Bugs, Bumps, and Bacteria: The Role of Virtual Collaborative Learning Network in Pediatric Dermatology

Abstract

Patients in rural and underserved areas face significant barriers in accessing specialty care due to unavailability of services, geographic isolation, travel burden, and other cultural and socioeconomic factors.¹ Pediatric dermatology is among the top three subspecialties that provides routine care for pediatric patients, however, shortage and maldistribution of pediatric dermatologists have remained a major hurdle for those living in remote and isolated areas.² Pediatric dermatologists cluster in urban areas with high-patient volume and estimated wait times for new patients that often exceed 13 weeks, making access one of the major drivers of inequity for rural patients.^2–4

Show-Me ECHO for Dermatology Extension

Complete inaccessibility of healthcare providers, physical and financial barriers, and insurance coverage are some of the reasons patients delay, miss, or postpone specialty medical appointments.³ Instead, rurally-located patients rely on community primary care providers (PCPs) to provide pediatric dermatologic care.^4,5 More than 65 percent of patients with dermatological problems seek initial care with their PCP and an estimated 10 to 30 percent of all pediatric outpatient visits in primary care settings include evaluation of one or more skin diseases.^2,6

Skin conditions, however, can be challenging to diagnose, which often leads to misdiagnosis and incorrect treatment resulting in poor health outcomes and increased costs for patients and healthcare systems.⁷ PCPs report lack of training, knowledge, and experience with skin diseases, especially in pediatric patients.⁸ Previous studies recommended solutions such as increased mentorship, training, and supervision of advanced non-dermatologist providers to improve access and alleviate some of the issues caused by maldistribution of general and pediatric dermatologists.⁹

The University of Missouri School of Medicine’s Department of Dermatology and the Missouri Telehealth Network implemented Dermatology Extension for Community Healthcare Outcomes (ECHO) project in 2015 with the aim of providing telementoring and education to PCPs across the state. The goal of Dermatology ECHO is to increase the capacity of community providers to diagnose, treat, and manage patients with complex skin conditions.¹⁰ Each ECHO session consists of an expert didactic lecture and one or more real-life de-identified patient cases presented by participating PCPs requiring guidance and mentoring from the Dermatologists ECHO hub team.

A total of 160 ECHO sessions were held from project inception in 2015 until June 18, 2021 with 550 cases reviewed and discussed. Dermatology ECHO has seen a steady increase in participation (Figure 1) and case presentations. A slight decrease in attendance was observed in 2019, when session frequency changed from weekly to bi-weekly in February 2019. As new attendees continue to join, participation increased in 2020 and 2021.

Figure 1.

Unique attendees by year

In this case series report we included four pediatric dermatology cases presented by PCPs between November 2015 and June 2021. A total of 97 pediatric dermatology cases were discussed during this time in four broad categories: inflammation/rashes (n=42), infectious diseases/infestations (n=13), neoplasms/lesions (n=27), and other (n=15) (Table 1).

Table 1.

Dermatology ECHO pediatric case presentation categories

Diagnostic Categories	Example Diagnoses	Number of Case Presentations
inflammatory/rashes	atopic dermatitis, hypersensitivity reaction, acne vulgaris, granuloma annulare	42
infectious/infestation	scabies, ezcema herpeticum, flat warts	13
neoplastic/lesion	infantile hemangioma, congenital nevus, angiofibroma	27
other	vitiligo, cutis aplasia/nevus, suture reaction	15
Total		97

All Dermatology ECHO cases are de-identified prior to submission for presentation in ECHO session. Data was collected from de-identified case forms submitted by PCPs and recommendation forms submitted by Dermatology ECHO hub team. Video recordings of ECHO sessions were also viewed to verify data quality and completeness.

The aim of this report is to describe characteristics, images and outcomes among pediatric dermatology patients presented in Dermatology ECHO. We will also highlight selected cases and review diagnoses and management strategies as recommended by the ECHO hub team dermatologists.

Case 1: STARI Disease vs. Anthropoid Bite

Erythema migrans (EM), an erythematous annular plaque, is the most common cutaneous feature of Lyme disease, a tickborne infection caused by the spirochete Borrelia burgdorferi.¹¹ Patients from the southeast and south-central United States may also develop EM-like lesions after tick bites, but testing for B. burgdorferi is negative¹². These patients are considered to have southern tick-associated rash illness (STARI) or Masters disease, originally described in Missouri.¹² The etiology has not been identified, although the vector is the lone star tick (Amblyomma americanum). STARI presents with a circular erythematous plaque with central clearing. Illness (with symptoms including fever, headache, arthralgias and/or myalgias) tends to be milder with STARI compared to Lyme disease.¹² Treatment with antibiotics (generally doxycycline or amoxicillin) is recommended, which usually results in prompt improvement in symptoms.¹³ While Lyme disease is not endemic to Missouri, it is important to consider STARI in a patient who presents with a targetoid rash and possible systemic symptoms, particularly if there is a history of a tick bite. The differential diagnosis of an acute annular plaque includes hypersensitivity reactions to other arthropod bites, which are more likely to have associated pruritus and less likely to exhibit expanding erythema¹³

In 2016, a 7-year-old male presented to his PCP in a rural Missouri county with a one-day history of an eruption on his left forearm (Figure 2). The child did not recall a specific incidence of a bite or sting but the family lives in the country and commonly encounters ticks. The rash was not particularly itchy or tender. In clinic, the child was afebrile and was not in any apparent distress. Examination revealed an approximately 5 cm by 7 cm erythematous patch with a zone of pallor and central punctum. No other lesions were noted by physical exam. The child was started on amoxicillin, 40mg/kg/day to cover for possible STARI. The PCP was a regular participant in Dermatology ECHO and presented this case with the main question for the specialist hub team regarding correct diagnosis.

Figure 2.

Erythematous patch with a zone of pallor and central punctum on left arm of a 7-year-old-male.

The Dermatology hub team reviewed the photograph and discussed a differential diagnosis of an urticarial hypersensitivity reaction to an arthropod bite, versus STARI. The hub team specialists agreed that in this case, STARI would be more likely if the erythema expanded over the next several days; however, the presence of a punctum or crust was more suggestive of a hypersensitivity reaction. In addition to continuing the prescribed treatment, they recommended adding symptomatic treatment such as antihistamines for itching, cold packs, anti-inflammatories or topical steroids if needed, and continued monitoring. The child’s rash resolved and the patient required no further treatment.

Case 2: Pitted Keratolysis

Pitted keratolysis is a common bacterial skin infection of the stratum corneum most often due to Gram-positive Kytococcus sedentarius, Corynebacterium species, Actinomyces species, or Dermatophilus congolensis.^14,15 It presents with discrete, superficial erosions or pits on the plantar feet with associated malodor; maceration and hyperhidrosis are commonly present. Bacterial proteases dissolve the stratum corneum, creating the pits, and produce sulfur-containing compounds, causing the foul smell.^14,15 Risk factors include hyperhidrosis, prolonged wearing of occlusive footwear, humid climates, poor foot hygiene, and immunodeficiency.^14–16 Young adults and adolescents are most often affected, with a male predominance.^14,15 The condition is also more common in athletes.¹⁶

In 2017, a 17-year-old male high school football player presented to his PCP in a rural Missouri county with a history of foul-smelling pitting on the bottom of his bilateral feet. The patient had used topical antifungals without improvement. On presentation, the physician noted thickened, stippled, malodorous skin over the sole of the foot, with minimal scale and no redness. KOH scraping was negative. A differential diagnosis was considered, including dyshidrosis and pitted keratolysis.

The PCP presented the case to Dermatology ECHO hub team with the main question regarding the correct diagnosis and treatment recommendations. The Dermatology hub team reviewed the photos and history and agreed with the diagnosis of pitted keratolysis (Figure 3). Treatment includes topical antibiotics such as clindamycin, erythromycin or mupirocin one to two times daily. Topical benzoyl peroxide is also an effective treatment, although patients should be warned that it may bleach clothing or linens. Oral antibiotics may be useful in treating recalcitrant disease. It is important to continue treatment until the infection has resolved, which may take several weeks. Continued use of benzoyl peroxide wash can be helpful as a preventive strategy in patients prone to recurrence. In patients with hyperhidrosis, measures such as absorbent socks (changed frequently when damp) and topical aluminum chloride should also be recommended. Patients should also be instructed to wash feet with soap and water at least daily.

Figure 3.

Pitted keratolysis on the plantar surface of both feet on a 17-year old male high school football player.

The patient was treated with topical erythromycin and benzoyl peroxide, and dryness measures were recommended. Patient required no further treatment.

Case 3: Scabies

Scabies is a highly contagious infestation by the mite Sarcoptes scabiei var hominis, which generally presents with an intensely pruritic rash.¹⁷ Although the worldwide prevalence is estimated to affect 200 to 300 million individuals annually, only 5–10% of these cases are thought to occur in children.¹⁸ The manifestation of scabies in the pediatric population can differ from adults, which can make it difficult to diagnose.^17,19

In 2020, a 12-month-old male presented to his PCP with a persistent rash on his feet, legs, abdomen, back, arms, and hands that had started eight months prior. The PCP made a provisional diagnosis of atopic dermatitis or arthropod bites. Initial treatment included two doses of prednisolone with temporary improvement, and triamcinolone ointment with partial improvement.

Mother breastfed the child and noted that she developed a similar rash on her abdomen. The father and brother had also experienced a similar intermittent rash. Primary care provider preformed viral and bacterial cultures which were negative. The patient was seen three times by the PCP over the course of eight months without any improvement in the condition.

PCP presented the case to Dermatology ECHO for recommendations regarding diagnosis and treatment. With the aid of images, the Dermatology ECHO hub team diagnosed the child with scabies (Figure 4). In infants and toddlers, scabies will often present on the plantar foot, instep, and the diaper region with erythematous papules and yellow-brown crust. The axillae and diaper region may also have pustular and nodular lesions. In adults, lesions are common in the interdigital spaces, axillae, areolae, flexor wrists, and genitals. To diagnose scabies, it is recommended to perform a mineral oil preparation to look for the scabies mite, ova, or scybala (feces) under the microscope. To achieve a better yield, sample should be obtained from the entire stretch of a linear papule (burrow), often found on the hands or feet.

Figure 4.

Scabies erythematous papules on a 12-month-old male.

Treatment with topical permethrin 5% cream was recommended for the entire household, including any asymptomatic members. This should be applied to all regions from the ear lobe down to the toes, including intertriginous areas; it should remain on the skin overnight and then washed off in the morning. Breastfeeding mothers must treat the areolas. One week following, this process should be repeated, for a total of two applications. All household members should be treated on the same night to eradicate all mites. In addition to permethrin treatment, a deep cleaning of the environment, including blankets, pillows, and stuffed animals should occur. It is important to note that the rash may remain for up to four to six weeks after the completion of treatment. Topical steroids and oral antihistamines may be used to treat symptoms.

The child was treated as recommended, and the condition resolved without the need for further care.

Case 4: Eczema Herpeticum

Eczema herpeticum is a disseminated cutaneous infection that presents with eruption of monomorphic, dome-shaped papulovesicles that form punched-out ulcers over previously existing eczematous areas.^20,21 This infection is due to herpes simplex virus, and children with atopic dermatitis have a higher risk of developing eczema herpeticum.^20,21.Early recognition is crucial, as the infection can progress to viremia and secondary septicemia.³

In 2019, a 4-year-old female was presented by her PCP to Dermatology hub team with questions regarding diagnosis and management. The patient was seen three times over 12 months by her PCP for a rash located on her arm, face, leg, and trunk region. She was diagnosed with eczema, which had recently started flaring. She was taking cetirizine and hydroxyzine and applying Aquaphor^® and triamcinolone 0.1% cream as needed with minimal improvement.

Images submitted for hub team review revealed several monomorphic “punched-out” ulcerations on the child’s forearm (Figure 5). The Dermatology ECHO hub team diagnosed the child with eczema herpeticum caused by herpes simplex virus. They recommended swabbing the erosions to confirm the diagnosis and initiating treatment with acyclovir while awaiting results.

Figure 5.

Eczema herpeticum cutaneous vesicular eruption on a 4-year-old female.

Household members of children with atopic dermatitis should be educated to recognize signs and symptoms of eczema herpeticum, including associated fevers or pain with eczema flares, and promptly notify their provider, as this can progress to a life-threatening condition.

The physician returned to the Dermatology hub team three weeks later to report that the child was treated with acyclovir and the rash resolved.

Conclusion

This series highlights the impact clinicians’ participation in ECHO can make on their patients’ lives. We presented four cases that had considerable impact on patients, as their suffering continued over many months or even years, and included multiple visits and treatments. One child suffered with undiagnosed scabies for several months, an infestation which can cause intense pruritus, disrupt sleep, and spread to other family members. Early identification, aggressive and rapid treatment of scabies provide relief to patients and help infection control. Eczema herpeticum is an infection which requires timely diagnosis with prompt initiation of antiviral therapy, as it can lead to serious complications and even mortality if left untreated, particularly in infants. The malodor associated with pitted keratolysis has been shown to have significant adverse impact on quality of life, so clinical recognition and appropriate treatment of the condition is key, particularly since effective cures are available.¹⁵ While Lyme disease is unlikely in Missouri, STARI should be considered in patients who present with an erythema migrans-like annular skin lesion, particularly with prior tick exposure and systemic symptoms.

It is estimated that over 40 percent of U.S. population lives in areas without access to dermatology expertise.²² Dermatologists are not able to meet patient demand due to workforce shortages and can only see one-third of all patients with skin conditions.²² This means that community PCPs now face increasing responsibilities of diagnosing and treating patients with complex and costly skin conditions. Telehealth technologies have become ubiquitous, and expanded from one-to-one patient care to many-to-many ECHO and ECHO-like models that benefit multiple providers and multiple patients at the same time. Dermatology ECHO is an “all teach, all learn” platform which serves as a trusted, local dermatology specialist hub that supports PCPs in providing care to patients with cutaneous diseases. Mentoring and guidance regarding cases presented in Dermatology ECHO does not only support presenting clinicians and their patients, but all other clinicians in attendance who care for patients with same conditions.

We invite you to consider joining Dermatology ECHO, or an ECHO in an area of interest. We hope that you will gain expertise that will benefit yourself and your patients. Virtual learning networks, such as ECHO, foster knowledge-sharing between specialists and PCPs with the aim of improving patient outcomes.