Saxon D Smith

Corticosteroid phobia and other confounders in the treatment of childhood atopic dermatitis explored using parent focus groups.

Background/Objectives:  Anxieties associated with corticosteroid treatment and preference for ‘safer natural therapy’ are common in parents of children with atopic dermatitis. We used focus groups to explore the source of these attitudes.

Childhood Onset Vulvar Lichen Sclerosus Does Not Resolve at Puberty: A Prospective Case Series

Abstract:  When vulvar lichen sclerosus occurs in prepubertal children it is widely believed that it is likely to remit at puberty. However when it occurs in adult women it is accepted that remission is unlikely and that in addition untreated or inadequately treated disease may be complicated by significant disturbance of vulvar architecture and less commonly squamous cell carcinoma. Our database reveals 18 girls who developed lichen sclerosus prior to puberty who are now adolescents or young adults. Twelve have remained under surveillance and the other six patients have been lost to follow‐up. We report a prospective series of these 12 patients. Three patients have achieved complete remission sustained for three or more years, all prior to menarche. Nine patients, or 75% of the cohort, who still had active lichen sclerosus at puberty continue to require maintenance therapy after menarche. Of the 12, six have had significant disturbance of vulvar architecture. The concept that prepubertal lichen sclerosus resolves at puberty would appear not to be true in the majority of patients. Even when diagnosed early and treated effectively, childhood onset lichen sclerosus may be complicated by distortion of vulvar architecture.

Evaluation of the Atrophogenic Potential of Topical Corticosteroids in Pediatric Dermatology Patients

Abstract:  We conducted a cross‐sectional observational study to determine the atrophogenic potential of TCS in children with dermatitis requiring long‐term TCS suppression. Children who were able to achieve good disease control, with a maximum Eczema Area and Severity Index score of 1.0, using TCS were examined for adverse effects of treatment. Cutaneous atrophy was assessed using a validated dermoscopic technique. Cutaneous sites exposed to TCS were compared with nonexposed sites in all patients. There was no significant atrophy in 70 TCS‐exposed and 22 TCS‐naïve children. Mild grade 1 telangiectasia of the cubital fossa was observed in 3.3% of the test group and 3.1% of the control group (p > 0.99). We conclude that routine, appropriate, long‐term use of TCS in children with dermatitis does not cause skin atrophy. These data do not support the widely held belief that routine use of TCS will “thin the skin.” Parents, pharmacists, and health practitioners should be confident about the safety of using this treatment.

Adverse effects of topical corticosteroids in paediatric eczema: Australasian consensus statement

Atopic eczema is a chronic inflammatory disease affecting about 30% of Australian and New Zealand children. Severe eczema costs over AUD 6000/year per child in direct medical, hospital and treatment costs as well as time off work for caregivers and untold distress for the family unit. In addition, it has a negative impact on a childs sleep, education, development and self‐esteem. The treatment of atopic eczema is complex and multifaceted but a core component of therapy is to manage the inflammation with topical corticosteroids (TCS). Despite this, TCS are often underutilised by many parents due to corticosteroid phobia and unfounded concerns about their adverse effects. This has led to extended and unnecessary exacerbations of eczema for children. Contrary to popular perceptions, (TCS) use in paediatric eczema does not cause atrophy, hypopigmentation, hypertrichosis, osteoporosis, purpura or telangiectasia when used appropriately as per guidelines. In rare cases, prolonged and excessive use of potent TCS has contributed to striae, short‐term hypothalamic‐pituitary‐adrenal axis alteration and ophthalmological disease. TCS use can also exacerbate periorificial rosacea. TCS are very effective treatments for eczema. When they are used to treat active eczema and stopped once the active inflammation has resolved, adverse effects are minimal. TCS should be the cornerstone treatment of atopic eczema in children.

Treatment failure in atopic dermatitis as a result of parental health belief

The gold standard for treatment of atopic dermatitis is topical corticosteroids. Parental alternative health beliefs and fear of topical corticosteroids may lead to non‐adherence and treatment failure. At the extreme end, such beliefs may result in neglect constituting reportable child maltreatment. We examine the legal repercussions of such abuse in the criminal case resulting from the death of Gloria Sam.

Paediatric vulval lichen sclerosus

Lichen sclerosus (LS) in children is uncommon; however, it is an important differential diagnosis in any pre‐pubertal child presenting with chronic vulval symptoms. The long‐term prognosis is unknown; however, recent data suggests that the assumption that the condition will resolve at puberty may be incorrect. Children with LS require long‐term management with topical corticosteroids, which remains the treatment of choice, as well as long‐term follow up. We review the current literature on paediatric vulval LS.

Pyogenic granuloma in ten children treated with topical imiquimod.

Abstract:  Traditional therapy for pyogenic granuloma is procedural. In young children it can require a general anesthetic and may be complicated by scarring, dyspigmentation, and recurrence. We report a series of 10 children, highlighting the safety and efficacy of topical 5% Imiquimod as an alternative noninvasive treatment of pyogenic granuloma. Ten children with a mean age of 2.5 years and 10.8 week duration of facial pyogenic granuloma lesion were recruited. Treatment regime with topical Imiquimod 5% cream varied in frequency of application and duration according to clinical response. Clinical outcome in the majority of the children was satisfactory. Three had no evidence of disease and five had small hypopigmented or erythematous lesions which were continuing to improve and more acceptable then a surgical scar. One child required a prolonged treatment course, and one progressed to surgical excision when prolonged treatment failed. There were no systemic side effects noted in any of the patients and no recurrence noted with resolution sustained over an average of 9.6 months of follow‐up. Imiquimod is a safe, cost‐effective, and clinically effective management option in the treatment of pyogenic granuloma.

Factors contributing to poor treatment outcomes in childhood atopic dermatitis.

Atopic dermatitis (AD) is a chronic relapsing inflammatory disease of the skin and is the most common paediatric dermatological condition. While no cure is available, it can be treated effectively if adherence to a therapeutic plan is maintained. Poor adherence to treatment is common in AD and can lead to treatment failure, which has significant impacts on the patient, family and society. A comprehensive literature search was conducted to identify factors that contribute to poor treatment adherence in childhood AD and to identify possible strategies to remedy these. Identified factors leading to poor treatment adherence include: complexity of treatment regimen, lack of knowledge, impaired quality of life, dissatisfaction with treatment strategies, infrequent follow up, corticosteroid phobia and the use of complementary and alternative medicine. Effective strategies to increase treatment adherence include: caregiver education and utilisation of education adjuncts, optimisation of the patient/caregiver–clinician relationship, early and frequent follow up and improvement of patient and caregiver quality of life.

Attitudes of Australian dermatologists to the use and safety of topical corticosteroids in paediatric atopic dermatitis

Atopic dermatitis is a common paediatric dermatological condition. Topical corticosteroids (TCS) are central to treatment, but non‐adherence leads to poor outcomes and treatment failure. Parents commonly cite TCS phobia as an obstacle to treatment adherence. Dermatologists play a key role as clinician educators around the use, safety and efficacy of TCS.

The use of intravenous immunoglobulin for treatment of dermatological conditions in Australia: A review

Intravenous immunoglobulin has been used in the treatment of various dermatological conditions, including toxic epidermal necrolysis, bullous pemphigoid and pemphigus vulgaris. From March 2008, the National Blood Authority has implemented the ‘Criteria for the clinical use of intravenous immunoglobulins in Australia’. The new criteria have formalized the eligibility requirements for several dermatological conditions. This may increase access to intravenous immunoglobulin for treatment for these conditions. However, there remain stringent eligibility criteria with which dermatologists need to be acquainted. In some conditions, dermatology review is mandated by these criteria while in other conditions with skin manifestations, referral to other specialists is required. The following article provides a summary of the salient points in relation to the clinical use of intravenous immunoglobulin in dermatology, as well as its production and supply in Australia.