Kelly M. Cordoro

Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies.

Atopic dermatitis is a common and chronic, pruritic inflammatory skin condition that can affect all age groups. This evidence-based guideline addresses important clinical questions that arise in its management. In this second of 4 sections, treatment of atopic dermatitis with nonpharmacologic interventions and pharmacologic topical therapies are reviewed. Where possible, suggestions on dosing and monitoring are given based on available evidence.

Guidelines of care for the management of atopic dermatitis: Section 3. Management and treatment with phototherapy and systemic agents

Atopic dermatitis is a chronic, pruritic inflammatory dermatosis that affects up to 25% of children and 2% to 3% of adults. This guideline addresses important clinical questions that arise in atopic dermatitis management and care, providing recommendations based on the available evidence. In this third of 4 sections, treatment of atopic dermatitis with phototherapy and systemic immunomodulators, antimicrobials, and antihistamines is reviewed, including indications for use and the risk-benefit profile of each treatment option.

“Eczema Coxsackium” and Unusual Cutaneous Findings in an Enterovirus Outbreak

OBJECTIVE: To characterize the atypical cutaneous presentations in the coxsackievirus A6 (CVA6)–associated North American enterovirus outbreak of 2011–2012. METHODS: We performed a retrospective case series of pediatric patients who presented with atypical cases of hand, foot, and mouth disease (HFMD) from July 2011 to June 2012 at 7 academic pediatric dermatology centers. Patients were included if they tested positive for CVA6 or if they met clinical criteria for atypical HFMD (an enanthem or exanthem characteristic of HFMD with unusual morphology or extent of cutaneous findings). We collected demographic, epidemiologic, and clinical data including history of skin conditions, morphology and extent of exanthem, systemic symptoms, and diagnostic test results. RESULTS: Eighty patients were included in this study (median age 1.5 years, range 4 months–16 years). Seventeen patients were CVA6-positive, and 63 met clinical inclusion criteria. Ninety-nine percent of patients exhibited a vesiculobullous and erosive eruption; 61% of patients had rash involving >10% body surface area. The exanthem had a perioral, extremity, and truncal distribution in addition to involving classic HFMD areas such as palms, soles, and buttocks. In 55% of patients, the eruption was accentuated in areas of eczematous dermatitis, termed “eczema coxsackium.” Other morphologies included Gianotti-Crosti–like (37%), petechial/purpuric (17%) eruptions, and delayed onychomadesis and palm and sole desquamation. There were no patients with serious systemic complications. CONCLUSIONS: The CVA6-associated enterovirus outbreak was responsible for an exanthem potentially more widespread, severe, and varied than classic HFMD that could be confused with bullous impetigo, eczema herpeticum, vasculitis, and primary immunobullous disease.

Guidelines of care for the management of atopic dermatitis: Section 4. Prevention of disease flares and use of adjunctive therapies and approaches

Atopic dermatitis is a common, chronic inflammatory dermatosis that can affect all age groups. This evidence-based guideline addresses important clinical questions that arise in its management. In this final section, treatments for flare prevention and adjunctive and complementary therapies and approaches are reviewed. Suggestions on use are given based on available evidence.

Efficacy and Safety of Oral Immunotherapy with Short Ragweed Extract

BACKGROUND Oral immunotherapy, if proven safe and effective, could be an alternative to subcutaneous immunotherapy. OBJECTIVE This pilot study investigated the clinic and immunologic effects of ragweed immunotherapy using a new microencapsulated, pH-sensitive, oral delivery system. METHODS A double-blind, placebo-controlled trial was conducted in 23 patients with allergic rhinitis to short ragweed. Following a baseline nasal challenge with ragweed allergen, oral immunotherapy with encapsulated short ragweed extract or placebo was administered once daily, 6 days/week. Dosed began at 3 micrograms Amb a 1 per day and were increased by 3 micrograms every three days as tolerated, to a maximum daily maintenance dose of 24 micrograms. A nasal challenge was repeated 6 weeks, later, followed by the continuation of maintenance therapy through the natural ragweed season. Daily allergy symptoms and relief medication usage was recorded. A final nasal challenge was performed at the end of the natural season. Short ragweed-specific serum IgE, IgG, and IgG4 antibody levels were measured every 2 weeks during the study. RESULTS Maximum tolerated doses ranged from 6 to 24 micrograms Amb a 1 per day (74% reached 24 micrograms). Adverse events were not serious or different between the active and placebo groups. The active group showed increased in short ragweed-specific serum IgG and IgG4 antibody levels. Symptom scores during the natural season were numerically but not statistically lower in the active treatment group. This group also experienced a greater reduction from baseline in nasal reactivity as assessed by nasal challenge. CONCLUSIONS These pilot data suggest that the encapsulated, pH-sensitive oral immunotherapy delivery system was safe, induced a brisk serologic response, and attenuated the symptomatic response to both experimental and environmental ragweed exposure.

Early detection of melanoma: reviewing the ABCDEs.

Over the course of their nearly 30-year history, the ABCD(E) criteria have been used globally in medical education and in the lay press to provide simple parameters for assessment of pigmented lesions that need to be further evaluated by a dermatologist. In this article, the efficacy and limitations of the ABCDE criteria as both a clinical tool and a public message will be reviewed.

Clinical Manifestations of Pediatric Psoriasis: Results of a Multicenter Study in the United States

The clinical features of pediatric psoriasis warrant further attention. A national study was conducted to determine the prevalence of scalp and nail involvement and a history of guttate psoriasis at onset according to age, sex, and disease severity. One hundred eighty‐one children ages 5 to 17 years with plaque psoriasis were enrolled in a multicenter, cross‐sectional study. Subjects and guardians were asked about a history of scalp and nail involvement and whether the initial presentation was guttate. Peak psoriasis severity was assessed and defined historically as mild psoriasis (MP) or severe psoriasis (SP) according to the Physicians Global Assessment and body surface area measures. One hundred forty‐three (79.0%) subjects reported a history of scalp involvement, and 71 (39.2%) described a history of nail involvement. Boys were less likely than girls to report a history of scalp involvement (odds ratio [OR] = 0.40, 95% confidence interval [CI] = 0.19–0.84) but more likely to have had nail involvement (OR = 3.01, 95% CI = 1.62–5.60). Scalp and nail involvement was not related to psoriasis severity. In contrast, subjects with SP (35.9%) more often reported a history of guttate lesions than did those with MP (21.8%) (p = .02). Antecedent streptococcal infection was more common in children with guttate than those with plaque psoriasis at onset (p = .02) but did not correlate with severity. Sex‐related differences in scalp and nail involvement suggest koebnerization. Preceding streptococcal infection predicts guttate morphology but not severity, and initial guttate morphology is associated with eventual greater severity of disease. More aggressive monitoring and management should be considered for guttate psoriasis, given its later association with more severe disease.

Central Obesity and High Blood Pressure in Pediatric Patients With Atopic Dermatitis

IMPORTANCE Atopic dermatitis (AD) is associated with multiple potential risk factors for obesity and high blood pressure (BP), including chronic inflammation, sleep disturbance, and mental health comorbidity. Previous studies found associations between general obesity and AD. However, it is unknown whether AD is associated with central obesity and/or high BP. OBJECTIVES To determine whether central obesity and high BP are increased in pediatric AD. DESIGN, SETTING, AND PARTICIPANTS This case-control study performed in multicenter pediatric dermatology practices in the United States recruited 132 children (age range, 4-17 years) with active moderate to severe AD and 143 healthy controls from April 1, 2009, through December 31, 2012. EXPOSURES Diagnosis and severity of AD assessed by a pediatric dermatologist. MAIN OUTCOMES AND MEASURES Body mass index, waist circumference, waist to height ratio, systolic BP, and diastolic BP. RESULTS Moderate to severe AD was associated with body mass index for age and sex of 97th percentile or greater (logistic regression; odds ratio [OR], 2.64; 95% CI, 1.15-6.06), International Obesity Task Force obesity cutoffs (OR, 2.38; 95% CI, 1.06-5.34), waist circumference in the 85th percentile or greater (OR, 3.92; 95% CI, 1.50-10.26), and waist to height ratio of 0.5 or greater (OR, 2.22; 95% CI, 1.10-4.50). Atopic dermatitis was associated with higher BP for age, sex, and height percentiles (systolic BP: OR, 2.94; 95% CI, 1.04-8.36; diastolic BP: OR, 3.68; 95% CI, 1.19-11.37), particularly a systolic BP in the 90th percentile or higher (OR, 2.06; 95% CI, 1.09-3.90), in multivariate models that controlled for demographics, body mass index and waist circumference percentiles, and history of using prednisone or cyclosporine. Atopic dermatitis was associated with higher systolic BP in Hispanics/Latinos (general linear model; β, .23; 95% CI, .04-.43) and Asians (β, .16; 95% CI, .03-.30). Severe to very severe AD was associated with systolic BP in the 90th percentile or higher (adjusted OR, 3.14; 95% CI, 1.13-8.70). Atopic dermatitis was associated with a family history of hypertension (adjusted OR, 1.88; 95% CI, 1.14-3.10) and type 2 diabetes mellitus (adjusted OR, 1.64; 95% CI, 1.02-2.68) but not obesity or hyperlipidemia. CONCLUSIONS AND RELEVANCE Moderate to severe pediatric AD may be associated with central obesity and increased systolic BP.

Physiologic changes in vascular birthmarks during early infancy: Mechanisms and clinical implications

Vascular birthmarks are the most common birthmarks encountered in newborns. Many dermatologists are unfamiliar with the normal physiologic changes that affect and alter their appearance during early infancy. In this article we discuss normal newborn hemodynamic/neurovascular physiology and the associated clinical findings in neonatal skin. The physiologic anemia of infancy and its resultant effects on skin color and the appearance of vascular birthmarks are detailed. Finally, the pitfalls and obstacles to early diagnosis of vascular birthmarks and the subtle differences between them are reviewed, as are the challenges in assessing response to early pulsed dye laser treatment in the context of the changing vascular physiology.

Systemic Treatments for Severe Pediatric Psoriasis: A Practical Approach

Severe psoriasis is uncommon in children, but when it occurs, can be physically, emotionally and socially disabling. Systemic treatments such as phototherapy, acitretin, methotrexate and cyclosporine have been used to manage severe pediatric psoriasis for decades. Newer biologic agents have demonstrated their effectiveness in adult psoriasis and are accumulating promising data in children. This article discusses the use of these treatments including their indications, efficacy, adverse effects, and monitoring requirements. The aim is to provide practical, clinically relevant information regarding the use of these medications alone and in various combinations based on available evidence and cumulative experience.