Ask the Pediatrician: Dr. Molly

Category: Skin

Dry skin: the Michigan winter scourge

Michigan's cold, dry winter air results in skin problems for many of us. Even if your house is well humidified, going in and out of the house, car, office, school and the like is stressful for skin. What can make it worse, believe it or not, is moisture, so rarely a week goes by that I don't see a kid in the office with a rash around his mouth from licking dry lips or hands dried out from frequent hand washing to avoid winter illness. Here are some strategies that can help:

First, keep your house moist. If you don't have a humidifier on your furnace, the easiest way to humidify the air in your child's bedroom is to put a medium-sized bowl of fresh water on the dresser every day. By changing the water every day, you avoid bacteria or fungal growth and you don't end up with "rain forest" effect of a room vaporizer or humidifier.

Second, have thick emollient creams available all the time. Carry some in your purse, send some to school in your child's backpack, keep it out in the bathroom and family room so as soon as your child feels that scratch of dry skin, she can reach for cream instead of itching or licking the area to relieve the symptom. The best emollients are not lotions but rather creams or even more viscous things like petroleum jelly. Products with shea butter, coconut or other natural oils are particularly good, but more readily available products designed for intensive skin therapy can often work, too. Avoid products with fragrances because these can sometimes be even more irritating.

Third, bathing or showering daily is actually a good thing as long as the water is comfortably warm but not super hot, you use a moisturizing soap rather than an anti-bacterial one and then lube up with the emollient after just barely drying the skin to trap the moisture.

If after using a thick emollient two or three times a day for a week or so your child is still having issues, it is a good idea to take him to the doctor. Sometimes dry skin can get infected and a little antibiotic cream along with the emollient is needed to get the job done.

Category: Skin

Stitches, glue or nothing? Managing cuts

All kids will get bumps and bruises and some will even get cuts and gashes. I get a lot of calls from parents unsure if they need to take their child to the ER for these wounds.

In general, you must get a wound closed within eight hours of the injury if stitches or glue are to be used. In other words, you often can't wait until the next morning when your doctor's office is open to make this decision.

Sometimes the need for stitches is obvious, but other times it's a tossup. When wounds are on joints or the face in areas near the lips or eyes, even if they are small, they often heal better if closed professionally. Any cut that doesn't stop bleeding quickly or whose edges can't easily be opposed and held that way by a bandage needs assessment. Even jagged wounds that look like they would be hard to stitch together often can be and will heal with less scarring if you do.

Usually, the option when you get to the ER is to stitch or use a a superglue designed for the skin. The location of the laceration and its severity often dictate which is best. Stitching the wound will ensure the ends will be opposed and stay that way as the wound heals, but it requires local anesthetic and may leave additional marks from the stitches as the wound heals. The glue is attractive because it requires no needles, but it isn't as much a sure thing when it comes to keeping the edges tightly together as the cut heals. If the cut reopens, there is no recourse because the wound will be too old at that point for a second glue attempt or stitches. Most of the time, the folks in the ER have so much experience with lacerations that they can tell on first glance which method is best and will recommend that one.

Parents often call from the ER and ask if I can facilitate having a plastic surgeon come in to close the wound if stitches are to be used. Unless the wound is severe enough that extensive repair is needed (usually under anesthesia) no plastic surgeon will come in anyway. To be honest, the doctors and physician assistants in the ERs close so many wounds, they are often as good, if not better, than the surgeon at closing these, especially because the wound is rarely made by something as precise and clean as a scalpel.

Abrasions or scrapes cannot be stitched up. Even if they are oozing for a long time, just keeping them covered is the best you can do.

Over-the-counter and prescription products that purport to minimize scarring have not been shown to make a difference in the severity of the scar in the long run and therefore are not beneficial. Just keep the wound clean and dry and nature will do its job.

Category: Skin

Teen acne can be managed with variety of treatments

This past weekend was homecoming at my daughter's high school and because I see a lot of teenagers in my practice, it was a busy week. Some came to the office to try to rid themselves of an illness in time for the dance while others arrived with the hope that I would be able to cure their acne quickly. If only the acne-laden kids had come in a few weeks earlier there would have been some hope for smoother skin by the weekend.

Almost everyone will have acne at some time and puberty brings on a hormonal storm that makes acne nearly ubiquitous at this time. Acne isn't caused by dirt or oil on the top of the skin but rather the small hair follicles (pores) in the skin get clogged with dead skin causing a blackhead or whitehead. Sometimes those blackheads will have bacteria growing in them causing a lumpy feeling under the skin. Usually the bacteria causes the body to respond with inflammation and that's what causes the redness and pus of a pimple.

Because there are three distinct components to acne (clogged pores, bacterial growth and inflammation) treating it can be complex. The first step in any regimen is to wash the skin twice a day with mild soap and warm water. Use very mild soaps without antibacterial properties because these will be too drying. Don't use a rough cloth or over scrub because this will actually worsen acne. Washing your face twice a day will remove the dead skin cells that clog the pores and are the primary set up for acne. If that alone isn't enough but if you aren't having red raised pimples, using an over the counter 10 percent benzoyl peroxide product twice a day after washing may make all the difference.

When a person has more than blackheads and whiteheads though, prescription medications might be needed. When the acne lesions are filled with pus or are red and raised, there is enough inflammation that benzoyl peroxide and washing alone won't be enough. To avoid scarring from the inflammation, using the prescription products regularly is very important. Most doctors will start with a topical cream or gel called Retin-A. The upside to Retin-A is that it is very effective; the downside is that it can cause some redness and irritation to the skin for the first few weeks it is used. This can be minimized by choosing the weakest strength needed to control the symptoms. Anyway you slice it, Retin-A takes a few weeks before the skin is clear. Retin-A works well because it is an anti-inflammatory product and as such, the pus and redness are greatly diminished. When used with a benzoyl peroxide wash to gently fight bacteria and clear away dead skin, the combo is a real winner.

Sometimes, the pimples aren't red and raised and when that is the case an anti-inflammatory like Retin-A isn't the first choice. Instead, a combination of benzoyl peroxide and an antibiotic to fight bacteria makes sense. In this case, topical antibiotics (usually clindamycin) and benzoyl peroxide are used to manage the acne. Retin-A can be added later if these aren't enough.

When acne is scarring or when the topical treatments aren't enough, low dose oral antibiotics like clindamycin and/or oral anti-inflammatory medications like Accutane are up for consideration. Usually it is at this point that I refer kids to the dermatologist.

Acne can be embarrassing for kids and often they won't even bring it up to me despite the fact it is effecting their self-confidence and esteem. Sometimes parents will bring it up but often I am the one to break the ice and talk about acne and its management. The good news is that it doesn't have to be a right of passage that must be weathered without treatment. Most of the time acne can be managed with a commitment from the teen to do the prescribed skin care regime twice a day and everyone will be happier.

Category: Skin

Hives in kids are not always a sign of allergy

It's 2 a.m. and your 4-year-old climbs into bed with you, squirming and irritated. He doesn't feel like he has a fever and hasn't had a bad dream and yet he can't seem to stop moving around. Exhausted yourself, you get frustrated with his constant movement and walk him back to his own bed for the night. As you pass by the bathroom with the nightlight on you notice something odd: your child has spots - everywhere! Quickly you turn on the big light and see he has hives all over his body and face.

Your tired mind starts racing: What did he have for dinner? Could it have been from the peanut butter cookie he had for dessert even though he's had peanut butter all along? Are those new PJs? did he take a bubble bath last night?

You get out the Benadryl and give him a dose. As he finally gets relief from the annoying itch, you and he fall asleep again. At 7 a.m., when you both get up for the day, you notice his hives are still there and the itching is back so as soon as the doctor's office opens you call for advice and an appointment.

By the time you get to the appointment at 11 a.m., his hives are barely visible and all seems well again. You feel a little silly talking to the doctor with no evidence of the rash anymore and yet you worry if this is the first sign of a serious allergy. After all, more kids seem to have food allergies and because nothing else has changed in his clothes or soaps, you figure this must be the cause.

Your doctor asks a bunch of questions: any new foods? (no), new soaps? (no), any family history of allergies? (yes), any diarrhea or vomiting? (no), new exposure to animals the day before? (no), any recent diarrhea or cold symptoms? (no).

After examining him and finding nothing more than the remnants of the hives you have been seeing, she tells you these are not likely due to allergy at all. In fact, most often the cause of hives in children is never determined and thought to be due to a viral illness. More than 70 percent of the time the exact cause is never known and the hives peter out after about two days.

Hives are caused when the body overreacts to something and the immune system responds as if it is an allergy. Because many viruses will turn on the immune system, sometimes things go a bit awry and hives are the result. Other times, hives can be caused by a food, medication or something in the environment like molds or even something innocuous like cold temperature. If hives are the only symptom of the reaction, whether it be to a virus or a true allergen, there is no need to worry. Benadryl for a day or two will take care of the itch although the rash will continue to come and go. The rash will look much worse at times during these couple of days and anything that makes the child hot (like a bath, sleeping under cozy blankets or running around outside) will make the rash look even worse.

Unless your child has joint swelling, breathing trouble or is vomiting a lot, this is not going to progress to a serious reaction. Sometimes hives will appear off and on for weeks. If that's the case, seeing an allergist is warranted.

Bottom line: Hives alone are no big deal. Use some Benadryl antihistamine if the itching is bad and let nature do its job.

Category: Skin

Cradle cap is yucky, but normal and harmless

Cradle cap is the scaly, crusty flakes and plaques that many infants have on their scalps. Cradle cap is common in the first year of life and is initiated by the withdrawal from the hormones of pregnancy.

What happens is that the hair follicles on the scalp make a greasy substance (think unwashed teenager) that can collect and then dry to a crusty scale on the scalps of infants. For some, the amount secreted is large enough to cause recurring scaly scalp until around 1 year of age. Sebum, the substance secreted, will also be secreted by the hair follicles on the skin in areas near hair, the eyebrows, in front of and behind the ears, on the temples and even on the upper neck and back of some babies. When the area isn't hairy, there isn't much of a crusty scale but instead a bumpy red rash appears with some flakiness noted.

Cradle cap is a nuisance. It can be unattractive (to parents at least), but is often without any symptoms for the baby. Occasionally the infant my be itchy as a result and will have scratch marks in areas where he can reach.

Treating cradle cap (and the skin version of it called seborrheic dermatitis) is often as simple as washing the hair and skin daily with a gentle soap and loosening the scale with your fingertips or a soft bristle brush. For tough to treat scales, soaking a little oil on the area will soften the scale and allow it it be gently scrubbed away.

Sometimes these remedies don't work, so if needed, an adult dandruff shampoo can be used to remove the scale and diminish the chance of recurrence. The downside to this is the chance that the shampoo will get in the child's eyes and cause pain. Over-the-counter steroid creams can also be used if the areas are quite itchy or if the skin areas look significantly inflamed. Using a thin layer of 1 percent hydrocortisone cream twice a day can diminish the redness and the itch.

Overall, cradle cap is a hassle but it is harmless and no specific treatment is needed unless the child is uncomfortable.

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Category: Skin

Head lice bugs parents, but it can be treated

Little else strikes fear and grossness in a parent that the yellow note in his child's backpack indicating her schoolmate has head lice. Just thinking about it makes your head itch! The thought of little bugs crawling around on your scalp, sucking your blood, laying eggs and generally causing an nuisance is disgusting. Here is the truth about head lice and how to treat it.

Head lice is not caused by lack of cleanliness. In fact, lice like clean hair best and especially hair adorned with gels and sprays and sweet smelling conditioners. So, don't be grossed out that some "dirty" kid brought this scourge upon you - just the opposite!

Not all white stuff near the scalp is lice related. Making a correct diagnosis is important. If you don't see live lice you can't be sure it is head lice. If you suspect your child has lice, comb her hair while it is wet and look for the actual bugs. If you find even one, you have an active infestation. Sometimes dandruff, cradle cap or just poorly rinsed shampoo can cake on the scalp in areas and flake off resembling nits. Be sure you have the real thing before you go through the hassle of treating it. If need be, take your child to the doctor to be sure.

Using an over the counter medicated shampoo is the best way to kill the lice, but be sure to use it correctly! Rid and Nix are the most common, but recently the FDA approved a nonpesticide containing product, Ulesfia, that is safe and effective for children 6 months and older. When you pick up your medicated shampoo, apply it to dry hair (not washed hair as the package suggests). When you wash the hair, the lice can sometimes ball up and protect themselves and the medicated shampoo won't do what it needs to. Instead, apply it to dry hair, everywhere, careful to get every hair near the scalp covered. Leave the shampoo on for the time recommended and wash it out.

Combing the hair thoroughly to remove all nits and lice is essential. Using the proverbial fine-toothed comb (I think metal ones are far superior to the plastic ones), meticulously comb through the hair, making sure you get every single hair between the tines of the comb at one point.

Put all hairbrushes, combs, hair accessories, hats, etc. either through the dishwasher or the laundry on high heat to kill any lice that remain.

Comb out the hair thoroughly every day for the next week. You will undoubtedly miss some nits (the lice eggs) so to ensure they don't hatch and lay new eggs, wet the hair and comb it out every day for the next week.

Reapply the medicated shampoo a week later to kill any hatchlings and comb out for another few days.

Lice don't live long off the scalp. No need to do laundry every day for this week or two. Just do the bedding on day one and any other day that you find live lice. There's some debate about whether you really need to bag up stuffed toys, hats that can't be washed, etc. It seems that since the lice can't live long off a human head to feed on, these items won't harbor live lice for long.

Natural remedies like mayonnaise, tea tree oil and other products have not been shown to be any more effective than just combing the wet hair.

Spraying your furniture or house with lice killing spray is not necessary because lice don't survive off the scalp. Pets can't get or carry lice either.

Don't treat your whole family just because one child has lice. You can't prevent lice infestation. Just comb your infested child's hair well, wash the hair accessories, combs, brushes and hats and stay on the lookout for lice.

Category: Skin

Summer is time to manage burns, sunburns

Bonfires, grilling dinner, spending a sunny day at the pool, roasting marshmallows, playing with sparklers on are the makings of summertime memories - and potential causes of burns. Even the best parents can't watch their kids 24/7 and the hot marshmallow just off the fire seems so fun to play with ...

Burns can be mild or serious with life-threatening consequences. Burns are divided into three major categories:

• first-degree: the skin turns pink or red and tender but no blistering has occurred
• second-degree: the skin is red and painful with blistered areas
• third-degree: the skin is charred black or stark white and painless. Usually, third-degree burns occur in house fires or when there is underlying neurologic damage that decrease your ability to sense what is happening (like drug intoxication or diabetes).

Sunburn is the prototypical first-degree burn. The skin becomes pink or red and tender to touch. Sometimes kids are nauseated or lightheaded if a large part of the body is sunburned and often the burn continues to evolve for up to 12 hours after the child is out of the sun. First-degree burns can be managed at home with pain relievers such as acetominophen or ibuprofen, drinking lots of liquids and using cool compresses to particularly painful areas. First- degree burns may resolve in just a day or may take up to a week to fully resolve depending on how extensive the burn is. Using butter on a burn, an old remedy still used at times, will actually make a burn worse because the fat in the butter will "fry" on the hot skin and exacerbate the burn. Another common treatment is aloe lotion or gel. Aloe, like any lotion, will moisturize the skin but has no additional medicinal or healing properties so don't waste your money!

Second-degree burns are more serious. They can be caused by the sun, too, but more commonly are caused by short contact with an extremely hot surface such as a roasted marshmallow, bonfire flame, sparklers, stove top, oven grate or curling iron to name a few. These burns extend beyond the surface layer of the skin into the deeper layers and as a result the skin responds by making a blister. The blister is like a natural bandage. In addition to protecting the underlying damaged skin from reinjury or infection, the liquid in the blister acts as a moisturizer aiding in the healing process. Second-degree burns that are bigger than 3 inches by 3 inches or involve the palm of the hand, extend over a joint area or private parts even if smaller require assessment and treatment in an emergency center. Children are at particular risk for severe scarring or infection if the burns are extensive anywhere or are on "softer" areas of skin of the palms, soles, buttocks or if they extend over the elbow or knee for example.

Sometimes people feel a bit silly going to the ER for a blistering sunburn that extends across the shoulders or a small marshmallow burn on the palm of the hand, but without specialty treatment these not only can scar more severely but leave the skin in the area contracted to the point of the hand (or shoulder) not being able to fully extend or flex. Don't feel silly - if the burn warrants it, head to the ER.

If the second-degree burn is small enough and doesn't involve these special areas, by all means stay home but don't touch the blister! By leaving the blister intact as long as possible you will encourage the best healing. If the blisters break after only a day or two, see your doctor. There is a special cream called Silvadene that can protect the skin from infection and moisturize it while it heals. All burns cause you to get a bit dehydrated due to radiating heat, so drink a lot more to make up for it.

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Category: Skin

Take care to avoid poison ivy summer scourge

With summer hiking, exploring grasslands near the beach or digging in a neighborhood park comes the possibility of running across poison ivy, oak or sumac. These summertime scourges look like unassuming ground cover but can cause up to three weeks of itchy, blistery discomfort.

Michigan is chock full of these unassuming plants that are chock full of urushiol, the oil that when it comes in contact with skin, causes a significant allergic reaction with itching and blisters a few days after exposure. Once you have been exposed to the oil and you develop blisters you cannot spread it through itching. The skin rash itself is not contagious but because the reaction will unfold over several days it does appear to spread. The oil can exist for incredibly long times on garments and sleeping bags so washing all items a poison ivy victim comes in contact with is essential or you can get in contact with the oil again the next time you use that sleeping bag or fireside throw.

Once the allergic reaction to the oil is underway, there is little you can do beyond applying cool compresses and hydrocortisone cream to control the itching. However, if you discover you have been exposed to poison ivy or similar and have not yet developed symptoms, you may be able to lessen the severity of the reaction or prevent it entirely by putting rubbing alcohol on the exposed skin or commercial products such as Zanfel. These work to remove the oil from the skin before the reaction can take root.

Avoiding these annoying plants is your best bet, but to do so on a 90 degree summer day can be challenging. The best approach is to wear long pants and/or tall socks when hiking in areas that my have it to prevent contact between your skin and the plants. Tell that to a fashion conscious 12-year-old! The other options include using Zanfel or rubbing alcohol immediately after all times of possible exposure to minimize the chance of getting the itchy rash. Be sure to wash all camping gear and clothes thoroughly if a member of the camp group has gotten exposed so you don't inadvertently cause the rash all over again the next time you take that sleeping bag out for a sleepover!

Download this pamphlet to take with you when you go outdoors to help identify the culprits.

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Category: Skin

Q&A on painful shingles

I get a lot of questions about shingles and whether or not exposure to a person with them is problematic. Here are the common questions and answers:

Q: What is shingles?
A: Shingles is a painful, stinging and itchy, red blister-like rash in a specific area that corresponds to a nerve in the body.

Q: What causes it?
A: Once you have been exposed to the chicken pox virus (either though having the illness or getting the vaccine) the virus will live in your nerves forever, dormant unless something reactivates it. Sometimes the trigger is clear: stresses, either physical or emotional, are most commonly linked to the virus' reactivation, but at times no clear trigger is known. Once reactivated, the virus crawls down the nerve itself causing inflammation and tingling pain until the nerve reaches its end points and the virus emerges on the skin as blisters on a red background.

Q: So can I get the chicken pox from someone with shingles?
A: Only if you have never before had the chicken pox or the vaccine and you come in direct contact with the blisters. In other words, if you had chicken pox as a kid or the vaccine, you can't get anything from someone with shingles. If you have not had chicken pox or the vaccine and come in contact with the blisters there is a chance you can get chicken pox from that exposure 10-21 days later.

Q: Can I carry it home to my kids even though I can't get it?
A: No. You can only spread it if you have the illness yourself.

Q: Can I get shingles from being exposed to someone with it?
A: No. Shingles isn't spread from person to person. It is an internal process so being exposed to someone else with it will not trigger it in you.

Q: Can shingles be treated?
A: Yes. Cover the area to be on the safe side and your doctor can prescribe Acyclovir, an antiviral medication to minimize the symptoms and prevent complications.

Q: Can kids get shingles?
A: Yes. Adults, especially older adults, get it much more frequently but kids can definitely get it, too, if they have had the chicken pox or the vaccine and they are under a stress of some sort.

Q: Is there a vaccine to prevent shingles?
A: Yes. For older adults, Zostavax, a version of the chicken pox vaccine children get, is available to boost immunity and decrease the likelihood of getting shingles.

Category: Skin

Sunscreen: how much, how often, how young

It's spring break time, with many families headed to warmer and sunnier spots. I know I should know better, but even though I am a very fair-skinned Irish-American woman in my mid-40s, I actively seek out the sun whenever possible. I love to soak in the warmth and develop a radiance to my skin that the cool and damp climes of my genetic roots didn't prepare my skin for.

When I was a child, sunscreen as we know it today barely existed and most people just used tanning oils and even tin foil-covered surfaces to increase the sun's tanning effects. For people like me that meant sunburn. And blisters. And nausea. Not fun. Worse yet, the bad sunburns I had as a kid have put me at significantly increased risk for skin cancers and melanoma.

Lucky for us, sunscreens are readily available and most of us are pretty smart about using them. Despite this though, parents have questions about what SPF to use, at what age can their child start to use sunscreens and how long can their children stay out in the sun before the dreaded sunburn. Here's the scoop:

Sunscreens have several different properties. Some block both types of ultraviolet rays while others only block one. The sun protection factor (SPF) is prominently displayed on the container, but how much better is a sunscreen if it's SPF is 50 vs 15. Some come in sprays, others as lotions. Some contain fragrances and PABA and others are more plain. Despite all of these differences the bottom line about sunscreen effectiveness has much more to do with the amount applied and frequency it is reapplied than any of these other factors.

Sunscreens are meant to be applied liberally. That means if you are using a lotion, you have to put enough on all areas of the skin that the skin looks white and it should take a minute or two to completely rub in. In other words, if your container of sunscreen is lasting for your whole weeklong vacation, you are not applying nearly enough. For an adult, you should use an ounce or more for each application and apply every hour or so to ensure adequate sun protection. If you do this, you needn't have an SPF higher than 15 to do the job.

However, kids are often less than patient as you apply the thick coat of lotion. With sweat or swimming or just rubbing it can get in their eyes and sting, so applying it at home or in your hotel room before you head to the beach or pool will not only allow for an easier go of it, but will also allow for more complete absorption before you are out in the sun.

Most sunscreens indicate only children 6 months or older should use it, but in actuality you can use sunscreens on tiny babies if needed. The big issue isn't how the skin will react to the lotion, but rather the fact that infants that young are much more susceptible to heat exhaustion and heat stroke because they can't get themselves out of the sun when they are feeling overheated. Keeping your infant out of direct sunlight is best. Also, have her clothed lightly to further diminish exposure. If you have to be in the sun at a family reunion picnic or other activity, then sunscreen is important, too.

The sun's rays are strongest around midday, from 10 a.m.-4 p.m. so to the extent everyone can be out of the sun during those times, all the better. But let's face it, we will be out during the peak sun times on many days so remember that liberal and frequent application of sunscreen can help prevent sunburn and decrease the chance of skin cancer later.