EAACI position paper for practical patch testing in allergic contact dermatitis in children.

INTRODUCTION: Allergic contact dermatitis (ACD) in children appears to be on the increase, and contact sensitization may already begin in infancy. The diagnosis of contact dermatitis requires a careful evaluation of a patient's clinical history, physical examination, and skin testing. Patch testing is the gold standard diagnostic test. METHODS: Based on consensus, the EAACI Task Force on Allergic Contact Dermatitis in Children produced this document to provide details on clinical aspects, the standardization of patch test methodology, and suggestions for future research in the field. RESULTS: We provide a baseline list of test allergens to be tested in children with suspected ACD. Additional tests should be performed only on specific indications.

Correlation between Objective SCORAD and Three-Item Severity Score used by physicians and Objective PO-SCORAD used by parents/patients in children with atopic dermatitis.

BACKGROUND: A self-assessment rating scale (SAS) is a good tool to assess the fluctuating disease severity and quality of life (QoL) in children with atopic dermatitis (AD). The European Task Force on Atopic Dermatitis created an SAS based on the Scoring Atopic Dermatitis (SCORAD) index, called the Patient-Oriented SCORAD (PO-SCORAD). OBJECTIVE: The aim of our study was to measure the correlation between alternative systems such as the OBJECTIVE SCORAD, the Three-Item Severity (TIS) score and the OBJECTIVE PO-SCORAD. We also investigated the correlations between the objective severity assessments and QoL. METHODS: In a specialized outpatient clinic, an observational prospective study was performed with children ≤16 years with AD. RESULTS: Seventy-five children were included. A good and significant correlation was shown between OBJECTIVE SCORAD and OBJECTIVE PO-SCORAD: Spearman's ρ correlation (rs) = 0.63 (p < 0.001). The correlation with QoL was moderate, but still significant (rs = 0.41-0.61, p < 0.001). CONCLUSION: The OBJECTIVE PO-SCORAD can be used for the evaluation of fluctuating AD and correlates significantly with the OBJECTIVE SCORAD and the less time-consuming TIS score.

The proactive wet-wrap method with diluted corticosteroids versus emollients in children with atopic dermatitis: a prospective, randomized, double-blind, placebo-controlled trial.

BACKGROUND: Wet-wrap treatment (WWT) has been advocated as a relatively effective treatment in children with severe atopic dermatitis (AD). WWT often serves as crisis intervention for AD. OBJECTIVES: We sought to evaluate the use of WWT with diluted corticosteroids in comparison with emollient in children with severe AD during 4 weeks in a proactive schedule during which the frequency of corticosteroid applications was tapered. METHODS: A randomized, double-blind, placebo-controlled study was performed in children aged 6 months to 10 years with severe AD (objective SCORAD at least 40 ± 5), comparing WWT with diluted corticosteroids (1:3 mometasone furoate 0.1% ointment and for the face 1:19 mometasone furoate 0.1% ointment under a mask) with emollient (petrolatum 20% in cetomacrogol cream). The primary outcome was improvement of the objective SCORAD; secondary outcomes included Patient-Oriented Eczema Measure and quality-of-life index. RESULTS: WWT with diluted corticosteroids acted faster and was more efficacious than WWT with emollients. Best results were obtained in age groups 6 to 9 years and 0 to 3 years. The difference in efficacy evaluated by objective SCORAD was significant at all measuring points. This also applied to the quality-of-life index. LIMITATIONS: The study group was relatively small. CONCLUSIONS: WWT for severe AD is an effective therapy option for at least a period of 4 weeks.

Allergic contact dermatitis in children: which factors are relevant? (review of the literature).

Allergic contact dermatitis (ACD) in children is increasing. Sensitization to contact allergens can start in early infancy. The epidermal barrier is crucial for the development of sensitization and elicitation of ACD. Factors that may influence the onset of sensitization in children are atopic dermatitis, skin barrier defects and intense or repetitive contact with allergens. Topical treatment of ACD is associated with cutaneous sensitization, although the prevalence is not high. ACD because of haptens in shoes or shin guards should be considered in cases of persistent foot eruptions or sharply defined dermatitis on the lower legs. Clinical polymorphism of contact dermatitis to clothing may cause difficulties in diagnosing textile dermatitis. Toys are another potentially source of hapten exposure in children, especially from toy-cosmetic products such as perfumes, lipstick and eye shadow. The most frequent contact allergens in children are metals, fragrances, preservatives, neomycin, rubber chemicals and more recently also colourings. It is very important to remember that ACD in young children is not rare, and should always be considered when children with recalcitrant eczema are encountered. Children should be patch-tested with a selection of allergens having the highest proportion of positive, relevant patch test reactions. The allergen exposure pattern differs between age groups and adolescents may also be exposed to occupational allergens. The purpose of this review is to alert the paediatrician and dermatologist of the frequency of ACD in young children and of the importance of performing patch tests in every case of chronic recurrent or therapy-resistant eczema in children.

Tumour necrosis factor (TNF)-blocking agents in juvenile psoriatic arthritis: are they effective?

OBJECTIVES: To evaluate the effectiveness of tumour necrosis factor (TNF) blockers in juvenile psoriatic arthritis (JPsA). METHODS: The study was a prospective ongoing multicentre, observational study of all Dutch juvenile idiopathic arthritis (JIA) patients using biologicals. The response of arthritis was assessed by American College of Rheumatology (ACR) paediatric response and Wallace inactive disease criteria. The response of psoriatic skin lesions was scored by a 5-point scale. RESULTS: Eighteen JPsA patients (72% female, median age onset 11.1 (range 3.3-14.6) years, 50% psoriatic skin lesions, 39% nail pitting, 22% dactylitis) were studied. The median follow-up time since starting anti-TNFα was 26 (range 3-62) months. Seventeen patients started on etanercept and one started on adalimumab. After 3 months of treatment 83% of the patients achieved ACR30 response, increasing to 100% after 15 months. Inactive disease reached in 67% after 39 months. There was no discontinuation because of inefficacy. Six patients discontinued treatment after a good clinical response. However, five patients flared and restarted treatment, all with a good response. During treatment four patients (two JPsA and two JIA patients with other subtypes) developed de novo psoriasis. In four of the nine patients the pre-existing psoriatic skin lesions improved. CONCLUSION: Anti-TNFα therapy in JPsA seems effective in treating arthritis. However, in most patients the arthritis flared up after treatment discontinuation, emphasising the need to investigate optimal therapy duration. The psoriatic skin lesions did not respond well and four patients developed de novo psoriasis.

Imatinib mesylate for children with dermatofibrosarcoma protuberans (DFSP).

Dermatofibrosarcoma protuberans (DFSP) is a rare malignant soft tissue tumor in children. DFSP is characterized by a specific fusion of the platelet-derived growth factor beta (PDGFbeta) with the collagen type 1alpha1 (COL1alpha1) gene which renders these tumors responsive to targeted therapy with tyrosine kinase inhibitors, such as imatinib mesylate, as is reported in adults. In the current report, we describe the first small pediatric DFSP series, in which response to imatinib mesylate contributed to successful treatment outcome.

Patch tests in children with suspected allergic contact dermatitis: a prospective study and review of the literature.

AIMS: The results of patch testing in children visiting our out-patient clinic with suspected allergic contact dermatitis (ACD) were prospectively investigated and compared with those reported in the literature. A review of the literature on patch testing and ACD in children is provided. METHODS: Children were patch tested using the TRUE test, supplemented with tixocortol-17-pivalate, budesonide and 3 commonly used emollients. Supplementary patch tests were undertaken on indication. RESULTS: Seventy-nine children (31 boys and 48 girls) were patch tested. Of the patients tested, 40 (51%) had 1 or more positive allergic patch test reactions. Twenty-two (55%) of these 40 children suffered from atopic dermatitis, 9 (23%) from hand or foot dermatitis, and 9 (23%) from other skin ailments. Nickel was the most common contact allergen, but many other common and less common allergens were noted to give positive patch tests in patients. CONCLUSION: Sensitization to contact allergens may begin in infancy and continue to be more common in toddlers and young children. In recalcitrant atopic dermatitis, especially at the age of 5 years and over, patch tests are indicated. Good information on preventing the development of ACD in children is useful for caregivers.

Efficacy of 25% diluted fluticasone propionate 0.05% cream as wet-wrap treatment in cutaneous mastocytosis.

BACKGROUND: Mastocytosis is a disorder that can be subdivided into two forms: cutaneous and systemic. Patients with cutaneous mastocytosis only may suffer from cosmetic problems. Topical steroid application has been shown to be effective in cases of limited skin lesions. METHODS: A case-controlled pilot study was conducted during a 6-weeks treatment using diluted 25% fluticasone propionate 0.05% cream under wet-wrap occlusion in 5 adults and 6 children. Improvement was measured up to the 24th week after treatment using the SCORMA Index. RESULTS: The results of this pilot study showed a partial but clear cosmetic improvement in 9 of the 11 patients. The mean SCORMA Index decreased after treatment from 38 to 26. CONCLUSION: 25% dilution of fluticasone propionate 0.05% cream under wet-wrap occlusion is an alternative treatment modality for alleviating the symptoms of cutaneous mastocytosis, but the improvement may be moderate and fall short of the patient's expectations.

Recent developments in the management of common childhood skin infections.

A literature review and clinical commentary on diagnosis and treatment of common childhood bacterial, fungal and viral skin infections is presented including impetigo, folliculitis, staphylococcal scalded skin syndrome, tinea capitis, warts and molluscum contagiosum.

Natural course of cow's milk allergy in childhood atopic eczema/dermatitis syndrome.

OBJECTIVE: This review was undertaken to determine the role of adverse reactions to bovine proteins in atopic dermatitis, recently called atopic eczema/dermatitis syndrome (AEDS). DATA SOURCES: A PubMed literature search was conducted with use of the following phrases: atopic dermatitis and food allergy, atopic dermatitis and cow's milk, and cow's milk and eczema. STUDY SELECTION: The authors' judgment and personal interest guided the literature selection. RESULTS: Food allergy has a role in at least 20% of the cases of AEDS in children younger than 4 years. Cow's milk is usually the first food given to an infant, and cow's milk hypersensitivity is often the first symptom of an atopic condition. Adverse reactions to cow's milk proteins are usually categorized as immunoglobulin (Ig)E-mediated or non-IgE-mediated cow's milk allergy and nonallergic hypersensitivity (intolerance); the symptoms do not allow differentiation of these entities. In patients with cow's milk allergy and AEDS, resolution occurs in 90% by the age of 4 years. Non-IgE-mediated cow's milk allergy often disappears before the age of 1 year. Associated reactions to other foods develop in approximately 45% of patients. Allergy to potential environmental inhalant allergens has been reported in up to 28% of patients by 3 years of age and up to 80% before puberty. After consumption of large amounts of cow's milk, 45% of 10-year-old children who had become tolerant of cow's milk, but also 15% of control subjects, still had gastrointestinal complaints. The presence of cow's milk allergy during infancy increases the risks for development of other food allergies, respiratory atopy, and persistence of AEDS. CONCLUSION: Adverse reactions to bovine proteins have an important role in AEDS.

Atopic dermatitis: review 2000 to January 2001.

A review on atopic dermatitis is given, considering as basic information articles published over the period of February 1, 2000 to January 31, 2001. Atopic dermatitis is a chronic, inflammatory, primarily genetic-determined skin disease of which the cause is unknown. Its prevalence is rising in the industrialized countries, and no one knows why. The hygienic theory is most promising. Although most cases of atopic dermatitis are mild, the disease may be severe and widespread, with much impact on morbidity and social life. Mild cases usually clear and compromise 60% of the cases. Atopic dermatitis may always turn back. The clinical features are age related. Recently, a new subgroup was noted by several dermatologists in different parts of the world, consisting of people who suffer from atopic dermatitis for the first time at adult age. Food allergy, intolerance, and diet are still controversial and play a role especially in children until the age of 5 years. Diagnostic tests, such as the Atopy Patch Test, using food allergens, adds 10% or more positives and imitates the late-phase clinical manifestations. The Atopy Patch Test is still experimental as a diagnostic tool and has shortcomings, like difficulty in reading. Financial costs of treating and caring for atopic dermatitis may be high, stressing the importance of health care.

Soluble E-selectin and soluble ICAM-1 levels as markers of the activity of atopic dermatitis in children.

The expression of adhesion molecules is up-regulated in the skin of atopic dermatitis (AD) patients, and the levels of the soluble adhesion molecules sE-selectin and sICAM-1 have been reported to reflect the endothelial activation in the skin of AD patients. The objective of the study was to investigate the relationship between symptom score and levels of sE-selectin, sICAM-1 and sVCAM-1 before and after 2 weeks of treatment. Eighteen children with an exacerbation of AD were admitted and treated with corticosteroid dilutions under occlusive wet dressings (wet-wrap treatment). Symptom score (objective SCORAD) and levels of sE-selectin, sICAM-1, and sVCAM-1 were assessed before and after 2 weeks of treatment. A significant correlation between the objective SCORAD before treatment and the level of sE-selectin (p < 0.05), but not the level of sICAM-1 (p = 0.7) or sVCAM-1 (p = 0.5) was observed. The treatment resulted in a high degree of remission, which was reflected by a significant decrease in the level of sICAM-1 (p < 0.01), whereas there was only a trend in the level of sE-selectin to decrease (p = 0.08). The level of sE-selectin after 2 weeks of treatment still correlated significantly with the objective SCORAD before treatment (p < 0.005). Soluble E-selectin is a relative objective marker for the severity of AD. SCORAD is a treatment-sensitive symptom of AD, whereas E-selectin may be a more stable underlying systemic representation of AD.