Incidence and clinical factors associated with ulceration in infantile hemangiomas.

BACKGROUND: Ulceration is an important complication in infantile hemangiomas (IHs). Prior to the use of ß-blockers, the estimated incidence of this complication in a referral population was between 15% and 30%. The incidence and factors associated with ulceration have not been systematically studied since the emergence of ß-blocker therapy. OBJECTIVE: Examine the incidence and clinical predictors for ulceration in IHs. METHODS: Retrospective study at tertiary referral centers. RESULTS: Compared with a previous large pre-propranolol cohort study, ulceration occurred at a significantly lower incidence of 11.4%. Clinical factors associated with ulceration included partial segmental morphology, location in the diaper area, and size greater than 5 cm. Higher risk of ulceration in Black patients was observed, suggesting barriers to care including delayed diagnosis and referral to specialty care. LIMITATIONS: Retrospective design at tertiary referral centers. CONCLUSION: Compared with reports before the use of ß-blockers became widespread, the incidence of ulceration in IHs has decreased. However, it continues to be a relatively frequent complication of IH.

Clinical characteristics of infantile hemangiomas with aggressive, persistent, and destructive ulceration.

BACKGROUND/OBJECTIVES: Ulceration is a common complication of infantile hemangioma (IH). Severe, persistent ulceration occurs in a minority of patients. This study aims to characterize the clinical features of IH with aggressive ulceration (AU). METHODS: Multicenter retrospective study of clinical features of IH with AU. RESULTS: Thirty-five patients with AU were identified and included in the study. The majority of AU occurred in segmental IH (23/35, 65%). Segmental IH with AU were large (≥10 cm2 ; 16/23, 69%, p < .001) with a thin (<3 mm) superficial component (16/23, 69%, p < .001). Localized IH with AU had a thick (>3 mm) superficial component (11/12, 92%, p < .001). All diaper area IH with AU (9/35) were segmental with thin superficial component (100%, p = .02). IH with AU in the head/neck (10/35) were more commonly localized (67%) and mixed (62.5%), while segmental, thick superficial morphology was more common on trunk (9/35) and upper extremities (7/35). CONCLUSIONS: IH resulting in AU differ in clinical features by anatomic site. Those in the diaper area are nearly always segmental with thin superficial component, whereas other sites tend to be localized, mixed, with thick superficial component. These distinct phenotypes may prove useful in the clinical setting for physicians to identify patterns of IH ulceration with increased risk of aggressive, persistent ulceration.

Weight counseling in pediatric hidradenitis suppurativa patients.

BACKGROUND/OBJECTIVES: Hidradenitis suppurativa is a chronic, painful, debilitating disease that may present in the pediatric years. Overweight and obesity are believed to worsen disease severity, but many patients do not receive counseling regarding weight control. The objective of this study is to examine the percentage of hidradenitis suppurativa patients who receive weight counseling as a part of their disease management and which specialties primarily care for these patients. METHODS: We performed a retrospective chart review of pediatric hidradenitis suppurativa patients between January 2011 and October 2018. Demographic data, height, weight, body mass index, body mass index percentiles, number of visits per department, referrals to the Center for Healthy Weight and Nutrition, and referring provider department data were collected. RESULTS: A total of 535 pediatric hidradenitis suppurativa patients were reviewed; 79.6% were female, and the mean age at diagnosis was 14.5 years. 11.6% of patients were overweight, and 54.2% were obese. 32.1% of overweight and obese hidradenitis suppurativa patients received a referral to the Center for Healthy Weight and Nutrition. The majority of referrals were placed by Primary Care. Dermatology placed 7.1% of the referrals to the Center for Healthy Weight and Nutrition for these patients. CONCLUSIONS: The results suggest that there is a need for increased awareness, education, and counseling on weight management and nutrition for pediatric hidradenitis suppurativa patients. Further studies are needed to determine the success of counseling on weight control and disease severity.

Severity of disease and quality of life in parents of children with alopecia areata, totalis, and universalis: A prospective, cross-sectional study.

BACKGROUND: Caregiver-oriented quality of life (QoL) research in alopecia areata is limited. No study has used a parent-tailored survey to examine the relationship between QoL and severity of alopecia as measured by Severity of Alopecia Tool (SALT) scores. OBJECTIVES: This is a prospective study that describes QoL in parents of pediatric patients with all subtypes of alopecia areata and investigates the relationship between QoL and severity of disease, duration of disease, and age of patients. METHODS: Pediatric patients and their parents were invited to participate during clinic visits. Participating parents completed the Quality of Life in a Child's Chronic Disease Questionnaire (QLCCDQ) and the Family Dermatology Life Quality Index (FDLQI). A subset of children completed the Children's Dermatologic Life Quality Index (CDLQI). SALT scores at time of survey completion were recorded. RESULTS: In total, 153 patients were included. Significant mild-to-moderate negative correlations were found between SALT scores and FDLQI scores, QLCCDQ scores, and QLCCDQ emotional domain scores. Age of child correlated negatively with QLCCDQ scores but not FDLQI scores. No significant correlation was found between duration of disease and FDLQI scores, QLCCDQ scores, or QLCCDQ emotional domain scores. LIMITATIONS: This study is limited by its small sample size and cross-sectional design. CONCLUSIONS: Impaired parent QoL might be associated with increasing severity of disease and age of affected child but not duration of disease. Providers should tailor counseling accordingly and help parents set realistic expectations for long-term experience with the disease.

Bullous diaper dermatitis with cloth diaper use.

Irritant diaper dermatitis occurs at a higher frequency with cloth diaper use than disposable diapers. We present four cases of vesiculobullous, erosive diaper dermatitis occurring in older infants and toddlers with cloth diaper use that resolved completely after transitioning to disposable diapers. This is the first report of vesicles and bullae as a type of irritant diaper dermatitis.

Hair loss in women.

Hair loss is a common cause of morbidity for many women. As a key member of the woman's health care team, the obstetrician/gynecologist may be the first person to evaluate the complaint of hair loss. Common types of nonscarring hair loss, including female pattern hair loss and telogen effluvium, may be diagnosed and managed by the obstetrician/gynecologist. A systematic approach to diagnosis and management of these common forms of hair loss is presented.

Evaluation of the Prevalence and Incidence of Pediatric Alopecia Areata Using Electronic Health Record Data.

Importance: Pediatric alopecia areata (AA) prevalence and incidence data are key to understanding the natural history of this medical disease. Objective: To determine the prevalence and incidence of AA in a pediatric population across time, age, sex, race and ethnicity, and geographic areas within the US. Design, Setting, and Participants: In this multicenter cohort study conducted among 5 children's hospitals, data (January 2009 to November 2020) were collected from a standardized electronic health record (PEDSnet database, version 4.0) to evaluate the incidence and prevalence of pediatric AA. The study cohort included patients younger than 18 years with at least 2 physician visits during which a diagnosis code for AA was recorded, or 1 dermatologist specialty visit for which AA was recorded. Main Outcomes and Measures: The prevalence denominator population comprised 5 409 919 patients. The incidence denominator population was 2 896 241. We identified 5801 children for inclusion in the AA cohort, and 2398 (41.3%) had 12 months or more of follow-up and were included in the incidence analysis. Results: Of 5801 patients in the AA cohort, the mean (SD) age was 9.0 (4.5) years, 3259 (56.2%) were female, 359 (6.2) were Asian, 1094 (18.9%) were Black, 1348 (23.2%) were Hispanic, and 2362 (40.7%) were White. The overall prevalence of pediatric AA was 0.11%, and the participants in the AA cohort were more often older, female, and members of a racial and ethnic minority group than the full PEDSnet population. The 11-year overall incidence rate of pediatric AA between 2009 and 2020 was 13.6 cases per 100 000 person-years (95% CI, 13.1-14.2). The incidence rate by age was normally distributed and peaked at age 6 years. Rates were 22.8% higher in female patients than male patients (15.1 cases per 100 000 person-years for females vs 12.3 cases per 100 000 person-years for males). Additionally, incidence rates were highest among Hispanic children (31.5 cases per 100 000 person-years). Conclusions and Relevance: This cohort study examined the prevalence and incidence rates of pediatric AA in the US across time, age, sex, race and ethnicity, and region from 2009 to 2020, finding a prevalence of 0.11% (doubling during the last decade) and incidence rate of 13.6 cases per 100 000 person-years. Additionally, the results identified Asian and Hispanic children as high-risk demographic subgroups who were shown to be 2 and 3 times more likely, respectively, to receive a diagnosis of AA.

Can performance in medical school predict performance in residency? A compilation and review of correlative studies.

BACKGROUND: The current resident selection process relies heavily on medical student performance, with the assumption that analysis of this performance will aid in the selection of successful residents. Although there is abundant literature analyzing indicators of medical student performance measures as predictors of success in residency, wide-ranging differences in beliefs persist concerning their validity. OBJECTIVE: We sought to collect and review studies that have correlated medical student performance with residency performance. METHODS: The English-language literature from 1996 to 2009 was searched with PubMed. Selected studies evaluated medical students on the basis of US Medical Licensing Examination scores, preclinical and clinical performance, research experience, objective structured clinical examination performance, medical school factors, honor society membership, Medical Student Performance Evaluations, letters of recommendation, and faculty interviews. Outcome measures were standardized residency examinations and residency supervisor ratings. RESULTS: The medical student factors that correlated most strongly with performance on examinations in residency were medical student examination scores, clinical performance, and honor society membership. Those that correlated most strongly with supervisor ratings were clinical grades, faculty interview, and medical school attended. Overall, there were inconsistent results for most performance measures. LIMITATIONS: In addition to the lack of a widely used measure of success in residency, most studies were small, single institution, and single specialty, and thus of limited ability to generalize findings. CONCLUSION: No one medical student factor can be used to predict performance in residency. There is a need for a more consistent and systematic approach to determining predictors of success in residency.

Clinical Features, Prognostic Factors, and Treatment Interventions for Ulceration in Patients With Infantile Hemangioma.

Importance: Ulceration is a common complication of infantile hemangioma (IH), which leads to substantial morbidity. Ulceration in IH has not been systematically studied since the advent of ß-blocker therapy for IH. Objectives: To examine treatment interventions used for ulceration in IH and identify clinical prognostic indicators of healing time. Design, Setting, and Participants: A retrospective, multicenter cohort study was conducted on 436 consecutive patients with a clinical diagnosis of ulcerated IH and available clinical photographs. Patients receiving care at tertiary referral centers evaluated between 2012 and 2016 were included; statistical and data analysis were performed from February 7 to April 27, 2020. Exposures: Clinical characteristics, treatment interventions, course, complications, and resource use were analyzed. Treatment interventions for ulceration in IH included local (wound care, topical), systemic (ß-blocker, corticosteroids), and procedural (pulsed-dye laser). Main Outcomes and Measures: The primary end point was time to complete or nearly complete ulceration healing. Clinical characteristics were analyzed to determine the responses to most common interventions and prognostic factors for healing of ulceration. Results: Of the 436 patients included in the study, 327 were girls (75.0%); median age at ulceration was 13.7 weeks (interquartile range, 8.86-21.30 weeks). The median heal time was 4.79 weeks (95% CI, 3.71-5.86 weeks) with wound care alone, 5.14 weeks (95% CI, 4.57-6.00 weeks) with timolol, 6.36 weeks (95% CI, 5.57-8.00 weeks) with a systemic ß-blocker, and 7.71 weeks (95% CI, 6.71-10.14 weeks) with multimodal therapy. After adjusting for IH size, a dose of propranolol less than or equal to 1 mg/kg/d was associated with shorter healing time compared with higher propranolol doses (hazard ratio, 2.04; 95% CI, 1.11 to 3.73; P = .02). Size of the IH was identified as a significant prognostic factor for healing time in multivariable analysis. Increasing size of IH portends a proportionately longer time to heal of the ulceration. Conclusions and Relevance: Despite the use of ß-blockers, this cohort study found that a subset of patients with IH ulceration continued to experience prolonged IH healing times. Larger IH size appears to be a poor prognostic factor for time to heal. For patients requiring systemic therapy, initiation of propranolol at lower doses (≤1 mg/kg/d) should be considered.

A Retrospective Analysis Comparing the New Standardized Letter of Recommendation in Dermatology with the Classic Narrative Letter of Recommendation.

Background: In an effort to avoid numerous problems associated with narrative letters of recommendation, a dermatology standardized letter of recommendation was utilized in the 2014-2015 resident application cycle. Objective: A comparison of the standardized letter of recommendation and narrative letters of recommendation from a single institution and application cycle to determine if the standardized letter of recommendation met its original goals of efficiency, applicant stratification, and validity. Methods: Eight dermatologists assessed all standardized letters of recommendation/narrative letters of recommendation pairs received during the 2014-2015 application cycle. Five readers repeated the analysis two months later. Each letter of recommendation was evaluated based on a seven question survey. Letter analysis and survey completion for each letter was timed. Results: Compared to the narrative letters of recommendation, the standardized letter of recommendation is easier to interpret (p<0.0001), has less exaggeration of applicants' positive traits (p<0.001), and has higher inter-rater and intrarater reliability for determining applicant traits including personality, reliability, work-ethic, and global score. Standardized letters of recommendation are also faster to interpret (p<0.0001) and provide more information about the writer's background or writer-applicant relationship than narrative letters of recommendation (p<0.001). Limitations: This study was completed at a single institution. Conclusions: The standardized letter of recommendation appears to be meeting its initial goals of 1) efficiency, 2) applicant stratification, and 3) validity. (J Clin Aesthet Dermatol. 2016;9(9):36-2.).