James G. Dinulos

Effect of cat and daycare exposures on the risk of asthma in children with atopic dermatitis

Atopic dermatitis (AD) in young children is often followed by the development of asthma (atopic march). The role of environmental exposures is unclear in this high-risk population. We aimed to determine the predictive relationship between indoor allergen exposures, particularly pets, rodents, and cockroaches, to the development of asthma in a prospective pediatric cohort. Children with AD and a family history of allergy were followed prospectively with questionnaire ascertainment of environmental exposure to cats, dogs, cockroaches, rats, and mice. Asthma was diagnosed by study physicians based on caregiver reports of symptoms continually assessed over the course of the study period. Fifty-five of the 299 children developed asthma by the end of the study. Cat exposure had a strong and independent effect to reduce the risk of developing asthma across all analyses (odds ratio [OR], 0.16; 95% confidence interval [CI], 0.05-0.53). Dog, mouse, rat, and cockroach exposures did not significantly influence the development of asthma. Daycare exposure had the largest risk reduction for the development of asthma (OR, 0.08; 95% CI, 0.03-0.19). Maternal asthma (OR, 2.93; 95% CI, 1.29-6.67), baseline body mass index (OR, 1.23; 95% CI, 1.08-1.42), and specific immunoglobulin E to house-dust mix at 3 years were each independent risk factors for the development of asthma. In children with AD, cat and daycare exposure may reduce the risk of developing early childhood asthma.

A Business Case for Shared Medical Appointments in Dermatology: Improving Access and the Bottom Line

OBJECTIVES To evaluate the economic viability of shared medical appointments (SMAs) in dermatology. Secondary objectives include a comparison of the hourly adjusted census levels generated by SMAs compared with regular clinic appointments (RCAs), as well as a comparison between the economic viability of dermatology SMAs and SMAs in other fields of medicine. DESIGN Cost-benefit analysis. SETTING Outpatient clinics within an academic medical center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire. PATIENTS No patient-identifying information was obtained or reported. The SMA census data included 301 SMAs (11 different programs and 5 separate departments), representing 2045 appointments over 16 months. Comparisons between patient groups were based on data from the SMA census and mean provider census (MPC) for RCAs, matched on reason for appointment. MAIN OUTCOME MEASURES Hourly adjusted census levels and profit differences (charges less costs) between SMAs and MPC for RCAs. RESULTS All individual and departmental SMAs generated significantly higher mean census levels and profits per hour than the respective non-SMA MPC of the health care provider leading the SMA (individual, P < .05; departmental, P < .001). All dermatology SMAs generated significantly greater differences in hourly adjusted census levels and profit in comparisons between SMAs and MPC for RCAs than the respective measures in all other departments (P < .001). CONCLUSION Taken together, the results of this study provide strong evidence to support a business case for SMAs in dermatology as a means of simultaneously improving access, productivity, and the bottom line.

Childhood skin and soft tissue infections: new discoveries and guidelines regarding the management of bacterial soft tissue infections, molluscum contagiosum, and warts.

Purpose of review Pediatric skin and soft tissue infections (SSTIs) constitute a significant number of office-based pediatric visits. With SSTIs on the rise, it is not only important to effectively treat the individual, but to do so appropriately and cost-consciously. In this article, we highlight new research related to the treatment of bacterial skin infections, molluscum contagiosum, and cutaneous warts, with the goal of guiding pediatricians in their practice against these common skin conditions. Recent findings Recent data supports the use of topical antibiotics for noncomplicated impetigo. Systemic antibiotics covering gram-positive cocci are recommended for complicated cases of impetigo and deeper nonpurulent SSTIs. Localized purulent bacterial SSTIs can be treated with incision and drainage alone but more systemic involvement warrants treatment with systemic antibiotics covering Staphylococcus aureus species, especially community acquired methicillin-resistant S. aureus. For the treatment of molluscum contagiosum, topical cantharidin has a high satisfaction rate among patients and providers. Potassium hydroxide solution is a potentially effective and cheap form of molluscum contagiosum treatment. Imiquimod, however, has an unfavorable efficacy and safety profile as a therapy for molluscum contagiosum. Regarding warts, high-risk human papilloma virus strains have been detected in cutaneous warts in children. Summary The high-risk human papilloma virus vaccine may play a role in treating pediatric cutaneous warts in the future, and topical squaric acid dibutylester may effectively treat recalcitrant warts. Finally, both molluscum contagiosum and warts have a high rate of resolution after an extended period of time without any intervention.

Dermal melanocytosis and associated disorders.

Purpose of review Dermal melanocytosis is commonly seen in the newborn period and is frequently a concern to parents and providers. Four clinically distinct entities are recognized: nevus of Ota, nevus of Ito, Mongolian spots, and dermal melanocyte hamartoma. This article reviews these disorders, with special emphasis on melanocyte biology and important associated systemic disorders such as rare malignant transformations and inborn errors of metabolism. Recent findings Recent findings have highlighted the increased risk of malignancy in patients with nevus of Ota, especially ocular, central nervous system, and cutaneous tumors. Although rarely seen, cutaneous melanoma occurs in association with nevus of Ito. Extensive, dark, and progressive Mongolian spots may be more likely than isolated lesions to be associated with inborn errors of metabolism, such as Hurlers disease and monosialotetrahexosylganglioside (GM1) gangliosidosis. New laser technology utilizing Q-switched alexandrite lasers has shown promise for the cosmetic improvement of dermal melanocytosis. Summary While most dermal melanocytosis resolves by the toddler years and does not pose long-term risks to the affected individuals, some patients may have underlying associated conditions that pose significant health concerns. Pediatric care providers must be familiar with these associated conditions and refer to a dermatologist when in doubt, to confirm the diagnosis and determine appropriate follow-up care.

Atypical Stevens-Johnson syndrome?

2. In general, auditory brainstem response (ABR) waves I, III, and V cannot be detected in all premature infants at a gestational age of 32 weeks’ as outlined in the methods section of our study. The ABR’s interpeak latencies were calculated only if absolute wave latencies required to measure interpeak latencies were available for a particular subject. These interpeak latencies were then averaged and reported in our Table 2. The subjects with ABR types II and III may not have had all 3 (wave I, II, and III) absolute latencies measurable. In this case, interpeak latencies were not measurable; however, the measured absolute wave latencies were reported. For example, for a subject with only absolute wave III identified and measured, interpeak latencies I–III, III–V, and I–V cannot be measured. This explains the difference in the values between calculated interpeak latencies that were derived by using the mean wave I and V latencies and the reported interpeak latencies (shown in our Table 2). The same reason explains the importance of using response types, which takes into account unmeasured absolute and interpeak latencies.

Core concepts in congenital melanocytic nevi and infantile hemangiomas.

Purpose of review Congenital melanocytic nevi (CMN) and infantile hemangiomas are commonly encountered in newborns and may present diagnostic and therapeutic dilemmas for medical practitioners. Herein, we review and discuss these two important clinical entities and focus on core issues and recent advances. Recent findings Melanoma risk for patients with CMN is greatest in infants with large CMN located on the trunk, CMN greater than 40 cm, and multiple satellite nevi. Recent histological and molecular findings have been described to assist in differentiating benign proliferative nodules arising in CMN from melanoma. Multiple CMN and associated neurological lesions have recently been shown to be due to a single postzygotic mutation in NRAS [neuroblastoma RAS viral (v-ras) oncogene homolog]. Over the last several years, numerous advancements have occurred in redefining the clinical course of infantile hemangiomas, describing clinical syndromes associated with infantile hemangiomas and treating complicated infantile hemangiomas. The nonselective &bgr;-blocker propranolol has become first-line therapy for the treatment of complicated infantile hemangiomas. Topical timolol shows promise for the treatment of certain types of infantile hemangiomas. Summary Although most CMN and infantile hemangiomas do not require active intervention, understanding which lesions may impact the overall health of the infant assists in early intervention. This article touches on core concepts in the clinical evaluation and treatment of CMN and infantile hemangioma.

Acute lymphocytic leukemia presenting as an isolated scalp nodule in an infant.

We describe the presentation and management of a patient referred for a presumed benign scalp lesion in infancy. The subcutaneous nodule was ultimately diagnosed as the first manifestation of acute lymphoblastic leukemia. We review leukemia cutis with special emphasis on the differential diagnosis of scalp nodules in infancy that may be encountered by the plastic surgeon.

Cosmeceuticals for children: should you care?

Purpose of review Cosmeceuticals are substances that exert physiologic changes to the skin for aesthetic purposes and are popular alternatives to invasive cosmetic procedures for antiaging. Cosmeceuticals are being used on children; yet studies of cosmeceuticals in the pediatric population are limited. Recent findings Cosmeceuticals remain an unrecognized category by the US Food and Drug Administration, and therefore stringent regulatory pathways do not exist to guide research and marketing. To date, no safety and efficacy study exists on cosmeceutical use in pediatric patients. Increasing knowledge of the mechanisms underlying intrinsic and extrinsic skin aging, including reactive oxygen species formation, effects of declining hormones, and ultraviolet radiation, forms the scientific basis for common cosmeceuticals such as retinoids, botanicals such as soy isoflavones, and even moisturizers and sunscreen. Virtually all studies on cosmeceuticals have been performed in women with varying degrees of skin aging. The cosmeceuticals most likely to be used by younger children are moisturizers and sunscreens. As the popularity and availability of other antiaging cosmeceuticals grow, practitioners will encounter more and more beauty-conscious teenagers using these products for preventive rather than restorative purposes. Summary Pediatricians should be familiar with the use of common cosmeceuticals used in children, especially the use of broad-spectrum sunscreen. In the future, more children will be exposed to cosmeceuticals and may experience side effects such as contact dermatitis and skin irritation.

Annular elastolytic giant cell granuloma after a cardiac pacemaker implantation

Annular elastolytic giant cell granuloma (AEGCG) is an uncommon condition belonging to the family of elastolytic granuloma, which also includes actinic granuloma, atypical necrobiosis lipoidica of the face and scalp, and Mieschers granuloma.1 Classification of AEGCG as a distinct entity has been controversial. Although some consider it synonymous with actinic granuloma, a term often used interchangeably with AEGCG in the literature, others regard elastolytic granulomas as a variant of granuloma annulare.2, 3 These controversies exist largely because the etiology and pathogenesis of AEGCG is still unknown. Here we describe an unusual case of AEGCG that developed after a cardiac pacemaker implantation. The circumstances that surrounded the eruption of our patients rash may suggest that trauma is a possible trigger for AEGCG.

Cutaneous manifestations of systemic viral diseases in neonates: an update

Purpose of review Dermatologic findings may be the first signs of a neonatal viral infection. This review provides an update of the diagnostic features and therapies for selected viral illnesses [herpes simplex virus (HSV), varicella zoster virus, enterovirus, and Zika virus] that present with cutaneous manifestations in the neonate. Recent findings HSV DNA polymerase chain reaction of plasma and cerebrospinal fluid, routinely used in the diagnosis of neonatal HSV, may have expanded utility in assessing prognosis and acyclovir therapeutic efficacy. Maternal antiviral suppressive therapy may alter the clinical appearance of congenital HSV, resulting in delayed diagnosis and treatment. VariZIG, a varicella zoster immune globulin, is a US Food and Drug Administration approved form of prophylaxis for varicella. The Centers for Disease Control and Prevention has expanded the period of VariZIG eligibility for preterm infants, a group particularly susceptible to severe varicella infection. For severe neonatal enterovirus sepsis, the results of a randomized, double-blind, placebo-controlled trial of pleconaril, a viral capsid inhibitor, suggest that this compound is an effective therapy. Human Parechovirus type 3, a strain within a newly formed viral genus, has a similar, and potentially underestimated, clinical presentation to enterovirus sepsis. However, a distinctive erythematous palmoplantar rash may be specific to human Parechovirus type 3 infection. Perinatal Zika virus infection in the neonate may present with a nonspecific macular and papular rash. As this rash is not specific, obtaining a maternal travel history and, if appropriate, requesting additional diagnostic testing are critical for early diagnosis. Summary Neonatal rashes may be harmless and transient, whereas others may reflect the presence of a severe systemic illness. Recognizing key cutaneous features of viral-associated rashes may aid in the prompt and accurate diagnosis and treatment of neonatal viral illnesses.