Tumor Necrosis Factor Inhibitor-Induced Psoriasis in a Pediatric Crohn's Disease Patient Successfully Treated with Ustekinumab.

BACKGROUND: Tumor necrosis factor (TNF) inhibitors are widely used in pediatric patients with inflammatory bowel disease, as well as psoriasis. However, there is growing evidence that these medications can also paradoxically induce a psoriasiform skin reaction in a subset of patients. GOALS: We seek to share our experience in treating severe TNF inhibitor-induced psoriasis in a pediatric patient with Crohn’s disease. STUDY: We report a case of a 10-year-old female with Crohn’s disease, who developed psoriasis after twelve months of infliximab therapy. Her skin disease was recalcitrant to topical therapies, methotrexate, and phototherapy. RESULTS: The patient was transitioned to ustekinumab with significant improvement in her symptoms and maintenance of remission of her bowel disease. CONCLUSION: This is the first reported case of a school-age pediatric patient with TNF inhibitor-induced psoriasis treated with ustekinumab. Controlled trials are warranted to fully assess the safety and efficacy of ustekinumab for treating TNF inhibitor-induced psoriasis in the pediatric population.J Drugs Dermatol. 2020;19(3): doi:10.36849/JDD.2020.2106.

Assessment of Infantile Hemangiomas Using a Handheld Wireless Diffuse Optical Spectroscopic Device.

BACKGROUND/OBJECTIVES: Infantile hemangiomas (IHs) are vascular tumors with the potential for significant morbidity. There is a lack of validated objective tools to assess IH severity and response to treatment. Diffuse optical spectroscopy (DOS), a noninvasive, nonionizing imaging modality, can measure total hemoglobin concentration and hemoglobin oxygen saturation in tissue to assess IH vascularity and response to treatment. Our objective was to evaluate the utility of a wireless, handheld DOS system to assess IH characteristics at selected points during their clinical course. METHODS: Thirteen subjects (initial age 5.8 ± 2.0 mos) with 15 IHs were enrolled. IHs were classified as proliferative, plateau phase, or involuting. Nine patients with 11 IHs were untreated; four patients with 4 IHs were treated with timolol or propranolol. Each IH was evaluated by placing the DOS system directly on the lesion as well a normal contralateral skin site. IH vascularity and oxygenation were scored using a newly defined normalized hypoxia fraction (NHF) coefficient. Measurements were recorded at various intervals from the initial visit to 1 to 2 years of age. RESULTS: For the nine untreated IHs, the NHF was highest at 6 months of age, during proliferation. Differences in NHFs between the proliferation and the plateau (p = 0.02) and involuting (p < 0.001) stages were statistically significant. In treated patients, the NHF normalized to 60% after 2 months. One treated IH came within 5% of the NHF for normal skin after 12 months. CONCLUSIONS: DOS can be used to assess the vascularity and tissue oxygenation of IHs and monitor their progression and response to treatment.

Porokeratotic eccrine ostial and dermal duct nevus: a unique case treated with CO2 laser.

Porokeratotic eccrine ostial and dermal duct nevus (PEODDN) is a rare eccrine hamartoma, with treatment generally being unsatisfactory. The unique features of PEODDN presented include bilateral and facial lesions, and extensive body involvement. Management with CO2 laser was successful, and follow-up will be necessary to monitor for recurrent lesions.

Apremilast for treatment of recurrent erythema multiforme.

Recurrent erythema multiforme with oralinvolvement is therapeutically challenging.Apremilast has been used with success in resolvingthe oral aphthae of Behçet disease, prompting theuse of the drug in patients with oral erosions fromerythema multiforme. Three patients with oralerythema multiforme were given apremilast at dosesof 30-60mg daily. Complete clearance of the lesionswere observed in all three patients, including thoserefractory to other standard therapies. Apremilast maypresent an effective option for recurrent erythemamultiforme for patients who have failed trials antiviraland immunosuppressive therapies.

Tumor necrosis factor antagonist-induced psoriasis in a 3-year-old boy with Kawasaki disease.

Tumor necrosis factor (TNF) antagonists have beenknown to trigger new-onset psoriasis in adult andpediatric patients. Here we report a case of TNFantagonist-induced psoriasis in a 3-year-old boytreated with infliximab for Kawasaki disease. Ourpatient is a 3-year-old boy with Kawasaki diseaseunresponsive to intravenous immunoglobulinwho was then treated with one dose of infliximab.A few days later he developed psoriatic plaqueson the face and extremities. The psoriatic plaqueswere treated with topical calcineurin inhibitors andtopical corticosteroids, with marked improvement.Prior reports of TNF antagonist-induced psoriasis inthe pediatric population have been in children withinflammatory bowel disease or juvenile idiopathicarthritis. To the best of our knowledge, this is thefirst case of TNF antagonist-induced psoriasis ina pediatric patient with Kawasaki disease, andthe youngest patient to date. Although we donot fully understand the mechanism behind thisphenomenon, in vitro studies have implicated theimportance of interferon-α, a pro-inflammatorycytokine, and plasmacytoid dendritic cells. Furtherresearch is necessary to understand who is at riskfor this condition and the molecular basis for thisparadoxical reaction.

Case of Pediatric Bullous Systemic Lupus Erythematosus Treated with Intravenous Immunoglobulin.

This is a case report of a 16-year-old girl recently diagnosed with systemic lupus erythematosus (SLE) who presented with multiple blisters on the face, hands, arms, legs, trunk, and vaginal and oral mucosa. Skin biopsy was consistent with bullous SLE (BSLE). Dapsone is often the first-line treatment option for BSLE, but the patient's history of anemia and leukopenia and long-term immunosuppression requirement for her systemic symptoms raised concerns about dapsone and bone marrow toxicity, especially hemolytic anemia and agranulocytosis. She was started on intravenous immunoglobulin (IVIG), 2 g/kg divided over 3 days, with significant improvement in her cutaneous symptoms. IVIG is a treatment option for BSLE patients in whom agents such as dapsone are contraindicated.

Update on indoor tanning legislation in the United States.

The incidence of melanoma has been increasing over the past several decades, with notable increases in the pediatric and adolescent population. Indoor tanning has been proven carcinogenic and is associated with an increased risk of melanoma, especially when used at a young age. The incidence and frequency of usage of indoor tanning in the United States is high, particularly among adolescents, with roughly 20% reporting using a tanning bed at least once. The Food and Drug Administration recently made changes to its regulation of indoor tanning devices, reclassifying them as class II devices necessitating stricter premarket review, and strengthened its warnings for these devices; however, federal regulation of indoor tanning is still limited and most regulation of indoor tanning in minors is done on a state-by-state basis. Three types of legislation exist: (1) absolute ban on minor use of indoor tanning devices, (2) age restriction of minor usage of indoor tanning devices other than age 18 years, and (3) requirement of parental consent. These regulations are inconsistent, and enforcement efforts are often limited. In this contribution, we provide an update on the prevalence of indoor tanning, the risks associated with indoor tanning, and the current federal and state legislation and enforcement efforts in the United States with regard to indoor tanning. Although efforts are being made to ban all use of indoor tanning devices by minors, there is still more work to be done before this becomes a reality in the United States.

Pityriasis Lichenoides in Childhood: Review of Clinical Presentation and Treatment Options.

Pityriasis lichenoides (PL) is a skin condition of unclear etiology that occurs not uncommonly in childhood. It is often classified into the acute form, pityriasis lichenoides et varioliformis acuta (PLEVA), and the chronic form, pityriasis lichenoides chronica (PLC). We performed a comprehensive review of the English-language literature using the PubMed database of all cases of childhood PL reported from 1962 to 2014 and summarized the epidemiology, clinical features, treatment options, and prognosis of this condition in children. The proposed etiologies are discussed, including its association with infectious agents, medications, and immunizations and evidence for PL as a lymphoproliferative disorder. We found an average age of PL onset of 6.5 years, with a slight (61%) male predominance. We also found that PLEVA and PLC tend to occur with equal frequency and that, in many cases, there is clinical and histopathologic overlap between the two phenotypes. When systemic therapy is indicated, we propose that oral erythromycin and narrowband ultraviolet B phototherapy should be first-line treatment options for children with PL since they have been shown to be effective and well tolerated. In most cases, PL follows a benign course with no greater risk of cutaneous T-cell lymphoma, although given the rare case reports of transformation, long-term follow-up of these patients is recommended.

Perimenstrual flare of adult acne.

BACKGROUND: Acne is typically regarded as an adolescent disease. A significant body of literature suggests a post-adolescent or adult form of acne. Female patients are known to experience perimenstrual acne flares, the exact prevalence of which is unknown. OBJECTIVE: To establish a pattern of perimenstrual acne flare in adult women in order to better characterize the disorder. METHODS: Subjects aged 18 and over were recruited during previously scheduled visits with their dermatologist at Mount Sinai Hospital in New York. An anonymous survey was distributed to women who reported their first menses at least six months earlier and had a complaint of acne within the last 30 days. Women <18 years of age and postmenopausal women were excluded from the study population. RESULTS: Participants included women 18- to 29-years old (67%) and women 30- to 49-years old (33%). The ethnicity of respondents was Caucasian (50%), African American (20%), Latino (19%), Asian (5%), and Other (6%). The majority of participants with perimenstrual acne reported the onset of acne between the ages of 12 and 18 years. Sixty-five percent of participants reported that their acne symptoms were worse with their menses. Of those who reported perimenstrual acne symptoms, 56 percent reported worsening symptoms in the week preceding their menses, 17 percent reported worsening symptoms during their menses, three percent reported worsening symptoms after their menses, and 24 percent reported worsening symptoms throughout their cycle. Thirty-five percent of patients with perimenstrual acne reported oral contraceptive pill use. CONCLUSION: A significant number of adult women have perimenstrual acne symptoms. This study has proven to be useful in characterizing perimenstrual acne flare and is one of the first qualitative documentations of the presence and degree of this disorder.

Epidermolysis bullosa simplex with mottled pigmentation due to a rare keratin 5 mutation: cutaneous findings in infancy.

Epidermolysis bullosa simplex with mottled pigmentation (EBS-MP) is an autosomal dominant inherited blistering skin disease characterized by nonscarring blistering and reticulated hyperpigmentation. It is most commonly due to a heterozygous point mutation, P25L, in the nonhelical V1 domain of keratin 5 (KRT5). Here we present a case of EBS-MP with early onset of reticulated hyperpigmentation during infancy due to a rare 1649delG mutation in the V2 domain of KRT5.

Retiform purpura: a new stigmata of illicit drug use?

We report a 50-year-old woman who presented with a six-month history of recurrent retiform purpura of uncertain etiology. Laboratory findings included neutropenia, positive anticardiolipin IgM antibody, and a weakly positive p-ANCA. Histopathology revealed a leukocytoclastic vasculitis with intravascular thrombi. Urine toxicology screen was positive for cocaine. These findings are similar to recent reports of agranulocytosis and purpura induced by levamisole-tainted cocaine. A review of the clinical and histopathological findings associated with levamisole-induced purpura will be discussed.

Birth order and breastfeeding initiation: results of a national survey.

BACKGROUND: Because of numerous health benefits for both mothers and babies, breastfeeding is the recommended method of infant feeding. We sought to determine the association between birth order and breastfeeding practices in families with multiple children. METHODS: The 2002 National Survey of Family Growth was used to analyze the demographic characteristics of a national probability sample of 2,115 U.S. mothers aged 15 to 44 with two, three, four, and five or more children younger than age 19. In-person, computer-assisted interviews were conducted by trained female interviewers. The main variable of interest was birth order; the main outcome measure was breastfeeding initiation for each mother-child pair. We used multiple logistic regression models to determine the demographic predictors of breastfeeding the second child in families with two children. RESULTS: Mothers with two, three, four, and five or more children breastfed all of their children 52.6%, 48.4%, 44.7%, and 57.1% of the time, respectively (p = 0.46). In families with multiple children, more than 70% of women made the same feeding choice for each of their children, whether it was breastfeeding or bottlefeeding. After controlling for demographic factors, Hispanic women and women with more than a high school education were significantly more likely to breastfeed their second child if they had breastfed the first child. CONCLUSION: U.S. mothers are likely to choose the same feeding method for each of their children, independent of the number of children they have. Breastfeeding promotion must take into consideration previous infant feeding experiences, if any.

Duration of breastfeeding among first-time mothers in the United States: results of a national survey.

AIM: To determine the characteristics of primiparous women who breastfeed for only short periods of time. METHODS: The 2002 National Survey of Family Growth was used to analyze the characteristics of a national probability sample of 3229 first-time US mothers aged 15 to 44 y with children ages 1 to 18 y old, 1960 of whom breastfed. Main outcome measures in the cross-sectional study included breastfeeding at birth and at 3 mo as determined by in-person, computer-assisted interviews conducted by trained female interviewers. RESULTS: Sixty-two percent of first-time mothers with singleton live births initiated any breastfeeding and 36% were still breastfeeding at 3 mo. Those who were older, married, and at higher educational levels were significantly more likely to continue breastfeeding beyond 3 mo. These same demographic factors were associated with differences in breastfeeding rates both early (within the first week of life) and consistently over the first 3 mo. In multivariate analyses, only educational level remained as a predictor of breastfeeding. CONCLUSION: Targeted breastfeeding interventions for young, single, less-educated women are warranted in a culturally sensitive context, both prenatally and immediately postpartum, to improve the duration of breastfeeding among first-time mothers in the US.