Don’t Be Rash: The Pediatric Dermatology Podcast

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Welcome to the Don’t Be Rash Pediatric Dermatology

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Podcast, the owner’s manual for your kid’s skin.

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I’m your host, Dr. K, board -certified pediatric

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dermatologist and father of two boys. I’m here

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to chat with you to promote dermatological education

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and improve skin health in our children everywhere.

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Let’s get started. Welcome to Don’t Be Rash,

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the pediatric dermatology show, coming to you

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from beautiful, historic Bethlehem, Pennsylvania.

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On today’s show, “The EYES Have It!”, we’re casting

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our eyes on a new horizon and exploring the intersection

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of kids’ skin conditions and their relationship

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to eye issues. In the first half of the show,

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we will discuss some common inflammatory skin

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rashes, such as eczema, psoriasis, and allergies,

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and learn how these conditions can affect your

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children’s eyes. Then, in the second half of

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the show… we’ll discuss how certain skin-specific

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medications and infections can affect your children’s

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vision. Joining us today as our guest co -host

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is board-certified pediatric ophthalmologist

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Dr. Robert Kitei. Dr. Kitei is a tremendous asset

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for our St. Luke’s Health System, and I’m going

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to wave HIPAA here and share that he also takes

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exceptional care of one of my own sons and my

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own mom. Dr. Kitei has helped thousands of kids

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and adults and has worked through the philanthropic

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Kaskey Foundation, works at even a higher level

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for the benefit of the public good. Welcome,

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Dr. Kitei. Thanks for joining me today for what

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promises to be a very EYE-opening experience

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for the both of us. I have lots of questions

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for you. To start us off, I’m hoping you might

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be able to explain a bit of the overlap of our

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two clinical worlds. How often is it you’re seeing

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kids coming into your office with eye problems

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when they also have concurrent skin conditions?

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Yeah, plenty of times. I mean, a lot of things

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that affect the eye are going to affect the skin.

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Because embryologically, the eye is made from

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ectoderm. And ectoderm is what the skin is made

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from. And a good portion of the eye is also made

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from that. So there’s a tremendous interplay.

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A lot of things that infect the skin can infect

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the eye. Inflammatory conditions that affect

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the skin can affect the eye. Allergic conditions

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can affect the eye. And lots of congenital anomalies

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of the skin. body and face can also have impact

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on the ocular tissues. So we’ve worked together

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a lot and see a lot of the same kids with a lot

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of different problems involving those organs.

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Most of the time, you and I seem to cross intersections

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with vascular lesions. So things like infantile

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hemangiomas and port wine birthmarks, we’ve worked

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together closely in that, but also some genetic

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skin conditions where absolutely things overlap.

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More and more I’m hearing in the news and within

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medical journals, they’re seeing that inflammatory

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skin conditions such as psoriasis or eczema are

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linked now to much more systemic involvement.

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So cardiovascular issues or metabolic issues.

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And I think part of that is coming to the surface

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that the eyes are involved in that as well. Yeah.

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I mean, it’s all connected. It’s all connected.

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If you have different abnormalities in your DNA

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that predispose you to different inflammatory

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conditions, they’re going to affect the eye.

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Sometimes we see uveitis, scleritis, and different

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things that can really be disabling or sometimes

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be kind of minor. It just depends on the patient.

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Well, there’s a lot of itis mentioned when you’re

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talking about ophthalmology. So most of this

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interview is going to be me trying to get you

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to explain what some of these things are. And

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also, am I supposed to be able to see that with

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my own eyes and know that it’s there when I refer

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my patients into you? But let’s take the one

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that probably I see the most in my clinic as

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a skin condition, which is eczema or atopic dermatitis.

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And just for the audience’s sake, we’re talking

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about what’s called a chronic and remittant,

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meaning it comes and goes, flares and resolves.

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dry, itchy, red skin rash that can affect really

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any part of the body. It certainly can affect

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the eyelids and the face. But how do you see

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atopic dermatitis kids present to your clinic?

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Yeah, most often they’ve been treated by their

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pediatricians or family doctors for a little

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bit. Sometimes the feeling was they had conjunctivitis.

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Other times the doctor felt that they had allergic

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conjunctivitis. They may have been given an antibiotic

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or an antihistamine topically to use for a little

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bit, and the kid is still suffering. Kids have

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tremendous immune responses, even if it’s autoimmune

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response, and they really just need cortisone

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drops most of the time, prednisone drops, to

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calm down the inflammation, at least short term.

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It’s not good to stay on those long term, but

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short term, it’s the way to get a child feeling

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better. faster because they’re really miserable.

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Their eyes hurt, they’re shying away from light,

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they’re hard to examine. And it’s a chronic intermittent

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condition. It really is very disabling because

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they can’t read, they don’t want to play, all

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that. And so I normally will see a kid sitting

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across from the room. We walk in, you can tell

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almost instantly, this guy’s got eczema, sure,

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everywhere. But then you can also see that they’re

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suffering from some sort of comorbidity, we would

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say. So an associated condition like hay fever

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or allergies with the atopic dermatitis. For

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me, the biggest clue to that are what, well,

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I don’t know, we’re going to use dermatological

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terms and then you correct me if I’m using it

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incorrectly. But what we would call “allergic

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shiners,” this concept that you would have this

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almost pinkish purplish circle around usually

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the lower portion of the cutaneous eyelid. It

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looks like you got punched. That’s why they call

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it a shiner. Dennie-Morgan lines or Morgan-Dennie

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lines, depending on who you ask. But these sort

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of extra little creases that you can see in the

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eye, I’ve been told it’s from edema or swelling

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local from from usually from rubbing is is that.

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accurate yeah yeah it’s from edema and from the

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resolution the cyclical resolution of edema that’s

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where you get the lines from but their eyes are

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always swollen they rub them that makes it worse

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they’re irritated you see flaking of the skin

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it’s a really characteristic appearance and like

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you when you walk in the room you can kind of

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figure it out. But it can happen at any season.

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It’s not just, you know, in late March or April.

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It’s not just in September. It’s any time. Usually

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the kids have, you know, a history of eczema

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as a little baby, you know, behind their knees,

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intertrigenous areas and things like that. But

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you look at them and you can just see how unhappy

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and uncomfortable they are. You know, they’ve

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been given a drop or two, a topical antihistamine,

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it’s not working. And then the family doctors,

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pediatricians, pediatricians will send them on

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to us and we universally will treat those kids

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at least for a short while with topical prednisone

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drops to make them feel better really in a couple

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days they start feeling better that’s uh it’s

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amazing so yes so For the audience that was concerned,

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because they’ve heard us say on other shows,

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that we really try to avoid oral prednisone for

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the management of atopic. Can you talk a little

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bit about how safe topical prednisone is delivered

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into the eye for a couple days here or there?

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We’re not talking months, right? Yeah, yeah.

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A couple days here and there, a couple weeks

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here and there. The most important thing is that

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pediatricians and family doctors and derms don’t

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prescribe steroids because sometimes… it can

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masquerade. Their inflammation of the eye is

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really herpetic, and it’s masquerading as something

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else. And also, the treatment with prednisone

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can make a quiescent herpetic condition manifest

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itself, and that happens. a lot. So you have

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to be really judicious, but kind of judiciously

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bold in using them to make the kids feel better,

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but you monitor them. There’s also an uncommon

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risk of glaucoma associated with steroid eye

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drops, and that happens in about 10 to 15 percent

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of people, usually older kids or adults, but

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we worry about it in everybody. Long term, they

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cause cataracts, so you don’t want to be using

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it in a five-year-old for any length of time,

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but short term, nothing beats it. For glaucoma,

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since you raised that, how long are you talking

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about? Normal use, so once or twice a day or

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whatever you would prescribe. How many days or

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weeks would you expect for that to even be an

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issue? You could see it in five days. Really?

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That would be the earliest presentation, but

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usually weeks and weeks of treatment. And, you

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know, if we see a child, we might not see them

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back for a couple of weeks because even if their

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pressure went up a little bit, they can tolerate

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it. Their nerves are healthy and the risk benefit

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is still in the child’s, you know, favor. And

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eczema itself can absolutely affect the eyelids.

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I’ve heard it said that the eyes are the window

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to the soul, right? But I guess in that case,

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then the eyelid is the curtain. But the kids

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that are suffering from the scale, the itch,

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the redness. and the swelling of their eyelids,

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it’s such a natural thing to make eye contact

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with someone. And that’s the first thing you

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see. You do want to get this under control for

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them. And as you pointed out, it’s really suffering.

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These kids have to go through this. So when would

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you decide to use a topical prednisone in the

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eye versus something like a topical calcineurin

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inhibitor like Protopic? Or what’s the Pataday?

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Is that another one that you guys might use?

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So Pataday is a. histamine blocker. It has

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some mast cell stabilizing effect and whatnot.

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It’s certainly a complement to a cortisone drop,

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but it’s not going to do it. And many of the

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kids have been on it already. As far as I know,

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there’s no calcineuron inhibitor that is a drop

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form. Maybe it could be compounded. But we use

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mid -potency or high -potency prednisone drops.

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But then, to your point, we usually will switch

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after a few weeks if the child needs continued

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care. to cyclosporine drops. It’s an off -label

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application. There’s a drop called Restasis,

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which is a really dilute, I think it’s like 0

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.005 % cyclosporine, which is an anti -rejection

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chemical. So it suppresses the immune system.

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And that works really well twice a day. There’s

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a higher concentration that has a brand name

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called Sequa. There are a million different drops.

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And those are geared more toward… Older patients

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with dry eye, which is often inflammatory in

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nature, and so cyclosporine is an anti -inflammatory,

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so it cuts down that. It helps the dry eye. But

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for the purposes of autoimmune or inflammatory

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condition, cyclosporine will cut down that cycle,

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and it’s really good, and then you don’t have

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the side effect of worrying about cataract, glaucoma,

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and things like that with the prednisone. But,

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you know, then you’re using something chronically

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for a long period of time. And a lot of these

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kids just have kind of episodic, you know, a

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month or two here and there. And sometimes just

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a mid or low potency cortisone drop is really

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all you need. We’re taught that cyclosporine

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in the eye can also help with your eyelashes.

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Is that true? Is that one of the side effects?

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Yeah, I don’t know. There’s some other prostaglandin

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things like, you know, Lumigan, Xalatan. The

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prostaglandins definitely, they’re the forerunner

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of a branded name called Latisse. which you can

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grow hair anywhere with Latisse. If you want

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to grow it on the front of your nose, you put

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a couple drops of Latisse on your nose and wait

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a few weeks and you’ll have hair right in the

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center of your nose. No, thank you. Some people

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use it who’ve had chemotherapy on their eyelashes

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and their eyebrows. And some people who just

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don’t have the voluminous lashes that they want

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use it just to… increase the volume of their

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lids of their lashes well so as it relates to

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eczema one of the things that you know still

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haunts me from my days of studying for boards

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was this complication called “keratoconus” – am i

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saying that correctly? yeah yeah. Can you talk

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a little bit about what that is and is it something

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that i’m supposed to as a dermatologist be able

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to see by the naked eye? It would be hard to see

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it with the naked eye. Keratoconus, it can be

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familial. It’s multifactorial inheritance. It

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can be run in families for sure. It can be sporadic.

00:12:44.789 –> 00:12:46.850
It’s associated with different developmental

00:12:46.850 –> 00:12:50.070
things. For example, Down syndrome have a higher

00:12:50.070 –> 00:12:53.850
incidence of keratoconus. It is also associated

00:12:53.850 –> 00:12:56.799
with eye rubbing. So that goes along with allergy

00:12:56.799 –> 00:12:59.519
and atopic conditions. So it’s always a good

00:12:59.519 –> 00:13:01.860
thing for a variety of reasons not to rub your

00:13:01.860 –> 00:13:04.679
eyes. Because really, when you rub your eyes,

00:13:04.820 –> 00:13:08.740
they really get compressed. It’s not good to

00:13:08.740 –> 00:13:11.700
do it. They even have MRIs of people rubbing

00:13:11.700 –> 00:13:13.840
their eyes and showing what happens to the eye

00:13:13.840 –> 00:13:16.279
and how it gets deformed. So don’t rub your eyes.

00:13:16.340 –> 00:13:19.940
Don’t let your kids rub their eyes. But it is

00:13:19.940 –> 00:13:23.059
associated with rubbing and with atopic conditions.

00:13:24.639 –> 00:13:27.419
But it would be really difficult to see that

00:13:27.419 –> 00:13:31.019
without a microscope. We have special machines

00:13:31.019 –> 00:13:34.039
to diagnose it. When would you suspect it? When

00:13:34.039 –> 00:13:36.080
would you think about referring someone in for

00:13:36.080 –> 00:13:38.940
possible? You know, if their eyes are affected,

00:13:39.159 –> 00:13:41.899
it’s probably a good idea for the child to see

00:13:41.899 –> 00:13:44.620
an ophthalmologist anyway. And just as part of

00:13:44.620 –> 00:13:48.919
an initial patient visit, most pediatric ophthalmologists

00:13:48.919 –> 00:13:51.820
will always dilate, do a complete exam, because

00:13:51.820 –> 00:13:54.059
then you have a baseline that’s comprehensive.

00:13:54.080 –> 00:13:56.740
You’re not just treating for conjunctivitis or

00:13:56.740 –> 00:13:59.240
pink eye from a cold or something. So that’ll

00:13:59.240 –> 00:14:01.759
be detected, you know, at that initial exam.

00:14:02.269 –> 00:14:04.690
that’s part of the routine sort of exam oh yeah

00:14:04.690 –> 00:14:07.950
most people you know do everything all the time

00:14:07.950 –> 00:14:11.090
the first time. It’s difficult if a child, for

00:14:11.090 –> 00:14:13.409
example, got something in their eye. You want

00:14:13.409 –> 00:14:15.649
to take care of that problem and not make the

00:14:15.649 –> 00:14:17.809
kid go through a prolonged experience, get the

00:14:17.809 –> 00:14:19.710
foreign body out, and then see them in a couple

00:14:19.710 –> 00:14:21.590
of days, make sure they heal, and then you would

00:14:21.590 –> 00:14:23.690
do a complete exam when they’re feeling better.

00:14:24.169 –> 00:14:27.250
But there’s really no substitute for a full exam

00:14:27.250 –> 00:14:31.110
in anything, right? In dermatology and podiatry,

00:14:31.110 –> 00:14:34.899
in any “-ology,” you need to be complete. Yeah,

00:14:34.960 –> 00:14:38.490
so a skin condition that can mimic… Atopic

00:14:38.490 –> 00:14:40.690
dermatitis is one called psoriasis, different

00:14:40.690 –> 00:14:44.370
inflammatory response and sort of cytokine cascade

00:14:44.370 –> 00:14:47.570
behind it driving it. But the idea that you would

00:14:47.570 –> 00:14:50.610
have a very discrete, well -demarcated, scaly

00:14:50.610 –> 00:14:54.789
pink flat top plaque on the skin is something

00:14:54.789 –> 00:14:58.470
we’re very commonly seeing in adults and also

00:14:58.470 –> 00:15:00.389
kids. In fact, I just mentioned the other day

00:15:00.389 –> 00:15:02.409
in clinic that it was really one of the hardest

00:15:02.409 –> 00:15:05.759
things for me to do as a… dermatology resident

00:15:05.759 –> 00:15:08.340
in training and then moving to fellowship was

00:15:08.340 –> 00:15:11.480
to make a new diagnosis of psoriasis in a kid.

00:15:11.580 –> 00:15:13.379
I don’t know why, but I just had a mental block

00:15:13.379 –> 00:15:16.460
many times because I always thought of that as

00:15:16.460 –> 00:15:19.200
a quote -unquote “adult” condition, but it is quite

00:15:19.200 –> 00:15:22.600
common in kids. We see it. It has a… sort of

00:15:22.600 –> 00:15:24.860
a more characteristic look about it than eczema.

00:15:24.919 –> 00:15:27.299
So many times you can walk in and make that diagnosis

00:15:27.299 –> 00:15:29.559
or through family history, or if you have to

00:15:29.559 –> 00:15:32.059
do a biopsy from some other portion of the skin,

00:15:32.120 –> 00:15:35.139
you can do that. But again, with the boards,

00:15:35.220 –> 00:15:38.879
we’re taught “uveitis” and that’s associated with

00:15:38.879 –> 00:15:40.720
psoriasis. Can you talk a little bit about what

00:15:40.720 –> 00:15:44.049
that is and what that looks like? So the uvea

00:15:44.049 –> 00:15:46.190
is the middle part of the eye. There’s the white

00:15:46.190 –> 00:15:48.470
part of the eye, the sclera. There’s the inside

00:15:48.470 –> 00:15:50.690
of the eye, the retina. And in between those

00:15:50.690 –> 00:15:53.629
is the uvea. And the uvea is named uvea because

00:15:53.629 –> 00:15:57.070
uvea in Greek or Latin means grape. And so if

00:15:57.070 –> 00:15:59.210
you dissected away the white part, you’d see

00:15:59.210 –> 00:16:03.669
this kind of bluish. brownish part that is full

00:16:03.669 –> 00:16:06.769
of blood so it tends to get inflamed a lot in

00:16:06.769 –> 00:16:10.090
any inflammatory condition it spills over uveitis

00:16:10.090 –> 00:16:13.490
is really painful we’re always teaching all the

00:16:13.490 –> 00:16:15.929
residents from st luke’s hospital the warning

00:16:15.929 –> 00:16:19.509
signs for when to refer to ophthalmology and

00:16:19.509 –> 00:16:22.610
if a child has pink eye or any kind of redness

00:16:22.610 –> 00:16:25.169
to their eye we say pink eye doesn’t hurt pink

00:16:25.169 –> 00:16:27.629
eye does not make you sensitive to light and

00:16:27.629 –> 00:16:29.789
so if you have a little kid who’s sensitive to

00:16:29.789 –> 00:16:32.620
light we ask that they always see an ophthalmologist

00:16:32.620 –> 00:16:36.460
because it’s just not pink eye associated with

00:16:36.460 –> 00:16:39.720
the cold when they’re shying away from the light.

00:16:40.320 –> 00:16:43.460
So uveitis is inflammation of that middle section

00:16:43.460 –> 00:16:45.860
of the eye. It takes a couple of days usually

00:16:45.860 –> 00:16:48.620
to develop associated with, you know, whether

00:16:48.620 –> 00:16:52.440
it’s psoriasis or juvenile arthritis and different

00:16:52.440 –> 00:16:55.519
things. And it takes days and weeks to respond

00:16:55.519 –> 00:16:59.259
to prednisone drops as well. But it’s very disabling.

00:16:59.279 –> 00:17:01.779
It’s really painful. It feels like you had your

00:17:01.779 –> 00:17:05.500
tooth pulled without anesthesia and it’s still

00:17:05.500 –> 00:17:07.440
being pulled again and again and again. It’s

00:17:07.440 –> 00:17:11.079
really, really painful. Rob, what level of light

00:17:11.079 –> 00:17:12.599
are we talking about? You’re talking about walking

00:17:12.599 –> 00:17:17.059
into a lamp -lit room? Yeah. Oh, well, they can’t

00:17:17.059 –> 00:17:19.420
go outside. They don’t play. They’ve been inside

00:17:19.420 –> 00:17:21.559
for a couple of days. They keep their eyes shut.

00:17:21.640 –> 00:17:23.640
They’re looking down. They want a hat on. They’re

00:17:23.640 –> 00:17:25.859
wearing somebody’s sunglasses or their parents

00:17:25.859 –> 00:17:29.400
bought them a pair of sunglasses on Amazon or

00:17:29.400 –> 00:17:32.319
something. And the kids are really unhappy. They’re

00:17:32.319 –> 00:17:34.799
really difficult to examine because they’re so

00:17:34.799 –> 00:17:37.559
unhappy because you need to examine them. You

00:17:37.559 –> 00:17:40.500
need light, right? you’d see in the dark and

00:17:40.500 –> 00:17:43.240
you know the kid is usually it’s their first

00:17:43.240 –> 00:17:45.380
visit with you they don’t trust you they’re scared

00:17:45.380 –> 00:17:49.160
all they know is they’re in pain and it’s really

00:17:49.160 –> 00:17:51.579
challenging in the beginning to make that diagnosis

00:17:51.579 –> 00:17:54.859
especially before you can really kind of reason

00:17:54.859 –> 00:17:57.900
with a child of four or five and get them to

00:17:57.900 –> 00:18:01.119
trust you. But they’re very unhappy. And again,

00:18:01.119 –> 00:18:04.380
a couple days’ worth of prednisone drops and

00:18:04.380 –> 00:18:08.319
other drops, cycloplegics, dilating drops, will

00:18:08.319 –> 00:18:11.440
reduce that spasm. But the best way to describe

00:18:11.440 –> 00:18:15.960
it is if you’ve ever been to a movie on a Friday

00:18:15.960 –> 00:18:18.359
afternoon at 2 and you come out of the movie

00:18:18.359 –> 00:18:21.799
theater, that first moment when the light hits

00:18:21.799 –> 00:18:24.279
you, And you’re like, wow, it’s really bright.

00:18:24.420 –> 00:18:26.900
No, that just hurt for a second. Just imagine

00:18:26.900 –> 00:18:30.660
that times 10 constantly. Wow. Okay. Yeah. No,

00:18:30.759 –> 00:18:34.619
I can immediately think of that and experience

00:18:34.619 –> 00:18:37.619
that in my head. So that’s very helpful. Appreciate

00:18:37.619 –> 00:18:41.119
that. Yeah. It’s very painful. So related to

00:18:41.119 –> 00:18:43.519
psoriasis is another condition called seborrheic

00:18:43.519 –> 00:18:46.099
dermatitis. We actually have enough of an overlap

00:18:46.099 –> 00:18:48.740
between those two conditions where there’s sort

00:18:48.740 –> 00:18:51.519
of a middle of the road called “sebo-psoriasis.”

00:18:51.720 –> 00:18:55.019
And that’s got a couple interesting specific

00:18:55.019 –> 00:18:57.400
findings, or maybe not specific, you’ll tell

00:18:57.400 –> 00:19:01.490
me. But what is blepharitis? Yeah, so blepharitis

00:19:01.490 –> 00:19:05.910
is debris around the eyelashes. It can be from

00:19:05.910 –> 00:19:08.529
a number of different causes. It can be nobody

00:19:08.529 –> 00:19:10.970
really washes their eyelashes, right? I mean,

00:19:10.990 –> 00:19:12.670
you get in the shower, you get in the bath, and

00:19:12.670 –> 00:19:14.869
they put your child in the bath. Nobody really

00:19:14.869 –> 00:19:17.549
pays a lot of attention. Your eyelashes are kind

00:19:17.549 –> 00:19:20.650
of on autopilot. But they can develop some flaking,

00:19:20.650 –> 00:19:23.769
scaling, and debris depending on everybody’s

00:19:23.769 –> 00:19:26.349
own body chemistry. Some people are more oily.

00:19:26.470 –> 00:19:28.410
Some people are not. You know more about that

00:19:28.410 –> 00:19:31.829
than I’ll ever know. And and so everybody’s a

00:19:31.829 –> 00:19:34.339
little different. But that. flaking material

00:19:34.339 –> 00:19:38.440
and oil debris gets into your tear film, and

00:19:38.440 –> 00:19:41.220
it’s very irritating. It also promotes bacterial

00:19:41.220 –> 00:19:43.960
overgrowth because the bacteria eat the dead

00:19:43.960 –> 00:19:46.839
skin. They love the oil. That gives things like

00:19:46.839 –> 00:19:50.759
styes, calazions, and it can make your eyes red

00:19:50.759 –> 00:19:54.940
and really irritated. Sometimes, and a lot more

00:19:54.940 –> 00:19:58.220
these days, we look specifically at the lashes,

00:19:58.279 –> 00:20:01.000
and we see little what’s called colorettes around

00:20:01.000 –> 00:20:03.539
the base of the lashes. And these are the little

00:20:03.539 –> 00:20:05.980
nests of something called Demodex, which is a

00:20:05.980 –> 00:20:08.960
little mite that inhabits the lash follicles

00:20:08.960 –> 00:20:13.150
of the lid preferentially over more. lash follicles

00:20:13.150 –> 00:20:16.029
elsewhere because they’re warm next to the eye

00:20:16.029 –> 00:20:20.230
and they’re, I think, the thinnest. And so Demodex

00:20:20.230 –> 00:20:24.390
really inhabits the lashes and that’s very irritating,

00:20:24.650 –> 00:20:28.730
causes keratitis. The life cycle of the Demodex

00:20:28.730 –> 00:20:31.710
is about three or four weeks. So when we see

00:20:31.710 –> 00:20:35.630
that in children, we have them use tea tree scrubs,

00:20:35.650 –> 00:20:39.289
tea tree shampoo. There’s a branded name, Claridex,

00:20:39.369 –> 00:20:42.789
which is a dilute concentrate. of tea tree you

00:20:42.789 –> 00:20:45.500
would never want to put pure tea tree oil near

00:20:45.500 –> 00:20:48.539
your eye would really be very painful and cause

00:20:48.539 –> 00:20:51.759
chemical injury but very dilute concentrations

00:20:51.759 –> 00:20:54.460
help and there are other treatments too baby

00:20:54.460 –> 00:20:57.299
shampoo scrubs hot compresses to open up the

00:20:57.299 –> 00:21:00.940
glands and the eyelashes and newer treatments

00:21:00.940 –> 00:21:04.759
there’s a branded name called Xdemvy which is

00:21:04.759 –> 00:21:09.680
lotilaner, which is a poison for the Demodex

00:21:09.680 –> 00:21:12.480
and you use that twice a day for six weeks which

00:21:12.480 –> 00:21:15.650
is twice the life cycle of the Demodex, sometimes repeating

00:21:15.650 –> 00:21:18.390
that every six to nine months. And that really

00:21:18.390 –> 00:21:21.329
helps, but it’s 18 and over. Nobody really uses

00:21:21.329 –> 00:21:24.970
it in children yet. And is most blepharitis caused

00:21:24.970 –> 00:21:28.109
by Demodex or not? Probably. Probably, yeah.

00:21:28.109 –> 00:21:32.549
Probably, yeah, probably. And we use Restasis

00:21:32.549 –> 00:21:37.109
a lot too, cyclosporine drops, because if you

00:21:37.109 –> 00:21:40.099
can’t beat them, you know, avoid them. So we

00:21:40.099 –> 00:21:43.019
can’t really, you know, get rid of the Demodex

00:21:43.019 –> 00:21:46.039
because it’s commensal for a lot of kids. So,

00:21:46.039 –> 00:21:49.259
and the Xdemvy is not approved yet, but we can

00:21:49.259 –> 00:21:52.019
tamp down the inflammation associated with it.

00:21:52.519 –> 00:21:55.220
And sometimes prednisone drops too. But again,

00:21:55.339 –> 00:21:58.299
we worry about that longer term with kids. One

00:21:58.299 –> 00:22:01.319
of our… colleagues and a very senior clinical

00:22:01.319 –> 00:22:03.799
dermatologist named Warren Heyman and myself

00:22:03.799 –> 00:22:06.640
and Steve Senft, whom I think you know from St. Luke’s?

00:22:06.720 –> 00:22:10.440
We wrote an article that was published in Pediatrics

00:22:10.440 –> 00:22:12.740
a couple of years ago as it was a case series

00:22:12.740 –> 00:22:16.839
from three patients who had been on dupixent,

00:22:16.839 –> 00:22:20.019
dupilumab, and they were developing conjunctivitis.

00:22:20.119 –> 00:22:24.160
And we threw out there as a possible link because

00:22:24.160 –> 00:22:28.589
of the way dupixent works. could you be decreasing

00:22:28.589 –> 00:22:31.650
the ability for your body to fight off Demodex?

00:22:31.990 –> 00:22:35.029
And it looks like there might be some legs to

00:22:35.029 –> 00:22:38.390
that. So we’ve seen some pretty horrible conjunctivitis

00:22:38.390 –> 00:22:40.529
cases with the use of that medicine, but you

00:22:40.529 –> 00:22:42.789
can usually get it under control. Yeah, I’ve

00:22:42.789 –> 00:22:44.630
seen it a couple of times and you withdraw the

00:22:44.630 –> 00:22:46.569
medicine, it gets better. And in the meantime,

00:22:47.049 –> 00:22:49.750
you know, again, prednisone, God’s gift to medicine

00:22:49.750 –> 00:22:53.829
and certainly God’s gift to dermatology. And

00:22:53.829 –> 00:22:55.970
it really just works. It makes them feel better

00:22:55.970 –> 00:22:58.509
in a day or two. right away well speaking of

00:22:58.509 –> 00:23:01.490
seborrheic dermatitis and Demodex we also have

00:23:01.490 –> 00:23:04.250
rosacea we not as commonly seen in young kids

00:23:04.250 –> 00:23:06.329
but certainly there are there are some kids that

00:23:06.329 –> 00:23:08.730
will show up with something that looks like acne

00:23:08.730 –> 00:23:11.549
but you’re looking very closely at their skin

00:23:11.549 –> 00:23:14.450
they don’t have blackheads or or what we would

00:23:14.450 –> 00:23:17.769
call open comedones or closed comedones for that

00:23:17.769 –> 00:23:20.650
matter they’ve got more sort of the juicier zits

00:23:20.650 –> 00:23:23.250
if you will the pustules the inflammatory papules

00:23:23.250 –> 00:23:25.990
without the comedones that’s a good clue that

00:23:25.990 –> 00:23:28.789
maybe you’re dealing more with rosacea in our

00:23:28.789 –> 00:23:32.390
world there is a subset of rosacea that is certainly

00:23:32.390 –> 00:23:36.190
driven we believe by Demodex and how does that

00:23:36.190 –> 00:23:41.799
show up in in a person’s eye Yeah. Their eyes

00:23:41.799 –> 00:23:45.220
are red, irritated, scratchy, chronically. You

00:23:45.220 –> 00:23:47.720
can usually see it’s especially red right where

00:23:47.720 –> 00:23:50.140
the blue or brown part of the eye meets the white.

00:23:50.240 –> 00:23:52.460
There’s like a ring of fire around that area.

00:23:52.799 –> 00:23:55.880
And just their lids never look right. A parent

00:23:55.880 –> 00:23:58.720
will say they just don’t look right. They look

00:23:58.720 –> 00:24:00.940
chronically red. Their margins of their eyelashes

00:24:00.940 –> 00:24:05.380
are red. And a lot of times those kids get recurrent

00:24:05.380 –> 00:24:08.680
styes, which are basically pimples. recurrent

00:24:08.680 –> 00:24:11.700
chalazia, which are basically… blocked up glands.

00:24:11.980 –> 00:24:14.380
Styes are the zits you could pop when you were

00:24:14.380 –> 00:24:17.779
a kid. Chalazia are the deeper kind of cystic

00:24:17.779 –> 00:24:19.640
things you couldn’t pop when you tried when you

00:24:19.640 –> 00:24:23.119
were, you know, a teenager. And those, you know,

00:24:23.119 –> 00:24:25.700
we treat them with hot compresses, antibiotics,

00:24:26.079 –> 00:24:29.140
antibiotic cortisone drops. And, you know, sometimes

00:24:29.140 –> 00:24:31.920
they just need to, you know, be cut out over

00:24:31.920 –> 00:24:34.759
time. But that’s an ordeal in a child, right?

00:24:34.839 –> 00:24:37.980
If you had a stye, I’d lay you back in the chair,

00:24:38.119 –> 00:24:42.319
give you a shot of lidocaine and cut it out and

00:24:42.319 –> 00:24:46.000
you’d go back to work in 15 minutes. A child

00:24:46.000 –> 00:24:48.660
has to have general anesthesia, which is really

00:24:48.660 –> 00:24:51.559
terrible. Going to sleep with general anesthesia

00:24:51.559 –> 00:24:55.819
for pimples but but it’s really disabling where

00:24:55.819 –> 00:24:58.299
there’s one there tends to be more and you know

00:24:58.299 –> 00:25:00.099
they kind of there’s something called “kissing”

00:25:00.099 –> 00:25:02.680
styes where you get one on your upper lid and

00:25:02.680 –> 00:25:04.559
then you get one adjacent to it on the lower

00:25:04.559 –> 00:25:07.559
lid and you get this cycle of infection and uh

00:25:07.559 –> 00:25:10.680
you know you have to cut the gland out and and

00:25:10.680 –> 00:25:13.480
uh get rid of it at a certain point but it’s

00:25:13.480 –> 00:25:16.599
you know it’s an ordeal for the child because

00:25:16.599 –> 00:25:19.259
they have to go to sleep we see it all the time

00:25:19.259 –> 00:25:22.529
all the time really it’s that common Oh, yeah.

00:25:22.809 –> 00:25:25.109
I mean, the pediatricians, family doctors will

00:25:25.109 –> 00:25:27.009
first try and treat with antibiotics and hot

00:25:27.009 –> 00:25:30.230
compresses. Really rarely oral. It’s usually

00:25:30.230 –> 00:25:33.329
not a cellulitic kind of thing. It’s more localized.

00:25:33.609 –> 00:25:36.650
And we’ll try stronger antibiotic drops, usually

00:25:36.650 –> 00:25:40.569
a quinolone class and prednisone with it, mixed

00:25:40.569 –> 00:25:43.509
with it. And if it doesn’t get better, you know,

00:25:43.529 –> 00:25:46.750
we wait months and months and months unless there’s

00:25:46.750 –> 00:25:49.109
a reason to intervene sooner. But after four,

00:25:49.170 –> 00:25:51.880
five, six months, you can get scarring. they’re

00:25:51.880 –> 00:25:54.339
really difficult to remove after a while. So

00:25:54.339 –> 00:25:57.660
usually that four or five, six month period is

00:25:57.660 –> 00:25:59.539
a good time to start thinking about removing

00:25:59.539 –> 00:26:03.140
them because by the time everybody’s schedules

00:26:03.140 –> 00:26:05.180
align and you can get into the operating room,

00:26:05.220 –> 00:26:07.859
it’s usually a month or two later anyway. Oh,

00:26:07.880 –> 00:26:09.779
that’s good to know. Yeah, maybe I need to get

00:26:09.779 –> 00:26:11.680
a little bit more aggressive in terms of when

00:26:11.680 –> 00:26:15.200
I refer in. Well, the next condition that I wanted

00:26:15.200 –> 00:26:19.240
to ask you about is certainly inflammatory, but

00:26:19.240 –> 00:26:22.240
it’s an autoimmune driven process called alopecia

00:26:22.240 –> 00:26:25.740
areata. And that’s sort of for the audience’s

00:26:25.740 –> 00:26:28.259
sake, that’s where your own immune system has…

00:26:28.670 –> 00:26:31.650
sort of bypass the normal protection that the

00:26:31.650 –> 00:26:34.369
hair follicles, the sort of portals for where

00:26:34.369 –> 00:26:37.569
your hair come out, normally protected, normally

00:26:37.569 –> 00:26:40.289
wouldn’t be attacked by your immune system. But

00:26:40.289 –> 00:26:42.809
now the immune system, for whatever reason, has

00:26:42.809 –> 00:26:45.650
decided that your hair is, quote unquote, a foreign

00:26:45.650 –> 00:26:48.250
object and wants to get rid of it, drives an

00:26:48.250 –> 00:26:51.890
inflammatory process around that hair. And eventually

00:26:51.890 –> 00:26:53.930
the hair just kind of gives up and says, I’m

00:26:53.930 –> 00:26:56.809
out of here and falls out. We see that and it

00:26:56.809 –> 00:26:58.950
could certainly on the scalp is when it’s most

00:26:58.950 –> 00:27:01.730
probably most commonly showing up in my clinic.

00:27:01.829 –> 00:27:04.650
And we call that alopecia areata. But certainly

00:27:04.650 –> 00:27:08.750
it can involve the eyebrows, the eyelashes. We

00:27:08.750 –> 00:27:12.509
call that alopecia totalis. And then we have

00:27:12.509 –> 00:27:15.490
alopecia universalis, which is where all of the

00:27:15.490 –> 00:27:18.690
hair is involved, including the groin area, the

00:27:18.690 –> 00:27:23.789
underarms, the legs, whatever. You have… really

00:27:23.789 –> 00:27:26.710
changed the way I approach that diagnosis because

00:27:26.710 –> 00:27:29.869
the first thing I look at is, is it one-sided

00:27:29.869 –> 00:27:32.690
or not? Can you talk a little bit about that?

00:27:33.170 –> 00:27:36.210
Yeah. So, you know, one thing to think of is

00:27:36.210 –> 00:27:39.539
if the kids have actually been… pulling their

00:27:39.539 –> 00:27:43.220
lashes out too and you have to look and see if

00:27:43.220 –> 00:27:46.200
the lashes are broken we can see it at the microscope

00:27:46.200 –> 00:27:48.480
we worry about something called trichotillomania

00:27:48.480 –> 00:27:51.079
where the kids are actually removing their lashes

00:27:51.079 –> 00:27:54.980
and you know those children need you know universally

00:27:54.980 –> 00:27:59.960
cognitive therapy and counseling it really usually

00:27:59.960 –> 00:28:04.180
takes the parents by surprise when we tell them

00:28:04.180 –> 00:28:08.799
that that’s what we suspect because yeah everybody

00:28:08.799 –> 00:28:11.160
has a hard time believing that their their child

00:28:11.160 –> 00:28:14.039
could be really suffering that way and have a

00:28:14.039 –> 00:28:16.740
lot of emotional distress causing them really

00:28:16.740 –> 00:28:20.319
self -harm you know when you see all the lashes

00:28:20.319 –> 00:28:23.460
gone then we think of alopecia when we see just

00:28:23.460 –> 00:28:27.460
clusters of them specifically you know across

00:28:27.460 –> 00:28:31.220
from their their dominant hand um it makes us

00:28:31.220 –> 00:28:35.119
think more of a volitional uh pulling so if you’re

00:28:35.119 –> 00:28:38.960
right -handed and the left eye alone is sort

00:28:38.960 –> 00:28:41.220
of intermittently affected that’s a, that’s a

00:28:41.220 –> 00:28:43.700
pretty good hint that maybe yeah usually they

00:28:43.700 –> 00:28:46.539
kind of go across you know that’s what i found

00:28:46.539 –> 00:28:49.859
you know i’m sure that i’m sure it’s not 50 -50.

00:28:50.180 –> 00:28:53.299
But usually it seems to be that they go across

00:28:53.299 –> 00:28:55.539
their face. Is there a preference for the top

00:28:55.539 –> 00:28:58.339
or bottom eyelids? The top. The top. The top

00:28:58.339 –> 00:29:03.920
eyelids. They always pull the top. And the parents

00:29:03.920 –> 00:29:08.180
absolutely will not believe you that this is

00:29:08.180 –> 00:29:11.839
not an infection. It must be an infection. And

00:29:11.839 –> 00:29:14.220
so sometimes, you know, along with recommending

00:29:14.220 –> 00:29:18.640
cognitive therapy, we’ll also recommend an antibiotic

00:29:18.640 –> 00:29:22.220
ointment. The antibiotic ointment just makes

00:29:22.220 –> 00:29:24.660
it harder for the kids to kind of get a purchase

00:29:24.660 –> 00:29:29.359
of the lashes and pull them out. But we explain

00:29:29.359 –> 00:29:31.920
to them it’s like putting WD-40 on your eyelashes.

00:29:32.779 –> 00:29:36.500
It’s not fighting anything. But they need to,

00:29:36.500 –> 00:29:40.220
you know, sit and talk to their child. and find

00:29:40.220 –> 00:29:42.099
out what’s going on or enlist a professional

00:29:42.099 –> 00:29:45.759
and really help out along the way. One skin condition

00:29:45.759 –> 00:29:48.240
close to my own heart, since I actually have

00:29:48.240 –> 00:29:50.619
it, is something called vitiligo, another autoimmune

00:29:50.619 –> 00:29:53.299
condition where, for whatever reason, your body

00:29:53.299 –> 00:29:55.579
has decided to attack the melanocytes that make

00:29:55.579 –> 00:30:00.640
the tan or the melanin in your skin. There are

00:30:00.640 –> 00:30:02.299
a couple conditions that we’re taught about when

00:30:02.299 –> 00:30:04.460
we’re learning pediatric dermatology where there’s

00:30:04.460 –> 00:30:07.039
an overlap between the skin and the eyes. Is

00:30:07.039 –> 00:30:10.160
that something that you would see or would want

00:30:10.160 –> 00:30:13.970
us to refer in more for that? In adults, we see

00:30:13.970 –> 00:30:16.589
it from time to time. They’re usually of Asian

00:30:16.589 –> 00:30:20.009
descent, and we can see it be very disabling.

00:30:20.029 –> 00:30:23.549
They have uveitis. They have diminished vision.

00:30:23.769 –> 00:30:27.509
And it’s usually been a chronic condition. In

00:30:27.509 –> 00:30:31.269
children, it’s uncommon. There is one condition,

00:30:31.450 –> 00:30:34.930
Vogt-Koyanagi-Harada. They can affect those.

00:30:35.190 –> 00:30:38.009
But thankfully, in children, it’s uncommon. It’s

00:30:38.009 –> 00:30:42.650
more of a 20 to 30. maybe 40 year old but that

00:30:42.650 –> 00:30:45.470
can be very impactful for vision and hard to

00:30:45.470 –> 00:30:48.130
treat really hard to treat do you want to see

00:30:48.130 –> 00:30:50.690
those kids if if the vitiligo is affecting their

00:30:50.690 –> 00:30:52.910
eyelids or their eyebrows or is that not necessarily

00:30:52.910 –> 00:30:56.250
a marker for involvement You know, I don’t know

00:30:56.250 –> 00:31:00.029
the clinical answer to that, but there’s no harm

00:31:00.029 –> 00:31:02.910
in ever looking because children never complain.

00:31:03.430 –> 00:31:06.769
They really don’t complain, especially if something’s

00:31:06.769 –> 00:31:10.750
only affecting one eye. They don’t know. Nobody

00:31:10.750 –> 00:31:13.549
covers one eye at a time to check and see what

00:31:13.549 –> 00:31:15.970
their vision is like when they’re eight or nine.

00:31:16.630 –> 00:31:20.430
So it’s never a bad idea to do a baseline exam

00:31:20.430 –> 00:31:23.970
to be sure, because if you don’t look, then you

00:31:23.970 –> 00:31:25.960
don’t. know. Well, switching gears back to something

00:31:25.960 –> 00:31:28.259
you mentioned earlier, you use the term “herpetic.”

00:31:28.539 –> 00:31:31.039
That for the audience refers to a virus called

00:31:31.039 –> 00:31:35.019
herpes simplex virus, HSV. I was taught that

00:31:35.019 –> 00:31:38.039
about 90% of us – almost universally – are walking

00:31:38.039 –> 00:31:41.220
around having been exposed to this virus, not

00:31:41.220 –> 00:31:43.799
necessarily showing symptoms or signs of it,

00:31:43.859 –> 00:31:47.759
but we have it. Very, very common. Can you talk

00:31:47.759 –> 00:31:49.920
a little bit about how that might show up in

00:31:49.920 –> 00:31:53.599
a kid? Yeah, so it would generally be the HSV

00:31:53.599 –> 00:31:57.759
-1, which gives the fabled cold sore of the lip.

00:31:57.900 –> 00:32:01.980
Usually it presents as pink eye in a child, unless

00:32:01.980 –> 00:32:05.019
they’re very small. And it’s a bilateral condition

00:32:05.019 –> 00:32:08.500
as a child, and it’s treated really with antibiotic

00:32:08.500 –> 00:32:12.359
drops because there are no telltale signs of

00:32:12.359 –> 00:32:16.980
herpes the first time. If it recurs, whether

00:32:16.980 –> 00:32:19.420
it’s a few months later or a few years later

00:32:19.420 –> 00:32:22.400
or decades later, you’ll have pain sensitivity

00:32:22.400 –> 00:32:25.240
and a chronic pink eye. And, you know, family

00:32:25.240 –> 00:32:27.819
doctors will often just treat with an antibiotic

00:32:27.819 –> 00:32:30.359
drop, you know, because most things don’t need

00:32:30.359 –> 00:32:32.900
to be referred to an ophthalmologist. But if

00:32:32.900 –> 00:32:35.119
you’re using a drop and a day or two goes by

00:32:35.119 –> 00:32:38.579
and there’s no improvement or the patient is

00:32:38.579 –> 00:32:40.980
sensitive to light or in pain, they’re always

00:32:40.980 –> 00:32:44.940
taught again to refer to ophthalmology. children

00:32:44.940 –> 00:32:49.019
or adults can have herpetic conjunctivitis. And

00:32:49.019 –> 00:32:51.079
you wouldn’t know it without a microscope. You

00:32:51.079 –> 00:32:54.920
can’t diagnose it without a slit lamp. In babies,

00:32:54.960 –> 00:32:58.259
through the birth canal, they can encounter HSV

00:32:58.259 –> 00:33:03.140
-1 or HSV -2. If a mother has an open lesion

00:33:03.140 –> 00:33:05.619
at the time of birth, those children present

00:33:05.619 –> 00:33:08.900
within the first day or two, or actually about

00:33:08.900 –> 00:33:12.259
three to five, with hyperacute conjunctivitis.

00:33:12.279 –> 00:33:14.269
So the child will be discharged. after birth

00:33:14.269 –> 00:33:16.670
and a couple days later have a rip-roaring pink

00:33:16.670 –> 00:33:19.049
eye. And those children are always readmitted

00:33:19.049 –> 00:33:21.690
back to the hospital given high-dose IV antibiotics

00:33:21.690 –> 00:33:25.829
and acyclovir, which is the treatment for herpes,

00:33:25.829 –> 00:33:28.809
along with eye treatment as well. But it’s very

00:33:28.809 –> 00:33:32.109
disabling. It can scar the eye quickly, and it

00:33:32.109 –> 00:33:35.509
needs to be treated expeditiously. So that’s

00:33:35.509 –> 00:33:38.690
an emergency. You’ll take the kids in right away?

00:33:38.789 –> 00:33:41.269
Oh, yeah, right away, yeah. Nobody wants to see

00:33:41.269 –> 00:33:44.220
a child in pain or discomfort. A little less

00:33:44.220 –> 00:33:47.240
of an emergency is another, well, another two

00:33:47.240 –> 00:33:50.259
viruses, I guess. HPV, human papillomavirus,

00:33:50.519 –> 00:33:54.779
which causes skin warts, and molluscum contagiosum,

00:33:54.779 –> 00:33:57.900
a pox virus that causes… molluscum also known

00:33:57.900 –> 00:34:00.420
as water bumps when those get around the eye

00:34:00.420 –> 00:34:02.259
i find that’s pretty much one of the hardest

00:34:02.259 –> 00:34:04.940
places to treat because i would not normally

00:34:04.940 –> 00:34:08.340
use my go-to molluscum medicine of cantharone or “beetle

00:34:08.340 –> 00:34:11.679
juice” in that area out of risk for damaging the

00:34:11.679 –> 00:34:15.420
eye itself i tend to fall back on either a topical

00:34:15.420 –> 00:34:18.360
retinoid like Retin-a or Differin – something

00:34:18.360 –> 00:34:21.000
on the weaker side – where you’re putting a pinhead

00:34:21.000 –> 00:34:23.239
amount of the medication on each of these little

00:34:23.239 –> 00:34:26.199
bumps over maybe six to nine months with hope

00:34:26.199 –> 00:34:29.079
that you’re irritating it away. Of course, anytime

00:34:29.079 –> 00:34:31.500
you’re causing irritation around the eye, you’re

00:34:31.500 –> 00:34:34.159
at risk, I guess, of causing irritation around

00:34:34.159 –> 00:34:37.039
the eye. Do you have any tricks when you see

00:34:37.039 –> 00:34:38.739
these patients come in? Yeah, well, when it’s

00:34:38.739 –> 00:34:42.579
not right on the margin, clear nail polish. can

00:34:42.579 –> 00:34:46.239
help. We’ve used that. Cimetidine in older kids,

00:34:46.360 –> 00:34:48.639
the old Tagamet, you know, will work. But we

00:34:48.639 –> 00:34:52.659
give them prednisone because the prednisone tamps

00:34:52.659 –> 00:34:55.699
down the response. It gets very irritated, inflamed.

00:34:55.739 –> 00:34:58.400
It’s basically an allergy to the viral particles

00:34:58.400 –> 00:35:02.679
that get shed from the lesion. Almost really

00:35:02.679 –> 00:35:05.619
universally 30 years later, I don’t think I’ve

00:35:05.619 –> 00:35:08.000
ever seen molluscum last more than about eight

00:35:08.000 –> 00:35:10.940
or nine months. But it looks very different around

00:35:10.940 –> 00:35:13.619
the eyelid margin than on the rest of the skin

00:35:13.619 –> 00:35:16.900
surface. You still have that umbilicated appearance,

00:35:17.239 –> 00:35:20.690
but it’s just…bigger, flatter, a little bit

00:35:20.690 –> 00:35:24.170
different looking. But it gets better. Once in

00:35:24.170 –> 00:35:27.690
a blue moon, you remove them if the child has

00:35:27.690 –> 00:35:30.809
problems with the prednisone drops. But removing

00:35:30.809 –> 00:35:33.130
them, they’re usually inflamed, irritated, and

00:35:33.130 –> 00:35:35.650
they can scar. So it’s better to just kind of

00:35:35.650 –> 00:35:38.030
wait it out and let the body figure it out and

00:35:38.030 –> 00:35:42.449
mount an immune response and get rid of it. That’s

00:35:42.449 –> 00:35:45.800
what we do. Yeah, yeah, I agree. I mean, I think

00:35:45.800 –> 00:35:48.239
I’ve heard of some people who might curette them

00:35:48.239 –> 00:35:50.280
off if they’re just one or two off to the side.

00:35:50.380 –> 00:35:53.019
But most of the time, we’re either using the

00:35:53.019 –> 00:35:55.159
topicals I mentioned or kind of just hoping for

00:35:55.159 –> 00:35:58.000
the best or treating aggressively the other ones

00:35:58.000 –> 00:36:00.639
not around the eye with the hope that the immune

00:36:00.639 –> 00:36:03.159
system kicks in and clears the virus everywhere.

00:36:03.300 –> 00:36:07.070
So speaking of chronic. pink eye one of the things

00:36:07.070 –> 00:36:10.349
that i have a hard time with sometimes is differentiating

00:36:10.349 –> 00:36:13.170
between infection versus some of these inflammatory

00:36:13.170 –> 00:36:16.409
skin conditions versus allergic reactions so

00:36:16.409 –> 00:36:19.210
an actual allergy to a product that the child

00:36:19.210 –> 00:36:21.590
might be using like what we call a “rinse-off”

00:36:21.590 –> 00:36:23.989
product where they’re using a shampoo that runs

00:36:23.989 –> 00:36:27.010
down their face and hits that very very thin

00:36:27.010 –> 00:36:32.739
eyelid skin which is is for the audience’s edification.

00:36:32.739 –> 00:36:35.480
It’s pretty thin skin, right? I don’t know how

00:36:35.480 –> 00:36:37.840
thin it is, but I know it is the thinnest skin

00:36:37.840 –> 00:36:39.780
of the body. The thinnest skin on the body. So

00:36:39.780 –> 00:36:43.820
we tell our patients that that’s many times the

00:36:43.820 –> 00:36:46.539
very first place that an allergic reaction that

00:36:46.539 –> 00:36:49.159
could happen anywhere else might pop up because

00:36:49.159 –> 00:36:51.619
there’s just less skin to have to go through

00:36:51.619 –> 00:36:54.260
in those areas. What are you seeing in terms

00:36:54.260 –> 00:36:56.340
of allergic reactions of the eyelids? What are

00:36:56.340 –> 00:36:59.230
kids coming in for? Yeah. You know, sometimes

00:36:59.230 –> 00:37:02.170
it’s really hard to figure it out because sometimes

00:37:02.170 –> 00:37:04.250
the parents haven’t done anything different.

00:37:04.429 –> 00:37:06.829
The same products that their child has used,

00:37:06.909 –> 00:37:09.110
the same shampoo, the same soap, everything’s

00:37:09.110 –> 00:37:12.309
the same. But the product itself has been reformulated.

00:37:12.610 –> 00:37:17.630
I had a really great. really good detective mother

00:37:17.630 –> 00:37:21.849
once who figured out that her child was allergic

00:37:21.849 –> 00:37:25.929
to ammonium quaternium 4. i think that was

00:37:25.929 –> 00:37:27.989
it and it was some kind of preservative that

00:37:27.989 –> 00:37:31.429
was not in the old formulation of whatever shampoo

00:37:31.429 –> 00:37:34.030
that was in a new formulation, or a child really

00:37:34.030 –> 00:37:37.650
broke out into just a fulminant allergic response.

00:37:37.949 –> 00:37:40.969
And we tell them to use Benadryl, shower off

00:37:40.969 –> 00:37:44.389
everything. And a lot of those kids, we give

00:37:44.389 –> 00:37:47.869
a topical antihistamine drop. It gets better

00:37:47.869 –> 00:37:51.369
kind of quick. It’s like right quick on, quick

00:37:51.369 –> 00:37:53.369
off. They don’t really need the prednisone as

00:37:53.369 –> 00:37:56.619
much. Do you guys in ophthalmology do a version

00:37:56.619 –> 00:37:58.400
of what we would call patch testing? Are you

00:37:58.400 –> 00:38:00.139
familiar with what I’m talking about? I know

00:38:00.139 –> 00:38:02.840
what a patch test is. Yeah, but we don’t have

00:38:02.840 –> 00:38:06.159
anything like that. Oh, okay. Yeah, not in the

00:38:06.159 –> 00:38:08.840
eye, no. Well, we can be a resource for you.

00:38:08.920 –> 00:38:11.699
We have our sort of eye panel where we have some

00:38:11.699 –> 00:38:13.699
of the products most commonly associated. You

00:38:13.699 –> 00:38:16.500
mentioned Quat-14, I think, is the formaldehyde

00:38:16.500 –> 00:38:18.960
releaser. These formaldehyde products are very

00:38:18.960 –> 00:38:22.179
commonly in fingernail polish. And the same way

00:38:22.179 –> 00:38:24.599
you referenced that for trichotillomania, the

00:38:24.599 –> 00:38:28.460
dominant hand touching the eyelid, that’s one

00:38:28.460 –> 00:38:30.079
of the very first places. You don’t actually

00:38:30.079 –> 00:38:32.860
get the nail polish allergy on the fingernails

00:38:32.860 –> 00:38:35.300
as much as you do up on the eyelid. So it’s just

00:38:35.300 –> 00:38:38.429
an interesting thing. But yeah, we can certainly

00:38:38.429 –> 00:38:41.210
help identify a specific culprit with that. And

00:38:41.210 –> 00:38:45.289
I think right now our go -to patch test is a

00:38:45.289 –> 00:38:49.889
90-test group. So there’s a lot of things on

00:38:49.889 –> 00:38:52.050
there that we can identify. So I mentioned

00:38:52.050 –> 00:38:54.289
earlier that you and I mostly work together for

00:38:54.289 –> 00:38:57.349
infantile hemangiomas and port wine birthmarks.

00:38:57.409 –> 00:38:59.610
For the pediatricians and family medicine doctors

00:38:59.610 –> 00:39:02.309
out there, when do you absolutely want to see?

00:39:02.969 –> 00:39:05.929
a kid with a suspected infantile hemangioma or

00:39:05.929 –> 00:39:09.050
port wine birthmark. Yeah, anytime it’s really

00:39:09.050 –> 00:39:12.389
around the eye perioral area, especially the

00:39:12.389 –> 00:39:14.769
upper lid, but even the lower lids can grow and

00:39:14.769 –> 00:39:19.289
be very disabling. They can really disturb your

00:39:19.289 –> 00:39:25.070
visual development. Vision is a birthright, but

00:39:25.070 –> 00:39:29.880
you’re not born with it. And if a child’s unable

00:39:29.880 –> 00:39:33.960
to see because their lid is closed over the eye,

00:39:34.079 –> 00:39:37.239
over the pupil. That eye, if it’s not open in

00:39:37.239 –> 00:39:39.900
a few months, we’ll never learn to see. The brain

00:39:39.900 –> 00:39:42.420
really develops. And there was a Nobel Prize

00:39:42.420 –> 00:39:46.739
won in 1972, Hubel and Wiesel. They did work

00:39:46.739 –> 00:39:49.980
on a cat. I’m sorry for all the cat lovers out

00:39:49.980 –> 00:39:53.480
there, but they sewed one cat’s eye shut, one

00:39:53.480 –> 00:39:56.179
eye shut and left the other open. They showed

00:39:56.179 –> 00:39:59.199
that the lateral geniculate, the neural pathways

00:39:59.199 –> 00:40:02.280
actually grow differently when not stimulated

00:40:02.280 –> 00:40:04.599
by light at an early age. After you’re three

00:40:04.599 –> 00:40:08.019
or four months old, that’s not really as much

00:40:08.019 –> 00:40:10.280
of an issue. But certainly in the beginning,

00:40:10.340 –> 00:40:14.340
you really need light to stimulate the visual

00:40:14.340 –> 00:40:18.159
cortex to grow and the optic path and track to

00:40:18.159 –> 00:40:22.059
grow. So we get very concerned. And propranolol,

00:40:22.099 –> 00:40:26.849
Hemangeol. was such a game changer maybe 15,

00:40:26.989 –> 00:40:30.889
18 years ago when it was really developed by

00:40:30.889 –> 00:40:34.230
chance. There was a child with cardiac failure

00:40:34.230 –> 00:40:36.969
who had a hemangioma around their heart. They

00:40:36.969 –> 00:40:38.989
gave the child propranolol because they were

00:40:38.989 –> 00:40:41.769
in failure and it made the hemangioma shrink

00:40:41.769 –> 00:40:44.980
in a couple days. And I guess in the old days,

00:40:45.059 –> 00:40:47.440
that would have taken a year or two in journal

00:40:47.440 –> 00:40:51.579
articles to come out. But it was in the internet

00:40:51.579 –> 00:40:54.440
era and there were message boards and chat rooms.

00:40:54.599 –> 00:40:56.440
And within a few months, everybody was doing

00:40:56.440 –> 00:40:59.119
it. A lot of those have been sequenced and found

00:40:59.119 –> 00:41:01.460
to have some antigens that come from the placenta,

00:41:01.500 –> 00:41:04.159
I’m sure you know. And they’re associated with

00:41:04.159 –> 00:41:07.099
premature birth. But Hemangeol has really been

00:41:07.099 –> 00:41:09.099
a game changer. In the old days, we would inject

00:41:09.099 –> 00:41:13.460
them with prednisone. respond. They could be

00:41:13.460 –> 00:41:17.099
resected, which was very disfiguring for the

00:41:17.099 –> 00:41:22.940
children. And this is night and day. It’s a miracle.

00:41:23.360 –> 00:41:27.039
I tell people I’ve witnessed at least two miracles.

00:41:27.079 –> 00:41:29.340
I think with the psoriasis medicines, I’m on

00:41:29.340 –> 00:41:32.219
my third sort of class of medications. But Hemangeol

00:41:32.219 –> 00:41:34.500
really was the first miracle that I’ve witnessed

00:41:34.500 –> 00:41:39.420
as a physician and a game changer. So these hemangiomas

00:41:39.420 –> 00:41:42.460
you’re referencing, as they affect vision, It

00:41:42.460 –> 00:41:45.199
really is a “use it or lose it” phenomenon, it

00:41:45.199 –> 00:41:48.119
sounds like. And getting them into you. It’s

00:41:48.119 –> 00:41:51.320
interesting. Can you share your technique for,

00:41:51.400 –> 00:41:54.539
I don’t want to compare the kids to the cats

00:41:54.539 –> 00:41:56.360
that you were mentioning, but you sort of do

00:41:56.360 –> 00:42:00.179
the opposite to force the affected eye to be.

00:42:00.570 –> 00:42:03.349
better utilized. Is that correct? Yeah. So, you

00:42:03.349 –> 00:42:05.849
know, if you have an eye that’s partially occluded

00:42:05.849 –> 00:42:09.309
because of the weight, the volume of the blood

00:42:09.309 –> 00:42:13.170
in the eyelid, you’ll patch the other eye. The

00:42:13.170 –> 00:42:16.269
good eye. You’ll patch the good one. It’s been

00:42:16.269 –> 00:42:19.769
done for 5 ,000 years for different problems,

00:42:19.989 –> 00:42:24.510
not hemangiomas. And you patch it so that you

00:42:24.510 –> 00:42:27.050
force that child to use their muscles, their

00:42:27.050 –> 00:42:30.050
brow muscles to open the lid or just get… more

00:42:30.050 –> 00:42:34.130
stimulation than they would without it. And that’s

00:42:34.130 –> 00:42:36.130
very effective. And again, all these children

00:42:36.130 –> 00:42:38.190
are very small. They’re a few weeks, a few months

00:42:38.190 –> 00:42:41.409
old. So an hour a day, if the child is up for

00:42:41.409 –> 00:42:43.590
three, four, five hours a day, an hour a day

00:42:43.590 –> 00:42:47.449
is 20, 25 % of their day. That’s a lot. That’s

00:42:47.449 –> 00:42:50.130
equivalent to four or five hours for an older

00:42:50.130 –> 00:42:53.170
child. So even a half an hour, an hour for some

00:42:53.170 –> 00:42:57.739
of these kids, but the medicine just works. days,

00:42:57.760 –> 00:43:01.900
the hemangiomas will shrink a whole bunch so

00:43:01.900 –> 00:43:05.440
that they really respond so well. It’s amazing.

00:43:05.679 –> 00:43:09.460
One of the skin conditions that does not respond

00:43:09.460 –> 00:43:12.079
to Hemangeol is a port wine birthmark, a flat

00:43:12.079 –> 00:43:16.099
red. birthmark that that can be usually pretty

00:43:16.099 –> 00:43:18.880
easily distinguished between infantile hemangiomas

00:43:18.880 –> 00:43:21.519
but when you talk about a segmental hemangioma

00:43:21.519 –> 00:43:24.280
early early on before the texture has changed

00:43:24.280 –> 00:43:27.199
sometimes it’s a little hard. When, when would

00:43:27.199 –> 00:43:30.199
you as a pediatric ophthalmologist want to see

00:43:30.199 –> 00:43:33.039
a kid with a port wine birthmark specifically?

00:43:33.039 –> 00:43:36.219
Well, that’s changed a little bit since i i started

00:43:36.219 –> 00:43:38.860
studying but where does it get you most nervous

00:43:38.860 –> 00:43:42.360
that this might be a harbinger of an underlying

00:43:42.360 –> 00:43:45.340
condition like Sturge -Weber syndrome? If it

00:43:45.340 –> 00:43:48.019
is involving the upper eyelid, brow, and usually

00:43:48.019 –> 00:43:51.159
if you pull the eyelid up, you’ll also see a

00:43:51.159 –> 00:43:54.780
little bit of a “blush” to the upper sclera. It’ll

00:43:54.780 –> 00:43:57.420
look a little red. And that’s a real serious

00:43:57.420 –> 00:44:00.559
warning that you have a Sturge-Weber that’s

00:44:00.559 –> 00:44:03.360
affecting the eye. Most children can go on to

00:44:03.360 –> 00:44:05.989
get glaucoma. and they’re very difficult to treat

00:44:05.989 –> 00:44:10.989
and without it they’ll you know lose vision at

00:44:10.989 –> 00:44:15.150
a very early age it’s very very important so

00:44:15.150 –> 00:44:17.750
anytime that certainly that involves the upper

00:44:17.750 –> 00:44:20.690
eyelid is especially impactful and that’s a patient

00:44:20.690 –> 00:44:23.010
that you would probably see once a year at least

00:44:23.010 –> 00:44:25.619
i would imagine Yeah, you know, sometimes even

00:44:25.619 –> 00:44:27.780
more, honestly, Andrew, in the beginning, because,

00:44:27.840 –> 00:44:31.119
you know, you can’t be sure and things change.

00:44:31.340 –> 00:44:35.960
Sometimes it can take a few months, but you’d

00:44:35.960 –> 00:44:38.980
probably see them after you’re sure that there’s

00:44:38.980 –> 00:44:42.860
nothing there for a few years yearly because

00:44:42.860 –> 00:44:46.699
things change. But usually you can tell. pretty

00:44:46.699 –> 00:44:49.380
soon in the first few months but if a child’s

00:44:49.380 –> 00:44:51.380
referred when they’re a few weeks or a month

00:44:51.380 –> 00:44:54.320
old it can be hard to make that determination

00:44:54.320 –> 00:44:59.659
and things can change. Back when i was training

00:44:59.659 –> 00:45:02.960
in pediatrics we did a study with a pediatric

00:45:02.960 –> 00:45:05.780
ophthalmologist at the hospital there that looked

00:45:05.780 –> 00:45:08.619
at lasering port wine birthmarks right around

00:45:08.619 –> 00:45:12.639
the eye with the specific goal in mind of proving

00:45:12.639 –> 00:45:17.929
in quotes that lasering the cutaneous lesion,

00:45:17.929 –> 00:45:20.949
the birthmark, did not increase the pressure

00:45:20.949 –> 00:45:23.670
of the eye, meaning maybe you were destroying

00:45:23.670 –> 00:45:27.610
some of the outlet flow of the blood and maybe

00:45:27.610 –> 00:45:30.389
that would back up the pressure. Have you ever

00:45:30.389 –> 00:45:33.869
sort of discussed or seen the contralateral of

00:45:33.869 –> 00:45:37.010
that, which is lasering helps with the glaucoma?

00:45:37.050 –> 00:45:39.530
Does it do anything for that? No, I’ve never

00:45:39.530 –> 00:45:41.610
seen it help, but I’ve also never seen it hurt.

00:45:42.010 –> 00:45:44.150
Okay, that’s good to know. Yeah, I’ve never seen

00:45:44.150 –> 00:45:47.210
it hurt. I haven’t seen it a lot. I mean, probably

00:45:47.210 –> 00:45:50.250
fewer than a dozen or two cases in my career.

00:45:50.650 –> 00:45:53.789
The kids have been lasered for that, but I’ve

00:45:53.789 –> 00:45:56.460
never seen it hurt. Great. That makes me feel

00:45:56.460 –> 00:45:59.739
a lot better. Yeah. And if anything, honestly,

00:45:59.880 –> 00:46:02.559
it helps because the children are no longer as

00:46:02.559 –> 00:46:07.639
self-conscious about the lesion. And so from

00:46:07.639 –> 00:46:10.820
a psychosocial development thing, it helps them

00:46:10.820 –> 00:46:12.840
a lot because kids don’t want to feel different

00:46:12.840 –> 00:46:15.739
in any way. Well, that’s a great segue into my

00:46:15.739 –> 00:46:18.139
acne question that I’ve been so excited to ask

00:46:18.139 –> 00:46:23.000
you. So obviously you have severe acne. We don’t

00:46:23.000 –> 00:46:25.199
have a cure for severe acne yet, but we’ve got

00:46:25.199 –> 00:46:27.159
something that comes pretty close to treating

00:46:27.159 –> 00:46:30.099
it in most people well, and that’s a medicine

00:46:30.099 –> 00:46:32.800
called isotretinoin. Used to be sold under the

00:46:32.800 –> 00:46:36.500
name Accutane. The history that I remember is

00:46:36.500 –> 00:46:38.360
that they stopped selling Accutane under that

00:46:38.360 –> 00:46:41.219
brand name because people kept suing the makers

00:46:41.219 –> 00:46:43.219
of Accutane. They said, we’re done. You guys.

00:46:43.280 –> 00:46:46.679
figure it out on your own. One of those side

00:46:46.679 –> 00:46:49.460
effects that I do talk to every one of my patients

00:46:49.460 –> 00:46:52.780
about, especially if they’re driving age, is

00:46:52.780 –> 00:46:56.039
what Accutane can do to your night vision. And

00:46:56.039 –> 00:46:57.840
is that something that you’re familiar with?

00:46:57.960 –> 00:47:01.460
Oh, yeah. Because it gives you very dry eye,

00:47:01.559 –> 00:47:04.579
okay? Universally, these kids all get dry eye.

00:47:04.719 –> 00:47:08.239
And the surface of your eye, the best analogy

00:47:08.239 –> 00:47:11.260
that I once heard, it’s like the surface of the

00:47:11.260 –> 00:47:15.260
Hubble. space telescope. It has to be perfectly

00:47:15.260 –> 00:47:20.159
smooth and clean and perfect. Anything that disturbs

00:47:20.159 –> 00:47:23.320
the surface gives you glare and gives you reduced

00:47:23.320 –> 00:47:27.119
vision. Whether you’re a 75-year-old with dry

00:47:27.119 –> 00:47:30.139
eyes or whether you’re a 12-year-old with dry

00:47:30.139 –> 00:47:32.860
eye, that’s why a lot of older people have trouble

00:47:32.860 –> 00:47:35.000
driving at night. It’s just because they have

00:47:35.000 –> 00:47:38.539
very dry eyes or they have cataracts. But when

00:47:38.539 –> 00:47:40.659
your eyes get dry, you have tremendous amount

00:47:40.659 –> 00:47:44.440
of glare. take a lot to irritate the surface

00:47:44.440 –> 00:47:47.579
of your eye and really interfere with your vision

00:47:47.579 –> 00:47:49.800
because it’s a very small area that really does

00:47:49.800 –> 00:47:53.840
most of the visual processing. So this is not

00:47:53.840 –> 00:47:56.500
an actual physical change that the medication

00:47:56.500 –> 00:47:58.920
isotretinoin is causing in the eye, it’s a side

00:47:58.920 –> 00:48:03.469
effect of the dryness? Yeah, I mean, look, because

00:48:03.469 –> 00:48:06.630
of its effects on vitamin, because it’s a vitamin

00:48:06.630 –> 00:48:10.230
A chemical, maybe it in some way impacts the

00:48:10.230 –> 00:48:14.889
visual cascade in the retina. Not in a way that

00:48:14.889 –> 00:48:18.070
I’m aware of. It’s mostly from dry eye, but we

00:48:18.070 –> 00:48:22.050
also worry as well about idiopathic intracranial

00:48:22.050 –> 00:48:26.630
hypertension from taking isotretinoin. And we

00:48:26.630 –> 00:48:29.809
have to be careful of kids who complain of blurred

00:48:29.809 –> 00:48:31.969
vision, trouble with their vision, or headache.

00:48:32.650 –> 00:48:35.570
um that they can rarely um you know have what

00:48:35.570 –> 00:48:38.610
we call pseudotumor cerebri from that any vitamin

00:48:38.610 –> 00:48:41.349
a derivative even eating a polar bear liver will

00:48:41.349 –> 00:48:44.130
give it to you uh. We have a couple of medications –

00:48:44.130 –> 00:48:46.769
you tell me if i’m missing any big ones- um the

00:48:46.769 –> 00:48:50.750
the tetracyclines: doxycycline, minocycline; oral

00:48:50.750 –> 00:48:53.949
contraceptive pills (birth control pills); isotretinoin,

00:48:54.090 –> 00:48:57.250
and which one else? What am I forgetting? Those

00:48:57.250 –> 00:48:58.690
are the three big ones that I think. That’s what

00:48:58.690 –> 00:49:01.389
I think of too. Yeah, exactly. Yeah. And that,

00:49:01.449 –> 00:49:04.449
like you said, will present as a severe headache

00:49:04.449 –> 00:49:07.449
that does not get better with a Tylenol or a

00:49:07.449 –> 00:49:10.469
Motrin. You go to sleep expecting your headache’s

00:49:10.469 –> 00:49:13.010
gone the next morning. You wake up, it might

00:49:13.010 –> 00:49:16.289
even be worse, right? It’s pretty debilitating.

00:49:16.989 –> 00:49:19.369
Well, that’s a great question. So for the Accutane

00:49:19.369 –> 00:49:23.369
user and just in general, what are the ways to

00:49:23.369 –> 00:49:26.389
prevent these sort of common eye problems that

00:49:26.389 –> 00:49:28.369
we talked about specifically, I guess, dryness

00:49:28.369 –> 00:49:31.250
of the eye? But if you were telling your own

00:49:31.250 –> 00:49:33.909
kids, hey, you’ve got a lifetime ahead of you.

00:49:34.250 –> 00:49:37.150
Here’s how I would take best care of your eyes.

00:49:37.329 –> 00:49:39.530
What are some of the suggestions you would have

00:49:39.530 –> 00:49:43.670
us do? Protective eyewear. It’s the most impactful

00:49:43.670 –> 00:49:49.599
thing. dumbest things happen when you don’t expect

00:49:49.599 –> 00:49:53.960
it. And just, you know, any sport, anything where

00:49:53.960 –> 00:49:57.260
you’re going to contact a ball, you should really

00:49:57.260 –> 00:50:01.039
wear protective eyewear. That it’s just wearing

00:50:01.039 –> 00:50:04.260
a seatbelt for your eye. And, you know, some

00:50:04.260 –> 00:50:06.780
of the injuries that we see are, you know, preventable,

00:50:06.820 –> 00:50:10.730
heartbreaking. permanent and life-changing.

00:50:10.989 –> 00:50:14.469
And it’s also very important for the two or three

00:50:14.469 –> 00:50:17.530
percent of the population that has a quote “lazy

00:50:17.530 –> 00:50:20.389
eye” – an eye that doesn’t see well. I’ve never

00:50:20.389 –> 00:50:24.409
seen the lazy eye injured. I’ve only seen the

00:50:24.409 –> 00:50:26.710
good eye injured because if you hear a sound,

00:50:26.869 –> 00:50:30.409
you turn so that you can see the sound and that’s

00:50:30.409 –> 00:50:32.690
the fist coming at your face and it hits your

00:50:32.690 –> 00:50:35.969
good eye or the ball. Anything always hits the

00:50:35.969 –> 00:50:40.849
good eye. So it’s really impactful, just like

00:50:40.849 –> 00:50:43.489
you wear a seatbelt to wear safety glasses. The

00:50:43.489 –> 00:50:47.230
normal everyday person without a skin condition

00:50:47.230 –> 00:50:50.449
or an eye condition, do they need or should they

00:50:50.449 –> 00:50:53.420
be using? eye lubricating drops is that is that

00:50:53.420 –> 00:50:57.219
good yeah i mean your eyes are kind of on autopilot

00:50:57.219 –> 00:50:59.980
when you’re on Accutane just like you might use

00:50:59.980 –> 00:51:04.460
vaseline on your lips you want to use artificial

00:51:04.460 –> 00:51:08.300
tears sometimes the non-preserved as opposed

00:51:08.300 –> 00:51:10.639
to the preserved ones because they’re less irritating

00:51:10.639 –> 00:51:14.460
but for the most part your eyes are really on

00:51:14.460 –> 00:51:17.000
autopilot if you just have a good nutritious

00:51:17.000 –> 00:51:21.059
you know diet you don’t really need artificial

00:51:21.059 –> 00:51:24.300
teardrops at a young age if you do um you probably

00:51:24.300 –> 00:51:27.059
need to go play outside more and look at you

00:51:27.059 –> 00:51:30.199
and and look at instagram a little bit less because

00:51:30.199 –> 00:51:33.739
your eyes dry out when you have a lot of screen

00:51:33.739 –> 00:51:37.900
time you don’t blink as much and the blink lubricates

00:51:37.900 –> 00:51:41.039
your eye but it also moves the mucus around and

00:51:41.039 –> 00:51:43.739
the oil from the meibomian glands in your lids

00:51:43.739 –> 00:51:46.820
and it’s important to kind of flex those glands

00:51:46.820 –> 00:51:51.179
so that they work properly and you know whether

00:51:51.179 –> 00:51:54.460
it’s screen time on a TV or an ipad or whatever

00:51:56.039 –> 00:51:58.280
you don’t blink as much and that contributes

00:51:58.280 –> 00:52:02.079
to dryness. But if you have no symptoms, it’s

00:52:02.079 –> 00:52:05.099
hard to fix something that isn’t broken. So I’d

00:52:05.099 –> 00:52:07.380
say probably not. Okay, that’s good to know.

00:52:07.920 –> 00:52:10.639
Good to know. Well, my last question before I

00:52:10.639 –> 00:52:13.400
let you out of here, this has been one that I’ve

00:52:13.400 –> 00:52:16.599
been really just, I’ve never been able to do

00:52:16.599 –> 00:52:19.719
this myself. So maybe I wasn’t being fair to

00:52:19.719 –> 00:52:22.880
myself. So very specific skin condition called

00:52:22.880 –> 00:52:27.849
“neurofibromatosis”. – NF1.. It’s a chromosome 17

00:52:27.849 –> 00:52:32.690
mutation. And there’s one of the specific findings

00:52:32.690 –> 00:52:36.730
in the constellation of this condition is something

00:52:36.730 –> 00:52:39.469
called Lisch nodules in the eye. Can you explain

00:52:39.469 –> 00:52:42.389
what they are? And very importantly, am I supposed

00:52:42.389 –> 00:52:46.190
to be able to see them before you? Absolutely

00:52:46.190 –> 00:52:49.630
not. You need a microscope to see them. At least

00:52:49.630 –> 00:52:52.510
I need a microscope to see them, especially in

00:52:52.510 –> 00:52:54.750
a little child who’s not sitting still for more

00:52:54.750 –> 00:52:57.789
than a minute. But technically, a lish nodule

00:52:57.789 –> 00:53:00.670
is a hamartoma, an overgrowth of tissue that’s

00:53:00.670 –> 00:53:03.789
normally there, but just more of it. It looks

00:53:03.789 –> 00:53:07.750
like a little wart on the iris. And you can have

00:53:07.750 –> 00:53:10.309
one or two of them. You can have dozens of them.

00:53:11.170 –> 00:53:14.900
They look very different. in a brown-eyed children

00:53:14.900 –> 00:53:21.820
than a blue-eyed child. But they’re uncommonly

00:53:21.820 –> 00:53:26.360
associated with NF. And we’re always asked to

00:53:26.360 –> 00:53:30.760
look. But at the end of the day, they don’t do

00:53:30.760 –> 00:53:35.139
anything to the vision. It’s just a feature of

00:53:35.139 –> 00:53:38.829
the genetic disease. but it doesn’t do anything

00:53:38.829 –> 00:53:41.210
to the vision. In the old days, before genetic

00:53:41.210 –> 00:53:43.869
testing, it was helpful, inclusive of the criteria

00:53:43.869 –> 00:53:48.650
and whatnot. Now we look, but whether the child

00:53:48.650 –> 00:53:51.269
has them or not, it doesn’t matter. Now, there

00:53:51.269 –> 00:53:55.489
are also hamartomas. of the retina in kids who

00:53:55.489 –> 00:53:58.949
have neurofibromatosis and their hamartomas in

00:53:58.949 –> 00:54:01.489
kids who have tuberous sclerosis, a different

00:54:01.489 –> 00:54:04.530
autosomal dominant condition, and you can see

00:54:04.530 –> 00:54:07.170
those they’re basically bumps in the retina and

00:54:07.170 –> 00:54:11.110
their retinal tissue but you should not even

00:54:11.110 –> 00:54:14.150
even you who is so excellent can’t be expected

00:54:14.150 –> 00:54:18.130
to look without a microscope. Thank God… i remember

00:54:18.130 –> 00:54:20.530
distinctly it was a picture on the front cover

00:54:20.530 –> 00:54:23.000
of one of our general dermatology – not even a

00:54:23.000 –> 00:54:25.840
pediatric dermatology textbook. And it had about

00:54:25.840 –> 00:54:28.739
five pictures of very specific things. One of

00:54:28.739 –> 00:54:33.960
them was a person’s eye, a person had a background

00:54:33.960 –> 00:54:36.599
diagnosis of neurofibromatosis-1. And when

00:54:36.599 –> 00:54:38.739
you read the little insert of what the pictures

00:54:38.739 –> 00:54:41.800
were, it said “demonstration of Lisch nodules.”

00:54:41.820 –> 00:54:44.820
And it’s like, I can’t see these things. I don’t

00:54:44.820 –> 00:54:48.460
know what’s wrong with me. Okay. Well, I want

00:54:48.460 –> 00:54:50.699
to thank Dr. Robert Kitei for taking the time

00:54:50.699 –> 00:54:52.739
out of his very busy clinic schedule to help

00:54:52.739 –> 00:54:55.440
educate us on these important topics. I felt

00:54:55.440 –> 00:54:58.440
like, dare I say, an eager “pupil” listening to

00:54:58.440 –> 00:55:00.619
him teach about kids’ overlapping skin and eye

00:55:00.619 –> 00:55:03.179
conditions. Thanks for joining us on this episode

00:55:03.179 –> 00:55:05.300
of Don’t Be Rash. It was great having you, Dr.

00:55:05.320 –> 00:55:08.199
Kitei. And to our audience, stay tuned for our

00:55:08.199 –> 00:55:13.719
next episode. Thanks for tuning in to this episode

00:55:13.719 –> 00:55:16.179
of the Don’t Be Rash Pediatric Dermatology Podcast.

00:55:16.760 –> 00:55:19.059
I’m your host, Dr. Andrew Krakowski. Don’t forget

00:55:19.059 –> 00:55:21.260
to subscribe to our show on your favorite podcast

00:55:21.260 –> 00:55:25.159
platform and check out don’tberash .org for more

00:55:25.159 –> 00:55:27.539
information. A special thank you to our nonprofit

00:55:27.539 –> 00:55:30.260
sponsor, the St. Luke’s University Health Network

00:55:30.260 –> 00:55:32.900
for making this episode possible. Until next

00:55:32.900 –> 00:55:35.880
time, remember, keep calm and don’t be rash.