Pediatric Skin Research Articles

Contact Dermatitis in Children.

Contact dermatitis (CD) is commonly encountered in the pediatric population. Allergic and irritant are the two forms of CD and both cause significant clinical problems in children, but they are often underrecognized. The skin lesions in CD may be polymorphic and closely mimic other common pediatric skin diseases. The diagnosis usually requires patch testing after obtaining a detailed history and performing a physical examination. Metals, fragrances, and certain preservatives are the most common causative agents in children. This article discusses the pathophysiology, diagnosis, and management of this common skin condition in the pediatric population. [Pediatr Ann. 2021(5):e198-e205.].

A 28-year single institution experience with primary skin malignancies in the pediatric population

The aim of this study is to report our institution’s experience with pediatric skin malignancies. A single institution retrospective review of pediatric patients with a primary skin malignancy from 1992 to 2020 was performed. Demographics, tumor characteristics and treatment outcomes were reviewed. Ninety-nine patients with 109 primary malignant skin lesions were reviewed. The most common lesion was malignant melanoma [MM] (n = 50, 45.9%). Compared to non-melanoma skin cancer (NMSC), MM were more likely to present on trunk or extremities (p=.01, OR = 3.2), and be misdiagnosed (p=.03, OR = 2.7). NMSC were more common in the head and neck region (p=.01, OR = 3.2), and were associated with a personal history of skin cancer (p=.0005, OR = 17.1) or a known risk factor (p=.04, OR = 2.5). Patients with MM were 12.4-times more likely to develop metastatic disease compared to NMSC (p<.0001). Increased Breslow’s thickness also increased the odds of developing metastatic disease (p=.03, OR = 1.6 per 1-mm increase). Interval time between lesion recognition and diagnostic biopsy or surgical treatment did not impact overall survival. Malignant melanoma was the most common malignancy in our cohort, followed by basal cell carcinoma. Malignant melanoma was the most likely tumor to be misdiagnosed and/or metastasize. Treatment delays did not impact risk of metastasis, recurrence or survival rate, though some patients succumbed to disease. These results may be attributed to small sample size or the biology of melanoma in pediatric patients. Awareness of skin malignancies in the pediatric population is imperative to providers and the public, with low threshold for specialty consultation and excision when warranted.

Effective Reduction in Opioid Prescriptions for Ambulatory Lesion Excisions in Pediatric Patients.

Background:Childhood opioid consumption is potentially deleterious to cognitive development and may predispose children to later addiction. Opioids are frequently prescribed for outpatient surgery but may not be necessary for adequate pain control. We aimed to reduce opioid prescriptions for outpatient pediatric skin and soft tissue lesion excisions using quality improvement (QI) methods.Methods:A multidisciplinary team identified drivers for opioid prescriptions. Interventions were provider education, improving computer order set defaults, and promoting non-narcotic pain control strategies and patient-family education. Outcomes included percentage of patients receiving opioid prescriptions and patient-satisfaction scores. Data were retrospectively collected for 3 years before the QI project and prospectively tracked over the 8-month QI period and the following 18 months.Results:The percentage of patients receiving an opioid prescription after outpatient skin or soft tissue excision dropped significantly from 18% before intervention to 6% at the end of the intervention period. Patient-reported satisfaction with pain control improved following the QI intervention. Satisfaction with postoperative pain control was independent of closure size or receipt of a postoperative opioid prescription. Intraoperative use of lidocaine or bupivacaine significantly decreased the incidence of postoperative opioid prescription in both bivariate and multivariate analyses. Results were maintained at 18 months after the conclusion of the QI project.Conclusion:Raising provider awareness, educating patients on expected postoperative pain management options, and prioritizing non-narcotic medications postoperatively successfully reduced opioid prescription rates in children undergoing skin and soft tissue lesion excisions and simultaneously improved patient-satisfaction scores.

Assessing comfort level with pediatric skin specimens among dermatopathologists and pediatric pathologists: A national cross-sectional survey.

Cutaneous histopathologic diagnoses in children often differ from those in adults. Depending on practice setting, these specimens may be evaluated by dermatopathologists or pediatric pathologists. We sought to determine whether comfort level with pediatric dermatopathology is associated with prior training, pediatric dermatopathology exposure during fellowship, career duration, or specimen subtype. We surveyed dermatopathologists and pediatric pathologists practicing in the United States. Training and practice variables were evaluated by multivariable regression for association with comfort level. Of the 156 respondents, 72% were dermatopathologists (response rate 11.6%) and 28% were pediatric pathologists (response rate 9.3%). Dermatopathologists reported higher comfort overall (P< .001); this was also true for inflammatory dermatoses and melanocytic neoplasms (P< .001). Thirty-four percent and 75% of dermatopathologists and pediatric pathologists, respectively, reported lower comfort with pediatric skin specimens than their usual cases. Pediatric pathologists were 28% more likely to refer these cases to colleagues. Among dermatopathologists, dermatology-trained were more comfortable than pathology-trained colleagues interpreting inflammatory dermatoses (P< .001). Pathologists' comfort with pediatric dermatopathology varied significantly based upon prior training, career duration, and specimen subtype. These results suggest opportunities for improving education in this domain.

Noninvasive diagnostic imaging in pediatric skin lesions

Optical coherence tomography (OCT) and reflectance confocal laser microscopy (RCM) allow noninvasive imaging diagnostics of the skin. Since the indication for abiopsy in children is generally made cautiously, OCT and KLM can be helpful in the clarification of pediatric skin lesions. In addition, biopsies only represent asnapshot of asmall area of the skin, while noninvasive methods allow several locations to be examined over time, so that dynamic changes and the course of therapy can also be determined. In pediatric dermatology, these diagnostic methods are particularly suitable for the clarification of atypical pigment lesions, for infectious dermatoses such as scabies or tinea, and for the diagnosis of inflammatory and degenerative dermatoses.

Subcutaneous abscess caused by Streptococcus pneumoniae serotype 28F in an infant: a case report

BackgroundInvasive pneumococcal disease (IPD) is defined by the detection of Streptococcus pneumoniae on culture from samples obtained from a normally sterile site. Pneumococcal conjugate vaccines (PCV) have been developed for the prevention of IPD that is caused by highly virulent serotypes. Despite the effective reduction of IPD caused by vaccine serotypes after the introduction of PCV, there has been a rapid increase in the incidence of IPD caused by non-vaccine serotypes, and serotype replacement has become a global issue.Case presentationWe report a previously healthy 4-month-old girl presenting with a large subcutaneous abscess caused by S. pneumoniae, identified as non-vaccine serotype 28F. The patient had received routine vaccination, including PCV vaccination. After the incision and drainage of the subcutaneous abscess, the patient was treated with antibiotics. She was discharged on Day 7 of hospitalization without any residual sequelae.ConclusionsSubcutaneous abscess is a common pediatric skin and soft tissue infection, whereas pneumococcal subcutaneous abscesses are quite rare. As the pneumococcal serotype 28F caused a subcutaneous abscess, this serotype possibly has a high virulence. The incidence of IPD caused by non-vaccine serotypes, such as 28F, is expected to increase in the future. The consolidation of international data on pneumococcal serotypes is important for the development of novel PCV.

Mini Review on Psychological Results of Intradermal Congenital Vascular Injuries

Vascular injuries are anomalies of vascular components that show up upon entering the world or in earliest stages. Cutaneous inherent vascular injuries are the most well-known pediatric skin colorations and can be partitioned into two distinct classifications: hemangiomas and vascular deformities. Hemangiomas tend to involute, as the kid becomes more seasoned while other vascular abnormalities will in general persevere. Inborn vascular injuries are discovered most normally on the head and neck and can be secluded or part of an innate condition like Klippel-Trenaunay disorder, Sturge-Weber condition and others. Vascular injuries, particularly on uncovered locales, can cause critical mental misery for patients and relatives.

Study of paediatric skin lesions in a tertiary care hospital

Background: Children below 14 years of age are vulnerable to many skin diseases mainly due to malnutrition, poor hygiene, less medical care provision, low socio-economic status, etc. The incidence and the spectrum of paediatric dermatological diseases vary from one part of the world to another depending on various factors. This study was aimed to study skin problems in children below 14 years age. Material and Methods: This was a cross-sectional, observational study done with children of age below 14 years attended skin outpatient department (OPD) with skin problems. Results: During study period 310 patients were included in the study of which 178 (57.26%) were male and 132 (42.74%) were female. The ratio of male: female was 1.34:1 in our study. Infectious skin lesions were seen in 163 (52.5%) children, while non-infectious skin lesions were seen in 157 (50.6 %) children. Conclusion: Infections and infestations are commonly noted in our paediatric population. Application of preventable measures by community, early diagnosis and proper counseling by pediatrician or dermatologist is needed to prevent further morbidity of skin lesions.

Upward trend in the frequency of community-acquired methicillin-resistant Staphylococcus aureus as a cause of pediatric skin and soft tissue infections over five years: a cross-sectional study.

The increasing prevalence of methicillin-resistant Staphylococcus aureus (MRSA) and its resistance to multiple antibiotics has become a serious challenge since the early 2000s. Especially, community-acquired MRSA (CA-MRSA) infections that appear mainly as skin and soft tissue infections (SSTIs) tend to increase worldwide. The objective of this cross-sectional study was to evaluate the trends in the frequency of SSTIs due to community-acquired S. aureus among children. All children with SSTIs caused by culture positive community-acquired S. aureus during the period from 2013 to 2018 were included in this study. Data of the outpatients were collected from medical records. Annual alteration in frequencies of CA-MRSA and community-acquired methicillin-sensitive S. aureus (CAMSSA) were evaluated. A total of 112 cases was evaluated. Of these, 35 (31.25%) were CA-MRSA. The rates of CA-MRSA had emerged from an increasing annual frequency of 9.5 cases per 10,000 SSTIs as of 2014 to 96.8 cases per 10,000 SSTIs in 2018. The ratio of cases with CA-MRSA to cases with CA-MSSA was 0 - 0.09 in two years of the study period and increased to a maximum ratio of 0.6 - 0.72 in the last two years. Consequently, the frequency of S. aureus in cases with SSTIs was significantly higher in 2016 - 2018 compared to the initial study period within the years of 2013-2015 [p < 0.001, relative risk increase: 7 (2.6-28.7) for CA-MRSA and p=0.002, relative risk increase: 2.1 (1.2-3.5)]. Cases with CA-MRSA increased approximately eight-fold during the six-year-study period. The rates of CA-MRSA in SSTIs among children increased significantly compared to CA-MSSA. The clinical impact of this increase should be evaluated, especially in patients with SSTI who are unresponsive to empirical treatment.

Opioid transdermal delivery system: a useful method for pain management in children.

Transdermal delivery system (TDDS) is a non-invasive and less expensive method for drug delivery. Despite its feasibility, only a restricted group of drugs can be delivered by TDDS, because of the little permeability of skin. Moreover, TDDS is limited to lipophilic drugs with small molecular masses and it is not indicated for peptides, macromolecules and hydrophilic drugs. Among opioids, fentanyl and buprenorphine are suitable for transdermal administration only for chronic pain management (not for acute pain). However, opioid TDDS still remains off-label for chronic pain management in children. In this review, we describe the main features of the adhesive TDDS and the main characteristics of pediatric skin and the differences from the adult one. Moreover, we focus on fentanyl and buprenorphine patches and their non-invasive mechanism of action, and on the main aspects that make them suitable for pain management among the pediatric population.

1349. Institutional Antibiograms Are Insufficient to Guide Clindamycin Use in Pediatric Skin and Soft Tissue Infections

BackgroundClindamycin (CLN) is a common empiric antimicrobial for pediatric skin and soft tissue infections (SSTI) despite decreasing susceptibility of Staphylococcus aureus (SA) to CLN on institutional antibiograms. This study inquired whether institutional antibiograms are an accurate representation of susceptibility for these infections. It also attempted to find patient and infection characteristics associated with being clindamycin susceptible (CLN-S).MethodsThis was a retrospective chart review of children with community-acquired (CA) SA infections in 2016 and 2017. A Staphylococcus aureus antibiogram was created based on infection type. Various patient and infection characteristics were compared between CLN-S and clindamycin-resistant (CLN-R) isolates to identify predictors of being CLN-S via binary logistic regression. Characteristics with p < 0.2 from a univariate analysis (chi-square or Fisher’s exact test) were included in the regression; p < 0.05 after the regression was considered statistically significant.Results362 SA infections were included. These were 76% CLN-S, similar to the institutional antibiogram (79% CLN-S, p = 0.168). MSSA CLN susceptibility was lower than the antibiogram (71% vs. 79% CLN-S, p = 0.042). MRSA susceptibility was similar (79% vs. 80% CLN-S, p = 0.859). Infection types assessed were abscess (n = 264, 81% CLN-S), osteomyelitis (n = 40, 75% CLN-S), lymph node (n = 16, 75% CLN-S), staphylococcal scalded skin syndrome (n = 9, 56% CLN-S), eczema superinfection (n = 17, 53% CLN-S), bullous impetigo (n = 7, 40% CLN-S), and non-bullous impetigo (n = 7, 29%). Characteristics found to be associated with being CLN-S included abscess (OR 3.883, p = 0) and high white blood cell count (OR 2.482, p = 0.001). Characteristics associated with CLN-R included contact to person with abscess (OR 0.468, p = 0.035) and hypotension during infection (OR 0.312, p = 0.005).ConclusionThe use of institutional antibiograms to guide CLN susceptibility in CA SA infections may be limited by the type of infection, patient characteristics, and the likelihood of MSSA vs. MRSA infection. In our patients, having an abscess was associated with CLN-S. Empiric therapy of CA SA infections in children should not be driven solely by institutional antibiograms.Disclosures All Authors: No reported disclosures

Tinea faciei caused by Trichophyton benhamiae in a child.

Tinea faciei is a common pediatric skin disease, most often caused by fungi of the genus Trichophyton. T benhamiae has been recently reclassified as a distinct species and is recognized as an emerging zoonotic dermatophyte with a wide range of possible infectious reservoirs worldwide. We present a previously healthy 7-year-old child presenting with unusual inflammatory facial plaques due to T benhamiae, confirmed by mass spectroscopy.

Atopic dermatitis in South African children: Experience from a tertiary-care centre

Background. Atopic dermatitis (AD) is a chronic, pruritic condition with significant morbidity and some variation in clinical characteristics across different populations. Objectives. To describe the characteristics and management of AD in a paediatric cohort. Methods. A cross-sectional, descriptive study of paediatric AD patients attending the skin clinic at the King Edward VIII Hospital in Durban, South Africa, is described. Results. The observed prevalence of AD was 60.1%. A preponderance of male patients (55.6%) was seen across the cohort. An onset of AD by 1 year of age was reported in more than half (53.5%) of the patients. Slightly more than a third of the patients presented with severe disease, as determined by affected body surface area (≥50%). The head, neck and limbs were the most involved areas. Eczema herpeticum was the most common co-existing dermatosis (2.4%). Bleach baths (2%), wet wrap therapy (3.6%) and systemic immunosuppressants (4.8%) were used in the management of recalcitrant cases. Conclusion. The observed prevalence of AD is one of the highest documented among paediatric skin diseases in hospital-based studies in Africa. Predominance in children of preschool age, onset of disease by the age of 5 years, co-existing eczema herpeticum and recalcitrant disease requiring systemic immunosuppressants are consistent with trends in patients from European or Asian descent, while the level of severe disease and head and neck involvement are more consistent with reports from Africa. Further studies in a local context are needed to better understand the disease and its presentation in different populations.

Incorporating joint pain screening into the pediatric dermatologic examination.

Joint manifestations are a feature of many pediatric skin disorders, among them psoriasis, autoimmune and autoinflammatory diseases, hypermobility disorders, and as an adverse effect of certain medications. Identifying joint disease early is important for intervention and prevention of chronic damage. However, pediatric musculoskeletal complaints are common and determining whether symptoms warrant a rheumatology referral for arthritis can be challenging. Pediatric dermatologists were surveyed for their comfort in screening for joint disease. Through literature review and interviews with three pediatric rheumatologists, key joints involved in disorders with skin manifestations and arthritis were identified and the essential evaluations were determined. Of 100 surveyed practicing board-certified pediatric dermatologists, 79% did not feel confident in their ability to perform a joint-focused physical examination, a key step in screening for joint disease. A rapid joint examination technique (R-JET) was developed, along with an accompanying three-question survey and body diagram for patient self-report of symptoms. A video demonstration of the R-JET was created as a teaching tool. Teaching and incorporation of a rapid screening examination for arthritis by pediatric dermatologists has the potential to identify pediatric arthritis earlier, facilitate referral, and reduce the risk of progressive joint disease. These instruments can easily be incorporated into a pediatric dermatology office visit.

Indian Academy of Pediatrics Guidelines for Pediatric Skin Care

To develop standard recommendations for skin care in neonates, infants and children to aid the pediatrician to provide quality skin care to infants and children. Though skin is the largest organ in the body with vital functions, skin care in children especially in newborns and infants, is not given the due attention that is required. There is a need for evidence-based recommendations for the care of skin of newborn babies and infants in India. A committee was formed under the auspices of Indian Academy of Pediatrics in August, 2018 for preparing guidelines on pediatric skin care. Three meetings were held during which we reviewed the existing guidelines/ recommendations/review articles and held detailed discussions, to arrive at recommendations that will help to fill up the knowledge gaps in current practice in India. The initial draft of the manuscript based on the available evidence and experience, was sent to all members for their inputs, after which it was finalized. Vernix caseosa should not be removed. First bath should be delayed until 24 hours after birth, but not before 6 hours, if it is not practically possible to delay owing to cultural reasons. Duration of bath should not exceed 5-10 minutes. Liquid cleanser with acidic or neutral pH is preferred, as it will not affect the skin barrier function or the acid mantle. Cord stump must be kept clean without any application. Diaper area should be kept clean and dry with frequent change of diapers. Application of emollient in newborns born in families with high risk of atopy tends to reduce the risk of developing atopic dermatitis. Oil massage has multiple benefits and is recommended. Massage with sunflower oil, coconut oil or mineral oil are preferred over vegetable oils such as olive oil and mustard oil, which have been found to be detrimental to barrier function.

Systematic review of Mohs micrographic surgery in children: Identifying challenges and practical considerations for successful application

Few data exist to guide the application of Mohs micrographic surgery (MMS) in the pediatric population. We sought to summarize the clinical characteristics of children undergoing MMS, identify challenges that limit the use of MMS in this population, and examine how these challenges can be overcome. A systematic review of PubMed and EMBASE, from inception of databases to November 2, 2019, identified all cases of pediatric skin lesions treated with MMS. A total of 111 patients were included. The median patient age was 11years (range 6weeks to 17years). The most commonly treated tumor was dermatofibrosarcoma protuberans (n=62), followed by basal cell carcinoma (n=30). The most common location was the head and neck (n=34), followed by the trunk (n=28) and the extremities (n=23). The most commonly cited challenges in the application of MMS in children included patient cooperation, concerns for the safety of prolonged general anesthesia, availability of a MMS service in the pediatric setting, and access to a histopathology laboratory experienced in MMS sectioning. Many articles did not report specific patient characteristics. Multiple obstacles limit the application of MMS in pediatric patients. This review describes practical methods to circumvent these obstacles to facilitate the appropriate use of MMS in children.

Clinical Case of Unilateral Laterothoracic Exanthem

Unilateral laterothoracic exanthem (ULE) is relatively rare self-limited pediatric skin inflammatory disease; its etiology still remains unknown. The diagnosis can be established due to specific clinical findings: presence of spotted and papular rash on one side of the body, more often in the axillary or inguinal area with possible generalization. This article presents the clinical case of ULE in the girl (4 years 8 months), it shows the dynamics of exanthematous syndrome at this pathology on different stages of the disease course.

Surgeon's practices and beliefs in Australia and New Zealand regarding the donor site wound for paediatric skin grafts.

Children's burns care in Australasia is performed by paediatric surgeons and by plastic surgeons. The aim was to determine practices regarding the donor site wound (DSW), and to explore any differences by training scheme or nature of unit (paediatric vs. mixed). Online survey of Australasian burns surgeons. Forty surgeons responded. 23/40 paediatric surgeons, 23/40 worked in a stand-alone children's burns unit. All used powered dermatomes. Alginates were the most common DSW dressing. Idealised dressings favour patient factors over cost. Plastic, and mixed-practice, surgeons use a broader range of dermatome settings in children >1 year. Mixed practice surgeons use thicker settings. All surgeons see pain as a common DSW problem. Paediatric surgeons recognise itch as a problem. While there are differences related to training scheme and the mix of patients being treated, there is a broader commonality of practice.

A practical review of dermoscopy for pediatric dermatology part I: Melanocytic growths.

The value of dermoscopy in the detection of skin cancer is well established. Less is published on the utility of dermoscopy in the evaluation of pediatric skin disease. Our review (in two parts) aims to serve as an update on pediatric dermoscopy and to provide readers with a practical application for the use of dermoscopy in pediatric dermatology clinics. In part I, we propose a dermoscopy algorithm for pediatric skin disease and melanocytic growths, and in part II, we address vascular growths, common skin infections, and inflammatory conditions for which dermoscopy is valuable.

Climate change and pediatric skin health.

Children are known to disproportionately bear the health impacts of climate change, particularly children living in impoverished areas. Owing to their developing physiology and immature metabolism, distinct exposure behaviors, and reliance on adults for care and protection, children are uniquely susceptible to the adverse effects of our warming planet. Herein, we summarize the known impacts of climate change on pediatric skin health, including its effects on atopic dermatitis, vector-borne and other infectious diseases, nutritional deficiencies, and psychodermatoses.