Paul J. Honig

Atopic dermatitis in children: Who cares? Who pays?

BACKGROUND Atopic dermatitis is an important cause of morbidity in children of all ages. Despite its high prevalence, there has been no examination of ways in which care for atopic dermatitis is delivered. OBJECTIVE This study reviewed the costs for care of childhood atopic dermatitis in an urban setting and estimated the national cost for treatment of the disease. METHODS We used data from one childrens hospital to study the use of the emergency room for atopic dermatitis and used national data sets to estimate the cost of care in the United States. RESULTS A large proportion of visits occur in the emergency department, during daytime office hours, and mostly by patients who have public insurance. The total national cost for treatment of childhood atopic dermatitis is

“Urticaria Multiforme”: A Case Series and Review of Acute Annular Urticarial Hypersensitivity Syndromes in Children

364 million annually, which is a conservative estimate. CONCLUSION Given its high prevalence, associated morbidity, and cost, resources must be better allocated to improve the organization of care for patients with atopic dermatitis.

Neonatal cutaneous fungal infections

Acute annular urticaria is a common and benign cutaneous hypersensitivity reaction seen in children that manifests with characteristic annular, arcuate, and polycyclic urticarial lesions in association with acral edema. It is mistaken most often for erythema multiforme and, occasionally, for a serum-sickness–like reaction. Although these 3 entities may present in a similar manner, specific clinical features help to distinguish them, and it is important for the clinician to be able to differentiate among them. We present herein a series of 18 patients who were given a diagnosis of acute annular urticaria and review the clinical distinctions between acute annular urticaria, serum-sickness–like reactions, and erythema multiforme. Because of the frequency of its clinical confusion with erythema multiforme, we propose the term “urticaria multiforme” as a more apt description to highlight the distinctive clinical features of this urticaria variant.

Naproxen-induced pseudoporphyria: A distinctive photodermatitis

Purpose of review Cutaneous fungal infections are not uncommon in newborns and are seen in premature or otherwise immunocompromised neonates as well as in healthy full-term neonates. Healthy newborns can develop clinical manifestations as a result of infection with Candida species or as a result of skin colonization with Malassezia species; cutaneous infection with other fungal pathogens is rare. Immunocompromised and premature neonates, however, are susceptible to infection with opportunistic pathogens and are also at higher risk for invasive infection with common pathogens such as Candida. This review discusses the fungal species associated with cutaneous fungal infection in neonates, emphasizes the relevant clinical features, and also reviews the use of newer antifungal agents, including lipid-associated amphotericin B, voriconazole, and caspofungin. Recent findings Neonatal cutaneous infections with opportunistic fungal pathogens, including Aspergillus and the Zygomycetes, have been reported with increasing frequency as advances in neonatal care have improved the survival rate in very low birthweight neonates. Although these infections are frequently fatal, survival in some neonates has been reported with the use of aggressive surgical debridement and systemic antifungal therapy. Newer antifungal agents, including voriconazole and caspofungin, show promise in the treatment of potentially fatal fungal infections in neonates. Summary Cutaneous fungal infections in neonates range from generally benign conditions such as congenital candidiasis and neonatal cephalic pustulosis to potentially fatal infections with opportunistic pathogens in very low birthweight or immunocompromised neonates. The prompt recognition and appropriate treatment of cutaneous fungal disease in neonates is critical to the prevention of adverse outcomes.

New Insights About Infant and Toddler Skin: Implications for Sun Protection

A distinctive photodermatitis developed in 22 children who had been receiving naproxen for prolonged periods. The eruption was marked by erythema, vesiculation, or increased skin fragility characterized by easy scarring of sun-exposed skin. Results of biochemical studies for porphyria were normal, and other causes of photosensitivity were believed to be unlikely. Of the 22 patients, 21 had juvenile rheumatoid arthritis; one patient had systemic lupus erythematosus. Twenty of the patients had fair skin and blue eyes. In each case, all findings except scarring resolved when naproxen was discontinued. Attention must be paid to complaints suggesting photosensitivity in children receiving naproxen.

Amoxicillin and diaper dermatitis

The skin is increasingly recognized as a component of the innate immune response, in addition to its role as a physical barrier. Although the deleterious effects of solar ultraviolet radiation (UVR), including immunosuppression and cutaneous tumorigenesis, are widely acknowledged, most studies to date have concentrated on adult skin. Despite the more sensitive nature of infant and toddler skin, little is known about its responses to UVR exposure, whether acute or long-term. Accumulating evidence suggests not only that the skins barrier protection remains immature throughout at least the first 2 years of life but also that accumulation of UVR-induced changes in the skin may begin as early as the first summer of life. Such evidence not only affirms the importance of sun protection during the infant and toddler years but underscores the need for more research to establish evidence-based standards of care in this area. In this article we review recent studies in which differences between the skin properties of infants and young children and those of adults were compared, and we discuss the implications of these differences for sun-protection practices.

Forehead Lipoblastoma Mimicking a Hemangioma

Multiple skin sites and the gastrointestinal tract of 57 infants with otitis media were cultured quantitatively for Candida albicans before and after antibiotic therapy. Ten days of systemic therapy with amoxicillin was associated with a twofold increase in the recovery of C. albicans from the rectum and skin. Infants who developed diaper dermatitis had a significant increase in the number of C. albicans organisms recovered from these sites. We conclude that the use of amoxicillin increases the risk for developing diaper dermatitis.

Hypocalcemic Tetany Following Hypertonic Phosphate Enemas

A case of forehead lipoblastoma simulating a hemangioma in a male infant is reported, to alert pediatricians to this rare tumor and to increase the index of suspicion in atypical hemangiomas. A 2-month-old male infant developed a protruding forehead mass with increased vascularity. It demonstrated progressive and accelerated growth over the subsequent 6 months, unresponsive to steroid therapy. A magnetic resonance imaging scan supported the diagnosis of hemangioma because of the hypervascular nature of the lesion. Surgical excision was performed because of visual obstruction. Pathologic examination of the specimen was consistent with a very primitive lipoblastoma. This tumor is a rare, benign lesion of immature fat cells that is found almost exclusively in the pediatric population. Lipoblastomas are more common in males than females and frequently present as asymptomatic, rapidly enlarging, soft lobular masses on the extremities. Complete surgical excision is the definitive treatment. In the vast majority of reported cases, however, the preoperative diagnosis was incorrect, underscoring the diagnostic dilemma presented by these rare tumors.

Nevus sebaceus in association with an intracranial mass

The Children’s Hospital of Philadelphia, Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pa. Correspondence to Paul J. Honig, M.D., The Children’s Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, Pa. 19104. HYPOCALCEMIC TETANY following absorption of inorganic phosphates from enemas has been reported in adults1.2 and only recently, in a child .3 This paper describes a five-month-old infant with an

H. influenzae pneumonia in infants and children.

A 7-week-old male infant with a seizure disorder and an extensive sebaceous nevus of the scalp was examined. Computerized axial tomography (CAT) scan identified an intracerebral mass which proved to be a hamartomatous malofrmation fo the brain. The association of intracranial masses with sebaceous nevi should be recognized. CAT scan is useful in the evaluation of infants with extensive lesions of the scalp or midline facial area, especially in the presence of neurologic abnormalities.