Cosmetic procedures in children.

PURPOSE OF REVIEW: Cosmetic procedures are being performed with increased frequency in the United States and worldwide. Many of these procedures are being performed on children for aesthetic reasons and for the management of dermatological conditions such as psoriasis and vitiligo. This review serves as an overview of selected cosmetic procedures with pediatric applications. RECENT FINDINGS: Recent developments in laser technology have improved our ability to treat a large number of pediatric cutaneous disorders. The vast majority of these technologies were first developed for aesthetic dermatology in adults. Collagen-stimulatory agents such as poly-L-lactic acid were first approved for lipoatrophy associated with human immunodeficiency virus. Poly-L-lactic acid and dermal fillers have potential therapeutic applications in children with atrophic disorders such as lipoatrophy and morphea. Injection of botulinum toxin is very successful in the treatment of hyperhidrosis in adults and can be utilized to improve quality of life in children with hyperhidrosis. SUMMARY: The field of cosmetic dermatology is evolving quickly, with limited safety and efficacy studies in the pediatric age group. Children may benefit from thoughtful application of these technologies.

Spitz nevi arising in speckled lentiginous nevus: clinical, histologic, and molecular evaluation of two cases.

Spitz nevi are small dome-shaped nodules that sometimes arise in areas of preexisting hyperpigmentation, such as a speckled lentiginous nevus (nevus spilus), where they present a diagnostic dilemma. We report clinical, histopathological, and molecular findings of two cases of multiple Spitz nevi arising in a speckled lentiginous nevus. We used immunohistochemistry to assess expression of Ki-67, epidermal growth factor receptor, vascular endothelial growth factor, and RelA in two cases of Spitz nevi arising in a speckled lentiginous nevus. We observed rare staining for the proliferative marker Ki-67, but positive staining for the growth and antiapoptotic factors epidermal growth factor receptor, vascular endothelial growth factor, and RelA. Characterization of the molecular phenotype of Spitz nevi arising in speckled lentiginous nevi may provide a useful adjunct to long-term monitoring in this rare but difficult clinical presentation.

Ichthyotic-appearing skin changes associated with childhood morphea, systemic sclerosis, and systemic lupus erythematosus/scleroderma overlap.

Ichthyotic-appearing skin changes have been associated with autoimmune disorders, including systemic lupus erythematosus and systemic sclerosis in adults. We report three children with ichthyotic-appearing skin changes that may be an early feature reflecting underlying dermal sclerosis. Detection of these subtle skin changes may be predictive of more widespread cutaneous involvement, ultimately prompting earlier treatment.

Multiple granular cell tumors in a child with Noonan syndrome.

Granular cell tumors are benign neurally derived neoplasms, involving cutaneous and subcutaneous tissues; and typically occur as solitary lesions. Multiple granular cell tumors occur in 10% of affected individuals, but are in children. Children with underlying somatic and genetic syndromes, including neurofibromatosis and Noonan syndrome, appear to be at higher risk of developing multiple granular cell tumors. Skin biopsy assists in diagnosis, since granular cell tumors have a similar appearance to other cutaneous nodules. Painful or rapidly growing granular cell tumors should be excised and asymptomatic non-growing granular cell tumors may be observed. Children with multiple granular cell tumors should have a complete physical examination to rule out an underlying genetic syndrome.

A business case for shared medical appointments in dermatology: improving access and the bottom line.

OBJECTIVES: To evaluate the economic viability of shared medical appointments (SMAs) in dermatology. Secondary objectives include a comparison of the hourly adjusted census levels generated by SMAs compared with regular clinic appointments (RCAs), as well as a comparison between the economic viability of dermatology SMAs and SMAs in other fields of medicine. DESIGN: Cost-benefit analysis. SETTING: Outpatient clinics within an academic medical center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire. PATIENTS: No patient-identifying information was obtained or reported. The SMA census data included 301 SMAs (11 different programs and 5 separate departments), representing 2045 appointments over 16 months. Comparisons between patient groups were based on data from the SMA census and mean provider census (MPC) for RCAs, matched on reason for appointment. MAIN OUTCOME MEASURES: Hourly adjusted census levels and profit differences (charges less costs) between SMAs and MPC for RCAs. RESULTS: All individual and departmental SMAs generated significantly higher mean census levels and profits per hour than the respective non-SMA MPC of the health care provider leading the SMA (individual, P < .05; departmental, P < .001). All dermatology SMAs generated significantly greater differences in hourly adjusted census levels and profit in comparisons between SMAs and MPC for RCAs than the respective measures in all other departments (P < .001). CONCLUSION: Taken together, the results of this study provide strong evidence to support a business case for SMAs in dermatology as a means of simultaneously improving access, productivity, and the bottom line.

Acute lymphocytic leukemia presenting as an isolated scalp nodule in an infant.

We describe the presentation and management of a patient referred for a presumed benign scalp lesion in infancy. The subcutaneous nodule was ultimately diagnosed as the first manifestation of acute lymphoblastic leukemia. We review leukemia cutis with special emphasis on the differential diagnosis of scalp nodules in infancy that may be encountered by the plastic surgeon.

Acrodermatitis due to nutritional deficiency.

PURPOSE OF REVIEW: Nutritional deficiency is prevalent in developing countries but should also be considered in developed countries in the setting of genetic or acquired disease states. The skin is commonly involved and is often one of the first organs affected in nutritional deficiency, providing a key to the diagnosis. This article will review the most common nutritional deficiencies causing a periorificial and/or acrodermatitis: zinc deficiency, biotin deficiency, kwashiorkor, and essential fatty acid deficiency. RECENT FINDINGS: Whereas older literature has focused on the relationship among nutritional deficiency, malnutrition and poverty, recent research has identified additional patient populations that are at risk for developing nutritional deficiencies. These populations include premature infants, patients with long-term total parenteral nutrition, Crohn's disease, cystic fibrosis, intestinal bypass procedures, chronic alcoholics, anorexia nervosa, and restrictive diets. Recent studies have also focused on further understanding the genetic basis of inherited nutritional deficiencies such as acrodermatitis enteropathica. SUMMARY: Skin manifestations can lead a provider to the diagnosis of a nutritional deficiency. In a child with a periorificial or acral dermatitis, the diagnosis of zinc, biotin, protein, or essential fatty acid deficiency should be considered, especially if accompanied by systemic signs of failure to thrive.

An enlarging tender nodule on the finger of a 4-year-old boy: an unusual presentation of infantile myofibromatosis.

Infantile myofibromatosis is a benign neoplasm most commonly seen in the neonatal period through infancy. We report a case of a 4-year-old boy who had a nodule on his left index finger. Biopsy specimen showed features of infantile myofibromatosis (solitary type). Unusual features of this case included location and the concept of an infantile myofibromatosis/infantile hemangiopericytoma continuum.

Update on sun protection and tanning in children.

PURPOSE OF REVIEW: In this article we examine the latest information regarding pediatric sun protection and specifically focus on the impact of indoor tanning on children. RECENT FINDINGS: We examine and discuss the prevailing views and trends on ultraviolet radiation exposure, sun protection and the attendant adverse health effects among children. We identify the challenges related to limiting ambient ultraviolet exposure in children. As children, particularly adolescents, gain an understanding of sun protection, their use of ultraviolet radiation protection does not increase concordantly. We discuss health policies regarding ultraviolet radiation protection, compliance with these policies and potential methods to increase compliance. We also examine addiction-like behavior and other psychosocial factors affecting those who are regular indoor tanners. Finally, we consider possible alternatives to ultraviolet radiation induced tanning and whether encouraging these options leads to a confusing, mixed message from healthcare providers. SUMMARY: In this article we examine and discuss current practices, attitudes and recent trends in sun protection. We discuss indoor tanning, with special emphasis on the potential addictive qualities of ultraviolet radiation. Our goal is to identify opportunities and future directions to promote sun safety and protect children from harmful ultraviolet radiation exposure.

Erythema multiforme due to Mycoplasma pneumoniae infection in two children.

Mycoplasma pneumoniae is an important and highly relevant cause of bullous erythema multiforme, isolated mucositis, and Stevens-Johnson syndrome in children. In this article, we present two children with respiratory Mycoplasma pneumoniae infection and associated cutaneous findings within the spectrum of erythema multiforme. We review the literature associating these three entities with Mycoplasma pneumoniae infection and discuss controversies regarding the classification of erythema multiforme, as well as update reported infectious causes of the bullous form. Many understand the erythema multiforme spectrum to include bullous erythema multiforme, mucositis, and Stevens-Johnson syndrome in the order of increasing severity. We feel that this relationship should be reconsidered to help better understand the prognosis and outcomes. It is our opinion that bullous erythema multiforme is a separate, yet related condition that can occur in the context of Mycoplasma pneumoniae infection. With many similarities to mucositis and Stevens-Johnson syndrome, bullous erythema multiforme can be considered part of a spectrum of disease that includes Stevens-Johnson syndrome. Unlike mucositis and Stevens-Johnson syndrome, bullous erythema multiforme caused by Mycoplasma pneumoniae infection has low morbidity for the child. Mycoplasma pneumoniae-associated mucositis and Stevens-Johnson syndrome seem to occur along a spectrum with separate prognosis and potential pathogenesis compared with bullous erythema multiforme. Making the distinction between these conditions is valuable for predicting the child's prognosis. Patients who develop symptoms consistent with these conditions should be appropriately evaluated for Mycoplasma pneumoniae infection and closely monitored.

Acute retroviral syndrome.

The acute retroviral syndrome (ARS), also known as primary HIV infection, acute HIV infection, and HIV seroconversion syndrome, is the earliest clinical manifestation of HIV infection. Early detection of HIV allows for medical and behavioral interventions critical to the management of HIV. This article reviews the clinical features and current management of individuals with ARS.

Infantile Crohn disease presenting with diarrhea and pyoderma gangrenosum.

Cutaneous erosions and ulcerations in the diaper area are common in infancy and usually result from local irritation. We describe an infant with chronic diarrhea and failure to thrive who developed extensive ulcerations in the inguinal folds and perineum that were initially thought to be exclusively caused by local irritation. A cutaneous examination found signs consistent with those of pyoderma gangrenosum, leading to a diagnosis of infantile Crohn disease. Cutaneous signs can lead to the diagnosis of an underlying systemic disease in infants with chronic diarrhea and rash. Prompt diagnosis is especially important in infantile Crohn disease, since many infants require surgical resection of affected bowel, and 60% die from disease complications. This article reports a rare instance of an infant who developed pyoderma gangrenosum due to Crohn disease and reviews cutaneous signs of systemic disease in infants presenting with chronic diarrhea and rash.