Nanette B. Silverberg

Calcipotriene and Corticosteroid Combination Therapy for Vitiligo

Abstract:  Corticosteroids and photochemotherapy, using a combination of psoralen and ultraviolet A (PUVA) exposure, are the most widely prescribed therapies for vitiligo. These treatments are not uniformly effective and many patients have inadequate responses. Calcipotriene has been shown to be effective in adults and children with psoriasis when used as monotherapy and in combination with corticosteroids and phototherapy. We hypothesized that since the mechanisms of action for calcipotriene and corticosteroids are different, patients may develop more repigmentation with a combination of the two agents, while decreasing the side effects from both agents.

Nickel contact hypersensitivity in children.

Nickel allergic contact dermatitis is the most prevalent allergy in North America, with an incidence of 14.3%. It is on the rise from 10 years ago, when the incidence was 10%. This has been presumed to represent an increased exposure to nickel in the environment—especially in costume jewelry and belt buckles. We examined a group of 30 pediatric patients who had either a personal history of umbilical or wrist dermatitis, or a family history of nickel allergic contact dermatitis. All of these patients had a positive patch test to nickel sulfate 5%. Moreover, 50% of patients had an id reaction; all of these patients had positive patch tests that were papular in nature, similar to their papular id reaction. We posit that the presence of a positive family history may be a positive predictor of nickel allergic contact dermatitis, requiring nickel avoidance, especially in atopic children. Based on the high level of positive reactions in patients with umbilical dermatitis and an id reaction, patch testing to nickel in these patients is most likely to yield a useful result. Knowledge of reactivity to nickel would then allow parents and patients to initiate nickel avoidance earlier in life.

Congenital Molluscum Contagiosum : Report of Four Cases and Review of the Literature

Abstract:  Molluscum contagiosum is a viral infection of the skin and mucous membranes that is caused by infection with the molluscum contagiosum virus. Molluscum contagiosum can be acquired from skin to skin contact which may be during play, in a swimming pool, or through sexual contact. Sexually acquired molluscum is rare in younger children, but becomes quite common during adolescence and young adulthood, after the sexual debut. It has been long known that the human papillomavirus, which causes genital warts, i.e., condyloma accuminatum, can be vertically transmitted through an infected genital tract. Children may not manifest condyloma lesions for a few years. The entity of congenital molluscum has been debated in the literature and only three cases of suspected congenital molluscum have been reported. We report on four more infants with congenital molluscum, two children with congenital lesions, and two children with onset of lesions at 6 weeks of age. Two children had single cutaneous lesions on the extremities and two had lesions of the scalp consistent with the site of cervical pressure. Congenital molluscum appears to be a more common entity than previously reported. Vertical transmission of molluscum should be considered for all infantile cases of molluscum.

Quality of Life Impairment in Children and Adolescents with Vitiligo

Vitiligo significantly affects quality of life (QOL) in adults, but little is known about the effect on QOL of pediatric vitiligo and whether the extent, distribution, and duration of vitiligo are associated with QOL. We performed an online parental questionnaire‐based study (N = 350) regarding children ages 0 to 17 years with vitiligo, including validated questions about body surface area (BSA), distribution, and age of onset of vitiligo, associated symptoms, and QOL using the Childrens Dermatology Life Quality Index (CDLQI). Vitiligo negatively affected numerous aspects of and total CDLQI score (median 3.0, interquartile range 5.0). Their vitiligo lesions did not bother only 4.1% of teenagers ages 15 to 17 years, versus 45.6% of children ages 0 to 6 years and 50.0% of those ages 7 to 14 years (p < 0.001). There was no association between the childs age and whether the childs vitiligo bothered the parents (p = 0.27). The most bothersome sites of vitiligo lesions for children and parents were the face (25.6% and 37.4%, respectively) and legs (26.2% and 26.2%, respectively). Eighty‐two patients (30.1%) reported itching and painful skin within the past week. Using multivariate ordinal logistic regression models, it was found that an affected BSA of more than 25% was associated with self‐consciousness, difficulty with friendships and schoolwork, and teasing and bullying. Lesions on the face and arms were associated with teasing and bullying. The extent of vitiligo is associated with QOL impairment in children and adolescents, especially self‐consciousness, but also bullying and teasing. Different distributions of vitiligo lesions are associated with different aspects of QOL impairment. Teenagers ages 15 to 17 years seem to experience the most self‐consciousness of all pediatric age groups.

Erythema Dyschromicum Perstans in Prepubertal Children

Abstract: Erythema dyschromicum perstans (EDP) is a rare disorder of pigmentation that is most common in Hispanic patients. In adults, EDP has a slow onset and is unlikely to resolve spontaneously. The etiology and clinical course in children is poorly defined. Physical examinations, chart reviews, and telephone interviews were performed for eight pediatric patients with EDP who were followed at Childrens Memorial Hospital in Chicago between 1990 and 1998. All the patients available for long‐term follow‐up (five of the eight) experienced complete clearance without recurrence in an average of 2.5 years. In all of our patients, the onset was noted from July to December. The administration of aminopenicillins was coincident with the development of EDP in two of the patients. Review of the English‐language literature reveals that 25 prepubertal children have previously been reported. Including our patients, 69% of prepubertal children with EDP experienced resolution. We concluded that the clinical course of childhood (prepubertal) EDP differs from that of adult EDP, and it is more likely to resolve within 2–3 years.

Tuberous sclerosis associated with congenital lymphedema.

To the Editors: Lichen nitidus (LN) is an uncommon cutaneous chronic eruption that usually affects children and young adults. It was described by Pinkus in 1907 (1) and is characterized by the presence of 1 to 2 mm, asymptomatic, skin-colored papules with a flat, shiny surface. Cutaneous lesions of LN are most often localized to the upper extremities, penis, abdomen, chest, and buttocks, but in some cases they can be generalized (2–4). The association with other systemic diseases is extremely rare, and to our knowledge LN has never been described in association with juvenile chronic arthritis. We report a 3-year-old girl who suffered from generalized lichen nitidus and developed polyarticular juvenile chronic arthritis months later. At the age of 11 months the infant began to have a generalized eruption consisting of papular lesions which were diagnosed by biopsy as lichen nitidus. At the age of 15 months, 10 days after receiving a triple viral vaccine, she developed a high fever with swelling and pain in the wrists and ankles for 4 days. When she was 24 months old she had a similar episode without previous infectious or vaccination antecedent that recurred at the age of 28 months, 3 days after she received antimeningococcal A+C vaccine. In spite of clinical improvement observed after these episodes, the swelling and impaired function of the affected joints persisted. Physical examination showed numerous small, flesh-colored papules which were generalized but predominated on the right side of the body, symmetrical polyarthritis of the proximal interphalangeal joints from the second to the fourth, metacarpusphalangical from the first to the fifth, wrists, knees, and ankles. Laboratory findings including complete serologic studies were normal. Rheumatoid factor and antinuclear antibodies were negative. Histologic examination of a skin biopsy specimen revealed a circumscribed lymphohistiocytic infiltrate in the superficial dermis that was characteristic of LN. After treatment with ibuprofen, methotrexate, and prednisone, a good clinical evolution was observed, with an increase in physical activity and improvement of articular function. Most patients suffering from LN have a spontaneous resolution of the lesions after several years, so treatment is not required. Some authors recommend treatment with topical steroids, astemizole, systemic steroids, or PUVA in generalized LN (4,5). Etretinate and acitretin have also been used in palmoplantar LN (6). In our patient, apart from hydration of the skin, specific treatment was not used, the lesions resolving with a residual hypopigmentation 2 years after onset. Familial cases or association with systemic diseases, aside from Crohn disease and atopic dermatitis, have not been reported (7,8). Kano et al. (7) described a 22-yearold man diagnosed with Crohn disease and erythema nodosum who developed LP and LN 2 years later. The clinical course of his LN and LP was independent of intestinal and erythema nodosum lesions. After evaluating immunohistochemical and gene expression studies, these authors suggest that the lesions of LN and LP are likely to be mediated by T cells with antigen specificity distinct from those that cause erythema nodosum and intestinal lesions. The observed association of generalized LN with juvenile chronic arthritis in our patient is the first description in the literature to our knowledge. In spite of the frequency of cutaneous manifestations in the connective tissue diseases, they are not as evident as in juvenile chronic arthritis, excepting the characteristic exanthem of this disease. Recently the development of skin alterations such as a rash in patients being treated with Dpenicillamine and gold salts has been reported (9). Two women suffering from rheumatoid arthritis who developed lesions of LP while being treated with sulfasalazine were described by Kaplan et al. (10). In our patient, the appearance of LN without administration of some type of antirheumatoid drug only a few months before the development of juvenile chronic arthritis, the coexistence of the lesions, and the occurrence of new outbreaks of LN, coinciding with worsening of the arthritis suggest to us that both diseases could be due to the same mechanism, probably immune. However, additional clinical observations and more complete studies are necessary to establish the possible link between these processes.

Cutaneous Manifestations of Chronic Renal Failure in Children of Color

Abstract: One hundred percent of adult patients with chronic renal failure (CRF) develop cutaneous findings as a result of uremia or due to therapeutic interventions. To date, pediatric incidence studies have been limited to Caucasian children. However, recent reports have indicated that more African American patients progress to end‐stage renal disease (ESRD). This is the first study to assess the prevalence of renal failure‐related skin disease in children of color, including African American and Hispanic patients. Thirty children were evaluated by history and physical examination, with assignment to one of three treatment categories: transplanted (n = 10), dialyzed (n = 16), or medically managed (n = 4). Skin findings were divided into uremic, drug‐related, or infectious disease types. The incidence of skin disease was 100%. Xerosis was the single most common finding, often accompanied by pruritus. Cushinoid features were common despite the addition of steroid‐sparing agents. Cyclosporin A‐treated African American children had a high incidence of gingival hypertrophy (72%) and an even higher incidence of hypertrichosis (100%). Acral warts and nevi were common findings, the latter correlating with the length of immunosuppression. There is a high incidence of cosmetically disfiguring side effects (Cushinoid facies, hypertrichosis, and gingival hypertrophy) in children within all treatment categories, primarily related to drug treatment. Further study is required to determine the long‐term sequelae, including psychological disturbances, of cutaneous disease in children of color with CRF.

Two cases of lichen striatus with prolonged active phase.

Lichen striatus is a localized, eczematous disorder distributed along the lines of Blaschko, primarily affecting children. In the literature, lesions have been described as having an active phase of inflamed lesions for 6 to 12 months followed by flattening and persistent pigmentary alteration. We describe two girls who had prolonged active‐phase lesions for 2.5 and 3.5 years, respectively. Practitioners should be aware that lesions of lichen striatus may have a prolonged active phase.

The “Jewelry Addict”: Allergic Contact Dermatitis from Repetitive Multiple Children's Jewelry Exposures

A 9‐year‐old girl with atopic dermatitis developed persistent plaques on the lips, hands, and fingers that were unresponsive to topical steroids. Her mother reported that she was “addicted” to costume jewelry and developed rashes in reaction to a number of adornments, ranging from rubber bracelets to costume metal jewelry and belt buckles. A careful history of jewelry exposures was taken and patch testing was performed to identify allergenic sources. Patch testing revealed allergy to nickel, gold, and thiuram mix. The case illustrates the importance of investigating a range of different types of allergens when evaluating for jewelry sensitivity in children with frequent use of accessories, including rubber jewelry, plastics, dyed yarns, beads, metals, and ceramics. This article provides an overview of jewelry allergies and the potential allergens requiring screening.

Pediatric Dermatology Training Survey of United States Dermatology Residency Programs

Variability exists in pediatric dermatology education for dermatology residents. We sought to formally assess the pediatric dermatology curriculum and experience in a dermatology residency program. Three unique surveys were developed for dermatology residents, residency program directors, and pediatric dermatology fellowship program directors. The surveys consisted of questions pertaining to residency program characteristics. Sixty‐three graduating third‐year residents, 51 residency program directors, and 18 pediatric dermatology fellowship program directors responded. Residents in programs with one or more full‐time pediatric dermatologist were more likely to feel very competent treating children and were more likely to be somewhat or extremely satisfied with their pediatric curriculums than residents in programs with no full‐time pediatric dermatologist (50.0% vs 5.9%, p = 0.002, and 85.3% vs 52.9%, p < 0.001, respectively). Residents in programs with no full‐time pediatric dermatologist were the only residents who were somewhat or extremely dissatisfied with their pediatric training. Residency program directors were more satisfied with their curriculums when there was one or more pediatric dermatologist on staff (p < 0.01). Residents in programs with pediatric dermatology fellowships were much more likely to report being extremely satisfied than residents in programs without a pediatric dermatology fellowship (83.3% vs 21.2%; p < 0.001). The results of this survey support the need for dermatology residency programs to continue to strengthen their pediatric dermatology curriculums, especially through the recruitment of full‐time pediatric dermatologists.