Dermatology with Dr. Teresa Wright, MD

Introduction and guest background 0:00

Hello, welcome to this week's episode of the Baby Manual Podcast. Today, I am so excited to be talking to Dr. Teresa Wright, MD. She is a dermatologist, a pediatric dermatologists, and I know Dr Wright through a lot of Facebook groups. We're on a lotta the same Facebook Mom, Dr Mom groups and it seems like whenever there's ever a skin question at all, explains it in a way that's really easy to understand. So I'm super jazzed to have her here on the podcast today. We're going to talk about things like birthmarks and things to watch out for in your child's skin that could potentially be dangerous and a little bit about eczema, which is also called atopic dermatitis.

So thank you, Dr. Wright, for being here. Anything else you'd like to add about, tell me a little bit about yourself and where you work, how you got into dermatology, that sort of thing. Sure. Okay. Well, thanks so much for having me. I'm excited to be here too. And I live in Memphis, Tennessee. Yeah, I work at Le Bonheur Children's Hospital and I am also faculty at the University of Tennessee Medical Center here in It's kind of a long winding road that brought me here. I grew up in Memphis.I went to college in the northeast of Massachusetts and took some time off before I went into med school but ended up going to University of Massachusets and actually planned to be a pediatrician and was kind well into my pediatrics residency when I stumbled upon and fell in love with pediatric dermatology which I had not even known was a thing.

during my medical school training and then decided I really wanted to pursue that. So I had to do a second residency in dermatology, which I did in Kansas, and a fellowship in pediatric dermatologist,which I also did Kansas City. And then I went to Houston for a few years and worked at Baylor College of Medicine and Texas Children's in Houston. And then full circle, I got recruited to come back to Memphis when the University of Tennessee was expanding and looking for a pediatric dermatologist. They had never had one on faculty here and, you know, Le Bonheur is a fairly large children's hospital.

It's been here quite a number of years. And of course, we have a very close affiliation with St. Jude, which everybody has heard of St Jude and they did not have the pediatric, dermatologists here in town at all. So it just kind of felt like the universe was set Come back home, you're needed at home. Well, great. Let's start off with a couple of things that you see in newborns, things parents might notice that they might be worried about, but that don't need to be. Some of the really common things would be things like little pink or red spots on the middle of forehead and or the eyelids.

Those are sometimes called angel kisses. We call that nevus simplex or there are some other medical terms for those.

Common newborn skin findings 3:00

Some babies will also have similar marks anywhere really in the middle of the face. So they may come down the nose. They may be here on the upper lip or even the chin. That's something that's a little bit more unusual form of nidus simplex, but still nothing to worry about. Those usually fade over time. You know, sometimes you will see an older child or an adult if they get mad or have a fever or something, you may see a bit of pink right on their forehead. But usually those fade overtime. If there's a child who's like school age and it hasn't really faded as well as parents would like, those can be treated with a laser in the office pretty easily and can lightened.

There's this similar kind of related mark that can occur on the nape of the neck and the occipital scalp. That's the same thing, but sometimes called a stork bite. But that's also nevus simplex. And then maybe we could just briefly touch on normal newborn rash and Ooh, so many of those. So many those, right? Yes. Yeah. There's transient neonatal pustule or melanosis, which is a little more common in babies with a lot more pigment in the skin. Usually, they can be present at birth. They'll have these tiny little pushtools that are non-inflamed.They're not usually very red around the background.

And some of them will have already ruptured, so then you'll just see like a little tiny sort of collared, like, a ring of scale at the edge where there was a roof that came off. And then, you will see some tiny little brown spots. They kind of look like freckles, but they're not freckels and they won't be like across the usual distribution of freccles. but like over the back. I saw one recently in one of the Facebook groups and people were saying erythematoxicum, which is a different rash, but the Etox doesn't cause those cholerates and doesn�t leave the hyperpigmented macules, the transient neonatal pusher melanosis does.

Also, ETOX is not usually present right at birth or in the first I mean, it can be, but that would be an outlier. Usually babies are going to be a few days old before you see that. And that usually looks a little more like flea bites or some kind of insect bite. Like sometimes parents will think, what's going on? Like, is something biting my baby? Because it looked like a swollen bump with a red blotch around it. Or almost kind like chicken pox also. Yeah, exactly. Kind of swollen in the middle and sometimes it will look a bit vesicular.

Nice. So these first few that we talked about, so the salmon patches or the angel kisses and dork bites and the dermal melanocytosis and etox or normal newborn rash and pustular melanosis are all things that don't need any treatment. They just self-resolve to kind of reassure. With neonatal acne, are there treatments that you recommend, or is that another you just sort of let it run its course? Well, it's totally self-limited, so you don't have to treat it. But it can look really bad, and it drive parents crazy, right?

So if the parent is really distressed about it, then I will usually just give some ketoconazole cream for something like that. And that will take care of it within a couple of days. Any things that parents should really watch out for in their babies that might show up that could potentially be dangerous or might need further like need to be brought to their pediatrician's attention. Yeah, that's what I'm trying to think. I mean, I think if there's a sudden onset of an extensive rash, especially if your baby's behavior seems to change, they seem really irritable or they seemed really very sleepier than usual or something, then obviously you want to get that checked out by your pediatrician.

I think most new parents are pretty nervous in anything that's more than like a couple of spots. They're probably going to get checked out. Sometimes I will see like bullis and pitigo in newborns. And with that, a lot of times it'll start like in the diaper area. If you're lucky, you'll see kind of big blisters that are very, very fragile. So oftentimes you won't even see the intact blister. You'll just see where the blist are ruptured and it will look like just a superficial open wound. But that needs attention pretty quickly because babies will have a pretty high tendency to potentially develop staph-scalded skin because bullous impetigo is caused by strains of staf that are producing a toxin.

And if enough toxins is produced that it kind of disseminates systemically, then they can actually cross over into steps called hid skin syndrome where they'll start to have more diffuse blistering and be more miserable and usually have to get admitted to the hospital for IV antibiotic. So that's something I think should be caught pretty early. I see two vesicles where you can see there's a bump that you could pop and there is fluid in it, whether it looks clear or it look like pus. or blisters which are going to be bigger, you know, and be clearly full of fluid or potentially pus, those things should be seen by a physician pretty quickly, just to make sure that it's not infectious.

Yeah, that makes sense. The other things that I usually worry about are patiquier, which are those little tiny red dots that don't blanch if you press on them. And if a baby has a cafe au lait spots, so which is sort of coffee cream colored, if they have multiple of them, right? One or two is fine. Yeah, three or more. Well, they have to have at least six to meet one of the diagnostic criteria for neurofibromatosis type 1, which is usually the top concern with multiple Caffeoli spots. Yeah. So I think if you have multiple, but I would say if they cafe au lait spots and they're kind of distinctly outlined and definitely there.

Warning signs in baby rashes and birthmarks 9:00

I would probably just get them checked because those can continue to appear during early childhood. So it's just one of those things that should probably be monitored. There's also things like plain nevuses or simple nevis that shows up on the body, which is sort of like a freckle, but not in an area that's sun exposed. Is there anything parents should keep an eye on for when their kids get these little devi or moles? So if your baby is born with a brown spot, I mean it's possible that could be a cafe au lait spot right, but those are usually fairly light in color.

But if they have something a little bit darker that looks like a mole, if it is present at birth or even if appears within about the first year of life, we consider that a congenital melanocytic nevus. And the reason that's important is because melanocyte nevi are composed of pigment producing cells called melanosites. and every melanocytic nevus has at least some low lifetime risk of developing malignancy like melanoma. They also tend to be a little bit larger and look a bit different over time as kids grow, so they're going to behave a lot differently from moles that develop on kids just as they grow and their skin develops and grows.

I'm always telling parents it's normal for children to get new moles. It's also normal to grow some over a time. I mean, I think dermatologists and doctors in general have done a pretty good job of educating people about kind of things that can be worrisome signs and moles, right? A lot of us have heard of like the ABCs, so it's like asymmetry, you know, A is for asymmetries, the shape should be fairly symmetrical, B is border, border should fairly regular, C is color, D is diameter. You know, so parents hear that and they're like, this mole is changing, right?

Because on an adult, if you have a mole that's changing that is potentially more concerning and should always be checked. But there are some changes that we see in children that are completely normal. Now, you know we're always happy to look at moles and reassure parents. Fortunately, melanoma in the children is extremely rare, but it does happen. But again, you continue to get new moles really up until early adulthood, routinely. And as I said, they can definitely grow and get a little bigger. Also, along with that, sometimes as moles get thicker they get darker in color because you have more layers of those pigmented cells.

So that can be normal, but apparently suddenly see their kid and notice a mole and think, oh my gosh, that looks a lot bigger. That looks lot darker. Sometimes that really tends to happen around puberty or with growth spurts. So they may suddenly like their 12 year old son who showers and bathes himself and they're not seeing him without a shirt. And suddenly it's summer and he's in a bathing suit and may see his back and there's mole there that catches their eye and they're really worried about it, but most of the time it's just kind of a normal change because of growth.

And hair coming out of moles isn't necessarily a dangerous thing, right? No, that's common with congenital moles. Also common within acquired kind of mole called an intradermal mevis, which is something we tend to see on adults. Those are usually kind like those thicker, kind-of fleshy-looking moles that people tend get on their faces and sometimes those will develop some hairs over time. So yeah, so hair coming out of a mole is neither a good nor a bad sign. I have heard people, people have told me, you know, they heard that the hair mint, it could never become cancerous.

And I've heard we get referrals and people come in because they're worried because all of the sudden the mole has hair. The hair doesn't mean anything. Okay. That's good to know. Yeah. Awesome. And I know we had talked a little about atopic dermatitis or eczema. It's one of the more common things that you see as a dermatologist. So I wonder if you could just sort of go through like If a parent thinks their child has eczema, what are they going to look out for? What should they start off doing? Is there any changes they should make?

Should they change anything in their children's diet or put creams on it or whatever? And then at what point they see their pediatrician and at which point should go to a dermatologist for that? Yes. So you're correct. That is by far the most common thing that I see in daily practice. Some days it feels like all I say. Fortunately, it's a bread and butter thing that I don't mind. What you're going to see is just basically red, bumpy, usually itchy, very often quite itchy rashes.

Recognizing and treating eczema 14:00

They can start right away. I see people all the time bring their babies and say, pretty much, this started at birth because that's what it feels like to people. But it can definitely start many people who have atopic dermatitis will have it within the first year of life. And I think statistics show that like 90 something percent are going to have a will present before age five. So it's pretty unusual to present with like typical atopic dermatitis after that age. Babies and kind of where it shows up, you know, has some patterns, although it can really be anywhere, from head to toe, babies will often start with kind and they tend to have more rashes over like the outer, what we call the extensor surfaces.

So like tops of the wrists and the elbows, the knees, that ankles, tops to the feet. But again, they can have it anywhere. And then as kids get a little older, it tends to kind of get better on the face. And then it likes the flexural surfaces so that's more creases like the neck like decreases your elbows behind your knees but again can still be anywhere including those other places but just red itchy rashes you know that can become very thickened over time. Kids can be prone to infections from scratching the skin open and bacteria getting in there.

The things I think that parents can do, there are things you can because we don't know what causes atopic dermatitis. I give talks on this all the time. It's a multifactorial condition. There's definitely genetics that play a role. A high percentage of people who have it have a strong family history of atopic dermatitis and or all kinds of allergies and tendency to develop asthma as well over time or environmental allergies, allergic rhinitis. But the second thing is they tend to have very dry skin, and dry skins tends to be more sensitive because you can think of dry-skin like a brick wall with cracks in it, right?

So moisture is getting out, making it more dry, then irritants and allergens in the environment get in more easily. So anything you can do to kind of mitigate or improve dryness and avoid exposure to known irritants and allergens is really important. So we very much emphasize that all products that come in contact with the skin are fragrance-free. And this is important and you should say fragrance free because One thing that blew my mind and maybe a little hard to comprehend is that unscented does not mean fragrance free, because there is something called masking fragrance, which does have a detectable order, but is often added to products to cover up unpleasant odors.

And it is considered a fragrance even though it does, not have. Detectable smells so unsented. products could still contain fragrance technically, so it should say fragrance free. And then we like dye free because dyes can also be a problem. So for soaps, cleansers, you know, moisturizers, and then I would say laundry detergent. For many years, people were kind of conditioned to believe that DREFT, if you had a baby, You needed draft, you know, they give it to you in the hospital when you have a baby.

And when I was first practicing, all the draft products contained fragrance. Now I do believe they have some fragrance free products, but you had to look very carefully because you cannot assume that just because it's draft it is fragrance-free. So, fragrance-free. Yeah. Once their child starts to develop these patches of eczema, how do they help them? We usually say to start with something sort of moisturizing. So making sure they're drinking enough water once they are over six months of age or at least having enough like breast milk and formula under that.

And then something like, I really like Aquaphor and Vaseline. I know Aquapor has lanolin in it and some babies are allergic to that because it's made from sheep. Right. From wool. Yes. But those are in general great moisturizers because we like things to be thick, right? We avoid lotions. Ointment is really preferable because it has fewer ingredients and it more occlusive vehicle. And then we liked creams. When you get to lotion contain a lot of water which tends to evaporate. And also the more water something contains, the easier bacteria can grow in it, so they tend to add more ingredients to inhibit growth of bacteria, etc.

So you have more kind of undesirable ingredients. The one thing I wanted to touch on was bathing, because that's always so controversial, right? how often to bathe and I see a lot of questions and even in huge groups like one of the groups that I'm sure you know me from, there's always people, even physicians in there who say, you even for their own kids, or somebody just asked like yesterday, how I often should I really be giving my kid a bath? And that always gets like thousands of comments, people saying like, well, I am lucky if I can bat my kids once a week and people going, my kind has dry skin.

Here's the bottom line. It is not true that bathing every day will worsen eczema or make your skin more dry. In general, most kids I see do much better with a daily bath or shower. The key is in the details. If you're taking a long, hot bath shower with bath and body works, cherry blossom, soap and then you're getting out and you are putting on nothing or you put on another Bath and Body Works lotion, you probably going to cause yourself some problems. But if you taking a short, and by that I mean like less than 10 minutes, just lukewarm bath or shower, and getting out and patting dry quickly, and then getting your medicine, like your topical steroid or whatever you're given to treat your eczema on the bad spots, then a good thick emollient on top of that, you are actually doing good things for your skin because you rinsing off dirt and germs, irritants.

You're decreasing the chance that there's something on your skins that's going to flare exima or cause an infection. Water puts moisture in your increasing the hydration of those top layers of skin. But the key is you have to lock it in. And also when those hot players are moist, they're going to absorb more readily whatever you put onto the skin and so it actually, you know, helps your medicine and your moisturizer do a better job. So I'm constantly fighting the battle to correct that misconception.

And I have to say, I mean, even my own emergency department here, you know, we'll see in the notes. I told parents to bathe once a week. Well, that's disgusting. Plus the kid is slicked up in Vaseline, it's 100 degrees outside, they're scratching. They basically go out and they are like a pollen magnet. Everything is sticking to them. I'm like, no, like babe every day, you know, but it's just about how you do it. So I always say with some of the devils and the details. If your kid needs medicine, it is okay.

You can start with an over-the-counter hydrocortisone. And you can buy one person over the counter. But I do emphasize looking for an ointment over a cream. And you really have to look because I've looked for it at drugstores. And for every like one brand that comes as an ointment, there are like 20 tubes that are a cream. So I'm always telling people, if you get it, you know, really try to get the oinment for the same reasons that we like oindment from moisturizer. Also, ointment is much less likely to burn or sting.

And if you have a child who has inflamed skin and they're scratching and it's open and bleeding, you put something on it that burns, after that you're going to have trouble putting anything on them, convincing them that anything isn't going hurt. So, we deal with that a lot too. Ointments for sure. Nice. So sort of stepwise is first making sure that they're hydrated enough, getting their baths, short bath, and then if that's not enough adding some greasy emollient on top of it like an ointment. And then, if not, going to hydrocortisone cream.

And if that's still not enough, then at that point, they'd probably go to their pediatrician, right, for prescription or potentially a dermatologist. Right, yes. And this is something pediatricians see all the time. So definitely starting with your pediatricia because I think that most pediatricans can easily handle, you know, run-of-the-mill mild to moderate atopic dermatitis. But if it's not responding to like mild, to a medium potency topical steroid, um, that I that that when, referring to derm and or allergy can be helpful.

My knee jerk is never to blame foods parents are often looking for a cause you know of course that's anybody's natural tendency would be to say well why is this happening i need to find out what's causing this so that i can fix it i think that every parents impulse. But in general, you're not going to identify a single thing and it's almost never going be a food or a particular food group. I always tell people, because that's a common question and sometimes when I see babies, their formula has been changed five times or their mother who's breastfeeding is eating rice and nothing else, cause she's afraid.

Then I say, well, I mean, has that worked? When you're seeing me, the answer is almost always no, it hasn't worked at all. We're all miserable and the baby is still miserable. Clearly, you can see that it's not something in your diet, baby's diet that is causing it. There's an association between atopic dermatitis and food allergies, but it is rarely a direct causal relationship. So I don't send every kid that I see straight to allergy. The ones I send are the ones who are more severe, more difficult to control, you know, with the usual measures and or the one's who really look like they're not thriving.

So if they are gaining weight poorly, if have a lot of reflux, a lots of loose spools, just kind of signs to me that something's kind not really going well with this child's ability to, you know, like take in the nutrition, and digest things properly, then I think it makes more sense. Or obviously if the parent says the kid is breaking out in hives, if they've got milk for the first time, or they got eggs for first and they had urticaria or hive, than that's more concerning for a type 1 allergic reaction, which could be more dangerous.

So of course I send them right to allergy. Anything that parents can be doing at home in between their regular appointment and seeing you, should they be keeping a diary of their kid's symptoms or a list of what they're trying or anything else that might be helpful for them to show up with? Well, I think sometimes that's helpful, but I would just look for general patterns because I'm like every doctor. I don't want to read a hundred page novel of like, every single tiny little thing, and I don't think that's usually useful.

But if you can tell me, especially if your baby's a little older and they are being introduced to new foods, you know what? Every time I've given him or her this, I really do feel like the eczema is worse, then I think, that is more meaningful. Then I'm more likely to say, okay, well, let's see. what allergy thinks about this. Because I think, you know, blood testing is notoriously inaccurate when it comes to diagnosing, food allergies in kids.

Sun protection for infants and closing remarks 26:00

And I thing it's good to try to avoid those just general blood test panels. Skin testing it more accurate, but most allergists that I've worked with really don't want to skin test young infants unless they really have clinical signs or a history that something more significant is going on. So I think it's more meaningful if kids are older, preferably like three or four, not an infant. And I know sometimes in GenPeds, we sometimes will suggest a bleach bath for children, which is really just a little bit of bleach in the bath.

And it's like dunk in and out, dry off afterwards, just to kind of sanitize the skin in case it is colonized with something like a yeast or fungus or a bacteria. But that's the only other kind before you get on the big guns things. Yes. I'm glad you brought up bleach baths. And I do recommend bleachbaths sometimes. As a general treatment for eczema, I tend to recommend them for kids with a lot more moderate to severe exema. Especially if they've had issues with infections. If they have had pustules, they had abscesses or boils.

Or if you just have a whole lot of open crusted skin because There have been a lot of studies showing that kids with more severe eczema especially do carry a higher burden of staph colonization on the skin. And those stap bacteria produce compounds that drive the inflammation, which drives poritis. So whatever you can do to decrease that staf can be helpful in general. And this I think was noted a long time ago that like in the summertime when kids are swimming in chlorinated pools, for a lot of them, their eczema would get a a better.

And I that was initially what led to this thought of potentially doing bleach baths. Sometimes parents look at you like you're crazy. But I always say, but it's like a swimming pool. Do you let your kids swim in a chlorinate pool? Because we're talking about one quarter cup of bleach, which is literally just a few tablespoons. in a half tub full of a standard size bathtub. So it's hardly enough to even detect. And I do tell people though, just about 10 minutes in there and then stand up and rinse off really well.

Because if there's any drawback with a lot of swimming or the bleach baths is that it can be drying and we're trying to also fight dryness, you know, so you want to like rinse them off. I would say, yeah, sure they can swim. But I think kids should do the normal activities as much as possible. but you do have to be a little bit more vigilant about rinsing them off and really like moisturizing them extra well. Yeah, and it's not an everyday thing either. It's like once a week at the most, right, with bleach.

Bleach baths. So if they're really severe and I'm recommending it, I'll say two to three times a week on the bleach bath, and then just rinsing off. But I am not telling everybody whose kid has eczema. The other thing that we sometimes have parents do is wet wraps, but that's something that I think parents should probably only do if their doctor really recommends it. And it's just a technique where after a bath and you put on your steroid ointment and then plain Vaseline oinment. And then you use like clothing.

I personally like a layer of damp clothing so you wet it in warm water and wring it out so it is damp and not drippy wet. You put that on over the affected area and they put a dry pair of clothing on top. So parents, you know, a lot of times, I mean, they're all these old wives tales, right? Like if your clothes are white, are you going to catch a cold? Are you gonna catch pneumonia? You know? So we have to be reassuring that we're not crazy. And when you put a dry layer on, and you hold in the moisture, so your child shouldn't feel cold.

They shouldn' t feel like chilled because they' re going have a dryer. But there are a lots of different techniques for doing wet wraps. I do recommend those sometimes. It can be helpful for the right patient. That screen is super important for everybody, right? I know it's been so controversial and there are so many like videos out there on social media. It says on the bottles, you can't use it in children less than six months of age. And I get a lot of questions about that. I'm like, it can use, is that it is not fully protected.

Yes, exactly. I think that's the AAP stance just because they don't want people who don t know any better to have a very small infant outside in direct bright sunlight without adequate protection. A very young infant should really be in the shade, should be covered up and not be out laying on the beach with just sunscreen on. But it is okay to use small amounts of a physical blocker-based sun black on exposed areas of skin in an infant who's less than six months. So I say, yes, but have them in the shade as much as possible.

But if you need to put a little on the tops of their hands, the top of the feet, just use one whose main ingredients are zinc oxide or titanium dioxide. Those are inert, they're very safe. They're what's in like diaper paste. You know they've been around for decades. There's no safety concerns there. And it's perfectly fine. And you can even use the diaper cream as sunscreen. Yeah, exactly. Just put a little of that on. So it is fine. Well, thank you so much for your time today. It was really great to talk to you and your real life.

Yes. Thank you. Dr. Wright, anything else, any closing remarks, things in case patients want to reach out to or anything? Well, you know where I am? That's okay, I'm at Le Potter in Memphis. And it was fun to be here and always happy to try and help and answer questions. So thanks for having me. Thank you for tuning in. Make sure that you like and subscribe so that can be the first to know when new episodes come out. Also, you can check out the four first seasons of the Baby Manual Podcast on your favorite podcasting platform, or check my YouTube channel for lots of videos and shorts that will help you feel empowered as a new parent as I answer all of common questions that tend to come up in the couple of years of life.

Have a wonderful day.