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    Pediatric psoriasis, eczema: Triggers and therapies


    Microbial triggers

    Dr. Siegfried: I’m a fan of looking for microbial triggers. Have you suspected herpes or group A Strep as a cause of eczema flares?

    Dr. Cordoro: I swab the pharynx and the anus of all of my new psoriasis patients to look for subclinical strep infections. In the younger kids we have data and we know it’s a driver. When a child continues to flare despite a good regimen, I will check an antistreptolysin O titer, because data have shown that even if you can’t find a culture-proven infection in the tonsils or in the anus, there can be strep in other places driving the psoriasis.

    In atopic dermatitis patients, I am very careful and selective about whom I swab. We know that if we swab an atopic dermatitis patient, 90% or more will be colonized,  but it doesn’t necessarily mean that in the absence of clinical infection it is driving their disease. I’ll typically only swab kids if they are actively clinically infected, and that is really to drive my choice of systemic antimicrobial if I go in that direction.

    Often I’ll try to do skin-directed therapy like bleach baths, and I try to stay away from oral antibiotics if I can, unless they have strep, pustules, or [they’re] systemically ill.

    READ: Probiotics for healthy skin

    I look for herpes simplex virus (HSV) if there are typical punched-out lesions or a pattern that looks like HSV or eczema herpeticum with a culture or a direct fluorescent antibody study. So yes, I am very often looking for bugs.

    Another pearl on psoriasis patients is that we can often overlook or forget in the clinic that there is some data that pityrosporum can drive scalp psoriasis. I will often prescribe an antifungal shampoo for my psoriasis patients who have scalp involvement, which I think can help in that regimen as well.

    Some of the allergists would use itraconazole or related anti-fungals for atopic dermatitis. I am not sure that the potential benefit would outweigh the potential risk.

    Check part one of this three part series: Clinical pearls in pediatric dermatology

    Dr. Siegfried: I have not used itraconazole or fluconazole (Diflucan, Pfizer). The only time I use oral anti-yeast agents is in kids with recurrent diaper dermatitis, who often have a predilection for psoriasis and then sometimes secondary yeast. I find that if I culture yeast, it’s more useful to use a systemic antifungal than an oral one, because the reservoir for the yeast is their stool, and also because all of the topical anti-yeast agents, with the exception of nystatin ointment, are primary irritants.

    Dr. Cordoro: I think topical Nystatin is the best for the reason you mentioned as well. A lot of these “oldie but goodie” time-proven medications are cycling back around as we’re forced to look for alternatives to the newest agents that are too expensive and no insurance plans will cover them.

    NEXT: Assessing systemic treatments


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