Bringing basic dermatology to the pediatric medical home session 4 wrapup

Bringing Basic Dermatology Care
to the Pediatric Medical Home:
A PPOC/CHICO Learning Community
& Integration Program
Derm 1.0 Wrap-up Session
Didactic Webinar
Thursday October 27, 2016
© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu

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We have no financial relationships with commercial
entities producing, marketing, re-selling, or distributing
health care goods or services consumed by, or used on,
patients relevant to the content we are planning,
developing, presenting, or evaluating.
Off-label uses of medications will be discussed.
Disclosure

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Glenn Focht, MD
PPOC Chief Medical Officer
Karen R. Barnett, MD, FAAP
Pediatric Physicians’ Organization at Children’s
Madeleine Kuhn, MPH
CHICO Program Coordinator
Faculty
Stephen E. Gellis, MD
Program Director, Dermatology
Boston Children’s Hospital
Sophie Delano, MD
Dermatology
Sadaf Hussain, MD
Dermatology

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Learning Community Schedule
Date Content
Thursday, May 19, 2016 Atopic Dermatitis
Thursday, August 4, 2016 Acne
Thursday, September 1, 2016 Warts, Molluscum, Hives
Thursday, October 27, 2016 Wrap-up
Didactic Webinars
7:30am – 9:00am

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Coursework
• Qstream
• Case Reviews
• Follow the
instructions on the
first page
• Submit on Blackboard
or email or by fax to
Madeleine Kuhn
• Process Maps, due by
11/11/2016

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Qstream Finish Line!
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Process Map Presenters
Dr. Nelken
Andover Pediatrics
Dr. Hyde
Westwood-Mansfield Pediatric Associates

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Patient
Calls for
acne appt
or derm
referral
Front desk
schedules Appt.
within a few days
PCP/PNP
examine patient
Severe
cystic
scarring
acne
Start topical or
oral medication
F/U in 6-8 weeks
Refer to
Derm
Adjust
meds if
needed
YES
NO
What happens to
patient after
referral?
Address Acne at
well/sick visits?
CURRENT PROCESS
Andover Pediatrics

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Patient
Calls for
sick/well
visit
Front desk
schedules Appt.
PCP/PNP examine
patient including
skin exam (starting
age 11)
Severe
cystic
scarring
acne
Talk with patient
about acne and
potential treatment
options
Offer Rx that day
or reschedule for
visit dedicated to
acne
Refer to Derm
YES
NO
Start topical or
oral medication
Follow-up in 6-8
weeks to
reassess
Patient
improving
Follow-up
in 6-8
weeks to
reassess
Follow-up
in 6-8
weeks to
reassess
Adjust meds Patient
improving
YES
YES
NO
NO
NEW PROCESS

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Annual well
visit 13 and up
Questionnaire given that
inquires about acne and
desire to treat
Patient has
acne and
wants to treat
Do not discuss
Discuss and make
treatment plan
Follow up in
office in 8
weeks
Are we missing patients who might not
be ready but become so during year –
Can we give them education and let
them know about our ability to treat
effectively?
No Yes
CURRENT PROCESS Westwood –Mansfield Pediatric
Associates
Karen Halle, MD; Jen Hyde, MD; Jill
Fischer, MD; Erin Kish, MD; Helen
Lyon, MD; Sandra Ventura NP;
Meridith Liebman, MD

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Annual well
visit 10 and up
All patients receive
handout on good skin care
and basic acne treatment
Discuss acne management and make
treatment plan. Acknowledge need for
and ability to recommend changes if
initial treatment not working
Providers routinely identify
and document patients
with acne on physical
exam
Patient with
acne
Provider
educates patient and
family about calling
office if acne develops
and otc treatments not
working
Make follow up
visit in 8 weeks
no
yes
NEW PROCESS
Patient reports interest in
treatment
yes
Provider educates
patient and family
regarding availability of
acne treatment if and
when they consider
no

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Process Map Coursework Q & A
1. How will you implement your new process? What do office-staff need to
know about it and how will you train them on the new process?
We will need to develop a handout to be placed in our well child packets (both
online and in office) and make sure that the office staff responsible for these
are aware. We will need to train our providers through provider meeting and
in office memo that this handout is being provided and that documenting and
discussing basics of acne treatment will improve the care of our patients. We
will inform front desk staff of the 8 week follow up on initial acne
management.
2. Will your new process require any patient/family outreach or education?
If so , how will you accomplish the necessary patient/family education? We
will need to develop the handout and formulate anticipatory guidance for well
visit discussion on acne. We will need to educate providers on such.
3. How will you monitor that the new process is happening correctly over
time in your practice?
We will check website and packets and will monitor referrals to dermatology
for patients we could have likely managed.

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 Itchy eruption in classic areas
 Assess for complicating factors
like contact dermatitis (airborne,
saliva) and infection
 When treating, remember to
treat both the barrier dysfunction
and the immune system
upregulation
 Don't be afraid to use a higher
potency topical steroid-when in
doubt, schedule frequent follow
ups and limit quantities and refills
Atopic Dermatitis

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Atopic Dermatitis Exacerbators:
Saliva

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Cocamidylpropyl Betaine

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Fragrances and Airbone Contactants

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Atopic Dermatitis Exacerbators: Molluscum

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Atopic Dermatitis: Treatment Goals
Barrier: gentle skin care,
moisturizing creams/ointments
Immune: topical
steroids/calcineurin inhibitors

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Acne Treatment:
Benzoyl Peroxide
Initial treatment for any patient with acne:
– My preference: once daily wash
– easier to get chest and back as well
– Panoxyl 4% creamy wash (or generic) = less drying
• BP creams an alternative to entire face
• Gels can be drying

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Acne Treatment
• Mild: Benzoyl peroxide wash QD & topical retinoid, topical
antibiotic if inflammatory
• Moderate: Mild + oral antibiotic +/- OCP
• Severe: Moderate + consideration of isotretinoin if scarring or
refractory
• Isotretinoin: Best bet for curing scarring acne
– Females need to be on two forms of birth control
– Not associated with increased risk for inflammatory bowel
disease

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Acne Treatment Commandments
All acne patients should be using a benzoyl peroxide and topical
retinoid.
All patients on an antibiotic should also be on a benzoyl peroxide.
Refer to Derm early for isotretinoin discussion if scarring.
Consider OCPs in female patients with acne.
Manage expectations for results that may take months.

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Questions: Acne Complications
Discoloration
 Post-inflammatory
Hyperpigmentation and
Hypopigmentation
– Sunscreen!
– Tretinoin targets this as well
– Pulsed dye laser decreases
redness
– Chemical peels and bleaching
agents may play a role

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Acne Complications: Scarring
• Remodel and improve in
appearance over time
• Chemical peels, laser
resurfacing, surgical procedures
(subcision) may play a role once
acne is well controlled
• Tretinoin has a modest role in
the remodeling of acne scars
http://acner.org/img/care_and_prevention/acne-scars-and-pitting_2_3157.jpg

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Acne Complications (contd.)
 Keloids: aberrant scar tissue
that grows beyond the direct
area of tissue damage
 Common sites: shoulders,
chest, back, jawline
 Treatments: PREVENTION IS
KEY (treat acne aggressively)
 Intralesional kenalog (steroid
injections), radiation therapy
 DO NOT EXCISE without a
game plan!

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Questions: Acne and Oral Contraceptives
 3 FDA approved OCPs for treatment of acne:
 Ortho Tri Cyclen (norgestimate/ethinyl estradiol)
 Estrostep (norethindrone acetate and ethinyl estradiol)
 Yaz (drosperinone/ethinyl estradiol)
 For moderate-severe acne in females who have had their menses
for 1 year

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Oral Contraceptives and Acne (Contd.)
 Pertinent History that Should Be
Elicited
 Family history of thrombotic
events
 Smoking history
 (Migraine with aura)
 Thrombotic events are rare in
adolescence
 Most common side effects: nausea,
vomiting, breast tenderness,
headache, weight gain, breakthrough
bleeding

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Oral Contraceptives and Acne: Important
Consideration
 Maximization of bone mineral density
 50% bone mass accrued between 12-18
years of age
 24 month study of postmenarchal girls on
OC did not reveal osteopenia; BMD
femoral neck 4.2% compared to 6.3% in
control; conclusion was effects of OC
unclear
 Prescribing of OC based on provider level
of comfort
Fertil Steril. 2008 Dec;90(6):2060-7. doi: 10.1016/j.fertnstert.2007.10.070. Epub 2008 Jan 28.

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Salicylic acid + duct tape at all times. Goal is maceration
Pare down before treatments to get to affected keratinocytes
Cryotherapy: 2 cycles of 7 seconds with slow thaw in between
Tretinoin cream for facial flat warts, imiquimod for genital warts
May take months of treatment
Potential benefit of HPV vaccine
Genital warts red flags: Child>4-5, out of diapers with no known
non-abuse exposure route)
Wart:
Treatment

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Questions: CRYOTHERAPY
Cryotherapy Costs
 Liquid nitrogen (10L): $128.36
 Dewar (container): $200-$900+
 Stryofoam cups and cotton-tip
applicators: negligible
 Cry-ac: ~$750-800 (optional)

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Questions: Cryotherapy Practical
Considerations
 Various methods (Cry-ac,
Q-tip, Q-tip with cotton
 “10-15 second” cycle
 The margin around the
lesion correlates to the
depth of your freeze
 Complications include
blister formation,
hyperpigmentation,
hypopigmentation and
ring wart formation

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Questions: Cryotherapy Billing
 CPT codes
 17110 (Destruction of flat warts,
molluscum or milia up to 14 lesions)
 17111 (Destruction 15 or more
lesions)
 ICD10 codes
 B07.0 plantar warts
 B07.8 other viral warts
 B07.9 viral wart, unspecified
 B08.1 molluscum contagiosum
 Procedure only v. procedure and an office visit
 Follow up treatment for destruction
only: bill the CPT code only
 Destruction and addressing of other
issues: bill the office visit and the CPT

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Molluscum Treatment
• Resolves 6-24 months
• Treat molluscum dermatitis with
emollients and lower potency topical
steroids
• OTC Treatment: tea tree oil, apple cider
vinegar, tape stripping
• Rx: Cantharidin, light cryotherapy,
extraction/curettage

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Questions: Imiquimod (Aldara) for Molluscum
• Imiquimod still used by Derms and
PCP for molluscum
• Based on 2 unpublished RTC, in 2007
FDA changed imiquimod prescribing
info to state that it was not effective
for molluscum.
• Concern that relative expensive med
used when not effective

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“Newbies”
Questions on disease entities not yet
covered
• Gianotti Crosti
• Papular Urticaria
For more dermatologic conditions, stay
tuned for Derm 2.0!

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Gianotti-Crosti
Tx: Topical steroids don’t help pruritus much but lower potency (desonide 
triamcinolone) likely doesn’t hurt BID for 1-2 weeks
Resolves in weeks without scarring
Triggers: EBV, HepB, entero, CMV, RSV, echo, vaccinations
Symmetric papules on extensor knees, elbows and buttocks
Localized id reaction
Papular Acrodermatitis of Childhood

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Papular Urticaria
Tx: topical steroids, antihistamines, evaluation of home for
infestations
Can wax and wane for weeks to months
Id response to arthropod bites
Misnomer: Lesions last > 24 hours

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Diaper Dermatitis
• Irritant contact dermatitis
• Potential for secondary bacterial and fungal infections
• Typically need a multiple-prong:
– Barrier Cream
– Antifungal given risk of candidiasis
– Lower potency topical steroids (Hydrocortisone 2.5% or
Desonide)
– Antibacterial if concern for infection

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Barrier Creams
• Thicker = Better.
• If you see the rash without wiping, it isn’t thick enough
• Wet diapers  pat dry and apply more gobs of cream
• Soiled diapers  wipe off soiled portions and apply more gobs of
cream
• Vaseline, Desitin, Triple Paste, A&D.
– Basically anything that is thick and non-irritating is ok.

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Bacterial Infections
Signs: spreading erythema,
pustules, peri-anal erythema
(think strep)
Add mupirocin
BID to topical
applications. Can
be mixed with
other treatments
(antifungal or
barrier)

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Diaper Derm Mimics
• Psoriasis – Typically will improve once out of diapers.
– Should improve with basic treatments (barrier, topical barriers)
• Langerhans cell histiocytosis (LCH)
– Petechial/non-blanching, favors inguinal creases
– Similar lesions on scalp, post-auricular
– Can have visceral lesions, including osteolytic lesions and
diabetes insipidus
– WONT RESPOND TO TOPICAL DIAPER TREATMENTS

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LCH
Source: http://www.psychiatrictimes.com/allergy/can-you-distinguish-among-these-diaper-dermatoses/page/0/7

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Learning Community Schedule
Date Content
Thursday, May 19, 2016 Atopic Dermatitis
Thursday, August 4, 2016 Acne
Thursday, September 1, 2016 Warts, Molluscum, Hives
Thursday, October 27, 2016 Wrap-up
Didactic Webinars
7:30am – 9:00am
You will receive the slides, handouts, the webinar recording
and the survey via email. All course information will be posted
on Blackboard by 10/29/2016 at 5 pm.

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Your Feedback Helps Us Succeed!
You will be receiving your MOC Attestation form and
survey directly after this session
Please make sure to fax back the form with your
signature and fill out the survey. We will need this
information by 11/11 to guarantee that the credits are
added in a timely manner

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We hope you enjoyed the
course!

Thank you!
For questions please email Madeleine Kuhn,
Course Director
Madeleine.kuhn@childrens.harvard.edu

Bringing basic dermatology to the pediatric medical home session 4 wrapup

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