Dr. Angelo Milazzo (Host): Hello and welcome to Pediatric Voices, a conversation with the people who make up the healthcare team at Duke Children's Hospital. I'm Dr. Angelo Milazzo. I'm a pediatric cardiologist and Professor of Pediatrics at Duke Children's and one of the hosts of the show. I'm here to bring you insights about children's health from my expert friends and colleagues.

On this episode of Pediatric Voices, I want to take a look at the field of Pediatric Dermatology. Dermatology, you may know, is the branch of Medicine that deals with the largest organ system of the body, the skin. And fortunately, I have the ideal expert to explore this subject with today. I'll be talking with Dr. Jane Bellet, Professor of Dermatology and Pediatrics here at Duke Children's Hospital and the Duke University School of Medicine. Dr. Bellet founded and directs the Nail Clinic and has a busy practice as a pediatric dermatologist and pediatric dermatologic surgeon. She has several areas of expertise, including the treatment of hemangiomas, which is an area where her expertise and my expertise overlap a bit, and hyperhidrosis. Dr. Bellet has a tremendous amount of experience dealing with skin disorders in children from the common rashes that plague many patients to the rarest conditions seen only in small numbers of patients. And it's a great pleasure to welcome someone I've known and worked with for a long time.

Welcome, Dr. Bellet. Jane, it's a great pleasure to have you on the show today.

Dr. Jane Bellet: I'm very glad to be with you. Thank you.

Host: Dr. Bellet, let's begin with an overview of your field, the field of Pediatric Dermatology. I gave a very basic definition at the open of the show, but I'd like to hear your definition, and I'd like you to also explain how Pediatric Dermatology differs from General Dermatology or Adult Dermatology.

Dr. Jane Bellet: Well, Dermatology itself is actually the specialty of caring for skin, hair, and nails. And so, it includes all of those things. And obviously for Pediatric Dermatology, it is for children and whether the definition is up to 18 or beyond, you know, may not matter so much. But I think the things that are different in Pediatric Dermatology versus Adult Dermatology is there are certain things that children are born with, and we think of these as birthmarks and things that really the adult dermatologist wouldn't see very often, but we would. These include some genetic conditions that children are born with, but other things that have nothing to do with genetics.

And then, there's certain things that primarily affect children. They might affect adults, but the bulk of the things, for example, things like eczema or acne. We usually think of this for a pediatric dermatologist, although again, an adult dermatologist might see it. And then, the way we treat things is often very different. So, it may be the exact same condition. But in Pediatric Dermatology, we might have a different approach for various reasons as compared to Adult Dermatology. So, it's very specific. There are a lot of things we see that the general dermatologist really doesn't see on a daily basis.

Host: Jane, one way we can organize this conversation might be thinking about the developmental stages of children. So if we start with your youngest patients, specifically thinking about newborns, what are the typical diagnoses you encounter in that group, children within the first few weeks of life?

Dr. Jane Bellet: Sure. So, the newborns of course are lovely and they can have things like baby acne. We sometimes call it neonatal acne cradle cap. Its fancy medical term is seborrheic dermatitis, but that's when you have some yellowish scale, usually on the crown of the scalp. There's something which has a big old fancy name called cutis marmorata, which is where The skin looks very mottled and sort of red and blue, but it's perfectly all right and nothing to be concerned about.

And of course, within the first few weeks after birth, the skin will begin to lightly peel and completely normal. It doesn't mean anything concerning at all. There are a few other things that we sometimes see, which can look alarming if you don't know what it is. There are some red, small bumps that again, fancy words in dermatology, erythema toxicum, which sounds awful, but is really nothing to worry about and will just go away. We actually don't need to treat it with anything. So, I think, you know, we're able to provide a lot of reassurance to parents for things like this. Of course, there are serious things as well in the newborn period. But luckily, many things are nothing to worry about.

Host: So, in terms of these newborns and the conditions that you've listed, are these conditions that you usually are asked to see patients in the nursery before they even go home from the hospital? Are these things that you get calls from primary care pediatricians and other primary care doctors when they're seeing these children? How do you usually become involved in cases at this age for this cohort of patients?

Dr. Jane Bellet: Well, the primary care pediatrician is just fantastic. And so most of all those diagnoses I mentioned, they recognize and they know they're okay. And so, most of the time, actually, the only time I might bump into those things would be I'm seeing them for something else and happen to see these things incidentally. Sometimes things, of course, don't follow the textbook. And so, even though it ends up being something not to worry about, it may look unusual when it presents.

There are other diagnoses that people classically call birthmarks. So, hemangiomas are one, port-wine birthmarks, and other things called congenital melanocytic nevi, which are moles that children are born with, are things that begin sometimes right at birth. It is visualized and seen by the obstetrician and then sometimes the pediatrician also. And those things often we are called. Sometimes it's clear what the diagnosis is, but not always. And then, of course, they may need our guidance in terms of treatment management, hopefully being able to reassure the family if we can, but at least to provide prognosis for those other diagnoses.

Host: So, we've talked a bit about the newborns, which most people define as patients in the first 28 days or first four weeks of life. Now, let's shift to children who are just outside of that first month, but still say up to a year of age. Do the diagnoses change? Are there new things that you're being asked to look at, new things that the pediatrician may be looking at, or that the family might see as the child is growing from that first month till about 12 months?

Dr. Jane Bellet: Sure. So, one of the things that often happens in this sort of one month and beyond time period is things like hemangiomas are changing, and they're really beginning to grow, which can alarm parents. And often, the pediatricians know how to watch what's okay, and actually when they need to send them to us for a consultation. So frequently, that's really beginning to happen. Something that was much smaller when they were very tiny now has grown and become bigger.

The other thing that often begins in this time period is things like eczema is really getting going. And there may have been a little bit in those first couple of weeks of life, but maybe not really noticed or not too severe. But often, then we'll really get going for infants that are going to have more severe eczema. And sometimes that overlaps with a condition I already mentioned, seborrheic dermatitis, where it's not just cradle cap on the scalp, but begins to involve the rest of the body.

Host: Now, let's think about that next cohort of patients. So, we've talked about the newborns. We've talked about children up to about a year of age. Past a year and maybe up to the early school ages, so those next few years of life, again, do the diagnoses change? Do the concerns change? Are there new things parents and pediatricians are worried about? What are you seeing in that group of kids?

Dr. Jane Bellet: Sure. So in that group of children, many of them are beginning to develop moles. We call them nevi in Dermatology, but usually brown or tan, sometimes dark brown. And so, that can be alarming, again, for parents and pediatricians for the most part. They're perfectly all right. But we're very happy to take a look. Obviously, some things look unusual and we need to evaluate them.

The other thing that really happens, I mentioned eczema already, but now it is really, really cranking up. And unfortunately, some children are very much suffering and maybe it was milder when they were younger, but now it's a real problem. They're very good at scratching. And so, we need to help them out.

The other thing of course is, as they go to kindergarten and then off to school, they begin to have viruses and come home with various things that include rashes. And so, frequently, we're asked to help out with that if it's unclear why a child has suddenly developed a rash. And so, we can help with that. They also begin to develop warts and a condition called molluscum, which is also caused by a virus, just like warts are. They're both benign, nothing to worry about. But it's not going to be the youngest kids, the newborn or really the first year of life that will have those, it's going to be the older children because they're beginning to be with other children, other people, and those things are spread from person to person. So, we begin to see that as children get older. Of course, children that still have their hemangioma, then, of course, we're finishing up, hopefully, management as they get older as well.

Host: You've mentioned eczema a few times now in the conversation, I want to take a little bit of a detour here because last season I had one of our colleagues from Gastroenterology on the show and we talked about sort of the changing incidents of things like celiac disease and food allergy, both in terms of our ability to make the diagnoses and what appears to be actually a shift in the incidence and prevalence of those conditions. Are you seeing a similar change in eczema, which I, in my non-expert opinion, see as another form of an immune or an allergic type of disease? Are you seeing changes in either the demographics or the number of kids coming to you with eczema as a primary complaint?

Dr. Jane Bellet: I think, certainly, we are seeing more children in general with eczema than when I began practice just a couple of years ago, many years ago, actually. But certainly, there are more and there's lots of theories as to why. I'm not sure we a hundred percent know, some people wonder if we're not eating enough dirt, and whether we really need to stimulate our immune system when we're young. And again, I'm not an expert in that, so I can't speak to that. But I would say, you know, just anecdotally and seeing who comes to the clinic with severe enough eczema that it really needs a pediatric dermatologist certainly has increased.

On the other hand, we have better medicines to offer, which is fantastic. And that certainly makes us feel better that we can help the kids that are the most severe, that we used to sort of just go round and round and do our best, but now we have much better things for them. So indeed, to answer your question, absolutely, I think it has increased.

Host: Well, I think that's fascinating, and I think that mirrors changes, again, not only in Gastroenterology, but in other conditions across other specialties that I've heard from other experts that have been on the show. So, thank you for that detailed answer.

So, to get back on track in our sort of chronologic survey, I want to get to a group, which I think some people, particularly parents and other laypeople, when they hear Pediatric Dermatology, their mind may directly go to teenagers, acne and other skin-related conditions during adolescence and puberty. Is that a large part of your practice or is that more confined to primary care and other specialists?

Dr. Jane Bellet: It certainly can be a large part of a pediatric dermatologist practice. I have a few areas of expertise that aren't necessarily for teenagers, so I'm a little bit different. But in general, absolutely, it can be a large part. And certainly acne, you know, everybody thinks of acne. And it pretty much affects almost everybody. There are a few lucky people out there that never really deal with acne at puberty. But in general, most people will have either a mild, moderate, or a severe form. And, of course, then the issue becomes what it looks like at the time. Obviously, the children are self-conscious as they become teenagers and young adults. And so, that's an issue, of course.

And then, from my perspective, which they may or may not realize, is whether it's beginning to scar, and so whether it will end up being a permanent issue, not just a teenage issue. So certainly acne, again, I've mentioned eczema, other things like psoriasis, these things that really impact the essence of the person's view of themselves and how other people see them as well. If it's something visual, which obviously almost all of Dermatology, these things are visual, can be a real problem.

The other thing that often ends up happening is the teenagers don't like their moles, which are perfectly all right in many cases, of course. But they just don't like them and they want them off. And that's a whole other issue in terms of whether medically something needs to be removed or not. Certainly, if it does need to medically be removed, I would do it. But we get into other issues that really are not so much a thing I need to think about in a three or four-year-old. But indeed, Pediatric dermatology doesn't encompass everybody at all these ages, which certainly keeps things interesting. That is certainly for sure.

Host: I promise you we're going to get to your specific areas of expertise. I definitely want to dive into that. But I want to not leave this subject quite yet, because I want to hear if and to what extent with this group, with the teenagers, the adolescents, maybe even the young adults, you talked about or you alluded to the idea that they may not like the way something looks, whether it's their acne or a birthmark. We think of aesthetics as part of Adult Dermatology. Maybe that's my misperception, but do you touch on issues of aesthetics with this population? Plastic surgery and all the pressures that are on kids today to look a certain way and to conform. To what extent do those issues bubble up in the patients that you're taking care of?

Dr. Jane Bellet: Sure. It certainly bubbles up. I am not a cosmetic dermatologist. I'm not trained that way. And I don't perceive my role as that, but I will say that I do feel that it is my job to help children and teenagers, adolescents, to go through life looking as "normal" as possible. And so I, don't want them bullied. I don't want them made fun of. I don't want people always pointing their finger at them, for example, with a birthmark that's on their face or something like that. So if there's anything possible that I can do to help the appearance, look, again, "more normal." And for me, that's different than better than would happen naturally, then I would absolutely do it.

You know, I think when we think about treating adults and aging skin, wrinkles, gray hair, things like that, many times people are working to improve their appearance and their perception. Again, I work very hard, for example, a lot of birth marks really do impact children as they grow up and become formed as adolescents and then young adults. And so, I want to do my absolute best to help them, as I mentioned, to really be able to face the world in a way that they can. And so, it also means that, especially for things I may not be able to help or may only be able to help a certain amount, I want to give them confidence. And that's something I talk to parents of newborns with birthmarks about, how important it is as they raise their child to imbue them with good confidence, no matter what their outward appearance looks like so that, again, they can move forward into life feeling very good about themselves. And I really do see the difference for the parents that are able to do that, which can be difficult of course, versus parents that really are unable to do that and, unfortunately, end up just focusing again and again and again upon the outward appearance. Those children unfortunately pick up on that and they sort of take it as their own. And again, I'm working at all angles. I'm not a psychiatrist, but again, not a cosmetic dermatologist either. But nonetheless, for me, that's very important. And I think that comes from my Pediatrics training, you know, that I did before Dermatology to know how important that is. I was even asking a girl this morning about a very minimal type of birthmark on her neck. And, you know, she's eight and I met her when she was much younger, two years old, and sort of, do other people ask her about it? You know, do friends, do strangers? All those sorts of things. And so, there's a lot to be taken into account, again, even though I'm not a cosmetic dermatologist.

Host: Well, I appreciate the complexity of the issue and the sophistication of your answer. And I think, you know, in many of the previous conversations I've had on this show, I've asked my expert colleagues and friends about these issues of patient's self-perception about a variety of different medical problems. We've also, with virtually every guest, talked about the role that social media plays, the role of self-diagnosis today, particularly in the teenagers and the young adults, the adolescents and children of similar age.

One thing I want to ask you before we leave this, so we hear about these memes and these ideas that are popularized on social media. One that has come across my radar recently is sort of a backlash to the use of sunscreen. I wasn't aware of this until my young adult children told me about this. And I was sort of horrified to hear it. I was wondering if you have a perspective on that and how you deal with that when it comes up in your practice, if it does.

Dr. Jane Bellet: Sure. Social media, you know, is influencing everything everywhere, but particularly in medicine. And I think that, to a certain extent, it makes our job harder, because not only are we educating and discussing things that we need to discuss, but then we're also combating misinformation or the fact that something is recommended by some influencer that really is probably not the best idea.

It's hard because, of course, the teen or the young child looks at the phone and it says that some amazing thing happens if they put, I don't know, some crazy sort of oil on their head, you know? And so, that's difficult to do it. And so, from my perspective and I feel the same way also in a way about complementary medicine, is that if something works, I want to know about it. I want to learn myself about it. I want to read and learn. And if it works, that's great. And I want to be sure it doesn't harm anybody. That's very important obviously to me as well. And so if I can give evidence, that's sometimes helpful, but sometimes I'm unaware, and they're bringing something to me that's new, and I must learn. But I think that it really does impact, and unfortunately, a lot of it's not great.

The sunscreen thing, for example, I, unfortunately, trained, you know, as an adult dermatologist as well, and so I see terrible skin cancers that absolutely were caused by the sun. And I don't want anybody to have to suffer through that. And so, I often will just talk to them, you know, if they don't want to use sunscreen, that's okay. If you look to other cultures in the world, particularly the Asian cultures, they just cover up, wear some clothes, and I'm okay with that. But protecting yourself from the sun is very important.

One fact I do share with families and teenagers, not little kids of course, is that the sun you get under the age of 18 is way more damaging than the sun you get when you're older, like me. It's not good for me either, but it's way, way worse. The exact same amount of sun and the damage it's doing to that nice young skin is way, way worse. And of course, even if they say, "Oh, I tan well," yeah, you're doing damage. Tan lets us know that there's change to the DNA, even if you don't have a sunburn. It doesn't have to be a sunburn. And so, I think that some people are understanding this, some people are not, and it's hard again with the teenagers. They look online and they see that some other person is nice and tan. They like the look. Why not? It says the sunscreen's bad, which brings me to another point often pediatricians are guiding families to not use sunscreen on babies six months and under, and I would posit that that's not the correct thing to be telling families. We live in North Carolina. It's very hot and sunny and we don't want babies to get burnt, because they were following the guidelines of their pediatrician who said no sunscreen under six months.

If you actually look at the guidelines of the American Academy of Pediatrics, that's not what they say. They say do your absolute best to prevent sun exposure in the babies and really as a last possible resort, use sunscreen on the babies. And so, again, I agree with that. Shade, don't go out in the middle of the day, all those good things that are easy and most people can do. Of course, we often recommend the physical blockers, which are the ones that have zinc oxide and titanium dioxide as the primary ingredients that are protecting the skin from the sun. We don't recommend the chemical blockers for the really, really young children. Those are also the ones that sting when you get them in your eyes anyway, and so that's just fine. But I know I've going on and on, but especially sun protection, obviously, is near and dear to every dermatologist's heart. And if we can prevent just one skin cancer, that is just fantastic.

Host: Well, there's no need to apologize for that expansive answer because it contained a ton of practical information for our listeners. So, I appreciate the specificity and the detail that you went into. So absolutely, that's fantastic stuff. As promised, I want to dive into some of the very specialized work you do. You know, one of the great things about being at a place like Duke Children's is that we have the benefit of colleagues who have trained in esoteric areas and rare disease areas, and we can provide a level of expertise, which is really elevated.

So, giving you the floor completely here, please tell us, tell the audience about some of the unique diagnoses, the treatments you offer, the procedures you do as a surgeon. I think we'd be very interested in hearing some of that detail.

Dr. Jane Bellet: Sure. Again, I'm very lucky to work at Duke where I have been afforded this opportunity to pursue actually a lot of different things. Interestingly enough, some of them are a little bit related, but some are very different. And so, it keeps my day to day work very, very interesting.

The first thing I do wish to are hemangiomas, which are the most common birthmark. I mentioned already that you begin to see them within usually the first week, two, three weeks of life. And they rapidly grow and they can really cause problems both in the young first year of life period, but also, what that's going to look like later on as the person grows up. And one of the most exciting advances in all of Pediatric Dermatology has been in the treatment of hemangiomas with oral beta blockers. And you as a cardiologist, of course, using beta blockers for high blood pressure, but about 15, 16 years ago, this amazing discovery happened in France that we can use these medicines, which essentially halt their growth. And so, as long as I am referred these babies early and I get treatment started as early as possible, we can halt growth and have amazing results that we never would have possibly dreamed of years ago. So, this has truly completely changed treatment, even just in my own career, which is exciting.

We do also have a topical version, which is not for everybody. So before the parents listening to this podcast go asking for the topical version, your child may not qualify, there are certain children that really, really must have the oral kind, but it's really, really fantastic. So, extremely gratifying to be helping these babies. You know, many of these children will never know me, and that's fine. But their parents will, and really can make a great difference for them.

Sort of attached to that, I also take care of other types of red birthmarks. Port-wine birthmarks babies are born with, and it's a flat red mark. They can occur anywhere on their body. And interestingly enough, just in my career, they have figured out the genetic mutation of why children have these, which we didn't know not that many years ago. And at the moment, I treat them with laser. I can't just erase them, unfortunately. But my goal, as I alluded to already, is to try to fade them as much as I possibly can, and then imbue them with confidence as well. And so, laser treatment is very, very specific and requires a certain level of being able to tolerate children crying. You know, I'm not doing it to harm them, but it does hurt. And I do it both for children who are awake in the office, if it's appropriate, and I also do it under general anesthesia, if that's appropriate for the particular patient.

Vascular malformations, which are much more rare things that children are born with, but do have to do with blood vessels are another area. That's a special interest of mine. I'm part of the vascular malformation team here at Duke, which includes many different specialists that are needed. And that's a whole other area that we really can make great differences for children. So, I always say to people, not every red or purple mark is going to be a hemangioma or even a port-wine birthmark could be one of these other rare things.

And switching gears, I take care of people who sweat too much. We call that hyperhidrosis. And interestingly enough, it can happen in very young babies. It's rare but the youngest child I've ever diagnosed who sweat too much was about six months old. Usually, we think about it starting in adolescence, puberty, and that's often the case, but it can be even younger, and it can be very severe, really severe, where somebody holds up their hand in literally just a fountain of water, what appears to be water, dripping off their hand. And so, you can imagine that impacts people really in just an incredible way, starting with their schoolwork, but also even in fun things. You know, they want to do artwork or play the piano or play golf or tennis or anything, even holding their mom's hand, you know, when they're learning to walk or later a girlfriend or a boyfriend's hand. You know, it really, really impacts people. Of course, it can occur in the armpits, the feet, it's more rare to occur on other parts of the body in children. But it's something that we do have treatments for.

I think many years ago, again, people didn't really think it was an issue. People sort of hide it. They don't know that it's severe and actually abnormal. But there are treatments. Again, some are appropriate for children, and some I do not offer children. They need to wait till they're older. But I can make a huge difference for these children. And so, I urge people who have any worries that their child is sweating too much to be evaluated. Certainly, we all need to sweat. If we can't sweat, then we cannot release heat. So, for example, again, we live in North Carolina. I think it was 95 degrees today. If I can't sweat, I'm going to overheat and that's a problem. And so, again, we're not trying to get rid of it completely, that would not be good, but to reduce it so it's not so noticeable and they can live their life without constantly thinking about it, rubbing their hand on their pants or wearing a extra jacket because they're trying to hide the sweat rings in their armpits. So, that's one thing.

And then, the last sort of interesting and special area is my nail clinic. And so, I see both children and adults who have nail problems, both finger nails and toenails. And it's a fascinating area. You know, we tend to not notice our nails until something is wrong with them. Either we hit it, you know, or slam it in the door, and then we certainly know that it's there, or if we have trouble trimming them. I think often people are aware of their nails if they've ever had an ingrown toenail. But there's lots of other things, actually, that affect the nails. For example, I already mentioned eczema today or psoriasis. There are particular appearances of those nails that we can treat, which is fabulous.

The thing that often I'm referred to in children regarding nails is that a child has developed a brown stripe on their nail, which was quite unusual and the parent and the pediatrician might not know what to do about it. And so, I'm very happy to evaluate those children. The good news is that almost all, we can never say 100% in Medicine, but almost all of them are going to turn out to be completely benign and often is a particular kind of mole something called a nail matrix nevus, but happy to evaluate those kids because those can certainly be a little worrisome when people are looking at their nails.

So yes, I certainly keep busy with lots of different sort of very specialized things. But certainly, I enjoy it. And if I can help those patients, that's fantastic.

Host: Well, that's an amazing survey. So, in practical terms, if a family is listening and they have a concern about a port-wine stain or hyperhidrosis or a nail issue, do you recommend that they start with their primary medical home and their family doctor or pediatrician, or is the pathway that they try to reach out and directly schedule an appointment with a pediatric dermatologist?

Dr. Jane Bellet: When they start with their pediatrician, their pediatric home, many times they're able to help. As I mentioned already, they can help and treat atopic dermatitis, otherwise known as eczema. They can evaluate moles. They can evaluate all these things. And if they don't have the knowledge, then they're certainly able to refer to us here at Duke. We do accept patients only on a referral basis at the moment. So, a family usually would not be able to just reach out. But if their pediatrician or family practitioner wishes to reach out, I'm very happy to. You know, I didn't mention some of the other procedures that I do, and those also, for sure, would require consultation. You know, it's not something they're just going to roll in, and we do it, is sort of how that works.

Host: Well, this has been a fascinating conversation and I appreciate this detailed look at your field of Pediatric Dermatology. I think many of our listeners probably had some passing familiarity with some of the things we touched on today, but I think we're all going to walk away much better informed about these issues.

So, Dr. Jane Bellet, thank you so much for being a guest of the show. I think we're going to need another episode in the future as a part two to continue this conversation. So, I hope you'll be willing to come back and join me again for a future conversation.

Dr. Jane Bellet: Oh, absolutely. It's been a great pleasure to speak with you, Dr. Milazzo. It's been great.

Host: Well, thank you so much. Pediatric Voices is brought to you by Duke Children's Hospital and the Department of Pediatrics at the Duke University Medical Center here in sunny, and as Dr. Bellet had said, very hot today, Durham, North Carolina. The show has a new co-host, Dr. Emily Greenwald. You will meet or be reintroduced to Dr. Greenwald in a future episode, so please welcome her aboard. I owe an unpayable debt to my former co-host, Dr. Richard Chung, who has left us to take advantage of a new professional opportunity. I wish him nothing but the best and hope to have Richard back as a guest soon. Thanks to Courtney Sparrow, who keeps this show on track and organizes the work. Thanks to Dr. Ann Reed and also to the wonderful people at Doctorpodcasting. You can find the show and please hit the subscribe button wherever you find your favorite podcasts. And you can connect with us online at our website, which is pediatrics.duke.edu/podcasts. We'd love to hear from you. So, leave us a review at Apple Podcasts or on your favorite podcasting application. Thank you all for being a part of the show. We'll see you next time.