Posted in Patient Information

Keratosis Pilaris

Keratosis pilaris is a very common harmless skin condition appearing as small, whitish bumps on the upper arms and thighs, especially of children and young adults. Individual lesions of keratosis pilaris begin when a hair follicle becomes plugged with keratin, a protein found in skin, hair, and nails.

Who’s At Risk

Keratosis pilaris can affect people of any age, any race, and either sex. It is more common in females.

Keratosis pilaris usually starts in early childhood (by age 10) and can worsen during puberty. However, it frequently improves or even goes away by early adulthood.

Keratosis pilaris can affect 50-80% of teenagers and up to 40% of adults. Many people have a family history of keratosis pilaris. A large number of individuals with ichthyosis vulgaris (an inherited skin condition characterized by very dry, very scaly skin) also report having keratosis pilaris.

Signs & Symptoms

The most common locations for keratosis pilaris include the following:

  • Backs of the upper arms
    • Fronts and sides of the thighs
    • Buttocks
    • Cheeks

Tiny (1-2 mm) white to gray bumps occur, centered in the hair follicle. Sometimes, a thin, red ring may surround the white bump, indicating inflammation. The bumps all look very similar to one another, and they are evenly spaced on the skin surface.

Rarely, people with keratosis pilaris may complain of mild itching.

Keratosis pilaris tends to improve in warmer, more humid weather, and it may worsen in colder, drier weather.

Self-Care Guidelines

There is no cure for keratosis pilaris, though its appearance can be improved. It is often helpful to keep the skin moist (hydrated) and to use mild, fragrance-free cleansers, with daily applications of moisturizer.

Creams and ointments are better moisturizers than lotions, and they work best when applied just after bathing, while the skin is still moist. The following over-the-counter products may be helpful:

  • Preparations containing alpha-hydroxy acids such as glycolic acid or lactic acid
    • Creams containing urea
    • Over-the-counter cortisone cream (if the areas are itchy) such as 1% hydrocortisone cream
Gold Bond rough & bumpy skin is an inexpensive cream which contains urea, lactic acid, and salicylic acid, all of which are helpful for keratosis pilaris.
Gold Bond rough & bumpy skin is an inexpensive cream which contains urea, lactic acid, and salicylic acid, all of which are helpful for keratosis pilaris.

Do not try to scrub the bumps away with a pumice stone or similar harsh material; these approaches may irritate the skin and worsen the condition.

Similarly, try to discourage your child from scratching or picking at the bumps, as these actions can lead to bacterial infections or scarring.

When to Seek Medical Care

Keratosis pilaris is not a serious medical condition and has no health implications. However, if self-care measures are not improving the appearance of the skin and it continues to bother your child there are some prescription options for treatment that could be considered.

Prescription Treatment Options

Treatments are aimed at controlling the rough bumps, not curing them. Keratosis pilaris bumps will come back if therapy is stopped.

Prescription treatments for keratosis pilaris sometimes include:

  • Prescription-strength alpha- or beta-hydroxy acids (glycolic acid, lactic acid, salicylic acid)
  • Prescription-strength urea
  • A retinoid such as tretinoin or tazarotene
  • High concentrations of propylene glycol
  • If the skin is itchy or inflamed, the short-term prescription strength topical corticosteroid to reduce the inflammation may be considered

Usually, consistent home use of over-the counter creams is enough to manage the symptoms of keratosis pilaris.

References

Posted in Patient Information

Picky Eating

Adapted (partially verbatim) from Am Fam Physician. 2015 Aug 15;92(4):274-278.

Kids don’t need as much food as you think!

One way children start to show their independence is by choosing what they want to eat. You should make meal times as pleasant as possible. The amount of calories and nutrition a child needs is less than many parents realize. You can find out how much your child needs by going to choose my plate.

Parents often describe their toddlers and preschoolers as picky eaters. The reluctance to eat or try new foods (food neophobia) is a normal developmental stage that the child usually outgrows. However, there are picky or fussy eaters who restrict their intake to only a few food items, regardless of whether they are new or familiar.

Some ways to reduce picky eating include:

  • Avoid offering many sweetened foods or foods with high carbohydrate content (breads, sweetened cereal, rice).
  • Don’t let your child drink too much milk or juice. The calories in liquids can take away appetite. A child should have no more than 16 to 24 oz of milk and 4 to 6 oz of juice per day.
  • Follow the rule of 10s: children should try a food at least 10 times before deciding they don’t like it.
  • Offer foods that are similar to ones your child likes. (For example, if your child likes canned peas, offer cooked carrots instead of raw carrots. The softness of the food may make a difference.)
  • Use an older sibling as a role model to help children try things they think they don’t like.
  • Mix foods, even if the mixture doesn’t make sense to you. (For example, a child may eat “ants on a log” because it is a fun way to present celery, peanut butter, and raisins.)

Mealtime Roles for Parents and Children:

The main approaches to picky eating include social modeling of normal eating behaviors, repeated exposures to new foods, and positive mealtime experiences. There is a strong correlation between parent and child nutritional behaviors. Parental efforts to control the child’s intake of food using pressure to eat a certain food or quantity of food, restriction of certain foods, or promise of a reward have negative effects on food acceptance and are discouraged. In the Satters’ Division of Responsibility Model, the parents’ role is to provide mealtime structure, positive social modeling, and a variety of healthy foods, whereas the child decides how much and which foods to eat.

Satters’ Division of Responsibility Model

Parents:

  • Provide mealtime structure: time and place.
  • Create a positive environment: pleasant interaction.
  • Allow the child to feed himself or herself.
  • Provide a variety of healthy foods.

Children:

  • Eat if he or she wants to.
  • Choose what to eat out of the offered foods.
  • Stop eating when full.
Posted in Patient Information

Thumb Sucking Parent Information

Adapted (partially verbatim) from Am Fam Physician. 2009Jul15;80(2):139-142.

About Thumb Sucking and Pacifiers

Thumb sucking is an innate reflex and one of the most common security and self-soothing mechanisms. In infants, thumb sucking and pacifier use are often classified together as nonnutritive sucking methods. Pacifier use has been linked to decreased breastfeeding duration, but the same effect of thumb sucking on breastfeeding has not been reported. In some studies, combinations of the use of pacifiers and thumb sucking have been reported to lead to decreased breastfeeding. Pacifier use has been documented to be protective against sudden infant death syndrome (SIDS) in children younger than six months and was included in the 2005 American Academy of Pediatrics SIDS guideline update; however, there have been few studies advocating thumb sucking as an equally preventive measure against SIDS.

The incidence of thumb sucking among children decreases with age, and most children spontaneously stop thumb sucking between two and four years of age.

When Should Children Stop Thumb Sucking?

School-aged children with persistent thumb sucking should be referred to a pediatric dentist. At this age, when the permanent teeth erupt, thumb sucking can affect a child’s teeth alignment and mouth shape. The greatest risk of developing malocclusive problems, such as overbite and crossbite, occurs in children who have persistent thumb sucking problems beyond four years of age.

American Dental Association Recommendations to Stop Thumb Sucking:

  • Praise children when they don’t suck their thumb (e.g., verbal praise, stickers).
  • Reward your child for not sucking his or her thumb (example: for every day children do not suck their thumb, they get to mark an “X” on a calendar. After a certain number of “X’s,” they can receive a reward).
  • Find alternative ways of comforting and soothing for children (e.g., stuffed toy or special blanket).
  • Provide reminders or negative reinforcement for thumb sucking (e.g., placing topical bitter liquids on the thumb, putting a bandage around the thumb to remind the child not to suck on it).
  • Involve older children in ways in which they can stop sucking (e.g., have children help create their own reward system).

Featured Image: Topical bitter liquids marketed to help discourage thumb sucking: Mavala Stop, Thum

Posted in Patient Information

Penile Adhesions in Male Children

Adapted from: Penile Adhesions Parent Information CHOP Website

What are penile adhesions

Penile adhesions in circumcised boys occur when the penile shaft skin adheres to the glans of the penis. There are three types of penile adhesions: glanular adhesions, penile skin bridges and cicatrix.

Causes

Some adhesions may develop due to an excess of residual foreskin following a newborn circumcision. Adhesions can also form as an infant develops more fat in his pubic area (the area around the penis and scrotum).

Symptoms

The penis may appear that it is “buried” in the prominent pubic fat pad. Because the penis remains hidden there is a tendency for the shaft skin to adhere to the glans.

With all adhesions you may notice a white discharge coming from the area of the adhesions. This is called smegma. Sometimes smegma can be mistaken for a cyst or pus under the skin, but it is not an infection and does not require antibiotics. Smegma consists of dead skin cells that accumulate underneath the adhesions and help to break them apart.

Diagnosis and treatment

Penile adhesions are generally benign and cause no pain or discomfort to your son. You or your pediatrician may notice them during a physical exam.

Treatment is generally performed by a urologist. They will determine by physical exam the type of penile adhesion and what treatment approach is recommended.

Glanular adhesions

On exam you may not be able to see the complete coronal margin. This is the purple line that separates the glans from the shaft of the penis. This is because the shaft skin has adhered to the glans, covering the coronal margin. Glanular adhesions are benign and when left alone tend to resolve on their own. To help the adhesions separate more quickly, we may suggest applying Vaseline® directly to the adhesions. The Vaseline will soften the adhesions, and with spontaneous erections, the adhesions will begin to break apart on their own.

Penile skin bridge

In some instance, the penile shaft skin will become attached to the coronal margin and develop a thicker permanent attachment that cannot be separated and will not separate on its own. You may notice a band of skin from the shaft adhering to the glans with a small tunnel underneath. In many situations the skin bridge can be divided during an outpatient procedure. Treatment may also involve division of the skin bridge and circumcision revision.

Cicatrix

Following a circumcision, the penis may drop back into the pubic fat pad and the surgical area may contract, trapping the penis. In this situation, you will not be able to expose the glans of the penis at all. We have found that cicatrix can be safely and effectively treated with a topical steroid cream. Your child’s doctor will give you instructions on the proper use of the cream. If the steroid cream fails and the penis remains trapped, a circumcision revision and correction of a concealed penis may be necessary.

Posted in Patient Information

Allergy Medication Dosing for Children

Quick reference of allergy med dosing for children.

Zyrtec (cetirizine) dosing:

  • 6-12 months: 2.5 mg once daily
  • 1-2 years: 2.5 mg once to twice daily
  • 2-5 years: 2.5 – 5 mg once daily
  • 6 years and up: 5 – 10mg once daily

Claritin (loratadine) dosing:

  • 2 – 5 years: 5 mg once daily
  • 6 years and up: 5 – 10 mg once daily

Allegra (fexofenadine) dosing:

  • 6 months and < 10.5kg: 15mg twice daily
  • < 2 years or < 10.5kg : 15 – 30 mg twice daily
  • 2 – 11 years: 30 mg twice daily
  • 12 years and up: 180 mg ER once daily

Flonase (fluticasone) dosing:

  • 4 years and up: 1 spray per nostril once daily. If not working, ok to increase to 2 sprays each nostril, but reduce to once daily as soon as possible
  • 12 years and up: 2 sprays each nostril once daily

Reference

Posted in Patient Information

Eczema Home Treatment Plan

“The itch that rashes.”

Managing the symptoms at home can seem can seem daunting, but patients can take control of this condition with changes to the daily routine and a stepwise approach when symptoms worsen.

Prevention (do this every day, always):

Apply moisturizer twice a day.

  • Ointment – most effective, greasy, hard to apply. Won’t burn the skin if it is scratched and dry.
  • Creams – next most effective, thick.
  • Lotions – least effective, easiest to apply.

Apply the maintenance steroid cream once a week as a proactive treatment to prevent flares.

Avoid drying the skin when bathing

  • Shorter showers (not baths) are better.
  • Use cooler water, less than 104 °F (40° C).
  • Use a simple bar soap like a Dove bar. Fancy soaps have fancy chemicals.
  • Soap the Face, Armpits, Groin, Feet, Hands. Other areas do not need soap unless they are soiled or very dirty.

Minor flare – use your steroid every day!

  • Apply your regular steroid to all affected areas twice a day, Monday through Friday. Take a break on the weekend to ensure the steroid continues to be effective.
  • Continue to use moisturizers and avoiding long hot baths.

Severe flare – time for a stronger steroid!

  • Apply stronger steroid twice a day, again Monday through Friday.
  • As always, keep using the moisturizer, and maintain your normal skin therapies.
  • When symptoms improve you should work your way back to Prevention in steps. First treat as a Minor flare and only reduce your use of regular steroid when your symptoms are back under control.

Links

Topical Steroid Potency Chart: National Psoriasis Foundation

Posted in Patient Information

Benign Paroxysmal Positional Vertigo (BPPV) Treatment

RIGHT: Epley maneuver for self-treatment of benign positional vertigo

Treatment of Right Sided BPPV (Epley maneuver)
  1. Lie back quickly with shoulders on the pillow and head reclined onto the bed. Wait for 30 seconds.
  2. Turn your head 90° to the left (without raising it) and wait again for 30 seconds.
  3. Turn your body and head another 90° to the left and wait for another 30 seconds.
  4. Sit up on the left side.
  5. Start sitting on a bed and turn your head 45° to the right. Place a pillow behind you so that on lying back it will be under your shoulders.

LEFT: Epley maneuver for self-treatment of benign positional vertigo

Treatment of Left Sided BPPV (Epley maneuver)
  1. Start sitting on a bed and turn your head 45° to the left. Place a pillow behind you so that on lying back it will be under your shoulders.
  2. Lie back quickly with shoulders on the pillow and head reclined onto the bed. Wait for 30 seconds.
  3. Turn your head 90° to the right (without raising it) and wait again for 30 seconds.
  4. Turn your body and head another 90° to the right and wait for another 30 seconds.
  5. Sit up on the right side.

Post treatment care

This maneuver should be carried out three times a day. Repeat this daily until you are free from positional vertigo for 24 hours.

Wait for 10 minutes after the maneuver is performed doing activities. This is to avoid “quick spins,” or brief bursts of vertigo as debris repositions itself immediately after the maneuver. Don’t drive immediately after performing the procedure.

Sleep semi-recumbent for the next night. This means sleep with your head halfway between being flat and upright (a 45 degree angle). This is most easily done by using a recliner chair or by using pillows arranged on a couch (see figure). During the day, try to keep your head vertical. You must not go to the hairdresser or dentist. No exercise which requires head movement. When men shave under their chins, they should bend their bodies forward in order to keep their head vertical. If eye drops are required, try to put them in without tilting the head back. Shampoo only under the shower. Some authors suggest that no special sleeping positions are necessary (Cohen, 2004; Massoud and Ireland, 1996). We, as do others, think that there is some value (Cakir et al, 2006)

Sleep with your head halfway between being flat and upright (a 45 degree angle). This is most easily done by using a recliner chair or by using pillows arranged on a couch.

For at least one week, avoid provoking head positions that might bring BPPV on again.

  • Use two pillows when you sleep.
  • Avoid sleeping on the “bad” side.
  • Don’t turn your head far up or far down.
  • Be careful to avoid head-extended position, in which you are lying on your back, especially with your head turned towards the affected side. This means be cautious at the beauty parlor, dentist’s office, and while undergoing minor surgery.
  • Try to stay as upright as possible.
  • Exercises for low-back pain should be stopped for a week.
  • No “sit-ups” should be done for at least one week and no “crawl” swimming. (Breast stroke is OK.)
  • Also avoid far head- forward positions such as might occur in certain exercises (i.e. touching the toes).
  • Wait to start doing BPPV exercises (Brandt-Daroff) for 2 days following the Epley or Semont maneuver, unless specifically instructed otherwise by your doctor.

At one week after treatment, put yourself in the position that usually makes you dizzy. Position yourself cautiously and under conditions in which you can’t fall or hurt yourself. Let your doctor know how you did.

Links

Dr. Hain’s BPPV Info
Vestibular Disorders Association
Geriatric Depression Scale
Berg Balance Scale (PDF)
Dizziness Handicap Inventory (PDF)

Posted in Patient Information

Sleeping Difficulties in Infants

Adapted verbatim from:
Am Fam Physician. 2009Jul15;80(2):139-142.

Guidance for Parents

Newborns usually wake up every two to three hours. Each baby will have different sleep habits. Babies will sleep longer as they get older. Most babies sleep through the night by one year of age, but some babies start sleeping through the night by four to six months of age.

If your baby is not sleeping through the night by the end of the first year, you can try some things to help him or her sleep longer. Responding less often to your baby’s cries may help. For example, at first go to your baby within five minutes of crying, then wait for 10 minutes the next time, and then a little longer each time. After awhile, your baby will learn to calm down and go back to sleep.

Having your baby wake up at the same time each morning and go to sleep at the same time each night can help. Waking up your baby before expected middle-of-the-night awakening times also might help. For example, if your baby usually wakes up at 1:00 a.m., 4:00 a.m., and 7:00 a.m., wake him or her 15 minutes earlier each time. Your baby may eventually sleep through his or her predicted times.

More Info: Development of Normal Sleep Pattern

An important part of the childhood development process is gaining independence, and one way in which an infant works toward this goal is by sleeping through the night. Approximately 80 percent of children sleep through the night by six months of age, and 90 percent by one year of age. The definition of “sleeping through the night” is variable, because sleep schedules for each family and person are unique. Some children sleep through the night at an early age, but temporarily revert to nighttime awakenings. These awakenings are usual in the nine- to 18-month age group, when separation anxiety is common.

American Academy of Sleep Medicine 2006 Recommended Methods for Prolonging Sleep in Infants (5 years and younger):

The Parental Guidance above is from on these recommendations. These recommendations were based on a review of 52 articles on sleep in children. There is insufficient evidence to favor one method of sleep intervention over another. There is also insufficient evidence to support a combination of methods as more favorable than one sleep intervention alone.

Unmodified extinction

Lay the infant down to sleep at a designated time and do not respond to any crying until morning

Graduated extinction

Gradually respond less frequently to the infant’s cries (e.g., initially respond within five minutes of crying, then space out the response to every 10 minutes, then longer)

Bedtime routines

Maintain the same sleep and wake schedule daily

Scheduled awakenings before expected awakening time

If the predicted awakening times for the infant are, for example, 1:00 a.m., 4:00 a.m., and 7:00 a.m., awaken the infant 15 minutes earlier than the predicted time; the infant will eventually sleep through the predicted times

Note: Some methods listed may not be feasible for some families; for example, a family that lives in a thin-walled apartment complex may have complaints from neighbors if they attempt to let their infant cry through the night. Parents can try a method that fits with their values, culture, and living arrangement.

Avoid Medications

Trial of Infant Response to Diphenhydramine (TIRED)
The TIRED study showed that diphenhydramine (Benadryl) was no more effective than placebo in reducing nighttime awakenings in infants. Medication should not be used to treat this normal developmental stage. Parents can be reassured that regardless of the method used, there is no difference in family functioning between children who have and do not have sleep issues.

Resources

Childhood Sleep Information from UM Pediatrics

Posted in Patient Information

Orthopedic Handouts

Need a handout for a common orthopedic injury? Here are some from two great resources.

The Sports Medicine Patient Advisor, 3rd edition

note: These handouts are actually from an old 2nd edition. The third edition has much nicer, color, updated stuff. If you find these old ones useful you should definitely buy the newest edition.

Abdominal_Muscle_Strain.pdf

Achilles_Tendon_Injury.pdf

ACL_Injury.pdf

ACL_Reconstruction.pdf

Ankle_Fracture.pdf

Ankle_Sprain.pdf

Arch_Pain–Metatarsalgia.pdf

Athletes_Foot.pdf

Bakers_Cyst.pdf

Biceps_Tendonitis.pdf

Brachial_Plexus-Stinger.pdf

Bunion.pdf

Calcium.pdf

Calf_Strain.pdf

Carpal_Tunnel.pdf

Cast_Care.pdf

Clavicle_Fracture.pdf

Coccyx_Injury.pdf

Crutches.pdf

DeQuervains_Tenosynovitis.pdf

Dislocated_Shoulder.pdf

Exercise_Asthma.pdf

Exercise_During_Pregnancy.pdf

Finger_Dislocation.pdf

Finger_Sprain.pdf

Frozen_Shoulder.pdf

GameKeepers_Thumb.pdf

Ganglion_Cyst.pdf

Gluteal_Strain.pdf

Golfers_Elbow.pdf

Groin_Strain.pdf

Hamstring_Strain.pdf

Herniated_Disk.pdf

Hip_Flexor_Strain.pdf

Hip_Pointer.pdf

Ice_And_Heat_Therapy.pdf

Ingrown_Toenail.pdf

Iron.pdf

IT_Band_Syndrome.pdf

Knee_Scope.pdf

Labral_Tear.pdf

LCL_Sprain.pdf

Little_Leaguers_Elbow.pdf

Low_Back_Pain.pdf

Mallet_Finger.pdf

MCL_Sprain.pdf

Meniscal_Tear.pdf

Metatarsalgia.pdf

Mortons_Neuroma.pdf

MRI.pdf

Neck_Spasm.pdf

Neck_Strain.pdf

Olecranon_Bursitis.pdf

Osgood_Schlatters.pdf

Osteochondritis_Dissecans_Knee.pdf

Osteochondritis_Elbow.pdf

Over_Pronation.pdf

Patellar_Subluxation.pdf

Patellar_Tendonitis.pdf

Patellofemoral_Pain.pdf

Pelvic_Avulsion_Fracture.pdf

Peroneal_Tendon_Strain.pdf

Pes_Bursitis.pdf

Piriformis_Syndrome.pdf

Plantar_Fasciitis.pdf

Prepatellar_Bursitis.pdf

Quad_Strain.pdf

Rhomboid_Strain.pdf

Rib_Injury.pdf

Rotator_Cuff.pdf

Scaphoid_Fracture.pdf

Scope_Menisectomy.pdf

Severs_Calcaneal_Apophysitis.pdf

Shin_Splints.pdf

Shoulder_Bursitis.pdf

Shoulder_Subluxation.pdf

Snapping_Hip_Syndrome.pdf

Spondylolysthesis.pdf

Sprains.pdf

SternoClavicular_Separation.pdf

Strains.pdf

Stress_Fractures.pdf

Tennis_Elbow.pdf

TFCC_Injuries.pdf

Triceps_Tendonitis.pdf

Trigger_Finger.pdf

Trochanteric_Bursitis.pdf

Turf_Toe.pdf

Ulnar_Neuropathy.pdf

Wrist_Sprain.pdf

Wrist_Tendonitis__Intersection_Syndrome.pdf

Essentials of Musculoskeletal Care

Achilles Tendinosis or Tendinitis Home Exercise.pdf

ACL Tear Home Exercise.pdf

Acromioclavicular Injuries Home Exercise.pdf

Ankle Sprain Home Exercise.pdf

Arthritis of the Knee Home Exercise.pdf

Collateral Ligament Tear Home Exercise.pdf

Foot and Ankle Conditioning Home Exercise.pdf

Home Exercise Program for Frozen Shoulder

Hip Conditioning Home Exercise.pdf

Knee Conditioning Home Exercise.pdf

Lateral and Medial Epicondylitis Home Exercise.pdf

Low Back Pain Acute Home Exercise.pdf

Low Back Pain Chronic Home Exercise.pdf

Lumbar Spine Conditioning Home Exercise.pdf

Medial Gastrocnemius Tear Home Exercise.pdf

Home Exercise Program for Meniscal Tear

PatellarQuadriceps Tendinitis Home Exercise.pdf

Patellofemoral Pain Home Exercise.pdf

Home Exercise Program for PCL Injury

Home Exercise Program for Plantar Fasciitis

Plica Syndrome Home Exercise.pdf

Posterior Heel Pain Home Exercise.pdf

Rotator Cuff Tear Home Exercise.pdf

Shoulder Conditioning Home Exercise.pdf

Shoulder Impingement Home Exercise.pdf

SLAP Lesions Home Exercise.pdf

Snapping Hip Home Exercise.pdf

Strains of the Hip Home Exercise.pdf

Strains of the Thigh Home Exercise.pdf

Thoracic Outlet Syndrome Home Exercise.pdf

Toe Strengthening Home Exercise.pdf

Trochanteric Bursitis Home Exercise.pdf

Miscellaneous

Plantar-Fasciitis.pdf