James E. Rasmussen

Disorders of transepidermal elimination. Part 1.

Transepidermal elimination (TE) is a mechanism whereby foreign or altered constituents can be removed from the dermis. This process involves unique morphologic alterations of the epidermis, which forms a channel and thereby facilitates extrusion of the desired dermal components. The phenomenon of TE may occur as a primary process characterizing disorders, such as elastosis perforans serpiginosa and reactive perforating collagenosis, Occasionally, TE may occur as a secondary phenomenon. Well-known examples are perforating granuloma annuiare and pseudoxanthoma elasticum.

Pediculosis and the Pediatrician

Abstract: Head lice commonly evoke feelings of disgust, revulsion, anger, and shame among parents and patients. There should, however, be no great cause for such alarm if a physician suspects pediculosis capitis. The recent introduction of several new pediculicidal drugs now allows a choice among four distinct therapeutic agents, which should substantially improve control of isolated cases and epidemics. Physicians must be aware that consumer groups are pressing public health authorities and drug manufacturers to establish proper treatment standards and safety warnings for the use of these agents. In addition, some controversy surrounds the use of lindane in children. This paper reviews the epidemiology and clinical appearance of pediculosis capitis in children, with emphasis on these recent developments. Pubic lice (Phthirus pubis) and body lice (Pedicutus humanus corporis), both of which are much less common pediatric infestations, are mentioned only briefly.

Perilesional linear atrophic streaks associated with intralesional corticosteroid injections in a psoriatic plaque

Abstract: Perilymphatic atrophy can be a complication of intralesional corticosteroid injections given for the treatment of conditions such as psoriasis, alopecia areata, and keloids, and intraarticular corticosteroid injections given in diseases such as rheumatoid arthritis. It may become manifest as perilesional linear, depigmented, atrophic streaks, which are usually most prominent in patients with dark‐colored skin.

Keratoderma Hereditaria Mutilans (Vohwinkel's Syndrome): A Trial of Isotretinoin

Abstract: An 8‐year‐old girl with the classic findings of keraloderma heredilaria mutilans (Vohwinkels syndrome) was seen. Treatment with isotretinoin was instituted to decrease the hyperkeratosis and to prevent further autoamputation. After a 12‐week course at 2 mg per kg per day, the patient had only minimal decrease in the amount of hyperkeratosis. Because of Ihe well‐known long‐term risks of systematic retinoids and her suboptimal improvement, therapy was discontinued.

Erythema Multiforme: A Practical Approach to Recent Advances

In this edition of Pediatric Dermatology Samimi and Siegfried report the interesting and provocative case of a 9-year-oldgirlwithhypocomplementemicsystemiclupus erythematosus and severe nephritis. Over an approximate 3-week time span this very ill patient was treated withsevendiAerentagentsincludingintravenousandoral corticosteroids.Within2‐3weeks(andwhileonsteroids) she developed a fever and a widespread eruption involving her face, trunk, and the mucous membranes of her eyes,mouth,andvulva.Intravenouscefuroximewasthen added.Atthattimeadermatologyconsultantsuggesteda diagnosis of bullous lupus erythematosus or Stevens‐ Johnson syndrome (SJS). The skin biopsy favored SJS and a direct immunofluorescence study was negative. Furosemide was discontinued as ‘‘the most likely cause’’ but the disease progressed over the next 2 days. At this pointa4-daycourseofintravenousimmunoglobin(IVIg) (750 mg/kg/day) and the reinstitution of intravenous methylprednisolone 1 mg/kg every 12 hours was begun. Hydroxychloroquine and cefuroxime were discontinued and replaced by vancomycin and cefazidime. Her condition continued to deteriorate for the next 3 days with critical care management including skin debridement, transfusion of blood and albumin, and intubation with mechanical ventilation. Gradual improvement began 4daysafterstartingIVIgandthepatientwasdischarged3 weeks later. There are several important new points regarding severe erythema multiforme (EM) that are illustrated by thiscasereportandotherrecentpublications.Thisarticle will comment on the practical importance for the involved clinician of increased susceptibility to EM in high-risk patient groups (disease predisposition), genetic predisposition, and the role of drugs in causing and treating SJS/toxic epidermal necrolysis (TEN).

Advances in Nondietary Management of Children with Atopic Dermatitis

Abstract: This paper discusses recent advances in therapy of atopic dermatitis (AD), excluding those that include dietary management. Some of these therapies are anecdotal, experimental, or somewhat controversial. It is important to emphasize that physicians should not try what is new without first having given standard therapy a long and reasonable chance to succeed. This is important because AD does not last forever, and in many patients, mild disease heals spontaneously.

What's New in ’92— The Past Decade of Pediatric Dermatology

No other group of compounds has had such a major impact on pediatric dermatology as the retinoids. We are all aware of the significant advance in the treatment of acne with 13-cis retinoic acid. No other agent can transform mutilating nodulocystic acne into a prolonged remission after such a short period of therapy. Together with this benefit, however, has come the knowledge that it is probably one of the most teratogenic medications available. At least in the United States, desire to prevent damage to the unborn fetus, as well as concern over potential litigation, has directed an unprecedented amount of effort toward preventing pregnancies in women taking retinoic acid. Million-dollar awards are mentioned in publications such as the Wall Street Journal, and some attempt has been made to regulate the availability of this drug because of its effects on fetuses. It is currently the standard in the United States to require written, informed consent before prescribing this drug. In addition, pregnancy tests must be performed before the institution of therapy, as well as during and after treatment. If we are to continue to have access to 13-cis retinoic acid, it is our duty as pediatric dermatologists to warn other physicians about its hazards. Fortunately, other serious side effects have proved quite uncommon. Also of interest is the recent awareness that vitamin A may be useful in ameliorating some of the more severe signs and symptoms of measles. This is particularly pertinent because measles is increasingly frequent in many parts of North America. Large epidemics (several thousand cases) have been reported from major cities where inner-city poor have limited access to health care. Epidemics have also occurred among migrant farm workers and recent immigrants to the United States. Several publications (N Engl J Med 19W;323: 160-164) documented the efficacy of vitamin A 200,000 IU/day for two doses versus placebo in children with measles treated within five days of the onset of the rash. Most of these studies came from countries where dietary intake of vitamin A may be substantially less than in the United States, and transferring these results from one continent to another may not be justified. Nevertheless, patients treated with vitamin A had fewer days of pneumonia (6.3 vs 12.4), fewer cases of croup (13 vs 27), and fewer deaths (2 vs 10) than a comparable group of 27 children given placebo. It was the conclusion of the authors that all children with severe measles should be given vitamin A supplementation. Similar studies have been reported from the subcontinent of India. A recent paper (Pediatr Infect Dis J 1992; 11:203209) demonstrated that vitamin A increases specific antimeasles IgG and lymphocyte counts. This prospective, blinded, controlled trial of vitamin A in South African children with measles used 100 to 200,0(X) IU on days 2 and 8 versus placebo. Recovery was substantially quicker in the vitamin A group, and both specific antimeasles IgG and total lymphocyte counts were substantially higher, suggesting that they may be involved in the process of improvement.

Proceedings of the 15th Annual Meeting of the Society for Pediatric Dermatology

The fifteenth annual meeting of the Society for Pediatric Dermatology was held in San Diego. California, hosted by Drs. Angela Castellano, Gerald Goldberg, and Ronald Hansen. The sixth annual Sidney Hurwitz lecture was delivered by Dr. Rudolf Happie of the University of Nymegen, The Netherlands. He discussed genetic mosaicism in dermatology, which he divided into X-linked and autosomal phenotypes.

Proceedings of the 17th Annual Meeting of the Society for Pediatric Dermatology, July 29–31, 1993, Snowmass, Colorado

i\t l Clinic, Childrens Hospital Medical Center, Cincinnati, Oh oj\tDivision of Pediatric Dermatology, Childrens Hospital and University of California, San Diego School of Medicine, San Diego, California; ^Section of Fediatric Dermatology, Childrens National Medical Center, Washington, D.C.; and §Department of Dermatology and Pediatrics, University of Michigan Medical Center, Ann Arbor, Michigan