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. Welcome to Don't Be Rash,
the pediatric dermatology show, coming to you
from beautiful, historic Bethlehem, Pennsylvania.
On today's show, "The EYES Have It!", we're casting
our eyes on a new horizon and exploring the intersection
of kids' skin conditions and their relationship
to eye issues. In the first half of the show,
we will discuss some common inflammatory skin
rashes, such as eczema, psoriasis, and allergies,
and learn how these conditions can affect your
children's eyes. Then, in the second half of
the show... we'll discuss how certain skin-specific
medications and infections can affect your children's
vision. Joining us today as our guest co -host
is board-certified pediatric ophthalmologist
Dr. Robert Kitei. Dr. Kitei is a tremendous asset
for our St. Luke's Health System, and I'm going
to wave HIPAA here and share that he also takes
exceptional care of one of my own sons and my
own mom. Dr. Kitei has helped thousands of kids
and adults and has worked through the philanthropic
Kaskey Foundation, works at even a higher level
for the benefit of the public good. Welcome,
Dr. Kitei. Thanks for joining me today for what
promises to be a very EYE-opening experience
for the both of us. I have lots of questions
for you. To start us off, I'm hoping you might
be able to explain a bit of the overlap of our
two clinical worlds. How often is it you're seeing
kids coming into your office with eye problems
when they also have concurrent skin conditions?
Yeah, plenty of times. I mean, a lot of things
that affect the eye are going to affect the skin.
Because embryologically, the eye is made from
ectoderm. And ectoderm is what the skin is made
from. And a good portion of the eye is also made
from that. So there's a tremendous interplay.
A lot of things that infect the skin can infect
the eye. Inflammatory conditions that affect
the skin can affect the eye. Allergic conditions
can affect the eye. And lots of congenital anomalies
of the skin. body and face can also have impact
on the ocular tissues. So we've worked together
a lot and see a lot of the same kids with a lot
of different problems involving those organs.
Most of the time, you and I seem to cross intersections
with vascular lesions. So things like infantile
hemangiomas and port wine birthmarks, we've worked
together closely in that, but also some genetic
skin conditions where absolutely things overlap.
More and more I'm hearing in the news and within
medical journals, they're seeing that inflammatory
skin conditions such as psoriasis or eczema are
linked now to much more systemic involvement.
So cardiovascular issues or metabolic issues.
And I think part of that is coming to the surface
that the eyes are involved in that as well. Yeah.
I mean, it's all connected. It's all connected.
If you have different abnormalities in your DNA
that predispose you to different inflammatory
conditions, they're going to affect the eye.
Sometimes we see uveitis, scleritis, and different
things that can really be disabling or sometimes
be kind of minor. It just depends on the patient.
Well, there's a lot of itis mentioned when you're
talking about ophthalmology. So most of this
interview is going to be me trying to get you
to explain what some of these things are. And
also, am I supposed to be able to see that with
my own eyes and know that it's there when I refer
my patients into you? But let's take the one
that probably I see the most in my clinic as
a skin condition, which is eczema or atopic dermatitis.
And just for the audience's sake, we're talking
about what's called a chronic and remittant,
meaning it comes and goes, flares and resolves.
dry, itchy, red skin rash that can affect really
any part of the body. It certainly can affect
the eyelids and the face. But how do you see
atopic dermatitis kids present to your clinic?
Yeah, most often they've been treated by their
pediatricians or family doctors for a little
bit. Sometimes the feeling was they had conjunctivitis.
Other times the doctor felt that they had allergic
conjunctivitis. They may have been given an antibiotic
or an antihistamine topically to use for a little
bit, and the kid is still suffering. Kids have
tremendous immune responses, even if it's autoimmune
response, and they really just need cortisone
drops most of the time, prednisone drops, to
calm down the inflammation, at least short term.
It's not good to stay on those long term, but
short term, it's the way to get a child feeling
better. faster because they're really miserable.
Their eyes hurt, they're shying away from light,
they're hard to examine. And it's a chronic intermittent
condition. It really is very disabling because
they can't read, they don't want to play, all
that. And so I normally will see a kid sitting
across from the room. We walk in, you can tell
almost instantly, this guy's got eczema, sure,
everywhere. But then you can also see that they're
suffering from some sort of comorbidity, we would
say. So an associated condition like hay fever
or allergies with the atopic dermatitis. For
me, the biggest clue to that are what, well,
I don't know, we're going to use dermatological
terms and then you correct me if I'm using it
incorrectly. But what we would call "allergic
shiners," this concept that you would have this
almost pinkish purplish circle around usually
the lower portion of the cutaneous eyelid. It
looks like you got punched. That's why they call
it a shiner. Dennie-Morgan lines or Morgan-Dennie
lines, depending on who you ask. But these sort
of extra little creases that you can see in the
eye, I've been told it's from edema or swelling
local from from usually from rubbing is is that.
accurate yeah yeah it's from edema and from the
resolution the cyclical resolution of edema that's
where you get the lines from but their eyes are
always swollen they rub them that makes it worse
they're irritated you see flaking of the skin
it's a really characteristic appearance and like
you when you walk in the room you can kind of
figure it out. But it can happen at any season.
It's not just, you know, in late March or April.
It's not just in September. It's any time. Usually
the kids have, you know, a history of eczema
as a little baby, you know, behind their knees,
intertrigenous areas and things like that. But
you look at them and you can just see how unhappy
and uncomfortable they are. You know, they've
been given a drop or two, a topical antihistamine,
it's not working. And then the family doctors,
pediatricians, pediatricians will send them on
to us and we universally will treat those kids
at least for a short while with topical prednisone
drops to make them feel better really in a couple
days they start feeling better that's uh it's
amazing so yes so For the audience that was concerned,
because they've heard us say on other shows,
that we really try to avoid oral prednisone for
the management of atopic. Can you talk a little
bit about how safe topical prednisone is delivered
into the eye for a couple days here or there?
We're not talking months, right? Yeah, yeah.
A couple days here and there, a couple weeks
here and there. The most important thing is that
pediatricians and family doctors and derms don't
prescribe steroids because sometimes... it can
masquerade. Their inflammation of the eye is
really herpetic, and it's masquerading as something
else. And also, the treatment with prednisone
can make a quiescent herpetic condition manifest
itself, and that happens. a lot. So you have
to be really judicious, but kind of judiciously
bold in using them to make the kids feel better,
but you monitor them. There's also an uncommon
risk of glaucoma associated with steroid eye
drops, and that happens in about 10 to 15 percent
of people, usually older kids or adults, but
we worry about it in everybody. Long term, they
cause cataracts, so you don't want to be using
it in a five-year-old for any length of time,
but short term, nothing beats it. For glaucoma,
since you raised that, how long are you talking
about? Normal use, so once or twice a day or
whatever you would prescribe. How many days or
weeks would you expect for that to even be an
issue? You could see it in five days. Really?
That would be the earliest presentation, but
usually weeks and weeks of treatment. And, you
know, if we see a child, we might not see them
back for a couple of weeks because even if their
pressure went up a little bit, they can tolerate
it. Their nerves are healthy and the risk benefit
is still in the child's, you know, favor. And
eczema itself can absolutely affect the eyelids.
I've heard it said that the eyes are the window
to the soul, right? But I guess in that case,
then the eyelid is the curtain. But the kids
that are suffering from the scale, the itch,
the redness. and the swelling of their eyelids,
it's such a natural thing to make eye contact
with someone. And that's the first thing you
see. You do want to get this under control for
them. And as you pointed out, it's really suffering.
These kids have to go through this. So when would
you decide to use a topical prednisone in the
eye versus something like a topical calcineurin
inhibitor like Protopic? Or what's the Pataday?
Is that another one that you guys might use?
So Pataday is a. histamine blocker. It has
some mast cell stabilizing effect and whatnot.
It's certainly a complement to a cortisone drop,
but it's not going to do it. And many of the
kids have been on it already. As far as I know,
there's no calcineuron inhibitor that is a drop
form. Maybe it could be compounded. But we use
mid -potency or high -potency prednisone drops.
But then, to your point, we usually will switch
after a few weeks if the child needs continued
care. to cyclosporine drops. It's an off -label
application. There's a drop called Restasis,
which is a really dilute, I think it's like 0
.005 % cyclosporine, which is an anti -rejection
chemical. So it suppresses the immune system.
And that works really well twice a day. There's
a higher concentration that has a brand name
called Sequa. There are a million different drops.
And those are geared more toward... Older patients
with dry eye, which is often inflammatory in
nature, and so cyclosporine is an anti -inflammatory,
so it cuts down that. It helps the dry eye. But
for the purposes of autoimmune or inflammatory
condition, cyclosporine will cut down that cycle,
and it's really good, and then you don't have
the side effect of worrying about cataract, glaucoma,
and things like that with the prednisone. But,
you know, then you're using something chronically
for a long period of time. And a lot of these
kids just have kind of episodic, you know, a
month or two here and there. And sometimes just
a mid or low potency cortisone drop is really
all you need. We're taught that cyclosporine
in the eye can also help with your eyelashes.
Is that true? Is that one of the side effects?
Yeah, I don't know. There's some other prostaglandin
things like, you know, Lumigan, Xalatan. The
prostaglandins definitely, they're the forerunner
of a branded name called Latisse. which you can
grow hair anywhere with Latisse. If you want
to grow it on the front of your nose, you put
a couple drops of Latisse on your nose and wait
a few weeks and you'll have hair right in the
center of your nose. No, thank you. Some people
use it who've had chemotherapy on their eyelashes
and their eyebrows. And some people who just
don't have the voluminous lashes that they want
use it just to... increase the volume of their
lids of their lashes well so as it relates to
eczema one of the things that you know still
haunts me from my days of studying for boards
was this complication called "keratoconus" - am i
saying that correctly? yeah yeah. Can you talk
a little bit about what that is and is it something
that i'm supposed to as a dermatologist be able
to see by the naked eye? It would be hard to see
it with the naked eye. Keratoconus, it can be
familial. It's multifactorial inheritance. It
can be run in families for sure. It can be sporadic.
It's associated with different developmental
things. For example, Down syndrome have a higher
incidence of keratoconus. It is also associated
with eye rubbing. So that goes along with allergy
and atopic conditions. So it's always a good
thing for a variety of reasons not to rub your
eyes. Because really, when you rub your eyes,
they really get compressed. It's not good to
do it. They even have MRIs of people rubbing
their eyes and showing what happens to the eye
and how it gets deformed. So don't rub your eyes.
Don't let your kids rub their eyes. But it is
associated with rubbing and with atopic conditions.
But it would be really difficult to see that
without a microscope. We have special machines
to diagnose it. When would you suspect it? When
would you think about referring someone in for
possible? You know, if their eyes are affected,
it's probably a good idea for the child to see
an ophthalmologist anyway. And just as part of
an initial patient visit, most pediatric ophthalmologists
will always dilate, do a complete exam, because
then you have a baseline that's comprehensive.
You're not just treating for conjunctivitis or
pink eye from a cold or something. So that'll
be detected, you know, at that initial exam.
that's part of the routine sort of exam oh yeah
most people you know do everything all the time
the first time. It's difficult if a child, for
example, got something in their eye. You want
to take care of that problem and not make the
kid go through a prolonged experience, get the
foreign body out, and then see them in a couple
of days, make sure they heal, and then you would
do a complete exam when they're feeling better.
But there's really no substitute for a full exam
in anything, right? In dermatology and podiatry,
in any "-ology," you need to be complete. Yeah,
so a skin condition that can mimic... Atopic
dermatitis is one called psoriasis, different
inflammatory response and sort of cytokine cascade
behind it driving it. But the idea that you would
have a very discrete, well -demarcated, scaly
pink flat top plaque on the skin is something
we're very commonly seeing in adults and also
kids. In fact, I just mentioned the other day
in clinic that it was really one of the hardest
things for me to do as a... dermatology resident
in training and then moving to fellowship was
to make a new diagnosis of psoriasis in a kid.
I don't know why, but I just had a mental block
many times because I always thought of that as
a quote -unquote "adult" condition, but it is quite
common in kids. We see it. It has a... sort of
a more characteristic look about it than eczema.
So many times you can walk in and make that diagnosis
or through family history, or if you have to
do a biopsy from some other portion of the skin,
you can do that. But again, with the boards,
we're taught "uveitis" and that's associated with
psoriasis. Can you talk a little bit about what
that is and what that looks like? So the uvea
is the middle part of the eye. There's the white
part of the eye, the sclera. There's the inside
of the eye, the retina. And in between those
is the uvea. And the uvea is named uvea because
uvea in Greek or Latin means grape. And so if
you dissected away the white part, you'd see
this kind of bluish. brownish part that is full
of blood so it tends to get inflamed a lot in
any inflammatory condition it spills over uveitis
is really painful we're always teaching all the
residents from st luke's hospital the warning
signs for when to refer to ophthalmology and
if a child has pink eye or any kind of redness
to their eye we say pink eye doesn't hurt pink
eye does not make you sensitive to light and
so if you have a little kid who's sensitive to
light we ask that they always see an ophthalmologist
because it's just not pink eye associated with
the cold when they're shying away from the light.
So uveitis is inflammation of that middle section
of the eye. It takes a couple of days usually
to develop associated with, you know, whether
it's psoriasis or juvenile arthritis and different
things. And it takes days and weeks to respond
to prednisone drops as well. But it's very disabling.
It's really painful. It feels like you had your
tooth pulled without anesthesia and it's still
being pulled again and again and again. It's
really, really painful. Rob, what level of light
are we talking about? You're talking about walking
into a lamp -lit room? Yeah. Oh, well, they can't
go outside. They don't play. They've been inside
for a couple of days. They keep their eyes shut.
They're looking down. They want a hat on. They're
wearing somebody's sunglasses or their parents
bought them a pair of sunglasses on Amazon or
something. And the kids are really unhappy. They're
really difficult to examine because they're so
unhappy because you need to examine them. You
need light, right? you'd see in the dark and
you know the kid is usually it's their first
visit with you they don't trust you they're scared
all they know is they're in pain and it's really
challenging in the beginning to make that diagnosis
especially before you can really kind of reason
with a child of four or five and get them to
trust you. But they're very unhappy. And again,
a couple days' worth of prednisone drops and
other drops, cycloplegics, dilating drops, will
reduce that spasm. But the best way to describe
it is if you've ever been to a movie on a Friday
afternoon at 2 and you come out of the movie
theater, that first moment when the light hits
you, And you're like, wow, it's really bright.
No, that just hurt for a second. Just imagine
that times 10 constantly. Wow. Okay. Yeah. No,
I can immediately think of that and experience
that in my head. So that's very helpful. Appreciate
that. Yeah. It's very painful. So related to
psoriasis is another condition called seborrheic
dermatitis. We actually have enough of an overlap
between those two conditions where there's sort
of a middle of the road called "sebo-psoriasis."
And that's got a couple interesting specific
findings, or maybe not specific, you'll tell
me. But what is blepharitis? Yeah, so blepharitis
is debris around the eyelashes. It can be from
a number of different causes. It can be nobody
really washes their eyelashes, right? I mean,
you get in the shower, you get in the bath, and
they put your child in the bath. Nobody really
pays a lot of attention. Your eyelashes are kind
of on autopilot. But they can develop some flaking,
scaling, and debris depending on everybody's
own body chemistry. Some people are more oily.
Some people are not. You know more about that
than I'll ever know. And and so everybody's a
little different. But that. flaking material
and oil debris gets into your tear film, and
it's very irritating. It also promotes bacterial
overgrowth because the bacteria eat the dead
skin. They love the oil. That gives things like
styes, calazions, and it can make your eyes red
and really irritated. Sometimes, and a lot more
these days, we look specifically at the lashes,
and we see little what's called colorettes around
the base of the lashes. And these are the little
nests of something called Demodex, which is a
little mite that inhabits the lash follicles
of the lid preferentially over more. lash follicles
elsewhere because they're warm next to the eye
and they're, I think, the thinnest. And so Demodex
really inhabits the lashes and that's very irritating,
causes keratitis. The life cycle of the Demodex
is about three or four weeks. So when we see
that in children, we have them use tea tree scrubs,
tea tree shampoo. There's a branded name, Claridex,
which is a dilute concentrate. of tea tree you
would never want to put pure tea tree oil near
your eye would really be very painful and cause
chemical injury but very dilute concentrations
help and there are other treatments too baby
shampoo scrubs hot compresses to open up the
glands and the eyelashes and newer treatments
there's a branded name called Xdemvy which is
lotilaner, which is a poison for the Demodex
and you use that twice a day for six weeks which
is twice the life cycle of the Demodex, sometimes repeating
that every six to nine months. And that really
helps, but it's 18 and over. Nobody really uses
it in children yet. And is most blepharitis caused
by Demodex or not? Probably. Probably, yeah.
Probably, yeah, probably. And we use Restasis
a lot too, cyclosporine drops, because if you
can't beat them, you know, avoid them. So we
can't really, you know, get rid of the Demodex
because it's commensal for a lot of kids. So,
and the Xdemvy is not approved yet, but we can
tamp down the inflammation associated with it.
And sometimes prednisone drops too. But again,
we worry about that longer term with kids. One
of our... colleagues and a very senior clinical
dermatologist named Warren Heyman and myself
and Steve Senft, whom I think you know from St. Luke's?
We wrote an article that was published in Pediatrics
a couple of years ago as it was a case series
from three patients who had been on dupixent,
dupilumab, and they were developing conjunctivitis.
And we threw out there as a possible link because
of the way dupixent works. could you be decreasing
the ability for your body to fight off Demodex?
And it looks like there might be some legs to
that. So we've seen some pretty horrible conjunctivitis
cases with the use of that medicine, but you
can usually get it under control. Yeah, I've
seen it a couple of times and you withdraw the
medicine, it gets better. And in the meantime,
you know, again, prednisone, God's gift to medicine
and certainly God's gift to dermatology. And
it really just works. It makes them feel better
in a day or two. right away well speaking of
seborrheic dermatitis and Demodex we also have
rosacea we not as commonly seen in young kids
but certainly there are there are some kids that
will show up with something that looks like acne
but you're looking very closely at their skin
they don't have blackheads or or what we would
call open comedones or closed comedones for that
matter they've got more sort of the juicier zits
if you will the pustules the inflammatory papules
without the comedones that's a good clue that
maybe you're dealing more with rosacea in our
world there is a subset of rosacea that is certainly
driven we believe by Demodex and how does that
show up in in a person's eye Yeah. Their eyes
are red, irritated, scratchy, chronically. You
can usually see it's especially red right where
the blue or brown part of the eye meets the white.
There's like a ring of fire around that area.
And just their lids never look right. A parent
will say they just don't look right. They look
chronically red. Their margins of their eyelashes
are red. And a lot of times those kids get recurrent
styes, which are basically pimples. recurrent
chalazia, which are basically... blocked up glands.
Styes are the zits you could pop when you were
a kid. Chalazia are the deeper kind of cystic
things you couldn't pop when you tried when you
were, you know, a teenager. And those, you know,
we treat them with hot compresses, antibiotics,
antibiotic cortisone drops. And, you know, sometimes
they just need to, you know, be cut out over
time. But that's an ordeal in a child, right?
If you had a stye, I'd lay you back in the chair,
give you a shot of lidocaine and cut it out and
you'd go back to work in 15 minutes. A child
has to have general anesthesia, which is really
terrible. Going to sleep with general anesthesia
for pimples but but it's really disabling where
there's one there tends to be more and you know
they kind of there's something called "kissing"
styes where you get one on your upper lid and
then you get one adjacent to it on the lower
lid and you get this cycle of infection and uh
you know you have to cut the gland out and and
uh get rid of it at a certain point but it's
you know it's an ordeal for the child because
they have to go to sleep we see it all the time
all the time really it's that common Oh, yeah.
I mean, the pediatricians, family doctors will
first try and treat with antibiotics and hot
compresses. Really rarely oral. It's usually
not a cellulitic kind of thing. It's more localized.
And we'll try stronger antibiotic drops, usually
a quinolone class and prednisone with it, mixed
with it. And if it doesn't get better, you know,
we wait months and months and months unless there's
a reason to intervene sooner. But after four,
five, six months, you can get scarring. they're
really difficult to remove after a while. So
usually that four or five, six month period is
a good time to start thinking about removing
them because by the time everybody's schedules
align and you can get into the operating room,
it's usually a month or two later anyway. Oh,
that's good to know. Yeah, maybe I need to get
a little bit more aggressive in terms of when
I refer in. Well, the next condition that I wanted
to ask you about is certainly inflammatory, but
it's an autoimmune driven process called alopecia
areata. And that's sort of for the audience's
sake, that's where your own immune system has...
sort of bypass the normal protection that the
hair follicles, the sort of portals for where
your hair come out, normally protected, normally
wouldn't be attacked by your immune system. But
now the immune system, for whatever reason, has
decided that your hair is, quote unquote, a foreign
object and wants to get rid of it, drives an
inflammatory process around that hair. And eventually
the hair just kind of gives up and says, I'm
out of here and falls out. We see that and it
could certainly on the scalp is when it's most
probably most commonly showing up in my clinic.
And we call that alopecia areata. But certainly
it can involve the eyebrows, the eyelashes. We
call that alopecia totalis. And then we have
alopecia universalis, which is where all of the
hair is involved, including the groin area, the
underarms, the legs, whatever. You have... really
changed the way I approach that diagnosis because
the first thing I look at is, is it one-sided
or not? Can you talk a little bit about that?
Yeah. So, you know, one thing to think of is
if the kids have actually been... pulling their
lashes out too and you have to look and see if
the lashes are broken we can see it at the microscope
we worry about something called trichotillomania
where the kids are actually removing their lashes
and you know those children need you know universally
cognitive therapy and counseling it really usually
takes the parents by surprise when we tell them
that that's what we suspect because yeah everybody
has a hard time believing that their their child
could be really suffering that way and have a
lot of emotional distress causing them really
self -harm you know when you see all the lashes
gone then we think of alopecia when we see just
clusters of them specifically you know across
from their their dominant hand um it makes us
think more of a volitional uh pulling so if you're
right -handed and the left eye alone is sort
of intermittently affected that's a, that's a
pretty good hint that maybe yeah usually they
kind of go across you know that's what i found
you know i'm sure that i'm sure it's not 50 -50.
But usually it seems to be that they go across
their face. Is there a preference for the top
or bottom eyelids? The top. The top. The top
eyelids. They always pull the top. And the parents
absolutely will not believe you that this is
not an infection. It must be an infection. And
so sometimes, you know, along with recommending
cognitive therapy, we'll also recommend an antibiotic
ointment. The antibiotic ointment just makes
it harder for the kids to kind of get a purchase
of the lashes and pull them out. But we explain
to them it's like putting WD-40 on your eyelashes.
It's not fighting anything. But they need to,
you know, sit and talk to their child. and find
out what's going on or enlist a professional
and really help out along the way. One skin condition
close to my own heart, since I actually have
it, is something called vitiligo, another autoimmune
condition where, for whatever reason, your body
has decided to attack the melanocytes that make
the tan or the melanin in your skin. There are
a couple conditions that we're taught about when
we're learning pediatric dermatology where there's
an overlap between the skin and the eyes. Is
that something that you would see or would want
us to refer in more for that? In adults, we see
it from time to time. They're usually of Asian
descent, and we can see it be very disabling.
They have uveitis. They have diminished vision.
And it's usually been a chronic condition. In
children, it's uncommon. There is one condition,
Vogt-Koyanagi-Harada. They can affect those.
But thankfully, in children, it's uncommon. It's
more of a 20 to 30. maybe 40 year old but that
can be very impactful for vision and hard to
treat really hard to treat do you want to see
those kids if if the vitiligo is affecting their
eyelids or their eyebrows or is that not necessarily
a marker for involvement You know, I don't know
the clinical answer to that, but there's no harm
in ever looking because children never complain.
They really don't complain, especially if something's
only affecting one eye. They don't know. Nobody
covers one eye at a time to check and see what
their vision is like when they're eight or nine.
So it's never a bad idea to do a baseline exam
to be sure, because if you don't look, then you
don't. know. Well, switching gears back to something
you mentioned earlier, you use the term "herpetic."
That for the audience refers to a virus called
herpes simplex virus, HSV. I was taught that
about 90% of us - almost universally - are walking
around having been exposed to this virus, not
necessarily showing symptoms or signs of it,
but we have it. Very, very common. Can you talk
a little bit about how that might show up in
a kid? Yeah, so it would generally be the HSV
-1, which gives the fabled cold sore of the lip.
Usually it presents as pink eye in a child, unless
they're very small. And it's a bilateral condition
as a child, and it's treated really with antibiotic
drops because there are no telltale signs of
herpes the first time. If it recurs, whether
it's a few months later or a few years later
or decades later, you'll have pain sensitivity
and a chronic pink eye. And, you know, family
doctors will often just treat with an antibiotic
drop, you know, because most things don't need
to be referred to an ophthalmologist. But if
you're using a drop and a day or two goes by
and there's no improvement or the patient is
sensitive to light or in pain, they're always
taught again to refer to ophthalmology. children
or adults can have herpetic conjunctivitis. And
you wouldn't know it without a microscope. You
can't diagnose it without a slit lamp. In babies,
through the birth canal, they can encounter HSV
-1 or HSV -2. If a mother has an open lesion
at the time of birth, those children present
within the first day or two, or actually about
three to five, with hyperacute conjunctivitis.
So the child will be discharged. after birth
and a couple days later have a rip-roaring pink
eye. And those children are always readmitted
back to the hospital given high-dose IV antibiotics
and acyclovir, which is the treatment for herpes,
along with eye treatment as well. But it's very
disabling. It can scar the eye quickly, and it
needs to be treated expeditiously. So that's
an emergency. You'll take the kids in right away?
Oh, yeah, right away, yeah. Nobody wants to see
a child in pain or discomfort. A little less
of an emergency is another, well, another two
viruses, I guess. HPV, human papillomavirus,
which causes skin warts, and molluscum contagiosum,
a pox virus that causes... molluscum also known
as water bumps when those get around the eye
i find that's pretty much one of the hardest
places to treat because i would not normally
use my go-to molluscum medicine of cantharone or "beetle
juice" in that area out of risk for damaging the
eye itself i tend to fall back on either a topical
retinoid like Retin-a or Differin - something
on the weaker side - where you're putting a pinhead
amount of the medication on each of these little
bumps over maybe six to nine months with hope
that you're irritating it away. Of course, anytime
you're causing irritation around the eye, you're
at risk, I guess, of causing irritation around
the eye. Do you have any tricks when you see
these patients come in? Yeah, well, when it's
not right on the margin, clear nail polish. can
help. We've used that. Cimetidine in older kids,
the old Tagamet, you know, will work. But we
give them prednisone because the prednisone tamps
down the response. It gets very irritated, inflamed.
It's basically an allergy to the viral particles
that get shed from the lesion. Almost really
universally 30 years later, I don't think I've
ever seen molluscum last more than about eight
or nine months. But it looks very different around
the eyelid margin than on the rest of the skin
surface. You still have that umbilicated appearance,
but it's just...bigger, flatter, a little bit
different looking. But it gets better. Once in
a blue moon, you remove them if the child has
problems with the prednisone drops. But removing
them, they're usually inflamed, irritated, and
they can scar. So it's better to just kind of
wait it out and let the body figure it out and
mount an immune response and get rid of it. That's
what we do. Yeah, yeah, I agree. I mean, I think
I've heard of some people who might curette them
off if they're just one or two off to the side.
But most of the time, we're either using the
topicals I mentioned or kind of just hoping for
the best or treating aggressively the other ones
not around the eye with the hope that the immune
system kicks in and clears the virus everywhere.
So speaking of chronic. pink eye one of the things
that i have a hard time with sometimes is differentiating
between infection versus some of these inflammatory
skin conditions versus allergic reactions so
an actual allergy to a product that the child
might be using like what we call a "rinse-off"
product where they're using a shampoo that runs
down their face and hits that very very thin
eyelid skin which is is for the audience's edification.
It's pretty thin skin, right? I don't know how
thin it is, but I know it is the thinnest skin
of the body. The thinnest skin on the body. So
we tell our patients that that's many times the
very first place that an allergic reaction that
could happen anywhere else might pop up because
there's just less skin to have to go through
in those areas. What are you seeing in terms
of allergic reactions of the eyelids? What are
kids coming in for? Yeah. You know, sometimes
it's really hard to figure it out because sometimes
the parents haven't done anything different.
The same products that their child has used,
the same shampoo, the same soap, everything's
the same. But the product itself has been reformulated.
I had a really great. really good detective mother
once who figured out that her child was allergic
to ammonium quaternium 4. i think that was
it and it was some kind of preservative that
was not in the old formulation of whatever shampoo
that was in a new formulation, or a child really
broke out into just a fulminant allergic response.
And we tell them to use Benadryl, shower off
everything. And a lot of those kids, we give
a topical antihistamine drop. It gets better
kind of quick. It's like right quick on, quick
off. They don't really need the prednisone as
much. Do you guys in ophthalmology do a version
of what we would call patch testing? Are you
familiar with what I'm talking about? I know
what a patch test is. Yeah, but we don't have
anything like that. Oh, okay. Yeah, not in the
eye, no. Well, we can be a resource for you.
We have our sort of eye panel where we have some
of the products most commonly associated. You
mentioned Quat-14, I think, is the formaldehyde
releaser. These formaldehyde products are very
commonly in fingernail polish. And the same way
you referenced that for trichotillomania, the
dominant hand touching the eyelid, that's one
of the very first places. You don't actually
get the nail polish allergy on the fingernails
as much as you do up on the eyelid. So it's just
an interesting thing. But yeah, we can certainly
help identify a specific culprit with that. And
I think right now our go -to patch test is a
90-test group. So there's a lot of things on
there that we can identify. So I mentioned
earlier that you and I mostly work together for
infantile hemangiomas and port wine birthmarks.
For the pediatricians and family medicine doctors
out there, when do you absolutely want to see?
a kid with a suspected infantile hemangioma or
port wine birthmark. Yeah, anytime it's really
around the eye perioral area, especially the
upper lid, but even the lower lids can grow and
be very disabling. They can really disturb your
visual development. Vision is a birthright, but
you're not born with it. And if a child's unable
to see because their lid is closed over the eye,
over the pupil. That eye, if it's not open in
a few months, we'll never learn to see. The brain
really develops. And there was a Nobel Prize
won in 1972, Hubel and Wiesel. They did work
on a cat. I'm sorry for all the cat lovers out
there, but they sewed one cat's eye shut, one
eye shut and left the other open. They showed
that the lateral geniculate, the neural pathways
actually grow differently when not stimulated
by light at an early age. After you're three
or four months old, that's not really as much
of an issue. But certainly in the beginning,
you really need light to stimulate the visual
cortex to grow and the optic path and track to
grow. So we get very concerned. And propranolol,
Hemangeol. was such a game changer maybe 15,
18 years ago when it was really developed by
chance. There was a child with cardiac failure
who had a hemangioma around their heart. They
gave the child propranolol because they were
in failure and it made the hemangioma shrink
in a couple days. And I guess in the old days,
that would have taken a year or two in journal
articles to come out. But it was in the internet
era and there were message boards and chat rooms.
And within a few months, everybody was doing
it. A lot of those have been sequenced and found
to have some antigens that come from the placenta,
I'm sure you know. And they're associated with
premature birth. But Hemangeol has really been
a game changer. In the old days, we would inject
them with prednisone. respond. They could be
resected, which was very disfiguring for the
children. And this is night and day. It's a miracle.
I tell people I've witnessed at least two miracles.
I think with the psoriasis medicines, I'm on
my third sort of class of medications. But Hemangeol
really was the first miracle that I've witnessed
as a physician and a game changer. So these hemangiomas
you're referencing, as they affect vision, It
really is a "use it or lose it" phenomenon, it
sounds like. And getting them into you. It's
interesting. Can you share your technique for,
I don't want to compare the kids to the cats
that you were mentioning, but you sort of do
the opposite to force the affected eye to be.
better utilized. Is that correct? Yeah. So, you
know, if you have an eye that's partially occluded
because of the weight, the volume of the blood
in the eyelid, you'll patch the other eye. The
good eye. You'll patch the good one. It's been
done for 5 ,000 years for different problems,
not hemangiomas. And you patch it so that you
force that child to use their muscles, their
brow muscles to open the lid or just get... more
stimulation than they would without it. And that's
very effective. And again, all these children
are very small. They're a few weeks, a few months
old. So an hour a day, if the child is up for
three, four, five hours a day, an hour a day
is 20, 25 % of their day. That's a lot. That's
equivalent to four or five hours for an older
child. So even a half an hour, an hour for some
of these kids, but the medicine just works. days,
the hemangiomas will shrink a whole bunch so
that they really respond so well. It's amazing.
One of the skin conditions that does not respond
to Hemangeol is a port wine birthmark, a flat
red. birthmark that that can be usually pretty
easily distinguished between infantile hemangiomas
but when you talk about a segmental hemangioma
early early on before the texture has changed
sometimes it's a little hard. When, when would
you as a pediatric ophthalmologist want to see
a kid with a port wine birthmark specifically?
Well, that's changed a little bit since i i started
studying but where does it get you most nervous
that this might be a harbinger of an underlying
condition like Sturge -Weber syndrome? If it
is involving the upper eyelid, brow, and usually
if you pull the eyelid up, you'll also see a
little bit of a "blush" to the upper sclera. It'll
look a little red. And that's a real serious
warning that you have a Sturge-Weber that's
affecting the eye. Most children can go on to
get glaucoma. and they're very difficult to treat
and without it they'll you know lose vision at
a very early age it's very very important so
anytime that certainly that involves the upper
eyelid is especially impactful and that's a patient
that you would probably see once a year at least
i would imagine Yeah, you know, sometimes even
more, honestly, Andrew, in the beginning, because,
you know, you can't be sure and things change.
Sometimes it can take a few months, but you'd
probably see them after you're sure that there's
nothing there for a few years yearly because
things change. But usually you can tell. pretty
soon in the first few months but if a child's
referred when they're a few weeks or a month
old it can be hard to make that determination
and things can change. Back when i was training
in pediatrics we did a study with a pediatric
ophthalmologist at the hospital there that looked
at lasering port wine birthmarks right around
the eye with the specific goal in mind of proving
in quotes that lasering the cutaneous lesion,
the birthmark, did not increase the pressure
of the eye, meaning maybe you were destroying
some of the outlet flow of the blood and maybe
that would back up the pressure. Have you ever
sort of discussed or seen the contralateral of
that, which is lasering helps with the glaucoma?
Does it do anything for that? No, I've never
seen it help, but I've also never seen it hurt.
Okay, that's good to know. Yeah, I've never seen
it hurt. I haven't seen it a lot. I mean, probably
fewer than a dozen or two cases in my career.
The kids have been lasered for that, but I've
never seen it hurt. Great. That makes me feel
a lot better. Yeah. And if anything, honestly,
it helps because the children are no longer as
self-conscious about the lesion. And so from
a psychosocial development thing, it helps them
a lot because kids don't want to feel different
in any way. Well, that's a great segue into my
acne question that I've been so excited to ask
you. So obviously you have severe acne. We don't
have a cure for severe acne yet, but we've got
something that comes pretty close to treating
it in most people well, and that's a medicine
called isotretinoin. Used to be sold under the
name Accutane. The history that I remember is
that they stopped selling Accutane under that
brand name because people kept suing the makers
of Accutane. They said, we're done. You guys.
figure it out on your own. One of those side
effects that I do talk to every one of my patients
about, especially if they're driving age, is
what Accutane can do to your night vision. And
is that something that you're familiar with?
Oh, yeah. Because it gives you very dry eye,
okay? Universally, these kids all get dry eye.
And the surface of your eye, the best analogy
that I once heard, it's like the surface of the
Hubble. space telescope. It has to be perfectly
smooth and clean and perfect. Anything that disturbs
the surface gives you glare and gives you reduced
vision. Whether you're a 75-year-old with dry
eyes or whether you're a 12-year-old with dry
eye, that's why a lot of older people have trouble
driving at night. It's just because they have
very dry eyes or they have cataracts. But when
your eyes get dry, you have tremendous amount
of glare. take a lot to irritate the surface
of your eye and really interfere with your vision
because it's a very small area that really does
most of the visual processing. So this is not
an actual physical change that the medication
isotretinoin is causing in the eye, it's a side
effect of the dryness? Yeah, I mean, look, because
of its effects on vitamin, because it's a vitamin
A chemical, maybe it in some way impacts the
visual cascade in the retina. Not in a way that
I'm aware of. It's mostly from dry eye, but we
also worry as well about idiopathic intracranial
hypertension from taking isotretinoin. And we
have to be careful of kids who complain of blurred
vision, trouble with their vision, or headache.
um that they can rarely um you know have what
we call pseudotumor cerebri from that any vitamin
a derivative even eating a polar bear liver will
give it to you uh. We have a couple of medications -
you tell me if i'm missing any big ones- um the
the tetracyclines: doxycycline, minocycline; oral
contraceptive pills (birth control pills); isotretinoin,
and which one else? What am I forgetting? Those
are the three big ones that I think. That's what
I think of too. Yeah, exactly. Yeah. And that,
like you said, will present as a severe headache
that does not get better with a Tylenol or a
Motrin. You go to sleep expecting your headache's
gone the next morning. You wake up, it might
even be worse, right? It's pretty debilitating.
Well, that's a great question. So for the Accutane
user and just in general, what are the ways to
prevent these sort of common eye problems that
we talked about specifically, I guess, dryness
of the eye? But if you were telling your own
kids, hey, you've got a lifetime ahead of you.
Here's how I would take best care of your eyes.
What are some of the suggestions you would have
us do? Protective eyewear. It's the most impactful
thing. dumbest things happen when you don't expect
it. And just, you know, any sport, anything where
you're going to contact a ball, you should really
wear protective eyewear. That it's just wearing
a seatbelt for your eye. And, you know, some
of the injuries that we see are, you know, preventable,
heartbreaking. permanent and life-changing.
And it's also very important for the two or three
percent of the population that has a quote "lazy
eye" - an eye that doesn't see well. I've never
seen the lazy eye injured. I've only seen the
good eye injured because if you hear a sound,
you turn so that you can see the sound and that's
the fist coming at your face and it hits your
good eye or the ball. Anything always hits the
good eye. So it's really impactful, just like
you wear a seatbelt to wear safety glasses. The
normal everyday person without a skin condition
or an eye condition, do they need or should they
be using? eye lubricating drops is that is that
good yeah i mean your eyes are kind of on autopilot
when you're on Accutane just like you might use
vaseline on your lips you want to use artificial
tears sometimes the non-preserved as opposed
to the preserved ones because they're less irritating
but for the most part your eyes are really on
autopilot if you just have a good nutritious
you know diet you don't really need artificial
teardrops at a young age if you do um you probably
need to go play outside more and look at you
and and look at instagram a little bit less because
your eyes dry out when you have a lot of screen
time you don't blink as much and the blink lubricates
your eye but it also moves the mucus around and
the oil from the meibomian glands in your lids
and it's important to kind of flex those glands
so that they work properly and you know whether
it's screen time on a TV or an ipad or whatever
you don't blink as much and that contributes
to dryness. But if you have no symptoms, it's
hard to fix something that isn't broken. So I'd
say probably not. Okay, that's good to know.
Good to know. Well, my last question before I
let you out of here, this has been one that I've
been really just, I've never been able to do
this myself. So maybe I wasn't being fair to
myself. So very specific skin condition called
"neurofibromatosis". - NF1.. It's a chromosome 17
mutation. And there's one of the specific findings
in the constellation of this condition is something
called Lisch nodules in the eye. Can you explain
what they are? And very importantly, am I supposed
to be able to see them before you? Absolutely
not. You need a microscope to see them. At least
I need a microscope to see them, especially in
a little child who's not sitting still for more
than a minute. But technically, a lish nodule
is a hamartoma, an overgrowth of tissue that's
normally there, but just more of it. It looks
like a little wart on the iris. And you can have
one or two of them. You can have dozens of them.
They look very different. in a brown-eyed children
than a blue-eyed child. But they're uncommonly
associated with NF. And we're always asked to
look. But at the end of the day, they don't do
anything to the vision. It's just a feature of
the genetic disease. but it doesn't do anything
to the vision. In the old days, before genetic
testing, it was helpful, inclusive of the criteria
and whatnot. Now we look, but whether the child
has them or not, it doesn't matter. Now, there
are also hamartomas. of the retina in kids who
have neurofibromatosis and their hamartomas in
kids who have tuberous sclerosis, a different
autosomal dominant condition, and you can see
those they're basically bumps in the retina and
their retinal tissue but you should not even
even you who is so excellent can't be expected
to look without a microscope. Thank God... i remember
distinctly it was a picture on the front cover
of one of our general dermatology - not even a
pediatric dermatology textbook. And it had about
five pictures of very specific things. One of
them was a person's eye, a person had a background
diagnosis of neurofibromatosis-1. And when
you read the little insert of what the pictures
were, it said "demonstration of Lisch nodules."
And it's like, I can't see these things. I don't
know what's wrong with me. Okay. Well, I want
to thank Dr. Robert Kitei for taking the time
out of his very busy clinic schedule to help
educate us on these important topics. I felt
like, dare I say, an eager "pupil" listening to
him teach about kids' overlapping skin and eye
conditions. Thanks for joining us on this episode
of Don't Be Rash. It was great having you, Dr.
Kitei. And to our audience, stay tuned for our
next episode. 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.