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Daily Dose

Brown Spots on Your Baby?

1:30 to read

I was examining a 4 month old baby the other day when I noticed that she had several light brown spots on her skin. When I asked the mother how long they had been there, she noted that she had started seeing them in the last month or so, or maybe a couple even before that.  She then started to point a few out to me on both her infant’s arm, leg and on her back.

These “caramel colored” flat spots are called cafe au lait macules, (CALMs) and are relatively common. They occur in up to 3% of infants and about 25% of children.  They occur in both males and females and are more common in children of color.  While children may have a few CALMs, more than 3 CALMS are found in only 0.2 to 0.3% of children who otherwise do not have any evidence of an underlying disorder.  

Of course this mother had googled brown spots in a baby and was worried that her baby had neurofibromatosis (NF).  She started pointing out every little speckle or spot on her precious blue eyed daughter’s skin, some of which I couldn’t even see with my glasses on. I knew she was concerned and I had to quickly remember some of the findings of NF type 1.

Cafe au lait spots in NF-1 occur randomly on the body and are anywhere from 5mm to 30 mm in diameter. They are brown in color and have a smooth border, referred to as “the coast of California”. In order to make the suspected diagnosis of NF-1 a child needs to have 6 or more cafe au lait spots before puberty, and most will present by 6 -8 years of age.

For children who present for a routine exam with several CALMs ( like this infant), the recommendation is simply to follow and look for the development of more cafe au lait macules. That is a hard prescription for a parents…watch and wait, but unfortunately that is often what parenting is about.

Neurofibromatosis - 1 is an autosomal disorder which involves a mutation on chromosome 17 and may affect numerous organ systems including not only skin, but eyes, bones, blood vessels and the nervous system. Half of patients inherit the mutation while another half have no known family history.  NF-1 may also be associated with neurocognitive deficits and of course this causes a great deal of parental concern. About 40% of children with NF-1 will have a learning disability ( some minor, others more severe).

For a child who has multiple CALMs it is recommended that they be seen by an ophthalmologist and a dermatologist yearly,  as well as being followed by their pediatrician.  If criteria for NF-1 is not met by the time a child is 10 years of age,  it is less likely that they will be affected, despite having more than 6 CALMs.

The biggest issue is truly the parental anxiety of watching for more cafe au lait spots and trying to remain CALM…easier said than done for anyone who is a parent. 

Daily Dose

Warm Weather Rashes Still Lurking

1.15 to read

It has been a rather warm winter throughout the country and because of this I have recently seen a few skin issues that are more commonly seen in the warmer months of the year.

One of these is intertrigo which is a skin condition that is often seen in infants who are chubby and have “no necks”.  Because of this “no neck” phenomena, a baby’s chin and lower jaw may rest right on the chest. When parents are bathing a baby they sometimes don’t realize that you have to lift up the baby’s chin and hyperextend the head to ensure that the skin folds around the neck are getting clean and staying dry. This is also true for skin folds under the arms, or in the inner thigh.

When the skin folds rub together the skin can break down and become red, raw and macerated.  If the moisture and rubbing are persistent the skin may even begin to weep a bit of yellowish fluid.

 Babies are constantly dribbling milk from their mouths onto their chins, and then the fluid runs right down and accumulates beneath the neck. On top of this moisture there is also perspiration, especially with warm weather, which accumulates in the skin folds. That is why intertrigo is more common during hot weather.

 I just saw a baby with terrible intertrigo and I think that her parents were dressing her in multiple layers (a T-shirt, flannel onesie and a blanket) and her neck was so inflamed and wet and weepy. I told her Mom that the first thing we needed to do was to take all of this off of her as she was overdressed and overheated. She just needed to be in a cotton gown as it was about 70 degrees outside. 

The best way to treat intertrigo is to stretch out the neck after bathing and really dry it well. I evened used the blow dryer on warm on my own boy’s necks so that I could make sure the skin folds were dry. If the area is still moist and starting to get inflamed I like to use Dommeboro soaks, which is soothing as well as drying. You can buy this at your drugstore (but it is a bit pricey) or you can make a similar solution by mixing 1 part vinegar to 4 parts water.  Apply this solution to the weepy/inflamed area several times a day. I soak cotton diapers or old t-shirts or burp pads and lay it over the area for awhile. There is another product called Zeasorb that absorbs moisture as well.

It sometimes also helps to use a topical cortisone cream to help with the inflammation. There are several products available OTC, or your doctor may also prescribe a steroid cream.

 Because the top layer of the skin has been damaged it is also prone to getting an infection. If the area is not getting better and appears infected you should see your doctor as the skin may get secondarily infected with bacteria as well as yeast. In these cases I use a topical antibacterial cream or anti-fungal cream. In some cases an oral antibiotic may be necessary. 

The best medicine is always prevention, so don’t over bundle your baby and make sure to get in those “creases” so you don’t end up having to treat intertrigo.

That’s your daily dose for today. We’ll chat again tomorrow.

Daily Dose

When Bug Bites Get Infected

1.00 to read

It is the season for bug bites and and I am seeing a lot of parents who are bringing their children in for me to look at all sorts of insect bites. I am not always sure if the bite is due to a mosquito, flea or biting flies, but some of them can cause fairly large reactions. 

The immediate reaction to an insect bite usually occurs in 10-15 minutes after bitten, with local swelling and itching and may disappear in an hour or less. A delayed reaction may appear in 12-24 hours with the development of an itchy red bump which may persist for days to weeks.  This is the reason that some people do not always remember being bitten while they were outside, but the following day may show up with bites all over their arms, legs or chest, depending on what part of the body had been exposed. 

Large local reactions to mosquito bites are very common in children. For some reason, it seems to me that “baby fat” reacts with larger reactions than those bites on older kids and adults. (no science, just anecdote). Toddlers often have itchy, red, warm swellings which occur within minutes of the bites. 

Some of these will go on to develop bruising and even spontaneous blistering 2-6 hours after being bitten. These bites may persist for days to weeks, so in theory, those little chubby legs may be affected for most of the summer. 

Severe local reactions are called “skeeter syndrome” and occur within hours of being bitten and may involve swelling of an entire body part such as the hand, face or an extremity. These are often misdiagnosed as cellulitis, but with a good history of the symptoms  (the rapidity with which the area developed redness, swelling, warmth to touch and tenderness) you can distinguish large local reactions from infection.

Systemic reactions to mosquito bites including generalized hives, swelling of the lips and mouth, nausea, vomiting and wheezing have been reported due to a true allergy to the mosquito salivary proteins, but are extremely rare. 

The treatment of local reactions to bites involves the use of topical anti-itching preparations like Calamine lotion, Sarna lotion and Dommeboro soaks.  This may be supplemented by topical steroid creams (either over the counter of prescription) to help with itching and discomfort. 

An oral antihistamine (Benadryl) may also reduce some of the swelling and itching. Do not use topical antihistamines. Try to prevent secondary infection (from scratching and picking) by using antibacterial soaps, trimming fingernails and applying an antibiotic cream (polysporin) to open bites. 

Due to an exceptionally warm winter throughout the country the mosquito population seems to be especially prolific. The best treatment is prevention!! Before going outside use a DEET preparation in children over the age of six months, and use the lowest concentration that is effective.  Mosquito netting may be used for infants in strollers.  Remember, do not reapply bug spray like you would sunscreen. 

Daily Dose


1:30 to read

The last patient of the day last week was a mother with her 3 adorable little girls…who were actually en route to the local high school football game but swung by my office first. While the mother had been dressing her daughters’ in their “mini-cheerleader” outfits, she noticed a rash on her oldest daughter’s trunk and kind of “freaked out” that she had ringworm. 


Ringworm is a common fungal skin infection and the medical term is tinea corporis (fungus of body). You can also get tinea on your feet ( athlete’s foot) in the groin area and on the scalp. Fungal infections are easy to acquire and they are nothing to be “too” alarmed about as they are typically fairly easy to treat. As I remind many a parent….this is not life threatening.


This sweet mother had not noticed the rash until that day and she assured me that she bathed her daughter every night.  Having ringworm has nothing to do with cleanliness as it is easily acquired by direct contact with other people and clothes, as well as from contaminated surfaces (locker rooms, pool decks) and for many kids from a family pet.  A new kitten or puppy may often be the source of the infection. Trying to track down the “source” is typically not necessary….it is just one of those common childhood issues.


The typical lesion of ringworm is easy to diagnose and rarely requires a trip to the dermatologist.  It is described as a circular lesion with a raised red rim and will often have decreased pigmentation in the central area of the skin lesion.  It may be itchy and scaly.  At times the edge of the lesion may form an “irregular” circular that looks like the wavy outline of a worm - and so the name. If your doctor has a Wood’s lamp they may shine the light on the lesion as it will “glow” in the black light. If the lesion is “atypical” a scraping may be obtained and prepared and can be looked at under the microscope.


Most infections of the skin may be treated with a topical over the counter anti-fungal cream or ointment.  It may take several weeks to a month or more to treat the infection and I usually recommend longer rather than shorter topical treatment.  In some cases an over the counter cream may not work as the fungus may be resistant and you may need a broader spectrum anti- fungal that will be prescribed by your pediatrician.

During elementary school one of my sons had gotten a new watch that he wore day and night. When he finally took it off I noticed what I thought to be a LARGE ringworm beneath the watch face….oh well. A few weeks of an anti-fungal cream on his wrist and he had that watch back on!!  

Daily Dose

Acne Problems

Adolescents and acne….the two often go together. With so many options, both over the counter and prescription available, most teens who are interested in treating their acne can achieve clear skin.  The first step is typically making sure that the tween-teen is washing their face every morning and before bed…which proves to be difficult for some.


Interestingly, diet may also play a role in acne. While we were told years ago that french fries and greasy hamburgers may cause acne a new study suggests that milk may actually be the culprit and contribute to the development of acne. I can even remember the dermatologist many years ago asking my sons (who unfortunately all dealt with acne) if they were big milk drinkers.  


There have been earlier studies (2005 - 2008) which showed a correlation between milk intake and acne…and the risk seemed to be greater in those that drank non fat milk over whole milk.  The newest study published in 2016 looked at teens with acne compared to controls who did not have acne and found “positive associations with total dairy and non-fat dairy, but not with whole-fat or low -fat dairy. In other words it seemed that skim milk might be involved in the pathogenesis of acne??  There have been proposed mechanisms as to why this might occur, but much of it is speculative.


At the same time that teens are developing acne they are also growing and building healthy bones, which means more calcium is needed in their diets. Nutritional guidelines recommend 1,300 mg of calcium every day for adolescents. Much of the dietary calcium intake comes from dairy products including milk, yogurt, and cheese.  It is often very hard for adolescents to meet the daily calcium and vitamin D requirements and stopping dairy may put them at risk nutritionally.


But, with that being said….in cases of teenage acne that do not seem to be improving on a well prescribed skin care regimen, it may be prudent to do a dairy free trial to see if this makes a difference in their acne. During the trial you can easily offer a calcium supplement.   If the teen’s face does not seem to improve with a 2-4 week dairy free trial I would recommend to resume normal dairy intake - but maybe use whole-fat or low-fat dairy rather than non fat.


This would be a good topic for discussion with your own dermatologist.

Daily Dose

An Infected Toe: Ouch!

iPhone App question for Dr. Sue: what to do for an infected toe?It's media office day and I just received an email via our new iPhone App (The Kid’s Doctor) from a parent who has a child with an infected toe.  I suspect that her child might be a ‘toenail’ picker which often leads to a local infection along the edge of the toenail.

This seems to involve the ‘great toe’ more often than other toes, due to the development of an ingrown toenail. I also seen it when a child or parent has cut the toenail too short and the toenail wants to grow down into the skin rather than ‘out’. Because the edge of the nail has penetrated the skin, and therefore there is a break in the skin, bacteria (remember our feet are dirty) can easily get into the skin and cause a local infection. The term for an infection of the toenail is a paronychia. But, regardless of the fancy term, it causes an infection which is painful. On occasion if the infection is minimal and you recognize it early you can treat it by using warm water soaks with an antibacterial soap and then applying a topical antibiotic such as Polysporin or a prescription called Mupiricin (many parents may have this from their doctor for a previous skin infection for a child after a bite or something). If the toe is getting more red, inflamed and tender then this will require a visit to your doctor. When I see a paronychia in the office I typically treat it with not only local care, but with an oral antibiotic that treats skin infections.  If there is a lot of “pus” at the site (some can get really bad before they are seen) then I like to take a culture of the pus to determine which bacteria I am dealing with in order that the appropriate antibiotic may be selected. It is always preferable to send a culture when possible as you not only identify the bacteria in question, but you also get the antibiotic sensitivities which allows you to select the most appropriate antibiotic for the infection. Often it seems that a paronychia will become recurrent, which will then require an appt with a foot doctor to remove the offending nail matrix. Best advice, don’t cut the nail too short and no toenail biting or picking!!  Easier said than done. That’s your daily dose for today. We’ll chat again soon.

Daily Dose

Scabies Scare

1.15 to read

Just home from the office and on call. Once again, I keep on learning and laughing with my patients.  I saw a mom, dad and their two young boys last  evening. The boys were about 4 and 6.  When I walked into the room, it was so quiet, and then I realized that their clever mother had them playing “the quiet game”.  Seems I lost as I talked first!

She brought the boys in that evening as she had just gotten a note from the school that there had been “several cases of scabies in her son’s class”. In her words, “she freaked out” and decided a trip to the pediatrician was necessary. 

So, when I asked her if the boys had a rash or had been complaining of being “itchy”, she just looked at me?  No there was none of that, it was just the whole idea that they might have SCABIES?!  Of course she had been online and could identify the mite if necessary.  She was certain that I needed to “treat” the boys, and maybe she and her husband?   She just said ,”do whatever you have to do!”

She then decided that maybe “we” should worry about lice as well, as “don’t these yucky bugs go together?” Luckily, her precious little boys had crew cuts, so that was an easy “rule out”. 

So, seeing that they did not have any rashes, really no complaints other than “maternal anxiety” (we moms are good at that), I told her all was well.  She seemed okay with that except she didn’t want to send her children back to school until the school “exterminated the whole building” and she thought she would “wash all of their sheets” and “vacuum her house” that night.  

I had to laugh as I told her there would always be “germs” and “bugs” around, no matter how clean we try to be. In fact, one of my own children had scabies many years ago and it took an allergist to diagnose him - no one had thought about scabies, but boy did he have a rash!  

I guess she felt a bit better knowing that my son now an adult had lived through it and her kids really did need to go back to school to learn to read! Just keep up good hand washing, and don’t look for problems - I promised her she would know if they got scabies and the rash - it is hard to ignore! 

Daily Dose

How to Treat Poison Ivy

1.15 to read

With the long weekend here, many families are enjoying the outdoors. But with outdoor activity, your children may develop summer rashes like poison ivy, poison oak or poison sumac. Each plant is endemic to different areas of the country, but unfortunately all 50 states have one of these pesky plants. Teach your children the adage “leaves of three, let it be”, so they come to recognize the typical leaves of the poison ivy.

The rash of poison ivy (we will use this as the prototype) is caused by exposure of the skin to the plant sap urushiol, and the subsequent allergic reaction. Like most allergies, this reaction requires previous exposure to the plant, and upon re-exposure your child will develop an allergic contact dermatitis. This reaction may occur anywhere from hours to days after exposure, but typically occurs one to three days after the sap has come into contact with your child’s skin and they may then develop the typical linear rash with vesicles and papules that are itchy, red and swollen. Poison ivy is most common in people ages four to 30. During the spring and summer months I often see children who have a history of playing in the yard, down by a creek, exploring in the woods etc, who then develop a rash. I love the kids playing outside, but the rash of poison ivy may be extremely painful especially if it is on multiple surface areas, as in children who are in shorts and sleeveless clothes at this time of year. The typical fluid filled vesicles (blisters) of poison ivy will rupture (after scratching), ooze and will ultimately crust over and dry up, although this may take days to weeks. The fluid from the vesicles is NOT contagious and you cannot give the poison ivy to others once you have bathed and washed off the sap. You can get poison ivy from contact with your pet, toys, or your clothes etc. that came in contact with the sap, and have not have been washed off. If you know your child has come into contact with poison ivy try to bath them immediately and wash vigorously with soap and water within 5

Daily Dose


1:15 to read

Many years ago when children asked their parents “where did I come from?” they answered “the stork brought you”.  The picture of the stork’s beak holding on to the baby’s neck and flying to drop the baby on the new parent’s doorstep was known by all….but things change and that visual is not known by my newest parents.  In fact they look at me with completely blank stares when I discuss the birthmark on the nape of their child’s neck.

But the term “stork bite” comes from that old story, and the red birthmark seen on up to 50% of babies necks is also called nevus flammeus or nevus simplex. They are flat, pink and irregularly shaped and while they occur most commonly on the nape of the neck, they are common on the forehead, eyelids and above the upper lip as well. They are due to capillaries close to the skins surface. The stork bites on the face typically fade over time while the ones on the nape of the neck may continue to be present but are obscured and typically forgotten once the baby has hair. Many people are not even aware that they themselves have one.

When I am doing a newborn exam I see so many of these little “flat red patches” that I often to forget to bring them up as they are small and typically fade….but sometimes a parent will specifically ask about them. After I apologize for not bringing it up….as I know they are small and fade, but they are concerned,  I tell them that they are “stork bites” and get that blank look.  Then I launch into the etiology for the name etc. But, things are getting ready to change as STORKS a new animated movie is just bring released.  The old myth of the stork is making a come back!

So…if your baby has this small birthmark, no need to worry.  Be assured that most will fade but if they have not resolved by the age of 3 or 4 years, there are now lasers available to treat them.

In the meantime..take your family to see "STORKS" so they are aware of where “you used to come from”!  We can still tell our children the myth of the stork and then make sure to discuss the truth about “where did I come from?”. 





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