Dr Heath Shares Clinical Pearls for Treating Pediatric Patients

Candrice Heath, MD, shared her insights on treating pediatric patients, and why it is important for all dermatologists, including those who only see adults, to learn about treating younger patients.

Dr Candrice Heath is an assistant professor of dermatology at Temple University’s Lewis Katz School of Medicine in Philadelphia, PA.

Transcript Dr Heath on Pediatric Patients

Melissa: Hello, welcome to another podcast with The Dermatologist. I am Melissa, associate editor. Today, I have the pleasure of speaking with Dr Candrice Heath, assistant professor of dermatology at Temple University’s Lewis Katz School of Medicine in Philadelphia, Pennsylvania.

Dr Heath will be sharing with us her clinical pearls for treating adolescents and children, which she presented at the Skin of Color Update. Thank you so much for joining us today, Dr Heath.

Why is it important for all dermatologists to understand the presentation and impact of skin diseases among pediatric patients, even if they only treat adults?

Dr Candrice Heath: I really do enjoy seeing kids and adults, and so I like making these observations. One of the things that I really like to talk about, especially with my residents, is that adult patients really bring their childhood experiences with their skin to the visit.

If you don’t get that concept, then you may be blowing off patients that come in with dark spots, and this, and you say, ‘wow, they’re really upset by this thing that seems so minor,’ but you have to understand that they’re really bringing all of their childhood experiences with their skin and hair to the appointment. Also, they can probably still hear some of the things that their parents told them about their skin or rode them. All of those things play a role.

Another thing is that I like to use it as an opportunity to remind adults that some things are just not your fault. Some things happen because of genetics. Some things happen because as a child, this is just how your hair was styled, and you didn’t really have any choice in that. It’s about taking that blame and fault away and starting on a fresh ground.

Sometimes, if that’s not acknowledged, the patient just feels like, ‘wow, all of this stuff is my fault,’ and ‘I could have done this,’ and ‘I could have done that.’

Then one of the other things that’s huge is that the education in that exam room that I’m providing for adult patients, they are going to go home and do what? They are going to implement some of those things on their kids who are pediatric patients.

When adult dermatologists are seeing, you’re seeing an adult, you’re giving information about moisturizing, about how to protect the hair, etc, just think, you are actually educating an entire family, even the kids in that home as well.

Melissa: What are some of the challenges of treating pediatric patients, and does this change as they age?

Dr Heath: Our pediatric patients, some of them, especially the youngest ones, they cannot speak. They have no words for you. Sometimes, the parents can be so in left field, giving you information about red herrings that had nothing to do with why this child is having this issue, but really the child’s skin is going to tell the story.

Uniquely in pediatrics, they may come in with very, very subtle findings, so we have to be really great skin detectives to really put the entire story together. This is something that I really enjoy doing and teaching. Sometimes, the signs may be there but the information you’re receiving is not there. Actually, being able to help other physicians put those subtle clues together is helpful.

Think about something that could be definitely lifesaving for a child. If the patient is an infant that has brown skin, and they are fussy, if you’re not able to recognize the erythematous or red infant in brown skin, you may miss a child with staph scalded skin syndrome, which can be very serious and often may have to be hospitalized for. Or, even recognizing very subtle follicular papules as a sign of early eczema in a patient who has more of a darker skin tone.

I really like being detectives. All skin diseases start somewhere, and often in childhood, all of the signs may not be there, but it is great practice to see kids so that you can continue to hone your skills even when all of the findings are not in front of you.

Melissa: How do you counsel pediatric patients to address the challenges they face with their skin disease and then set them up for success as adults, especially if they have something like eczema, which we now know can carry throughout their life?

Dr Heath: Exactly. I like this question, because I take pride in helping kids to establish a healthy skin relationship. Sometimes, I get to say some of the things that their parents have told them but they don’t really believe their parents. Washing your face every day is important. Then we will strive to actually wash their face twice a day.

Washing your body once a day is important. [laughs] These are things that I actually get paid to do, and I just add those on, because, yes, you may be there for acne, or you may be there for something else, but sometimes, it’s an opportunity to really reinforce great skin habits that they may not believe from their parents.

The other thing that I do, sometimes, I can really pick up on teens, especially teen girls who are feeling very self-conscious about the way they look, and they’re telling me that I saw this on Instagram, and so I asked my mom to order for me, and then I tried this, I tried this, da-da-da.

I have to really explain to them, hey, you know what, you may not think I’m very cool, but I’m active on social media as well and I can tell you, from a dermatologist standpoint, that there’s lots of filters in technology that people use to make their skin look completely flawless on Instagram. That is not what we will compare ourselves to, and really give them a little self-esteem boost right there in the exam room. Sometimes, they did not even realize that some of the ideals that they were trying to obtain were not even real ideals. That goes into establishing a healthy skin relationship.

Also, as part of that relationship, I love to let kids and families off the hook. What do I really mean by that? Often, usually teenage years, the skin care can become a battleground. It can be something that they use to rebel against their parents, especially if they have chronic atopic dermatitis, as you mentioned, and patients with brown skin, particularly those of African descent, our black children, really do have persistent atopic dermatitis.

This can be around for a while, the statistics show. Using this as a battleground to say, ‘no, I’m not going to do what they say,’ and ‘oh, no, she’s not doing what she’s supposed to do.’ It’s like this constant battle that my head is going to the left from the child, to the parent, the child, to the parent [laughs] watching this tennis match up of resistance.

What I like to do, and even in cases of acne with lots of hyperpigmentation, same thing. I say, guess what, you don’t have to be perfect. If you remember to put on your medication three or four times a week, that is great, and I am happy with that. That is a great starting point.

The parents are thinking, ‘what? No, don’t tell them that.’ That really gets the teen to really have some buy-in in their own health. It’s like ‘what the doctor is telling me, if I can remember it three to four times…I can do that.’

You set the bar low, establish that relationship, and then as you continue to see the child over time, they can either be great at compliance, or they’ll say, ‘hey I’ll be able to do it three, four times, because I have football practice,’ etc, and just reaffirming that that is OK.

Then I also ask them at the end, I say sometimes it’s hard to remember, so if your parents are looking, and you see that the bottles have not been moved in three or four days, would you give them permission to just remind you? I think that would be great.

I get that verbal OK in the room so that nobody is annoying anyone, and they can really blame it on Dr Heath if they really need to. We’re all trying to get to the same end result, which is important.

Melissa: What has been your experience with pediatric patients who are transitioning to young adulthood?

Dr Heath: I was a pediatrician before becoming a dermatologist, and there was this notion of sick kids, or kids who were always in the hospital and that sort of thing. In dermatology, we don’t really have that kind of population as much, but we do take care of kids who have chronic illnesses like atopic dermatitis, psoriasis, etc.

There’s something special that starts to happen in high school. I think it really begins to sink in that, ‘wow, I’m going to have this for a while.’ You begin to set goals like, OK, if you really want your arms to be clear for prom, then we really need to be consistent three to four months beforehand with the plan. I want to rev up your visits just so we can hand-hold to some goals like that.

I think that is really where that transition, it really starts to sink in like, wow, I do have something that I’m going to have to actually manage even when my parents are not around, possibly into college. That is a very special time. I like supporting teens through that, especially now that we have so many great medications that can help with pediatric chronic illnesses like atopic dermatitis, and psoriasis, and other things.

It can make a huge impact on an adolescent’s journey from adolescent teen into young adulthood.

Melissa: You discussed this a little bit, but what other conditions in your presentation do you discuss that have a unique presentation in children or adolescents, particularly ones with darker skin type?

Dr Heath: Of course, we have to talk about atopic dermatitis again. Those with darker skin tones can certainly present with differences. Instead of these red, scaly patches, or red patches on the skin, you may not really see everything but very well at all, but you may see follicular prominence, as I mentioned before, or papular variants of atopic dermatitis.

You also may see a lot of the aftermath. You may see some hypopigmentation or lightening of the skin, hyperpigmentation, darkening of the skin. You may see lichenification that’s also hyperpigmented. Yes, there are some subtle—actually, not so subtle—differences in how it presents.

Also, even common things like hemangiomas. Hemangiomas are bread-and-butter diagnoses in pediatric dermatology. It’s the most common benign vascular tumor that presents in children, but sometimes, people forget that it can happen in brown skin, too.

I definitely highlight that in my presentation. The teaching point is that we don’t want to delay diagnosis, because we’re thinking, could this really be a hemangioma in a brown child?

Therefore, the number of weeks that go by, months that go by, it delays their advanced treatments, and therefore their outcomes may be impacted by that late treatment that can be very helpful for disfiguring hemangiomas and hemangiomas that may impact the child’s anatomy like blocking their eye, preventing their vision, and preventing them from eating without pain. Just things like that. That’s one of the other things that I bring up.

Then some of the complications of atopic dermatitis happen more commonly in people with brown skin. The Asian population, Asian children are at highest risk for something called eczema herpeticum where herpes simplex virus infection gets on the active areas of eczema and really wreaks havoc.

It definitely requires systemic medication to help to solve that issue. It’s important to really recognize that, especially when it gets on the eye and it can affect the vision. Some of those things happen in other skin tones, but it is important to really recognize those populations that are at highest risk for those things.

Melissa: What clinical pearls or recommendations do you like to share to improve the treatment of adolescents and children?

Dr Heath: Probably one of the biggest things that impacts patients with brown skin are pigmentation disorders.

Often, patients may come in talking about dark spots on the skin, but I have to educate them and their families that yes, I see the dark spots, which is very important to acknowledge that you see it, and then to say we need to treat the underlying cause that’s causing the dark spots, and actually explaining the steps and what they’re going to do, and really specifically say that it’s going to help with the hyperpigmentation or the dark spots that they don’t like.

The reason that it’s important to actually verbally say that is that studies have been done talking about quality of life, and hyperpigmentation, and the impact. One of the highest impacts on quality of life, there were some studies that were done of all these different skin issues, and post-inflammatory hyperpigmentation was at the top of the list for the type of pigment disorder that really impacted quality of life.

I am very aggressive about trying to prevent that from happening, treating around it, and also educating the families about it as well.

Then, also something that I bring up in the talk that I give is about recognizing all of the factors that impact a person’s life. Sometimes, when you’re taking care of adult patients, you may just think about, the adult is coming in for this, you have this, here’s your medication, and we send you on your way. I don’t really do that, because I really like to give everyone the Dr Candrice Heath experience as best as possible.

Think about a child. This is interesting. Let’s say you have a patient, I’ve seen this many times, who has, let’s say, atopic dermatitis come in. You just can’t really seem to get them under control, and all these things, and they land in my office as they’ve been bouncing around.

When I really dive in, I ask questions like who is the skin caregiver in the family? Who is the one that’s responsible for caring for the child, doing the baths? When are they done? What do they do Monday through Friday? Where is the child on the weekend?

Often, what I may find is that especially in certain populations, they may be going between two homes. Let’s say there is a divorce, or there’s grandparents that are caring for the child during certain times of the week, etc, or they go to daycare, or school, or what have you.

I find out all of those things, and then my treatment plan may be something like this. I think I do share this in the presentation. Instead of giving a 60-gram tube of a specific topical steroid for an example, I may have the pharmacist dispense two 30-gram tubes.

That way, at each of the skincare providers’ homes, we have medication. We don’t have to pack up a bag, and OK, we left the bag at the other house, therefore it’s going to be a whole week before you have medication, etc, just something like that.

Or, I write a lot of “prescriptions” to please apply moisturizer to the child as frequently as possible during the day at daycare for itchy episodes. It’s not a medication. They don’t have to have this whole major thing about, ‘oh, we can’t do medications at daycare,’ but certainly, they can put moisturizer on.

I try to figure out what the child’s life is like and then meet them where they are. If you don’t ask, then you don’t know. I may even have them get the other skincare people at the other house on the phone so they can hear the recommendations that I’m making, and have them take a picture of the printed instructions that I give and text it on the spot to that other family.

Things like that really can impact the child’s life. Guess who else would benefit from having a global, holistic assessment like that? Adults. If you have an adult patient and you’re like, why is this patient not getting...Why is this not getting better? Dig deeper. There could be some other things happening, and then maybe you can help to bring those things to light so that person can actually get help with those things.

Melissa: Are there any other key takeaways you’d like to share?

Dr Heath: It’s important to explain what treatments you’re giving and why you’re giving those things. That’s how you really get buy-in from your patient regardless of their age. If they know why they’re doing something, then they are invested in the process as well.

Also, I would just challenge others to really look beyond the patient’s diagnosis and see what other factors may be impacting their skin disease that you can actually control or help with in some way, because it can certainly impact adherence, the patient-physician relationship as well, and their overall quality of life, just because you inquired, you asked about it, and it showed that you cared for your patient.

Then finally, my favorite thing to do is to let teenagers off the hook, tell them they do not have to be 100% compliant, and I will guarantee you that their head will pop up, and they will look at the parent and say, ‘I told you.’

Therefore, you have definitely hit the bonus button in getting an adolescent to be engaged in their own healthcare.

Melissa: Thank you so much for joining us today, Dr Heath.

Dr Heath: Thank you so much.

Melissa: If you have any questions or comments, please submit them in the feedback box below. We really appreciate your feedback and thank you for listening.