Collin M. Blattner

A practice gap in pediatric dermatology: Does breast-feeding prevent the development of infantile atopic dermatitis?

In part because of a substantial increase in the number of cases of pediatric atopic dermatitis (AD) in the developing world during the last 3 decades, 1 there is an urgency to determine if any preventative measure can reduce the disease incidence. Common questions that dermatologists encounter from parents with a family history of severe atopy or from mothers breast-feeding infants with AD are whether or not dietary restriction, maternal antigen avoidance, or breast-feeding can reduce the risk of onset of AD. After breast-feeding rates declined dramatically in the early 20th century, a movement to understand the health benefits of breast-feeding ensued that resulted in evidence-based recommendations for breast-feeding mothers. 2 There is strong evidence to support that breast-feeding during the first 4 months of life causes a reduction in the incidence andseverityofatopic disease in patients athigh risk. 3 However, the risk reduction from breast-feeding is modest, and is estimated to be at most 33%. 3-5 It is important to note that this risk reduction only applies to children at high risk, 4-6 defined as a child who has a first-degree relative with AD. Therefore, if the infant is not a child at high risk, breast-feeding has no effect on the incidence of AD. There is also no difference in atopic risk reduction between infants exclusively breast-fed for 6 months, as the World Health Organization recommends, and those in whom breast-feeding is supplemented with solids or nonbreast-milk liquids such as formula. 4-6

Interventional treatments for Hailey-Hailey disease.

Hailey-Hailey disease or familial benign chronic pemphigus is a rare blistering dermatosis that is characterized by recurrent erythematous plaques with a predilection for the skin folds. For extensive Hailey-Hailey disease that is recalcitrant to conventional therapy, laser ablation, photodynamic therapy, electron beam radiotherapy, botulinum toxin type A, dermabrasion, glycopyrrolate, and afamelanotide have been reported as useful treatments, but comparative trials are lacking. This review discusses the various treatment modalities for Hailey-Hailey disease and a summary of the evidence for the most recommended treatments.

Central centrifugal cicatricial alopecia

Central centrifugal cicatricial alopecia is a common cause of progressive permanent apical alopecia. This unique form of alopecia includes entities previously know as “hot comb alopecia,” “follicular degeneration syndrome,” “pseudopelade” in African Americans and “central elliptical pseudopelade” in Caucasians. The etiology appears to be multifactorial and the condition occurs in all races.

Update: Do probiotics prevent or treat pediatric atopic dermatitis?

To the Editor, On March 11, 2011, a massive earthquake of magnitude 9.0 struck the Tohoku region of Japan. More than 18,000 people have been reported dead or missing, and many others have been forced to live in evacuation centers. Children are particularly vulnerable in such disasters, especially those with allergic diseases. Immediately following the disaster, to determine the condition of children with allergic diseases in the affected areas, the Japanese Society of Pediatric Allergy and Clinical Immunology (JSPACI) established a network of physicians in the affected areas, pediatric allergists throughout Japan, and private organizations engaging in support activities in the affected areas. Children and their parents and guardians had experienced various difficulties immediately after the disaster. For example, at regional evacuation centers, there was a lack of understanding regarding food allergies. Government officials told parents attempting to check the ingredient labels of the food products being distributed that ‘Children with food allergies should not eat relief food supplies because they are at high risk’. Others were warned that ‘During this time of emergency, children cannot afford to avoid foods because of allergy’. To improve the quality of life of children with allergic diseases and their parents, the JSPACI created the ‘Manual for Dealing with Allergy Ailments in Children during Disasters’. Allergic diseases covered include asthma, atopic dermatitis, and food allergies, and the manual consists of three parts: one for patients and their families, one for refugees evacuated from an affected area, and one for government administrative personnel. During weeks in which this manual was developed, many detailed opinions and proposals were obtained from physicians in the affected areas and patient advocacy groups. This collaboration between physicians and patient advocacy groups enabled the creation of a practical manual. While the effect of this manual will be investigated in future studies, favorable responses have already been obtained. The English version of the manual is available online (1). Major disasters can occur at any time in any part of the world. We hope that this manual will help ensure that children with allergic diseases who survive disasters but are subsequently forced to evacuate do not suffer because of a lack of understanding or poor disease control. Finally, we would like to express our sincere gratitude to all our friends worldwide who have kindly offered words of encouragement to those affected by the disaster in Japan.

Treatments for microcystic adnexal carcinoma – A review

Abstract Introduction: Microcystic adnexal carcinoma (MAC) is a rare malignant cutaneous neoplasm presenting as a slow-growing, indurated nodule, papule or plaque. Clinically, the lesion can blend into the surrounding skin, obscuring borders and consequently delaying diagnosis histologically. Surgical and histologic techniques that emphasize examination of all margins may optimize management through early diagnosis and prevention of recurrences. Objective: This review aims to assess the current surgical and histology techniques that result in lower rates of tumor recurrence and, consequently, better clinical outcomes. Methods: A literature search of the PubMed database was conducted to identify studies examining wide local excision (WLE), Mohs micrographic surgery (MMS), radiotherapy (RT) and chemotherapy in the treatment of MAC. Results: WLE had a high likelihood of positive margins and local recurrence. MMS was found to have the lowest recurrence rates. Definitive RT could be considered for elderly patients or those who are poor surgical candidates, as large surgical defects may be required to obtain free margins with either WLE or MMS. Chemotherapy was found to be ineffective. Conclusion: Complete margin evaluation with MMS permits complete tumor removal with subsequently low recurrence rate.

Understanding the new FDA pregnancy and lactation labeling rules

Dermatologists should be aware that the new Pregnancy and Lactation Labeling Rule (PLLR) has taken effect on June 30th, 2015. This mandate from the Federal Drug Administration (FDA) eliminated the standard pregnancy category letters for prescription medications (A, B, C, D and X). The new recommendations are now in the form of drug labeling that contains increased detail but also increased complexity. This editorial describes the newdrug-labeling rule and its potential impact in clinical dermatology. The PLLR introduced a new drug labeling schema to help physicians better communicate the risks and benefits of pharmacologic treatment to patients during pregnancy and lactation. Sandra Kweder, M.D., Deputy Director of the Office of New Drugs in the FDA’s Center for Drug Evaluation and Research, stated, “The previous letter category system was overly simplistic and was misinterpreted as a grading system, which gave an over-simplified view of the product risk.” (US Food andDrugAdministration, 2015) Consequently, the new package insert content and formatting requirements aim to provide a more consistent way of disclosing relevant information about the risks and benefits of prescription drugs and biological products used during pregnancy and breastfeeding. However, some have expressed criticism of the PLLR. Many question how labels will be revised to reflect new data as it becomes available. Drugmanufacturers face a significant challenge in condensing vast amounts of varying quality data into concise, clear paragraphs. Despite these challenges, the rule immediately applies to all drugs approved by the FDA after June 30th 2015 and requires that all labels be continually updated as new information becomes available (US Food and Drug Administration, 2015). Pregnancy labels for products approved between 2001 and June 30th 2015 will be revised using a staggered implementation schedule, and those approved before 2001 must be revised within 3 years (US Food and Drug Administration, 2015). To aid in transition, the FDA issued draft guidance to assist drug manufacturers in complying with the new labeling content and format requirements (US Food and Drug Administration, 2015). Unfortunately, labels for over-the-countermedications are not affected by the PLLR. The most notable change of the PLLR is that it will remove arbitrary and often misinterpreted pregnancy-labeling categories for pharmaceuticals (A, B, C, D, X). Instead, package inserts will now

Newborn and Infant Pain Control

Unlike most patients, babies are incapable of rating their pain on a scale of 0 to 10, and yet from the moment they take their first breath, newborns are exposed to pain. Heel lancets, circumcisions, injections, and immunizations are all vital components of ensuring a healthy baby. Although a cry is an almost expected response from a baby, how can one be certain that unnecessary pain is not being inflicted? Due to the sensitive nature of a newborn and the risks associated with traditional pain control, this article aims to review pharmacologic and alternative treatments for pain management in newborns. Studies have shown that babies may be more sensitive to pain than older individuals. A scarceness of inhibitory neurotransmitters in unmyelinated fibers, large receptive fields, and a higher concentration of substance P receptors all support this hypothesis. Infants do not simply display a reflex response to nociception; they develop the neuronal connections to experience all aspects of pain perception while still in the womb. The 5 S’s are a well-known physical intervention developed by pediatrician Dr. Harvey Karp that decrease infantile pain during painful procedures. The 5 S’s involve swaddling the baby, placing the baby on its side or stomach as an adult swings with a pacifier in its mouth to suck on, and softly shushes the infant. Implementing the 5 S’s prior to painful procedures has been shown to increase analgesia compared to sucrose water, which has traditionally been used to calm infants. Although combination therapy would be surmised to be more effective, there is no synergistic effect of using sucrose with the 5 S’s. In one study, a modified Riley Infant Pain Scoring Method analyzed quality of cry, facial grimace, and body movement to determine the infant’s post-vaccination pain score. Another study demonstrated a synergistic response in pain reduction when skin-to-skin contact and dextrose solution were administered. Other approaches to pain control included breastfeeding and distraction with a toy, but the results are not as well documented as traditional therapy. Acetaminophen and topical anesthetics are relatively safe, traditional approaches to reducing pain during immunizations and injections, but while effective, they have certain downfalls. Recent literature has shown administering acetaminophen before primary immunization decreases immune response. Topical anesthetics like lidocaine/prilocaine cream are also effective for subcutaneous and intramuscular injection pain control and do not affect vaccine immunogenicity. Despite these attributes, the onset of action ranges from 10 minutes to an hour, and therefore must be placed an hour prior to injection, which may not be practical in all instances. Heel lancets are used for routine neonatal metabolic disease screening, blood glucose monitoring, and other blood tests in the newborn nursery and neonatal intensive care unit. It is important to perform heel blood sampling on the side of the foot, extending posteriorly from a point between the fourth and fifth toes and running parallel to the lateral aspect of the heel. Alternatively, a line extending posteriorly from the middle of the great toe running parallel to the medial aspect of the heel may be used; a depth of less than 2.4 mm is desirable to minimize pain and bruising. In a study assessing the most effective form of pain control for this procedure, feeding and breastfeeding were found to be superior compared to the control, nonnutritive sucking, being held by the mother, and oral glucose solution. The assessment measured physiologic markers of pain including heart rate, oxygen saturation, respiratory rate, blood pressure, facial expression, body movements, and cry. Another study suggested that a 25% glucose solution was more effective at reducing pain and crying times when compared to breastfeeding prior to heel lancets and venipuncture. Oral sucrose with or without facilitated tucking has also been shown to decrease pain while facilitated tucking alone was not as effective. Unfortunately, topical anesthetics that decrease pain from injection do not confer the same benefit with heel sticks. While more research must be done, a plausible explanation may include increased sensory discrimination and decreased absorption due to thicker, more callus skin found on the heel. Nonetheless, consistent results are difficult to attain because various pain scales have been implemented to assess pain reduction from oral 540043 CPJXXX10.1177/0009922814540043Clinical PediatricsSabic et al research-article2014

Non-traditional melanoma prevention strategies in the young adult and adolescent population

Malignant melanoma is the most common cancer among women and men aged 25–29 [1]. Unfortunately, the incidence of melanoma far surpasses the rate of any other malignancy in this demographic. Due to the growing trends of tanning and advanced nail art, the incidence of melanoma may increase in the coming years. Less than a quarter of patients examine their own skin on a regular basis [2]. An Austrian study concluded that patients deemed physicians as the fourth most reliable source for skin health information behind print media, television, and family members [3]. With this in mind, physicians must develop non-traditional melanoma prevention strategies to increase early detection. In a society where the majority of the population uses the internet, non-traditional screening tools for melanoma recognition include implementation of an electronic health system designed for regular self-evaluation of skin and nevi surveillance. E-health tools may detect melanoma at an earlier stage, reducing overall morbidity and mortality from disease [4]. However, experts are concerned that inaccurate readings may lead patients to neglect a physician consult, which could thwart early diagnosis of treatable melanocytic lesions [4]. Other non-traditional strategies for early detection of melanoma in young women and men are also noteworthy. For example, hair stylists may aid in early detection of scalp lesions since young women and men frequently visit the same stylist. Training stylists to recognize the signs of skin cancer in the scalp may increase rates of early detection of head and neck lesions that would have otherwise been discovered in later stages due to their inconspicuous locations [5]. These locations represent 6% of all melanomas, but are responsible for 10% of all deaths from melanomas [5]. Similarly, massage therapists who see the same client on a regular basis may be able to report new neoplasms and changes in nevi on the body. Nail artists represent another demographic that can be trained to recognize nail melanoma between appointments and alert their clients of pathologic nail changes. Only 66% of patients address melanocytic changes observed in nails [6]. Women will often use nail polish, various gel techniques, and wrapping procedures to conceal nails for prolonged periods of time. Training these professionals may be an effective population-based strategy to increase rates of early stage melanoma detection. A survey of 206 hair professionals found that only 28.1% had received formal skin cancer education, but almost fifty percent of hair professionals were interested in a skin cancer education program [7]. About 37% looked at greater than 50% of their customers’ scalps, 29% looked at greater than 50% of their customers’ necks, and 15% looked at greater than 50% of their customers’ faces for concerning lesions during the preceding month.7 Hair professionals’ personal health practices corresponded with frequency of observation of customers’ lesions (P < .001) [7]. This study led to development of The Skinny on Skin, an educational program designed to aid in the early detection and prevention of melanoma by beauty industry professionals. Counseling the young demographic can be difficult due to the pressure the media places on young women and men to enhance their appearance. With this in mind, appeals to the negative cosmetic impact of sun and indoor tanning may be more effective than health-based appeals [8]. It is important to explain to patients that intermittent periods of excessive sun exposure early in life may lead to an increase in fine lines, wrinkles, lentiginous proliferations, and rapidly evolving nevi that may develop into melanoma [9]. Although counseling against tanning bed use may be successful in some patients, it has been shown that even after learning the associated risks, patients continue to tan [10]. The use of tanning beds has been associated with addictive behavior and may contribute to a compulsive desire to tan [11]. The brain of a person who habitually tans exhibits activity similar to that of a substance abuser and can experience tolerance, dependence, and withdrawal [11]. The brain responds to ultraviolet radiation (UVR) and can differentiate UVR from non-UVR tanning beds.11 When counseling these patients, it may be beneficial to use screening tools including the CAGE questionnaire (Table 1) to determine the motivation and goals associated with excessive tanning [12]. Understanding these desires will improve the ability of a provider to suggest appropriate alternatives to tanning [12]. For example, individuals who tan for relaxation may substitute yoga as an appropriate alternative, while those who tan for aesthetic purposes may choose to use dihydroxyacetone, the active ingredient in sunless tanners, as an alternative. It is also pertinent to discuss tanning in the pediatric and teenage populations to fully understand familial beliefs about tanning. Children whose parents tan indoors are more likely to do the same compared to children whose parents do not tan; a population based survey found that indoor tanning was 30% in the twelve to eighteen year old age group when the caregiver personally tanned compared to only 10% when the caregiver did not tan [13]. TABLE 1 In conclusion, primary care providers and dermatologists should continue to educate women and men about the major modifiable risk factors for melanoma, including unprotected sun exposure and monitoring of existing nevi. Education of hair stylists, nail artists, and massage therapists may expedite a referral to health-care professionals. Through the institution of both traditional and non-traditional melanoma prevention strategies, patients and physicians may achieve greater awareness, early detection, and prevention of disease.

The use of a suture retention device to enhance tissue expansion and healing in the repair of scalp and lower leg wounds

MMS: Mohs micrographic surgery BCC: basal cell carcinoma INTRODUCTION Dermatologic surgery defects on the scalp and lower leg present unique reconstruction challenges because of decreased skin laxity and excessive wound tension. Several options avoid this adverse outcome, but when a patient declines flap or graft, there is a paucity of alternatives aside from second-intent healing. One promising method is the use of a suture retention device (SUTUREGARD, SUTUREGARD Medical, Portland, OR) that may allow for stress relaxation of wounds (Fig 1). After relaxation, the wound can then be closed under lower tension, avoiding flap or graft. The authors present 5 cases of large defects after Mohs micrographic surgery (MMS) that were closed successfully with this novel suture retention device method.

Simple technique to avoid unnecessary Burow triangles

SURGICAL CHALLENGE Residents and fellows often experience difficulties with closure of crescentic excisions, advancement, and rotation flaps because of asymmetric edge lengths. Consequently, surgeons often create an unnecessary Burow triangle in hopes of alleviating tension and avoiding ‘‘bunching’’ of the apices. In some instances, however, it is best not to remove Burow triangles because of spatial limitations or the desire to conserve healthy skin.