© The Children's Mercy Hospital, 2016

Kimberly A. Horii, MDProfessor of Pediatrics

Children’s Mercy Hospitals & ClinicsDivision of DermatologyKansas City, Missouri

Lumps & Bumps in Children

Lumps & Bumps in Children

I have no financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity I will discuss off label use of a commercial

product in my presentation– For verruca vulgaris and molluscum contagiosum

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Practice Change

As a result of attending this lecture, I encourage you to incorporate these changes in your practiceChange 1: Recognize several different lumps and bumps that can present in a child

Change 2: Discuss possible work up for a variety of "bumpy" skin lesions that can occur in children

Change 3: Devise an initial treatment plan for several "bumpy" skin lesions that can occur in children 3

Common Lumps & Bumps in Children

Pilomatricomas Dermoid cysts Granuloma annulare Juvenile xanthogranulomas Mastocytomas Verruca Vulgaris (warts) Molluscum contagiosum

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Pilomatricoma Benign tumor of hair structures usually seen in

children/adolescents Solitary, firm (due to calcification) papule or

nodule on the face, neck, upper extremities (>50% occur on head and neck) Skin colored to slightly discolored

– Pink, red, or blue tint 5

Pilomatricoma

“Tent sign” -multiple facets and angles visualized when overlying skin is stretched Variable size Usually asymptomatic stable lesions Distinct histology Definitive treatment: surgical excision

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“Tent Sign”

Dermoid Cysts

Congenital subcutaneous lesions occurring along embryonic fusion lines– Results from faulty development

Congenital, but may not be noticed until later in infancy or early childhood with enlargement 1-4 cm firm, skin colored, non-tender, fixed

subcutaneous nodules 13

Dermoid Cysts

Common location: upper lateral forehead or scalp Treatment: surgical excision Midline lesions may be at risk for intracranial

connection Midline dermal cysts should have radiologic

imaging prior to surgical excision to rule out an intracranial connection

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Granuloma Annulare Skin colored subcutaneous papules or nodules often

grouped in a ring configuration– No scale! (often misdiagnosed as ring worm)– Borders may be elevated

Commonly located on feet, ankles, shins, & hands Usually asymptomatic Enlarge over time with central clearing

– Size range from 0.5 cm to 3-5 cm 18

Granuloma Annulare

Unknown etiology

Histology is diagnostic

Usually resolve spontaneously over many months to years

Limited therapeutic options24

Juvenile Xanthogranuloma Form of non-Langerhans cell histiocytosis Benign, self limited disorder seen in infants & children Usually appears by 1 year, can be present at birth

– Can increase in number over time Firm, round papule or nodule

– May be solitary or multiple– Color ranges from pink to orange, yellow or tan– Variable sizes 25

Juvenile Xanthogranuloma Commonly located on the head, neck, or trunk Usually asymptomatic Ulceration and crusting rarely occurs Classic histologic appearance May rarely have extracutaneous involvement with the eye

being the most common location Spontaneous regression occurs over 3-6 years No therapy needed

– Surgical excision is definitive therapy 31

Regressing JXG

Juvenile Xanthogranuloma

Screening eye exam recommended if under 2 years of age and has multiple head or neck lesions If numerous cutaneous lesions consider

workup for further visceral involvement

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Solitary Mastocytoma Represent 10-30% children with mastocytosis May be solitary or multiple (5 or fewer lesions) Present at birth or appears within first 2 years of life Yellow to red-brown round to oval, slightly raised

papule, plaque or nodule (peau d’orange texture) Average size 1 to 5 cm Most commonly located on arms, neck, and trunk 35

Mastocytoma May have intermittent blistering, urtication, &

itching Positive “Darier’s sign”

– Stroking leads to urtication (hive formation) Prognosis

– Urtication and blistering improves over time– Usually involutes spontaneously over several years

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Positive Darier’s Sign

Treatment

Oral antihistamines & topical steroids Avoidance of mast cell degranulators

– Medications: Aspirin, alcohol, dextromethorphan, narcotics,

polymyxin B, procaine, amphotericin B, atropine, thiamine, radiographic contrast media containing iodine, and decamethonium

– Physical stimuli (cold, heat, sunlight, friction/rubbing) 42

Urticaria Pigmentosa 70-90% of childhood mastocytosis Numerous brown/red macules or plaques

– Usually densely distributed on trunk or acral areas Systemic involvement rare

– Flushing, diarrhea, fainting, headache, bone pain Prognosis is good

– Most children will have resolution or reduction of lesions and symptoms by adolescence 43

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Verruca Vulgaris (Warts)

Also known as common warts Occur in approximately 10% of children Caused by Human Papillomavirus (HPV)

– Over 80 different HPV types Rough skin colored firm papules

– Common on hands, feet, face Therapeutic challenge 49

Treatment Options

Active Nonintervention– Warts may spontaneously resolve 2/3 of cases may clear within 2 years

– Need to consider cost and side effects of treatment

– No “ideal” single therapy50

Treatment Options

Tissue Destruction– Topical Salicylic acid (17-40%)– Duct tape?– Cryotherapy with liquid nitrogen– Immune therapy– Laser?

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Mollusum Contagiosum

Cutaneous infection caused by Pox virus Common in children <8 years old

– May affect up to 5% of children in the US Skin to skin transmission and autoinoculation Often seen more commonly in children with

atopic dermatitis Usually spontaneously resolve within 2 years56

Molluscum Contagiosum

Skin colored 2-5 mm erythematous smooth, dome shaped papules– May have central umbilication

Usually located on the trunk, axilla, or extremities Commonly found in intertriginous regions

(autoinoculation) Differential diagnosis: folliculitis, comedones, warts

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Molluscum Contagiosum Surrounding skin may be erythematous (molluscum

dermatitis) May develop pruritus or pain May rarely develop associated secondary infection Inflammation usually precedes resolution

– “BOTE” sign-beginning of the end May leave depressed scar/pit with or without

treatment 64

Molluscum Treatment Gentle skin care

– Mild soap– Bland emollient

Antipruritics– Diphenhydramine, hydroxyzine

Low potency topical steroid for molluscum dermatitis– 1% hydrocortisone ointment

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Molluscum Treatment No FDA approved treatments for molluscum Active non-intervention

– Usually Self Limited Destruction (physical and chemical)

– Cryotherapy– Curettage with topical anesthesia– Cantharidin

Applied in office washed off with soap and water in 3-4 hours

Topical irritants ? Immune modulator 68

Common Lumps & Bumps in Children

Pilomatricomas Dermoid cysts Granuloma annulare Juvenile xanthogranulomas Mastocytomas Verruca Vulgaris (warts) Molluscum contagiosum

69

Practice Change

As a result of attending this lecture, I encourage you to incorporate these changes in your practiceChange 1: Recognize several different lumps and bumps that can present in a child

Change 2: Discuss possible work up for a variety of "bumpy" skin lesions that can occur in children

Change 3: Devise an initial treatment plan for several "bumpy" skin lesions that can occur in children 70

ReferencesPrice HN et al. Diagnosis and management of benign lumps and bumps in

childhood. Curr Opin Pediatr 2007;19(4):420-424.Bellet JS. Developmental anomalies of the skin. Semin Perinatol 2013;37:20-25.Golden BA et al. Craniofacial and orbital dermoids in children. Oral Maxillofacial

Surg Clin N Am 2012;24:417-425.Benjamin LT. Birthmarks of medical significance in the neonate. Semin Periantol

2013;37:16-19.Paradis J et al. Pediatric teratoma and dermoid cysts. Otolaryngol Clin N Am

2015;48:121-136.Sorenson EP et al. Scalp dermoids: a review of their anatomy, diagnosis, and

treatment. Childs Nerv Syst 2013;29:375-380.71

ReferencesCyr PR. Diagnosis and management of granuloma annulare. Am Fam Physician

2006;74(10):1729-1734.Dahl MW. Granuloma annulare: long term follow-up. Arch Dermatol 2007;143(7):946-

947.Goldminz AM et al. Noninfectious granulomatous dermatitides. Semin Cutan Med

Surg 2013;32:177-182.Thornsberry LA et al. Etiology, diagnosis, and therapeutic management of granuloma

annulare. Am J Clin Dermatol 2013;14:279-290.Bhambri S et al. Juvenile xanthogranuloma. Cosmetic Dermatol 2008;21(1):21-24.Torrelo A et al. Childhood mastocytosis. Curr Opin Pediatr 2012;24:480-486.Castells M et al. Diagnosis and treatment of cutaneous mastocytosis in children. Am

J Clin Dermatol 2011;12(4):259-270. 72

ReferencesBajoghli AA et al. Urticaria pigmentosa. Arch Pediatr Adolesc Med 2008;162(4):383-

384.Hartmann K et al. Cutaneous manifestations in patients with mastocytosis. J Allergy

Clin Immunol 2016;137:35-45.Meni C et al. Paediatric mastocytosis: as systematic review of 1747 cases. Br J

Dermatol 2015;172:642-651.Kwok CS et al. Efficacy of topical treatments for cutaneous warts. Br J Dermatol

2011;165:233-246.Bruggink SC et al. Natural course of cutaneous warts among primary schoolchildren.

Ann Fam Med 2013;11(5):437-441.Boull C et al. Update: treatment of cutaneous viral warts in children. Pediatr Dermatol

2011;28(3):217-229. 73

ReferencesKeogh-Brown MR et al. To free or not to freeze. Br. J Dermatol 2007;156:687-692.

Nofal A et al. Intralesional antigen immunotherapy for the treatment of warts. Am J Clin Dermatol 2013;14:253-260.

Kwok CS et al. Topical treatments for cutaneous warts. Cochrane Database of Systematic Reviews 2012;9:CD001781

Silverberg JI et al. Childhood atopic dermatitis and warts are associated with increased risk of infection. J Allergy Clin Immunol 2014;133:1041-7.Coloe J et al. Molluscum contagiosum: what’s new and true? Pediatr Ann2009;38(6):321-325.Lee R et al. Pediatric molluscum contagiosum Part 2. Cutis 2010;86:287-292.Lee R et al. Pediatric molluscum contagiosum Part 1. Cutis 2010;86:230-236. 74

ReferencesBerger EM. Experience with molluscum contagiosum and associated inflammatory

reactions in a pediatric dermatology practice. Arch Dermatol 2012;148(11)1257-1264.

Butala N et al. Molluscum BOTE sign: a predictor of imminent resolution. Pediatrics2013;131:e1650-e1653.

Basdag H et al. Mollscum contagiosum: to treat or not to treat? Pediatr Dermatol2015;32(3):353-7.

Netchiporouk E et al. Recognizing and managing eczematous reactions to molluscum contagiosum virus in children. Pediatrics 2012; 129(4):e1072-1075.

Mathes EF et al. Treatment of molluscum contagiosum with cantharidin: a practical approach. Pediatr Ann 2010;39(3):124-129.

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ReferencesMoye VA et al. Safety of cantharidin: a retrospective review of cantharidin treatment

of 405 children with molluscum contagiosum. Pediatr Dermatol 2014;31(4):450-454.

Olsen JR et al. Time to resolution and effect on quality of life of molluscumcontagiosum in children in the UK. Lancet Infect Dis 2015;15:190-195.

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