Pediatric Dermatology Practice Research Articles

Retrospective chart review of patient socioeconomic status and language preference associated with live video telehealth in a pediatric dermatology practice.

Pediatric teledermatology rapidly expanded with the COVID-19 pandemic, and the impacts of this expansion on patients' access to care have not yet been entirely defined. In this retrospective study of 3027 patients in an academic pediatric dermatology practice, patients who identified as having a primary language other than English were less likely to access pediatric dermatology care during the COVID lockdown. This study did not identify a significant or meaningful difference in age, geography, socioeconomic status, ethnicity, or race between patients who were offeredpediatric dermatology care that was either in-person or via synchronous telehealth. These findings are overall reassuring that there were not major disparities in telehealth utilization during the COVID shelter-in-place mandate, although highlight the need for institutions to ensure systems are in place to enhance telehealth access for patients with non-English primary language.

Comparison of Pediatric Dermatology Conditions Across Telehealth and In-Person Visits During the COVID-19 Pandemic.

Understanding the utility of virtual visits in pediatric dermatology practice has become increasingly important in the telehealth era. We compared the conditions diagnosed in pediatric dermatology between traditional in-person visits and virtual telehealth visits during the initial 8-month phase of the COVID-19 pandemic at an urban medical institution. When given the option, pediatric dermatology patients and their families were more likely to choose telehealth visits for the diagnosis and/or management of acne, hemangiomas, and contact dermatitis; however, they were more likely to choose in-person visits for atopic dermatitis, viral warts, and alopecia areata. These differences may be attributed to clinical features of pediatric skin conditions, treatment options, and other factors which may influence patient preference for telehealth or in-person care for their condition. J Drugs Dermatol. 2022;21(11):1260-1263. doi:10.36849/JDD.6843.

Disparities in the Use of Teledermatology During the COVID-19 Pandemic Lockdown in a Pediatric Dermatology Practice.

Background: The COVID-19 pandemic required a rapid expansion of teledermatology services. Objective: Analyze demographic shifts in a pediatric dermatology practice session with children of color. Methods: A retrospective chart review of pediatric dermatology patients seen in the 4 practice weeks preceding the New York COVID-19 lockdown and comparable teledermatology visits during the COVID-19 pandemic lockdown. Demographic differences (e.g., race, age, gender, and household income) were analyzed. Results: A greater proportion of patients seen were White during lockdown (59.7%), compared with pre-lockdown (43.6%), with a reduction in Asian patients seen in lockdown (6.0%) compared with pre-lockdown (24.5%). A lower proportion of no-show patients (4.3%, 3/70 scheduled) were noted in lockdown compared with pre-lockdown (16%, 18/112). Preferred provider organizations (PPO) and higher-income zip codes were more common for children seen during lockdown. Limitations: The sample addresses a limited New York pediatric dermatology practice during a short time period. Conclusions: White patients and patients with PPO were more likely to access telehealth, supporting disparity in teledermatology services. These results demonstrate reduced health care access for lower-income and Asian children during the COVID-19 pandemic lockdown.

Emergency contraception in the iPLEDGE program: A cross-sectional survey of pediatric dermatology provider understanding and practice.

For patients with acne treated with the teratogen isotretinoin, emergency contraception (EC) is the only recourse when abstinence fails or effective contraception is not properly used. The purpose of this study was to evaluate the current understanding and provision of EC among pediatric dermatology providers. The survey found that 37% (21/57) of providers indicated they were at least somewhat confident in their understanding of EC. 7% (4/57) of providers agreed/strongly agreed that they provided EC counseling to all patients of reproductive potential at their initial visit and 3.5% (2/57) agreed/strongly agreed that they provide EC counseling at follow-up visits. Our survey results suggest the need for improved EC education for pediatric dermatology providers and subsequent counseling for patients of reproductive potential on isotretinoin therapy.

Follicular keratosis of the face in pediatric patients of color.

Follicular keratosis (FK) is a poorly understood disorder presenting with multiple, grouped hyperkeratotic follicular papules typically affecting the chin or jawline. This study describes the clinical presentation, histopathology, management, and outcomes of a series of pediatric patients of color with FK of the face, thought to be related to rubbing or friction on the skin. Retrospective review of 20 pediatric patients with FK of the face who presented to our pediatric dermatology practice between April 2019 and October 2021. Twenty patients (mean age 12.1years, 13 females), all self-identified as Black/African American, were included. All presented with an initially asymptomatic, hyperpigmented patch containing multiple hyperkeratotic follicular papules, located on the cheek, chin, upper lip, and/or jawline. Five patients endorsed a history of rubbing the site. Nine patients had onset of the lesions during the COVID-19 pandemic. Treatments included topical vitamin D analogs, corticosteroids, and/or retinoids. Topical vitamin D analogs and retinoids improved the texture and hyperpigmentation of the follicular lesions in only four patients, while topical corticosteroids had no effect. Histopathological examination of two patients revealed multiple dilated follicles containing keratinized material and associated with a sparse dermal inflammatory infiltrate in one patient and granulomatous inflammation within the dermis in the other. In our cohort of pediatric patients with FK, patients of color were preferentially affected, and all cases were associated with hyperpigmentation. Some patients presented during the COVID-19 pandemic suggesting that friction from facial mask wearing may have induced or exacerbated this uncommon condition.

Recommendations for Pediatric Dermatology Practice during COVID-19 Pandemic.

The current scenario of the coronavirus disease (COVID-19) pandemic has resulted in a huge disease burden worldwide affecting people across all age groups. Although children get infected by coronavirus, they are less commonly affected. Only 2% of cases are being reported among patients aged less than 20 years of age and childhood cases constitute around 1–5% of them. Moreover, they are less likely to be seriously affected when compared to adults, with more than 90% of them being either asymptomatic or having mild to moderate disease. This could be attributed to less exposure or sensitivity to COVID-19, varying immune response mechanisms, differences in the expression/function of the Angiotensin Converting Enzyme 2 receptors or higher antibody levels to viruses owing to exposures to multiple respiratory infections, protective role of measles and BCG vaccine, and few associated comorbidities. However, children with certain underlying medical conditions like cardiac or respiratory disease, diabetes, immunodeficiency disorders, cancer or on immunosuppressants may be at a higher risk for developing severe disease.

Large inflamed facial cysts in teenagers

Facial cysts can become large (1-5cm) or giant (>5cm) on the face. To describe the medical course of large and giant facial cysts in adolescents. A case series of 11 patients with large or giant facial cysts seen in an outpatient pediatric dermatology practice. Seven patients underwent incision and drainage with culture of cyst contents growing Cutibacterium acnes in six, while the seventh grew Cutibacterium acnes from a frequently worn hat. All patients were treated with traditional therapeutics for cystic acne including intralesional triamcinolone (n=9), oral antibiotics (n=10), and isotretinoin (n=1). Three patients who did not undergo cyst drainage had persistent symptomatology requiring cyst excision, whereas the seven patients whose cysts were drained (3 on initial management and 4 after recurrence) eventually had complete healing without need for surgery. Incision and drainage (I & D) and culture of cyst contents can identify cases of cysts related to Cutibacterium acnes. For some cases of large facial cysts related to Cutibacterium acne, I&D combined with conservative acne management (using standard acne guidelines) can prevent the need for surgical excision in some patients. Prospective studies are needed to determine whether this combination of therapy leads to best outcomes clinically and cosmetically.

Early Introduction of Peanut in a Solo Allergy Practice

We aim to report our experience with peanut challenges for early introduction of peanut in a solo allergy practice. In the spring of 2015 we wrote all offices whose patients we had seen in the past to encourage them to send patients suitable for early peanut introduction. All referred patients has PST to peanut, egg, milk, wheat and soy. Patients with a negative PST to peanut were asked to begin peanut at home. However some families opted for an in office challenge (Group 1) Patients with a positive PST to peanut were offered an open graded challenge (group 2). Between 5-15 and 6-18, 37 infants had a peanut challenge. The mean age at challenge was 6.6 months. Group 1 had 9 infants and 100% passed their challenge. However 3 (33%) of the infants subsequently developed a positive PST and clinical symptoms of peanut allergy. Group 2 had 28 infants. Nineteen children passed the graded challenge and 7 failed (36%).The mean wheal size for all infants was 4.7mm. Four of the seven who failed had a PST > 8mm. No infants in group 2 developed peanut allergy in follow up. Eleven of the infants (30%) were referred from one pediatric dermatology practice. Infants with a negative PST were at high risk of becoming peanut allergic with time suggesting that careful follow is required. A PST greater than 8mm posed a risk for failing. A single pediatric dermatology practice accounted for 30% of referrals

Demographic characteristics of teenage boys with horizontal striae distensae of the lower back.

This study examines the clinical characteristics and demographics of teenage boys with horizontal striae distensae of the lower back in an outpatient setting. Retrospective medical chart reviews and telephone survey studies were completed on an outpatient cohort of 12 boys 11 to 17 years of age with a clinical diagnosis of transverse striae distensae of the lower back at a single-center, university-based, pediatric dermatology practice. We evaluated the clinical features of the striae, participant demographic characteristics, and past medical history. A review of the literature concerning risk factors was conducted using PubMed and Google Scholar. Of the 14 patients we contacted, 12 agreed to participate. The average age of onset for the striae was 14.3years. All boys were above the 50th percentile in height at the time of onset. Eight (66.7%) reported a significant growth spurt before the appearance of the stretch marks. Most were asymptomatic. None of the boys had a history of unmonitored exogenous steroid use or prior infection with Bartonella henselae or Borrelia burgdorferi. Only one (8.3%) had a chronic medical condition. Eleven (91.7%) had at least one first-degree relative with striae distensae. Our results indicate that horizontal striae distensae of the lower back in adolescent boys is associated with a rapid growth spurt, tall stature, and family history of striae distensae. There is no association between this type of striae distensae and any chronic medical condition, bacterial infection, or exogenous steroid use. Thus a careful review of systems and counseling without further medical testing is reasonable management.

Wound culture isolated antibiograms and caregiver-reported skin care practices in children with epidermolysis bullosa.

Many patients with epidermolysis bullosa (EB) require intensive daily wound care and individualized treatment plans. Understanding patient's home skin care routines and emerging antibiotic resistance patterns in EB wounds is necessary to optimize treatment recommendations. The objective was to identify patterns of antimicrobial resistance in EB wounds and characterize patient's home practices of skin care and bathing. This was an observational study of 23 children with EB at an outpatient pediatric dermatology practice in New York City from 2012 to 2014. Information on individual bathing and skin care practices and wound cultures was collected as part of routine examinations and an institutional review board-approved antibiogram protocol. Sixty wound cultures were collected from 23 patients. Eleven organisms were isolated, most commonly methicillin-susceptible Staphylococcus aureus, methicillin-resistant S. aureus, Streptococcus species, and Pseudomonas aeruginosa. Six patients (26%) were colonized with methicillin-resistant S. aureus. Over the course of the study, 13 patients (56%) were found to have mupirocin-resistant S. aureus. More than half of participants reported mupirocin or bacitracin use. Fewer than half indicated that they regularly used dilute bleach or dilute vinegar as part of their bathing routine. Numerous organisms, including resistant bacteria, are known to colonize the wounds of individuals with EB. Mupirocin resistance was prevalent and more than half of the participants reported its use. Testing for mupirocin resistance may be considered for certain patients. These observations may help guide questions for future longitudinal multicenter studies with the goal of optimizing EB wound care recommendations.

Characterization of Herpes Simplex Virus Infections Seen in the Pediatric Dermatology Office.

Atypical and severe clinical manifestations of primary and recurrent herpes simplex virus (HSV) infections may present to a pediatric dermatologist for evaluation. The purpose of this study was to characterize the clinical features of the population diagnosed with HSV referred to a pediatric dermatology office. This retrospective case series examined patients diagnosed with HSV in a pediatric dermatology practice at an academic medical center from 2005 to 2015. Characteristics of the population were collected and analyzed. In this study of 48 children diagnosed with HSV, 33% presented at age 2 years or younger, with approximately half having exhibited initial symptoms before 2 years of age; 39.6% of the population had six or more outbreaks per year. The outbreaks were equally divided between unifocal and multifocal presentations, with 60% of children without any labial or mucosal involvement. Suppressive treatment was initiated in 33% of patients; the average age at initiation was 6 years. Our data characterize a subset of immunocompetent young children who present to pediatric dermatologists with frequent HSV outbreaks that are often multifocal and involve cutaneous sites, with or without mucosal involvement.

The Fanny Pack: No Ifs, Ands, or Buts.

Although the white coat is central to the practice of adult medicine, pediatricians often shed it to avoid creating negative associations and provoking fear in children. In our pediatric dermatology practice, the fanny pack (FP) has replaced many of the functional elements of the white coat. The FP is a kid-friendly way to readily carry key medical supplies from one patient encounter to the next. It is more hygienic, light weight, and affordable than traditional doctor's bags and white coats. In this article we outline the benefits of the FP, which include storage, ergonomics, efficiency, cleanliness, kid-friendliness, and cost-effectiveness.

The U.S. Pediatric Dermatology Workforce: An Assessment of Productivity and Practice Patterns.

Pediatric dermatology has always played an important role in children's healthcare, but there has been a shortage of pediatric dermatologists nationwide for more than a decade, and few metrics of productivity and practice patterns exist. This study sought to provide insight into these and other factors of the pediatric dermatology workforce. Electronic surveys were distributed to all 226 U.S. board-certified pediatric dermatologists. A total of 108/226 (48%) of the electronic surveys were returned. Sixty percent of respondents were employed full- or part-time in academic environments and 81% were salaried. Respondents reported that children constituted 79.5% of their practice, and the average respondent spent 3.8 days/week treating 92.6 patients, considerably lower than the 136.3 patients/week that the average general dermatologist sees. The academic practice environment was associated with children constituting a larger proportion of the practice (p < 0.001), fewer patients seen per week (85.9, p < 0.001), and longer median new patient wait times (60 vs 15 days) than in other practice environments. Private practitioners saw significantly more patients per week than those in academic environments (112.7, p = 0.005). Male and female practitioners reported approximately equal patient care days per week, similar wait times, and similar proportions of children in their practices. This assessment revealed productivity and practice pattern differences between the various pediatric dermatology practice environments and between pediatric and general dermatology. This study provides important information for workforce planning and care availability assessments and baseline information for future studies.

Early-onset childhood vitiligo is associated with a more extensive and progressive course

Vitiligo commonly presents in children, with half of all cases developing before 20years of age. Although studies have characterized differences between pediatric and adult vitiligo, little is known about vitiligo presenting in early childhood. The purpose of this study was to compare clinical features of early-onset (<3years old) and later-onset (3-18years old) childhood vitiligo. This retrospective case series examined patients given a diagnosis of vitiligo in a pediatric dermatology practice at an academic medical center from 1990 to 2014. Characteristics of the early- and later-onset groups were compared by χ(2) and t test for categorical and continuous variables, respectively. Of the 208 children in the study, 31 had early-onset and 177 had later-onset disease. Early-onset vitiligo was associated with higher percentages of body surface area involvement and increased rates of disease progression during an average 1.9years of follow-up. There were no significant differences between the 2 groups in repigmentation, vitiligo type, halo nevi, gender ratio, or personal and family history of autoimmune diseases. This was a retrospective, single-institution study. Patients given a diagnosis of vitiligo at younger ages tend to have more extensive and progressive disease.

Children with Warts: A Retrospective Study in an Outpatient Setting.

The purpose is to investigate the demographics and course of common warts in children in an outpatient setting. A retrospective medical chart review and telephone survey study were completed on an outpatient cohort of children (0-17 yrs) with a clinical diagnosis of warts at a single-center, university-based pediatric dermatology practice. The main outcome measures included management, time to resolution, and associated factors of warts in children. Of the 254 patients we contacted, 214 agreed to participate in the survey. The most commonly involved sites were the hands and the head and neck area. Most children received some form of therapy, but it is unclear that any form of treatment altered the course. However, children with a medical history of childhood infections or more than one anatomic site had significantly greater risk of having a longer time to resolution. Warts resolved in 65% of children by 2 years and in 80% within 4 years, regardless of treatment. With the exception of a history of childhood infections and having more than one anatomic site, time to resolution was not altered by wart or patient characteristics. Thus counseling without aggressive destructive treatment is a reasonable approach to managing warts in most children. Our findings will provide guidance in the process of shared decision making with parents and children.

Central obesity and high blood pressure in pediatric patients with atopic dermatitis.

Atopic dermatitis (AD) is associated with multiple potential risk factors for obesity and high blood pressure (BP), including chronic inflammation, sleep disturbance, and mental health comorbidity. Previous studies found associations between general obesity and AD. However, it is unknown whether AD is associated with central obesity and/or high BP. To determine whether central obesity and high BP are increased in pediatric AD. This case-control study performed in multicenter pediatric dermatology practices in the United States recruited 132 children (age range, 4-17 years) with active moderate to severe AD and 143 healthy controls from April 1, 2009, through December 31, 2012. Diagnosis and severity of AD assessed by a pediatric dermatologist. Body mass index, waist circumference, waist to height ratio, systolic BP, and diastolic BP. Moderate to severe AD was associated with body mass index for age and sex of 97th percentile or greater (logistic regression; odds ratio [OR], 2.64; 95% CI, 1.15-6.06), International Obesity Task Force obesity cutoffs (OR, 2.38; 95% CI, 1.06-5.34), waist circumference in the 85th percentile or greater (OR, 3.92; 95% CI, 1.50-10.26), and waist to height ratio of 0.5 or greater (OR, 2.22; 95% CI, 1.10-4.50). Atopic dermatitis was associated with higher BP for age, sex, and height percentiles (systolic BP: OR, 2.94; 95% CI, 1.04-8.36; diastolic BP: OR, 3.68; 95% CI, 1.19-11.37), particularly a systolic BP in the 90th percentile or higher (OR, 2.06; 95% CI, 1.09-3.90), in multivariate models that controlled for demographics, body mass index and waist circumference percentiles, and history of using prednisone or cyclosporine. Atopic dermatitis was associated with higher systolic BP in Hispanics/Latinos (general linear model; β, .23; 95% CI, .04-.43) and Asians (β, .16; 95% CI, .03-.30). Severe to very severe AD was associated with systolic BP in the 90th percentile or higher (adjusted OR, 3.14; 95% CI, 1.13-8.70). Atopic dermatitis was associated with a family history of hypertension (adjusted OR, 1.88; 95% CI, 1.14-3.10) and type 2 diabetes mellitus (adjusted OR, 1.64; 95% CI, 1.02-2.68) but not obesity or hyperlipidemia. Moderate to severe pediatric AD may be associated with central obesity and increased systolic BP.

The role of patient (parent) education and counseling in pediatric dermatology practice

Effective treatment and management of any dermatoses is dependent not just on simple prescription of medicines to a patient. Adequate education and counseling are equally important when it comes to the holistic management of a disease. It improves patient compliance as well as satisfaction with any treatment. It also improves the doctor-patient (parent) relationship. Patient (parent) education and counseling is even more important when it comes to pediatric dermatology because here patients are young children who can neither verbalize their discomfort nor adhere to the treatment prescribed and are often completely dependent on their parents (caregivers). Thus, adequate counseling and education becomes imperative for the successful outcome of any management protocol.

Clinical spectrum of capillary malformation-arteriovenous malformation syndrome presenting to a pediatric dermatology practice: a retrospective study.

Capillary malformation-arteriovenous malformation syndrome (CM-AVM) is an autosomal dominant disorder caused by RASA1 mutations. The prevalence and phenotypic spectrum are unknown. Evaluation of patients with multiple CMs is challenging because associated AVMs can be life threatening. The objective of this study was to describe the clinical characteristics of children presenting with features of CM-AVM to an academic pediatric dermatology practice. After institutional review board approval was received, a retrospective chart review was performed of patients presenting between 2009 and 2012 with features of CM-AVM. We report nine cases. Presenting symptoms ranged from extensive vascular stains and cardiac failure to CMs noted incidentally during routine skin examination. All demonstrated multiple CMs, two had Parkes Weber syndrome, and two had multiple infantile hemangiomas. Seven patients had family histories of multiple CMs; three had family histories of large, atypical CMs. Six had personal or family histories of AVMs. Genetic evaluation was recommended for all and was pursued by six families; four RASA1 mutations were identified, including one de novo. Consultations with neurology, cardiology, and orthopedics were recommended. Most patients (89%) have not required treatment to date. CM-AVM is an underrecognized condition with a wide clinical spectrum that often presents in childhood. Further evaluation may be indicated in patients with multiple CMs. This study is limited by its small and retrospective nature.

Genital melanocytic nevi in children: Experience in a pediatric dermatology practice

Little is known about the prevalence and clinical characteristics of genital melanocytic nevi in children. We sought to describe the epidemiology, clinical and dermoscopic features, and natural history of genital nevi in pediatric patients. We reviewed charts of 1159 children given the diagnosis of melanocytic nevi over 11 years. Those with genital nevus as a chief symptom were contacted for follow-up. Among children/adolescents evaluated for nevi, the prevalence of genital nevus was 3.5% (40/1159), with a male:female ratio of 1.3:1. There were no statistically significant differences in age, sex, total nevus number, presence of acral and scalp nevi, or family history of dysplastic nevi and melanoma between patients with and without genital nevi. Genital nevus onset was before age 2 years in 63.6% of patients. A globular dermoscopic pattern was observed in 93.3%. Most genital nevi underwent a gradual change in diameter, elevation (becoming soft papules), color, texture, or a combination of these. After median follow-up of 1.5 years, no melanoma or other adverse outcome was observed. This was a retrospective chart analysis and questionnaire-based study of a limited number of patients. Increased awareness of the clinical characteristics, dermoscopic features, and evolution ofgenital nevi in children may help to avoid unnecessary surgery.

Therapy of Ulcerated Hemangiomas

Cutaneous ulceration is the most common complication of infantile hemangiomas (IHs) seen in a pediatric dermatology practice. The most effective treatments in our experience are compared to those in the current literature. The study was a retrospective chart review of therapy of 169 ulcerated IHs at a tertiary care pediatric hospital and a literature review. Combination therapy was the rule. Local wound care was required in all, pain management in 72%, pulsed dye laser in 42%, infection control in 38%, diminution of the hemangioma through systemic therapy in 36%, and suppression of bleeding in 2%. A retrospective review compared to a case-control study has inherent bias. In addition, our cases were all at a tertiary referral center. All ulcerated IHs benefit from local barrier creams or dressings. Pulsed dye laser, antibiotics, topical morphine 0.1% in hydrogel, topical becaplermin, and, most importantly, systemic therapy (especially propranolol) to reduce the hemangioma may be useful.