Epidemiologic Analysis of Onychomycosis in the San Diego Pediatric Population.

BACKGROUND: Onychomycosis (OM) is thought to be a rare disease in children, although there are few epidemiologic studies. METHODS: This 3-year retrospective case series of nearly 400 children seen at Rady Children's Hospital-San Diego (RCHSD) describes the characteristics of OM found in this pediatric population. RESULTS: From 2011 to 2013, the Pediatric and Adolescent Dermatology Clinic at RCHSD saw a total of 36,634 unique patients, of whom 433 were unique patients with OM. Thirty-four patients met exclusion criteria, leaving 399 (1.1%) with a diagnosis of OM by a pediatric dermatologist. Nail cultures were obtained in 242 cases (60.7%), 116 (48.0%) of which were positive. Trichophyton rubrum was the most commonly isolated pathogen, responsible for 106 cases (91.3%) of positive cultures in the cohort. CONCLUSIONS: Our study provides important regional information regarding epidemiologic data in pediatric onychomycosis, highlighting the diagnostic methods most commonly used and the pathogens most frequently encountered in our practice.

Can long-term alopecia occur after appropriate pulsed-dye laser therapy in hair-bearing sites? Pediatric dermatologists weigh in.

BACKGROUND: The risk of long-term alopecia after pulsed-dye laser (PDL) therapy is unknown. To identify how many practitioners treat hair-bearing sites with PDL and how commonly long-term alopecia occurs, the authors queried pediatric dermatologists about their experiences using this modality. METHODS: A survey was designed to evaluate the frequency of and factors contributing to long-term alopecia after PDL treatment of port-wine stains (PWS). "Long-term" was defined as no sign of hair regrowth after several years of nontreatment. The survey was administered to attendees at the 2014 Society for Pediatric Dermatology biannual meeting. RESULTS: Sixty-four pediatric dermatologists completed the survey, 50 of whom had experience using PDL. Of these physicians, 86% have used PDL to treat PWS of the eyebrow and 80% have treated PWS of the scalp. Over one-quarter of respondents (25.5%) using PDL on hair-bearing areas had at least 1 of their patients develop long-term alopecia after PDL treatment. The incidence of long-term alopecia after PDL treatment in the surveyed population was 1.5% to 2.6%. CONCLUSION: The occurrence of long-term alopecia at hair-bearing sites after treatment with PDL may be greater than previously thought. Because the majority of physicians using PDL treat hair-bearing areas, prospective studies are needed to more accurately determine the risk of long-term alopecia and the factors that contribute to it.

Successful Treatment of a Lichenoid-Like Granulomatous Reaction to Purple Tattoo Pigment With Intralesional Kenalog.

Tattoo reactions can be clinically challenging to diagnose and treat. We present a case of a biopsy-proven granulomatous reaction to purple tattoo ink that clinically mimicked lichen planus. This reaction was successfully treated with one course of intralesional kenalog (ILK), with no recurrence six months after treatment. To our knowledge, this is the first report of a granulomatous tattoo reaction appearing clinically like lichen planus, and one of the few reports of a reaction to purple tattoo pigment. It highlights the importance of biopsying tattoo-related dermatoses prior to treatment in order to confirm the diagnosis. It also illustrates how a minimally invasive technique utilizing ILK to treat a granulomatous tattoo reaction can result in excellent dermatologic, cosmetic, and symptomatic outcomes. Based on this therapeutic success, we believe treatment with ILK injections should be attempted before more invasive modalities such as excision or laser therapy.

Successful treatment of pearly penile papules with carbon dioxide laser resurfacing after local anesthesia in an adolescent patient.

Pearly penile papules (PPP) can cause significant psychological morbidity. Herein we report the successful use of a macrofractionated carbon dioxide laser at full-field ablative density settings for the treatment of PPP in a 17-year-old boy using local anesthetic alone. Our experience leads us to believe that PPP can be successfully treated in the pediatric and adolescent populations using this novel and relatively noninvasive technique.

Agminated flexural melanocytic nevi: a late sequela of Langerhans cell histiocytosis?

Agminated flexural melanocytic nevi in children with a history of Langerhans cell histiocytosis (LCH) are rare and thought to be coincidental or related to systemic chemotherapy. We report on an 11-year-old boy in remission from LCH, treated with only topical steroids, who presented years later with an eruption of melanocytic nevi in the bilateral inguinal and axillary regions. Rather than coincidence, we hypothesize that agminated flexural melanocytic nevi are a late sequela of LCH, possibly resulting from immune tolerance or a reaction to local inflammation.

A review of scar assessment scales.

At our current level of understanding, scars are an unavoidable result of disruption of the integument following trauma and other sources of injury in the postnatal period. Millions of people worldwide suffer from diminished quality of life due to varying degrees of disfigurement, functional impairment, and psychosocial comorbidity. Scars also represent a significant financial burden to the healthcare system at large. Substantial momentum currently exists in scar research associated with innovative techniques and devices devoted to treating scars. In order to properly ascertain and compare responses to various therapies, accurate and reproducible qualitative and quantitative assessments are vital. At least 10 different scar assessment scales and tools have been created to date in an attempt to quantify scar severity. However, a "gold standard" scar scale still does not yet exist. A major limitation of most scar scales is their focus on a relatively narrow group of individual subjective and objective features, while failing to address the overall cosmetic, functional, and psychological sequelae. Herein, we provide a brief review of current scar assessment scales, discuss some of the major advantages and limitations of each, and introduce several characteristics that might be addressed in a new "gold standard" scar scale. The assessment and treatment of scars, particularly large traumatic scars, is frequently a multidisciplinary effort. The creation of an "ideal" scar scale will undoubtedly require input from therapists, surgeons, dermatologists, and other professionals alike.

Successful medical treatment of a severe reaction to red tattoo pigment.

Tattoo allergies are often eczematous skin rashes that can be complicated by ulceration and infection. These allergies are difficult to resolve, sometimes requiring surgical or laser intervention, with varying success. Here we present a case of a 29-year-old woman with a serious skin allergic reaction to red tattoo ink that ulcerated and became secondarily infected. The patient expressed a desire to have the tattoo allergic reaction treated while preserving the cosmetic appearance of her tattoo for sentimental reasons. This case is being presented to provide an effective treatment algorithm for managing allergic tattoo reactions with ulceration and co-infection, while preserving the aesthetic integrity of the tattoo.

Filling in Pediatric Acne Practice Gaps: A Prospective Multicenter Study of Case-Based Education.

PURPOSE: Studies have documented practice gaps in acne management between pediatricians and dermatologists. Evidence-based recommendations for acne management were published by the American Acne and Rosacea Society and the American Academy of Pediatrics in 2013. We assess the impact of a case-based learning intervention on pediatrician knowledge and treatment of acne in accordance with published recommendations. METHODS: Participants were recruited at four conferences for pediatric providers. Knowledge of the recommendations and confidence in utilizing them was assessed. Five case-based questions were presented, with providers choosing acne treatments before, immediately after, and 3 months after a case-based educational presentation. Answer selections consistent with the recommendations were scored as correct, and all responses were evaluated for patterns of medication selection. RESULTS: A total of 150 individuals participated, most with over 10 years experience. Knowledge of the recommendations and confidence in prescribing acne therapy was poor. The average preintervention management selections were 70% correct, increasing significantly to 86% 3 months after intervention (p < .01). The most significant improvements were demonstrated in provider's ability to choose regimens for moderate acne consistent with published recommendations, and in recommendation-consistent usage of retinoids and benzoyl peroxide (p < .05). Persisting practice gaps included a reluctance to use topical retinoids in preadolescents and lack of initiating oral combination therapies in patients with severe acne. CONCLUSIONS: A case-based educational intervention significantly increased providers choosing acne treatments in accordance with evidence-based recommendations in an examination setting. Limitations of the study include an inability to assess actual provider prescribing behavior through this methodology.

Antifungal therapy for onychomycosis in children.

Onychomycosis is a chronic infection of the nail unit, and its prevalence increases with age. Treatment options for children are similar to those for adults and include both oral and topical therapies. Oral agents, such as terbinafine, itraconazole, and fluconazole have been reported to have good efficacy and a low rate of side effects in children. Topical therapies, such as amorolfine and ciclopirox, can also be used as monotherapy or combined with oral agents to treat onychomycosis. Due to their thinner, faster-growing nails, children are more likely to respond to topical monotherapy than adults. There is currently insufficient data comparing emerging medical devices, such as laser therapy, with standard therapeutic options to recommend their use in children.

Drug-induced Telogen Effluvium in a Pediatric Patient due to Error of Transcription.

"Errors of transcription" are rarely reported, but may cause significant adverse effects in patients. Here, the authors report the case of a 15-year-old Burmese girl presenting with telogen effluvium after being dispensed the wrong medication due to a pharmacy auto-complete error.

Chemical Burn from Vinegar Following an Internet-based Protocol for Self-removal of Nevi.

"Natural home remedies" for nevi removal found on the Internet can be ineffective, or worse, dangerous. Children and teens, in particular, may be more likely to attempt self-treatment in order to avoid discussing their concerns with their parents. Here, the authors report a case of an adolescent who presented with a chemical burn after following an Internet-based protocol for nevi removal using apple cider vinegar.

Beta blockers: an innovation in the treatment of infantile hemangiomas.

Infantile hemangiomas are benign vascular tumors seen in 4.5 percent of neonates and infants. While most infantile hemangiomas can be managed with active nonintervention, a subset of patients will require more aggressive management. Here the authors review the use of beta-blockers in the treatment of infantile hemangiomas, including oral, topical, and multimodal treatment options. They discuss the latest data on propranolol, including criteria for patient selection, dosing recommendations, and appropriate monitoring for side effects and efficacy. Lastly, they review indications for topical timolol treatment and the potential benefits of concomitant laser therapy.

Itching to learn: school chair allergic contact dermatitis on the posterior thighs.

A 10-year-old girl with a history suggestive of nickel allergy presented with pruritic, eczematous plaques on her posterior thighs. Patch testing revealed sensitivities to nickel, cobalt, and chromium. The pattern of her involvement suggested an "outside job," and subsequent investigations confirmed that the exposed metal fasteners on her school chair were the likely source of her focal contact dermatitis. Medical history-taking, clinical observation, and investigative follow-through are essential when trying to identify a specific source of contact dermatitis in the pediatric and adolescent populations.

Myeloid cell HIF-1α regulates asthma airway resistance and eosinophil function.

Hypoxia-inducible factor (HIF)-1α is a master regulator of inflammatory activities of myeloid cells, including neutrophils and macrophages. These studies examine the role of myeloid cell HIF-1α in regulating asthma induction and pathogenesis, and for the first time, evaluate the roles of HIF-1α and HIF-2α in the chemotactic properties of eosinophils, the myeloid cells most associated with asthma. Wild-type (WT) and myeloid cell-specific HIF-1α knockout (KO) C57BL/6 mice were studied in an ovalbumin (OVA) model of asthma. Administration of the pharmacological HIF-1α antagonist YC-1 was used to corroborate findings from the genetic model. WT, HIF-1α, and HIF-2α KO eosinophils underwent in vitro chemotaxis assays. We found that deletion of HIF-1α in myeloid cells and systemic treatment with YC-1 during asthma induction decreased airway hyperresponsiveness (AHR). Deletion of HIF-1α in myeloid cells in OVA-induced asthma also reduced eosinophil infiltration, goblet cell hyperplasia, and levels of cytokines IL-4, IL-5, and IL-13 in the lung. HIF-1α inhibition with YC-1 during asthma induction decreased eosinophilia in bronchoalveolar lavage, lung parenchyma, and blood, as well as decreased total lung inflammation, IL-5, and serum OVA-specific IgE levels. Deletion of HIF-1α in eosinophils decreased their chemotaxis, while deletion of the isoform HIF-2α led to increased chemotaxis. This work demonstrates that HIF-1α in myeloid cells plays a role in asthma pathogenesis, particularly in AHR development. Additionally, treatment with HIF-1α inhibitors during asthma induction decreases AHR and eosinophilia. Finally, we show that HIF-1α and HIF-2α regulate eosinophil migration in opposing ways.

Protein kinase C η is required for T cell activation and homeostatic proliferation.

Protein kinase C η (PKCη) is abundant in T cells and is recruited to the immunological synapse that is formed between a T cell and an antigen-presenting cell; however, its function in T cells is unknown. We showed that PKCη was required for the activation of mature CD8+ T cells through the T cell receptor. Compared with wild-type T cells, PKCη-/- T cells showed poor proliferation in response to antigen stimulation, a trait shared with T cells deficient in PKCθ, which is the most abundant PKC isoform in T cells and was thought to be the only PKC isoform with a specific role in T cell activation. In contrast, only PKCη-deficient T cells showed defective homeostatic proliferation, which requires self-antigen recognition. PKCη was dispensable for thymocyte development; however, thymocytes from mice doubly deficient in PKCη and PKCθ exhibited poor development, indicating some redundancy between the PKC isoforms. Deficiency in PKCη or PKCθ had opposing effects on the relative numbers of CD4+ and CD8+ T cells. PKCη-/- mice had a higher ratio of CD4+ to CD8+ T cells compared to that of wild-type mice, whereas PKCθ-/- mice had a lower ratio. Mice deficient in both isoforms exhibited normal cell ratios. Together, these data suggest that PKCη shares some redundant roles with PKCθ in T cell biology and also performs nonredundant functions that are required for T cell homeostasis and activation.