Dean S. Morrell

Systemic Treatment of Pediatric Atopic Dermatitis with Azathioprine and Mycophenolate Mofetil

Abstract:u2002 Severe forms of atopic dermatitis (AD) cause significant morbidity in vulnerable pediatric populations and necessitate treatment with systemic therapy. The existing literature concerning the treatment of severe pediatric AD with azathioprine (AZ) and mycophenolate mofetil (MM) is sparse. The purpose of this case series is to examine the use of these two drugs in the treatment of severe pediatric AD. Medical records of 28 pediatric patients with AD from the University of North Carolina at Chapel Hill pediatric dermatology clinic treated using these two drugs were analyzed for laboratory values, thiopurine methyltransferase (TPMT) levels, symptoms, infections, and other relevant data. Patients were also contacted via the telephone to ascertain outcomes and any missing data. Treatment outcomes were scored into three categories: significant improvement, some improvement, and no improvement. AZ dosing was correlated to TPMT levels successfully, with comparable levels of improvement in the heterozygous and homozygous wild‐type groups. Absolute eosinophil count corresponded to AD activity and treatment response across both treatment modalities in 18 of 26 (69%) patients. Seventeen of 28 (61%) patients treated with AZ and eight of 12 (66%) treated with MM reported significant improvement. We had lower rates of laboratory abnormalities and side effects with MM than with AZ but similar rates of cutaneous infections. Treatment outcomes did not appear to differ with race, sex, or TPMT level. We experienced success with AZ and MM in the treatment of severe pediatric AD. Coordinating treatment to each patient’s unique morbidities is the best way to choose systemic treatments.

Cantharidin Use Among Pediatric Dermatologists in the Treatment of Molluscum Contagiosum

Abstract:u2003 Cantharidin is cited often in the dermatology and pediatric literature as a valuable treatment option for molluscum contagiosum (MC). However, there have been no prospective, randomized, vehicle‐controlled trials that have been able to quantify cantharidin’s efficacy in MC. The purpose of this study was to determine the breadth of usage of cantharidin, most frequently used protocols, and common side effects seen with use of cantharidin. An eighteen question survey was administered to the Society of Pediatric Dermatology. The survey sought to evaluate treatments used in MC and experiences with cantharidin including: protocol, side effects, specific products used, and satisfaction with cantharidin. A total of 300 surveys were distributed via email, 101 surveys were initiated, and 95 (94%) of these were completed. Cantharidin, imiquimod, benign neglect, curettage, cryotherapy, and retinoids were the most common approaches to pediatric MC reported by respondents. Ninety‐two percent of respondents reported satisfaction with cantharidin’s efficacy, but 79% reported side effects, with discomfort/pain and blistering being the most common. Cantharidin is a common modality in the treatment of MC among pediatric dermatologists. While efficacy data is still lacking, subjective satisfaction with cantharidin is reported. Cantharidin remains a viable treatment option for children with MC.

Pediatric Sweet Syndrome and Immunodeficiency Successfully Treated with Intravenous Immunoglobulin

Abstract:u2002 Painful erythematous plaques and a pathognomonic, dense, dermal infiltrate of neutrophils characterize Sweet syndrome. Although numerous instances of this disease have been reported in children, only four have had an associated immunodeficiency to date. Sweet syndrome has been traditionally treated with systemic corticosteroids despite an unknown pathogenesis. Prior reports suggest that immunodeficient children with Sweet syndrome may have a persistent course and fail to respond to standard treatment. We describe a child with debilitating Sweet syndrome and a primary immunodeficiency whose symptoms were controlled with intravenous immunoglobulin and dapsone.

Periumbilical Allergic Contact Dermatitis: Blue Jeans or Belt Buckles?

Abstract:u2002 Nickel is the most ubiquitous contact allergen among children and adolescents. Metal blue jeans buttons and belts have been noted to cause nickel dermatitis around the umbilicus. For these children, traditional teaching is strict avoidance of all pants with metal snaps/buttons, particularly blue jeans. In this study we tested 90 pairs of blue jeans and 47 belts for nickel using the dimethylglyoxime spot test. Only 10% of blue jeans tested positive, while 53% of belts tested positive. Furthermore, 10 pairs of nickel‐negative blue jeans remained negative after 10 washings. Overall we found no resistance to testing in clothing stores. From these results, we recommend that patients with allergic contact dermatitis secondary to nickel need not strictly avoid blue jeans and metal belt buckles. Rather, families should be encouraged to use the dimethylglyoxime spot test to test these items for nickel prior to purchase.

Eruptive Post‐Chemotherapy In Situ Melanomas and Dysplastic Nevi

Abstract:u2002 A 22‐year‐old white man without a personal or family history of atypical nevi had received chemotherapy for pre‐B‐cell acute lymphocytic leukemia at age 17 that included l‐asparaginase, prednisone, methotrexate, mercaptopurine, daunorubicin, and cytoxan. Two to three months after completing maintenance chemotherapy, the patient reports he developed many moles, which remained stable for approximately 2u2003years.

Eccrine Angiomatous Hamartoma: A Report of Symmetric and Painful Lesions of the Wrists

Abstract: Eccrine angiomatous hamartoma (EAH) is a rare, benign cutaneous lesion histologically defined as a proliferation of eccrine glands within a closely associated vascular stroma. Typically EAH presents as a solitary flesh‐colored, hyperhidrotic, painful papule or plaque appearing at birth or during childhood. Only two previously reported cases have been described involving multiple, symmetrically located lesions. The occurrence of knuckle pads in patients with EAH has not been reported. We present an instance of multiple painful EAH lesions occurring symmetrically on the extensor wrists in a 14‐year‐old girl with knuckle pads.

Lupus Erythematosus Panniculitis in Children: Report of Three Cases and Review of Previously Reported Cases

Abstract:u2002 Lupus erythematosus panniculitis (LEP) is a rare finding in children, with only 12 fully reported prior cases in the English literature. We describe three cases of LEP in children younger than 18 and compare them to previous cases reported in the literature. We examine laboratory tests performed, biopsy results, age at onset and diagnosis, presence or absence of systemic symptoms, and outcomes after treatment. It is unknown what the risk is of these patients developing future systemic lupus erythematosus. We also discuss the relevance of subcutaneous panniculitis‐like T‐cell lymphoma, because the clinical and pathologic pictures are similar in presentation.

Examining the efficacy and safety of squaric acid therapy for treatment of recalcitrant warts in children.

The objective of the study was to determine the safety and efficacy of squaric acid dibutyl ester (SADBE) therapy on the treatment of recalcitrant warts in children. This retrospective chart review examined 72 patients treated using SADBE from July 2002 to December 2012. Patients were followed for 6 months to 11 years. Patients were treated at a pediatric dermatology outpatient clinic at the University of North Carolina at Chapel Hill. Seventy‐two children with verrucae who failed initial treatment for warts were selected for the study. Full long‐term follow‐up was obtained in 48 patients. Four patients discontinued the use of SADBE because of adverse effects. The primary study outcome was efficacy of SADBE treatment. Adverse effects, dosages administered, type of wart, other cutaneous disease present, and level of immunosuppression were measured. Forty of 48 (83%) patients in whom treatment outcomes could be obtained reported complete resolution of their warts. Seventy percent of patients used a maximum concentration of 0.4% SADBE and 60% of patients reported no adverse effects. The majority of patients treated with SADBE reported complete resolution of warts. Most patients reported no adverse effects even while receiving doses as high as 2% daily. This study shows that SADBE is a safe and effective treatment for recalcitrant warts in children.

Extensive fixed drug eruption secondary to vancomycin.

Abstract:u2002 Fixed drug eruption is an infrequent but well‐known adverse event most commonly associated with antibiotics and nonsteroidal anti‐inflammatory medications. We herein describe a second reported instance of vancomycin‐induced fixed drug eruption involving an extensive area of the body surface.

Anaplastic large cell lymphoma: an unusual presentation in a 7-year-old girl.

Abstract:u2002 Anaplastic large cell lymphoma (ALCL) accounts for 10% to 30% of all childhood lymphomas and approximately 5% of all non‐Hodgkin’s lymphoma. ALCL is considered to be a T‐cell non‐Hodgkin’s lymphoma that can be divided into two major groups with distinct genetic, immunophenotypic, and clinical behaviors. The first group consists of a spectrum of CD30+ T‐cell lymphoproliferative disorders that include primary cutaneous ALCL (C‐ALCL) and lymphomatoid papulosis. The second group is systemic ALCL (S‐ALCL), which is further divided into two subgroups: anaplastic lymphoma kinase positive (ALK+) and ALK‐negative. Between 30% and 60% of S‐ALCL express ALK, which is usually the result of a t(2;5) translocation that correlates with onset in the first three decades of life, male predominance, and good prognosis. Although morphologically similar, ALK− ALCL shows varied clinical behaviors and immunophenotypes; is commonly seen in older age groups, with a peak incidence in the sixth decade of life with no preference as to sex; and has an overall poorer prognosis. We present a case of CD30+, ALK− S‐ALCL in a 7‐year‐old girl.