who are giving me a chance to share few points about scabies

and other common neonatal dermatosis and neonatal dermatosis are a unique group of disorders which day in and day out you have to manage and many a times the management

sometimes becomes complicated and many times they are self-limiting that is the biggest advantage but it is most important to recognize the complicated problems

and to early may early manage these complicated issues if they are present thank you thank you thank you so much sir for that uh

useful and elaborate presentation on disorders skin disorders and newborn and you have given us very valuable points uh i i am very sure that it would have

benefited all the pediatricians particularly the pgs who have attended the uh talk and uh it's a very good take-home point that uh scabies um

liken children even a newborn if it happens you'll have to treat the immediate caregiver the mother um thank you very much sir we do not

have any questions in the chat box so uh one question about the claudion baby and the harlequin fetus like uh though they are very rare we see them in

newborn units uh do they actually um kind of survey well sir colorado and baby and harlequin fetus are quite different colorado and baby is more common allocators is very

rare probably you see in big institute maybe once or twice in your lifetime you see halogen fetus and most of them do not survive in indian setup because it is a total

maintenance of parental nutrition and they are very susceptible and the treat the treatment also becomes very tough while collodian baby is self-limiting it's just the collada and membrane which

occurs so when you see the baby when it's delivered itself it is in a membranous structure it's enclosed membrane structure and most of the time you just give moisturizers and

emollients the membrane just like that ruptures then heals but what happens collodion babies are always to be followed up very rarely uh they just subside most of

them result into some other type of ecthesis like a lamellar ectosis or many of the theosy form syndromes like repsons and norms yogurt larson so they have to be

followed up colored on babies are not to be just like that left because initially within a neonatal period and early infancy they subside they become becomes absolutely normal the skin becomes normal but slowly they

start developing the features of ethiosis the dryness starts and they develop so an initial stages it is hydration and moisturizes these two can uh be useful i didn't include colorado and

baby because i thought it's not so common it's a bit rare condition that's why i didn't want to yes okay thank you sir so though out of topic like uh

babies with infantile scabies uh norwegian like how is the prognosis like uh if they develop a newborn period or a does it progress much into a

pediatric age group or into beyond that or does it subside within infancy sir infancy itself if you appropriate treats scabies cavities

subsides if it is norwegian scabies and infants neonates is very not reported but infants is reported and if it is reported probably there is um underlying

immunosuppression we have to rule out maybe a hiv or it can be any of the immunodeficiency disorders so in that conditions they can develop crusted scabies which can be very severe

yes so um one participant wants to know the treatment for capillary hemangioma and newborn a capillary hemangioma newborn then you have to create the capillary imaging

what site what did we classify as a high risk and low risk and the high risk capillary hemangiomas depending upon the site like face neck and this it has to be managed so

there are various regiments we can use topical simple agents like topical timolol steroids and they are useful but in a high risk area then you have to go in for uh systemic treatment

there are various modalities of treatment and better these high risk cases are managed in a proper icu setup because they can suddenly develop it's a imaginable on the face they can develop

respiratory distress and other problems so that is there so if it's a low risk area and away from the face and the limbs better left alone if it's not causing

problem or otherwise it's topical steroids and then timolol is good enough it'll mean good enough yes when it is limited to the skin alone not involving

the viscera the role of retinoic acid in uh i mean in treating colored ion babies babies need not be treated with retinoic acid actually only for

halogen fetus you have to give acetyl because collagen baby we have to see what they progress into because one umbrella condition collada and baby can progress to anything sometimes it is self-leaning they do not develop any

disease at all so we don't start retinoids for a collada and baby but for halogen feeders definitely we have to start on a citroen and that's the biggest challenge and how the child responds and

sometimes with retinoids in a neonate it's high very risky lot of side effects will be there and the liver function you have to monitor the liver function and so it creates certain issues and the

therapy itself can be toxic to the child so that is the issues with halogen fetus yes probably that limits the use of fit and resource limited settings

thank you so much sir thank you for answering the questions patiently thank you sir thank you thank you thank you uh we'll now move to the

next speaker madam is now the professor and hector of the department of uh dermatology and leprosy at sri venkateshwara medical college hospitals and research center at

pondicherry and she is uh presently the president of the indian academy of dermatology and leprosy of puducherry chapter and she's done her

undergraduation at trishur medical college keller and the post graduation at calicut medical college kerala her special interests include

acne herceutism a genital dermatosis and sexually transmitted infections madam has lot of publications to her credit and has been

a prominent speaker in many of the zonal and national conferences oh to madam for her talk on atopic dermatitis in children thank you mom

[Music] mom you're not audible mom you're muted thank you i'll just try to share my screen yeah

i think it's visible no mom your screen is visible thank you man so uh let me first of all thank you

thank all the organizers of this pediatric dermatology cme uh this atopic dermatitis uh it's a chronic disease and it's a real

problem in uh when you come to the real life situation for managements in your hospital or in your clinic because

because you have to deal with a very uh like irritable child and uh ever anxious parents so it's a it's not that easy to

manage this this is uh so i'll be mostly you know this is the time this is a huge sebas topic and uh uh i cannot give a justice to within uh

some 30 minutes of presentation so most i'll be mostly uh concentrating on the clinical features that do special clinical features the usual clinical features everybody knows

and the management strategies so i'll be focusing on that now yeah here you can see three pictures

actually the first picture the is you can see uh uh erythematous plaque with lots of pustules uh oozing

and uh yellowish crushed and this entire thing is looking angry isn't it so this is called an acute eczema and the second part second picture is

something like a slightly arithmetic base a shiny slightly edimato skin in the popliteal area and the third picture what you are able to see is a chronic

irritated skin that is actually you can see the lycanified skin lycophyte means exaggerated skin markings so in the nape of the neck as well which is extending to the

uh lower back also suboccipital to that this is a very common area of likenification because it's very easy for the child or the patient to scratch that area so

here you can see the acute eczema subacute eczema and chronic external this is what you see in different stages of atopic dermatitis

now atopic dermatitis as you all know we all know it's a chronically relaxing inflammatory skin disease and it can occur at any age but most of

mostly it is seen it's more common in uh children and a percentage around seven to ten percentage of the children who had atop

atopic dermatitis progress to the adult stage which is usually a more severe kind of that is whichever whoever has progress from the child's

childhood stage to adult stage will be having a more of us more of a severe disease but this particular disease can occur at any age so uh even up an adult without much

history in the childhood can also develop it that will be a slightly uh kind of okay risks now this can be this atomic dermatitis can be a part of ectopic

diathesis so usually this is seen in a group of atopic dermatitis asthma and allergic rhinitis so usually uh children with

ectopics with the 50 of atopics can develop asthma later and around 75 percent will develop allergic rhinitis

in children also by 6 months around 45 to 50 percentage of children will show the science if at all they are ectopic and by around 50 percent 45 to 50 percent will

be showing by six months of age so ah and as you know this entropy there is no specific test for atopic dermatitis and it is diagnosed with clinical criteria there are so many different

types of criteria available and uh the most recently followed is a modified henishing and significant criteria and the uk criteria i'm not going to the details of it everything is

available in the textbooks now there are and this as you all know it is a multi-factorial disease so very strong family history so genetic role

then the environmental triggers immunological issues and epidermal factors so epidural factors are very very important and a very consistent factor in atypical dermatitis is a

uh problem with the epidermal barrier and there is something called a failure it's protein actually filament aggregating protein that mutation is the most important genetic change which is

happening in the head of the dermatitis and as the patient develops goes through the as the you know the along the duration of the disease uh

so many other commodities secondary to the atopic dermatitis also will develop like sleep problems adhd depression anxiety and the child becomes very very irritable so we can actually manage can

actually imagine what the parents are also going through when the child is having a such a chronic permitting and relapsing problem

so these are the common triggers you have to educate the patients as well as the parents regarding the sugars because they have to avoid these triggers during

the entire uh maybe it depends on how long the patient is having the disease so a decreased temperature a decreased humidity that is cold dry weather definitely sugars entropy dermatitis and

all kinds of irritants like soaps detergents uh tight fitting dresses woolen dresses and food items good items is food

allergy is not uh very common in all atopics it is around 20 to 30 percent of atomics only will have food allergies but if a particular they are giving a strong history of suggestive of

foodology then it has to be taken into account and certain food items are flat as a potential allergen like milk and milk products eggs seafoods

peanut wheat etc so if you have a doubt it is better to avoid but there is no blanket um recommendation that you have to

you know avoid all the non-waste uh nothing like that it all depends on the patience is that your parents will very clearly will give you that history and the potential

contact allergens like um especially the preservatives which we which will be present in many of the topical applications the fragrances uh those things can actually produce a

contact allergens and all these figures um will trigger the an attack of atopic dermatitis so here you can see uh atopic dermatitis

actually we can divide clinically uh in an infantile stage and that childhood stage and an adult stage so a childhood and adolescent and they are almost like

overlapping picture but infancy the picture is a bit different uh so here you can see three pictures the baby the baby's face you can see the

rash on the cheeks as well as the forehead and forehead i think her mother has put some powder or basma or something like that that's like

seen as white whereas here you can see the red erythematous inflamed skin where the baby will be scratching you can even see the excoriation marks of the on the

abdomen and typically sparing the diaper area so this is very typical of infantile entropic dermatitis and here in the leg you can see a proper oozing

has started so it is going for an acute accessory so it's going to an acute excimator stage you can see that glistening skin with the crusting all this crusting are actually

dry secretions which has already dried and this is the typical oozing kind of eczema this baby is having so and usually this infinite stage starts

after three months of age because the each reflex starts only after uh i mean it gets completed only after three months of phase so you will see it uh

symptoms will start after roughly after three months of age in pediatric age group you will get some more uh this thing now what you're

seeing here is a follicular patients slightly hypopigmented follicular patients as a group lesions you can see the group lesions this you would have seen this kind of

picture in many of these atopic children they generally have a dry skin so a general cirrhosis of the skin is very common in atomic children and some people will

have a slightly higher grade of dryness amounting to ectosis also here in this child you can see there is another finding also called keratosis pilaris which can also occur in these kind of

children but maybe in an slightly older children and adolescents and adults they are slightly bigger lesions and they won't be this much grouped as you see in

uh like in spinal hostess and here in this baby you can see this very uh prominent denim organ fold the extra fold below

the lower eyelid and he has an acute patch here and even his body is also very dry you can see from the picture and here you can see the

two big white patches white means hypo pigmented patches here as well as here it's a very dry patch you can i hope you can appreciate that dryness

of the patch and this is what is called as ptds alba it's a very very common uh association of atopic dermatitis hyper linearity of palms and souls so

here you can appreciate the hyperline it is a very very common finding with in atopic uh children uh and this is actually a slightly higher grade of ectosis

ah which is seen associated with the dermatitis and here you can appreciate because of chronic scratching see the children keep on scratching even the adults keep on is very difficult to control

uh even if you tell whatever you tell it is very difficult to control the scratching sensation here you can see because of chronic scratching the skin has become uh hyper

pigmented uh there is a bit of thickness that thickness has increased and there is superficial scaling so these are all this is also called atopic dirty neck

sign foot and hand hand and foot dermatitis is common in atopics not in not much in infants but more in

children and adolescence you can see typically it affects the uh docile dosal aspect whereas you can have a combination of contact dermatitis in that picture you

will see contact dermatitis features also but this is typically an atopic hand dermatitis the other one which you can see here are small small uh papules deep seated recycles

ah this is a highly itchy condition this is called this hydraulic eczema or palm solids now pampholics can occur in different different conditions one of it is atopi atopy there is a strong

association similar things even this palm folic can occur in the food as well as food dermatitis also the same these two are a bit uncommon

here you can see uh where the root of the penis joins with the rest of the skin there is a fissure similarly here also in the infra auricular as well as the retro oracular

area there can be development of fissures the patient will be scratching a lot later and the skin changes occurs and you see a fissure developing in this

particular area these are all seen in atopic kids now atopic key light is again uh when the

let's become a bit dry the child keep on licking the lips also so that saliva also can produce a contact dermatitis ah you can see the difference between these two pictures

this is called perioral dermatitis this is a bit different from this here you can see this entire vermilion border of the lip is involved you cannot actually differentiate the dermatitis is actually

uh affecting the border and it's merging with the surrounding skin whereas here in uh perioral diameter is a bit different ah here the vermilion border is that is

preserved and you can see a normal stretch of skin between the lip and so here the redness the eczema just changes erythema that [Music]

that is seen a bit um away from the lip martial perioral dermatitis uh the exact that there are so many uh theories about the causation of periodic dermatitis but

that is also seen a slightly uh more associated with atopic dermatitis children whereas atopic helita is more common than periodontal dermatitis in a picture

then the problem of recurrent infections in atopic dermatitis see the problem is basically there is a defect in the skin barrier now skin barrier means stratum

corneum stratum corneum is a homogeneous uh keratin layers which is the outermost covering of the epidermis so you have a

barrier problem in case of all atopic uh skin and there is suppression of cutaneous immunity and there is something called a cutaneous anti-microbial peptide that

they are the things actually which prevents uh frequent skin infections so they are all at fault and cutaneous dysbiosis that means there is an imbalance there are normal

skin flora and abnormal abnormal skin flora so this balance is actually uh a bit the balance is lost because of this ectopic nature

and also this uh staphylococcus aureus this is a very common this is a bacteria which is very commonly seen on the skin surface but its adherence that

adherence of this bacteria to the skin is very much increased in ectopics due to various reasons so they are all a bit of more complex and not going to those things so just

keep in mind there is an increased adhesion of pathogens to the skin epithelium so you get recurrent infections now in addition to the direct invasion

causing an infection the infective agents can also act as allergens for example staphylococcus aureus toxins a and b and toxic shock syndrome toxin

one malaysia sympodalys trichophyton all these things can act as allergens so now what do these allergens do they act as super antigens so as we all know there

is a particular pathway for an allergen to cause a immune response whereas in in a simpler word i should tell the super antigens actually bypasses many of these

steps so they increase an allergen specific ige ige a damage to the regulated t cell function and they can induce

corticosteroid resistance so here you can see a baby usually this is this this is crusted impetigo or and usually we see it around the

anterior layers or just by the side of the mouth this is the usual uh picture whereas here in this child which is almost effective on one side of the

face and here in this picture you can see this is just a malaria rubra or of which the patient has crashed a lot and it has gone for uh impetigenization that

secondary infection so this is out of proportion uh clinical features of a simple skin problem so that is what's happening exaggerated bacterial infection

and an uncommon site of infection usually in children and all this is actually tedia of the face tina infection of the phase we call it the senior facial this is not a very common

thing which you see in children uh in adults with diabetes or other any other cause of liminal separation or you may see it but otherwise in children healthy children we don't see it

but it is seen in atopic children uh here you can see very well appreciate the denim morgan fallen's child so this is actually including the hairy area the

tina facial and this popliteal area you can see what is this this is actually molluscum it is also very uncommon site uh see the

problem is the child keeps on scratching all these viral diseases molluscum or vat all those things they auto inoculate due to the

constant scratching or rubbing by the child so you get it in uncommon areas now uh this is just a word of caution because these are actually complication

it's not common at all it is rare but these things can progress to potentially fatal conditions actually eczema herpeticum something like a

generalization of her herpes simplex virus infection usually herpes simplex is a very localized mild infection uh

but in case of iotropic dermatitis or some other skin disorders also but i will be discussing only with atopic dermatitis the child has the propensity to develop dissemination of

herpes so the patient would have had just a localized therapist simplex infection later within few days the patient is becoming i mean developing all systemic

uh symptoms uh multiple uh varicella likely chicken pox like lesions small fluid fill lesions and not uh responding to the not uh not at

all uh you know responding to the usual lines of management so in this uh especially when the patient is uh if he is an active pig you you have to rule out something called an eczema herpetic

as a generalization same thing uh eczema coxsackiem for foxy virus infection and here actually what we can do is if you have a doubt you can do a smear from the

small pasture this particular picture is already crusted and it has gone for even secondary infection with a bacterial secondary bacterial infection that is further complication

ah so if you do a samsmir with from this blisters small vesicles you will get a multinucleated giant cell or if you have a doubt beyond that if you are not able to

you can still go for further uh investigations like pcr viral culture and things like that but start as a clover at the correct moment there won't

be much problem the problem with this particular disease is late detection so by that time your precious time would have been lost now ocular involvement ocular problems

are very common in atopic children because they will constantly scratch there they'll keep on rubbing their eyelids even recurrent style is common in this

children and recurrent persistent rubbing can cause character corners and atopic blepharitis that is um

you know inflammation of the eyelids blepharoconjunctivitis and seasonal and perennial atopic papillary conjunctivitis and cataract attract is not common but

more directly due to adoption you can develop anterior subcapsular cataract and posterior has a complication of uh corticosteroid use so here you can see in both this picture

you can see that here it is redness denim organ salt is seen a mind scaling is there this is even more uh that edema redness and peeling of skin this is

atopic blepharitis so differential diagnosis now uh differential diagnosis is important now why the problem is many times we won't see

it in the correct you know textbook kind of description as uh professor um suggested he has pointed out this point of scabies

dermatitis as well as these two infections can coexist together so when you are managing you have to actually rule out these two things before you start uh any kind of uh

steroids topical steroids or something like that so you just imagine if you just start a topical steroid over a course over a plaque of scabies or dermatophytosis so

we can rule out scabies by doing a scraping and put it in a mineral mineral oil mount or a liquid paraffin mound you'll be able to demonstrate the sky bala or the

that is excretory material or the eggs possible dermatophytosis just a kh mound will show you the fungal filaments so we have to especially when it is a generalized and you are suspecting this

kind of generalized infection or infestation rule it out before starting the specific therapy then uh

psoriasis i'll just show a few pictures and uh whenever it is not at all responding to the usual line of management we have to think of some immunodeficiency disorders because in

viscotile rich job syndrome and combine immunodeficiency and all the patient presents with generalized examiner solutions so that is only we can keep it in mind now another 10 syndrome is a

congenital syndrome which is actually associated one of its component is atopic dermatitis it has a peculiar type of ectosis ah called ectosis linearis

circumflex which is actually uh something like a scale which is attached to the sender with the periphery of the scale will be detached from the skin so a particular different

kind of ethiosis you get then the acrylic dermatitis centropathica and along with other general deficiency disorders also sometimes can present like this

so this is a picture of seborrheic dermatitis here you can see a bit of glazed reddish lesion you can see that this genital is involved it's a bit of dry

which is actually a subsiding symbolic dermatitis that is why it is not that much red and you can see this all the souls and you can see the dryness this

particular diaper area exclusion involvement will not be seen in atopica now flexural psoriasis here you can see

this also looks like atopic dermatitis but here it is a plaque ah because it is a fluctual area and there is moisture there that is why you are not able to appreciate the typical scales of

psoriasis but if you have a doubt you can take a biopsy and that will show typical features of psoriasis now investigation there are no specific tests diagnosed only by clinical

criteria but uh some people do certain tests as such we don't require a particular test for this uh some people do a total serum immunoglobulin e which is in increase in

uh more than 80 percent there are but there are some people in which uh the pa that is negative also but we don't get any extra information from uh with the for the severity course or prognosis of

the disease but there are some specific allergen allergen specific igs are available uh that can also be done that is to find out a specific allergen for the

particular patient now skin prick test these are all not routinely done i am just mentioning for the sake of post graduate students food or arrow elegancy actually skin

prick test is a test to demonstrate the immediate hyper sensitivity immediate is what is actually operating in entropy food allergy again i told you it is 20 to 30 percent patients only will be

having food allergy so actually if you want to demonstrate the test is oral food challenge test again you have to admit the patient and there are so many paraphernalia associated with it allergy

patch test this is mostly we do we use it for contact dermatitis to diagnose which all the patient is allergic to again in atopic dermatitis it has a poor prediction it doesn't predict much it

has a poorly predictive of trigger triggering factors now we come to the management uh now the problem with uh as you all know the atopy child has always a dry

skin now this dry skin can directly cause each the patient will age a patient will have itching sensation and he will start scratching and finally that will finally go for eczema eczema

once it becomes settles again it goes for dry skin and as a secondary thing there can be a secondary infection also any triggers will stimulate all this this cycle again and

again so number one i should feel like before starting any kind of treatment number one and the foremost one should be patient but the pattern counseling

depending on the age of the child uh parent counselling so they have to be explained about the chronic nature of the disease exacerbating factors and they should many times what the parents

ask all of us doctors are whether it will be it is fully curable so sometimes i think it is better to talk uh better to tell them the truth only to the parents that how

much you can you cannot cure the disease we can only control it uh provided you do so and so things okay the patient can be really free of all the problems if

they follow a particular uh style of skin care regimen so [Music] and along with this when the child becomes a bit uh

older and all know they have this kind of highly irritable children behavioral problems some psychological issues sleep disturbance so all this can actually uh

even make the problems worse so we have to actually address these problems also so the goals is number one is not to cure but to control sugar should be

reduced and number one reduce the pruritus very very important the patient should be symptom free otherwise each and scratch is a cycle so if there is an itching sensation the

patient will scratch the scratching as such will increase the itching sensation so unless and until we break the cycle there won't be any uh improvement in the patient's condition so that is very very

important this is uh aerated that is evidence a rated approaches by american academy of dermatology moisturizers topical corticosteroids

topical calcium urine inhibitors and they are dead against routine use of topical and staphylococcal treatments so topical continuous use of

antibiotic creams it's not at all advised in atrophy dermatitis because it brings about resistance skin hydration these are all the things which we should actually educate the

parents uh bathing followed by immediate application of emollient that is a cornerstone of maintaining the skin in nitro pedometers so the water

can be just warm lukewarm so cooking is better than just taking a shower five to ten minutes actually in small children we can just put put them in a tub with water they actually like

playing in water and regarding soaps it is better to use uh low ph hypoallergenic fragrance free

non-soaked cleansers non-stop cleansers are available so it is better especially for atypical children that is better and there is no specific advantage for antiseptic soaps

and in case where there is extensive like moderate to severe kind of atopic dermatitis and the child is highly irritable the skin is very much red and angry looking and small children the wet

traps are useful actually so that traps before this also be you can teach the parents so number one is actually first step number one is

actually leave a bath uh in water likely just pat dry and apply steroid that is appropriate steroids to the affected

area and emollient to the other normal areas then you put the first layer that is mildly warm water you just dip it in and just wrap

it just cover the area with the bed dressings followed by a dry something like a pajama and full sleeves uh shirts so depending on the uh

condition of the severity of the of the condition uh it can be applied for few hours or even it can be if it is very similar you can do an overnight wrapping also so around two to three times per

week actually you can give this this is can't be very very useful it really reduces the itching and oozing only thing is when it is secondarily infected when it is too much

of beeping and crushed then you better don't use it now bleach bath is uh actually this is very useful for moderate to severe air to be dermatitis with recurrent skin

infections now how to prepare it this is just a six percent household breach only um that uh for per bucket of water that is

15 liters you can just put one teaspoon of uh bleaching powder and just soak the child in that till they can just uh lie down with the neck and head out

now advantages it reduces the staphylococcus aureus and mrsa colonization and decreases the severity so immediately after bath we should be uh applying the moisturizers now there

are three types if you really go into the moisturizer but there are three types one is occlusives they are actually uh something like uh petrol atom that is a thick oily

uh application which actually forms a barrier uh just above the stratum conium layer and it prevents evaporation and whereas

humectants they are actually agents which actually absorb water from the environments examples are glycerin propylene glycol urea etc and emollience

is one which seals the crevices so a dry skin immediately after taking bath apply emollient so it will seal the crevices uh between the corneal sides so all our

coconut oil is well and it's very good steering linolenic all these things palm oils even sunflower oils they're all good emollients

and only in children we don't recommend propylene glycol and urea so all the other agents you can apply and in addition to the moisturizing

effect they also have anti-inflammatory antimicrobial and steroid sparing effects so it can be coupled with topical corticosteroids so these are the topical agents now very

much uh no when whenever a patient comes to you we have to first assess the severity there are so many scoring systems available i'm not going to those details but depending at least mild moderates tv here in a clinical setup we

can do that uh so accordingly according to the severity you can choose the topical agents so extensive severe disease again we may have to start systemic therapy otherwise localized

uh not much moderate disease we can uh choose a topical steroid so topical corticosteroids can be chosen then topical calcium urine inhibitors that is

by micro lemons one percent cream and tacrolimus point zero three ointments point one is mostly research for uh adolescents and adults and uh phosphodiesterate four inhibitors

christopher two percent oil is not available in india and dog shipping creams are also available toxic tablets are also available creams are all also available actually a topical doxapin is

available uh it is belonging to a tricyclic antidepressant with the very prominent and the h1 and h2 action so when you are applying now you have to tell the parent how much to apply for

this we will just uh you see the fingertip unit measurement uh the index finger tip of the finger to the first digital crease that means the digital digital

crease ah this is roughly a one finger tip unit and it's roughly a 0.5 gram tube the taking uh assuming that the nozzle is 5 mm size diameter and this is

actually almost equivalent to two adult palm size so that much now how much to apply and all all tablet columns are available in the textbook as well as in

the nets so now the selection on the basis of site very very important so very in detrigenous areas genital areas face and all we we should not be

applying um buttons anyway for uh infants definitely potent steroid creams are out uh even in children or adolescents adolescents we usually treat just like adults only

so in the we have to choose a very low potent or a mid-potential for that in age again extreme surface the skin thickness is uh less so we have to choose again uh mild

to moderate potent steroids frequency of application they all depending on the condition uh and just keep in mind that monthly use should not because they are all chronic

patients should not exceed 15 gram in infants 30 grams in children and sixty to ninety grams in adolescent organs so this is the roughly that means uh they should not be using

beyond that particular now there is something called a pro proactive therapy now what is this now actually when when you take an atopic dermatitis patient there are some affected areas there are some

non-affected area now when the acute stage is over by appropriate treatment it comes to the subacute stage isn't it so even that time you need a maintenance of therapy you cannot just stop therapy

just like that because this can uh get access accelerated at any time so even a normal looking skin in an atomic patient is not normal

by structure they are still there it is still having a barrier uh defect so you need a long term loados intermittent and inflammatory agents to previously

affected yes also so what they will do they will you better start with the continuous steroid applications after a few days

maybe 10 days or two weeks will become better you can reduce the potency of the steroid or the due the frequency of application and whereas still the rest of the area you should be applying

moisturizers and when everything becomes normal still you will be applying moisturizers when you get uh again uh exacerbation again here so that is how it is so proactive in

between attacks uh how to manage the skin also should be taught to the patient now systemic therapy uh as we know miscellaneous miscellaneous number one is oral antihistamines very very

important antihistamines the patient has to sleep if they don't sleep they will keep on scratching and each scratch cycle gets activated so that's very very important and sedating that first generation and hysteresis is the best

for entropy dermatitis now systemic antibiotics only if there is a significant skin infections and antivirus anti fungals everything when it is appropriate now regarding the other drugs you know suppressants so

immunosuppressants uh we usually go for first as a first line we may go for a cortico systemic corticosteroids that is only to manage an acute extra submission and the

duration should be short you need not uh taper and on give or just uh shortcuts to steroids and immediately stop and just shift to moisturizers and topical

steroids so that is the safest thing but in certain cases the atomic dermatitis is very severe so in that case you start with this and along with that you can go

along with that you can start the other drugs that is immunosuppressants and slowly stop the corticosteroids so all these things cyclosporine syrups are available 2.5 to 5 milligram per

kilogram body weight metric state around 3 to 0.7.3 to 0.7 milligram per kilogram body weight per week so only thing is all these things as you know it needs a proper monitoring

close monitoring should be done and whenever it is under control switch over to topicals now photo therapy is very good actually uh narrow bands uvb is available but

it's only reserved for adults narrowband uvb for chronic eczema and uva one for um acute excellence narrowband is very actually very good but the problem is long-term therapy

because of the safety concern it is not being given for children now these are the newer agents dupilumab is actually uh fd has approved it for

adults and uh the the last race trials are going on for more than 12 year old kids and it is not uh all these things the other

animal is all these things are under trials and uh right now only diploma oma omali sumab is there which is actually a monoclonal antibody which is given for a

chronic persistent very severe kind of urticaria many studies have done but that is not actually showing much uh road in the management of atopic dermatitis

now topical this is a boron uh based uh uh chemical uh crystal boron it is supposed for distress four inhibitors uh again this this is available safe if

they are crude available in uh united states not still available in india if at all if it's available it is can be given only about three months of age and

uh solitaire this is also under trial japan's inhibitors to facetime is being tried all the others are under trials these are the new drugs for the benefit of postgraduate students

uh oral uh um pda4 inhibitor the apprist is there in this in the market for quite some time now we use it for uh mostly for uh

psoriasis along with the full prescription with other agents for psoriasis it is also found to uh show certain effects good effects with this probiotics none of the studies are showing

that much benefit melatonin is actually regulating sleep and circadian rhythm and it is found to be beneficial as a co prescription

and there are a new allergen specific immunotherapies available but again showing conflicting results

no challenges challenges for doctors challenges for the parents so as doctors the problem one thing which we all encounter is a poor adherence to the

instructions and drugs from the on on patient side see the problem with this is we may not be aware of this we will think it as a lack of response to whatever drugs we have given and we may

unnecessarily escalate the treatments so we have to really talk with the patient's parents and motivate them to adhere to the regimen and steroid phobia this is a very very

important thing because every other patient because of this google uh internet surfing or whatever uh they think that steroids is something like a poison which should not be given to kids

madam message steroids this is the first question they ask so again we have to address that their fears otherwise if they have this fear they will never give

apply as per our instructions so this apprehensions to irrational fear should be addressed uh in the with the parents and there is always

increased susceptibility in that mind and detrimental effect on the quality of life and again behavioral problems irritability embarrassment and socialization the

problems which the child is going to face and just uh just giving a treatment for the skin is definitely not enough we have to address and if necessary take a help

in dealing with these problems that is the behavioral problems and psychological problems so atopic dermatitis is a chronic disease with significant impact on quality of

life social academic the academic performance will be affected and available treatments have to be evaluated because affordability is a big

question because many of the drugs are costly a patient may not take it properly and parental and patient counseling is very very critical and one more thing which i would like to

highlight is many times it is often it is the each that rashes rather than the rash that pictures so mostly it starts all with itching

itching giving to a rash and again it getting scratched and again it becomes the eczema so if you can cut it at the level of switching that is again highlighting

each and scratch cycle and the histamines and the proper soothing uh applications that will i think will be will be able to address the problem in a

better way if you think in that line thanks a lot for giving me this opportunity thank you mom the last code delivered it all it's the itch that rushes rather

than the rash that itches thank you so much ma'am this is this topic has always been an enigma both for the exams and for treatment and you made it uh appear very easy uh through your

crystal clear presentation thank you mom mom uh just a question uh like you said that the common skin uh hydrogens they act as super antigens but uh against the

use of empirical use of antibiotics to treat them by the american academy of dermatology like uh is it a

victim or kind of an indian makeup that we can might as well treat those infections also see the problem is no if it is just a superficial infection

yes definitely we can give you the patient we need not give a systemic antibiotic to the child you can actually even a soap and water wash is enough for that

immediately apply moisturizers in practice i have always seen this coconut oil has as a very good antiseptic action and it's a very safe thing to apply especially to fractures

because we see a lot of inditrogenous infection in this kind of patients so uh if it is extensive extensive uh infection definitely we have to go with

uh antibiotic uh systemic antibiotic but definitely i have just referred many uh articles they are all uh telling against uh the use of regular use of topical

antibiotics so i think we also should not be uh you know contributing to the resistance yeah true and what is the difference between how to differentiate between atopic

dermatitis and fungal infection in new born participant once you know actually the fungal infections say mostly newborn the commoner

fungal infection is a candidiasis not uh you know compared to dermatophyte candida is candidiasis is more common and candidiasis is very common in the i

think a doctor [Music] cartigan has already shown the slide in the indian trigenic area the neck the in the trigenosis area but in the in the triges area the candidacy affects the

depth of the fold whereas i have already mentioned the diaper area is always paired in atropic dermatitis and one more thing is etob

dermatitis eczema starts with itching which acts which starts after three months of phage when the each reflex starts so before three months it's very difficult to see atopic dermatitis very

very rare if it is you are seeing lot of eczematous lesions in before three months of age think of the immune deficiency syndromes hypergamma global anemias all those

things and again see always there is a method of diagnosis for cutaneous fungal infection take a scrapping put it under the microscope to add a drop of khmc under microscope you

can always rule out yes ma'am mum uh you said that uh common viral infections exaggerate uh a.d

uh herpeticum and cox accumulator relating to uh does that mean that no no it is not exaggerating eddie because of aid because of atopic dermatitis

yeah because of atopic dermatitis the viral infections can become systematized disseminated so it's better that we treat even common viral infections in children who are

predisposed to ad is that so much no you need not give routine uh antivirals are not required in this patient but we should have an eye for that that's soft

yes see a small group of slavialists we usually do not clean you don't the patient doesn't require that but we have to have an eye

for that unless and until we think about and pre-empt it you know [Music] what the mind does not know the eyes do not see

yes yes definitely so if we are sensitized we will think about it okay yeah that was a very good uh take home point that was delivered well thank you so much mam for the

patience and the elaborate discussion thank you mom so the next speaker for the day thank you mom um i invite dr deva prabha

senior assistant officer of dermatology and veneeriology from government rajaji hospital madurai medical college to deliver her talk on

faqs in dermatology she's done her undergraduation and post graduation at mothering medical college she's a very favorite teacher among the post graduates and

her phone fondness among them best testimony to her teaching um so she'll cover all the frequently seen uh cases pediatric cases in the

dermatological uh department and oh to dr deva prabham thank you for giving me this opportunity um the pediatrics

yes ma'am you're audible and your screen is visible okay thank you my topic for today is frequently asked questions in periodic dermatology

but the slides aren't moving [Music] yeah no problem your screen is visible the first slide is visible slightly visible

yes yes ma'am your slide is visible no now it's not visible ma'am yes ma'am your screen is visible yeah yes ma'am uh okay thank you mom

uh my topic is frequently asked questions in periodic dermatology uh this is the overview of the skin topics skin conditions which i am going to be in short these are the conditions we have

commonly seen in your day-to-day work coming to first condition petraeus alpha as already madame and sir has already spread i only elaborate a few points it

is a common eczematous dermatosis occurring in children is most common during winter association with atop is present the clinical features are ill-defined

erythematous or hypopigmented patches its fine case scene common sights on face sheath and chin it can also occur in other states such as

neck shoulders arms these are the common differential diagnosis and we have difficulty in diagnosing in the op these are the conditions which confuses us

first first one is virtually go but we tell you go there will be the clinical presentations be pigmented patch instead of hypopigmented patch it can occur over

any areas in all age groups coming to uh indeterminate leprosy seborrheic dermatitis these are the pictures

i am going to explain the picture which is seen on the left is a classical picture of the tinia versicolor audible

hello your audible mom your audible your screen is visible okay this is a clinical picture of mercy

the clinical morphology is multiple hypo pigmented scaly molecules which is present in the perioral region and also in the perinasal region we can you can see

scaly scaly molecules and patches over the period and perinasalis it is classically senior mexicolar we will have doubt

whether it is ptsd salva argenia vestibular but in this we can see perinasal distribution and the consistency when we perfect the lesion that with velvet appearance and when we

if you want to ah confirm the diagnosis as man told we can do cave scraping and do kevush move and see the hyphen the second picture is a classical

picture of a baby with the skin lesion present over the face this is a erythematous block with pathos scattered in the bodies

in this baby we have a doubt whether it is tinea facial or any other discolored eczema but on closer view we can see mild scaling present in the patch and

that is the farm history of dermatophyte infection with the mother we can confirm it by doing scraping the third one is indeterminate leprosy there will be

hypo pigmented patch which is present in the face uh but there will be some amount of infiltration be present on closed loop

but sensation cannot be tested in yearly lesion because fails have a very rich supply of nerves so we have to confirm the diagnosis by biopsy

coming to treatment ah topical emollients should be given and my topical series such as dissonant hydrocortisone plane can be applied

coming to second condition in particular this is a condition we will commonly encountered in a day to day impetigo is a contagious bacterial infection of skin it occurs in infants

and in children it is mainly cast by staphylococcus aureus and streptococcus pylorines there are two types bullets and non-bullets in particular

coming to the picture the left one it is the non holeless impetigo the the classical presentation of the non-rulers impetigo mainly consists of the clinical lesion

consists of multiple hyper-pigmented thrusted blocks with air oceans present over the very nasal very oral

over the around the eyes and a few lesions also present in the trunk this is a common sight of appearance of non-buddhist impetigo there will be uh the diagnosis will be helpful by

morphological seeing honeycomb like rest on the surface of fusion the right one picture in this uh we can see multiple

thrusted blocks with erosions and the borders we can see few bulla and blisters at the borders this this children child has impetigo

bullas impetigo is mainly cast by staphylococcus aureus and it is a low policed form of isis the sss is also caused by staphylococcus aureus

is also caused by staphylococcus aureus but the toxin it is both are toxin mediated in bloodless impetigo the staff produces exfoliating toxin which

uh which cleaves the stratum corneum mainly it will uh cause blister at the level of superficial level so in

in both the babies we will have difficulty in diagnosis but the clinical tubes which help in diagnosis or in nonpolar sympathetic it is common around the

orifices that staff normally call nasa's we can see the skin lesions around the orifices in bullets in particular also there will be multiple trusted block

coming to diagnosis we will have a differential diagnosis staphylococcal skin syndrome hipposimplex contact them chronic bullets disease of childhood we will see one by one

coming to this picture surges already described about the staphylococcal syndrome staphylococcal skin syndrome occurs in infants and children mainly it will present as a

tender skin lesions the skin will be tender to touch nicole's key sign will be positive when we touch the skin and give pressure that will be peeling of skin in the

peripheral areas and it is the nikon skin will be positive the babe the child will be toxic and sick inseparable syndrome it will start first in the face

and in the flexors we can see superficial blisters and erosions and there will be peeling and burning or rolling of skin in the

borders like potato chip appearance the second picture is hepas labialus this picture we can see grouped vesicles

with trusted erosions in the lower level this is a classical site of episabialis it will cause difficulty in diagnosis when it is present in upper perinasal

area if it is present we will get some more difficulty in diagnosing but hepas labialis we can confirm by doing zhang test a simple bedside test

and by seeing multinucleated gene cells the third picture is the chronic boneless disease of childhood and this is a homeless disorder which is commonly seen in children we can see

vulnera and vesicles around the arithmetic floor this is classical string of pearl's appearance the baby will be but in this

it is a goodless disorder mainly antibodies against collagen type 17 which means uh most of the mothers will ask whether it

is hypnosis infection no it is not viral it is bacterial infection is it recurrent yes it can occur recurrent because some babies children will call this staph aureus so recurrent infection

occurs and under poor environmental condition poor hygiene it will occur recurrent how to prevent complications yearly identification yearly treatment and

avoiding any native application of medicine will prevent complications common misconception of patients in our copy in our department we will commonly

encounter the patients will think us in tamil asaki and they will apply they will apply some native medication over that and will come to op with secondary infection baby we will be in

sepsis so the patient should be educated it is not any viral infection it is only bacterial infection don't apply any mean

application or any topical navi they will don't apply any topical native medications uh because the child will end up in complications the early treatment we can

prevent the complications such as glomerulonephritis and sepsis coming to folliculitis this is on one of the another frequent condition we encountered in our opinion it is a bacterial

infection confined to the hair follicle it is caused mostly by staphylococcus aureus in this clinical picture we can see multiple arithmetic tender papules and costumes

commonly seen over the scalp face and also drunk it is most common we can see during summer precipitating factors are occlusion over hydration excessive mineral oil

application or it's the very ram produce of topical steroids non-infected person folliculitis such as in chemical factories those persons are working will get folliculitis and it occurs mostly in

adults treatment we we should improve local hygiene correct any more nutrition if it is present topical antibiotics for extensive machines use systemic

anticiprocal antibiotics coming to another top other topic it commonly occurs in the nape of the neck inframammar regions

in the groin in the gluteal region integra is most common in children because due to maceration and due to the sweating increased weighting it will

occur in children in babies we commonly encounter interdepo because of the uh frequent drooling of milk in the neck and so we are commonly encounter instructions lesions in the

neck this is a classical picture of drago which is present in the groin we can see arithmetic scaly block lithium at this block with my scaling only we can see satellite lesions

in in this patient mostly nuclear tribos flexures will be involved and the force will also be involved but in atropic dermatitis the groin

region will be mostly the this region would be spared and atopic dermatitis moreover in inter drago it will be super that will be super added infection with

staphylococcus and candida this is some diaper rash which is nowadays we commonly encountered in a rupee in this condition uh the diaper rash formally occurs

which is confined to the diaper bearing areas most commonly seen in the gluteal region in the classical diaper rash the

intetragenous folds are span we can compare with the previous picture the folds are involved but in diaper

rash the inter folds are spam coming to the treatment in tetrago we should give topical antifungals and antibiotics if any secondary infection

present in diaper rash by replication we should uh application of zinc oxide and mild topical steroids and we have to look for any super added fungal

infection diaper rash is commonly occurs in babies due to increased the children will have increased ph in the diaper bearing area so it is more

prone for infection uh this escape is already sir has mentioned so i will uh quickly give a short description only

it is caused by sarcoptes it occurs predisposing factors are poor hygiene overcrowding children and in no suppressed individual we get norwegian

scapes and more of spread mostly with our contact and forming clinical features the classical asian present in scabies are burrows burrows are nothing but the linear drug which is present in

the epidermis extending from the stratum corneum to stratum rpg burrows cannot be visualized by normalized it can be seen in dermoscopy or any special link application then we can view by

dermascopy burrows are most commonly seen around the wrist and in the web spaces the government side scabies might launch on the

no mainly the areas are the interdistal spaces the flexor aspect of the wrist the inner aspect of the uh cubital fossa the inner aspect of the

axilla breast region umbilical region inner aspect of uh genital region inner aspect of time on joining these points we will get the circle and the circle is known as circle

of hebrew the kb smite will normally launch in that areas but in children uh scale these lesions can occur in phase palms and souls

but palms and souls is not involved in other face forms and souls are more important infants and children in front of scabies we will see vesicles

papules and explorations and moreover bullish lesion can also be seen in school going children age group another entity is animal scabies animals kv cisco's be sarcophagus kb or canis

in this the unusual sites there will be skin lesions where they have contact with the pit animals because they will carry the bit animals in the hands so there will be skin lesions present over

the forearm and in the abdomen areas and the periapical region underneath conditions burrows will be absent there will be exploration spatulas should be present

differential diagnosis therapy uh most common problem in diagnosing scabies with insect bite reaction and also another conclusion confusing one is atopic

dermatitis and another condition is in particular we can see in um this is a classical picture of scabies we will uh present multiple particles explorations present over the

inter different spaces there will be uh insect tattoos and sequels which is present in the board souls hosting whether it is spread among

family members yes it is spread among close family contact and close above the hostel rooms at least four hours of contact is enough to for the spread of

scabies animal information present or not is animal and for me transmission is present and the mite will be present in the formats bed sheets and other materials for 48 hours how long we have

to treat the patients these are the frequent questions they will enquire uh before that i will tell a few points about insect bed reaction insect bite

reaction will occur mainly over exposed regions but scabies occurred mostly over the common sides in circular fibra and other sites

moreover atopic dermatitis will commonly occur in the all areas as mentioned in particular is common around the orifices there are usually staff

colonises and moreover there will be no family history in all these conditions there will be positive family history in scabies when coming to papular active area

uh then treatment how to treat the patient in scabies we have to treat all the family members at the same time as always sir had mentioned uh

already have given a description about the treatment so available treatments available on topical five percent perimeter nutrient it should be applied below neck to feet

not even uh leaving any space we have to operate continuously below net to feet thorough application six to eight hours contact

period and then they should take bath immediately after in the morning they should also wash the clothes and the bedliners all family members should apply the

anti-stability treatment on the same day if the baby has a chance of licking thumbs again we can apply the medicine and we can use any gloves hot

and clothes like that breastfeeding mothers we should ask the mothers to wash the breast before giving breast milk and then reapply the breastfeeding mothers should be

instructed that baby for babies uh the contact period can be limited after few hours and if it is not treated by the topical

treatment we can give oral either mental 200 microgram per kilogram body weight single tablet the dose is repeated in the next week we should also ask the

parents any history of pet animals if that is present the animal should also be treated coming to other topic uh next topic

area it is commonly encountered in uh in op sunanam is the insect bite allergy uh otherwise known as ib it is common between two to ten years of

age it is an acquired hypersensitivity reaction to the insect bites plus the biting of the insect results in immediate ig reactions so there will be

wheel formation with central fountain the ideal lesions will have it will help and differentiate from the other lesion then repeated bytes that would be

followed by delayed hypothesis reaction which results in itchy factual [Music] it commonly occur over the exposed areas

this is a classical insect bite reaction we can see fabulous with central phantom we can see fabulous with central function

partners with central phantom but mostly present over exposed regions the areas which is not covered by clocks so we can ask history

whether which we can ask the history whether it is present only in the exposed region or inside differential diagnosis it should be differentiated from scabies

folliculitis pioderma and atopic dermatitis insect bite allergy and scabies how to differentiate insect bite allergy is symmetrically over it present

symmetrically over the exposed regions scabies over finger whips this axilla groin and periumbrical region papules with central puncture of the classical ocean scabies which we will see burrows

fabulous and explorations the family history will be negative but scabies family history will be positive absent diurnal variation that'll be they will still constant itching all the time but

scale is nocturnal which is common treatment coming to treatment in iba usually the parents will be so much uh tends to repeat the baby is getting repeated infection they will ask how

long it will be present whether it is india so whether it is associated with any condition we should first educate the patient about typing we should educate the parent that it is a hyper sensitive reaction pattern of

the skin to the insect but they will ask we we use all among all type of mosquito repellents and muscular then why it occurs we should tell that

a single mosquito bite can cause allergic reactions moreover we can see the children coming from abroad for the first time to india they will encounter they will have immediately they will

develop insect bite reaction this uh mainly we should advise the patient to have protective clothing near full sleeves uh in the night time and for true dates

control we should give antihistamines and if it is not resolving we can give topical steroids and if any secondary biodemolition is present we can give systemic oral antibiotics and patients

is very important we should tell the patient that will be improvement when the child grows because on repeated bites hypo synthesis will occur and no lesions will occur when the baby is

grown into adolescent period coming to sebor indium titus this is also uh discussed about previously this is topless formulas disorder in sebaceous glands each area

fitters for a mobile is one of the positive organisms present as the clinical futures is arithmetic sharply modulated blocks with greasy looking scales the scales are

under under but in sources the scales are freeze kids we can easily the scales when touch they will tell the skills of falling from the scalp through scales but in several dermatitis

we will have greasy looking scales there are two types in frontal suburb dermatitis and seborrheic damages of adam in uh coming to them that infantile in front of suburban democrats it is

asymptomatic normally we don't have any tourists yearly onset it occurs in the mostly in the first three to four months of age it occurs over the scan and over the

flexors that we are the matrix form of lesions present when it occurs over this camp it is known as gradient gap cradle cap people have yellowish trusted scaly lesions present over the frontal areas and

vertex the mother will be very much worried about that we should advise the mother that will be dissolved by its own and no specific measures will be needed and so we should apply

oil and remove the crust then mild shampoos can be used you can also occur over the napkin areas and also the face forehead eyebrows and retroregular areas differential

diagnosis has already mentioned atopic dump like this psoriasis contact dermatitis and coming to a point of longer and silky osteocytosis the baby will have

a severe seborrheic dermatitis of scalp perhaps erosions with oozing most commonly present over the hydrocoracular area we can see a

particular creations or some bleeding spots in the post oracular areas it will help in diagnosing us moreover the baby will have systemic symptoms the baby will be somewhat sick a baby will have

systemic complaints and history of recurrent biogenic infections and institute auditors media will help to differentiate we can take excel of this column we can see austenitic issues and

we can evolve it but but in that condition sephoric number this would be severe then candidates one of the treatment topical selenium sulfate shampoo

we can see very few cases but we can but we already have seen cases in our rupee uh autosomal disorder of zinc deficiency it is uh

mainly due to more exceptional zinc from the intestine triad of clinical future present is diarrhea alopecia perioral and actual eruptions mostly it occurs

pre-pre-term infants are more prone for sync deficiency because uh they can't uh there will be defect in the absorption of zinc from the intestinal epithelium and moreover the zinc source stores the

babies less compared to term babies and more of a zinc requirement is more in freedom babies in children the clinical issues are symmetrical exhibitors block

in perioral actual energy acryl regions and genital regions that will be delayed wound healing paranakia and alopecia differential diagnosis it should differentiate from biotin deficiency and

seborrheic temperatures biotin deficiency there will be similar lesions like that of scaly clock present over the perioral phase natural regions in genital region

also we see but there will be the baby will be ha features such as uh seizures ataxia and failure to thrive moreover biotin deficiency will occur

yearly in the babies in the first three months of life mainly due to multiple hollow carbohydrates deficiency or brightness deficiency but the biotinous deficiency we should evolve it for any

metabolic acidosis systemic evaluation should be done ah coming to this this is a picture we see in our opi we can see in this picture we can see erity mata

scaly block which is present over the groin involving the folds also coming to next picture very overall distribution

and also present over the cheeks in the both axillary region this is the classical picture sync deficiency treatment for arthritis lifelong supplementation of three

milligrams kilogram of elemental zinc should be given for aquatic efficiency 0.1 to 1 milligram kilogram of zinc should be given coming to another condition mr beetle

dumplings uh this is nowadays you are commonly encountering this you know because it is called it is seasonal soon after monsoon it is mostly occurred this typical dominate

this is caused by details of the family melody insect the different the defensive secretion of the uh on the insect the blistering agent cantheridin is the

mainly caustic for the heel can contact them that is which occurs it is seasonal soon after monsoon the usually the mother notices in the child immediately

after uh in the awakening in the morning they will tell sudden onset they will tell skin lesion will occurs in the children two types of reaction can occur the second reaction this mainly due to

cantheridin and the irritant which causes irritant contact dermatitis and other one is allergic to this lesion most common are the exposed parts but can also occur in

the trunk or back what are the this is of blistered beetle dermatitis we can see a linear distribution of the skin

lesion uh just like we can see any bonds or any acid splash we can see in a whiplash pattern in a linear pattern erythematous block in a linear pattern

the classical pattern will give success it will treatment will be local steroid topical application of steroids and antibiotics if any secondary infection you should

educate the mother it will dissolve in few days but continuous in one area certain areas and certain household all people will get any contact with the

insect coming to a few words about topical steroids in periodic practice madam has told about the fingertip units and how to use

another i will only elaborate a few points mild at least put in topical steroids ought to be used for your funds and need to moderate potential in children these

are potential for use in flexural areas moreover dissonant hydrocortisone kim can be used over the face meters from pain is to be used about two years of age creams to be used over the body

and safe and ointments over the thicker regions like parmesan sauce in this i will give a few words about cream sun almond what is an ointment an ointment will have a greasy

and will be thickened when you squeeze of the tube the one will be thickened and it is difficult spreadability is difficult difficult to spread so it is applied over the palms and soles regions

and thicken the blocks and over the likelihood areas but creams it disease when it is a clean base when you squeeze the cream of the tube we can easily this

cream will be come out and the spreadability is more easier in the body so cream can be used for subacute lesions we can use the dry lesions we

can use for ointments duration of application of steroids is usually for two weeks to four weeks in case of least potent steroids then we have to taper the potency or change to intermittent

application because long-term application of topical steroids the result in complications such as atrophy philanthropist processing acne form

eruptions historism and other complications so topical steroids should be properly advised to the patient and counsel to the parents parents

adolescent patients have to be counseled about complaints treatment adverse effects about the long-term use this will give a short idea about that hydrocortisone green and dissonant gel

or very used can be used about three months of age and then fluticas soon can be used above one year and about two years uh fluctuating and vomiting so ointment is safer and about values we can use low

beta sol or invention kill syndrome green a few words about newborn skincare usually the newborn skin is 40 to 60

times thinner than the other skin so cash should be good for the skin so what any uh any infections in others the the newborn skin is less hydrated the ideas

will have reduced natural moisturizing factor and and almost the preterm skin is somewhat more thinner than the dumb babies that we impart thermoregulation and increase trans epidermal water loss

so increased care should be taken few words about the common asked questions in our opi can i borrow my baby daily the we mainly need this and dependent on

the regional culture and climatic conditions bubble bars and bath additives should be avoided because it increases skin ph and gas irritation use of a synthetic region synthetics will be

more will be means more safer soaps tends to damage the epidermal barrier so it is better to avoid soap instead of that liquid cleansers can be used with acidic and it will be your chocolate food can i

massage my baby with oil you can massage for a few minutes few minutes while trying mix with oil but and before that they have to wash their hands under uh

clean condition can i apply powder to the baby uh you should not ask but i will advise the mother not to use any puffs because by using puff the powder in the face uh

the baby uh automatically they will increase that and cause any respiratory infection can a bigger scrubbing should be avoided first

part delayed until 24 hours preferably mainly knee based and dependent waste then coming to care of a scalp cradle camp is common and we can

advise the mother to apply mineral is just listed perfect to the scalp and the crust can be removed easily and has should be washed twice a week using mild shampoos powder forming will be routine use the

powder that's not advocated if they said mother should be able to smear the powder on the hands now then apply with the hands not to apply it in the groins neck arm and lip folds because in that

areas more amount of moisture in present and mass ratio it will result in infection care of diaper radium excessive hydration and musculation more common in the diaper area increase ph due to the

local action of fecal invasions so we should advise the patient use moist cloth or cotton ball soaked in lukewarm water to clean the area not to use wet pipes

nowadays a lot of people are using wet wipes uh better advise the patient not to use with pipes because it will cause the diaper dumplings and eat it and dermatitis in the babies

uh diaper chain should be frequent every two hours in united and three to four hours even fun diaper usually we can use mainly cloth content cloth diapers and

it should be washed in warm water and dried in sunlight thank you thank you so much mom um thank you so much madam for the

wonderful talk um each slide was a take home message and you have given us a lot of practical tips on newborn and

child skin care uh thank you very much madam uh just a question like uh regarding the treatment of animals kbs and children is it the same concentration of permethrin that has to

be used or uh is it different none same same topical pyramidal and same uh if it does not resolve same topical

and they will always handle yeah that is a very common practice these days this is the main reason for getting animals we are handling we are robotic animals but it is not we should avoid the

animals to entertain the living place and also treatment for uh this nickel dermatitis or contact dermatitis ah you should dominate this contact demonstrators we

should ask whether uh what are the common sites with like mostly nickel dominators we imported nowadays on from the any artificial jewelries and the

watch strap under that any safety pins are on that areas we will encounter nickel but constant uh we should ask the patient to avoid but we should ask avoid

that objects won't be if persistent depression we can use topical steroids okay depending on the instead exposure to anything thank you so much ma'am all this thank you beetle uh

dermatitis all that that was even new to us but uh still it is common in many parts of our state thank you so much it was very practical and very useful and thanks for making it very illuminating

thank you ma'am and thank you so much thank you mom um and to end uh that was the last topic for today's cme and i thank all the speakers

uh and all the uh the audience for uh waiting patiently until then uh because uh dermatology is always uh a very very elaborate uh topic and however many

times we uh tend to go acro and go across it we lose track that is the usual mode so uh our speakers today have made

it very elaborate very crisp and uh incremental i thank one and all uh once again and the office bearers of iap tamilnadu for having uh given this opportunity uh

thank you one and all and thanks to the audience thank you mom thank will you the cme the