WEBVTT 00:00:02.320 --> 00:00:05.080 Welcome to the Don't Be Rash Pediatric Dermatology 00:00:05.080 --> 00:00:07.679 Podcast, the owner's manual for your kid's skin. 00:00:07.839 --> 00:00:10.820 I'm your host, Dr. K, board -certified pediatric 00:00:10.820 --> 00:00:13.640 dermatologist and father of two boys. I'm here 00:00:13.640 --> 00:00:15.839 to chat with you to promote dermatological education 00:00:15.839 --> 00:00:18.859 and improve skin health in our children everywhere. 00:00:19.480 --> 00:00:29.140 Let's get started. Welcome to Don't Be Rash, 00:00:29.339 --> 00:00:31.440 the pediatric dermatology show, coming to you 00:00:31.440 --> 00:00:33.399 from beautiful, historic Bethlehem, Pennsylvania. 00:00:33.719 --> 00:00:36.280 On today's show, "The EYES Have It!", we're casting 00:00:36.280 --> 00:00:38.799 our eyes on a new horizon and exploring the intersection 00:00:38.799 --> 00:00:41.219 of kids' skin conditions and their relationship 00:00:41.219 --> 00:00:44.200 to eye issues. In the first half of the show, 00:00:44.340 --> 00:00:46.579 we will discuss some common inflammatory skin 00:00:46.579 --> 00:00:49.299 rashes, such as eczema, psoriasis, and allergies, 00:00:49.460 --> 00:00:51.700 and learn how these conditions can affect your 00:00:51.700 --> 00:00:54.700 children's eyes. Then, in the second half of 00:00:54.700 --> 00:00:57.200 the show... we'll discuss how certain skin-specific 00:00:57.200 --> 00:01:00.259 medications and infections can affect your children's 00:01:00.259 --> 00:01:03.600 vision. Joining us today as our guest co -host 00:01:03.600 --> 00:01:06.019 is board-certified pediatric ophthalmologist 00:01:06.019 --> 00:01:09.700 Dr. Robert Kitei. Dr. Kitei is a tremendous asset 00:01:09.700 --> 00:01:12.000 for our St. Luke's Health System, and I'm going 00:01:12.000 --> 00:01:14.540 to wave HIPAA here and share that he also takes 00:01:14.540 --> 00:01:17.319 exceptional care of one of my own sons and my 00:01:17.319 --> 00:01:20.379 own mom. Dr. Kitei has helped thousands of kids 00:01:20.379 --> 00:01:22.579 and adults and has worked through the philanthropic 00:01:22.579 --> 00:01:25.540 Kaskey Foundation, works at even a higher level 00:01:25.540 --> 00:01:28.799 for the benefit of the public good. Welcome, 00:01:28.900 --> 00:01:30.799 Dr. Kitei. Thanks for joining me today for what 00:01:30.799 --> 00:01:33.280 promises to be a very EYE-opening experience 00:01:33.280 --> 00:01:35.640 for the both of us. I have lots of questions 00:01:35.640 --> 00:01:38.640 for you. To start us off, I'm hoping you might 00:01:38.640 --> 00:01:40.760 be able to explain a bit of the overlap of our 00:01:40.760 --> 00:01:43.500 two clinical worlds. How often is it you're seeing 00:01:43.500 --> 00:01:45.799 kids coming into your office with eye problems 00:01:45.799 --> 00:01:48.079 when they also have concurrent skin conditions? 00:01:49.180 --> 00:01:51.340 Yeah, plenty of times. I mean, a lot of things 00:01:51.340 --> 00:01:54.140 that affect the eye are going to affect the skin. 00:01:54.680 --> 00:01:57.579 Because embryologically, the eye is made from 00:01:57.579 --> 00:02:00.859 ectoderm. And ectoderm is what the skin is made 00:02:00.859 --> 00:02:03.420 from. And a good portion of the eye is also made 00:02:03.420 --> 00:02:05.640 from that. So there's a tremendous interplay. 00:02:05.719 --> 00:02:08.319 A lot of things that infect the skin can infect 00:02:08.319 --> 00:02:11.639 the eye. Inflammatory conditions that affect 00:02:11.639 --> 00:02:14.539 the skin can affect the eye. Allergic conditions 00:02:14.539 --> 00:02:17.680 can affect the eye. And lots of congenital anomalies 00:02:17.680 --> 00:02:21.090 of the skin. body and face can also have impact 00:02:21.090 --> 00:02:23.889 on the ocular tissues. So we've worked together 00:02:23.889 --> 00:02:27.990 a lot and see a lot of the same kids with a lot 00:02:27.990 --> 00:02:29.909 of different problems involving those organs. 00:02:30.449 --> 00:02:33.490 Most of the time, you and I seem to cross intersections 00:02:33.490 --> 00:02:36.449 with vascular lesions. So things like infantile 00:02:36.449 --> 00:02:38.990 hemangiomas and port wine birthmarks, we've worked 00:02:38.990 --> 00:02:40.710 together closely in that, but also some genetic 00:02:40.710 --> 00:02:43.449 skin conditions where absolutely things overlap. 00:02:44.210 --> 00:02:47.650 More and more I'm hearing in the news and within 00:02:48.219 --> 00:02:51.139 medical journals, they're seeing that inflammatory 00:02:51.139 --> 00:02:54.979 skin conditions such as psoriasis or eczema are 00:02:54.979 --> 00:02:57.460 linked now to much more systemic involvement. 00:02:57.560 --> 00:03:01.060 So cardiovascular issues or metabolic issues. 00:03:01.300 --> 00:03:04.120 And I think part of that is coming to the surface 00:03:04.120 --> 00:03:07.770 that the eyes are involved in that as well. Yeah. 00:03:07.830 --> 00:03:10.050 I mean, it's all connected. It's all connected. 00:03:10.169 --> 00:03:13.990 If you have different abnormalities in your DNA 00:03:13.990 --> 00:03:15.889 that predispose you to different inflammatory 00:03:15.889 --> 00:03:17.729 conditions, they're going to affect the eye. 00:03:17.889 --> 00:03:21.789 Sometimes we see uveitis, scleritis, and different 00:03:21.789 --> 00:03:24.389 things that can really be disabling or sometimes 00:03:24.389 --> 00:03:27.210 be kind of minor. It just depends on the patient. 00:03:27.409 --> 00:03:29.449 Well, there's a lot of itis mentioned when you're 00:03:29.449 --> 00:03:32.270 talking about ophthalmology. So most of this 00:03:32.270 --> 00:03:33.969 interview is going to be me trying to get you 00:03:33.969 --> 00:03:36.020 to explain what some of these things are. And 00:03:36.020 --> 00:03:38.960 also, am I supposed to be able to see that with 00:03:38.960 --> 00:03:41.340 my own eyes and know that it's there when I refer 00:03:41.340 --> 00:03:44.060 my patients into you? But let's take the one 00:03:44.060 --> 00:03:46.319 that probably I see the most in my clinic as 00:03:46.319 --> 00:03:49.539 a skin condition, which is eczema or atopic dermatitis. 00:03:49.659 --> 00:03:52.900 And just for the audience's sake, we're talking 00:03:52.900 --> 00:03:55.780 about what's called a chronic and remittant, 00:03:55.819 --> 00:03:58.599 meaning it comes and goes, flares and resolves. 00:03:59.099 --> 00:04:02.620 dry, itchy, red skin rash that can affect really 00:04:02.620 --> 00:04:04.419 any part of the body. It certainly can affect 00:04:04.419 --> 00:04:08.360 the eyelids and the face. But how do you see 00:04:08.360 --> 00:04:11.419 atopic dermatitis kids present to your clinic? 00:04:12.060 --> 00:04:14.780 Yeah, most often they've been treated by their 00:04:14.780 --> 00:04:17.160 pediatricians or family doctors for a little 00:04:17.160 --> 00:04:20.620 bit. Sometimes the feeling was they had conjunctivitis. 00:04:20.660 --> 00:04:23.500 Other times the doctor felt that they had allergic 00:04:23.500 --> 00:04:26.500 conjunctivitis. They may have been given an antibiotic 00:04:26.500 --> 00:04:29.220 or an antihistamine topically to use for a little 00:04:29.220 --> 00:04:31.949 bit, and the kid is still suffering. Kids have 00:04:31.949 --> 00:04:35.129 tremendous immune responses, even if it's autoimmune 00:04:35.129 --> 00:04:38.569 response, and they really just need cortisone 00:04:38.569 --> 00:04:41.769 drops most of the time, prednisone drops, to 00:04:41.769 --> 00:04:44.129 calm down the inflammation, at least short term. 00:04:44.329 --> 00:04:47.230 It's not good to stay on those long term, but 00:04:47.230 --> 00:04:49.389 short term, it's the way to get a child feeling 00:04:49.389 --> 00:04:52.430 better. faster because they're really miserable. 00:04:52.569 --> 00:04:55.329 Their eyes hurt, they're shying away from light, 00:04:55.470 --> 00:04:58.949 they're hard to examine. And it's a chronic intermittent 00:04:58.949 --> 00:05:01.810 condition. It really is very disabling because 00:05:01.810 --> 00:05:04.990 they can't read, they don't want to play, all 00:05:04.990 --> 00:05:08.329 that. And so I normally will see a kid sitting 00:05:08.329 --> 00:05:10.189 across from the room. We walk in, you can tell 00:05:10.189 --> 00:05:13.449 almost instantly, this guy's got eczema, sure, 00:05:13.550 --> 00:05:15.949 everywhere. But then you can also see that they're 00:05:15.949 --> 00:05:19.850 suffering from some sort of comorbidity, we would 00:05:19.850 --> 00:05:22.329 say. So an associated condition like hay fever 00:05:22.329 --> 00:05:24.709 or allergies with the atopic dermatitis. For 00:05:24.709 --> 00:05:27.029 me, the biggest clue to that are what, well, 00:05:27.089 --> 00:05:28.910 I don't know, we're going to use dermatological 00:05:28.910 --> 00:05:30.790 terms and then you correct me if I'm using it 00:05:30.790 --> 00:05:33.230 incorrectly. But what we would call "allergic 00:05:33.230 --> 00:05:36.170 shiners," this concept that you would have this 00:05:36.170 --> 00:05:39.389 almost pinkish purplish circle around usually 00:05:39.389 --> 00:05:43.110 the lower portion of the cutaneous eyelid. It 00:05:43.110 --> 00:05:45.089 looks like you got punched. That's why they call 00:05:45.089 --> 00:05:48.889 it a shiner. Dennie-Morgan lines or Morgan-Dennie 00:05:48.889 --> 00:05:51.250 lines, depending on who you ask. But these sort 00:05:51.250 --> 00:05:53.170 of extra little creases that you can see in the 00:05:53.170 --> 00:05:56.509 eye, I've been told it's from edema or swelling 00:05:56.509 --> 00:05:59.750 local from from usually from rubbing is is that. 00:06:00.160 --> 00:06:03.040 accurate yeah yeah it's from edema and from the 00:06:03.040 --> 00:06:06.079 resolution the cyclical resolution of edema that's 00:06:06.079 --> 00:06:08.160 where you get the lines from but their eyes are 00:06:08.160 --> 00:06:10.399 always swollen they rub them that makes it worse 00:06:10.399 --> 00:06:13.259 they're irritated you see flaking of the skin 00:06:13.259 --> 00:06:15.620 it's a really characteristic appearance and like 00:06:15.620 --> 00:06:18.079 you when you walk in the room you can kind of 00:06:18.079 --> 00:06:20.540 figure it out. But it can happen at any season. 00:06:20.600 --> 00:06:23.680 It's not just, you know, in late March or April. 00:06:23.819 --> 00:06:27.180 It's not just in September. It's any time. Usually 00:06:27.180 --> 00:06:29.540 the kids have, you know, a history of eczema 00:06:29.540 --> 00:06:31.620 as a little baby, you know, behind their knees, 00:06:31.720 --> 00:06:34.480 intertrigenous areas and things like that. But 00:06:34.480 --> 00:06:37.259 you look at them and you can just see how unhappy 00:06:37.259 --> 00:06:39.620 and uncomfortable they are. You know, they've 00:06:39.620 --> 00:06:42.220 been given a drop or two, a topical antihistamine, 00:06:42.279 --> 00:06:46.180 it's not working. And then the family doctors, 00:06:46.300 --> 00:06:47.730 pediatricians, pediatricians will send them on 00:06:47.730 --> 00:06:50.949 to us and we universally will treat those kids 00:06:50.949 --> 00:06:53.990 at least for a short while with topical prednisone 00:06:53.990 --> 00:06:56.689 drops to make them feel better really in a couple 00:06:56.689 --> 00:07:00.050 days they start feeling better that's uh it's 00:07:00.050 --> 00:07:03.829 amazing so yes so For the audience that was concerned, 00:07:04.089 --> 00:07:05.750 because they've heard us say on other shows, 00:07:05.930 --> 00:07:09.069 that we really try to avoid oral prednisone for 00:07:09.069 --> 00:07:11.470 the management of atopic. Can you talk a little 00:07:11.470 --> 00:07:15.170 bit about how safe topical prednisone is delivered 00:07:15.170 --> 00:07:17.230 into the eye for a couple days here or there? 00:07:17.410 --> 00:07:19.649 We're not talking months, right? Yeah, yeah. 00:07:19.709 --> 00:07:21.449 A couple days here and there, a couple weeks 00:07:21.449 --> 00:07:24.470 here and there. The most important thing is that 00:07:24.470 --> 00:07:27.589 pediatricians and family doctors and derms don't 00:07:27.589 --> 00:07:31.680 prescribe steroids because sometimes... it can 00:07:31.680 --> 00:07:34.639 masquerade. Their inflammation of the eye is 00:07:34.639 --> 00:07:37.639 really herpetic, and it's masquerading as something 00:07:37.639 --> 00:07:40.480 else. And also, the treatment with prednisone 00:07:40.480 --> 00:07:45.800 can make a quiescent herpetic condition manifest 00:07:45.800 --> 00:07:49.689 itself, and that happens. a lot. So you have 00:07:49.689 --> 00:07:52.050 to be really judicious, but kind of judiciously 00:07:52.050 --> 00:07:54.310 bold in using them to make the kids feel better, 00:07:54.389 --> 00:07:56.850 but you monitor them. There's also an uncommon 00:07:56.850 --> 00:08:00.430 risk of glaucoma associated with steroid eye 00:08:00.430 --> 00:08:03.069 drops, and that happens in about 10 to 15 percent 00:08:03.069 --> 00:08:06.589 of people, usually older kids or adults, but 00:08:06.589 --> 00:08:09.189 we worry about it in everybody. Long term, they 00:08:09.189 --> 00:08:11.709 cause cataracts, so you don't want to be using 00:08:11.709 --> 00:08:14.329 it in a five-year-old for any length of time, 00:08:14.430 --> 00:08:18.209 but short term, nothing beats it. For glaucoma, 00:08:18.209 --> 00:08:20.629 since you raised that, how long are you talking 00:08:20.629 --> 00:08:24.889 about? Normal use, so once or twice a day or 00:08:24.889 --> 00:08:27.350 whatever you would prescribe. How many days or 00:08:27.350 --> 00:08:29.509 weeks would you expect for that to even be an 00:08:29.509 --> 00:08:32.269 issue? You could see it in five days. Really? 00:08:32.389 --> 00:08:34.809 That would be the earliest presentation, but 00:08:34.809 --> 00:08:37.289 usually weeks and weeks of treatment. And, you 00:08:37.289 --> 00:08:39.669 know, if we see a child, we might not see them 00:08:39.669 --> 00:08:41.990 back for a couple of weeks because even if their 00:08:41.990 --> 00:08:44.570 pressure went up a little bit, they can tolerate 00:08:44.570 --> 00:08:46.649 it. Their nerves are healthy and the risk benefit 00:08:46.649 --> 00:08:51.149 is still in the child's, you know, favor. And 00:08:51.149 --> 00:08:53.929 eczema itself can absolutely affect the eyelids. 00:08:54.110 --> 00:08:57.190 I've heard it said that the eyes are the window 00:08:57.190 --> 00:08:59.909 to the soul, right? But I guess in that case, 00:08:59.950 --> 00:09:06.330 then the eyelid is the curtain. But the kids 00:09:06.330 --> 00:09:10.309 that are suffering from the scale, the itch, 00:09:10.309 --> 00:09:13.309 the redness. and the swelling of their eyelids, 00:09:13.450 --> 00:09:15.990 it's such a natural thing to make eye contact 00:09:15.990 --> 00:09:17.450 with someone. And that's the first thing you 00:09:17.450 --> 00:09:19.370 see. You do want to get this under control for 00:09:19.370 --> 00:09:22.250 them. And as you pointed out, it's really suffering. 00:09:22.570 --> 00:09:25.509 These kids have to go through this. So when would 00:09:25.509 --> 00:09:30.169 you decide to use a topical prednisone in the 00:09:30.169 --> 00:09:32.629 eye versus something like a topical calcineurin 00:09:32.629 --> 00:09:37.470 inhibitor like Protopic? Or what's the Pataday? 00:09:37.590 --> 00:09:39.490 Is that another one that you guys might use? 00:09:39.649 --> 00:09:42.370 So Pataday is a. histamine blocker. It has 00:09:42.370 --> 00:09:44.990 some mast cell stabilizing effect and whatnot. 00:09:45.250 --> 00:09:47.970 It's certainly a complement to a cortisone drop, 00:09:48.129 --> 00:09:50.230 but it's not going to do it. And many of the 00:09:50.230 --> 00:09:53.289 kids have been on it already. As far as I know, 00:09:53.330 --> 00:09:56.250 there's no calcineuron inhibitor that is a drop 00:09:56.250 --> 00:10:00.149 form. Maybe it could be compounded. But we use 00:10:00.149 --> 00:10:03.590 mid -potency or high -potency prednisone drops. 00:10:03.809 --> 00:10:07.210 But then, to your point, we usually will switch 00:10:07.210 --> 00:10:09.769 after a few weeks if the child needs continued 00:10:09.769 --> 00:10:14.129 care. to cyclosporine drops. It's an off -label 00:10:14.129 --> 00:10:16.509 application. There's a drop called Restasis, 00:10:16.809 --> 00:10:19.269 which is a really dilute, I think it's like 0 00:10:19.269 --> 00:10:24.889 .005 % cyclosporine, which is an anti -rejection 00:10:24.889 --> 00:10:27.029 chemical. So it suppresses the immune system. 00:10:27.370 --> 00:10:30.289 And that works really well twice a day. There's 00:10:30.289 --> 00:10:32.450 a higher concentration that has a brand name 00:10:32.450 --> 00:10:34.509 called Sequa. There are a million different drops. 00:10:34.710 --> 00:10:38.440 And those are geared more toward... Older patients 00:10:38.440 --> 00:10:41.659 with dry eye, which is often inflammatory in 00:10:41.659 --> 00:10:45.840 nature, and so cyclosporine is an anti -inflammatory, 00:10:45.860 --> 00:10:48.779 so it cuts down that. It helps the dry eye. But 00:10:48.779 --> 00:10:53.100 for the purposes of autoimmune or inflammatory 00:10:53.100 --> 00:10:57.360 condition, cyclosporine will cut down that cycle, 00:10:57.399 --> 00:10:59.860 and it's really good, and then you don't have 00:10:59.860 --> 00:11:03.200 the side effect of worrying about cataract, glaucoma, 00:11:03.200 --> 00:11:06.399 and things like that with the prednisone. But, 00:11:06.399 --> 00:11:08.779 you know, then you're using something chronically 00:11:08.779 --> 00:11:10.919 for a long period of time. And a lot of these 00:11:10.919 --> 00:11:13.759 kids just have kind of episodic, you know, a 00:11:13.759 --> 00:11:16.299 month or two here and there. And sometimes just 00:11:16.299 --> 00:11:18.779 a mid or low potency cortisone drop is really 00:11:18.779 --> 00:11:22.480 all you need. We're taught that cyclosporine 00:11:22.480 --> 00:11:25.159 in the eye can also help with your eyelashes. 00:11:25.440 --> 00:11:27.340 Is that true? Is that one of the side effects? 00:11:28.199 --> 00:11:32.019 Yeah, I don't know. There's some other prostaglandin 00:11:32.019 --> 00:11:35.700 things like, you know, Lumigan, Xalatan. The 00:11:35.700 --> 00:11:39.580 prostaglandins definitely, they're the forerunner 00:11:39.580 --> 00:11:44.309 of a branded name called Latisse. which you can 00:11:44.309 --> 00:11:47.409 grow hair anywhere with Latisse. If you want 00:11:47.409 --> 00:11:49.389 to grow it on the front of your nose, you put 00:11:49.389 --> 00:11:52.149 a couple drops of Latisse on your nose and wait 00:11:52.149 --> 00:11:54.029 a few weeks and you'll have hair right in the 00:11:54.029 --> 00:11:57.250 center of your nose. No, thank you. Some people 00:11:57.250 --> 00:12:00.509 use it who've had chemotherapy on their eyelashes 00:12:00.509 --> 00:12:05.029 and their eyebrows. And some people who just 00:12:05.029 --> 00:12:08.830 don't have the voluminous lashes that they want 00:12:08.830 --> 00:12:11.460 use it just to... increase the volume of their 00:12:11.460 --> 00:12:16.480 lids of their lashes well so as it relates to 00:12:16.480 --> 00:12:18.480 eczema one of the things that you know still 00:12:18.480 --> 00:12:20.899 haunts me from my days of studying for boards 00:12:20.899 --> 00:12:24.740 was this complication called "keratoconus" - am i 00:12:24.740 --> 00:12:27.059 saying that correctly? yeah yeah. Can you talk 00:12:27.059 --> 00:12:29.059 a little bit about what that is and is it something 00:12:29.059 --> 00:12:31.159 that i'm supposed to as a dermatologist be able 00:12:31.159 --> 00:12:34.629 to see by the naked eye? It would be hard to see 00:12:34.629 --> 00:12:37.789 it with the naked eye. Keratoconus, it can be 00:12:37.789 --> 00:12:40.850 familial. It's multifactorial inheritance. It 00:12:40.850 --> 00:12:44.769 can be run in families for sure. It can be sporadic. 00:12:44.789 --> 00:12:46.850 It's associated with different developmental 00:12:46.850 --> 00:12:50.070 things. For example, Down syndrome have a higher 00:12:50.070 --> 00:12:53.850 incidence of keratoconus. It is also associated 00:12:53.850 --> 00:12:56.799 with eye rubbing. So that goes along with allergy 00:12:56.799 --> 00:12:59.519 and atopic conditions. So it's always a good 00:12:59.519 --> 00:13:01.860 thing for a variety of reasons not to rub your 00:13:01.860 --> 00:13:04.679 eyes. Because really, when you rub your eyes, 00:13:04.820 --> 00:13:08.740 they really get compressed. It's not good to 00:13:08.740 --> 00:13:11.700 do it. They even have MRIs of people rubbing 00:13:11.700 --> 00:13:13.840 their eyes and showing what happens to the eye 00:13:13.840 --> 00:13:16.279 and how it gets deformed. So don't rub your eyes. 00:13:16.340 --> 00:13:19.940 Don't let your kids rub their eyes. But it is 00:13:19.940 --> 00:13:23.059 associated with rubbing and with atopic conditions. 00:13:24.639 --> 00:13:27.419 But it would be really difficult to see that 00:13:27.419 --> 00:13:31.019 without a microscope. We have special machines 00:13:31.019 --> 00:13:34.039 to diagnose it. When would you suspect it? When 00:13:34.039 --> 00:13:36.080 would you think about referring someone in for 00:13:36.080 --> 00:13:38.940 possible? You know, if their eyes are affected, 00:13:39.159 --> 00:13:41.899 it's probably a good idea for the child to see 00:13:41.899 --> 00:13:44.620 an ophthalmologist anyway. And just as part of 00:13:44.620 --> 00:13:48.919 an initial patient visit, most pediatric ophthalmologists 00:13:48.919 --> 00:13:51.820 will always dilate, do a complete exam, because 00:13:51.820 --> 00:13:54.059 then you have a baseline that's comprehensive. 00:13:54.080 --> 00:13:56.740 You're not just treating for conjunctivitis or 00:13:56.740 --> 00:13:59.240 pink eye from a cold or something. So that'll 00:13:59.240 --> 00:14:01.759 be detected, you know, at that initial exam. 00:14:02.269 --> 00:14:04.690 that's part of the routine sort of exam oh yeah 00:14:04.690 --> 00:14:07.950 most people you know do everything all the time 00:14:07.950 --> 00:14:11.090 the first time. It's difficult if a child, for 00:14:11.090 --> 00:14:13.409 example, got something in their eye. You want 00:14:13.409 --> 00:14:15.649 to take care of that problem and not make the 00:14:15.649 --> 00:14:17.809 kid go through a prolonged experience, get the 00:14:17.809 --> 00:14:19.710 foreign body out, and then see them in a couple 00:14:19.710 --> 00:14:21.590 of days, make sure they heal, and then you would 00:14:21.590 --> 00:14:23.690 do a complete exam when they're feeling better. 00:14:24.169 --> 00:14:27.250 But there's really no substitute for a full exam 00:14:27.250 --> 00:14:31.110 in anything, right? In dermatology and podiatry, 00:14:31.110 --> 00:14:34.899 in any "-ology," you need to be complete. Yeah, 00:14:34.960 --> 00:14:38.490 so a skin condition that can mimic... Atopic 00:14:38.490 --> 00:14:40.690 dermatitis is one called psoriasis, different 00:14:40.690 --> 00:14:44.370 inflammatory response and sort of cytokine cascade 00:14:44.370 --> 00:14:47.570 behind it driving it. But the idea that you would 00:14:47.570 --> 00:14:50.610 have a very discrete, well -demarcated, scaly 00:14:50.610 --> 00:14:54.789 pink flat top plaque on the skin is something 00:14:54.789 --> 00:14:58.470 we're very commonly seeing in adults and also 00:14:58.470 --> 00:15:00.389 kids. In fact, I just mentioned the other day 00:15:00.389 --> 00:15:02.409 in clinic that it was really one of the hardest 00:15:02.409 --> 00:15:05.759 things for me to do as a... dermatology resident 00:15:05.759 --> 00:15:08.340 in training and then moving to fellowship was 00:15:08.340 --> 00:15:11.480 to make a new diagnosis of psoriasis in a kid. 00:15:11.580 --> 00:15:13.379 I don't know why, but I just had a mental block 00:15:13.379 --> 00:15:16.460 many times because I always thought of that as 00:15:16.460 --> 00:15:19.200 a quote -unquote "adult" condition, but it is quite 00:15:19.200 --> 00:15:22.600 common in kids. We see it. It has a... sort of 00:15:22.600 --> 00:15:24.860 a more characteristic look about it than eczema. 00:15:24.919 --> 00:15:27.299 So many times you can walk in and make that diagnosis 00:15:27.299 --> 00:15:29.559 or through family history, or if you have to 00:15:29.559 --> 00:15:32.059 do a biopsy from some other portion of the skin, 00:15:32.120 --> 00:15:35.139 you can do that. But again, with the boards, 00:15:35.220 --> 00:15:38.879 we're taught "uveitis" and that's associated with 00:15:38.879 --> 00:15:40.720 psoriasis. Can you talk a little bit about what 00:15:40.720 --> 00:15:44.049 that is and what that looks like? So the uvea 00:15:44.049 --> 00:15:46.190 is the middle part of the eye. There's the white 00:15:46.190 --> 00:15:48.470 part of the eye, the sclera. There's the inside 00:15:48.470 --> 00:15:50.690 of the eye, the retina. And in between those 00:15:50.690 --> 00:15:53.629 is the uvea. And the uvea is named uvea because 00:15:53.629 --> 00:15:57.070 uvea in Greek or Latin means grape. And so if 00:15:57.070 --> 00:15:59.210 you dissected away the white part, you'd see 00:15:59.210 --> 00:16:03.669 this kind of bluish. brownish part that is full 00:16:03.669 --> 00:16:06.769 of blood so it tends to get inflamed a lot in 00:16:06.769 --> 00:16:10.090 any inflammatory condition it spills over uveitis 00:16:10.090 --> 00:16:13.490 is really painful we're always teaching all the 00:16:13.490 --> 00:16:15.929 residents from st luke's hospital the warning 00:16:15.929 --> 00:16:19.509 signs for when to refer to ophthalmology and 00:16:19.509 --> 00:16:22.610 if a child has pink eye or any kind of redness 00:16:22.610 --> 00:16:25.169 to their eye we say pink eye doesn't hurt pink 00:16:25.169 --> 00:16:27.629 eye does not make you sensitive to light and 00:16:27.629 --> 00:16:29.789 so if you have a little kid who's sensitive to 00:16:29.789 --> 00:16:32.620 light we ask that they always see an ophthalmologist 00:16:32.620 --> 00:16:36.460 because it's just not pink eye associated with 00:16:36.460 --> 00:16:39.720 the cold when they're shying away from the light. 00:16:40.320 --> 00:16:43.460 So uveitis is inflammation of that middle section 00:16:43.460 --> 00:16:45.860 of the eye. It takes a couple of days usually 00:16:45.860 --> 00:16:48.620 to develop associated with, you know, whether 00:16:48.620 --> 00:16:52.440 it's psoriasis or juvenile arthritis and different 00:16:52.440 --> 00:16:55.519 things. And it takes days and weeks to respond 00:16:55.519 --> 00:16:59.259 to prednisone drops as well. But it's very disabling. 00:16:59.279 --> 00:17:01.779 It's really painful. It feels like you had your 00:17:01.779 --> 00:17:05.500 tooth pulled without anesthesia and it's still 00:17:05.500 --> 00:17:07.440 being pulled again and again and again. It's 00:17:07.440 --> 00:17:11.079 really, really painful. Rob, what level of light 00:17:11.079 --> 00:17:12.599 are we talking about? You're talking about walking 00:17:12.599 --> 00:17:17.059 into a lamp -lit room? Yeah. Oh, well, they can't 00:17:17.059 --> 00:17:19.420 go outside. They don't play. They've been inside 00:17:19.420 --> 00:17:21.559 for a couple of days. They keep their eyes shut. 00:17:21.640 --> 00:17:23.640 They're looking down. They want a hat on. They're 00:17:23.640 --> 00:17:25.859 wearing somebody's sunglasses or their parents 00:17:25.859 --> 00:17:29.400 bought them a pair of sunglasses on Amazon or 00:17:29.400 --> 00:17:32.319 something. And the kids are really unhappy. They're 00:17:32.319 --> 00:17:34.799 really difficult to examine because they're so 00:17:34.799 --> 00:17:37.559 unhappy because you need to examine them. You 00:17:37.559 --> 00:17:40.500 need light, right? you'd see in the dark and 00:17:40.500 --> 00:17:43.240 you know the kid is usually it's their first 00:17:43.240 --> 00:17:45.380 visit with you they don't trust you they're scared 00:17:45.380 --> 00:17:49.160 all they know is they're in pain and it's really 00:17:49.160 --> 00:17:51.579 challenging in the beginning to make that diagnosis 00:17:51.579 --> 00:17:54.859 especially before you can really kind of reason 00:17:54.859 --> 00:17:57.900 with a child of four or five and get them to 00:17:57.900 --> 00:18:01.119 trust you. But they're very unhappy. And again, 00:18:01.119 --> 00:18:04.380 a couple days' worth of prednisone drops and 00:18:04.380 --> 00:18:08.319 other drops, cycloplegics, dilating drops, will 00:18:08.319 --> 00:18:11.440 reduce that spasm. But the best way to describe 00:18:11.440 --> 00:18:15.960 it is if you've ever been to a movie on a Friday 00:18:15.960 --> 00:18:18.359 afternoon at 2 and you come out of the movie 00:18:18.359 --> 00:18:21.799 theater, that first moment when the light hits 00:18:21.799 --> 00:18:24.279 you, And you're like, wow, it's really bright. 00:18:24.420 --> 00:18:26.900 No, that just hurt for a second. Just imagine 00:18:26.900 --> 00:18:30.660 that times 10 constantly. Wow. Okay. Yeah. No, 00:18:30.759 --> 00:18:34.619 I can immediately think of that and experience 00:18:34.619 --> 00:18:37.619 that in my head. So that's very helpful. Appreciate 00:18:37.619 --> 00:18:41.119 that. Yeah. It's very painful. So related to 00:18:41.119 --> 00:18:43.519 psoriasis is another condition called seborrheic 00:18:43.519 --> 00:18:46.099 dermatitis. We actually have enough of an overlap 00:18:46.099 --> 00:18:48.740 between those two conditions where there's sort 00:18:48.740 --> 00:18:51.519 of a middle of the road called "sebo-psoriasis." 00:18:51.720 --> 00:18:55.019 And that's got a couple interesting specific 00:18:55.019 --> 00:18:57.400 findings, or maybe not specific, you'll tell 00:18:57.400 --> 00:19:01.490 me. But what is blepharitis? Yeah, so blepharitis 00:19:01.490 --> 00:19:05.910 is debris around the eyelashes. It can be from 00:19:05.910 --> 00:19:08.529 a number of different causes. It can be nobody 00:19:08.529 --> 00:19:10.970 really washes their eyelashes, right? I mean, 00:19:10.990 --> 00:19:12.670 you get in the shower, you get in the bath, and 00:19:12.670 --> 00:19:14.869 they put your child in the bath. Nobody really 00:19:14.869 --> 00:19:17.549 pays a lot of attention. Your eyelashes are kind 00:19:17.549 --> 00:19:20.650 of on autopilot. But they can develop some flaking, 00:19:20.650 --> 00:19:23.769 scaling, and debris depending on everybody's 00:19:23.769 --> 00:19:26.349 own body chemistry. Some people are more oily. 00:19:26.470 --> 00:19:28.410 Some people are not. You know more about that 00:19:28.410 --> 00:19:31.829 than I'll ever know. And and so everybody's a 00:19:31.829 --> 00:19:34.339 little different. But that. flaking material 00:19:34.339 --> 00:19:38.440 and oil debris gets into your tear film, and 00:19:38.440 --> 00:19:41.220 it's very irritating. It also promotes bacterial 00:19:41.220 --> 00:19:43.960 overgrowth because the bacteria eat the dead 00:19:43.960 --> 00:19:46.839 skin. They love the oil. That gives things like 00:19:46.839 --> 00:19:50.759 styes, calazions, and it can make your eyes red 00:19:50.759 --> 00:19:54.940 and really irritated. Sometimes, and a lot more 00:19:54.940 --> 00:19:58.220 these days, we look specifically at the lashes, 00:19:58.279 --> 00:20:01.000 and we see little what's called colorettes around 00:20:01.000 --> 00:20:03.539 the base of the lashes. And these are the little 00:20:03.539 --> 00:20:05.980 nests of something called Demodex, which is a 00:20:05.980 --> 00:20:08.960 little mite that inhabits the lash follicles 00:20:08.960 --> 00:20:13.150 of the lid preferentially over more. lash follicles 00:20:13.150 --> 00:20:16.029 elsewhere because they're warm next to the eye 00:20:16.029 --> 00:20:20.230 and they're, I think, the thinnest. And so Demodex 00:20:20.230 --> 00:20:24.390 really inhabits the lashes and that's very irritating, 00:20:24.650 --> 00:20:28.730 causes keratitis. The life cycle of the Demodex 00:20:28.730 --> 00:20:31.710 is about three or four weeks. So when we see 00:20:31.710 --> 00:20:35.630 that in children, we have them use tea tree scrubs, 00:20:35.650 --> 00:20:39.289 tea tree shampoo. There's a branded name, Claridex, 00:20:39.369 --> 00:20:42.789 which is a dilute concentrate. of tea tree you 00:20:42.789 --> 00:20:45.500 would never want to put pure tea tree oil near 00:20:45.500 --> 00:20:48.539 your eye would really be very painful and cause 00:20:48.539 --> 00:20:51.759 chemical injury but very dilute concentrations 00:20:51.759 --> 00:20:54.460 help and there are other treatments too baby 00:20:54.460 --> 00:20:57.299 shampoo scrubs hot compresses to open up the 00:20:57.299 --> 00:21:00.940 glands and the eyelashes and newer treatments 00:21:00.940 --> 00:21:04.759 there's a branded name called Xdemvy which is 00:21:04.759 --> 00:21:09.680 lotilaner, which is a poison for the Demodex 00:21:09.680 --> 00:21:12.480 and you use that twice a day for six weeks which 00:21:12.480 --> 00:21:15.650 is twice the life cycle of the Demodex, sometimes repeating 00:21:15.650 --> 00:21:18.390 that every six to nine months. And that really 00:21:18.390 --> 00:21:21.329 helps, but it's 18 and over. Nobody really uses 00:21:21.329 --> 00:21:24.970 it in children yet. And is most blepharitis caused 00:21:24.970 --> 00:21:28.109 by Demodex or not? Probably. Probably, yeah. 00:21:28.109 --> 00:21:32.549 Probably, yeah, probably. And we use Restasis 00:21:32.549 --> 00:21:37.109 a lot too, cyclosporine drops, because if you 00:21:37.109 --> 00:21:40.099 can't beat them, you know, avoid them. So we 00:21:40.099 --> 00:21:43.019 can't really, you know, get rid of the Demodex 00:21:43.019 --> 00:21:46.039 because it's commensal for a lot of kids. So, 00:21:46.039 --> 00:21:49.259 and the Xdemvy is not approved yet, but we can 00:21:49.259 --> 00:21:52.019 tamp down the inflammation associated with it. 00:21:52.519 --> 00:21:55.220 And sometimes prednisone drops too. But again, 00:21:55.339 --> 00:21:58.299 we worry about that longer term with kids. One 00:21:58.299 --> 00:22:01.319 of our... colleagues and a very senior clinical 00:22:01.319 --> 00:22:03.799 dermatologist named Warren Heyman and myself 00:22:03.799 --> 00:22:06.640 and Steve Senft, whom I think you know from St. Luke's? 00:22:06.720 --> 00:22:10.440 We wrote an article that was published in Pediatrics 00:22:10.440 --> 00:22:12.740 a couple of years ago as it was a case series 00:22:12.740 --> 00:22:16.839 from three patients who had been on dupixent, 00:22:16.839 --> 00:22:20.019 dupilumab, and they were developing conjunctivitis. 00:22:20.119 --> 00:22:24.160 And we threw out there as a possible link because 00:22:24.160 --> 00:22:28.589 of the way dupixent works. could you be decreasing 00:22:28.589 --> 00:22:31.650 the ability for your body to fight off Demodex? 00:22:31.990 --> 00:22:35.029 And it looks like there might be some legs to 00:22:35.029 --> 00:22:38.390 that. So we've seen some pretty horrible conjunctivitis 00:22:38.390 --> 00:22:40.529 cases with the use of that medicine, but you 00:22:40.529 --> 00:22:42.789 can usually get it under control. Yeah, I've 00:22:42.789 --> 00:22:44.630 seen it a couple of times and you withdraw the 00:22:44.630 --> 00:22:46.569 medicine, it gets better. And in the meantime, 00:22:47.049 --> 00:22:49.750 you know, again, prednisone, God's gift to medicine 00:22:49.750 --> 00:22:53.829 and certainly God's gift to dermatology. And 00:22:53.829 --> 00:22:55.970 it really just works. It makes them feel better 00:22:55.970 --> 00:22:58.509 in a day or two. right away well speaking of 00:22:58.509 --> 00:23:01.490 seborrheic dermatitis and Demodex we also have 00:23:01.490 --> 00:23:04.250 rosacea we not as commonly seen in young kids 00:23:04.250 --> 00:23:06.329 but certainly there are there are some kids that 00:23:06.329 --> 00:23:08.730 will show up with something that looks like acne 00:23:08.730 --> 00:23:11.549 but you're looking very closely at their skin 00:23:11.549 --> 00:23:14.450 they don't have blackheads or or what we would 00:23:14.450 --> 00:23:17.769 call open comedones or closed comedones for that 00:23:17.769 --> 00:23:20.650 matter they've got more sort of the juicier zits 00:23:20.650 --> 00:23:23.250 if you will the pustules the inflammatory papules 00:23:23.250 --> 00:23:25.990 without the comedones that's a good clue that 00:23:25.990 --> 00:23:28.789 maybe you're dealing more with rosacea in our 00:23:28.789 --> 00:23:32.390 world there is a subset of rosacea that is certainly 00:23:32.390 --> 00:23:36.190 driven we believe by Demodex and how does that 00:23:36.190 --> 00:23:41.799 show up in in a person's eye Yeah. Their eyes 00:23:41.799 --> 00:23:45.220 are red, irritated, scratchy, chronically. You 00:23:45.220 --> 00:23:47.720 can usually see it's especially red right where 00:23:47.720 --> 00:23:50.140 the blue or brown part of the eye meets the white. 00:23:50.240 --> 00:23:52.460 There's like a ring of fire around that area. 00:23:52.799 --> 00:23:55.880 And just their lids never look right. A parent 00:23:55.880 --> 00:23:58.720 will say they just don't look right. They look 00:23:58.720 --> 00:24:00.940 chronically red. Their margins of their eyelashes 00:24:00.940 --> 00:24:05.380 are red. And a lot of times those kids get recurrent 00:24:05.380 --> 00:24:08.680 styes, which are basically pimples. recurrent 00:24:08.680 --> 00:24:11.700 chalazia, which are basically... blocked up glands. 00:24:11.980 --> 00:24:14.380 Styes are the zits you could pop when you were 00:24:14.380 --> 00:24:17.779 a kid. Chalazia are the deeper kind of cystic 00:24:17.779 --> 00:24:19.640 things you couldn't pop when you tried when you 00:24:19.640 --> 00:24:23.119 were, you know, a teenager. And those, you know, 00:24:23.119 --> 00:24:25.700 we treat them with hot compresses, antibiotics, 00:24:26.079 --> 00:24:29.140 antibiotic cortisone drops. And, you know, sometimes 00:24:29.140 --> 00:24:31.920 they just need to, you know, be cut out over 00:24:31.920 --> 00:24:34.759 time. But that's an ordeal in a child, right? 00:24:34.839 --> 00:24:37.980 If you had a stye, I'd lay you back in the chair, 00:24:38.119 --> 00:24:42.319 give you a shot of lidocaine and cut it out and 00:24:42.319 --> 00:24:46.000 you'd go back to work in 15 minutes. A child 00:24:46.000 --> 00:24:48.660 has to have general anesthesia, which is really 00:24:48.660 --> 00:24:51.559 terrible. Going to sleep with general anesthesia 00:24:51.559 --> 00:24:55.819 for pimples but but it's really disabling where 00:24:55.819 --> 00:24:58.299 there's one there tends to be more and you know 00:24:58.299 --> 00:25:00.099 they kind of there's something called "kissing" 00:25:00.099 --> 00:25:02.680 styes where you get one on your upper lid and 00:25:02.680 --> 00:25:04.559 then you get one adjacent to it on the lower 00:25:04.559 --> 00:25:07.559 lid and you get this cycle of infection and uh 00:25:07.559 --> 00:25:10.680 you know you have to cut the gland out and and 00:25:10.680 --> 00:25:13.480 uh get rid of it at a certain point but it's 00:25:13.480 --> 00:25:16.599 you know it's an ordeal for the child because 00:25:16.599 --> 00:25:19.259 they have to go to sleep we see it all the time 00:25:19.259 --> 00:25:22.529 all the time really it's that common Oh, yeah. 00:25:22.809 --> 00:25:25.109 I mean, the pediatricians, family doctors will 00:25:25.109 --> 00:25:27.009 first try and treat with antibiotics and hot 00:25:27.009 --> 00:25:30.230 compresses. Really rarely oral. It's usually 00:25:30.230 --> 00:25:33.329 not a cellulitic kind of thing. It's more localized. 00:25:33.609 --> 00:25:36.650 And we'll try stronger antibiotic drops, usually 00:25:36.650 --> 00:25:40.569 a quinolone class and prednisone with it, mixed 00:25:40.569 --> 00:25:43.509 with it. And if it doesn't get better, you know, 00:25:43.529 --> 00:25:46.750 we wait months and months and months unless there's 00:25:46.750 --> 00:25:49.109 a reason to intervene sooner. But after four, 00:25:49.170 --> 00:25:51.880 five, six months, you can get scarring. they're 00:25:51.880 --> 00:25:54.339 really difficult to remove after a while. So 00:25:54.339 --> 00:25:57.660 usually that four or five, six month period is 00:25:57.660 --> 00:25:59.539 a good time to start thinking about removing 00:25:59.539 --> 00:26:03.140 them because by the time everybody's schedules 00:26:03.140 --> 00:26:05.180 align and you can get into the operating room, 00:26:05.220 --> 00:26:07.859 it's usually a month or two later anyway. Oh, 00:26:07.880 --> 00:26:09.779 that's good to know. Yeah, maybe I need to get 00:26:09.779 --> 00:26:11.680 a little bit more aggressive in terms of when 00:26:11.680 --> 00:26:15.200 I refer in. Well, the next condition that I wanted 00:26:15.200 --> 00:26:19.240 to ask you about is certainly inflammatory, but 00:26:19.240 --> 00:26:22.240 it's an autoimmune driven process called alopecia 00:26:22.240 --> 00:26:25.740 areata. And that's sort of for the audience's 00:26:25.740 --> 00:26:28.259 sake, that's where your own immune system has... 00:26:28.670 --> 00:26:31.650 sort of bypass the normal protection that the 00:26:31.650 --> 00:26:34.369 hair follicles, the sort of portals for where 00:26:34.369 --> 00:26:37.569 your hair come out, normally protected, normally 00:26:37.569 --> 00:26:40.289 wouldn't be attacked by your immune system. But 00:26:40.289 --> 00:26:42.809 now the immune system, for whatever reason, has 00:26:42.809 --> 00:26:45.650 decided that your hair is, quote unquote, a foreign 00:26:45.650 --> 00:26:48.250 object and wants to get rid of it, drives an 00:26:48.250 --> 00:26:51.890 inflammatory process around that hair. And eventually 00:26:51.890 --> 00:26:53.930 the hair just kind of gives up and says, I'm 00:26:53.930 --> 00:26:56.809 out of here and falls out. We see that and it 00:26:56.809 --> 00:26:58.950 could certainly on the scalp is when it's most 00:26:58.950 --> 00:27:01.730 probably most commonly showing up in my clinic. 00:27:01.829 --> 00:27:04.650 And we call that alopecia areata. But certainly 00:27:04.650 --> 00:27:08.750 it can involve the eyebrows, the eyelashes. We 00:27:08.750 --> 00:27:12.509 call that alopecia totalis. And then we have 00:27:12.509 --> 00:27:15.490 alopecia universalis, which is where all of the 00:27:15.490 --> 00:27:18.690 hair is involved, including the groin area, the 00:27:18.690 --> 00:27:23.789 underarms, the legs, whatever. You have... really 00:27:23.789 --> 00:27:26.710 changed the way I approach that diagnosis because 00:27:26.710 --> 00:27:29.869 the first thing I look at is, is it one-sided 00:27:29.869 --> 00:27:32.690 or not? Can you talk a little bit about that? 00:27:33.170 --> 00:27:36.210 Yeah. So, you know, one thing to think of is 00:27:36.210 --> 00:27:39.539 if the kids have actually been... pulling their 00:27:39.539 --> 00:27:43.220 lashes out too and you have to look and see if 00:27:43.220 --> 00:27:46.200 the lashes are broken we can see it at the microscope 00:27:46.200 --> 00:27:48.480 we worry about something called trichotillomania 00:27:48.480 --> 00:27:51.079 where the kids are actually removing their lashes 00:27:51.079 --> 00:27:54.980 and you know those children need you know universally 00:27:54.980 --> 00:27:59.960 cognitive therapy and counseling it really usually 00:27:59.960 --> 00:28:04.180 takes the parents by surprise when we tell them 00:28:04.180 --> 00:28:08.799 that that's what we suspect because yeah everybody 00:28:08.799 --> 00:28:11.160 has a hard time believing that their their child 00:28:11.160 --> 00:28:14.039 could be really suffering that way and have a 00:28:14.039 --> 00:28:16.740 lot of emotional distress causing them really 00:28:16.740 --> 00:28:20.319 self -harm you know when you see all the lashes 00:28:20.319 --> 00:28:23.460 gone then we think of alopecia when we see just 00:28:23.460 --> 00:28:27.460 clusters of them specifically you know across 00:28:27.460 --> 00:28:31.220 from their their dominant hand um it makes us 00:28:31.220 --> 00:28:35.119 think more of a volitional uh pulling so if you're 00:28:35.119 --> 00:28:38.960 right -handed and the left eye alone is sort 00:28:38.960 --> 00:28:41.220 of intermittently affected that's a, that's a 00:28:41.220 --> 00:28:43.700 pretty good hint that maybe yeah usually they 00:28:43.700 --> 00:28:46.539 kind of go across you know that's what i found 00:28:46.539 --> 00:28:49.859 you know i'm sure that i'm sure it's not 50 -50. 00:28:50.180 --> 00:28:53.299 But usually it seems to be that they go across 00:28:53.299 --> 00:28:55.539 their face. Is there a preference for the top 00:28:55.539 --> 00:28:58.339 or bottom eyelids? The top. The top. The top 00:28:58.339 --> 00:29:03.920 eyelids. They always pull the top. And the parents 00:29:03.920 --> 00:29:08.180 absolutely will not believe you that this is 00:29:08.180 --> 00:29:11.839 not an infection. It must be an infection. And 00:29:11.839 --> 00:29:14.220 so sometimes, you know, along with recommending 00:29:14.220 --> 00:29:18.640 cognitive therapy, we'll also recommend an antibiotic 00:29:18.640 --> 00:29:22.220 ointment. The antibiotic ointment just makes 00:29:22.220 --> 00:29:24.660 it harder for the kids to kind of get a purchase 00:29:24.660 --> 00:29:29.359 of the lashes and pull them out. But we explain 00:29:29.359 --> 00:29:31.920 to them it's like putting WD-40 on your eyelashes. 00:29:32.779 --> 00:29:36.500 It's not fighting anything. But they need to, 00:29:36.500 --> 00:29:40.220 you know, sit and talk to their child. and find 00:29:40.220 --> 00:29:42.099 out what's going on or enlist a professional 00:29:42.099 --> 00:29:45.759 and really help out along the way. One skin condition 00:29:45.759 --> 00:29:48.240 close to my own heart, since I actually have 00:29:48.240 --> 00:29:50.619 it, is something called vitiligo, another autoimmune 00:29:50.619 --> 00:29:53.299 condition where, for whatever reason, your body 00:29:53.299 --> 00:29:55.579 has decided to attack the melanocytes that make 00:29:55.579 --> 00:30:00.640 the tan or the melanin in your skin. There are 00:30:00.640 --> 00:30:02.299 a couple conditions that we're taught about when 00:30:02.299 --> 00:30:04.460 we're learning pediatric dermatology where there's 00:30:04.460 --> 00:30:07.039 an overlap between the skin and the eyes. Is 00:30:07.039 --> 00:30:10.160 that something that you would see or would want 00:30:10.160 --> 00:30:13.970 us to refer in more for that? In adults, we see 00:30:13.970 --> 00:30:16.589 it from time to time. They're usually of Asian 00:30:16.589 --> 00:30:20.009 descent, and we can see it be very disabling. 00:30:20.029 --> 00:30:23.549 They have uveitis. They have diminished vision. 00:30:23.769 --> 00:30:27.509 And it's usually been a chronic condition. In 00:30:27.509 --> 00:30:31.269 children, it's uncommon. There is one condition, 00:30:31.450 --> 00:30:34.930 Vogt-Koyanagi-Harada. They can affect those. 00:30:35.190 --> 00:30:38.009 But thankfully, in children, it's uncommon. It's 00:30:38.009 --> 00:30:42.650 more of a 20 to 30. maybe 40 year old but that 00:30:42.650 --> 00:30:45.470 can be very impactful for vision and hard to 00:30:45.470 --> 00:30:48.130 treat really hard to treat do you want to see 00:30:48.130 --> 00:30:50.690 those kids if if the vitiligo is affecting their 00:30:50.690 --> 00:30:52.910 eyelids or their eyebrows or is that not necessarily 00:30:52.910 --> 00:30:56.250 a marker for involvement You know, I don't know 00:30:56.250 --> 00:31:00.029 the clinical answer to that, but there's no harm 00:31:00.029 --> 00:31:02.910 in ever looking because children never complain. 00:31:03.430 --> 00:31:06.769 They really don't complain, especially if something's 00:31:06.769 --> 00:31:10.750 only affecting one eye. They don't know. Nobody 00:31:10.750 --> 00:31:13.549 covers one eye at a time to check and see what 00:31:13.549 --> 00:31:15.970 their vision is like when they're eight or nine. 00:31:16.630 --> 00:31:20.430 So it's never a bad idea to do a baseline exam 00:31:20.430 --> 00:31:23.970 to be sure, because if you don't look, then you 00:31:23.970 --> 00:31:25.960 don't. know. Well, switching gears back to something 00:31:25.960 --> 00:31:28.259 you mentioned earlier, you use the term "herpetic." 00:31:28.539 --> 00:31:31.039 That for the audience refers to a virus called 00:31:31.039 --> 00:31:35.019 herpes simplex virus, HSV. I was taught that 00:31:35.019 --> 00:31:38.039 about 90% of us - almost universally - are walking 00:31:38.039 --> 00:31:41.220 around having been exposed to this virus, not 00:31:41.220 --> 00:31:43.799 necessarily showing symptoms or signs of it, 00:31:43.859 --> 00:31:47.759 but we have it. Very, very common. Can you talk 00:31:47.759 --> 00:31:49.920 a little bit about how that might show up in 00:31:49.920 --> 00:31:53.599 a kid? Yeah, so it would generally be the HSV 00:31:53.599 --> 00:31:57.759 -1, which gives the fabled cold sore of the lip. 00:31:57.900 --> 00:32:01.980 Usually it presents as pink eye in a child, unless 00:32:01.980 --> 00:32:05.019 they're very small. And it's a bilateral condition 00:32:05.019 --> 00:32:08.500 as a child, and it's treated really with antibiotic 00:32:08.500 --> 00:32:12.359 drops because there are no telltale signs of 00:32:12.359 --> 00:32:16.980 herpes the first time. If it recurs, whether 00:32:16.980 --> 00:32:19.420 it's a few months later or a few years later 00:32:19.420 --> 00:32:22.400 or decades later, you'll have pain sensitivity 00:32:22.400 --> 00:32:25.240 and a chronic pink eye. And, you know, family 00:32:25.240 --> 00:32:27.819 doctors will often just treat with an antibiotic 00:32:27.819 --> 00:32:30.359 drop, you know, because most things don't need 00:32:30.359 --> 00:32:32.900 to be referred to an ophthalmologist. But if 00:32:32.900 --> 00:32:35.119 you're using a drop and a day or two goes by 00:32:35.119 --> 00:32:38.579 and there's no improvement or the patient is 00:32:38.579 --> 00:32:40.980 sensitive to light or in pain, they're always 00:32:40.980 --> 00:32:44.940 taught again to refer to ophthalmology. children 00:32:44.940 --> 00:32:49.019 or adults can have herpetic conjunctivitis. And 00:32:49.019 --> 00:32:51.079 you wouldn't know it without a microscope. You 00:32:51.079 --> 00:32:54.920 can't diagnose it without a slit lamp. In babies, 00:32:54.960 --> 00:32:58.259 through the birth canal, they can encounter HSV 00:32:58.259 --> 00:33:03.140 -1 or HSV -2. If a mother has an open lesion 00:33:03.140 --> 00:33:05.619 at the time of birth, those children present 00:33:05.619 --> 00:33:08.900 within the first day or two, or actually about 00:33:08.900 --> 00:33:12.259 three to five, with hyperacute conjunctivitis. 00:33:12.279 --> 00:33:14.269 So the child will be discharged. after birth 00:33:14.269 --> 00:33:16.670 and a couple days later have a rip-roaring pink 00:33:16.670 --> 00:33:19.049 eye. And those children are always readmitted 00:33:19.049 --> 00:33:21.690 back to the hospital given high-dose IV antibiotics 00:33:21.690 --> 00:33:25.829 and acyclovir, which is the treatment for herpes, 00:33:25.829 --> 00:33:28.809 along with eye treatment as well. But it's very 00:33:28.809 --> 00:33:32.109 disabling. It can scar the eye quickly, and it 00:33:32.109 --> 00:33:35.509 needs to be treated expeditiously. So that's 00:33:35.509 --> 00:33:38.690 an emergency. You'll take the kids in right away? 00:33:38.789 --> 00:33:41.269 Oh, yeah, right away, yeah. Nobody wants to see 00:33:41.269 --> 00:33:44.220 a child in pain or discomfort. A little less 00:33:44.220 --> 00:33:47.240 of an emergency is another, well, another two 00:33:47.240 --> 00:33:50.259 viruses, I guess. HPV, human papillomavirus, 00:33:50.519 --> 00:33:54.779 which causes skin warts, and molluscum contagiosum, 00:33:54.779 --> 00:33:57.900 a pox virus that causes... molluscum also known 00:33:57.900 --> 00:34:00.420 as water bumps when those get around the eye 00:34:00.420 --> 00:34:02.259 i find that's pretty much one of the hardest 00:34:02.259 --> 00:34:04.940 places to treat because i would not normally 00:34:04.940 --> 00:34:08.340 use my go-to molluscum medicine of cantharone or "beetle 00:34:08.340 --> 00:34:11.679 juice" in that area out of risk for damaging the 00:34:11.679 --> 00:34:15.420 eye itself i tend to fall back on either a topical 00:34:15.420 --> 00:34:18.360 retinoid like Retin-a or Differin - something 00:34:18.360 --> 00:34:21.000 on the weaker side - where you're putting a pinhead 00:34:21.000 --> 00:34:23.239 amount of the medication on each of these little 00:34:23.239 --> 00:34:26.199 bumps over maybe six to nine months with hope 00:34:26.199 --> 00:34:29.079 that you're irritating it away. Of course, anytime 00:34:29.079 --> 00:34:31.500 you're causing irritation around the eye, you're 00:34:31.500 --> 00:34:34.159 at risk, I guess, of causing irritation around 00:34:34.159 --> 00:34:37.039 the eye. Do you have any tricks when you see 00:34:37.039 --> 00:34:38.739 these patients come in? Yeah, well, when it's 00:34:38.739 --> 00:34:42.579 not right on the margin, clear nail polish. can 00:34:42.579 --> 00:34:46.239 help. We've used that. Cimetidine in older kids, 00:34:46.360 --> 00:34:48.639 the old Tagamet, you know, will work. But we 00:34:48.639 --> 00:34:52.659 give them prednisone because the prednisone tamps 00:34:52.659 --> 00:34:55.699 down the response. It gets very irritated, inflamed. 00:34:55.739 --> 00:34:58.400 It's basically an allergy to the viral particles 00:34:58.400 --> 00:35:02.679 that get shed from the lesion. Almost really 00:35:02.679 --> 00:35:05.619 universally 30 years later, I don't think I've 00:35:05.619 --> 00:35:08.000 ever seen molluscum last more than about eight 00:35:08.000 --> 00:35:10.940 or nine months. But it looks very different around 00:35:10.940 --> 00:35:13.619 the eyelid margin than on the rest of the skin 00:35:13.619 --> 00:35:16.900 surface. You still have that umbilicated appearance, 00:35:17.239 --> 00:35:20.690 but it's just...bigger, flatter, a little bit 00:35:20.690 --> 00:35:24.170 different looking. But it gets better. Once in 00:35:24.170 --> 00:35:27.690 a blue moon, you remove them if the child has 00:35:27.690 --> 00:35:30.809 problems with the prednisone drops. But removing 00:35:30.809 --> 00:35:33.130 them, they're usually inflamed, irritated, and 00:35:33.130 --> 00:35:35.650 they can scar. So it's better to just kind of 00:35:35.650 --> 00:35:38.030 wait it out and let the body figure it out and 00:35:38.030 --> 00:35:42.449 mount an immune response and get rid of it. That's 00:35:42.449 --> 00:35:45.800 what we do. Yeah, yeah, I agree. I mean, I think 00:35:45.800 --> 00:35:48.239 I've heard of some people who might curette them 00:35:48.239 --> 00:35:50.280 off if they're just one or two off to the side. 00:35:50.380 --> 00:35:53.019 But most of the time, we're either using the 00:35:53.019 --> 00:35:55.159 topicals I mentioned or kind of just hoping for 00:35:55.159 --> 00:35:58.000 the best or treating aggressively the other ones 00:35:58.000 --> 00:36:00.639 not around the eye with the hope that the immune 00:36:00.639 --> 00:36:03.159 system kicks in and clears the virus everywhere. 00:36:03.300 --> 00:36:07.070 So speaking of chronic. pink eye one of the things 00:36:07.070 --> 00:36:10.349 that i have a hard time with sometimes is differentiating 00:36:10.349 --> 00:36:13.170 between infection versus some of these inflammatory 00:36:13.170 --> 00:36:16.409 skin conditions versus allergic reactions so 00:36:16.409 --> 00:36:19.210 an actual allergy to a product that the child 00:36:19.210 --> 00:36:21.590 might be using like what we call a "rinse-off" 00:36:21.590 --> 00:36:23.989 product where they're using a shampoo that runs 00:36:23.989 --> 00:36:27.010 down their face and hits that very very thin 00:36:27.010 --> 00:36:32.739 eyelid skin which is is for the audience's edification. 00:36:32.739 --> 00:36:35.480 It's pretty thin skin, right? I don't know how 00:36:35.480 --> 00:36:37.840 thin it is, but I know it is the thinnest skin 00:36:37.840 --> 00:36:39.780 of the body. The thinnest skin on the body. So 00:36:39.780 --> 00:36:43.820 we tell our patients that that's many times the 00:36:43.820 --> 00:36:46.539 very first place that an allergic reaction that 00:36:46.539 --> 00:36:49.159 could happen anywhere else might pop up because 00:36:49.159 --> 00:36:51.619 there's just less skin to have to go through 00:36:51.619 --> 00:36:54.260 in those areas. What are you seeing in terms 00:36:54.260 --> 00:36:56.340 of allergic reactions of the eyelids? What are 00:36:56.340 --> 00:36:59.230 kids coming in for? Yeah. You know, sometimes 00:36:59.230 --> 00:37:02.170 it's really hard to figure it out because sometimes 00:37:02.170 --> 00:37:04.250 the parents haven't done anything different. 00:37:04.429 --> 00:37:06.829 The same products that their child has used, 00:37:06.909 --> 00:37:09.110 the same shampoo, the same soap, everything's 00:37:09.110 --> 00:37:12.309 the same. But the product itself has been reformulated. 00:37:12.610 --> 00:37:17.630 I had a really great. really good detective mother 00:37:17.630 --> 00:37:21.849 once who figured out that her child was allergic 00:37:21.849 --> 00:37:25.929 to ammonium quaternium 4. i think that was 00:37:25.929 --> 00:37:27.989 it and it was some kind of preservative that 00:37:27.989 --> 00:37:31.429 was not in the old formulation of whatever shampoo 00:37:31.429 --> 00:37:34.030 that was in a new formulation, or a child really 00:37:34.030 --> 00:37:37.650 broke out into just a fulminant allergic response. 00:37:37.949 --> 00:37:40.969 And we tell them to use Benadryl, shower off 00:37:40.969 --> 00:37:44.389 everything. And a lot of those kids, we give 00:37:44.389 --> 00:37:47.869 a topical antihistamine drop. It gets better 00:37:47.869 --> 00:37:51.369 kind of quick. It's like right quick on, quick 00:37:51.369 --> 00:37:53.369 off. They don't really need the prednisone as 00:37:53.369 --> 00:37:56.619 much. Do you guys in ophthalmology do a version 00:37:56.619 --> 00:37:58.400 of what we would call patch testing? Are you 00:37:58.400 --> 00:38:00.139 familiar with what I'm talking about? I know 00:38:00.139 --> 00:38:02.840 what a patch test is. Yeah, but we don't have 00:38:02.840 --> 00:38:06.159 anything like that. Oh, okay. Yeah, not in the 00:38:06.159 --> 00:38:08.840 eye, no. Well, we can be a resource for you. 00:38:08.920 --> 00:38:11.699 We have our sort of eye panel where we have some 00:38:11.699 --> 00:38:13.699 of the products most commonly associated. You 00:38:13.699 --> 00:38:16.500 mentioned Quat-14, I think, is the formaldehyde 00:38:16.500 --> 00:38:18.960 releaser. These formaldehyde products are very 00:38:18.960 --> 00:38:22.179 commonly in fingernail polish. And the same way 00:38:22.179 --> 00:38:24.599 you referenced that for trichotillomania, the 00:38:24.599 --> 00:38:28.460 dominant hand touching the eyelid, that's one 00:38:28.460 --> 00:38:30.079 of the very first places. You don't actually 00:38:30.079 --> 00:38:32.860 get the nail polish allergy on the fingernails 00:38:32.860 --> 00:38:35.300 as much as you do up on the eyelid. So it's just 00:38:35.300 --> 00:38:38.429 an interesting thing. But yeah, we can certainly 00:38:38.429 --> 00:38:41.210 help identify a specific culprit with that. And 00:38:41.210 --> 00:38:45.289 I think right now our go -to patch test is a 00:38:45.289 --> 00:38:49.889 90-test group. So there's a lot of things on 00:38:49.889 --> 00:38:52.050 there that we can identify. So I mentioned 00:38:52.050 --> 00:38:54.289 earlier that you and I mostly work together for 00:38:54.289 --> 00:38:57.349 infantile hemangiomas and port wine birthmarks. 00:38:57.409 --> 00:38:59.610 For the pediatricians and family medicine doctors 00:38:59.610 --> 00:39:02.309 out there, when do you absolutely want to see? 00:39:02.969 --> 00:39:05.929 a kid with a suspected infantile hemangioma or 00:39:05.929 --> 00:39:09.050 port wine birthmark. Yeah, anytime it's really 00:39:09.050 --> 00:39:12.389 around the eye perioral area, especially the 00:39:12.389 --> 00:39:14.769 upper lid, but even the lower lids can grow and 00:39:14.769 --> 00:39:19.289 be very disabling. They can really disturb your 00:39:19.289 --> 00:39:25.070 visual development. Vision is a birthright, but 00:39:25.070 --> 00:39:29.880 you're not born with it. And if a child's unable 00:39:29.880 --> 00:39:33.960 to see because their lid is closed over the eye, 00:39:34.079 --> 00:39:37.239 over the pupil. That eye, if it's not open in 00:39:37.239 --> 00:39:39.900 a few months, we'll never learn to see. The brain 00:39:39.900 --> 00:39:42.420 really develops. And there was a Nobel Prize 00:39:42.420 --> 00:39:46.739 won in 1972, Hubel and Wiesel. They did work 00:39:46.739 --> 00:39:49.980 on a cat. I'm sorry for all the cat lovers out 00:39:49.980 --> 00:39:53.480 there, but they sewed one cat's eye shut, one 00:39:53.480 --> 00:39:56.179 eye shut and left the other open. They showed 00:39:56.179 --> 00:39:59.199 that the lateral geniculate, the neural pathways 00:39:59.199 --> 00:40:02.280 actually grow differently when not stimulated 00:40:02.280 --> 00:40:04.599 by light at an early age. After you're three 00:40:04.599 --> 00:40:08.019 or four months old, that's not really as much 00:40:08.019 --> 00:40:10.280 of an issue. But certainly in the beginning, 00:40:10.340 --> 00:40:14.340 you really need light to stimulate the visual 00:40:14.340 --> 00:40:18.159 cortex to grow and the optic path and track to 00:40:18.159 --> 00:40:22.059 grow. So we get very concerned. And propranolol, 00:40:22.099 --> 00:40:26.849 Hemangeol. was such a game changer maybe 15, 00:40:26.989 --> 00:40:30.889 18 years ago when it was really developed by 00:40:30.889 --> 00:40:34.230 chance. There was a child with cardiac failure 00:40:34.230 --> 00:40:36.969 who had a hemangioma around their heart. They 00:40:36.969 --> 00:40:38.989 gave the child propranolol because they were 00:40:38.989 --> 00:40:41.769 in failure and it made the hemangioma shrink 00:40:41.769 --> 00:40:44.980 in a couple days. And I guess in the old days, 00:40:45.059 --> 00:40:47.440 that would have taken a year or two in journal 00:40:47.440 --> 00:40:51.579 articles to come out. But it was in the internet 00:40:51.579 --> 00:40:54.440 era and there were message boards and chat rooms. 00:40:54.599 --> 00:40:56.440 And within a few months, everybody was doing 00:40:56.440 --> 00:40:59.119 it. A lot of those have been sequenced and found 00:40:59.119 --> 00:41:01.460 to have some antigens that come from the placenta, 00:41:01.500 --> 00:41:04.159 I'm sure you know. And they're associated with 00:41:04.159 --> 00:41:07.099 premature birth. But Hemangeol has really been 00:41:07.099 --> 00:41:09.099 a game changer. In the old days, we would inject 00:41:09.099 --> 00:41:13.460 them with prednisone. respond. They could be 00:41:13.460 --> 00:41:17.099 resected, which was very disfiguring for the 00:41:17.099 --> 00:41:22.940 children. And this is night and day. It's a miracle. 00:41:23.360 --> 00:41:27.039 I tell people I've witnessed at least two miracles. 00:41:27.079 --> 00:41:29.340 I think with the psoriasis medicines, I'm on 00:41:29.340 --> 00:41:32.219 my third sort of class of medications. But Hemangeol 00:41:32.219 --> 00:41:34.500 really was the first miracle that I've witnessed 00:41:34.500 --> 00:41:39.420 as a physician and a game changer. So these hemangiomas 00:41:39.420 --> 00:41:42.460 you're referencing, as they affect vision, It 00:41:42.460 --> 00:41:45.199 really is a "use it or lose it" phenomenon, it 00:41:45.199 --> 00:41:48.119 sounds like. And getting them into you. It's 00:41:48.119 --> 00:41:51.320 interesting. Can you share your technique for, 00:41:51.400 --> 00:41:54.539 I don't want to compare the kids to the cats 00:41:54.539 --> 00:41:56.360 that you were mentioning, but you sort of do 00:41:56.360 --> 00:42:00.179 the opposite to force the affected eye to be. 00:42:00.570 --> 00:42:03.349 better utilized. Is that correct? Yeah. So, you 00:42:03.349 --> 00:42:05.849 know, if you have an eye that's partially occluded 00:42:05.849 --> 00:42:09.309 because of the weight, the volume of the blood 00:42:09.309 --> 00:42:13.170 in the eyelid, you'll patch the other eye. The 00:42:13.170 --> 00:42:16.269 good eye. You'll patch the good one. It's been 00:42:16.269 --> 00:42:19.769 done for 5 ,000 years for different problems, 00:42:19.989 --> 00:42:24.510 not hemangiomas. And you patch it so that you 00:42:24.510 --> 00:42:27.050 force that child to use their muscles, their 00:42:27.050 --> 00:42:30.050 brow muscles to open the lid or just get... more 00:42:30.050 --> 00:42:34.130 stimulation than they would without it. And that's 00:42:34.130 --> 00:42:36.130 very effective. And again, all these children 00:42:36.130 --> 00:42:38.190 are very small. They're a few weeks, a few months 00:42:38.190 --> 00:42:41.409 old. So an hour a day, if the child is up for 00:42:41.409 --> 00:42:43.590 three, four, five hours a day, an hour a day 00:42:43.590 --> 00:42:47.449 is 20, 25 % of their day. That's a lot. That's 00:42:47.449 --> 00:42:50.130 equivalent to four or five hours for an older 00:42:50.130 --> 00:42:53.170 child. So even a half an hour, an hour for some 00:42:53.170 --> 00:42:57.739 of these kids, but the medicine just works. days, 00:42:57.760 --> 00:43:01.900 the hemangiomas will shrink a whole bunch so 00:43:01.900 --> 00:43:05.440 that they really respond so well. It's amazing. 00:43:05.679 --> 00:43:09.460 One of the skin conditions that does not respond 00:43:09.460 --> 00:43:12.079 to Hemangeol is a port wine birthmark, a flat 00:43:12.079 --> 00:43:16.099 red. birthmark that that can be usually pretty 00:43:16.099 --> 00:43:18.880 easily distinguished between infantile hemangiomas 00:43:18.880 --> 00:43:21.519 but when you talk about a segmental hemangioma 00:43:21.519 --> 00:43:24.280 early early on before the texture has changed 00:43:24.280 --> 00:43:27.199 sometimes it's a little hard. When, when would 00:43:27.199 --> 00:43:30.199 you as a pediatric ophthalmologist want to see 00:43:30.199 --> 00:43:33.039 a kid with a port wine birthmark specifically? 00:43:33.039 --> 00:43:36.219 Well, that's changed a little bit since i i started 00:43:36.219 --> 00:43:38.860 studying but where does it get you most nervous 00:43:38.860 --> 00:43:42.360 that this might be a harbinger of an underlying 00:43:42.360 --> 00:43:45.340 condition like Sturge -Weber syndrome? If it 00:43:45.340 --> 00:43:48.019 is involving the upper eyelid, brow, and usually 00:43:48.019 --> 00:43:51.159 if you pull the eyelid up, you'll also see a 00:43:51.159 --> 00:43:54.780 little bit of a "blush" to the upper sclera. It'll 00:43:54.780 --> 00:43:57.420 look a little red. And that's a real serious 00:43:57.420 --> 00:44:00.559 warning that you have a Sturge-Weber that's 00:44:00.559 --> 00:44:03.360 affecting the eye. Most children can go on to 00:44:03.360 --> 00:44:05.989 get glaucoma. and they're very difficult to treat 00:44:05.989 --> 00:44:10.989 and without it they'll you know lose vision at 00:44:10.989 --> 00:44:15.150 a very early age it's very very important so 00:44:15.150 --> 00:44:17.750 anytime that certainly that involves the upper 00:44:17.750 --> 00:44:20.690 eyelid is especially impactful and that's a patient 00:44:20.690 --> 00:44:23.010 that you would probably see once a year at least 00:44:23.010 --> 00:44:25.619 i would imagine Yeah, you know, sometimes even 00:44:25.619 --> 00:44:27.780 more, honestly, Andrew, in the beginning, because, 00:44:27.840 --> 00:44:31.119 you know, you can't be sure and things change. 00:44:31.340 --> 00:44:35.960 Sometimes it can take a few months, but you'd 00:44:35.960 --> 00:44:38.980 probably see them after you're sure that there's 00:44:38.980 --> 00:44:42.860 nothing there for a few years yearly because 00:44:42.860 --> 00:44:46.699 things change. But usually you can tell. pretty 00:44:46.699 --> 00:44:49.380 soon in the first few months but if a child's 00:44:49.380 --> 00:44:51.380 referred when they're a few weeks or a month 00:44:51.380 --> 00:44:54.320 old it can be hard to make that determination 00:44:54.320 --> 00:44:59.659 and things can change. Back when i was training 00:44:59.659 --> 00:45:02.960 in pediatrics we did a study with a pediatric 00:45:02.960 --> 00:45:05.780 ophthalmologist at the hospital there that looked 00:45:05.780 --> 00:45:08.619 at lasering port wine birthmarks right around 00:45:08.619 --> 00:45:12.639 the eye with the specific goal in mind of proving 00:45:12.639 --> 00:45:17.929 in quotes that lasering the cutaneous lesion, 00:45:17.929 --> 00:45:20.949 the birthmark, did not increase the pressure 00:45:20.949 --> 00:45:23.670 of the eye, meaning maybe you were destroying 00:45:23.670 --> 00:45:27.610 some of the outlet flow of the blood and maybe 00:45:27.610 --> 00:45:30.389 that would back up the pressure. Have you ever 00:45:30.389 --> 00:45:33.869 sort of discussed or seen the contralateral of 00:45:33.869 --> 00:45:37.010 that, which is lasering helps with the glaucoma? 00:45:37.050 --> 00:45:39.530 Does it do anything for that? No, I've never 00:45:39.530 --> 00:45:41.610 seen it help, but I've also never seen it hurt. 00:45:42.010 --> 00:45:44.150 Okay, that's good to know. Yeah, I've never seen 00:45:44.150 --> 00:45:47.210 it hurt. I haven't seen it a lot. I mean, probably 00:45:47.210 --> 00:45:50.250 fewer than a dozen or two cases in my career. 00:45:50.650 --> 00:45:53.789 The kids have been lasered for that, but I've 00:45:53.789 --> 00:45:56.460 never seen it hurt. Great. That makes me feel 00:45:56.460 --> 00:45:59.739 a lot better. Yeah. And if anything, honestly, 00:45:59.880 --> 00:46:02.559 it helps because the children are no longer as 00:46:02.559 --> 00:46:07.639 self-conscious about the lesion. And so from 00:46:07.639 --> 00:46:10.820 a psychosocial development thing, it helps them 00:46:10.820 --> 00:46:12.840 a lot because kids don't want to feel different 00:46:12.840 --> 00:46:15.739 in any way. Well, that's a great segue into my 00:46:15.739 --> 00:46:18.139 acne question that I've been so excited to ask 00:46:18.139 --> 00:46:23.000 you. So obviously you have severe acne. We don't 00:46:23.000 --> 00:46:25.199 have a cure for severe acne yet, but we've got 00:46:25.199 --> 00:46:27.159 something that comes pretty close to treating 00:46:27.159 --> 00:46:30.099 it in most people well, and that's a medicine 00:46:30.099 --> 00:46:32.800 called isotretinoin. Used to be sold under the 00:46:32.800 --> 00:46:36.500 name Accutane. The history that I remember is 00:46:36.500 --> 00:46:38.360 that they stopped selling Accutane under that 00:46:38.360 --> 00:46:41.219 brand name because people kept suing the makers 00:46:41.219 --> 00:46:43.219 of Accutane. They said, we're done. You guys. 00:46:43.280 --> 00:46:46.679 figure it out on your own. One of those side 00:46:46.679 --> 00:46:49.460 effects that I do talk to every one of my patients 00:46:49.460 --> 00:46:52.780 about, especially if they're driving age, is 00:46:52.780 --> 00:46:56.039 what Accutane can do to your night vision. And 00:46:56.039 --> 00:46:57.840 is that something that you're familiar with? 00:46:57.960 --> 00:47:01.460 Oh, yeah. Because it gives you very dry eye, 00:47:01.559 --> 00:47:04.579 okay? Universally, these kids all get dry eye. 00:47:04.719 --> 00:47:08.239 And the surface of your eye, the best analogy 00:47:08.239 --> 00:47:11.260 that I once heard, it's like the surface of the 00:47:11.260 --> 00:47:15.260 Hubble. space telescope. It has to be perfectly 00:47:15.260 --> 00:47:20.159 smooth and clean and perfect. Anything that disturbs 00:47:20.159 --> 00:47:23.320 the surface gives you glare and gives you reduced 00:47:23.320 --> 00:47:27.119 vision. Whether you're a 75-year-old with dry 00:47:27.119 --> 00:47:30.139 eyes or whether you're a 12-year-old with dry 00:47:30.139 --> 00:47:32.860 eye, that's why a lot of older people have trouble 00:47:32.860 --> 00:47:35.000 driving at night. It's just because they have 00:47:35.000 --> 00:47:38.539 very dry eyes or they have cataracts. But when 00:47:38.539 --> 00:47:40.659 your eyes get dry, you have tremendous amount 00:47:40.659 --> 00:47:44.440 of glare. take a lot to irritate the surface 00:47:44.440 --> 00:47:47.579 of your eye and really interfere with your vision 00:47:47.579 --> 00:47:49.800 because it's a very small area that really does 00:47:49.800 --> 00:47:53.840 most of the visual processing. So this is not 00:47:53.840 --> 00:47:56.500 an actual physical change that the medication 00:47:56.500 --> 00:47:58.920 isotretinoin is causing in the eye, it's a side 00:47:58.920 --> 00:48:03.469 effect of the dryness? Yeah, I mean, look, because 00:48:03.469 --> 00:48:06.630 of its effects on vitamin, because it's a vitamin 00:48:06.630 --> 00:48:10.230 A chemical, maybe it in some way impacts the 00:48:10.230 --> 00:48:14.889 visual cascade in the retina. Not in a way that 00:48:14.889 --> 00:48:18.070 I'm aware of. It's mostly from dry eye, but we 00:48:18.070 --> 00:48:22.050 also worry as well about idiopathic intracranial 00:48:22.050 --> 00:48:26.630 hypertension from taking isotretinoin. And we 00:48:26.630 --> 00:48:29.809 have to be careful of kids who complain of blurred 00:48:29.809 --> 00:48:31.969 vision, trouble with their vision, or headache. 00:48:32.650 --> 00:48:35.570 um that they can rarely um you know have what 00:48:35.570 --> 00:48:38.610 we call pseudotumor cerebri from that any vitamin 00:48:38.610 --> 00:48:41.349 a derivative even eating a polar bear liver will 00:48:41.349 --> 00:48:44.130 give it to you uh. We have a couple of medications - 00:48:44.130 --> 00:48:46.769 you tell me if i'm missing any big ones- um the 00:48:46.769 --> 00:48:50.750 the tetracyclines: doxycycline, minocycline; oral 00:48:50.750 --> 00:48:53.949 contraceptive pills (birth control pills); isotretinoin, 00:48:54.090 --> 00:48:57.250 and which one else? What am I forgetting? Those 00:48:57.250 --> 00:48:58.690 are the three big ones that I think. That's what 00:48:58.690 --> 00:49:01.389 I think of too. Yeah, exactly. Yeah. And that, 00:49:01.449 --> 00:49:04.449 like you said, will present as a severe headache 00:49:04.449 --> 00:49:07.449 that does not get better with a Tylenol or a 00:49:07.449 --> 00:49:10.469 Motrin. You go to sleep expecting your headache's 00:49:10.469 --> 00:49:13.010 gone the next morning. You wake up, it might 00:49:13.010 --> 00:49:16.289 even be worse, right? It's pretty debilitating. 00:49:16.989 --> 00:49:19.369 Well, that's a great question. So for the Accutane 00:49:19.369 --> 00:49:23.369 user and just in general, what are the ways to 00:49:23.369 --> 00:49:26.389 prevent these sort of common eye problems that 00:49:26.389 --> 00:49:28.369 we talked about specifically, I guess, dryness 00:49:28.369 --> 00:49:31.250 of the eye? But if you were telling your own 00:49:31.250 --> 00:49:33.909 kids, hey, you've got a lifetime ahead of you. 00:49:34.250 --> 00:49:37.150 Here's how I would take best care of your eyes. 00:49:37.329 --> 00:49:39.530 What are some of the suggestions you would have 00:49:39.530 --> 00:49:43.670 us do? Protective eyewear. It's the most impactful 00:49:43.670 --> 00:49:49.599 thing. dumbest things happen when you don't expect 00:49:49.599 --> 00:49:53.960 it. And just, you know, any sport, anything where 00:49:53.960 --> 00:49:57.260 you're going to contact a ball, you should really 00:49:57.260 --> 00:50:01.039 wear protective eyewear. That it's just wearing 00:50:01.039 --> 00:50:04.260 a seatbelt for your eye. And, you know, some 00:50:04.260 --> 00:50:06.780 of the injuries that we see are, you know, preventable, 00:50:06.820 --> 00:50:10.730 heartbreaking. permanent and life-changing. 00:50:10.989 --> 00:50:14.469 And it's also very important for the two or three 00:50:14.469 --> 00:50:17.530 percent of the population that has a quote "lazy 00:50:17.530 --> 00:50:20.389 eye" - an eye that doesn't see well. I've never 00:50:20.389 --> 00:50:24.409 seen the lazy eye injured. I've only seen the 00:50:24.409 --> 00:50:26.710 good eye injured because if you hear a sound, 00:50:26.869 --> 00:50:30.409 you turn so that you can see the sound and that's 00:50:30.409 --> 00:50:32.690 the fist coming at your face and it hits your 00:50:32.690 --> 00:50:35.969 good eye or the ball. Anything always hits the 00:50:35.969 --> 00:50:40.849 good eye. So it's really impactful, just like 00:50:40.849 --> 00:50:43.489 you wear a seatbelt to wear safety glasses. The 00:50:43.489 --> 00:50:47.230 normal everyday person without a skin condition 00:50:47.230 --> 00:50:50.449 or an eye condition, do they need or should they 00:50:50.449 --> 00:50:53.420 be using? eye lubricating drops is that is that 00:50:53.420 --> 00:50:57.219 good yeah i mean your eyes are kind of on autopilot 00:50:57.219 --> 00:50:59.980 when you're on Accutane just like you might use 00:50:59.980 --> 00:51:04.460 vaseline on your lips you want to use artificial 00:51:04.460 --> 00:51:08.300 tears sometimes the non-preserved as opposed 00:51:08.300 --> 00:51:10.639 to the preserved ones because they're less irritating 00:51:10.639 --> 00:51:14.460 but for the most part your eyes are really on 00:51:14.460 --> 00:51:17.000 autopilot if you just have a good nutritious 00:51:17.000 --> 00:51:21.059 you know diet you don't really need artificial 00:51:21.059 --> 00:51:24.300 teardrops at a young age if you do um you probably 00:51:24.300 --> 00:51:27.059 need to go play outside more and look at you 00:51:27.059 --> 00:51:30.199 and and look at instagram a little bit less because 00:51:30.199 --> 00:51:33.739 your eyes dry out when you have a lot of screen 00:51:33.739 --> 00:51:37.900 time you don't blink as much and the blink lubricates 00:51:37.900 --> 00:51:41.039 your eye but it also moves the mucus around and 00:51:41.039 --> 00:51:43.739 the oil from the meibomian glands in your lids 00:51:43.739 --> 00:51:46.820 and it's important to kind of flex those glands 00:51:46.820 --> 00:51:51.179 so that they work properly and you know whether 00:51:51.179 --> 00:51:54.460 it's screen time on a TV or an ipad or whatever 00:51:56.039 --> 00:51:58.280 you don't blink as much and that contributes 00:51:58.280 --> 00:52:02.079 to dryness. But if you have no symptoms, it's 00:52:02.079 --> 00:52:05.099 hard to fix something that isn't broken. So I'd 00:52:05.099 --> 00:52:07.380 say probably not. Okay, that's good to know. 00:52:07.920 --> 00:52:10.639 Good to know. Well, my last question before I 00:52:10.639 --> 00:52:13.400 let you out of here, this has been one that I've 00:52:13.400 --> 00:52:16.599 been really just, I've never been able to do 00:52:16.599 --> 00:52:19.719 this myself. So maybe I wasn't being fair to 00:52:19.719 --> 00:52:22.880 myself. So very specific skin condition called 00:52:22.880 --> 00:52:27.849 "neurofibromatosis". - NF1.. It's a chromosome 17 00:52:27.849 --> 00:52:32.690 mutation. And there's one of the specific findings 00:52:32.690 --> 00:52:36.730 in the constellation of this condition is something 00:52:36.730 --> 00:52:39.469 called Lisch nodules in the eye. Can you explain 00:52:39.469 --> 00:52:42.389 what they are? And very importantly, am I supposed 00:52:42.389 --> 00:52:46.190 to be able to see them before you? Absolutely 00:52:46.190 --> 00:52:49.630 not. You need a microscope to see them. At least 00:52:49.630 --> 00:52:52.510 I need a microscope to see them, especially in 00:52:52.510 --> 00:52:54.750 a little child who's not sitting still for more 00:52:54.750 --> 00:52:57.789 than a minute. But technically, a lish nodule 00:52:57.789 --> 00:53:00.670 is a hamartoma, an overgrowth of tissue that's 00:53:00.670 --> 00:53:03.789 normally there, but just more of it. It looks 00:53:03.789 --> 00:53:07.750 like a little wart on the iris. And you can have 00:53:07.750 --> 00:53:10.309 one or two of them. You can have dozens of them. 00:53:11.170 --> 00:53:14.900 They look very different. in a brown-eyed children 00:53:14.900 --> 00:53:21.820 than a blue-eyed child. But they're uncommonly 00:53:21.820 --> 00:53:26.360 associated with NF. And we're always asked to 00:53:26.360 --> 00:53:30.760 look. But at the end of the day, they don't do 00:53:30.760 --> 00:53:35.139 anything to the vision. It's just a feature of 00:53:35.139 --> 00:53:38.829 the genetic disease. but it doesn't do anything 00:53:38.829 --> 00:53:41.210 to the vision. In the old days, before genetic 00:53:41.210 --> 00:53:43.869 testing, it was helpful, inclusive of the criteria 00:53:43.869 --> 00:53:48.650 and whatnot. Now we look, but whether the child 00:53:48.650 --> 00:53:51.269 has them or not, it doesn't matter. Now, there 00:53:51.269 --> 00:53:55.489 are also hamartomas. of the retina in kids who 00:53:55.489 --> 00:53:58.949 have neurofibromatosis and their hamartomas in 00:53:58.949 --> 00:54:01.489 kids who have tuberous sclerosis, a different 00:54:01.489 --> 00:54:04.530 autosomal dominant condition, and you can see 00:54:04.530 --> 00:54:07.170 those they're basically bumps in the retina and 00:54:07.170 --> 00:54:11.110 their retinal tissue but you should not even 00:54:11.110 --> 00:54:14.150 even you who is so excellent can't be expected 00:54:14.150 --> 00:54:18.130 to look without a microscope. Thank God... i remember 00:54:18.130 --> 00:54:20.530 distinctly it was a picture on the front cover 00:54:20.530 --> 00:54:23.000 of one of our general dermatology - not even a 00:54:23.000 --> 00:54:25.840 pediatric dermatology textbook. And it had about 00:54:25.840 --> 00:54:28.739 five pictures of very specific things. One of 00:54:28.739 --> 00:54:33.960 them was a person's eye, a person had a background 00:54:33.960 --> 00:54:36.599 diagnosis of neurofibromatosis-1. And when 00:54:36.599 --> 00:54:38.739 you read the little insert of what the pictures 00:54:38.739 --> 00:54:41.800 were, it said "demonstration of Lisch nodules." 00:54:41.820 --> 00:54:44.820 And it's like, I can't see these things. I don't 00:54:44.820 --> 00:54:48.460 know what's wrong with me. Okay. Well, I want 00:54:48.460 --> 00:54:50.699 to thank Dr. Robert Kitei for taking the time 00:54:50.699 --> 00:54:52.739 out of his very busy clinic schedule to help 00:54:52.739 --> 00:54:55.440 educate us on these important topics. I felt 00:54:55.440 --> 00:54:58.440 like, dare I say, an eager "pupil" listening to 00:54:58.440 --> 00:55:00.619 him teach about kids' overlapping skin and eye 00:55:00.619 --> 00:55:03.179 conditions. Thanks for joining us on this episode 00:55:03.179 --> 00:55:05.300 of Don't Be Rash. It was great having you, Dr. 00:55:05.320 --> 00:55:08.199 Kitei. And to our audience, stay tuned for our 00:55:08.199 --> 00:55:13.719 next episode. Thanks for tuning in to this episode 00:55:13.719 --> 00:55:16.179 of the Don't Be Rash Pediatric Dermatology Podcast. 00:55:16.760 --> 00:55:19.059 I'm your host, Dr. Andrew Krakowski. Don't forget 00:55:19.059 --> 00:55:21.260 to subscribe to our show on your favorite podcast 00:55:21.260 --> 00:55:25.159 platform and check out don'tberash .org for more 00:55:25.159 --> 00:55:27.539 information. A special thank you to our nonprofit 00:55:27.539 --> 00:55:30.260 sponsor, the St. Luke's University Health Network 00:55:30.260 --> 00:55:32.900 for making this episode possible. Until next 00:55:32.900 --> 00:55:35.880 time, remember, keep calm and don't be rash.