Assessment of the American Academy of Dermatology diagnostic criteria for pediatric atopic dermatitis and modification into a checkbox form: A cross-sectional study.

BACKGROUND/OBJECTIVES: Diagnostic criteria for atopic dermatitis (AD) are limited in their performance and/or usability. The American Academy of Dermatology (AAD) consensus criteria include hierarchical categories of disease features to improve these metrics but have not been validated. Our objective was to create and validate a checkbox form of the AAD consensus criteria in the pediatric population. METHODS: We performed a cross-sectional study of 100 pediatric patients with AD (n = 58) and diseases in the differential diagnosis of AD (n = 42). RESULTS: Having three or more "Essential," ≥2 "Important," ≥1 "Associated" features of the AAD criteria was optimal for the diagnosis of AD in children. This combination was 91.4% (95% CI, 84.2%-98.6%) sensitive and 95.2% (88.8%-100%) specific. The UK working party criteria and the Hanifin-Rajka criteria had sensitivities of 96.6% (95% CI 91.9%-100%) and 98.3% (95% CI 94.9%-100%) and specificities of 83.3% (95% CI 72.1%-94.6%) and 71.4% (95% CI 57.8%-85.1%), respectively. The AAD criteria had significantly greater specificity than the Hanifin-Rajka criteria (p = .002). CONCLUSIONS: This study represents an important step in validating the AAD consensus criteria and formulating a useable checkbox form for diagnosing AD in the pediatric population.

Evidence-based skin care in preterm infants.

Most guidelines on neonatal skin care emphasize issues pertaining to healthy, term infants. Few address the complex task of skin barrier maintenance in preterm, very preterm, and extremely preterm infants. Here, we provide an evidence-based review of the literature on skin care of preterm neonates. Interestingly, the stratum corneum does not fully develop until late in the third trimester, and as such, the barrier function of preterm skin is significantly compromised. Numerous interventions are available to augment the weak skin barrier of neonates. Plastic wraps reduce the incidence of hypothermia while semipermeable and transparent adhesive dressings improve skin quality and decrease the incidence of electrolyte abnormalities. Tub bathing causes less body temperature variability than sponge bathing and can be performed as infrequently as once every four days without increasing bacterial colonization of the skin. Topical emollients, particularly sunflower seed oil, appear to reduce the incidence of skin infections in premature neonates-but only in developing countries. In developed countries, studies indicate that topical petrolatum ointment increases the risk of candidemia and coagulase-negative Staphylococcus infection in the preterm population, perhaps by creating a milieu similar to occlusive dressings. For preterm infants with catheters, povidone-iodine and chlorhexidine are comparably effective at preventing catheter colonization. Further studies are necessary to examine the safety and efficacy of various skin care interventions in premature infants with an emphasis placed on subclassifying the patient population. In the interim, it may be beneficial to develop guidelines based on the current body of evidence.

Speckled lentiginous nevus: A rare presentation associated with motor neuropathy and muscular atrophy in a child.

Speckled lentiginous nevus syndrome has been described in individuals with a speckled lentiginous nevus with rare associated neurologic deficits. Because speckled lentiginous nevus syndrome almost always affects adults, it is not typically considered when evaluating children. We present the first reported case of speckled lentiginous nevus syndrome presenting in a young child with muscle atrophy and motor deficits affecting muscles along the same distribution as the speckled lentiginous nevus.

Primary cutaneous aspergillosis at the site of cyanoacrylate skin adhesive in a neonate.

Primary cutaneous aspergillosis is a rare but potentially life-threatening disease. We present the case of a premature infant who developed primary cutaneous aspergillosis with Aspergillus niger at the site of a skin abrasion that had been treated with a purple-colored cyanoacrylate product. The infection was treated successfully with gentle debridement of the cyanoacrylate product, followed by intravenous voriconazole and topical fluconazole. To our knowledge, this is the first reported case of primary cutaneous aspergillosis occurring at the site of cyanoacrylate-based skin adhesive.

Allergic Contact Dermatitis Due to Methylisothiazolinone in a Young Girl's Laundry Detergent.

Methylisothiazolinone (MI) is an emerging and increasing cause of allergic contact dermatitis (ACD) in children. We present the case of a 7-year-old girl with an unusual dermatitis suspicious for contact allergy. Patch testing confirmed allergy to MI, found only in the patient's laundry detergent. This case highlights the importance of checking household product ingredients and the role of MI as an increasing cause of ACD in children.

Countering Staphylococcus Overgrowth During Patch Testing in Children with Moderate to Severe Atopic Dermatitis.

BACKGROUND: Patients with moderate to severe atopic dermatitis (AD) often have a concurrent diagnosis of contact dermatitis, but patch testing in these patients presents a unique set of challenges. Barrier impairment and Staphylococcus aureus colonization and infection, along with the sealed occlusion that takes place during the patch testing procedure, can create an optimal environment for bacterial overgrowth. AIMS: To identify patients at risk for S. aureus overgrowth during patch testing and provide pre- and peripatch testing interventions to aid clinicians in obtaining the best possible patch test results in this complicated population. MATERIALS AND METHODS: A retrospective review was performed of five patients with moderate to severe AD for which S. aureus overgrowth and superinfection complicated patch test evaluation. RESULTS: All five patients were able to complete the patch test procedure and all had relevant positive patch test reactions. Complications during patch testing included erythema, oozing, foul odor under the patches, and purulent material at the patch sites. One patient had a culture performed during patch testing that showed methicillin-sensitive S. aureus. DISCUSSION: Patch testing can play an important role in the examination and management of patients with refractory AD. CONCLUSIONS: Moderate to severe AD and concern regarding S. aureus overgrowth should not preclude patch testing.

Palisaded Neutrophilic Granulomatous Dermatitis in a Child with Juvenile Idiopathic Arthritis on Etanercept.

Palisaded neutrophilic granulomatous dermatitis (PNGD) is a rare neutrophilic dermatosis that may be associated with significant morbidity because of associated pruritus and pain. It is typically seen in adults with collagen vascular diseases, but may be associated with medications as well. PNGD is rarely reported in children. We describe a girl with polyarticular juvenile idiopathic arthritis who developed PNGD after administration of etanercept and demonstrated rapid and significant improvement upon treatment with topical triamcinolone 0.1% ointment.

Religious Allergic Contact Dermatitis.

Henna, derived from a combination of natural leaves and coloring additives, is a common decorative dye traditionally used in many Islamic religious celebrations. Para-phenylenediamine (PPD), a major component of black henna tattoo, is a strong sensitizer and common allergen. We report a case of severe connubial allergic contact dermatitis after black henna heterotransfer in a girl.

Ecthyma Gangrenosum-Like Lesions Secondary to Methicillin-Sensitive Staphylococcus aureus in an Immunocompetent Child.

We describe a previously healthy 15-month-old girl who developed ecthyma gangrenosum (EG)-like lesions secondary to methicillin-sensitive Staphylococcus aureus (MSSA). Her systemic symptoms and negative blood cultures suggested MSSA toxin-mediated effects. When toxin-mediated systemic symptoms accompany such lesions, pathogens other than Pseudomonas aeruginosa should be considered.

Methylisothiazolinone: a case of perianal dermatitis caused by wet wipes and review of an emerging pediatric allergen.

Methylisothiazolinone (MI) is a preservative found in cosmetic, personal hygiene, and industrial products. It has been characterized as a moderate to strong sensitizer and is an emerging allergen in the pediatric population. We discuss a case of perianal dermatitis in a child caused by contact allergy to MI-containing wet wipes.

Nickel allergy--a potential cause of razor dermatitis.

We discuss a case of razor-associated dermatitis to highlight a potential source of nickel exposure in allergic patients.

Systemic contact dermatitis in children: how an avoidance diet can make a difference.

Systemic contact dermatitis is an under-recognized skin reaction that occurs secondary to systemic (oral, intravenous, intramuscular, inhaled, or subcutaneous) exposure to a hapten in a previously sensitized individual. Medicaments are the most common cause of SCD in the adult population, but other chemicals like nickel, cobalt, balsam of Peru, and formaldehyde have been implicated as well. Few reports in children exist to date. Dietary restriction has shown to be of some benefit in managing some adult patients. We present a case series of 8 pediatric patients diagnosed with SCD from the contact dermatology clinic, who showed marked improvement of their dermatitis after adequate dietary avoidance. We review common presentations of chemicals causing SCD in children and potential dietary modifications.

Infant clothing snaps as a potential source of nickel exposure.

Children's clothes with metal snaps are a potential source of nickel exposure to consider in infants and very young children. Further more avoidance of this exposure may help prevent nickel sensitization.

The importance of checking for delayed reactions in pediatric patch testing.

Patch testing is often performed with the final reading being completed at 72 hours. Studies in adults have shown that performing an additional reading several days later increases the yield of relevant positive reactions. We report a study of this matter in children. We conducted a prospective patch test study of 38 affected children aged 6 to 17 (mean 11.6 years), with presumed allergic contact dermatitis between April and July 2009. The patients were required to return at 48 hours for patch test removal and assessment of early reactions, at 72 to 96 hours (3-4 days) for evaluation of delayed reactions, and again at 168 to 216 hours (7-9 days) for a final late delayed reading. We tallied the number of patients with "equivocal" (+/?), +, ++, and +++ reactions and noted these as potential positive reactions by reading date. Twenty-five of the 38 children (66%) had a positive reaction at 48 hours; 32 children (84%) had a positive reaction at 72 hours (day 3); 19 children (50%) had a positive reaction at 168 to 216 hours (day 7-9). Of those 19, 16 (42%) had persistent reactions, while 5 children (13%) had new late delayed reactions. Among the new late delayed reactions, there were six allergens identified, four of which were considered of probable clinical relevance. When patch testing with Thin Layer Rapid-Use Epicutaneous test panels, a delayed reading beyond 72 hours may be needed to identify the offending agent(s) responsible for allergic contact dermatitis in some children. Additional studies are needed to assess optimal readings schedules.

Nickel allergy: localized, id, and systemic manifestations in children.

Nickel is the most common allergen causing allergic contact dermatitis in patch-tested children, especially in female children. Allergy to this metal can manifest in a variety of ways. In this case series, we present four children to illustrate the different presentations of nickel allergy confirmed by patch testing. Localized, id, and systemic nickel reactions are reviewed, as well as the diagnosis and management of nickel allergic contact dermatitis. While localized dermatitis in areas of direct contact to the allergen is the most common and easiest form of nickel allergy to identify, recognition of varying presentations is critical as these can result in more chronic and severe symptoms, and can be misdiagnosed as atopic dermatitis.

Children with atopic dermatitis appear less likely to be infected with community acquired methicillin-resistant Staphylococcus aureus: the San Diego experience.

Given the increasing rate of community-acquired methicillin resistant Staphylococcus aureus skin infections in the population, such infections might be concurrently increasing in patients with atopic dermatitis. This study assessed current and prior rates of community-acquired methicillin resistant Staphylococcus aureus and methicillin-susceptible Staphylococcus aureus skin and soft tissue infections in children with atopic dermatitis compared to the general pediatric population. Other antibiotic sensitivity and resistance patterns, including clindamycin-inducible resistance, were also identified. Retrospective study of all skin and soft tissue isolates were positive for Staphylococcus aureus during two distinct 1-year periods, obtained by the outpatient services and the emergency department at Rady Children's Hospital, the major regional pediatric health center in San Diego, California. Of the Staphylococcus aureus isolates obtained from January to December 2000, none from atopic dermatitis patients were methicillin resistant Staphylococcus aureus, while 4.2% of those obtained from the general outpatient pediatric population showed methicillin resistance. In the period from June 2007 to May 2008, 11 of 78 isolates (14.1%) from children with atopic dermatitis were methicillin resistant Staphylococcus aureus. This was significantly lower than the rate of increase noted in the general pediatric population (658 of 1482, or 44.4%, in 2007/2008, p < 0.05). Clindamycin-inducible resistance was noted in 1.9% of the isolates in the general population; all six tested isolates from atopic patients lacked clindamycin-inducible resistance. In this study, children with atopic dermatitis had a much lower rate of community-acquired methicillin resistant Staphylococcus aureus infection compared to the general outpatient pediatric population. Clindamycin-inducible resistance was very low in both groups.

Contact Dermatitis in Atopic Dermatitis Children-Past, Present, and Future.

Allergic contact dermatitis (ACD) used to be considered a rarity in children, but recently has been estimated to effect 4.4 million children in the USA alone, with a notable rise in investigative research in the field of pediatric ACD. Researchers have shown that patch testing is safe and effective in afflicted children and that those with atopic dermatitis (AD) have similar sensitization rates, although they have a higher sensitization to certain allergens, thought to be related to the inflammatory (IL-4) milieu. Patch testing assessment guidelines in children include five key considerations: if a patient's dermatitis worsens, changes distribution, fails to improve with topical therapy, or immediately rebounds after removal of topical treatments; if a patient has a particular distribution of dermatitis; if a working patient has hand eczema that fails to improve with therapy; if the patient has AD that started in adolescence or adulthood with definitely no history of childhood eczema; and importantly, if a patient has severe or widespread atopic dermatitis that will require immunosuppressive systemic medication.

Pediatric Contact Dermatitis Registry Inaugural Case Data.

BACKGROUND: Little is known about the epidemiology of allergic contact dermatitis (ACD) in US children. More widespread diagnostic confirmation through epicutaneous patch testing is needed. OBJECTIVE: The aim was to quantify patch test results from providers evaluating US children. METHODS: The study is a retrospective analysis of deidentified patch test results of children aged 18 years or younger, entered by participating providers in the Pediatric Contact Dermatitis Registry, during the first year of data collection (2015-2016). RESULTS: One thousand one hundred forty-two cases from 34 US states, entered by 84 providers, were analyzed. Sixty-five percent of cases had one or more positive patch test (PPT), with 48% of cases having 1 or more relevant positive patch test (RPPT). The most common PPT allergens were nickel (22%), fragrance mix I (11%), cobalt (9.1%), balsam of Peru (8.4%), neomycin (7.2%), propylene glycol (6.8%), cocamidopropyl betaine (6.4%), bacitracin (6.2%), formaldehyde (5.7%), and gold (5.7%). CONCLUSIONS: This US database provides multidisciplinary information on pediatric ACD, rates of PPT, and relevant RPPT reactions, validating the high rates of pediatric ACD previously reported in the literature. The registry database is the largest comprehensive collection of US-only pediatric patch test cases on which future research can be built. Continued collaboration between patients, health care providers, manufacturers, and policy makers is needed to decrease the most common allergens in pediatric consumer products.