Welcome to the Don't Be Rash Pediatric Dermatology Podcast, the owner's manual for your kid's skin.
I'm your host, Dr. K, board certified pediatric dermatologist and father of two boys.
I'm here to chat with you to promote dermatological education and improve skin health in our children everywhere.
Let's get started.
Hello again. I'm excited to welcome back to the show pediatrician and star Community Health's own chief medical officer, Dr. Alicia Walty.
How's it going, Dr. Walty? Nice to have you back.
Great. I'm happy to be here. Thank you so much for having me.
Wonderful. I wanted to jump right in with a seasonal topic.
How often are you seeing kids come to your pediatrician's office for bug bites and stings?
So, it depends on the time of year, but this time of year, it's pretty consistent.
We're definitely seeing it when kids are outside more. When they're warmer, they're able to kind of be outside.
So, we see it a lot in the Spring and then during the Summer and then the Fall as much.
So it definitely depends on the weather, but all the time. Yeah.
And for the audience's sake, when we're talking about bug bites, sure, they're itchy, they're scratchy, it's a nuisance.
But like on a worldwide level, insects do some real damage, right?
Oh, absolutely. So the insects themselves aren't necessarily the problem.
It's all the different diseases that they can spread.
And so, you know, in the United States, we're a little bit luckier.
We definitely have some more serious and more significant illnesses that can be transmitted by mosquitoes outside of the United States.
It's a much, much bigger problem. And there are much more fatal, much more long term,
chronic, devastating diseases that you get with those mosquitoes.
So it's definitely kind of nothing to be laughed at. But we have our own share of illnesses here within the United States
that range from just kind of being annoying to hospitalizations and longer term consequences.
Yeah. I mean, pound for pound, mosquitoes are responsible for more deaths every year than any other animal.
Through diseases like malaria, it's crazy to think about. But it's true.
And we've had cases of malaria in the United States, down south mostly.
But certainly we've seen West Nile, Zika, Rocky Mountain spotted fever from ticks.
Lyme disease is one that's rampant in our area.
I don't know if you've seen the uptick, no pun intended, but of late.
It's been really bad coming into our offices.
And we've seen some really strange presentations of Lyme disease as well.
But now as we're getting closer to Fall, we're seeing the stinging insects get a little bit more active
as they go sort of wrapping up the summer season. They get a little bit more aggressive.
They're angry.
Yeah, they're angry. And then, of course, it's not too far away from Halloween to mention spiders,
black widows and brown recluse spiders.
Black widows are supposed to be in every state other than I think Hawaii and Alaska, last time I looked.
And brown recluse, not really in our area, but nowadays with Amazon delivery trucks,
you never know what you're going to get at your front door.
So it is kind of crazy to think about how small the world's become and how we are now sort of using technology
to figure out conditions and diseases that we probably wouldn't have otherwise had to think about.
Bug bites and stings certainly are one way that those diseases can get transmitted.
Thank you very much for scaring me and brightening the day. That's awesome. Thank you.
Yeah, it's a doomsday show. No, but for the most part, I mean, here's the good news, right?
For the most part, what are bug bites? They're just itchy, nuisance bugs, right?
And, you know, 90, and this is what I try to tell my patients, 90, 95 percent of the time, they're, like you said, they're an annoyance.
It's not going to be a problem. It's not going to get infected. It's not going to lead to any kind of infection in your body.
It's just that those five or 10 percent of the time definitely have worse outcomes.
So you want to kind of keep an eye on that. And to your point, yeah, exactly.
That's why the Gates Foundation put so much money into not a particular disease or a particular condition.
But they said, hey, if we can really work on the mosquitoes and work on mosquito nets, we're going to hit, you know, 20 different, 30 different diseases.
And we're going to have a much bigger impact. So it's actually really progressive thinking when you look at it that way.
Cool. Let's go through, since you brought up mosquitoes, let's go through sort of the usual suspects, if you will,
of what's out there that could bite or sting you and maybe talk a little bit about how they present differently in a kid or an adult, for that matter.
Any biting or stinging insect would potentially be on the list. But mosquitoes, for example, where are you going to see mosquito bites on a kid?
So anything that's really exposed to the skin, anywhere where they're outside, you're generally going to see it - arms and legs.
Older kids, you're going to see it a little bit more on their face and their neck because they're just kind of out and they're out in the grass.
They're rolling around a little bit more. Younger kids, you'll still generally see it kind of arms and legs.
You're not going to see it palms and soles. If they're wearing clothes, you know, they're wearing their t-shirt, they're wearing their shorts.
You're not going to see it too much on their trunk. You're generally not going to see it in their genitals or their privates as much.
If they have hair, you're not going to see it on their scalp as much. And they're pretty classic.
You know, there's always the kids that come in and say, I get bitten every single time and my brother never gets bitten.
Generally younger kids, toddlers, will get bit more than older kids. There have actually been some studies that have shown that.
We have no idea why. Maybe you're smarter than me, you know why. But usually younger toddler, younger elementary school kids will get bit a little bit more than older kids.
So the research I'm familiar with around mosquitoes is that there certainly are things that can attract them.
If you're an adult, know that alcohol is one thing that might be a risk factor for attracting mosquitoes up around your face and neck area.
Carbon dioxide, so exhaling. So if you're working in the yard, if you're playing sports and you're exhaling a greater amount of CO2,
that's been one thing that they've used as a potential indicator for a risk factor for mosquitoes as well.
So the idea that dusk and dawn when things are happening, that's when the bugs are out.
Sure, we all know that just from being out in our backyard.
Flies, I kind of lump in there with the mosquitoes too. I mean, same ideas. It's sun exposed or clothing unprotected areas, sitting out on the Jersey Shore, getting chewed up by the black flies or green flies.
Bees, wasps, hornets, we can kind of lump them in. Those I don't think of any real anatomical distribution except, you know, hands, right?
So somebody's reaching into something, although I guess there have certainly been cases where you drink out of an aluminum soda can that's been left on the picnic table and a bee or hornet got in there and you don't know it.
Now all of a sudden you got stung on your lip. That's happened a couple of times.
I knew growing up outside of Philadelphia, there was a girl that we were friends with who wound up getting I think it was a hornet in her eye, which sounds about like the most excruciating thing you could possibly imagine.
Yeah, definitely.
Yeah, usually when we see the bee stings, it's upper extremity, to your point. Yeah, it's usually hands, arms, things like that.
Ants, we don't see a lot of. I can't say that I've seen any in the office. That's not to say it doesn't happen, but it's probably just that they're not serious enough or they're not itchy and painful enough for the parents to bring them in.
Yeah, I think it's more geographical. The fire ants seem to be more south and you hear about them down there. Same with the chiggers. We have them up here, but it's not as big of a problem where you sit down for five seconds and all of a sudden you're covered in those little red bugs.
Flea bites, we see a ton. How about you guys? Yes, definitely a lot of flea bites.
Again, ankles like you kind of mentioned before, so definitely all around the ankles, all around the feet. Sometimes hands too from younger kids are kind of playing more aggressively and kind of up in the fur and the dander a little bit more.
But that's definitely something around the feet and lower ankles and both sides. So you're going to see it on both sides of the kids.
Yeah, I think that's a really important point. So fleas, they don't actually want to take a blood meal from a human being. They want either a dog or a cat. So they'll jump on to whatever thing is walking by them, a kid's foot or an adult's leg or whatever.
And they'll take a bite and they go, "Well, that's not what I thought it was going to be!" And then they might move a little bit and take another bite. And then they move a little bit and take another bite. And that gives that classic pattern of what we call "breakfast, lunch, and dinner!"
Sometimes there's also dessert if you get lucky, there's a fourth one. But then they realize that, hey, this isn't a dog or cat and they jump off.
And so, yeah, so I'm usually seeing flea bites south of the knees and north of the socks. So somewhere in that area is pretty good for flea bites, usually on both sides of the legs.
And if you're lucky, there's a great history that the family will give you that, yes, we have a dog or cat and yes, they've had fleas. But that's usually not what happens. You got to dig a little deeper.
And that also includes asking about, you know, maybe it's your neighbor that has a dog or cat or maybe there's a cat or dog that walks through your neighborhood and runs through your backyard.
Well, in the summer, the cold weather is not there to kill those fleas. So they could be out in the yard where your kids are playing. So, just because you don't have a dog or cat doesn't mean you can't get flea bites.
Mm hmm. Or did you have the dog and cat and the cat and dog is gone now, but the fleas are still there and the fleas are still in the room and the bedding and the clothes and stuff like that.
Great point. So say you watch your relatives dog for the weekend. That counts, right? So it's the gift that keeps on giving.
Yeah. And then I'll just throw in there under "usual suspects," which is not a bug per se. I guess it's a microbe. So you could call it a bug, but a different kind of bug is just the good old fashioned bacteria, Staph aureus, which always seems to be what people call a "spider bite."
They'll say, "Oh, this is a spider bite for sure!" And you know, it's not really a spider bite. You know, it's what a spider bites look like.
The presentation for spider bite again, usually extremities on the hands. Spiders are not seeking out human blood, right? It's more that you did something to scare them and they're reacting as a defensive mechanism and they might bite you.
If you're lucky, you'll see on the skin for a spider bite two "punctum" - two little holes - because it represents their fangs taking that that bite. That'll usually be up in the hands.
It's very, very uncommon that you would get multiple bites from one spider. It would be like in a movie. They would make a movie about that crazy spider!
So and in the right population, you'll ask a couple questions: "I hear you play sports?" "Yeah, I wrestle." OK, this is probably not a spider bite. This is probably a Staph aureus folliculitis or abscess or something like that.
And that's where the value of doing a culture on some of these pus filled bumps can really help the person figure out what's going on. And I think it's important to also really pay attention to the timeline.
And that's what I tell a lot of the students in the residency...that when someone's coming in, just because it started as a bug bite doesn't mean it's still just a bug bite or just because it's an infection now doesn't mean it didn't start as the bug bite.
And so if you're one of those, hey, we missed it or we, you know, we didn't diagnose you properly the first time there's a progression to these things.
And even if you just start as any kind of those awful just creatures that you just mentioned, it can definitely progress if it's not either taken care of or, you know, all children are somewhat.
They're all itching. They're all scratching and no children are clean. My children included. And so they're all going to change and they're all going to just be kind of creatures of habit and scratch at those things. So keep the fingernails short. Right. Yes, exactly.
And keep it - if you can, If it's not too hot - keep it covered. So keep it. If you can wear a long sleeve shirt, if you can wear pants, that's kind of one of those things that we tell them. If you're inside and there's air conditioning and you can just try to keep the area covered and the kids are going to definitely scratch it a lot less.
Well, that's a great segue. How do you counsel your families to try to prevent bug bites and stings? Just be aware of where you're going. Definitely. You can use bug repellent and insect repellent. I know we definitely recommend using things that have DEET in them unless you have a previous sensitivity to DEET or unless you're definitely younger.
So under a year, we're kind of a little bit skeptical of that. I don't know if that kind of matches up with what the DERM recommendations are, but we usually say under a year we try to avoid it a little much just because they're all skinned. So there's a little bit higher absorption. Over a year, DEET's fine.
And then just making sure that you're reapplying it. And really it's just common sense in looking. So put hair up in ponytails, making sure you're checking all the kids for different bug bites. You know, when you're taking them off, making sure you're showering when it's all done, things like that.
You kind of forget if you're just sitting out there in your yard, you're exposing yourself. And then if you're looking at what time of year it is, you're wearing shorts, short sleeve shirt, "Suns out, bums out!" that kind of thing. You might be in your bathing suit.
There's a lot of skin that's being exposed that wouldn't normally be exposed in, say, the wintertime. Maybe, maybe not. But you brought up insect repellent. So there are a bunch out there that are technically have been approved by the EPA and registered with the EPA as acceptable ingredients.
There's a bunch that are out there that could be used in kids. A couple that I just don't ever use under kids of 3 years of age. That's the oil lemon of eucalyptus and PMD (para-menthane-diol). I'm not sure if you ever come across people who use that.
But the standard line is to say, "Hey, avoid that in kids under 3 because it can be very irritating to the skin." I am absolutely a proponent of DEET. I think worldwide it's used the most. We have the most years of experience with DEET. It's been tested.
It's actually been deemed safe in pregnant women. That's a very vulnerable population. So the science around that has to be good for that recommendation to be made.
There are reports - it's very, very rare - I mean you're talking about millions of people worldwide using DEET and having only like three to 10 out of a million patients having issues with it. And the very, very serious but very, very, very rare issue could be that it's neurotoxic.
It could hurt the brain. Sometimes it's been proven that it's not even associated with the actual repellent. But other times it can be that they were exposing themselves, the patient who was affected, too much. Either they were putting it on their mucosal surfaces and they were absorbing it or they were reapplying way too often and wound up getting too much of it onto their skin.
But that DEET is still by far... We're not recommending drinking it, but you should definitely apply it to your skin. No, and don't eat it. Just put it on. Don't eat it. But people sometimes don't even realize that when they're spraying insect repellent, they might be doing it near the picnic table where the food is. Right.
So if the wind's blowing, now you contaminated potentially the food source or the water source. Or if you're a young child and you're a parent who's doing 8,000 different things at once, you got to remember, yes, it's a lot easier just to hand the kid the insect repellent and say, try to put it on yourself.
But they're going to either spray it directly onto their face, which would include the mouth, the eyes. That's increased absorption. What you want to do is put it on your hands and apply it to their skin for them. And then you're really kind of preventing that contamination from happening.
But once it's on, it's great. Now, higher levels, my understanding is higher levels of DEET only really afford longer lasting protection. And I don't know, do you have an approach to what percentage you recommend?
I don't recommend a specific percentage. I'm more attuned to and what I kind of tell the patients is to just making sure that they're reapplying and they're covering all the areas that are actually exposed.
So, you know, just don't put it just on your arms. Your legs may be out too. Your face may be out to the back of your neck is going to definitely be out. You know, kids forget that all the time.
So that's usually where I put my emphasis is just making sure you're covered and making sure that if you put it on in the morning before you start your hike, you're putting it on again. Several hours later, you don't know that's not going to cover you for the whole day. It's definitely not.
No. So what I've read is that DEET at about a 10 or 15 percent concentration will last you about one and a half hours of protection. Whereas like DEET 50 percent. So that's deep woods off. Right. So that's that's up to four hours of protection.
People don't need four hours of protection. If you're out in your yard with your kids playing wiffle ball after school or after work, what do you do out there for an hour and a half? If you're at a family picnic, well, maybe four hours then.
But I would much rather - and my recommendation to my family is - I would much rather have you use a weaker concentration of DEET that you would then reapply as needed then burdening yourself with any greater concentration that wasn't necessary.
But that's, you know, different strokes for different folks. But that's how we do it, at least in my own family. So now, do you guys ever do anything with you mentioned mosquito nets? But do you do anything with insect repellent sort of impregnated into clothing or materials?
Is that something that you've seen or I've seen it? I haven't used it myself. I haven't really seen any families in my own practice utilize it. I have to imagine that it works.
I have to imagine that someone's actually studied it somewhere along the line. I have faith in people. I'm not completely a cynic. I can't imagine - and this is just me, this is not like an AP statement. I am not speaking for anyone else -
I can't imagine that it holds up after you're actually washing the clothes repeatedly, repeatedly, repeatedly. Now, again, I'm sure somebody will send me some kind of nasty email saying that's not actually true.
But to me, it seems like I would rather have the protection as I need it when I need it in that circumstance. I think it's too easy to say like, oh, they have the shirt on and then you're not really paying attention to how much exposure you you have.
Or did you really cover the rest of the surface just because you have the shirt on doesn't mean again that you're covering the back of your neck or you're covering that bottom part where your shorts don't cover.
I think it's really just common sense. I feel like the impregnated clothes may just make it a bit too easy to not pay attention. Yeah, that's just me because I forget things.
Well, and I've never gone anywhere where there's malaria, but that's where you kind of I think of like that's where that extra layer.
And you can buy I mean you can go to any camping store in the area in the United States and you can buy tubs of what are called pyrethrins. And they're actually, I know it's kind of interesting story they're made from an extract from the chrysanthemum plant
mums right which we're starting to see now pop out for the fall and if you ever go and look at mums growing in the wild. Take a look, five seconds, take a quick look, you'll see that relative to the other plants in there there's not a lot of bugs crawling on those things
and it's sort of like a natural defense mechanism that the chrysanthemum has come up with but we've turned it into it's usually the chemical also that when you call your exterminator and you're trying to prevent bugs from coming into the home they'll spray the house with
but yes you can actually impregnate your clothing or I guess more likely it would be your tent or whatever you were using if you were camping.
And I think if I was going somewhere and I knew that it was dengue season and something like that yeah I'd probably be extra careful if I was just to your point kind of outside and doing evening sports or something like that I'm not sure that it would be worth the squeeze.
One thing I feel very strongly is I am not a fan and do not support the combination products of insect repellents with the sunscreen. We'll talk a little bit about sunscreens in the second half of this but I do want to make that point the, that the insect repellent
combined with the sunscreen can actually lower the SPF - the sun protection factor - of your sunscreen. Sort of a dilution effect but it's more than that. But on top of that, usually, again talking about the long lasting protection that DEET affords, you usually have to reapply your sunscreen way more frequently
than you need the insect repellent. Right. That makes sense. So if you're doing the combo product at the cadence that you would want to put your sunscreen on, you're actually kind of loading up the insect repellent unnecessarily so I don't love those products.
Do you have any, any thoughts on that? No, I and again I think it makes it almost too easy to, to not pay attention, I think you kind of in your head you're like oh I put it all on everything is good and you're not really going to be paying attention to that cadence to that
frequency to oh it's actually been two hours since this and four hours since that. It's, it's almost the same reason that we tell people and this is not related to bug bites but we tell people not to mix Motrin and Tylenol. It's not necessarily because they have any kind of a contraindication, they don't have any kind of contraindication but it's because people inherently then are going to be confused as to which one is four hours, which one is six hours, oh I'm going to take two Tylenol, two, like, that's the issue is that you're not able to really distinguish what you need to do more accurately so I think again if you're dunking your sunscreen, you're
you know your shirt and your, you know your bug repellent and then you're putting your sunscreen with your but like it, I just think it's going to get a little murky and you're not going to be as attentive to the actual needs.
One thing I do like about sunscreen use in the setting of insect repellent is the order that you apply it so I always counsel our patients that you put the sunscreen on first, first, very importantly, let it dry.
And then you can put the insect repellent on top of that. Now, I don't think I know of any formal study that's been done around this but the thought is that especially if you're using a physical blocker sunscreen again we'll talk about that in a little bit.
But that's sitting up on the skin. It's acting as a "shield."
And you apply exactly it's another barrier between you and the insect repellent, which is also helping to decrease the absorption. So, important part is you got to let it dry but that's probably not as practical in real life when you're trying to fight your two kids who don't want to use either of those products.
Anything and just want to get in the water or the woods. Yeah.
I think the only other point that I really did want to make is that we get a lot of parents that come in the bug bite happened, either the last night or even that day and it's very red it's very angry looking it's super itchy and, oh my gosh, it's getting worse and it's getting bigger
and it's really hard especially bees bee stings. Things like that. It's infected. Oh my gosh, I really I need an antibiotic. You need to give me an antibiotic.
I think again it's really important to remember that sometimes those things can have a lot of local toxins and a local reaction that looks super severe and some kids are very, very sensitive specifically to mosquitoes or to those bee stings.
And you're right, it looks awful, and it looks painful and it is painful and it's very itchy. It doesn't necessarily mean that it's infected, so that's where that time kind of plays into it.
So if you're coming and you're coming in the office and it's 24 hours, chances are, and I'm not saying 100% but chances are your body hasn't had a chance to actually mount any kind of an infection yet.
That's more than likely just a pretty bad, unlucky, extreme kind of reaction.
So I'd want to watch and watch that progression, but it's not likely that we're going to put you on antibiotics at that first visit that soon we're going to tell you to kind of watch it and kind of see what happens and look for more systemic signs so are you getting a fever, is it getting worse, is it spreading things like that.
And most of the time these insects are not stinging very deeply, it's the top surface of the skin because to your point they're not actually always looking sometimes with a bee sting or something like that they're really just more frightened or startled than anything else.
They're not hitting the deeper levels of your skin, they're not hitting you know in a muscle things like that where they're planting bacteria that's then going to grow and become an infection.
It's not as easy to get an infection from all of these things now. I already said children are dirty little animals and they have long nails and they are constantly with mucus and they're gross, kids are gross, I love children, they're gross. They're going to be scratching, so if anybody's going to get an infection from a bite, it's going to be a child.
That being said, it's not always a safe bet that it's infected just because it looks like it may be within that first day or so so just as hard as it is as a parent to kind of keep calm and just kind of keep an eye on it.
It may not be anything yet so just kind of try to be patient.
Yeah, I usually say after 72 hours, things should be getting better. I mean that's kind of my litmus test for. What do you counsel your patients to specifically look for as it relates to true signs of infection? What are you talking about when you're saying?
Worsening after the day, I usually say it's going to get worse that first day, sometimes even the first day and a half after that it should start getting better. I usually will also tell them to put some topical hydrocortisone on it or benadryl, benadryls or something like that.
If it gets better with those things, then generally it's more of an allergic or kind of a sensitivity reaction than it is infection. If you've got a raging bacterial infection and you take a benadryl, it's not going to do anything. It's still going to be very red, very hot, very swollen.
It may be a little bit less tender, but it's going to look the same. It's not going to change the appearance. So generally if it's not getting better and you're giving kind of the benadryl and the hydrocortisone, then it may be infected.
Everybody has phones nowadays so what I always tell people is, "Take pictures!" Take pictures. This is day one. This is day two. This is day three.
Most physicians' offices at this point you can send in pictures to your doc to say, hey, what do you think? Do you think it's getting better? Do you think it's getting worse? Here's three pictures.
You know, if it's a St. Luke's doctor, you can use my chart. Most offices have that capacity at this point. So you can always just let us know. Or when you go into the office, if you make an appointment, just bring your phone because we're going to say, is it getting better? Is it getting worse?
And to actually be able to see those pictures really helps us qualitatively to assess that. And certainly fever or other symptoms. If your kid is physically ill, we need to see them. We need to know.
Fever, chills, that sort of thing, systemically.
Absolutely.
One of the easiest, most accessible tools that I encourage the families to use is a simple black Sharpie, or any colored Sharpie for that matter, where, okay, if you were just stung within 24 hours, like you said, you're going to expect this to get worse. 72 hours, I'm saying it should be better.
Or it's certainly not getting worse after 72 hours. So I'll have many times the family draw a line around the perimeter of where the redness is. And that's, don't wash that off. Believe it on there. That's why I'm telling you to use a permanent Sharpie.
And then 24 hours from now, if that redness is spreading, okay, if it's in the 24 to 72 hours, that's expected. But after 72 hours, if the redness is streaking or moving outside of that area, I probably want to see that. How about you?
Yeah, absolutely. And you're generous. I'd probably say 48 to 72 hours.
The other thing I always say is like, how are they acting? So if they have this, you know, red hot finger and they're holding their hand, you know, up in the air and they're not using it and they're avoiding anyone touching it and they're not playing, eating, doing their thing, that's a much bigger warning sign to me than if they have a big red finger, but they're playing with Play-Doh, eating, using it, using their fork and spoon, you know, they're playing baseball, like they don't care.
That's a very different sign for me than someone who's really letting it impact what their normal life would be. Kids don't generally act over-dramatic. Some do. My kids do. But some kids generally are not going to act over-dramatic. So if you've got a toddler who's refusing to walk on his leg because he has a bug bite, that's a problem. So we need to see that.
Well, speaking of problems, when, when would you counsel patients to worry about something like, God forbid, anaphylaxis from a bug bite? What are they? What are signs that you want them to call 911? Don't, don't try to get to your pediatrician. Don't try to call your dermatologist. You call the ambulance. And if you have epinephrine, deliver it.
So what we, well, two different things. So one is if you know that you have an allergy and you feel even the remotest signs. So if you've already had an anaphylactic reaction to a bug bite or to, you know, particular type of sting or bug bite, and you feel like if you feel like you're going to fart the wrong direction, that's when you take the epinephrine. Like you don't wait. You don't try to determine. There are obviously side effects to epinephrine. You'll survive those. You know, if you wait too long, you may not. So in the terms of like risk-based,
you know, if you're not going to get the benefit, just take it. If you, if it's a new thing, you don't know for sure. You're not 100% sure. What I usually tell families is anaphylaxis means your whole body is reacting. So the minute you see something that's not related to the actual exposure. So if you get bitten on your finger and your lip is swelling, you get bitten on your finger and now you're nauseous and you're throwing up. You get bitten on your finger and you're coughing and you think maybe you're wheezing. That has nothing to do with your finger. That means your body is reacting, not just the bug bite.
You need to seek serious help. So it's generally going to be belly things like throwing up. People kind of overlook the belly part of anaphylaxis, but most kids will say, my belly hurts. I don't feel good. My nauseous. They're throwing up any kind of swelling in your face. So your lips, um, your face, your tongue, the kids will say that their throat itches a lot. They'll say that it itches or feels funny. Um, or coughing. Even if you don't know if it's wheezing, if they're coughing and they weren't before that's close enough. So you don't need hives to be an anaphylaxis.
Which some people really don't understand. But, um, I, and I think that's really critical to hit the point that for kids, GI related stuff could be a sign, the first sign of something going on systemically. So,
like you don't need a target rash for it to be Lyme. Oh, good one. There you go. Yeah. We've, I've seen about six cases now - as a department where we've talked about them - where not only did we not see the bullseye rash of Lyme,
but what we've seen was disseminated Lyme as a presenting sign without any initial rash.
Any of the early signs.
So just a systemic rash. So kind of nutty. How do you approach treating itch when it, when it's caused by a bee sting or a bite?
Um, step wise. Uh, so usually I'll start with a topical hydrocortisone. So over the counter, you don't need us. You don't need a doctor. You can just go get the 1%. That's over the counter. That will cover a lot of them.
Um, most people also have over the counter oral Benadryl. Um, just know that you're going to be a little bit drowsy.
Most about 75 to 85% of kids get drowsy. The rest of them. It's like you gave them a shot of adrenaline and don't try it for the first time on a plane.
Um, but so Benadryl, Zyrtec, something like that, that's an antihistamine, um, will generally work. We, if you're coming in to see us, um, we may go with a stronger topical hydrocortisone if they're super, super itchy.
Um, so we may do something that's either a stronger hydrocortisone or a more potent topical steroid. If we know it's not infected, um, we're not going to give you a topical hydrocortisone if we're worried that we're like on the line with an infection, because that would make the infection part worse.
Um, there are a couple of other antihistamines that we will sometimes do if the itching is very bad, um, that don't have as much of the sedating side effects, but I have more of the anti-piridic side effects.
So there's a couple of medicines that will give you for, um, itching specifically. Um, but generally the Benadryl kind of knocks you out and makes you less miserable anyway.
So it's kind of like a silver lining. Um, cold, cold compresses, uh, again, cover them. Kids aren't necessarily going to be as itchy if they don't see it and they don't know about it. It's kind of a mental trick.
Um, so it's covered. Yeah. If it's covered, they may not be as aware of it. So those are grandma tricks. Those are not things I learned in medical school. Those are like things that my grandma did. So.
Oh, so my grandma would cover us in calamine lotion. Calamine. Yeah. Can't hurt anything. Usually didn't do too, too much. Uh, I will make a point when you're talking about Benadryl, you're talking about oral Benadryl, not topical Benadryl. Yes. Yes. No, no, no, no, no. I've never told anybody ever to use it. I think it's silly actually.
Yeah. It's a, it's one of those tricks that had been played on humankind where we know not, not the active ingredient itself probably, but some of the constituent ingredients that make up topical. It'll make it worse. They're very sensitizing.
Yeah. So yeah, the alcohol is in it will really hurt. Um, oatmeal baths help a lot to, um, the Avino oatmeal baths and just generic oatmeal baths. Um, I think kids really do well with that and they think it's funny. So.
Another plug also for what not to do. Uh, I remember having friends that would put mud on my bee sting or, or saliva. Right. So spitting on the open wound is not really what we do since the civil war. So no, no, that's gross. No.
That's our third. Don't eat that. Yeah. Don't eat that. Don't eat that.
Don't eat that. Swelling. I think you mentioned, uh, can be alleviated with direct application of an ice pack. Do you do the whole rice something?
I don't usually for bites. Um, I don't think it's going to be as effective. Um, but usually cold compresses. Um, so for like injuries, we do cold and then eventually warm with, um, bites. I just stick with cold. Um, it just generally will feel better. So.
And then you alluded a little bit to the use of some over the counter pain medicines earlier, but if someone's actually having pain, what do you recommend?
Regular Tylenol, Motrin. Um, I'm using brand names, but it should probably be generic cause it's just cheaper. So Tylenol, Motrin, um, we don't ever recommend aspirin or salicylates in kids. So we wouldn't recommend anything like that, but yeah, Tylenol, Motrin, whatever makes them feel a little bit better.
Avoid aspirin.
No, we never give aspirin in kids. Never aspirin, never any salicylates. No.
Good. Now you, I think one of the most interesting points that you made way in the beginning of the show was that it can't be bug bites because little Johnny is the only one who's getting bit. How could, how could nobody else be affected by these bug bites? And, um, I don't know if you have a spiel for that, but you mentioned that the, there's some literature that maybe the younger kid in the family is at greater risk.
At greater risk from the dermatological side of things, we know that there's actually a separate clinical entity. I make that point very specific. It's not just bug bites, but there's something called papular urticaria. And this is really a hypersensitivity reaction to the bug bites, meaning your immune system is incorrectly way more than it should be revved up against whatever, whatever bit you were stung you.
And you now have this crazy immune response happening in your skin. Uh, it could be that the same exact bug bit, your sibling or your mom or dad, their immune systems figured out that the world around them is not necessarily trying to kill them.
Although it is kind of, but you know, not a, not a simple little bite.
But, um, these, these kids will come in and they'll have, um, bug bites. They're long lasting because you have to imagine the immune system got so revved up that they actually formed a lump in the skin.
And, um, it is not uncommon for those lumps to last weeks, months. I've even seen them last years.
Yeah. And it's very difficult to explain. Um, and I think sometimes people are defensive about it. So they kind of, they hear you have bugs in your home or, you know, your, your kid has a bug bite again.
And that's very much not what we're saying. It's just that again, to your point, this one child is affected more severely. Um, and it, usually we see the bug bites around. I, I usually will see the papular urticaria more like ankles and feet.
I don't know if that's something you see more commonly and sometimes elbows, sometimes elbows, but I generally see more, like I said, like kind of ankles, lower legs.
Um, and again, I think people kind of have a defensive response to it and that's not at all. We're, trust me, we're not judging. We totally get it. And the kids feel miserable. They're generally very itchy.
Um, a lot of times we see these kids when they have actually done some damage to their skin, like there's some change to the color in their skin or some thickening of the skin, um, because they've just scratched and scratched and scratched and scratched and, um, the parents will come in and say, listen, there aren't any more, but it's just not getting any better.
Like we're not getting more bug bites, but these are still there and they're, they're very firm. Um, and they're, you, you almost want to pick at them. They're, they're annoying, um, for these little kids. And if you're a toddler, that's irresistible. You're going to just keep going for it. Um, and I do tend to see it in younger kids. I don't, I don't actually know if that's common or not, but I tend to see it more in the toddler age.
So, all right. So we're going to switch gears a little bit, but not too much because it's still sort of a summer related topic. But, uh, for the second portion of today's show, I'd love for us to focus Dr. Walty a little bit on sun safety, sun protection and sunscreen.
I have given up talking about skin cancer to my own boys. Okay. They don't care. They could not care one iota about something that they have no concept of.
Which is developmentally appropriate, especially in younger kids and especially in teenagers. They're not supposed to care about those risks, which is why they have parents.
Um, which is why you need to be the one that's looking out for them. Um, because it is one of the very, very few things that we can actually do to reduce cancer in our children. So.
Actually, I'm going to say my advice is not to start with sunscreens. I sunscreen for me is third or fourth tier as it relates to sun protection and sun safety. For me.
Okay. It starts with being smart in terms of your own exposure, right? Like if you can avoid the sun at the strongest, most intense times of day, uh, that you're being exposed to it.
That's one of the best things you could do right out of the gate. One of the questions that I get a lot, um, is, you know, how, how young can I use, um, my sunscreen on my kids? So these are very young babies. These are six, seven, eight month old kids.
And is it safe to use sunblock on them? And I will say, I mean, if you have to, I guess I said, but I really would prefer you just don't put yourself in that situation. You bring it to your point.
Don't put them in that situation. You know, put, bring some shade, bring an umbrella, keep them somewhere where they don't need the sunblock. Um, obviously if you need to, I'm going to say yes, because I would prefer nothing over a sunburn, but I would really prefer if those kids didn't have to be out in the sun at all.
Period. Um, and, and I think that really backs up what your point is, is, is use your common sense. There's no amount of sunblock or sun protective clothing or reapplying your sunblock that is going to prevent you from having damage to your skin.
If all you are doing is sitting outside at the beach, at the tournament, you know, doing whatever from sunup to sundown repeatedly, there's, there's just not, it's going to happen no matter what you do.
Even the most tyrannical lifeguards at the Jersey shore where they have rules about what you can do at the beach. I've never seen them. I've absolutely seen them say no enclosed tent structures where you can zip it closed and no one knows what's going on in there.
But I've never seen them say you can't bring an open sort of canopy tent for your kids to sit under, you know, no, they, especially for little kids, um, they're usually very good about that. And even if you have to just go old school and get the umbrellas, the regular beach umbrellas, um, that's, that's completely fine.
They will never stop that even to your point as sports events and things like that. Most, um, chairs now you can get chairs that have kind of the top options. All baby strollers have some option at some point for kind of putting up even, even just like the regular walking strollers have some option for a cover.
Yeah. And then it's good segue into what do I, what do I do next after being smart about my exposure? Uh, it's clothing for me. So it's, it's sun protective clothing. That's UPF rated clothing where the weave and the material that's being used provides a level of sun protection.
And that regular old cotton, especially when you get it wet, just simply doesn't do. So it's not just having a t-shirt on it's having the right kind of material on that will block some of the sun's rays. Most of the stuff's at UPF rating 50, which is sort of analogous to an SPF of 50.
And that's pretty darn good. The neat thing about it is it's on, it's on, it's working all the time.
Does it last? Is your, does your experience that it lasts after getting back from the leave or no?
It lasts until the weave. If you, if you, if you're wearing it for 20 years, you know, you probably should have retired it 19 years ago. But the point is if it's in good shape and you're taking good care of it, it's working.
So it's not something that just wears off. Uh, it's not a chemical that's applied to the clothing that would wear off.
It's the clothing itself.
It's in part the clothing itself, the way it's weaved and, um, I mean, you can do some additives. There are some things that you can put in your clothing that offer an additional layer of sun protection.
But honestly, I've, I've never needed them or bothered with them. It's just a good sun protective shirt and they used to be truly dorky looking. I mean, there's no way around that, but, um, you would look like the, the guy, you know, there's the dermatologist son, right?
That's the only person on the beach who could look that stupid.
But they're, they're not now because I get that. So I get those for my kids. Um, they, and they sell them in package deals at Walmart, you know, with the board shorts, they sell the shirts now and they do have some degree of protection.
They have a lot of them now.
They're vented. So they're more breathable. The air as the, you get a nice little breeze, it goes right through the clothing, cools you off. You're not, you're not hot in them.
And I got to say wide brim hats. That was the toughest sell. They're back in style. Now that, you know, you can go to any sporting goods store and you'll find sort of the Gilligan's Island wide brim hat is really kind of cool for kids right now.
And even more affirming or reaffirming, I got for my father's day gift this year, one of those big straw. Uh, I mean, they look like, you know, I don't know. It looks ridiculous. Like if I was wearing this by myself without anybody else on the beach wearing one, I would obviously be that guy.
But no, the dads out there are wearing these sort of straw, wide brim hats, total shade for your head, your neck. And I'm not alone out there anymore. So it's kind of neat. But that's, that for me is the next step.
And here's the one that I always forget until recently. Eye protection. So sunglasses. I never wore, I don't like stuff sitting on my face.
Now as I've gotten older, I have to wear reading glasses. So I've had to suck that up, but I, I am not the kind of person that would want to go outside and wear sunglasses.
Be unless I had to, and now I have to, because when I got out to San Diego a long time ago, 2006, I think I went out there. I had this feeling like something was in my eye, like a foreign object, a gritty sand piece of sand or something.
And it just kept happening. I knew it wasn't that, but I went and saw an eye doctor out there, an ophthalmologist. And he took one look at me and said, "You've got sun damage in your eye."
Really? I grew up in Pennsylvania, New Jersey. I didn't go to the beach much. Like how is that possible? Because everybody has this, but you got to wear sun sunglasses. And I just had never done that.
But from that day forward, it's become sort of a part of my life. And hopefully I've at least stopped the progression of that, that damage.
I will also say, I texted Dr. Krakowski this summer. Well, while I was on the beach and said, should I be putting the chapstick that has sunblock in it on, or is that just a marketing hoax?
Because I've never had a sunburn on my lips and I feel like this is just, I feel like I'm a sucker right now. And he said, indeed you are and you don't need to put that on. So I just wanted everybody to know.
For a regular, yeah, for a regular day. But now listen, you're going to Death Valley. Okay. No. Yeah. You probably need to protect your lips and there's probably better stuff for your lips than good old chapstick.
It was not in Death Valley. I was not. But see, even I had something to learn. So that was good.
Yeah. I mean, there's what you read in a textbook and then there's what's practical for, I guess, what's practical for physicians' families and then what's practical for normal human beings.
And that's not always the same.
No. And I tell that to all of my families is that there's the book and then there's you have to survive through the night. And those are often very, very different things. So, yeah.
Well, after being smart about when you're out there and after sun protective clothing, that's when I get down to the sunscreen question, right? And the real important point to understand is just because you're wearing sunscreen or put it on one time,
whatever you've chosen, we haven't even gotten to that stuff yet, but whatever you've chosen, there's a good chance. I'm going to say 90% chance, just empirically. I'm making that up.
But there's a 90% chance that you're not putting on the right amount of sunscreen. And most people, they don't put too much on. They're putting way too little.
Yeah. And you miss a spot. And you miss a spot. You always miss a spot. Especially if you're doing the sprays.
You definitely missed a spot. If you're spraying a sunscreen, which is okay. I mean, I use that stuff on my kids' legs because it's one of the things they'll tolerate and it's quick for reapplication. But if the wind is blowing, you're not getting that on there like you think you are.
So if you apply it, at least put it on with the spray, concentrate it, and still use your hands to apply it evenly over an area. But even just the good old sunscreen lotions that you can buy and have been able to buy for 30 years, we know that you've got to use about an ounce of sunscreen.
An ounce. To use a horrible analogy, that's a "shot glass" size worth of sunscreen. Imagine that in your mind. That's about each application. And people who've looked at it know that adults, this is adults, let alone kids, no kids putting on the right amount.
I can guarantee that. But most adults are putting on only about a quarter of that amount. That's a little scary, right? You're underutilizing what you're kind of believing is protecting you that day.
Now here's the real crazy thing. I can tell you from just how long my sunscreen lasts in the summer that I'm not using that much because I should be running out much faster.
Well, you're right. And if you think about the fact that you typically will need to reapply your sunscreen about every two hours, that's kind of the going rate that we tell people that they should be thinking about, especially if you're tallying off.
Anytime you come out of the water, you should reapply. But anytime you even just kind of wipe your face because you're sweating or whatever, you're removing some of that sunscreen.
So two hours is pretty legit. I got this off the internet. For a family of four, this would mean that a six ounce bottle of sunscreen, which is the standard issue kind of purchase, would last you only about three to four hours.
Right? I can guarantee I am guilty myself of having bottles of sunscreen that have lasted not one but two summers back when I was a teenager.
Oh yeah. I've had to check expiration dates. Yeah. Oh yeah, no, that's a problem.
Let alone a bottle a visit to the beach, basically is what you're saying, right?
Not even. Yeah. Like a half a day.
So we're all guilty of that. And it's entirely...
Well, that's validating.
That's very invalidating.
So, okay. So when you're talking sunscreens, do you have an approach to them?
I do have an approach, actually. So my one son is a surfer, so he's out on the water. He uses zinc because it's really the only thing that will work for him. So he does put zinc on his face, but he does have a...he's got a wetsuit.
So the rest of him is for the most part covered, but he does use zinc on his face. For the rest of us, we use regular, typical chemical sunscreens.
And it's...if the approach...if by approach you mean tackle, I use kind of like a...I use the tush push to try to get my kids down, and I try to do that.
But usually we do...and this is completely personal preference, but I try to do a stick on their face because I find that it's easier to actually get in the nooks and crannies, and I don't miss as much.
And then the rest of the...I either use...I'm guilty of using the spray because again, to your point, it's easier to get on them, or I use a cream for the rest of them. They do...both my kids will wear shirts, the sun shirts, so that's a little bit easier.
That's a win.
It is. It is. They use the sport ones, the no-sting ones, like the no-drip sweat ones. And the kids I always make wear 50. I'm not going to say I do the same for myself, so you can judge me, but you should always wear 50.
That's my party line as well. You mentioned zinc. So zinc oxide, titanium dioxide. Those we would kind of classify as what we would call mineral sunscreens.
These are the ones that, for lack of a better explanation, kind of just sit up on top of your skin. They act as a shield, reflect the sunlight off of you, rather than absorb the energy and prevent it from going quote unquote deep into your skin.
You might hear these called physical blockers or sun blocks. The FDA, the Food and Drug Administration, actually kind of stopped the use of the term "sunblock" because nothing truly blocks all the sun.
What's the good of the mineral or physical sunscreens? As you pointed out, Dr. Walty, as soon as you put them on, they're working. And they really are hard to get off, which is a good and a bad, right?
So for your surfing son who's getting rolled in the waves and getting beat up out in the ocean, it's not going to come off as easily as maybe another product might.
But I've always had the most difficult part for me for a sunscreen is when I get home from the beach or shore and I got to get the stuff off me. Yeah, it's two or three soaps.
It's very hard. And his is purple. They tend to be white, purple, red. They tend to be colors. And so he is colorful for a few days.
So that's like the old 80s Zinca. Yeah, that stuff's great. And the other good thing about it is if it's on, you know it's on because you can see it. You look like if it's the white color, you look like Casper the friendly ghost.
So you know if it's on, it's on. But getting it off, I find, is always the real hardest part. There are some clear options that have and some tinted so it looks more like correct skin of color, that sort of thing.
But they're a little bit more expensive and maybe a little harder to get. The chemical sunscreens are the ones that you put on your skin usually about 20, 30 minutes before you intend to go out because they have to have some time to work in.
I recommend that you do the 50 SPF or higher. But if you look at the data for that, it's not a linear progression of an SPF, which by the way stands for sun protection factor.
So it's the amount of time that you have that you would that what you normally would burn, the SPF gives you that multiple of time to probably not burn when it's on.
Around 30, it's really, it starts to plateau. You're not gaining a tremendous amount of benefit. So 30, if you just had to do something, 30 or higher would be fine.
I say 50, I even pushed to 75 or 100 because we know you're not using the amount of sunscreen that they used in a lab to get that SPF number. That's the important part.
That makes sense.
Yes. So that's a lab value. That's not if you just put your finger into the bottle and touch your face, that doesn't necessarily mean that area is going to have SPF 30. You have to apply it at the right thickness, which is like 2 milligrams per centimeter squared, if I remember correctly, from the FDA.
That's like a real lab value that you have to follow to get to that SPF. And nobody, as we as we already discussed, nobody's doing that. So if you use the thought is if you use a higher SPF and you know that you're going to get less.
Well, maybe if you use the 75, you get you'll get a 50 or if you use the 50, you'll get a 30. If you use the 30, you might not be getting 30. That's kind of the thought behind behind that.
The eight oil is not that's
eight mixed with suntan oil is not the way to go.
Baby oil. I was going with baby oil.
Baby oil is not the way to go. And you mentioned SPF eight actually saw a beach umbrella. There was one study that I know that looked at that a beach umbrella gives you about an SPF eight. Interestingly, I didn't know that.
Yeah, there's there's some reflection off the sand and stuff.
I didn't know that. Okay. Yeah, I just assumed if I sat under the umbrella, I was safe.
No, no, you you are still getting some sun. And that's, don't forget the sand and reflective surfaces like concrete and snow. Right. So if you're skiing, no, I know. Yeah, I've gotten reflection back up.
And this, and this area under your neck is not an area of your body that's normally getting sun. So if that reflections happening, you can get a sunburn much easier on that area than say for your example your forearms where they've already gotten a little bit of resistance to the sun.
Oh, I'm in trouble. Yeah, I, that's all I'm saying. It sounds like you're doing all the right things. It's the guy that runs like you said that has his significant other sprays back and jumps in there. Are you using a sunscreen that is deemed water resistant?
Is that something that you will use? Yes, yes, of course. Yeah, because we're yes. Yeah. So because they're also sweaty little monsters. So yes. Yeah. So typically there's two designations there. There's a water resistant 40 minutes and water resistant 80 minutes.
Again, the FDA. One of the good things the FDA has done for sunscreens is that they removed the term "waterproof." Again, no such thing. You can't put sunscreen on one time and sit in the ocean for six hours boogie boarding all day and expect that that's still working.
So they gave you a 40 minute and 80 minute mark to kind of use as a reset point. Now that time period comes also from a lab test where they use sort of a whirlpool a whole bunch. Yeah, and they will they will put that on and you will put your arm into the whirlpool.
And that's how they test that. So if it's got a 40 or 80 minute designation, you know that that's actually been tested and will hold up. Ultimately, I had kind of have had to just get to the point where I will use a sunscreen on my kids that they'll tolerate.
And as I I think we have probably three, I won't say the specific products, but three approaches, two of which sounds like you use as well. We'll use the stick for the face and neck. Yeah, before lacrosse games. We'll use the spray for the arms and legs.
And then because the backs of their necks really do take a beating. I'll be using either the stick on the back of the neck or the stick with the traditional sunscreen lotion on that area. I like the sticks a lot, especially like I said for the face because I can control it more.
I can get kind of the nooks and crannies around their eyes, their nose. I just think it's a little bit easier to control. When we do use the sprays, I try to get the sprays that come out that are a little thicker so you can see where it is.
I know they even actually make some that come out with a color for younger kids. I think it comes out purple or green or something so you can actually see where you're spraying.
Those are fairly expensive though, so I'm not super keen on that. But yes, again, for the bigger areas, for backs and stuff like that, then yeah, we're using the cream. I will also say, and again, I'm not going to use any kind of brand names, I will say that younger kids, babies and toddlers, I've had a ton of visits during my career where parents have used brands that you would think by much of the time that they're born.
I would think by marketing and names are specifically for babies and younger kids, and those are the worst. Those create a ton of rashes and sensitivities, and I see more reactions to those than I do for kind of the no-name generic Walmart CVS.
I almost never see kids that have problems with those. It's usually, honestly, the more expensive kind of baby specific, and I'm not talking about the hypoallergenics, any of that, but the brands that are specific to younger kids that I do see a lot of kids having reactions to.
Yeah, that's a huge part of my life is seeing kids who will come in with sun-related conditions, and I'm telling them if it's something like, God forbid, lupus or dermatomyositis where the sun can make that worse, I'm telling them to use sunscreen as part of their everyday regimen.
The thing that I'll sometimes counsel them on, or at least it's always in the back of my mind, is there is this phenomenon known as photo allergy. So a chemical that you would put on, and if you could live in a closet, would never cause a problem.
That same chemical when exposed to the sunlight and UV radiation can morph, change chemically, and it's kind of like we don't really talk about it too much, but one of, if not the most common chemicals that undergo photoallergenic transformation are actually sunscreen, specifically some of the avobenzone-type materials that are out there.
So it's not impossible that someone actually is getting an allergy from their sunscreen, and it's not impossible that they're getting that allergy only when they go out in the sun. So it can be a real trick to figure that one out, and then you lost the therapeutic alliance with the family because you've been telling them to use the sunscreen, and now their kid's got an allergy to it, so it's pretty tough.
And so on that topic, reminding families in the summer when kids come in and they do need antibiotics or just are on kind of some baseline meds, especially like with acne and kids that take stuff every day, that they're now more photosensitive.
So even if they could kind of get away with not using a sunblock sometimes, we would never recommend that, of course, but if they don't, now they do. So just kind of making sure that they're aware of that.
And just in general, I find that the mineral sunscreens are way less sensitizing than the chemical ones. Yes, very much so.
My go-to is to recommend, if there's any concern, get a mineral sunscreen and avoid those chemical ones that have to absorb into the skin.
It's the same as anything. They don't smell good and they don't look pretty and they're not pretty flavors and smells and colors, so generally they're going to be more well received.
Well, with that, I'd like to thank Dr. Walty for joining me today to talk about bees and stings and sun protection and sun safety.
Always a blast to hear from you and get your perspective. Thanks so much, Dr. Walty.
Every time you ask, I will probably say yes. Thank you so much.
Probably.
Probably. Depends on the topic. Depends on the topic. I said yes to fungus, so here I am.
All right. Have a great day.
Thanks for tuning in to this episode of the Don't Be Rash Pediatric Dermatology Podcast.
I'm your host, Dr. Andrew Krakowski. Don't forget to subscribe to our show on your favorite podcast platform and check out Don'tBeRash.org for more information.
A special thank you to our nonprofit sponsor, the St. Luke's University Health Network, for making this episode possible.
Until next time, remember, "Keep calm and don't be rash!"