Paediatrics

This new dermatologist podcast is sponsored by La Roche Posse in Cerevi. La Roche Posse has been evaluated in over 700 clinical studies and 124 publications, contributing to dermatology research and innovation in common skin concerns. La Roche Posse, a better life for sensitive skin. Cerevi has a unique slow release technology with three naturally-occurring ceramides that are essential in supporting the skin barrier. Cerevi, developed with dermatologist Worldwide, available from selected retailers, pharmacies and online. Welcome to the new dermatologist podcast. We are a group of consultant dermatologists who are friends as well as colleagues. We have done a number of educational events together and this podcast came about because we wanted to help GP colleagues who are managing common skin conditions in the community. Although the podcast is aim primarily at GP's, we hope that anyone with an interest in managing common skin conditions will find it useful. I am Vicki Atcrass, a consultant dermatologist at St. George's Hospital in London. My special interest are skin cancer and connective tissue disease. I would like to welcome back Dr. Raki Ramesh. Raki has been a consultant dermatologist for over 10 years and she now leads the pediatric dermatology service at Walsall Health Care Trust. So hello again, Raki. Hi, Vicki. Dr. Bill Chaudhary, a GP principal in Beckinham Kent, specialised in minor surgery has joined us again today on this podcast on common childhood skin condition. So hello Bill and welcome. Hello, both of you again. Hi Bill. The information in this podcast is based on available evidence and the experience of the doctors involved and it has to be adapted to each individual patient accordingly. So let's hear your questions on skin problems that you're seeing in kids in primary care then Bill. So I thought I'd start with tinier capitals in children. We see a lot of this and I just thought what your, what the general treatment plan that you would suggest is. So first of all just to give a bit background, tinier capitals are just sort of this morning just before coming here. So it remains a common childhood infection and although it's common, its recognition still remains a bit hit and miss in the community. The prevalence of tinier capitals has been increasing over the years and as a result of that there have been requests to put this on the public health agenda and this was in the BMJ not that long ago. The main changes again just to give the background to the epidemiology of tinier capitals over the years has been a spread of tricophyte and tonsurance and this is mainly in urban communities in the UK which has different to mainland Europe where micro-sporum canus remains the endemic, dematified species, the main fungus. Tinier capitals continues to be predominantly an infection seen in school age children. So these are pre-pubertal children. It's commonly seen in a city communities as said. And mainly in children of African descent, although it can still be seen in children of other ethnicities like Asian children have seen it in and occasionally Caucasian children. It's very, very terror presents. It always presents with hair loss, with varying degrees of scaling and erythema. If there's an inflammatory lesion that can be very swollen and pastured on the scalp, that's referred to as Kerian. The scalp scaling without hair loss occurs in a number of other conditions when you're thinking of differentials and the most common one that I see in clinic are children who've got extensive eczema, who have this find a few scaling in the scalp. And they may also possibly have palpable lymph nodes as well due to their eczema. But obviously that becomes more obvious when you start examining the rest of them with the history as well. Other causes separate dermatitis, psoriasis, or pitoriasis amantissia in which you get thick scales around the hairs that look like these tiled scales and they don't break, the hairs don't break in this. The other one that can be sometimes confused is alopecia reata, where there are patches of hair loss, but usually there's no scaling. And there are a number of broken hairs, of broken tapering hairs. So again, it looks quite different. So if there's a scaling with hair loss, we should be thinking to neocaptives. Definitely. Yeah. Can I just ask, I mean, we do get a number of adults referred, who have with scaly scalps, who have been treated with oral antifungals for a presumed tiniacaptives. But we know that adults are not affected anywhere near as much as kids are by this condition. Why are adults not affected to the same degree? In adults, they're a medium chain length fatty acids in the sebum, which are inhibitory to dematified growth. And they're more numerous in post-pubertal scouts, which is why I don't see an older children so much as well. Very interesting. So you've mentioned a couple of fungi that are responsible. Is it necessary for GPs to carry out mycology, or should we just treat? It's very helpful to do the mycology. This is, you know, to identify the type of fungus as well. We can see emerging patterns as well. And also, you know, there may not be the trygophyte and tonsurins, which are the most common type. But it's good to have that, because you're giving four weeks of a systemic treatment. To do that, you just have to gently remove the scales from the scalp with a blunt edge of a scalpel. The scales may only become apparent when you're attempting to do this, because sometimes it looks like there's no scale there to take. And only when you do it, you can see them lift off. Sometimes they're infected hairs that may be removed with the flat-ended four-sets or you can brush out loose hairs with a blunt edge of the scalpel or with small brushes. And you collect the hair with the scales in paper or card packs for mycology. And the mycoscopy gives us a quick confirmation of the fungus and the culture takes a few weeks. So two or three weeks to identify the specific fungus as well. We sometimes, I know that my pediatric dermatology colleagues use citer brushes for the kids clinics to take fungal specimens. Do you ever do that? Yeah, so we've got two departments. One of them use the citer brushes, the other one we don't have it. So, you know, I do sort of end up relying on the derm pack, so using the blunt scalp or more. Also, at the moment there's a bit of an issue, some of the labs aren't processing mycology at the moment because of COVID. So, you know, we're not doing it as much. And can I ask, would you, as a GP, would I be starting treatment, pending culture and sensitivity, or would you just wait for the results to come back? No, you would just start, you don't wait for the result. If it looks clinically like tiniacapetus, you would just start. And we basically use tabinifin in primary care, and I'm aware that this is not licensed for children. And I've had a couple of disgruntled patients, mums, saying the pharmacist has raised this issue. Is there anything we should be considering when we're prescribing it, and how long should we treat patients for? Yeah, no, glad you raised that Bill, because there's quite a few points about that. Firstly, just to be clear, tiniacapetus always requires systemic therapy. And often the referrals come in without having either topical steroids or topicals only. So, like you pointed out, tiniacapetus is now the preferred first line treatment in most centres, especially when you're taking into account cost-efficiency and compliance. There's no licensed liquid preparation available for tiniacapetus. We often prescribe it with a tablet cutter so that you can score the tablet, break it, crush it, and you can disperse it in water, or you can mix it with non-acidic foods such as yogurt or bananas. And I mean, it's different in the US. They have granules available over there, and they can sprinkle that over food. And that has been licensed for young children there, but it's not available to us yet. But, you know, we get around it by crushing the tablet. Just to point out, because historically, grizzly for venue used to be the first line treatment. And this was as a result of it being the first oral drug available for the treatment of fungal infections. And so we've got 50 years and over of experience with it. It also remains the only licensed product for the treatment of tiniacapetus and children in the UK. But the suspension is no longer a licensed formulation in the UK. And so it's become increasingly expensive as a result of this to prescribe it. And a community pharmacy prescription can be as high as 600 pounds. And that was a couple of years ago when I got that data. So to avoid the high cost of this, it's rather than prescribing it in the community. It's prescribed as a hospital special from dermatology. And that can be, you know, you can lower the price into maybe around £50 or so. But on the other hand, to benefit is about £2 for £28, £250. And it works, right? And it works just as well. So, Cochrane Review in 2018 has supported to benefit as more efficacious than grizzly or fulvin in children who have t-tonser and infection, which we know is the main cause of tiniacapetus in the UK. We do know that grizzly or fulvin is more efficacious in treating micro-sporam infections compared to to binifin. So, you know, it works better for that. But itchriconazole is the preferred agent in most of the European countries and haxactivity against both micro-sporam and tricophyton species. So, itchriconazole can also be given as well as maybe second line. So, and that community prescription of that would cost about £60 for itchriconazole. Okay. So, I think you've answered my next query. Is it worth using topical antifungals, maybe in addition to t-tobinifin, but definitely not on their own? With topical antifungals they don't penetrate the hair follicle so they've got little place really in the management of tiniacapetus on their own but they can be used as an adjunct to orotherapy and topical treatments like topical agents can reduce the carriage of the viable fungal spores and so neither old shampoo which is 2% ketoconazole, selenium sulphide which is selen shampoo they've all been shown to have efficacy so you can use it two or three times a week to reduce that sort of load of fungal spores so they're helpful for that. Do you advise children to stay off school until they've completed treatment? It's so impractical really, we tend to advise them to go to school if they've commenced oral and topical treatment but there is in we know that there's evidence that kids can still be contagious even after starting the treatment but because it's so impractical the British Association of Dermatologist Guidelines advise that not to exclude them from from school because the treatment takes four weeks and yeah it's too impractical. And do you screen family members for tinia because I remember one of my mentors when I was a junior always made a great show of detecting ringworm in the parent company it was like a theater. Yeah I do and that's quite it's quite nice to hear that because it has to be sort of made a bit of a demonstration to realise that it is actually likely to be in family members about 50% of them are likely to have signs of it or maybe not realise that they've got signs of it so treat the whole family and if you given the diagnosis to the index family I asked the family member to get treatment for the rest of the family from the GP because often only one member of the families come or I just say look this is what you need and then ask them to get it even if it's just having the nice royal shampoo two to three times a week for for those family members to reduce any chance of spreading it in the household. It's very benefit in applying a topical steroid to reduce inflammation in in this in tinia cap. Oh I'm glad you asked that Bill because even today this morning I had a little boy six-year-old came in and had been on beta-methasone scalp application for his and no there's no there's no role for the steroids they will probably just propagate the the fungal infection so so no don't use any topical steroids avoid that it's all about systemic oral antifungals so yeah thank you for pointing that out. You touched on carry-on in tinia capitals and something I'm not really very familiar with so can you tell me a little bit about that? Yeah so this is the most severe reaction pattern that you'll see in tinia capitals it's a very inflammatory boggy mass in which those hairs that remain there are quite loose and so that causes some hair loss and despite the degree of inflammation they're often not very painful the mass is not very painful. The follicles where the hairs come out discharge pus is quite limited often but it might be a large confluent area involving maybe quite a large area of the scalp. You'll often see you can actually see the lymphvenopathy sometimes before you feel it and but often that pasture formation which it's actually more an inflammatory response to the fungus itself rather than a secondary bacterial infection so actual secondary bacterial infection is not not very common in it even though the carrying does look can look infected but if there is bacterial infection it's underneath the crust that you might see there so just to say it's often a misdiagnosis a bacterial abscess can be made but yeah it's carrying it is a reaction pattern that you can see in tinia capitals. So maybe personally with it so been if and before running to the flu clocks are selling that's right yeah that's right. Alright I'm gonna go a little bit left feel now. When would you say nappy rash isn't just nappy rash? Well just just to first sort of put it into perspective first it's a very common reason to come to dermatology so it makes up about 25% of dermatology visits to healthcare providers and during the first year of their lives so overall it's usually very mild it's normally self-limiting but the majority of these nappy rash is a purely an irritant contact dermatitis so about over 40% from just wearing that a clusive nappy that keeps the urine in the poo in close contact with skin for a long periods of time and you know it's made worse if the skin's macerated or there's a lot of friction the high pH as well so if friction is more of a problem than a chaffing dermatitis can also become a bigger issue and you would normally see the skin folds are spared with these nappy rashes so fortunately since the introduction of hyperallergenic super absorbent modern disposable nappies the incidence of the irritant and allergic contact dermatitis has reduced a lot so I mean would you say that it's still worth having those periods of time where possible that the baby doesn't wear a nappy exactly yeah I mean as much as possible yeah you don't see it as much in countries where that you know well you don't see it in countries where babies are not wearing nappies so yeah not for that cause anyway obviously and and where you've you've tried or you've advised the mum and dad about the the basic treatments for nappy rash you know the pseudocrams the metany appointments and what are the other possible diagnoses when the rash isn't improving yeah so other causes of nappy rash is that a less common include there's a there's a few think of things like inverse psoriasis so this is when you see psoriasis in the folds so it's very sharply demarcated thin plaques in the folds of the nappy area you might see another body fold sites like the Xyle as well separate dermatitis which the infantile type of exma affects the folds like the neck again in the armpit folds as well associated with cradle cap you know you often see it with cradle cap as well so that's the first few months of life if you see alopecia with a nappy rash and you might even see a rash around their mouth as well you would need to consider a zinc deficiency which can they can be either born with so congenital or it's acquired as a transient form that's an important one not it's not common but it's an important one to think about and another very rare diagnosis to consider in infants or with odd nappy rashes with belanga hand cell histiosytosis it's a very rare condition but it's a rare condition that presents in the skin quite a lot and in you know you the the classic sort of case would be an inguinal rash or a rump eruption and it's described as being a more wet macerated look or erosive but it is just again one to think about so it's a bit more angry looking than than than the average nappy rash yeah so I think I think yeah a bit more wet and odd not responsive to any treatment so rather than just inspecting the nappy area the important thing is to inspect the whole body as well yeah you look at other sites as well around the mouth the hair and the scalp okay false yeah and and should we ever consider food intolerances or allergies when when children have resistance you know nappy rash yes I mean a stubborn nappy rash in addition to gastrointestinal symptoms and you know you'd get all about from the history so you'd already be alerted to something else going on if the babies have been vomiting got diarrhea failure to thrive I think is always a key thing alerts you to cow's milk protein intolerance and in young infants they may also have widespread recalcitrant x-mer again you know where you're starting to think you know something else going on here cow's milk intolerance is one of the most common presentations of food intolerance is seen in early childhood childhood and so almost all cases present before one year of age so yeah definitely you'd be thinking of that with GI symptoms and secondary bacterial fungal infections is it are they common yeah so infections are probably the second most common cause of nappy rashes and the most common one that I think most of us have come across would be primary or secondary candidysis so you know that's got that typical appearance where you see the bright red scaly plaques with satellite red papules and pustules that involves the skin folds so the nappy you know the inguinal folds scrapings can be taken from the edge or swabs from fresh pustules the infants may have a history of using antibiotics having had a course of antibiotics maybe for the rash before the rash before and then got secondary candidysis or there might be a history of diarrhea making them more susceptible to candida so you know if you're thinking that way that might be good idea also check the oral cavity at the same time if they got thrushed there as well sorry other infect of course there are other ones not as common as candidysis but perienal streptococcal sadly lightest can be easily mistaken for irritant that can dermatitis but this is a beta hemolytic streptococcal infection that would need antibiotics and you get very sharply demarcated bright red areas around the in the perienal area can be itchy can be painful as well so it might affect them when they're going for a poo be very painful for babies so that's another one and another infection that's more commonly seen as the the warm human environment of the nappy area can predispose to bullies and patego and you might see that a little bit more newborns due to colonization of the umbilikus with staph aureus so you can see these sort of flaccid boulay that rupture easily leaving red moist denuded areas or maybe the more classic honey colored crusting that you see and that can spread quickly to other sites so that's when it's caused by the staph aureus toxin great and what would you advise gps to tell parents about managing nappy rash rucky. I mean, if they're changing the nappies regularly and they still have some persistent disease, what do you tell them to do? Yeah, so it's always going back to the basics for nappy rash. So like you said, regular nappy changes use of the super absorbent nappies, washing the area with water and soap, free cleansers, so avoiding all the fragmented soaps and avoiding fragmented fragrance wet wipes. Topical steroids, if that's needed, it's best to use very low potency, so dactical so that you can knock out any candida as well at the same time. But that'd be once a day for about a week, it really should be adequate with the occlusion that happens from the nappy and large areas may be affected. So I think one week be enough before you're thinking of something else going on. Amolients, greasy, the better form of barrier to help that compromised skin barrier and reducing friction as well, that will help barrier creams such as titanium oxide, which is titanium, always helpful, the pasty-like barrier creams, and of course time out of nappies like Bills already said, always helpful. When to refer? I think when would you refer when we advise GPs? I think if you're just not sure about the diagnosis, the rash is persisting despite all the treatment that you've recommended there, it's recurrent and you're getting severe and explained episodes there, so that would be the key time really. Great. Fantastic. I'd like to ask you about maluscom contegiosum, now to me as a GP, is it the one time that a patient comes in, a parent comes in, and you immediately tell them what it is and you give them this amazing diagnosis and they light up and say, "My GP's the best," and then you tell them there's nothing I can do. And you can see their face drops. Is there anything that I can do to relieve patient disappointment or parents disappointment? I'm afraid I'm going to disappoint you as well. I wish there was something else out there, but it's really sort of the sales pitch, it's how you're delivering it sometimes. There are different things, but it's just how you're going to decide those patients that you're going to pick out for that. So there aren't any new treatments, and again, just a bit of background, maluscom contegiosum, it's identified as one of the 50 most frequent diseases worldwide, and that gives you an idea of how common it is. And like most viruses, we just haven't managed to find a consistent treatment. The diagnosis, it's always nearly a clinical one, you can't easily confirm it in the clinic, and most primary care physicians are very good at recognising it. However, we still get a lot of referrals in, and I think it's mainly because of the reason that you're saying, you know, patients are keen for treatment, parents are keen for treatment, and occasionally a bit of diagnostic uncertainty. So in the UK, we continue to be very conservative about maluscom contegiosum, because we know it tends to clear in two or three years. There's no evidence that treatment speeds up resolution, so we often wait and see. Patients should be advised, you know, the basic advice, don't share towels, try and avoid rubbing or scratching the lesions, which then can auto-annoculate the skin and spread it. So we have the same spiel that you have in that context, you know, that generally, that's what we're also saying as well. So are there any caveats if you've got, for example, a child that's being bullied because of lesions that are visible on the hand or the arm? Is there anything more aggressive that can be done? Yeah, so if a child is being stigmatised like that or excluded, or like you say, you know, they've come because of a special reason like that, there are different treatments catered at sort of trying to remove it, either with destructive techniques or immunomodulatory or chemical. So I think really quite therapy would be the preferred one. You know, you have to warn them though about, you know, this could lead to scarring or pigmented changes, particularly in more pigmented skin. But there is evidence that, you know, we still know it is an effective treatment and we know from clinic, you know, if you use it gently with the spray guns, you can try and keep it as gentle as possible. Curatorage can also be used, but it's painful. It can cause scarring again for the same reasons, particularly again, with pigmented skin, you know, you're running a slightly higher risk there. Very few kids will tolerate it in the tricky sites of as visual on the face. Again, that's harder to do. You have to weigh up those risks there. So again, it's still difficult to weigh up those things, but those are the tools that would be used more commonly to try and deal with it. And I'm talking about when it's more in a visual place. So quite isolated cases. Yeah. Yeah. I have used needle extraction and then applied poverty on iodine. Have you ever done that, Rocky? I've had quite good results with that. Yeah, and scarred. Yes. No, that's good to hear that, Vicki, because you've told me that and a few other colleagues have used the same thing of using this manual extrusion, using their fingers, even had a colleague at a conference showing me the video that he'd taken of doing this on a child. And so it is a simple technique. It's helpful where you, you know, you do this manual extrusion using fingers, or you can even try and use four steps as well to do it more gently. But I haven't done it myself, but, you know, maybe actually I should actually show the videos more to patients so that they can also try that themselves. I do say to patients, you know, when you look on Dermner NZ, for example, it does say about using manual extrusion. And I do say to them, you can have a go of this to try it yourself. For individual ones, you know, you can do that, and you know, it does work. For some people, it is successful. So I'm like, you've said, Vicki, you know, it's been helpful for you as well. Yeah. And chemical treatments, any of them effective, any that you can tell GPs to maybe advise patients to use before they refer in. Yeah. So the popular one that's tolerated well and does seem to have some response to it, is the potassium hydroxide applications, like Molydub, which is 5%, it's sold online for about 20 pounds. In fact, I've had a few patients coming privately just to ask about Molydub because it's not given on the NHS. There's no NHS prescription for it. They've read about it and sort of wanted to know a bit more. It tends to lead to less irritation than some of the other high salicylic acid preps or even the hydrogen peroxide ones. So, you know, this one, you know, makes people happy they're using something if it's not on the face. You know, you can use these preparations and there does seem to be some benefit, at least it's an option as well to use. And do you ever use a Miquimod? I haven't used it recently. I have in the past, but quite a long time ago, but I definitely think that is a good option when you've just got a few melaskin that you want to try and treat. And that's really because you're limiting the side effects then. So if you're picking out two, three, four melaskin and you want to use the aldar or 5% of Miquimod cream, apply it three nights a week until it resolves, wash it off the following morning. Definitely one. I know colleagues of mine have used it on selected patients as well. And time-wise, I normally say two years for it to resolve, is that about? Yeah, two to three years. I mean, two years, I think, you know, you're giving them a little bit more hope. I might say four, though. So I suppose moving on to another thing that I'm very good at diagnosing, but not good at helping generally. Verucas and warts, are there any more successful treatments than we already have? Oh, it's going back to the traditional. There is no one definitive treatment, really, effective at just getting rid of viral warts, but in practice, it goes back to the basics, you know, pairing down the warts with combination of salicylic acid, preparations, so the high concentrations in combination with liquid nitrogen. And you've got to apply it frequently, help clear the warts. But, you know, there are restrictions in the NHS, which means that they're making it a bit tricky for us to do that. We're often having to reject those referrals anyway, at the front door, in hospital, so, you know, more of it is coming to primary care. But those are the ones that, those are the treatments that generally work. It's that combination in practice that seems to help more. But there's no new treatments, unfortunately. And like Malaskan, you know, it's more just sort of educating about, you know, they are going to clear up. They will get better, but yeah. And do you have any tips for the treatment of facial warts? Because those can be quite disagree again. They can't believe it. Yeah. So the same thing, what we said about Malaskan, on the face, you do have to be careful because a lot of these agents are very caustic and with pigmented skins, again, it can cause hypo or hyperpigmentation and leave them with a bigger problem. So, cryotherapy is the best thing to use if there are facial warts that are causing problems, but you have to do it very gently. And so I will put gasoline on the normal skin surrounding it. And you have to be quite skillful, gently applying the cryotherapy. You can attach a spray nozzle on the canister, or you can even use a cotton bud or, you know, a swab stick, dip that and then use that with shorter freezing times on the actual viral warts. So you get to make it go white, use 10 to 15 seconds, and then you've got the protection of the gasoline around the normal skin. And so you just got to be a bit experienced, repeat it every couple of weeks if you can, two or three weeks. And if there's no response at that point, then you might, then you would consider maybe surgically removing it if there was a need. So just to give an example, I had a five-year-old girl just a few weeks back and she had a phyloform viral wart that had been there for quite a long time on her lower eyelid. And so I've referred her to the eye plastics, people to remove that under general anaesthetic because it's got too big radiance, too deform, too deforming, too disfiguring. So my next question was, it was brought about because a friend of mine had an 11-year-old and the child got referred two-week weight on the cancer pathway for a shoulder lesion that was diagnosed as a pyogenic granuloma but they needed to find out the cause and it removed under general anesthetic and it made me think that I never really refer or look at moles in children that closely. I've never really thought about two-week weights for skin lesions in children, so what should I be looking for in moles in children? Wow, you should come to my patch Bill, I'm getting them through every, I'm getting so many referrals from all of them in children. I get a lot of referrals but obviously melanomes in childhood are very rare. Only 2% of melanomes occur in people under the age of 20 and only 0.3% occur in kids under the age of 15 years of age, so in the perspective, the referrals should be actually quite low for moles in children. But for the risks, I think people are very worried and so we do sometimes get quite a few referrals. Nodular melanomas make up a larger percentage of childhood melanomas than adult melanomas and around 50% of childhood melanomas do not present with the typical ABCD criteria that we educate patients about. And these patients can present with an amelinotic new nodular lesion and that may bleed. So any lesions fitting with that description of a bleeding, changing lesion, they fit with the differential of a nodular melanoma. But then you would also think about pygenic granuloma because that's much more common in children or even spits nevers which is rare but that does occur more and more in the head and neck area. But those ones we also would remove just because of the risk of atypical spits. But yeah, so they're all removed if they like that. But you know, like you say, I think it just depends on areas whether who's referring them on. So bleeding, rapidly changing. Yeah. Yeah. And especially if nodular, we have had quite a few nodular melanomas in kids, I mean, not many, but the ones that we tend to have seen in children have tended to be nodular fun. They can be anywhere in the body. Yeah. Yeah. Thank you. Okay. So Rocky, the last time we did a podcast, you had a little exome mishpuster section at the end. Can I ask if you can give us a list this time of five other common scenarios where you would advise GP's to refer earlier rather than yes. Gladly. Okay. So these are ones to refer in quickly. So just to point out propanol, which have just prescribed this morning for a little one seven month old, but that's revolutionized the treatment of infantile hemanjomas. So even in the last two years, now we can just give that inclinic prescription or all there we go to treat these little ones. So if you get infants with infantile hemanjomas at tricky sites, eyelids, nose tip, lips, ulcerated hemanjomas, large ones, lumpy, effect function, those are the ones that refer them in as soon as possible. The earlier they're referred in better because most of the proliferation is going to take place in the first six months or first six to nine months. So you want to catch them early so that it can do less, less damage or cause less problems. Number two, and we've been over this. We've got a whole podcast on this with eczema and infants. Infants with extensive eczema are often referred in late, and it's best to refer these ones in early because you can get them on top of their eczema earlier, but also to make the pediatric referral, pediatric sorry, allergy referral at the same time. Number three, to please refer in older children and teenagers with scarring acne or with significant post-inflammatory hyperpigmentation due to acne for consideration of isotretinone early. This severe acne is going to cause quite significant scarring that isotretinone is not going to be able to help with. And so we can just get on with the treatment earlier because otherwise we can't help them with that. And we also know now that the onset of puberty is occurring earlier now than in the past. And so with puberty occurring earlier, you see acne earlier as well. Don't forget psoriasis. It's a condition that we see a lot in children in certain areas that I've worked in. They've been misdiagnosed in children and also because it affects all ethnicities. It can often look quite different in darker skin types. So it can look a bit more hypopegmented in children. And so those are the ones where there's been quite a delay. That earlier onset can be triggered in children if they're very overweight or obese. And if they've got moderate or severe nail signs, it's also important to consider their joint disease as well. So they might need a referral for rheumatology as well. So it's just a window of opportunity just to treat joint disease as well if that's there. Last one, again, we've been over this. But to refer in young children, school age children with diffuse scaling in the scalp. And just to remember, tinia capitis is the key thing here. It's often very contagious in the home and at schools. And just to remember that it always requires systemic therapy with oral antifungals. And that's it. That's great. Thank you. Thank you very much. Yeah, thank you both for a really informative and practical session. I hope our listeners have enjoyed this as much as I have. And please join us again soon for more podcasts by the New Dermatologist Group. 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