2024 Pediatric Pearls With Karan Lal, DO

In pediatric dermatology, it is crucial to recognize that children are not simply smaller versions of adults; their physiological responses and psychological experiences can differ significantly. Karan Lal, DO, the first and only dual fellowship trained pediatric and cosmetic dermatologist at Affiliated Dermatology in Scottsdale, Arizona, presented his top 5 pediatric dermatology pearls from unique cases he has encountered this year at the 2024 Fall Clinical Dermatology Conference for PAs and NPs. He delves into each pearl in an interview with Dermatology Times.

Pediatric Pearl #1: Do not assume what is tolerable for adults is tolerated in children.

Lal: You know, it's really funny, a lot of people, especially when you start out in training, you learn how to do things differently. So, using liquid nitrogen, using intralesional kenalog, or steroid injections all seem like easy things and seem like painless things. They usually seem that way, because we do them in adults all the time. But you really, in kids, it's really easy to underestimate pain. I've been trained not to consider those types of treatments. And I recommend the same thing to all the people that I train working with patients under the age of 12. Because even though kids look like they're very mature at that age, they still are getting exposed and learning a lot of new things, and we don't want to traumatize them in the healthcare setting, to prevent them from seeking care in the future, right? We don't want to induce fear. And I get that all the time--people will come to me and I feel like I'm the bad guy, because I have to, I come in and automatically there's fear, the alerts are up, and I have to calm them down. So I traditionally tend to stay away from steroid injections, and liquid nitrogen or freezing in kids under the age of 12. Because I think that you're more likely to induce fear than really get a reasonable outcome, and we have a lot of other good treatments for some of the things that we do use to treat those conditions.

Pediatric Pearl #2: Meyerson phenomenon is a common eczematous reaction to benign and malignant lesions.

Lal: The Meyerson phenomenon is really common. I get so many referrals for psoriasis, or tinea capitis, which is fungus on the scalp all the time. I see it more often in kids, but you can see it in adults. And most commonly, I see it with, you know, Neva simplex, which is just a type of birthmark that people have on the back of their scalp. But you can see with other benign lesions like dermatofibromas. It's also been reported with some malignant lesions like melanoma. And often people always come in thinking it's concerning. Oftentimes, it's not concerning. So, it's really a cute little pearl that if you see a scaly plaque surrounding some sort of birthmark or growth, you don't have to be concerned. It's called the Meyerson phenomenon. I'm more of a splitter than a lumper, and so I like having a name to something.

Pediatric Pearl #3: Scarring inflammatory alopecias are starting to be recognized in adolescents and can mimic other forms of alopecia.

Lal: I have learned over time that it's always good to have more data and we don't like messing with hair. It's really easy to look at something and say, "It's this." Hair is a little bit more complicated, because hair can be a lot of things. The differential for hair loss, while it's not that long in pediatric patients, the treatments vary significantly. So you can have alopecia areata, which is autoimmune hair loss that can be patchy or it can be your whole scalp. You can have trichotillomania, which I've been fooled by, which can be patchy and has a specific pattern, or it can be the whole scalp. Or you can have telogen effluvium, which is stress induced hair loss. We're also catching a lot of people with scarring forms of hair loss. So my biggest thing now is making sure that there's a lot of patients that don't have scarring alopecia, or lichen planopilaris, which I've caught now in a number of patients. It'svery important that if the diagnosis is not a slam dunk, and they're not responding and/or they're not responding to the typical therapies, that you do the 2-punch biopsies, as you would with an adult, to make sure you're getting the accurate diagnosis. Because like I said, the treatments do vary significantly and when it comes to hair, time does matter.

Pediatric Pearl #4: Segmental hemangiomas on the lower body may be associated with internal abnormalities.

Lal: This all started from a recent case of LUMBAR syndrome that I had. These cases don't come that often, but when they do you have to act on them because they're emergencies in kids. And so LUMBAR syndrome is basically any any size of a segmental hemangioma, often one that has minimal arrested growth on the lower extremity or in the genital area or in the perineal area, and making sure that you ask for symptoms. This is a case that I recently had, and I don't know why I thought about it, but I said to the patient's mom, "Do you think that this is going on inside?" It was a big hemangioma in the genital area, and the mom reported that there was some screaming and some foot jerking every time the baby would pee. I said, "I'm concerned that there might be some involvement of the urogenital tract." At this point, you want to send the patient to urology. You want to make sure before they go to urology, if you can, you get the appropriate imaging, so MRI with and without contrast of the abdomen, the pelvis, and the lower extremity if that's involved, because you can have bony abnormalities, kidney abnormalities, you can have neurologic abnormalities of the lower spine. And so you want to make sure you rule those out because those are real issues that need emergent treatment if there is an abnormality that's present. Also, it's good to have that information before You start treatment with something like propranolol to make sure you know that you're able to track the progress.

Pediatric Pearl #5: New onset eczematous reactions should alert you to think of molluscum infection.

Lal: I think it's really easy to call something eczema, and it happens all the time. We all do it, but you don't randomly just get, you know, a 6-year old or a 7-year old that hasn't had a history of eczema in the past with a new onset eczema. You can, it's just rare. And I think oftentimes what I've noticed is I get referred patients for eczema that isn't responding to treatment, and it's new onset eczema. And the patient ends up having molluscum. It's very well described that molluscum is associated with these eczematous reactions, and it'sactually just the body's way of getting rid of the molluscum with this immunologic response. So, I think it's really important to remember that if you have a kid that has new onset eczema, and they're not under the age of 2, you really want to start looking for other things. You want to look in the armpits, you want to look in the groin, you want to look for molluscum because I bet you it's there, you just have to find it. It's the molluscum that is starting to go away and it's triggering this immunologic eczematous reaction.

Reference

Lal K. Pediatric pearls. Presented at: 2024 Fall Clinical Dermatology Conference for PAs and NPs; May 31-June 2, 2024; Scottsdale, AZ