Leah Belazarian

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.

Safety of Systemic Agents for the Treatment of Pediatric Psoriasis

Importance Use of systemic therapies for moderate to severe psoriasis in children is increasing, but comparative data on their use and toxicities are limited. Objective To assess patterns of use and relative risks of systemic agents for moderate to severe psoriasis in children. Design, Setting, and Participants A retrospective review was conducted at 20 centers in North America and Europe, and included all consecutive children with moderate to severe psoriasis who used systemic medications or phototherapy for at least 3 months from December 1, 1990, to September 16, 2014. Main Outcomes and Measures The minimal core data set included age, sex, severity of psoriasis, systemic interventions, monitoring, adverse events (AEs), and reason for discontinuation. Results For 390 children (203 girls and 187 boys; mean [SD] age at diagnosis, 8.4 [3.7] years) with psoriasis who used 1 or more systemic medications, the mean interval between diagnosis and starting systemic therapy was 3.0 years. Methotrexate was used by 270 patients (69.2%), biologic agents (primarily etanercept) by 106 (27.2%), acitretin by 57 (14.6%), cyclosporine by 30 (7.7%), fumaric acid esters by 19 (4.9%), and more than 1 medication was used by 73 (18.7%). Of 270 children taking methotrexate, 130 (48.1%) reported 1 or more AEs associated with methotrexate, primarily gastrointestinal (67 [24.8%]). Folic acid 6 days per week (odds ratio, 0.16; 95% CI, 0.06-0.41; P < .001) or 7 days per week (OR, 0.21; 95% CI, 0.08-0.58; P = .003) protected against gastrointestinal AEs more than once-weekly folic acid, regardless of the total weekly dosage. Methotrexate-associated hepatic transaminase elevations were associated with obesity (35 of 270 patients [13.0%]), but a folic acid regimen was not. Injection site reactions occurred in 20 of 106 patients (18.9%) treated with tumor necrosis factor inhibitors, but did not lead to discontinuation of treatment. Having 1 or more AEs related to medication, gastrointestinal AE, laboratory abnormality, or AE leading to discontinuation of the drug was more likely with methotrexate than tumor necrosis factor inhibitors, but having 1 or more infections related to medication (predominantly upper airway) was less likely. Six patients developed a serious treatment-related AE (methotrexate, 3; fumaric acid esters, 2; and adalimumab, 1), but methotrexate and biologic agents were taken for a mean duration that was 2-fold greater than the mean duration for cyclosporine or fumaric acid esters. No patient developed tuberculosis or a malignant neoplasm. Conclusions and Relevance Medication-related AEs occur less often with tumor necrosis factor inhibitors than with methotrexate. Folic acid administration 6 or 7 times per week protected more against methotrexate-induced gastrointestinal AEs than did weekly administration. A prospective registry is needed to track the long-term risks of systemic agents for pediatric psoriasis.

The Integrated Skin Exam film: An educational intervention to promote early detection of melanoma by medical students

BACKGROUND Knowledge of the skin cancer examination (SCE) and its practice remain relevant competency gaps among medical students. OBJECTIVE We elaborate on a method of SCE known as the Integrated Skin Exam and discuss the development of an instructional film that illustrates its principles. We assess the tools effect on knowledge, attitudes, and perceptions related to the SCE. METHODS Second-year students among 8 randomized schools viewed the film and completed pre-post questionnaires. RESULTS After viewing The Integrated Skin Exam film, students demonstrated improved melanoma knowledge, including identification of high-risk demographic groups (61% vs 42.9%, P < .001), high-risk anatomic sites in women (88.6% vs 46.5%, P < .001) and men (92.1% vs 34.8%, P < .001), and the ABCDEs of melanoma (98.4% vs 91.2%, P < .001). Students demonstrated increased confidence in the SCE (66.93% vs 16.40%, P < .001) and augmented intentions to practice it (99.05% vs 13.9%, P < .001). A greater proportion (70.4% vs 41.9%, P < .001) of students thought less than 3 minutes were required to integrate SCE into the routine examination. LIMITATIONS Longitudinal impact of the film was not assessed. CONCLUSION The Integrated Skin Exam film introduces an integrated approach to the SCE that addresses knowledge gaps, mitigates perceived barriers, and augments intention related to practice of the SCE.

The deep penetrating nevus

The deep penetrating nevus (DPN), also known as the plexiform spindle cell nevus, is a pigmented lesion that commonly arises on the head and neck in the first few decades of life. Histopathologically, the DPN is wedge-shaped and contains melanocytes that exhibit deep infiltration into the dermis. Given these features, DPN may clinically and histopathologically mimic malignant melanoma, sparking confusion about the appropriate evaluation and management of these lesions. The goal of this review is to summarize the clinical and histopathological features of DPN and to discuss diagnostic and treatment strategies for dermatologists.

New insights and therapies for teenage psoriasis.

Purpose of review Psoriasis is an important disorder in the adolescent population and has a tremendous physical and psychological impact on patients. It is important to understand the genetics, various clinical presentations, comorbidities, and treatment options associated with psoriasis. Recent findings The human leukocyte antigen-C gene likely contains a susceptibility locus for psoriasis. Cytokines interleukin-12 and interleukin-23 have been implicated in the pathogenesis of psoriasis as well. Psoriasis is likely associated with an increased risk of myocardial infarction, metabolic syndrome, Crohns disease, and depression; it is difficult to assess the implications in the adolescent population. Summary Psoriasis is not rare in the adolescent population. It is important for physicians to be aware of the different clinical presentations as well as the spectrum of treatment options that are available.

Pityrosporum Folliculitis: A Retrospective Review of 110 Cases

Background Pityrosporum folliculitis is an under‐recognized eruption of the face and upper portion of the trunk that may be confused with, or occur simultaneously with, acne vulgaris. Objective We sought to characterize risk factors for Pityrosporum folliculitis, its clinical presentation, and its response to treatment. Methods A retrospective chart review was performed on all patients age 0 to 21 years seen at our facility from 2010 to 2015 with Pityrosporum folliculitis confirmed by a potassium hydroxide preparation. Results Of 110 qualifying patients, more than 75% had acne that had recently been treated with antibiotics, and when recorded, 65% reported pruritus. Clinical examination demonstrated numerous 1‐ to 2‐mm monomorphic papules and pustules that were typically on the forehead extending into the hairline and on the upper portion of the back. The most common treatment was ketoconazole shampoo, which led to improvement or resolution in most cases. Some patients required oral azole antifungals. Limitations This study was retrospective and relied on providers describing and interpreting the clinical findings and potassium hydroxide preparations. No standard grading system was used. Conclusion Unlike classic acne vulgaris, Pityrosporum folliculitis was more common after antibiotic use. It presented as fine monomorphic, pruritic papules and pustules along the hairline and on the upper portion of the back, and it improved with topical or oral azole antifungal therapy.

Chevron nails: a normal variant in the pediatric population.

A 7‐month‐old girl was evaluated for V‐shaped ridging of the fingernails consistent with chevron nails. Chevron nails are a normal variant in the pediatric population that is frequently outgrown. This case nicely demonstrates this normal finding that has so rarely been reported in the literature.

Satisfaction with care and likelihood to recommend ratings attributed to dermatology trainees

To the Editor: The Affordable Care Act directs value-based adjustments to Medicare payments that account for quality measures, including patient satisfaction. However, federally mandated or third-party vendor surveys do not capture unique considerations for academic institutions, including trainee involvement in patient care. Trainees typically have the initial, most durable, and sometimes the most consistent contact with the patient, yet little is known about care experiences attributed to them. We sought to prospectively evaluate the factors associated with highest ratings for satisfaction-withcare (SWC) and likelihood-to-recommend (LTR) attributed to dermatology trainees at Northwell Health and 6 other institutions with accredited programs ranging in size and location. Adults (n 1⁄4 1520) participated in an anonymous survey immediately after completing an encounter with 1 of 84 trainees (Table I). Survey responses, which were based on 5-point Likert scales, were dichotomized to identify factors associated with the highest ratings. Covariates having P values\.25 in bivariate analyses were included in multivariable regression models for each primary outcome. Fixed effects indicator variables were added to account for clustering. Final regression models used complete data from 81.9% (1245/1520) of patients. Highest SWC and LTR ratings were provided to trainees in 86.7% and 83% of encounters, respectively. Patients rating their skin health as good and excellent were more likely to provide highest SWC and LTR ratings, as were those rating overall experience with the health care institution as excellent (Table II). Importantly, factors such as sex concordance, postgraduate year, continuity encounters or number of prior visits with the trainee, and expecting to see a trainee had less (or no) influence on experience ratings than factors unrelated to the trainees themselves. In a study involving family medicine trainees, 92% of patients rated their satisfaction as good to excellent. Prior studies also support the association of satisfaction with self-reported health status and with system performance. With respect to achievement of training milestones, our results on satisfaction attributed to dermatology trainees should reassure training directors, faculty, and residents. If asked, most patients might also endorse the same sense of reassurance. However, based on institutional and national benchmarking, raw scores #90 points typically translate into below target percentile scores for dermatology providers. Whether ratings attributed to dermatology trainees have an influence on experience scores ultimately assigned to the provider of record needs to be explored further. Curricular opportunities might exist for trainees aimed at improving the patient experience, in particular for patients with poor skin health. Trainees must also appreciate that, as stewards of the patient experience, their halo effect facilitates learning opportunities for others. Likewise, we may speculate that institutional reputation might afford trainees initial trust from patients. In balancing the interests of programmatic training objectives, including advancement of graduated autonomy, programs can also make a deliberate effort to educate patients on its training mission, the roles of trainees and their prior education, and the responsibilities maintained by attending physicians throughout the episode of care. Institutions must also support these educational initiatives while also recognizing the complexities accounting for the patient experience.

Menkes Disease Mimicking Child Abuse

Althouygh Menkes disease has well‐recognized neurologic, developmental, and cutaneous features, the initial presentation may resemble child abuse. We describe a 5‐month‐old boy with multiple fractures indicative of nonaccidental trauma who was ultimately diagnosed with Menkes disease. Copper deficiency leads to connective tissue abnormalities and may result in subdural hematomas, wormian bones, cervical spine defects, rib fractures, and spurring of the long bone metaphyses. Several of these findings, including fractures and subdural hematomas, may be misinterpreted as child abuse.

Multiple Café au Lait Spots in a Group of Fair-Skinned Children without Signs or Symptoms of Neurofibromatosis Type 1.

The presence of six or more café au lait (CAL) spots is a criterion for the diagnosis of neurofibromatosis type 1 (NF‐1). Children with multiple CAL spots are often referred to dermatologists for NF‐1 screening. The objective of this case series is to characterize a subset of fair‐complected children with red or blond hair and multiple feathery CAL spots who did not meet the criteria for NF‐1 at the time of their last evaluation.