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among these problems are atopic with oral propranolol. Timolol 0.5%, a
2017;10(3 Suppl1):S8S15
Disclosures: The authors have no conflicts of interest relevant to the content of this article.
Author correspondence: Dr. Leslie Castelo-Soccio; email: castelosocciol@email.chop.edu
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established for the initiation, distribution of port wine stains PWS, but not in any of the affected
treatment indications, and clinical (PWS) follows the trigeminal nerve, tissue of others with unrelated
monitoring of propranolol therapy but new evidence has found a cerebrovascular malformations or
for IH, the role of relation to genetic mosaicism.15 control patients. The mutant allele
electrocardiography (ECG) testing PWS on the face, which appear to was prevalent in affected tissue at
remains unclear. There is no follow the embryonic vasculature rates of 1.0 to 18.1 percent.17
consensus as to whether it is (rather than the trigeminal nerve), In a study of 192 pediatric
required for pretreatment may be an isolated finding or may patients with facial PWS, adverse
evaluation. The use of routine ECG occur along with Sturge-Weber outcomes (defined as seizures,
testing was evaluated in a two- Syndrome (SWS). Today, it is more abnormalities in neurodevelopment,
center study of 162 patients who useful to consider embryologic glaucoma, and abnormal MRI scans)
were examined prior to the planned segments when discussing PWS were calculated. Based on the
commencement of propranolol rather than the older V1, V2, V3 Fishers exact p-value, patients with
treatment for IH.13 In this study, 43 criteria. forehead plaques were significantly
percent of patients who underwent SWS may be diagnosed when the more likely to have seizures,
routine ECG monitoring obtained patient presents with malformations abnormal neurodevelopment, and
abnormal results. This, in turn, led of the cerebral and ocular vascular glaucoma (p<0.001 for all) and an
to 28 formal consultations with systems along with facial PWS. In a abnormal MRI (p=0.002) than
pediatric cardiologists, but none of study of 192 children with facial patients with PWS without forehead
those abnormal results were PWS, two predictors of adverse involvement.16 A flowchart based on
ultimately precluded from outcomes emerged: a PWS these experiences is presented in
propranolol therapy. Moreover, no involving any part of the forehead Figure 1. Thus, PWS on the
patient in this study experienced any (defined by the line joining the outer forehead represent the highest risk
adverse effects from propranolol canthus of the eye to the top of the for SWS, and MRI scans are the test
therapy that could have been ear, including the upper eyelid) and of choice.
predicted by an ECG. Thus, the role an abnormal magnetic resonance
of ECG monitoring in this context imaging (MRI) scan. Thus, it may be
remains unclear, but this evidence important for pediatric patients
NOVEL TOPICAL THERAPY FOR PORT
suggests that ECG testing may not presenting with PWS on the The preferred treatment for PWS
WINE STAINS
be necessary.14 For patients with forehead to undergo an remains pulsed dye laser (PDL),
bradycardia or a history of ophthalmology review and a brain although it is thought that as much
arrhythmias, features of posterior MRI.16 as 90 percent of PWS are refractory
fossa brain malformations (PHACE PWS and SWS are thought to be to PDL. This therapeutic resistance
syndrome), familial history of early somatic mosaic mutations that is attributed to revascularization
cardiac death or congenital heart disrupt vascular development. It has post-laser-therapy. Oral sirolimus
disease, or maternal history of been theorized that the development has been used with some success as
connective tissue disease, an ECG time at which these mutations occur adjunctive therapy to help reduce the
may still be helpful and appropriate. defines the severity and extent of possibility of revascularization, but it
Thus, the potential benefits of an PWS and SWS. In a study of whole- is associated with considerable side
ECG should be weighed against its genome sequencing of DNA, a effects. A case report in the literature
cost and potential utility. nonsynonymous single-nucleotide described a 56-year-old man with
variant in GNAQ was identified in extensive PWS who was treated
affected tissue samples of 88 percent with PDL and topical sirolimus
of participants with SWS and 92 (rapamycin) 0.5% ointment.
PORT WINE STAINS AND STURGE-
It has long been thought that the percent of patients with non-SWS Significant improvement occurred
WEBER SYNDROME
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randomized into four study arms: industrialized world, affecting 79 to intake or body mass index (BMI)
placebo, PDL + placebo, sirolimus 95 percent of American adolescents, with respect to acne. Thus, in this
(rapamycin), and PDL + sirolimus epidemiological studies suggest that study, full-fat milk was not
(rapamycin). The best result, defined acne rates are very low or associated with acne, but low-fat
as lowest digital photographic image nonexistent in some nonwestern milk and skim milk were. However,
score and lowest percentage of societies, such as the Kitavan in a case-control study of 88 patients
vessels in histologic analysis, was Islanders of Papua, New Guinea, aged 18 to 30 years with and without
significantly better for patients in the and the Ach hunter-gathering acne, interviews found that patients
PDL + sirolimus group.19 society of Paraguay, where no cases with acne had a significantly greater
It is thought that topical sirolimus of acne have been observed.24 These dietary glycemic load (17535 vs.
(rapamycin) suppresses the stark differences in the incidence of 12228, p<0.001) and significantly
regeneration and revascularization of acne cannot be entirely explained by greater consumption of milk and ice
photo-coagulated blood vessels genetic differences; it is likely that cream (p<0.01).29 The intake of
produced by PDL.20 Topical environmental factors, including refined sugar products has also been
sirolimus (rapamycin) has been used diet, play a role. Recent evidence associated with acne.30
to treat angiofibromas as well.2123 It suggests that diet affects the By contrast, a longitudinal
is available in 1% or 0.5% cream proliferation of basal keratinocytes survey-based study of students
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between the ages of 15 and 19 allergy development. the study, and no patients withdrew
conducted in Norway found that Thus, for infants with early-onset from the study because of adverse
severe acne had a prevalence rate of atopic disease (allergies), early events. Clinicians treating children
about 13.9 percent in this peanut introduction may be with atopic dermatitis should ask
population, and consumption of two beneficial. Skin testing or in-clinic them or their parents about their
or more glasses of full-fat dairy milk observation of peanut ingestion is sleep hygiene.
per day was associated with recommended because of the Looking ahead in atopic
moderate-to-severe acne, but there sometimes severe nature of such dermatitis, a new topical PDE4-
was no association between the allergic reactions. An initial inhibitor currently in Phase III trials,
consumption of low-fat or skim consultation with an allergist may be crisaborole ointment, may be on the
milk products and acne.31 Thus, the appropriate. Peanut introduction horizon.38 Systemic agents in the
evidence in the literature about may then be carried on at home once pipeline include dupilumab, a
dietary links to acne remains the clinician can determine that the human monoclonal antibody against
equivocal and warrants further patient is not clinically reactive. IL-4 (SQ),39,40 and apremilast, an oral
study. Disordered sleeping and sleep PDE4-inhibitor.41
deficits occur in children with atopic
dermatitis and may cause a lower
quality of life and negatively impact
ATOPIC DERMATITITS, ALLERGIES, JANUS-KINASE INHIBITORS FOR
Prior to 2008, experts development.36 While the discomfort disease with strong associations to
PEANUTS
recommended that peanut of dermatitis, itching, and scratching the genetic loci near immune-
introduction be delayed in infants at in the night may contribute to poor function genes. In murine studies
high risk for allergies, although sleep in these children, it is likely and early human studies, Janus-
observational studies have that the cause of their sleep problems kinase (JAK) inhibitors interrupted
suggested that complementary food is more complex. In a randomized, these immune signaling pathways.42
introduction of high-risk allergens double-blind, placebo-controlled, Two new JAK inhibitors considered
may offer a protective effect. The crossover study of 73 pediatric for use in alopecia areata in adults
Learning Early About Peanut patients (aged 118 years) with are tofacitinib and ruxolitinib.43,44
Allergy (LEAP) study consolidated atopic dermatitis over at least five However, the safety of these drugs
this evidence and found that early percent of the body surface area, for use in pediatric patients remains
introduction may indeed be patients were treated with either undetermined. A case report showed
beneficial.3234 A recent study melatonin 3mg/day or placebo for the successful treatment of alopecia
randomized 640 infants with severe four weeks, followed by a two-week universalis with topical ruxolitinib (a
eczema and/or egg allergy to either washout period, and then a crossover topical JAK inhibitor).44 In a
consume or avoid peanuts until five four-week study.37 Children were literature review, oral tofacitinib was
years of age. In the peanut- evaluated using the Scoring Atopic found to be effective in the treatment
avoidance group, the prevalence of Dermatitis (SCORAD) index and of alopecia areata as well as other
peanut allergy at 60 months was were also evaluated for sleep-onset conditions, including psoriasis and
13.7 percent, while in the peanut- latency. SCORAD indices decreased vitiligo.43
consumption group, the prevalence by 9.1 versus placebo from a mean This early evidence suggests that
was 1.9 percent at five years 49.124.3 to 40.220.9. Sleep-onset JAK inhibitors may offer an
(p<0.001).35 Thus, early introduction latency decreased 21.4 minutes after alternative therapeutic option for
of peanuts into the diet of high-risk melatonin treatment compared to alopecia areata, and though they
children was associated with placebo (p=0.02). No adverse events should be avoided as first-line
decreased frequency of peanut were reported during the course of therapy, may be considered in
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limited cases. There is no data on the not all cases resolve spontaneously.49 injury, and underlying pathology all
long term safety of this medication Infants with CSHRH have a play a role in pediatric vasculitis.51
in children..45 Topical JAK inhibitors mortality risk of three percent and a The signs of medium vessel
may also be an appropriate 10-percent chance of relapse.49 vasculitis include fixed livedo,
prescribing choice. There is Infantile LCH may occur in the skin nodules, ulcers, and stellate purpura.
considerable interest at this time in folds. Diagnosing CSHRH requires To arrive at a differential diagnosis,
finding a safe, effective, and that the physician first rule out the physician must consider
convenient treatment for alopecia. infection and then conduct a granulomatosis with polyangiitis
physical examination and a biopsy (previously Wegeners
with a complete blood count, a granulomatosis), polyarteritis
comprehensive metabolic panel, nodosa, various vasculopathies (for
CONGENITAL LANGERHANS CELL
histiocytosis (LCH) is a clonal thromboplastin time test, a chest X- antibodies), and calciphylaxis. A
disorder of the histiocytes, which are ray, and skeletal history. Timely blood panel should be ordered
cells derived from the bone marrow. diagnosis and prompt treatment with (complete blood count, complete
Morphologically, LCH appears to be systemic agents are important. An metabolic panel, erythrocyte
a benign proliferation of oncology consultation may be of sedimentation rate/C-reactive
inflammatory cells that somehow value. protein, prothrombin time/partial
have evaded the bodys regulatory thromboplastin time test,
mechanisms, but our current antiphospholipid antibodies,
understanding is that there is clonal Kawasaki disease (KD) is a type cryoglobulins, and QuantiFERON-
MEDIUM VESSEL VASCULITIS
proliferation of immune-processing of medium vessel vasculitis that Gold hepatitis panel).52 Imaging can
cells (Langerhans cells), which typically presents in pediatric be of great value.51 A skin biopsy
suggests a malignant pathology.46 patients. Infantile KD may exhibit and consultation with a
LCH manifests itself most incomplete or atypical forms. dermatologist or rheumatologist may
commonly as a solitary lesion on the Typical infant manifestations of KD be warranted. These conditions carry
orbital bone of the eye, and can be include mucosal changes (64%), a high morbidity and mortality
treated with minimally invasive extremity changes (64%), rash burden and are characterized by
procedures. Recent studies have (53%), conjunctival injection (47%), frequent relapse.52
suggested that LCH may be a risk and cervical lymphadenopathy
marker for central nervous system (17%). KD is associated with
(CNS) disorders.46 While LCH may abnormalities in the coronary
PEDIATRIC DERMATOLOGY:
be systemic, it often affects only the arteries. KD typically presents Dermatology frequently involves
MAINTENANCE AND HOME CARE
skin. LCH most commonly presents incompletely in infants younger than strategies aimed at maintaining
in pediatric patients who exhibit six months of age; KD should be therapeutic results and thus relies to
infiltration of mast cells and suspected when a baby presents with a great extent on home care and
Langerhans cells.47 unexplained fever extending beyond tips.Here the authors present
LCH has four known variants: five days.50 several of the latest tips for clinicians
congenital self-healing Other types of pediatric vasculitis and their patients.
reticulohistiocytosis (CSHRH, also can be challenging to diagnose Perioral irritant dermatitis is a
called Hashimoto-Pritzker disease), because their clinical manifestations, frequent cause for clinic visits. This
Letterer-Siwe disease, Hand- particularly in young children, can distressing condition may be
Schller-Christian disease, and be highly variable. The size of the triggered by excessive drooling,
eosinophilic granuloma.48 CSHRH vessels involved, the organs pacifiers, and the use of wet wipes.
appears to be a misnomer, because involved, the extent of vascular Parents of children suffering from
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perioral irritant dermatitis should further help treat this uncomfortable as the relationship of diet to acne and
avoid putting socks on the hands of condition. In some cases, diaper the early introduction of allergens to
these children during sleep and dermatitis may actually be an high-risk patients have re-emerged
discourage sucking on blankets or allergic reaction to blue dye (blue- with more data to help guide
other items. This encourages saliva dye diaper dermatitis). In the event treatment. Finally, pediatric
production and, in turn, irritation. that the response is to blue dye, the dermatology requires maintenance
Before the child eats or goes to parents should switch to dye-free efforts, and parents should be
sleep, a thick barrier-type ointment diapers (Huggies Natural, 7th counseled on things that they can do
should be applied to the cheeks and Generation, Earths Best) and treat at home to help these conditions in
chin. the rash with a mid-potency topical their children.
While phototherapy and systemic steroid ointment. If that ointment is
agents such as methotrexate, not entirely effective, mupirocin
azathioprine, and mycophenolate ointment can be added at signs of 1. Hurwitz S. The history of pediatric
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CONCLUSION
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