WEBVTT 00:00:02.319 --> 00:00:05.040 Welcome to the Don't Be Rash Pediatric Dermatology 00:00:05.040 --> 00:00:07.679 Podcast, the owner's manual for your kid's skin. 00:00:07.820 --> 00:00:10.820 I'm your host, Dr. K, board -certified pediatric 00:00:10.820 --> 00:00:13.619 dermatologist and father of two boys. I'm here 00:00:13.619 --> 00:00:15.859 to chat with you to promote dermatological education 00:00:15.859 --> 00:00:18.839 and improve skin health in our children everywhere. 00:00:19.500 --> 00:00:27.839 Let's get started. Welcome to Don't Be Rash, 00:00:28.019 --> 00:00:29.980 the pediatric dermatology show coming to you 00:00:29.980 --> 00:00:31.899 from beautiful, historic Bethlehem, Pennsylvania. 00:00:32.280 --> 00:00:34.200 I'm your host and board -certified pediatric 00:00:34.200 --> 00:00:37.079 dermatologist, Dr. Andrew Krakowski. On today's 00:00:37.079 --> 00:00:39.420 show, we're going to get "down in the dumps.". That's 00:00:39.420 --> 00:00:41.380 right, we're going to be discussing diaper rashes, 00:00:41.520 --> 00:00:44.100 or as we call them in pediatric dermatology, more 00:00:44.100 --> 00:00:47.579 generally,, "diaper dermatitis." Here's the clinical 00:00:47.579 --> 00:00:49.880 scenario: You have a six -month-old baby with 00:00:49.880 --> 00:00:53.159 a bright red rash and satellite pustules. Don't 00:00:53.159 --> 00:00:54.780 worry, if you don't know what that is, you soon 00:00:54.780 --> 00:00:58.210 will. Is this caused by irritation from the poop 00:00:58.210 --> 00:01:01.289 and pee? Or is this yeast? Or is it a combination 00:01:01.289 --> 00:01:05.349 of both? Helping me "get to the bottom" - so to 00:01:05.349 --> 00:01:07.810 speak - is our guest pediatric dermatologist co 00:01:07.810 --> 00:01:11.129 -host, Dr. Caroline Piggott. In addition to being 00:01:11.129 --> 00:01:13.010 one of my best personal friends and colleagues, 00:01:13.450 --> 00:01:16.269 Dr. Piggott is a pediatric dermatologist at Scripps 00:01:16.269 --> 00:01:19.489 Clinic, in San Diego. Welcome, Dr. Piggott. Thanks 00:01:19.489 --> 00:01:21.569 for joining me today to talk about a topic not 00:01:21.569 --> 00:01:24.269 everyone would be so willing to try to tackle. 00:01:24.969 --> 00:01:27.370 Thank you so much for having me. This is something 00:01:27.370 --> 00:01:29.870 we encounter really often in clinic, a major 00:01:29.870 --> 00:01:32.049 concern for families. So I think this is a great 00:01:32.049 --> 00:01:35.189 topic to discuss. Yeah, it really is one of the 00:01:35.189 --> 00:01:38.310 most common things that I see in my pediatric 00:01:38.310 --> 00:01:40.930 dermatology clinic, which means if it got to 00:01:40.930 --> 00:01:44.769 me, I can only imagine how many cases of diaper 00:01:44.769 --> 00:01:47.930 rash our pediatrician and family medicine colleagues 00:01:47.930 --> 00:01:50.629 are seeing before they refer those kids to us. 00:01:50.629 --> 00:01:53.439 Is that fair? Oh, totally. And just as a mom 00:01:53.439 --> 00:01:55.400 in general, it's a concern you have with any 00:01:55.400 --> 00:01:57.280 baby and probably a lot of them don't even go 00:01:57.280 --> 00:02:01.659 to the doctor. Yeah. And it's and it's such you 00:02:01.659 --> 00:02:04.560 know, it's such an opportunity, I feel, for education... 00:02:04.700 --> 00:02:08.599 You...you have a baby. No one. I mean, I've 00:02:08.599 --> 00:02:11.719 had two of them. Right. So I've never had someone 00:02:11.719 --> 00:02:13.819 come into the room before we were discharged 00:02:13.819 --> 00:02:16.860 from the hospital to tell us. There's a right 00:02:16.860 --> 00:02:19.139 way or a wrong way to take care of poop and pee 00:02:19.139 --> 00:02:21.780 in the diaper area. And if you just got that 00:02:21.780 --> 00:02:24.740 little bit of education, I think you'd be 100% 00:02:24.740 --> 00:02:28.620 better off. Absolutely. And there's a lot of 00:02:28.620 --> 00:02:31.659 misinformation online too. Even if you haven't 00:02:31.659 --> 00:02:33.219 been taught about it, when you read about it 00:02:33.219 --> 00:02:35.159 online, there's just so many different opinions. 00:02:35.280 --> 00:02:37.580 It's hard to know where to begin. Yeah, it's 00:02:37.580 --> 00:02:39.020 actually kind of scary because some of the stuff 00:02:39.020 --> 00:02:41.800 is just wrong, so we'll get to that. Let's talk 00:02:41.800 --> 00:02:43.960 a little bit about what makes the diaper area 00:02:43.960 --> 00:02:45.979 such a unique environment. I mean, it's normal 00:02:45.979 --> 00:02:49.620 skin, right? But there's some things that happen 00:02:49.620 --> 00:02:53.659 in that specific environment under an occlusive 00:02:53.659 --> 00:02:57.110 diaper that changes some things for us. Absolutely. 00:02:57.310 --> 00:03:00.250 And we're the only species that uses a diaper, 00:03:00.270 --> 00:03:02.590 really. The problem, there's a couple issues. 00:03:02.789 --> 00:03:05.849 First, there's occlusion. You have moist environment 00:03:05.849 --> 00:03:09.449 due to urine or stool. And then you have something 00:03:09.449 --> 00:03:11.889 pressed right up against it that's rubbing against 00:03:11.889 --> 00:03:14.530 it all day. Added on to that, there's sweat, 00:03:14.650 --> 00:03:17.189 especially in kids who live in warm climates. 00:03:17.270 --> 00:03:19.650 There's also all those things mixed together 00:03:19.650 --> 00:03:22.490 make a perfect environment for a rash or irritation 00:03:22.490 --> 00:03:25.750 to occur. Yeah. And on top of that, you're talking 00:03:25.750 --> 00:03:28.189 about a newborn baby. So, you know, we know the 00:03:28.189 --> 00:03:30.650 skin barrier on children is a little thinner 00:03:30.650 --> 00:03:33.870 compared to our adults. In that particular area, 00:03:34.069 --> 00:03:36.750 you're probably talking a higher pH, so not what 00:03:36.750 --> 00:03:40.229 the normal skin is used to seeing. And everything 00:03:40.229 --> 00:03:42.849 is a little leakier as well because of that thinner 00:03:42.849 --> 00:03:45.129 skin barrier. And then you've got, you know, 00:03:45.150 --> 00:03:48.509 obvious change or the obvious big difference 00:03:48.509 --> 00:03:52.610 is you're pooping into. basically a bucket that's 00:03:52.610 --> 00:03:55.169 held right up against the skin for at least a 00:03:55.169 --> 00:03:58.810 couple of minutes right and you know to me when 00:03:58.810 --> 00:04:01.509 I talk about it with my families they always 00:04:01.509 --> 00:04:06.449 are amazed at why the skin can get so irritated 00:04:06.449 --> 00:04:09.229 just from that and it's like well I don't know 00:04:09.229 --> 00:04:12.189 how you approach that but I use the analogy or 00:04:12.189 --> 00:04:13.889 not analogy it's really kind of a story like,.. 00:04:13.889 --> 00:04:17.550 Imagine you're a bite of food that gets taken 00:04:17.550 --> 00:04:20.850 into the mouth goes down the esophagus in your 00:04:20.850 --> 00:04:22.529 stomach. Now it's going through the intestinal 00:04:22.529 --> 00:04:25.189 tract and finally it comes out the other end. 00:04:25.670 --> 00:04:28.250 It had to have been digested. And what is it 00:04:28.250 --> 00:04:30.470 getting digested by? Enzymes, chemicals that 00:04:30.470 --> 00:04:32.829 are breaking down that food into something that 00:04:32.829 --> 00:04:36.389 your body can then absorb into it for sustenance 00:04:36.389 --> 00:04:39.670 and energy, right? Well, those enzymes are also 00:04:39.670 --> 00:04:41.949 coming out the bottom end and landing right in 00:04:41.949 --> 00:04:43.970 that diaper. And when you put that on the skin, 00:04:44.129 --> 00:04:47.139 you can get into some real trouble. Yeah. And, 00:04:47.240 --> 00:04:49.839 you know, we all have normal skin flora on our 00:04:49.839 --> 00:04:52.220 skin, but stool also can carry with it certain 00:04:52.220 --> 00:04:55.100 pathogens that like to live in that environment 00:04:55.100 --> 00:04:57.860 that are then sitting against the skin for, you 00:04:57.860 --> 00:05:00.899 know, minutes to hours. There's also, you know, 00:05:00.899 --> 00:05:03.040 depending, especially when babies are a little 00:05:03.040 --> 00:05:05.079 bit older or depending on what the mother is 00:05:05.079 --> 00:05:07.839 eating in her diet, if the baby's breastfed, 00:05:07.939 --> 00:05:11.339 different foods process differently and have 00:05:11.339 --> 00:05:13.560 different pHs when they come out the other end. 00:05:13.639 --> 00:05:16.069 Is it a spicier diet? Is it more bland of a diet? 00:05:16.149 --> 00:05:18.470 Things like that even play a role. Yeah. And 00:05:18.470 --> 00:05:20.949 then you get into even more specific clinical 00:05:20.949 --> 00:05:23.949 scenarios where let's say you never had a problem 00:05:23.949 --> 00:05:27.990 with diaper dermatitis, but now your baby or 00:05:27.990 --> 00:05:32.550 young infant is suffering through like a gastroenteritis 00:05:32.550 --> 00:05:35.470 where, hey, everything else is probably going 00:05:35.470 --> 00:05:38.670 to be okay, but you're pooping 14 times in 24 00:05:38.670 --> 00:05:41.589 hours. No matter what, that's going to cause 00:05:41.589 --> 00:05:44.139 some sort of irritation. Exactly. Or a kid on 00:05:44.139 --> 00:05:47.579 antibiotics. The antibiotics themselves can change 00:05:47.579 --> 00:05:50.899 the pH of the poop or, you know, what's in the 00:05:50.899 --> 00:05:54.459 poop and make it looser, more irritated. Or another 00:05:54.459 --> 00:05:56.860 thing that can affect it is even if kids have 00:05:56.860 --> 00:05:59.519 allergies, it changes their poop and then that 00:05:59.519 --> 00:06:02.610 poop is then rubbing against the skin. Yeah. 00:06:02.730 --> 00:06:06.430 So let's take more of a 50,000 -foot view look 00:06:06.430 --> 00:06:08.170 at this, although I don't know if you want to 00:06:08.170 --> 00:06:10.470 look at it any more than I do. But let's say 00:06:10.470 --> 00:06:13.850 we're considering diaper rash in general. There's 00:06:13.850 --> 00:06:16.550 a lot of specific causes for why a kid could 00:06:16.550 --> 00:06:19.750 have diaper rash, right? Oh, absolutely. There's 00:06:19.750 --> 00:06:22.089 about a dozen different things that are on our 00:06:22.089 --> 00:06:24.430 what we call "differential diagnosis" - or things 00:06:24.430 --> 00:06:27.310 that can potentially cause them. And one of the 00:06:27.310 --> 00:06:29.470 key things to know about is some of the clues 00:06:29.470 --> 00:06:33.220 to look for to figure out. which one it is. So 00:06:33.220 --> 00:06:35.920 the one that kind of already put our foot in, 00:06:35.939 --> 00:06:39.579 so to speak, is this idea that poop and pee itself 00:06:39.579 --> 00:06:42.980 can irritate the skin. And we call that "Irritant 00:06:42.980 --> 00:06:46.259 Diaper Dermatitis." That doesn't sound very specific, 00:06:46.399 --> 00:06:48.639 but if you mention that to a pediatric dermatologist, 00:06:48.779 --> 00:06:52.180 we know that what you're basically saying is 00:06:52.180 --> 00:06:56.040 that the urine and feces itself is irritating 00:06:56.040 --> 00:06:58.279 the skin. And I think we already alluded to the 00:06:58.279 --> 00:07:00.399 fact that that's the most common cause, right? 00:07:00.439 --> 00:07:04.480 Like, way more than anything else. Yeah. Yeah. 00:07:04.560 --> 00:07:07.160 When in doubt, statistically speaking, that's 00:07:07.160 --> 00:07:11.480 what is the most common cause. And what we typically 00:07:11.480 --> 00:07:15.259 do when a baby presents is we look for first 00:07:15.259 --> 00:07:17.420 some of the key visual clues to figure out what's 00:07:17.420 --> 00:07:21.839 going on. And with this particular type of dermatitis 00:07:21.839 --> 00:07:25.339 or irritant diaper dermatitis, It typically presents 00:07:25.339 --> 00:07:29.220 as sort of a beefy red-colored rash or plaque. 00:07:30.100 --> 00:07:32.660 Sometimes it might look a little shiny, not always 00:07:32.660 --> 00:07:35.319 though. And one of the things, because if you 00:07:35.319 --> 00:07:38.259 think about the anatomy and where the skin is 00:07:38.259 --> 00:07:41.439 rubbing with the diaper, it typically is located, 00:07:41.660 --> 00:07:44.860 you know, sort of in the pubic area, maybe on 00:07:44.860 --> 00:07:47.459 the inner thigh, but because of where the diaper 00:07:47.459 --> 00:07:51.040 rubs more and rubs less, it often spares the 00:07:51.040 --> 00:07:54.720 actual very edge of the folds and the groin so in other 00:07:54.720 --> 00:07:57.279 words there's a skip area where the rash often 00:07:57.279 --> 00:07:59.759 you know it disappears and then then reforms 00:07:59.759 --> 00:08:03.079 on the other edge passing sort of jumping from 00:08:03.079 --> 00:08:05.420 the inner thigh skipping the fold and and then 00:08:05.420 --> 00:08:08.819 moving over onto the pubic area. Basically the 00:08:08.819 --> 00:08:13.199 "area under the chunk" is sort of protected is 00:08:13.199 --> 00:08:17.160 that fair? Yes, it spares the folds. Spares the 00:08:17.160 --> 00:08:20.600 folds, yeah. And that's a mechanical thing, right? 00:08:20.660 --> 00:08:24.519 So, if the chunk wasn't there and that poop and 00:08:24.519 --> 00:08:26.980 pee could get into that area, it would also cause 00:08:26.980 --> 00:08:29.100 the same rash that you can see everywhere else. 00:08:29.199 --> 00:08:31.300 But it's a clue that it's something that's right 00:08:31.300 --> 00:08:34.620 up against the diaper, right up in contact, hence 00:08:34.620 --> 00:08:37.379 the name "Irritant Contact Dermatitis." And is 00:08:37.379 --> 00:08:39.279 this one like, this is one where I would say, 00:08:39.340 --> 00:08:41.919 geez, when your history of recent antibiotic 00:08:41.919 --> 00:08:46.500 use or upset. stomach causing diarrhea that's 00:08:46.500 --> 00:08:48.220 where you really start to think about this one 00:08:48.220 --> 00:08:51.360 as well. Exactly but you know it's not always 00:08:51.360 --> 00:08:53.240 the case where there's a history of that some 00:08:53.240 --> 00:08:57.279 babies you know one of the most common things 00:08:57.279 --> 00:09:00.039 that pediatrician sees is parents you know calling 00:09:00.039 --> 00:09:02.450 in with questions: Why did my baby's poop change? 00:09:02.590 --> 00:09:04.889 You don't always have a reason. Sometimes it's 00:09:04.889 --> 00:09:07.129 looser. Sometimes it's more foreign. Depends 00:09:07.129 --> 00:09:09.549 on what the baby or mother is eating. And so 00:09:09.549 --> 00:09:12.590 it's not always history of an infection or things 00:09:12.590 --> 00:09:14.590 like that. Sometimes just the stool changes on 00:09:14.590 --> 00:09:17.789 its own periodically. Now, within this category, 00:09:18.129 --> 00:09:20.929 I also include something that's really much more 00:09:20.929 --> 00:09:23.429 severe in my mind, something called Jacquet's 00:09:23.429 --> 00:09:27.970 or Jacquet's erosive diaper dermatitis. Is that 00:09:27.970 --> 00:09:31.139 fair? Yes, it's almost like it's basically a 00:09:31.139 --> 00:09:34.779 fancy name for an extreme form of this. We see 00:09:34.779 --> 00:09:37.399 it a lot in like premature babies who have really 00:09:37.399 --> 00:09:42.220 thin skin or just cases where the stool is loose 00:09:42.220 --> 00:09:45.240 just for longer periods of time just consistently. 00:09:45.480 --> 00:09:48.980 The irritation becomes so bad that it actually 00:09:48.980 --> 00:09:51.840 tears a little layer superficially of the skin 00:09:51.840 --> 00:09:55.179 and the baby has these very painful ulcers. I 00:09:55.179 --> 00:09:57.240 mean, imagine whether it's in your diaper or 00:09:57.240 --> 00:09:59.700 not, if you have a little sore on your skin and 00:09:59.700 --> 00:10:02.019 you rub a piece of material against it over and 00:10:02.019 --> 00:10:04.220 over all day, anybody is going to have a sore 00:10:04.220 --> 00:10:07.940 area. And the poor baby unfortunately suffers 00:10:07.940 --> 00:10:10.960 from this. Yeah, it's very painful. It has to 00:10:10.960 --> 00:10:12.899 be differentiated from something called "herpes 00:10:12.899 --> 00:10:16.600 simplex virus," especially in a younger kid, two 00:10:16.600 --> 00:10:19.539 weeks old. You have to make sure it's not herpes 00:10:19.539 --> 00:10:21.899 before you think about anything, in fact. But 00:10:21.899 --> 00:10:24.919 I don't know about you, but some clues that I 00:10:24.919 --> 00:10:29.110 have is it tends to be worse. closer to the actual 00:10:29.110 --> 00:10:32.049 anus. And then as you get farther and farther 00:10:32.049 --> 00:10:34.629 away, it seems to kind of get a little better. 00:10:34.730 --> 00:10:37.309 That sometimes can be a clue that it's this Jaquet's. 00:10:37.409 --> 00:10:42.009 But yeah, it can be tremendously painful and 00:10:42.009 --> 00:10:46.230 horrific looking. It would scare anybody, right? 00:10:46.700 --> 00:10:49.059 Yeah. And I agree completely. One of the things 00:10:49.059 --> 00:10:50.940 on your differential for those would be infection. 00:10:51.080 --> 00:10:53.679 But usually these ulcers are very dry looking, 00:10:53.860 --> 00:10:55.559 like they might be open and sore, but there's 00:10:55.559 --> 00:10:58.740 no pus - or we call it purulence - coming out or 00:10:58.740 --> 00:11:01.419 fluid. They're often just very just dry and raw. 00:11:01.639 --> 00:11:04.200 So probably in my mind, at least the next most 00:11:04.200 --> 00:11:07.879 common diaper dermatitis cause, specific cause, 00:11:08.000 --> 00:11:11.720 would be yeast. And we call that... "Candidal, 00:11:11.759 --> 00:11:14.620 Diaper Dermatitis." Candida is the species 00:11:14.620 --> 00:11:16.919 name of the yeast in this particular case that's 00:11:16.919 --> 00:11:19.700 driving the problem. Talk a little bit about 00:11:19.700 --> 00:11:21.639 what you're looking for when you're considering 00:11:21.639 --> 00:11:25.049 is yeast possibly the culprit. When you have 00:11:25.049 --> 00:11:27.730 just the regular irritant diaper dermatitis, 00:11:27.769 --> 00:11:30.070 yeast can eventually infect it. So this is always 00:11:30.070 --> 00:11:32.710 something you want to look for on your differential. 00:11:32.870 --> 00:11:34.970 And sort of the classic clue is we call them 00:11:34.970 --> 00:11:37.750 "satellite pustules." So you'll have the rash, 00:11:37.909 --> 00:11:40.309 but then there might be individual discrete bumps 00:11:40.309 --> 00:11:43.429 or papules that have a little pus or fluid in 00:11:43.429 --> 00:11:46.149 the center, almost white or off-white. And there 00:11:46.149 --> 00:11:48.210 will be often a couple of them, that's why we 00:11:48.210 --> 00:11:50.429 call them "satellites," often around the periphery. 00:11:50.879 --> 00:11:53.080 And that's one of the clues. Often the color 00:11:53.080 --> 00:11:56.779 is even more red than the typical rash. And oftentimes 00:11:56.779 --> 00:12:01.539 you even smell a little bit of an odor. I'm not 00:12:01.539 --> 00:12:03.759 getting that close because I don't want to smell 00:12:03.759 --> 00:12:08.620 any odor. The mom will tell you it smells weird. 00:12:08.700 --> 00:12:12.799 Okay, sure. And now this one, the satellite port, 00:12:12.860 --> 00:12:15.559 do you attribute that to sort of the yeast organism 00:12:15.559 --> 00:12:17.519 itself kind of getting on the skin and spreading 00:12:17.519 --> 00:12:19.980 on its own, right? It can go outside of the normal 00:12:19.980 --> 00:12:22.799 diaper spot. Yes. And the thing with this is 00:12:22.799 --> 00:12:25.159 it does, we mentioned that the sort of conventional 00:12:25.159 --> 00:12:28.000 diaper dermatitis will spare sometimes the folds. 00:12:28.080 --> 00:12:30.120 Well, this one, this one does not spare anything. 00:12:30.240 --> 00:12:32.779 It just keeps going and it'll continue even within 00:12:32.779 --> 00:12:35.980 that fold of the skin. And I don't know, you 00:12:35.980 --> 00:12:37.840 and I were trained at the same place, but I remember 00:12:37.840 --> 00:12:40.500 Dr. Friedlander, one of our mentors, always telling 00:12:40.500 --> 00:12:43.080 you, you got to check the mouth, right? Because 00:12:43.080 --> 00:12:47.480 yeah, many times, like a lot. more than half 00:12:47.480 --> 00:12:50.460 you're going to find oral thrush that white tongue 00:12:50.460 --> 00:12:53.419 which is yeast on the tongue on that baby too. 00:12:53.419 --> 00:12:55.440 And it makes sense you're swallowing that and 00:12:55.440 --> 00:12:57.779 pooping it out into the diaper which again is 00:12:57.779 --> 00:13:00.080 just really kind of a bucket now you've got that 00:13:00.080 --> 00:13:03.039 yeast organism held in the bucket up against 00:13:03.039 --> 00:13:05.000 the skin it's no surprise that it's taken off. 00:13:05.470 --> 00:13:10.470 I agree. And then if you're not sure, we dermatologists 00:13:10.470 --> 00:13:14.809 do a test called a KOH, which is we take a little 00:13:14.809 --> 00:13:16.830 sample of the skin and look at it under the microscope. 00:13:16.870 --> 00:13:18.909 But if you don't have access to that, it's okay. 00:13:19.309 --> 00:13:22.149 There's another way to test it. The swab that 00:13:22.149 --> 00:13:24.490 we use for a lot of our bacterial cultures can 00:13:24.490 --> 00:13:26.590 also be used to take what's called a fungal culture. 00:13:26.750 --> 00:13:29.570 And you just take a gentle Q-tip, swab it against 00:13:29.570 --> 00:13:31.649 the skin, and you can actually have your lab 00:13:31.649 --> 00:13:34.289 plate it on a Petri dish and look for yeast or 00:13:34.289 --> 00:13:36.840 fungus or things. things like that. Within three 00:13:36.840 --> 00:13:39.899 to five days, you got an answer. Yes. Yes. Although 00:13:39.899 --> 00:13:42.700 I do, we typically leave it for yeast. We do 00:13:42.700 --> 00:13:44.580 have to sometimes leave it a little bit longer. 00:13:45.500 --> 00:13:48.379 But yes, so even if you don't have a microscope, 00:13:48.720 --> 00:13:52.419 Worry not, That's another way to do it. And I 00:13:52.419 --> 00:13:55.100 think your point that no matter what rash you're 00:13:55.100 --> 00:13:57.820 talking about, within a certain amount of time, 00:13:57.879 --> 00:14:00.440 you almost always get colonization where the 00:14:00.440 --> 00:14:03.539 yeast is living on the skin. So you kind of have 00:14:03.539 --> 00:14:06.720 to build that into any treatment plan for a rash 00:14:06.720 --> 00:14:08.419 that's there more than a couple of days. Is that 00:14:08.419 --> 00:14:12.059 fair? Correct. And not just yeast, but also you 00:14:12.059 --> 00:14:15.240 have other organisms like Strep or Staph that 00:14:15.240 --> 00:14:18.259 also can infect the area too. Talk a little bit 00:14:18.259 --> 00:14:20.960 about sort of "cradle cap" in the diaper area. 00:14:21.639 --> 00:14:24.659 So our term for that is "Seborrheic Dermatitis" 00:14:24.659 --> 00:14:29.220 or "seborrhea." And so on the scalp, it'll present 00:14:29.220 --> 00:14:32.399 with flaking, sort of like a greasy, scaly plaque 00:14:32.399 --> 00:14:34.500 that often extends sort of onto the facial area 00:14:34.500 --> 00:14:37.039 as well. But kids with this can also have the 00:14:37.039 --> 00:14:40.139 same condition. in the diaper area. We like to 00:14:40.139 --> 00:14:43.500 say a "salmon-colored" red as opposed to the beefy 00:14:43.500 --> 00:14:46.720 red of the previous one. And this one will tend 00:14:46.720 --> 00:14:49.879 to be a lot more scaly, a little bit greasier 00:14:49.879 --> 00:14:52.539 in color. And the clue is often that you do have 00:14:52.539 --> 00:14:54.679 rashes elsewhere on the body in these cases. 00:14:55.220 --> 00:14:58.559 And it can look just like eczema or atopic dermatitis. 00:14:59.100 --> 00:15:01.899 Correct. Correct. And so what, what, what's also 00:15:01.899 --> 00:15:04.279 always helpful in a baby is not to just examine 00:15:04.279 --> 00:15:06.679 their diaper area, but do an exam elsewhere on 00:15:06.679 --> 00:15:08.740 the skin. Even sometimes parents don't even realize 00:15:08.740 --> 00:15:11.240 it's elsewhere, but you can look in the, in the 00:15:11.240 --> 00:15:14.480 folds of the armpit neck, look at the scalp behind 00:15:14.480 --> 00:15:17.779 the ears, et cetera. And, you know, correct me 00:15:17.779 --> 00:15:19.799 if I'm wrong, but in my mind, what I'm trying 00:15:19.799 --> 00:15:23.419 to figure out is this seborrheic dermatitis versus 00:15:23.419 --> 00:15:26.960 something else or eczema versus seborrheic dermatitis. 00:15:27.399 --> 00:15:31.620 I'm thinking - relative to seborrheic dermatitis - 00:15:31.799 --> 00:15:35.000 atopic dermatitis or eczema tends to spare, not 00:15:35.000 --> 00:15:39.820 involve the diaper area as much. Is that fair 00:15:39.820 --> 00:15:42.779 to say? I'm much more likely, if it looks like 00:15:42.779 --> 00:15:45.419 eczema and it's in the diaper area, I'm leaning 00:15:45.419 --> 00:15:47.779 towards seborrheic dermatitis. At the same time, 00:15:47.799 --> 00:15:51.340 you can often have both. Yeah, right. They run 00:15:51.340 --> 00:15:56.129 together. It can be really tricky. Let's talk 00:15:56.129 --> 00:15:58.049 a little bit about "eczema/atopic dermatitis" 00:15:58.049 --> 00:15:59.570 in the diaper area. What are some clues there? 00:16:00.470 --> 00:16:03.570 Usually these are very, very dry patches. You 00:16:03.570 --> 00:16:07.690 don't have as many pustules or greasy look. It's 00:16:07.690 --> 00:16:12.600 just a dry. scaly, often scratched area. Sometimes 00:16:12.600 --> 00:16:14.940 there's thickening of the skin from frequent 00:16:14.940 --> 00:16:19.000 scratching. And the key with that is, you know, 00:16:19.039 --> 00:16:21.320 you very rarely have isolated to the diaper as 00:16:21.320 --> 00:16:23.120 well with eczema. You'll have clues elsewhere, 00:16:23.220 --> 00:16:26.700 sort of in the antecubital popliteal fossa, there 00:16:26.700 --> 00:16:29.700 will be rashes. The child might have a sibling 00:16:29.700 --> 00:16:33.509 with eczema or atopic dermatitis. Or even the 00:16:33.509 --> 00:16:36.769 child or siblings might have other conditions 00:16:36.769 --> 00:16:40.169 in the atopic family. And when I say atopic family, 00:16:40.289 --> 00:16:43.090 I mean things like asthma, hay fever, things 00:16:43.090 --> 00:16:48.149 like that. Yeah, and classically, you are taught 00:16:48.149 --> 00:16:52.129 that eczema does tend to spare the diaper area 00:16:52.129 --> 00:16:54.549 because it's that occlusive, humid environment. 00:16:54.669 --> 00:16:58.090 But to your point, if it's bad enough, it can 00:16:58.090 --> 00:17:00.429 be in the diaper as well. One of the things that 00:17:00.429 --> 00:17:03.330 I think I see... in the diaper area when it's 00:17:03.330 --> 00:17:06.609 eczema more than other rashes is this sort of 00:17:06.609 --> 00:17:08.630 thickening of the skin or lichenification, which 00:17:08.630 --> 00:17:11.349 can be a clue that this is long-standing chronic 00:17:11.349 --> 00:17:14.450 inflammation that's caused the skin to almost 00:17:14.450 --> 00:17:16.690 thicken up in response to getting rubbed and 00:17:16.690 --> 00:17:20.069 scratched as much as it has been. But that can 00:17:20.069 --> 00:17:22.990 be pretty tricky, I think. And to make it even 00:17:22.990 --> 00:17:25.769 trickier, they can also have a thick condition 00:17:25.769 --> 00:17:28.029 in their diaper area called "psoriasis," which 00:17:28.029 --> 00:17:30.630 can also manifest there. That's one of the, that 00:17:30.630 --> 00:17:33.589 I stand by the fact that it took me longer to 00:17:33.589 --> 00:17:35.650 be able to pull the trigger and make the diagnosis 00:17:35.650 --> 00:17:38.430 of psoriasis in a kid. But now you're talking 00:17:38.430 --> 00:17:40.430 baby. It's even more because in my head, I've 00:17:40.430 --> 00:17:42.369 told, I've talked about this. I've had that in 00:17:42.369 --> 00:17:46.390 my brain as an adult problem. And even in pediatric 00:17:46.390 --> 00:17:48.670 dermatology fellowship, it was just hard for 00:17:48.670 --> 00:17:51.369 me to say, "Geez, this is probably psoriasis." 00:17:51.390 --> 00:17:53.710 Now I make the diagnosis a couple of times a 00:17:53.710 --> 00:17:56.029 week and I'm comfortable with it, but it really 00:17:56.029 --> 00:17:58.490 took me a long time to get comfortable saying 00:17:58.490 --> 00:18:01.130 this is, this is probably psoriasis. What clues 00:18:01.130 --> 00:18:03.529 are you looking for for something to be labeled 00:18:03.529 --> 00:18:07.150 psoriasis? One of the first things I've noticed 00:18:07.150 --> 00:18:09.809 is with the psoriasis kids is a lot of it extends 00:18:09.809 --> 00:18:12.670 up onto the pubic area a lot more, a lot higher. 00:18:13.809 --> 00:18:17.329 It typically has very sharp or we call it well 00:18:17.329 --> 00:18:20.470 demarcated borders.. So with eczema, so basically 00:18:20.470 --> 00:18:23.059 imagine you took a pen. With psoriasis, you 00:18:23.059 --> 00:18:25.700 can literally take a perfect outline of the edge 00:18:25.700 --> 00:18:29.019 of the lesion, usually, and tell where the skin 00:18:29.019 --> 00:18:31.859 of psoriasis ends and the normal skin begins. 00:18:32.019 --> 00:18:34.380 Whereas in eczema, we call it ill-defined. You 00:18:34.380 --> 00:18:37.279 know, it's hard to, it almost melts into the 00:18:37.279 --> 00:18:39.460 surrounding skin. Whereas, you know, really with 00:18:39.460 --> 00:18:42.759 psoriasis, you can see a sharp outline. Yeah, 00:18:42.799 --> 00:18:45.779 and psoriasis is unique, at least compared 00:18:45.779 --> 00:18:48.680 to atopic dermatitis and seborrheic dermatitis 00:18:48.680 --> 00:18:52.140 and irritant contact dermatitis, because it often 00:18:52.140 --> 00:18:55.099 can do something called "koebnerize," which is wherever 00:18:55.099 --> 00:18:59.180 there is friction or trauma to the skin. In this 00:18:59.180 --> 00:19:01.220 case, it's the friction of the diaper rubbing 00:19:01.220 --> 00:19:05.140 on the kid. You can actually see a totally perfect 00:19:05.140 --> 00:19:09.250 match of rash to diaper. And it takes it right 00:19:09.250 --> 00:19:11.009 up to the waistband, all the way down to the 00:19:11.009 --> 00:19:13.849 waistbands, or I guess what you call them, leg 00:19:13.849 --> 00:19:16.450 bands. And you can say, geez, that looks exactly 00:19:16.450 --> 00:19:18.589 like where the diaper would be. Yeah, that's 00:19:18.589 --> 00:19:21.309 exactly right. Absolutely. And two of my other 00:19:21.309 --> 00:19:24.250 favorite clues for baby psoriasis especially 00:19:24.250 --> 00:19:28.869 is looking in two other folds, armpit and groin. 00:19:28.910 --> 00:19:31.849 So if there's another well demarcated plaque 00:19:31.849 --> 00:19:33.990 elsewhere, that's really helpful. And then the 00:19:33.990 --> 00:19:37.640 third most favorite area. uh sort of on the torso 00:19:37.640 --> 00:19:41.339 is actually in the umbilical - the "bebo" - yep yep 00:19:41.339 --> 00:19:46.339 on and then with psoriasis too that often not 00:19:46.339 --> 00:19:49.019 always but often runs in families so does grandma 00:19:49.019 --> 00:19:52.160 does mom dad have any history of psoriasis and 00:19:52.160 --> 00:19:54.160 then the last thing that's always important to 00:19:54.160 --> 00:19:57.559 check is Sometimes you can get ridging or little 00:19:57.559 --> 00:20:00.559 dots we call pits in the fingernails or toenails. 00:20:00.700 --> 00:20:02.660 But again, not all of these things are always 00:20:02.660 --> 00:20:04.839 present. So that's why it's so hard to diagnose. 00:20:04.839 --> 00:20:08.400 And to treat, right? I mean, they can all be 00:20:08.400 --> 00:20:11.500 hard to treat, even irritant contact if the 00:20:11.500 --> 00:20:13.680 poop and pee just keep coming, you're really 00:20:13.680 --> 00:20:15.900 kind of behind the eight ball. But psoriasis, 00:20:15.900 --> 00:20:20.339 I feel like that definitely requires longer treatment, 00:20:20.599 --> 00:20:23.819 longer direct treatment than some of these other 00:20:23.819 --> 00:20:26.609 conditions. Probably in part because of that 00:20:26.609 --> 00:20:29.490 koebnerization phenomenon where if the rubbing 00:20:29.490 --> 00:20:32.369 is still there, so is the skin condition. That's 00:20:32.369 --> 00:20:34.450 just my take. I don't know. Absolutely. And often 00:20:34.450 --> 00:20:36.650 prescription strength medicine is needed, whereas 00:20:36.650 --> 00:20:38.930 many of these other things, especially if we're 00:20:38.930 --> 00:20:40.670 talking steroids and things like that, stronger 00:20:40.670 --> 00:20:42.589 medicine is needed for psoriasis, certainly. 00:20:43.970 --> 00:20:46.470 Now, one thing that I don't feel is as common 00:20:46.470 --> 00:20:48.130 as these other things that we just have been 00:20:48.130 --> 00:20:52.230 talking about is a true allergy to the diaper, 00:20:52.390 --> 00:20:54.849 right? For whatever reason, it seems the most 00:20:54.849 --> 00:20:57.849 common question I get when I see patients with 00:20:57.849 --> 00:21:00.650 diaper rashes from families, and I understand 00:21:00.650 --> 00:21:03.470 why. "Is my child allergic to something we're 00:21:03.470 --> 00:21:05.849 using?" Is it an allergy to the diaper? Is it 00:21:05.849 --> 00:21:08.990 an allergy to the butt paste? Is it an allergy 00:21:08.990 --> 00:21:12.890 to the wipes? Certainly these are possible, but 00:21:12.890 --> 00:21:17.309 actually quite rare. Yeah, yeah. I mean, it makes 00:21:17.309 --> 00:21:20.150 sense. You're putting a plastic sheet on your 00:21:20.150 --> 00:21:23.549 kids - on your newborn baby's most sensitive skin 00:21:23.549 --> 00:21:27.049 area. As a new mom or dad, I would certainly 00:21:27.049 --> 00:21:29.009 understand why someone could think, geez, they 00:21:29.009 --> 00:21:31.549 must be allergic to the plastic. But where it's 00:21:31.549 --> 00:21:35.230 very common for older kids and adults to develop 00:21:35.230 --> 00:21:38.250 allergies to the chemicals in their sneakers 00:21:38.250 --> 00:21:40.890 or their gloves that they wear for their occupation, 00:21:40.950 --> 00:21:44.089 it's pretty rare to have a kid with true allergy 00:21:44.089 --> 00:21:47.269 to their diaper. thankfully. Yeah especially if 00:21:47.269 --> 00:21:49.470 it's not the whole way around towards the back 00:21:49.470 --> 00:21:53.809 on the bottom um and but but if it is going to 00:21:53.809 --> 00:21:55.390 be an allergy some of the things that can do 00:21:55.390 --> 00:21:58.130 it are is it a wipe that has a lot of fragrance? 00:21:58.130 --> 00:22:00.410 Fragrances are never a good idea when you're 00:22:00.410 --> 00:22:05.680 talking about baby wipes um. Does your diaper 00:22:05.680 --> 00:22:09.059 rash cream have lavender in it or something extra 00:22:09.059 --> 00:22:11.440 that you don't need? Those are some of the culprits 00:22:11.440 --> 00:22:12.640 if there is going to be something. That's a great 00:22:12.640 --> 00:22:15.339 point. And thankfully, we have the ability, even 00:22:15.339 --> 00:22:18.640 in babies, to do what's called patch testing. 00:22:19.160 --> 00:22:21.200 Do you have an age limit that you go down to 00:22:21.200 --> 00:22:25.420 for patch testing? You know, we'll do it on babies, 00:22:25.500 --> 00:22:27.519 but it's not my favorite thing to do. Just there's 00:22:27.519 --> 00:22:30.849 not much room on the back to do testing. Right. 00:22:30.970 --> 00:22:34.529 I mean, at may be a year or two. I would probably, 00:22:34.569 --> 00:22:35.910 you know, I'm not doing it much younger than 00:22:35.910 --> 00:22:37.730 that because the risk is you might sensitize 00:22:37.730 --> 00:22:40.170 them also, right, with some of the testing products 00:22:40.170 --> 00:22:42.569 that you're using. But I don't have a problem 00:22:42.569 --> 00:22:46.289 if it's a one and a half year old and mom or 00:22:46.289 --> 00:22:48.450 dad thinks that they're allergic to their diaper. 00:22:48.750 --> 00:22:51.119 I mean, you can always just test for. the diaper 00:22:51.119 --> 00:22:53.519 as a use test as well. Right. So you don't have 00:22:53.519 --> 00:22:55.700 to do it. Correct. I'd rather do something like 00:22:55.700 --> 00:22:58.660 that or, or, or do a trial and error of elimination. 00:22:58.839 --> 00:23:00.799 Right. Right. Exactly. Does it get any better 00:23:00.799 --> 00:23:03.319 when you don't wear this diaper or, or a different, 00:23:03.359 --> 00:23:05.240 different kind? You have to be, if you're going 00:23:05.240 --> 00:23:07.039 to switch out the diaper, then you have to make 00:23:07.039 --> 00:23:09.980 sure you're completely switching it out so that 00:23:09.980 --> 00:23:12.200 it's, if it was a plastic diaper before, maybe 00:23:12.200 --> 00:23:14.400 you're going to an all cotton diaper instead, 00:23:14.500 --> 00:23:18.460 or a, or even one of those washable cotton cloth. 00:23:19.039 --> 00:23:21.839 napkins that they call, right? So try that for 00:23:21.839 --> 00:23:23.619 a couple of weeks. Yeah, which unfortunately 00:23:23.619 --> 00:23:27.200 rarely solves the problem, but can. One infection 00:23:27.200 --> 00:23:29.779 that we see, not infrequently, I don't know about 00:23:29.779 --> 00:23:34.039 you guys out in San Diego, but beefy red, right 00:23:34.039 --> 00:23:40.059 around the sort of perirectal area, Strep. Strep 00:23:40.059 --> 00:23:45.680 bacteria. Correct. And in these kids, it's often 00:23:45.680 --> 00:23:47.740 persistent despite, you know, multiple different 00:23:47.740 --> 00:23:50.779 creams that they've tried, switching diaper paste, 00:23:50.960 --> 00:23:54.460 etc. It's quite a bright rash. Sometimes you 00:23:54.460 --> 00:23:57.839 have little fissures around the area. And it's 00:23:57.839 --> 00:24:00.339 typically just in the perianal area, not elsewhere. 00:24:00.640 --> 00:24:03.160 What I usually do is take a little swab and culture. 00:24:03.559 --> 00:24:07.200 And it usually responds pretty well to oral antibiotics 00:24:07.200 --> 00:24:10.079 in the penicillin/amoxicillin family, barring 00:24:10.079 --> 00:24:12.680 allergies. Sometimes in these kids, throat cultures 00:24:12.680 --> 00:24:15.059 can be positive. I've been fooled and it's not 00:24:15.059 --> 00:24:17.960 Strep and it's actually Staph. For point of clarification, 00:24:18.180 --> 00:24:19.799 when you say that they are walking around with 00:24:19.799 --> 00:24:21.640 strep in their throat, you would do a culture 00:24:21.640 --> 00:24:23.380 and it's positive. Doesn't necessarily mean they 00:24:23.380 --> 00:24:26.339 have to show symptoms of strep throat. Yes, there's 00:24:26.339 --> 00:24:28.400 no sore throat. They're not otherwise ill. They 00:24:28.400 --> 00:24:31.319 just sometimes are even carriers. Yeah, another 00:24:31.319 --> 00:24:35.599 place I've seen. Strep also kind of land is in 00:24:35.599 --> 00:24:38.140 the neck crease and sometimes the armpits. I 00:24:38.140 --> 00:24:40.019 mean, it's rare, but sometimes usually it's just, 00:24:40.019 --> 00:24:43.519 it's just in that diaper area. And when it's, 00:24:43.519 --> 00:24:45.980 when it's just there and nothing else is involved, 00:24:46.160 --> 00:24:48.259 it's, I think that's the strongest clue that 00:24:48.259 --> 00:24:50.119 you're probably dealing with something infectious, 00:24:50.160 --> 00:24:52.599 like, like perianal strep. And the good news 00:24:52.599 --> 00:24:56.160 is it gets very better, very quickly with, as 00:24:56.160 --> 00:24:58.339 you said, I usually just use Keflex. I don't 00:24:58.339 --> 00:25:01.660 know about you, but. Yeah, Keflex. Because that 00:25:01.660 --> 00:25:04.619 way it covers for Staph if it happens to be Staph 00:25:04.619 --> 00:25:07.819 as well, in most cases. Well, the next one I'll 00:25:07.819 --> 00:25:12.660 throw at you is not a common diagnosis, but quite 00:25:12.660 --> 00:25:16.880 severe if you're suffering from it. And that's 00:25:16.880 --> 00:25:19.160 a "zinc deficiency," of which there can be a lot 00:25:19.160 --> 00:25:21.500 of different versions of how you can end up being 00:25:21.500 --> 00:25:24.720 zinc deficient. But tell us how you might expect 00:25:24.720 --> 00:25:27.420 someone to come into your clinic as a child with 00:25:27.420 --> 00:25:30.009 zinc deficiency. So first of all, this is super 00:25:30.009 --> 00:25:32.609 rare. I maybe see it once every year or two. 00:25:32.710 --> 00:25:35.549 So it's not something that, you know, most families 00:25:35.549 --> 00:25:37.829 need to worry about, but they'll come in with 00:25:37.829 --> 00:25:40.069 the, you know, sort of a diaper rash, but they'll 00:25:40.069 --> 00:25:44.259 also have. basically a similar looking rash on 00:25:44.259 --> 00:25:46.819 the perioral area. So it's not just in the diaper 00:25:46.819 --> 00:25:49.839 area. It can be on the perioral area or also 00:25:49.839 --> 00:25:54.640 even on the hands or feet or other areas. They 00:25:54.640 --> 00:25:59.000 are very scaly, very red, resistant to sort of 00:25:59.000 --> 00:26:01.140 the typical treatments that you might give. So 00:26:01.140 --> 00:26:03.279 it's not the first thing that I think of. I wouldn't 00:26:03.279 --> 00:26:06.720 go jump right to that diagnosis, but I'll ask 00:26:06.720 --> 00:26:11.200 mom's history. Is the baby breast? fed or not? 00:26:11.200 --> 00:26:13.660 Did it start after you stopped breastfeeding? 00:26:13.660 --> 00:26:18.380 um Was the baby born early any other issues medically 00:26:18.380 --> 00:26:21.839 like you know syndromes of malabsorption things 00:26:21.839 --> 00:26:24.000 like that and the reason you're asking about 00:26:24.000 --> 00:26:25.960 if the baby was breastfed because sometimes mom's 00:26:25.960 --> 00:26:28.220 breast milk just simply doesn't have enough zinc 00:26:28.220 --> 00:26:31.359 in it To get the baby's zinc levels up, right? 00:26:31.519 --> 00:26:34.579 Right. Or sometimes the mom's breast milk has 00:26:34.579 --> 00:26:36.640 enough and you don't notice it until the mom 00:26:36.640 --> 00:26:39.119 stops breastfeeding. Stops breastfeeding. And 00:26:39.119 --> 00:26:42.700 then premature, they just can't stack the amount 00:26:42.700 --> 00:26:45.240 of zinc that they need. Correct. To not get deficient. 00:26:45.319 --> 00:26:48.849 Correct. If this is on my differential, which 00:26:48.849 --> 00:26:50.869 again, it is not the first thing I think of in 00:26:50.869 --> 00:26:55.009 most cases, but if it is, oftentimes a way to 00:26:55.009 --> 00:26:57.390 figure it out is to do labs and blood work, which 00:26:57.390 --> 00:27:01.009 what we look for is low alkaline phosphatase 00:27:01.009 --> 00:27:03.890 levels. We check zinc levels, which would be 00:27:03.890 --> 00:27:07.250 low. There's good treatment available. This is 00:27:07.250 --> 00:27:09.650 totally fixable, but the labs are really helpful 00:27:09.650 --> 00:27:12.670 in this case. Well, that's the miracle of zinc 00:27:12.670 --> 00:27:14.970 deficiency. I mean, the couple of kids that I've 00:27:14.970 --> 00:27:18.869 had, actually have zinc deficiency when you supplement 00:27:18.869 --> 00:27:22.210 them with zinc what, what looks like the most 00:27:22.210 --> 00:27:26.950 horrific diaper rash in three, five, seven days 00:27:26.950 --> 00:27:29.349 it's gone i mean it just gets better it's amazing! 00:27:29.349 --> 00:27:33.809 So it's important to make that diagnosis and 00:27:33.809 --> 00:27:36.750 i don't know about you but i always kind of think 00:27:36.750 --> 00:27:39.509 of the rash on the face that you mentioned as 00:27:39.509 --> 00:27:41.509 being an important part of this it's sort of 00:27:41.509 --> 00:27:44.630 got this distinct "U-shape" to it. And it's, I 00:27:44.630 --> 00:27:46.410 don't know, it's always looked pinkish yellow 00:27:46.410 --> 00:27:48.349 to me whenever I've seen it in real life. Now, 00:27:48.410 --> 00:27:50.650 how many have I seen? Not that many, but you 00:27:50.650 --> 00:27:53.950 know. Right, right. And again, in most of these 00:27:53.950 --> 00:27:56.410 cases, it's not that. It's probably just eczema 00:27:56.410 --> 00:27:58.650 on the face as well, but definitely something 00:27:58.650 --> 00:28:01.430 to have in your differential and not to be forgotten. 00:28:01.789 --> 00:28:04.589 So now I'm going to get your pulse up because 00:28:04.589 --> 00:28:08.349 I know you and I know you always think of what 00:28:08.349 --> 00:28:13.140 the worst case scenario could be. When you have 00:28:13.140 --> 00:28:15.200 a kid that comes in with a diaper rash that's 00:28:15.200 --> 00:28:17.720 not responsive to treatment, the zinc's normal, 00:28:17.920 --> 00:28:20.180 everything that we've talked about up to this 00:28:20.180 --> 00:28:23.559 point is just not making sense. What are you 00:28:23.559 --> 00:28:27.519 concerned about? So there's this really rare 00:28:27.519 --> 00:28:31.440 condition called "Langerhans Cell Histiocytosis." 00:28:31.460 --> 00:28:37.019 We call it LCH. And most of these children, something 00:28:37.019 --> 00:28:40.829 doesn't... look right on their rash. So the first 00:28:40.829 --> 00:28:43.690 thing you'll notice on kids with this condition, 00:28:43.869 --> 00:28:47.490 which basically what it is, it's this inflammatory 00:28:47.490 --> 00:28:51.609 myeloid condition that the reason it's significant 00:28:51.609 --> 00:28:54.170 is it not only affects the skin, but it can affect 00:28:54.170 --> 00:28:56.990 the child's bones, blood cell counts, livers, 00:28:57.009 --> 00:28:59.829 etc. What you'll do on your exam, you'll see... 00:29:00.269 --> 00:29:03.190 just the usual scale redness plaques but there's 00:29:03.190 --> 00:29:05.809 sometimes these little bumps called "purpura" which 00:29:05.809 --> 00:29:08.309 like the name it looks almost like a little darker 00:29:08.309 --> 00:29:11.849 red or purple in color, or something called "petechiae", 00:29:12.009 --> 00:29:15.670 which is these little dark red, purple, flat 00:29:15.670 --> 00:29:18.789 lesions that do not blanch when you touch them, 00:29:18.849 --> 00:29:21.109 which means when you push on them, the color 00:29:21.109 --> 00:29:24.369 doesn't go away at all. And then some of the 00:29:24.369 --> 00:29:28.450 lesions will be very open sores that scab or 00:29:28.450 --> 00:29:31.569 crust, whereas most typical rashes don't have 00:29:31.569 --> 00:29:34.390 that presentation. And so if a baby comes in 00:29:34.390 --> 00:29:36.849 with this type of rash, doesn't respond to the 00:29:36.849 --> 00:29:39.630 usual treatment, I usually recommend to the family. 00:29:39.690 --> 00:29:42.910 to consider taking a small biopsy of the skin. 00:29:43.509 --> 00:29:46.910 And the reason this is very important is these 00:29:46.910 --> 00:29:49.710 babies can get very sick, not really from the 00:29:49.710 --> 00:29:51.730 skin lesions, but from what can be happening 00:29:51.730 --> 00:29:55.609 inside their body. Yeah, and we don't... We don't 00:29:55.609 --> 00:29:57.670 just biopsy kids willy-nilly. I mean, if you're, 00:29:57.670 --> 00:29:59.710 you know, if you're talking about doing a biopsy 00:29:59.710 --> 00:30:02.029 in the diaper area where again, poop and pee 00:30:02.029 --> 00:30:03.609 can get into an open wound. Now you're putting 00:30:03.609 --> 00:30:05.809 that kid at risk for infection. So, you know, 00:30:05.910 --> 00:30:08.869 or you should know if you're a parent and a pediatric 00:30:08.869 --> 00:30:11.950 dermatologist is suggesting a biopsy in the diaper 00:30:11.950 --> 00:30:14.150 area to make sure it's not that we've already 00:30:14.150 --> 00:30:17.299 considered the worst case scenario, and that's 00:30:17.299 --> 00:30:19.660 what we're trying to make sure it's not. Right, 00:30:19.740 --> 00:30:21.559 right. And there's usually some other clues with 00:30:21.559 --> 00:30:23.839 this too. Often they have skin lesions on the 00:30:23.839 --> 00:30:26.660 palms or soles as well. So sometimes we actually 00:30:26.660 --> 00:30:28.880 can get away with not biopsying the diaper area. 00:30:29.619 --> 00:30:31.640 I've had a couple diagnosed elsewhere. Oh, that's 00:30:31.640 --> 00:30:33.980 interesting, yeah. Yeah, and I've had a couple 00:30:33.980 --> 00:30:38.180 with also scalp lesions. And for me, one of the 00:30:38.180 --> 00:30:41.599 worst things to see is to open up a baby's diaper. 00:30:42.299 --> 00:30:44.140 When you're looking at the rash and you're trying 00:30:44.140 --> 00:30:46.640 to figure out if it's this Langerhans Cell Histiocytosis, 00:30:46.660 --> 00:30:52.039 LCH, and what do you see in those folds are huge 00:30:52.039 --> 00:30:55.259 hulking lymph nodes. You can actually see their 00:30:55.259 --> 00:30:59.319 swollen glands in the creases, and that's not 00:30:59.319 --> 00:31:01.859 a good thing. Yeah. Often these children also 00:31:01.859 --> 00:31:05.200 have systemic symptoms. Sometimes they'll have 00:31:05.200 --> 00:31:08.799 weight loss. Sometimes if you palpate their tummy, 00:31:08.839 --> 00:31:11.119 they'll have elevated or enlarged, excuse me, 00:31:11.119 --> 00:31:14.059 liver, things like that too. So often there's 00:31:14.059 --> 00:31:18.279 other clues as well. Yeah, I'm not, and I've 00:31:18.279 --> 00:31:21.380 really never been great at feeling a liver or 00:31:21.380 --> 00:31:24.000 a spleen for what we call hepatosplenomegaly. 00:31:24.359 --> 00:31:27.450 When in doubt. I'll get an ultrasound and find 00:31:27.450 --> 00:31:30.130 out if the liver and the spleen are within normal 00:31:30.130 --> 00:31:32.710 size for that kid. And that's reassuring. It 00:31:32.710 --> 00:31:35.630 doesn't mean it's not LCH, but you certainly 00:31:35.630 --> 00:31:37.470 don't want to see something being bigger than 00:31:37.470 --> 00:31:39.569 normal in those kids that you're concerned with. 00:31:39.769 --> 00:31:42.589 And sometimes, let's say I'm really suspicious 00:31:42.589 --> 00:31:45.690 and I order blood work to look for anomalies 00:31:45.690 --> 00:31:49.450 there. If it does end up being, you know, just 00:31:49.450 --> 00:31:51.470 to go down this rabbit hole, if it does end up 00:31:51.470 --> 00:31:54.789 being LCH. It's a condition that you involve 00:31:54.789 --> 00:31:57.069 other specialists with, like oncologists, to 00:31:57.069 --> 00:31:59.690 look inside the body as well. Yeah. This is managed 00:31:59.690 --> 00:32:02.009 by cancer doctors. I mean, let's, right, this 00:32:02.009 --> 00:32:05.509 is, we're outside of the realm of a skin doctor 00:32:05.509 --> 00:32:07.589 at this point. This is a systemic illness that 00:32:07.589 --> 00:32:10.549 has to be managed as if it was a cancerous process. 00:32:10.809 --> 00:32:12.829 Right. The good news is a lot of them actually 00:32:12.829 --> 00:32:15.269 have really good prognosis. So when I hear the 00:32:15.269 --> 00:32:18.329 word cancer, it's almost not the right word or 00:32:18.329 --> 00:32:20.509 there almost needs to be an adjacent word for 00:32:20.509 --> 00:32:23.920 it. but we treat it very seriously nonetheless. 00:32:24.319 --> 00:32:28.599 Yeah. Now the good news is that again, you know, 00:32:28.619 --> 00:32:33.019 upwards of 50-70 % of your diaper rash cases 00:32:33.019 --> 00:32:36.799 are really just, again, the basic irritant contact 00:32:36.799 --> 00:32:40.099 dermatitis from the feces and urine in that area. 00:32:40.740 --> 00:32:44.940 Knowing that just with some basic routine diaper 00:32:44.940 --> 00:32:48.920 area skincare, most of the time you can knock 00:32:48.920 --> 00:32:51.630 out. 90% of the problem, even before they become 00:32:51.630 --> 00:32:56.250 larger ones. So, give me your sort of gold standard 00:32:56.250 --> 00:32:59.950 routine for how you approach diaper area skincare. 00:33:00.250 --> 00:33:02.329 What are you recommending to your families? So 00:33:02.329 --> 00:33:05.289 the first thing is to talk about is how are they 00:33:05.289 --> 00:33:08.529 cleaning the area? So a lot of the times parents 00:33:08.529 --> 00:33:11.210 are actually cleaning too aggressively, using 00:33:11.210 --> 00:33:15.940 too much soap. So, while gentle soap and water 00:33:15.940 --> 00:33:17.660 are good, you don't want to use anything with 00:33:17.660 --> 00:33:20.980 fragrance. And sometimes you can do soap not 00:33:20.980 --> 00:33:23.980 every day, maybe every other day or every third 00:33:23.980 --> 00:33:28.019 day. You want to make sure they're using wipes 00:33:28.019 --> 00:33:33.160 that are gentle and fragrance-free. Um, and 00:33:33.160 --> 00:33:35.420 that they're not wiping too hard. Sometimes I'll 00:33:35.420 --> 00:33:38.279 watch parents change diapers in front of me and 00:33:38.279 --> 00:33:41.099 the - how, how much friction and rubbing is going 00:33:41.099 --> 00:33:44.200 on is just far too much. So, you know, especially 00:33:44.200 --> 00:33:46.559 if there's open areas, you want to almost dab 00:33:46.559 --> 00:33:49.880 instead of rub. The other thing I will do if 00:33:49.880 --> 00:33:52.380 soap is the issue, sometimes I'll have them do 00:33:52.380 --> 00:33:55.759 a bath with no soap, you know, multiple times 00:33:55.759 --> 00:33:59.519 a week. Um, the, the, the next thing to make 00:33:59.519 --> 00:34:02.049 sure is that this child is not sitting in the 00:34:02.049 --> 00:34:06.109 diaper too long. I have some kids who go to daycare 00:34:06.109 --> 00:34:08.269 and they're not changed as frequently and they 00:34:08.269 --> 00:34:10.570 come home rashy and then overnight things get 00:34:10.570 --> 00:34:14.369 better just because families are able to uh change 00:34:14.369 --> 00:34:17.650 the diaper more often so whenever possible frequent 00:34:17.650 --> 00:34:21.150 diaper changes um do the trick. I have some parents 00:34:21.150 --> 00:34:23.429 who i'm not saying you need to do it every hour 00:34:23.429 --> 00:34:26.329 but at least if you can when they're having acute 00:34:26.329 --> 00:34:29.510 flares to do it as often as you can especially 00:34:29.510 --> 00:34:33.829 after bowel movements. You know urine you don't 00:34:33.829 --> 00:34:35.570 have to do it quite as frequently but if possible 00:34:35.570 --> 00:34:37.889 the minute you notice a child has a bowel movement 00:34:37.889 --> 00:34:41.079 you want to do a clean and diaper change. Yeah, 00:34:41.079 --> 00:34:43.260 that's, you know, this is a case where technology 00:34:43.260 --> 00:34:45.719 maybe is not our best friend. They have this 00:34:45.719 --> 00:34:50.119 super ultra-potent absorbing gel technology in 00:34:50.119 --> 00:34:52.239 the diapers now that it can suck up anything 00:34:52.239 --> 00:34:56.179 and hold it there for hours. And, you know, not 00:34:56.179 --> 00:34:59.260 saying it's a matter of being lazy, but when 00:34:59.260 --> 00:35:02.480 you have that convenience, you do tend to let 00:35:02.480 --> 00:35:06.230 the kids sit in the diaper and have that. urine 00:35:06.230 --> 00:35:09.550 and poop sort of stew in the diaper area because 00:35:09.550 --> 00:35:11.909 it's not dripping out. So you don't need to feel 00:35:11.909 --> 00:35:13.650 like you have to change the diaper as much. But 00:35:13.650 --> 00:35:16.630 to your point, yeah, once an hour, take a peek. 00:35:16.909 --> 00:35:20.469 I get it. Diapers are expensive. You're talking 00:35:20.469 --> 00:35:23.269 up to 50 cents a diaper now, I think, last time 00:35:23.269 --> 00:35:25.849 I looked. So I don't want you to just have to 00:35:25.849 --> 00:35:27.429 feel like you have to change a diaper no matter 00:35:27.429 --> 00:35:30.300 what. taking a quick peek and making sure that 00:35:30.300 --> 00:35:33.239 your baby's not, you know, carrying a huge load 00:35:33.239 --> 00:35:34.940 in there that you didn't know about and it's 00:35:34.940 --> 00:35:37.300 up against their skin can make a huge difference. 00:35:38.579 --> 00:35:42.280 Absolutely. And then if possible, every now and, 00:35:42.400 --> 00:35:45.039 you know, when at home, if you can give a little 00:35:45.039 --> 00:35:48.219 bit of time for some air drying or naked time, 00:35:48.440 --> 00:35:51.960 that always helps after a diaper change, if possible. 00:35:52.039 --> 00:35:54.219 And I get it, can't always be done. But if you 00:35:54.219 --> 00:35:55.860 have a chance when they're at home, let them 00:35:55.860 --> 00:36:00.539 run around for a little bit. Yeah, I do. I do 00:36:00.539 --> 00:36:03.800 try to encourage that as well. Letting them just 00:36:03.800 --> 00:36:05.840 take the diaper off and air it out. You know, 00:36:05.900 --> 00:36:09.340 that's but invariably you hear the story. It's 00:36:09.340 --> 00:36:12.480 like it was off for 30 seconds and kid went to 00:36:12.480 --> 00:36:14.340 the bathroom on the floor. Yeah, I'm sorry. Sorry 00:36:14.340 --> 00:36:19.500 about it. Sorry. We meant well. The other thing 00:36:19.500 --> 00:36:22.699 I did with my son, probably PTSD from seeing 00:36:22.699 --> 00:36:25.059 so many diaper rashes in clinic, is I made sure 00:36:25.059 --> 00:36:29.880 I had a barrier ointment at each change. So instead 00:36:29.880 --> 00:36:34.119 of just applying the diaper alone, I alternated 00:36:34.119 --> 00:36:37.139 every change. It was either a petroleum-based 00:36:37.139 --> 00:36:40.519 product or a zinc oxide-based barrier product. 00:36:40.920 --> 00:36:44.019 And if there was no diaper rash, I actually... 00:36:44.510 --> 00:36:46.750 would alternate them because the benefit of the 00:36:46.750 --> 00:36:49.170 petroleum-based ones is they're more hydrating, 00:36:49.309 --> 00:36:51.969 not as good of a barrier. And then the benefit 00:36:51.969 --> 00:36:54.289 of the zinc oxide-based ones, better barrier, 00:36:54.369 --> 00:36:57.190 not as moisturizing. So I found if I alternated, 00:36:57.329 --> 00:37:00.550 I got a little bit of both. Yeah. Out of those 00:37:00.550 --> 00:37:02.789 two products, I like triple paste, something 00:37:02.789 --> 00:37:05.789 like that with the zinc oxide is there. The issue 00:37:05.789 --> 00:37:08.289 there is, my goodness, it gets everywhere. I 00:37:08.289 --> 00:37:11.019 mean, once you get that on your hands, It's going 00:37:11.019 --> 00:37:13.840 to be on whatever furniture is closest to you. 00:37:13.920 --> 00:37:15.760 Then you got to change the diaper for that kid. 00:37:16.000 --> 00:37:18.440 I mean, I know what I'm putting the parent through 00:37:18.440 --> 00:37:21.860 when I suggest using zinc oxide. But to your 00:37:21.860 --> 00:37:25.159 point, to me, at least, it works the best. And 00:37:25.159 --> 00:37:26.980 the nice thing is some of those brands even have 00:37:26.980 --> 00:37:29.880 ones with, like, if there is a little yeast component, 00:37:30.119 --> 00:37:32.940 you can buy ones that have a little antifungal 00:37:32.940 --> 00:37:36.039 property to them, like triple paste AF. Yeah. 00:37:36.179 --> 00:37:40.619 What do you not do for your normal diaper care? 00:37:41.239 --> 00:37:43.880 Fragrance. I actually didn't do any of those 00:37:43.880 --> 00:37:46.900 super absorbent disposal type, or excuse me, 00:37:46.920 --> 00:37:49.119 I didn't do any of those cloth type diapers. 00:37:49.400 --> 00:37:52.159 Like if the diaper itself has a fragrance, is 00:37:52.159 --> 00:37:54.679 that something you're? Oh, absolutely not. Yeah. 00:37:54.780 --> 00:37:57.019 I've seen that for whatever reason. I've been 00:37:57.019 --> 00:37:59.260 seeing that a lot in clinical of late - diapers 00:37:59.260 --> 00:38:01.619 coming in with actually a fragrance to them. 00:38:02.059 --> 00:38:05.119 Yeah. I just stuck with sort of the fragrance 00:38:05.119 --> 00:38:08.429 free, you know. pretty commonly available brand. 00:38:08.710 --> 00:38:11.170 Did not do the cloth diapers. Not that they're 00:38:11.170 --> 00:38:14.050 bad. It's just, I didn't find honestly that there 00:38:14.050 --> 00:38:16.670 was much of an added benefit to them for the 00:38:16.670 --> 00:38:20.110 effort and expense. Well, let's take a deeper 00:38:20.110 --> 00:38:23.349 dive into the topic of Candida or the yeast that 00:38:23.349 --> 00:38:25.090 we mentioned earlier, because that does require 00:38:25.090 --> 00:38:27.090 some special consideration. And again, you know, 00:38:27.110 --> 00:38:29.909 that's living everywhere. You can throw a softball. 00:38:30.519 --> 00:38:32.500 right now in any part of your room and you could 00:38:32.500 --> 00:38:34.780 hit some yeast, it's there. It normally doesn't 00:38:34.780 --> 00:38:37.400 cause any problems because it's not getting sort 00:38:37.400 --> 00:38:40.800 of into the skin or even, you know, really there 00:38:40.800 --> 00:38:43.380 at any given time for an extended period of time. 00:38:43.440 --> 00:38:46.820 But once you start talking about a diaper that's 00:38:46.820 --> 00:38:49.860 occluding it, You've got, again, what I loved 00:38:49.860 --> 00:38:52.139 is you mentioned the antibiotics, more frequent 00:38:52.139 --> 00:38:55.179 pooping, diarrhea. Now all of a sudden you got 00:38:55.179 --> 00:38:57.460 a chance for that Candida to really take a 00:38:57.460 --> 00:38:59.900 hold and cause some problems. So what are you 00:38:59.900 --> 00:39:03.019 doing to treat yeast in the diaper area? The 00:39:03.019 --> 00:39:06.440 first thing that I usually will try is a topical. 00:39:07.900 --> 00:39:10.119 There's a couple ointments available that treat 00:39:10.119 --> 00:39:14.480 yeast like Nystatin. There's also an oral medication 00:39:14.480 --> 00:39:18.769 that you can prescribe - Diflucan being one of 00:39:18.769 --> 00:39:22.070 the more common ones that's pretty safe and requires 00:39:22.070 --> 00:39:24.369 a pretty short treatment. A lot of the diaper 00:39:24.369 --> 00:39:27.510 paste versions of them that have an antifungal 00:39:27.510 --> 00:39:29.730 property. So some of the zinc oxide ones you 00:39:29.730 --> 00:39:32.090 can buy that way. But I try to avoid putting 00:39:32.090 --> 00:39:34.469 things like cornstarch or things like that on 00:39:34.469 --> 00:39:36.449 top because sometimes those actually make it 00:39:36.449 --> 00:39:38.949 worse. Yeah. And do you have a particular order 00:39:38.949 --> 00:39:40.590 that you'd be applying these things in? Like 00:39:40.590 --> 00:39:43.170 what would you put to the skin directly? Let's 00:39:43.170 --> 00:39:45.210 say I was doing Nysatin. I might put that 00:39:45.210 --> 00:39:47.869 first and then I would put my diaper paste on 00:39:47.869 --> 00:39:51.010 top and then apply the diaper. And then maybe 00:39:51.010 --> 00:39:53.429 the next diaper change, I would do my Nystatin 00:39:53.429 --> 00:39:56.489 with a little petrolatum based product. Yeah, 00:39:56.510 --> 00:39:59.190 that's exactly what I would do as well. That's 00:39:59.190 --> 00:40:01.289 good. It makes me feel good when I hear smart 00:40:01.289 --> 00:40:04.349 people are doing what I'm doing. That's great. 00:40:05.480 --> 00:40:07.480 Yeah. So, okay. So let's talk a little bit about 00:40:07.480 --> 00:40:09.699 some of those other conditions. So psoriasis, 00:40:09.699 --> 00:40:12.519 seborrheic dermatitis, atopic derm. What's the 00:40:12.519 --> 00:40:14.980 extra step there that you're adding to try to 00:40:14.980 --> 00:40:17.639 treat that? So in many cases, we actually use 00:40:17.639 --> 00:40:20.800 very, very low potency steroids against the skin. 00:40:21.320 --> 00:40:24.360 And these are not like anabolic steroids that, 00:40:24.380 --> 00:40:27.309 you know you hear about it on social media. 00:40:27.389 --> 00:40:30.010 These are very low strength topical steroids. 00:40:30.190 --> 00:40:34.570 So even over-the-counter, you can buy them. Widely 00:40:34.570 --> 00:40:37.250 available is 1% over the counter hydrocortisone 00:40:37.250 --> 00:40:41.309 ointment, for example. When you buy those, it's 00:40:41.309 --> 00:40:43.130 better to always do the thicker ointment than 00:40:43.130 --> 00:40:45.110 the cream versions. And you don't want to buy 00:40:45.110 --> 00:40:48.070 one that has extra things added. Like if you 00:40:48.070 --> 00:40:50.510 look at the pharmacy aisle where hydrocortisone 00:40:50.510 --> 00:40:53.190 is located, you'll see some that have aloe, some 00:40:53.190 --> 00:40:55.369 that have fragrance, some that have Neosporin. 00:40:55.429 --> 00:40:58.969 None of that. You want to buy the plain 1% hydrocortisone. 00:40:59.730 --> 00:41:01.969 I would always recommend getting your doctor's 00:41:01.969 --> 00:41:05.239 advice first. But if that's the way they want 00:41:05.239 --> 00:41:07.480 to go, I do that and I do it for a very short 00:41:07.480 --> 00:41:10.599 time, very thin layer underneath your, underneath 00:41:10.599 --> 00:41:13.260 whatever your selected barrier cream is. I might 00:41:13.260 --> 00:41:16.179 do it twice a day for maybe seven days max. And 00:41:16.179 --> 00:41:18.219 then it, you know, every now and then we have 00:41:18.219 --> 00:41:20.039 to do even stronger versions of that, but that 00:41:20.039 --> 00:41:22.929 would be under the guidance of your doctor. I 00:41:22.929 --> 00:41:25.190 love what you said about avoiding the additives 00:41:25.190 --> 00:41:28.650 to the 1% hydrocortisone. When you're a parent 00:41:28.650 --> 00:41:31.289 going into the pharmacy looking for exactly that 00:41:31.289 --> 00:41:33.909 product, do you have a particular vehicle that 00:41:33.909 --> 00:41:36.190 you're like, it comes as a lotion, it comes as 00:41:36.190 --> 00:41:38.030 a cream, it comes as an ointment? I love the 00:41:38.030 --> 00:41:39.949 ointments. The thicker, the better. You want 00:41:39.949 --> 00:41:42.329 to think of it like the old school Vaseline version 00:41:42.329 --> 00:41:44.550 of hydrocortisone. That's great. So what would 00:41:44.550 --> 00:41:46.329 you do for a condition like psoriasis, where 00:41:46.329 --> 00:41:48.489 we said earlier, it's even a little harder to 00:41:48.489 --> 00:41:52.219 treat? So psoriasis, we actually treat very similar 00:41:52.219 --> 00:41:54.940 to eczema or atopic dermatitis, but sometimes 00:41:54.940 --> 00:41:57.199 we have to use more potent medications, sometimes 00:41:57.199 --> 00:42:00.019 prescriptions, drinks, steroids. There's also 00:42:00.019 --> 00:42:04.070 for actually both... and psoriasis, some prescription 00:42:04.070 --> 00:42:07.469 non -steroidal anti-inflammatories available 00:42:07.469 --> 00:42:11.570 that can decrease the inflammation without having 00:42:11.570 --> 00:42:14.349 to worry about the risk of thinning of the skin, 00:42:14.429 --> 00:42:17.909 which is the main concern with steroids. One 00:42:17.909 --> 00:42:21.570 of the oldest treatments on the market for psoriasis, 00:42:21.570 --> 00:42:24.090 for example, is a topical vitamin D-based ointment 00:42:24.090 --> 00:42:28.389 called calcipotriene. But even modern day, there's 00:42:28.389 --> 00:42:31.530 even more effective a non-steroidal on steroid 00:42:31.530 --> 00:42:34.110 alternatives out there as well as systemic options. 00:42:34.570 --> 00:42:36.789 One that I like in the diaper area, if I know 00:42:36.789 --> 00:42:39.789 it's going to require a long-term use is a topical 00:42:39.789 --> 00:42:42.769 calcineurin inhibitor called Protopic or tacrolimus. 00:42:43.150 --> 00:42:45.230 In this age range, you're kind of stuck using 00:42:45.230 --> 00:42:48.630 0 .03% unless you have some trick that I don't 00:42:48.630 --> 00:42:52.530 know about to get approved for the 0 .1%. You 00:42:52.530 --> 00:42:54.409 have to be - I do have a trick. You have a trick? 00:42:54.469 --> 00:42:57.880 What's your trick? I have some specialty pharmacies 00:42:57.880 --> 00:43:00.019 available that you can get them for about $30 00:43:00.019 --> 00:43:03.219 cash. The tacrolimus 0 .1.%. 0 .1%, yeah. Technically, 00:43:03.280 --> 00:43:07.579 only for 16 years of age or older, we commonly 00:43:07.579 --> 00:43:09.880 would, as dermatologists, we commonly would love 00:43:09.880 --> 00:43:12.739 to use that stronger product on younger kids. 00:43:12.840 --> 00:43:15.219 But as soon as the insurance company sees that 00:43:15.219 --> 00:43:18.579 the child's younger than 16, they can say, sorry, 00:43:18.760 --> 00:43:21.360 the FDA did not give approval for this medicine, 00:43:21.460 --> 00:43:25.219 so we don't have to pay for it. So I have specialty 00:43:25.219 --> 00:43:27.179 pharmacies where I can get the generic version 00:43:27.179 --> 00:43:29.760 and you can also get them if needed through compounding 00:43:29.760 --> 00:43:31.840 pharmacies. Yeah, that's great. That's a good 00:43:31.840 --> 00:43:34.800 trick. Awesome. So when as a pediatric dermatologist, 00:43:34.960 --> 00:43:37.280 would you want a pediatrician or family medicine 00:43:37.280 --> 00:43:40.440 physician to absolutely refer these kids into 00:43:40.440 --> 00:43:43.539 you? When is it appropriate for you to be taking 00:43:43.539 --> 00:43:48.519 a look and doing something extra? So my favorite 00:43:48.519 --> 00:43:50.800 referral would be someone who's been cultured, 00:43:50.800 --> 00:43:54.869 Someone who's had a trial of you know, if you're 00:43:54.869 --> 00:43:58.130 not sure, maybe a topical antifungal or a topical 00:43:58.130 --> 00:44:00.369 over -the -counter strength steroid that just 00:44:00.369 --> 00:44:02.550 hasn't worked, that I'm happy to see a patient. 00:44:03.570 --> 00:44:06.929 I have pediatricians who sort of know my typical 00:44:06.929 --> 00:44:10.329 technique. We'll do sort of the intro-level 00:44:10.329 --> 00:44:11.809 treatments, and if they don't work, I'm happy 00:44:11.809 --> 00:44:15.750 to see the baby. Yeah, for me as well, I would 00:44:15.750 --> 00:44:18.670 add to that, you know, anytime you've got blisters 00:44:18.670 --> 00:44:22.510 in the area or, again, if you can see those lymph 00:44:22.510 --> 00:44:25.730 nodes, That's something that we want to take 00:44:25.730 --> 00:44:28.590 a look at. And that's not like a, hey, I'm just 00:44:28.590 --> 00:44:31.329 going to refer and whatever happens, happens. 00:44:32.440 --> 00:44:34.519 because it might be nine months before you get in to 00:44:34.519 --> 00:44:36.820 see me. I don't want to wait nine months. You 00:44:36.820 --> 00:44:39.420 pick up the phone and either call my personal 00:44:39.420 --> 00:44:42.659 cell, which I give out to everybody, or use whatever 00:44:42.659 --> 00:44:46.320 your health system or clinic's messaging system 00:44:46.320 --> 00:44:48.440 is and get a message to that person directly 00:44:48.440 --> 00:44:50.679 and say, hey, you need to see this person because 00:44:50.679 --> 00:44:53.179 they've got something really concerning sounding. 00:44:53.400 --> 00:44:56.909 Is that fair? Agreed. Well, I want to thank Scripps 00:44:56.909 --> 00:44:59.150 Clinic's own Dr. Caroline Piggott for joining 00:44:59.150 --> 00:45:01.269 me today. I cannot have handled this "messy load," 00:45:01.449 --> 00:45:05.469 so to speak, without her expert existence. And 00:45:05.469 --> 00:45:07.989 just always a pleasure speaking with you, Dr. 00:45:08.150 --> 00:45:10.610 Piggott. I look forward to doing many, many more 00:45:10.610 --> 00:45:12.670 of these things with you and getting smarter 00:45:12.670 --> 00:45:15.389 as a result. Thank you for having me, Dr. K. 00:45:15.530 --> 00:45:17.570 It's good to see you and it's a pleasure doing 00:45:17.570 --> 00:45:26.760 this anytime. Thanks for tuning in to this episode 00:45:26.760 --> 00:45:29.179 of the Don't Be Rash Pediatric Dermatology Podcast. 00:45:29.559 --> 00:45:32.079 I'm your host, Dr. Andrew Krakowski. Don't forget 00:45:32.079 --> 00:45:34.280 to subscribe to our show on your favorite podcast 00:45:34.280 --> 00:45:38.179 platform and check out don'tberash .org for more 00:45:38.179 --> 00:45:40.579 information. A special thank you to our nonprofit 00:45:40.579 --> 00:45:43.300 sponsor, the St. Luke's University Health Network, 00:45:43.460 --> 00:45:45.920 for making this episode possible. Until next 00:45:45.920 --> 00:45:48.900 time, remember, keep calm and don't be rash.