Consensus on Neonatal Through Preadolescent Acne.

BACKGROUND: Acne vulgaris is the most common dermatological disorder. Pediatric acne may be a manifestation of the underlying pathology and can occur in the first weeks, months, or years of life. Acne in childhood can be categorized by age and pubertal status. OBJECTIVE: An expert panel of pediatric dermatologists and dermatologists developed a consensus paper on neonatal through preadolescent acne, providing information on differential diagnosis, prevention, treatment, and maintenance of the condition. METHODS: A systematic literature review explored present clinical guidelines, treatment options, and therapeutic approaches addressing neonatal through preadolescent acne. The information from the literature searches was used together with the panel’s expert opinion and experience to adopt consensus statements following established standards. RESULTS: The panel members reached unanimous consensus on seven statements addressing the various age categories of pediatric acne: neonatal acne: birth to ≤ 8 weeks; infantile acne: 8 weeks to ≤1 year; mid-childhood acne: 1 year to <7 years; preadolescent acne: ≥7 to 12 years; adolescent acne: ≥12 to 19 years or after menarche for girls. Health care providers treating children need to pay more attention to pediatric acne and should monitor the risk of endocrine-associated abnormalities, especially in mild-childhood acne. When prescribing acne treatment, newer medications approved for use in children older than nine years of age may offer a suitable option. CONCLUSION: The differential diagnosis of pediatric acne, as well as its treatment and maintenance, requires much more attention and consideration from health care providers treating children. J Drugs Dermatol. 2020;19(6):592-600. doi:10.36849/JDD.2020.5065.

RASA1 mutations and associated phenotypes in 68 families with capillary malformation-arteriovenous malformation.

Capillary malformation-arteriovenous malformation (CM-AVM) is an autosomal-dominant disorder, caused by heterozygous RASA1 mutations, and manifesting multifocal CMs and high risk for fast-flow lesions. A limited number of patients have been reported, raising the question of the phenotypic borders. We identified new patients with a clinical diagnosis of CM-AVM, and patients with overlapping phenotypes. RASA1 was screened in 261 index patients with: CM-AVM (n = 100), common CM(s) (port-wine stain; n = 100), Sturge-Weber syndrome (n = 37), or isolated AVM(s) (n = 24). Fifty-eight distinct RASA1 mutations (43 novel) were identified in 68 index patients with CM-AVM and none in patients with other phenotypes. A novel clinical feature was identified: cutaneous zones of numerous small white pale halos with a central red spot. An additional question addressed in this study was the "second-hit" hypothesis as a pathophysiological mechanism for CM-AVM. One tissue from a patient with a germline RASA1 mutation was available. The analysis of the tissue showed loss of the wild-type RASA1 allele. In conclusion, mutations in RASA1 underscore the specific CM-AVM phenotype and the clinical diagnosis is based on identifying the characteristic CMs. The high incidence of fast-flow lesions warrants careful clinical and radiologic examination, and regular follow-up.

Novel sodium hypochlorite cleanser shows clinical response and excellent acceptability in the treatment of atopic dermatitis.

The intermittent use of dilute sodium hypochlorite "bleach baths" has shown efficacy as adjunctive therapy for atopic dermatitis (AD). This feasibility study evaluated the clinical response and patient acceptability of treatment with a cleansing body wash containing sodium hypochlorite in children with AD. This was a 12-week open-label feasibility study of 18 children with AD conducted in a pediatric dermatology outpatient clinic between May 2011 and July 2012. Children with moderate to severe AD, defined as an Investigator Global Assessment (IGA) score of at least 3 on a 5-point scale, who were age 6 months and older and had lesional cultures positive for Staphylococcus aureus at baseline were included. Patients were instructed to wash 3 days/week for 12 weeks with the sodium hypochlorite-containing cleansing body wash. During the study period, patient's individualized topical and systemic treatment regimens were continued. Clinical response to treatment was measured using an IGA score and the percentage of body surface area (BSA) affected. Parents were also administered a retrospective questionnaire evaluating acceptability of the product. There was a statistically significant reduction in IGA score at all time points, with an overall mean reduction from baseline to final measurement using the last observation carried forward in all patients of 1.0 (p = 0.001, n = 18). Similarly the mean reduction of BSA affected was 14.8% (p = 0.005, n = 18). Parents reported that the body wash was significantly easier to use than traditional bleach baths (p < 0.001). The significant reductions in clinical disease severity scores with use of this formulation are encouraging.

"Car seat dermatitis": a newly described form of contact dermatitis.

Over the last several years, our clinic has documented an increasing trend of contact dermatitis presenting in areas that are in direct contact with certain types of car seats composed of a shiny, nylon-like material. Our practice has encountered these cases in both atopic and nonatopic infants, with a seasonal predilection for the warmer months. This brief report highlights some of the key features of this condition and alerts the clinician to this newly described form of contact dermatitis.

Changing the face of acne therapy.

Many innovations in acne therapy have evolved since the discovery in 1949 that vitamin A derivatives affected epidermal proliferation. Approval of topical tretinoin solution in 1971 was followed by modifications in the formulation to improve tolerability and provide flexibility in dosing. Identification of retinoid receptors led to research that resulted in 2 receptor-selective synthetic retinoids: adapalene and tazarotene. Today, topical retinoids are one of the cornerstones of acne therapy and are recommended as first-line therapy for all but the most severe forms of acne. They are used as monotherapy in mild comedonal acne; for inflammatory acne, topical retinoids are used in combination with benzoyl peroxide (BPO) and antibiotics (topical or oral) and/or hormonal therapy for females. Because of the high prevalence of antibiotic-resistant strains of Propionibacterium acnes, topical antibiotics should no longer be used as monotherapy. Topical retinoid monotherapy is recommended for maintenance because it prevents formation of microcomedones, the precursor lesions in acne. Combination topical retinoid/antimicrobial therapy has become the current recommended standard of care for the management of patients with acne. Combination therapy can target multiple pathogenic factors: abnormal follicular keratinization, P acnes proliferation, inflammation, and increased sebum production. A number of fixed-combination products are available. These products are effective, generally well-tolerated, and more convenient for patients than multiple individual agents. By reducing the number of medications and applications, fixed-combination products have the potential to improve patient adherence, thereby improving treatment outcomes.

Congenital atrophic dermatofibrosarcoma protuberans in a 7-month-old boy treated with Mohs micrographic surgery.

Dermatofibrosarcoma protuberans is a rare, malignant, slow-growing, locally invasive tumor of the skin. Although most cases are acquired and diagnosed in adulthood, there have been an increasing number of congenital dermatofibrosarcoma protuberans mimicking benign birthmarks described in the literature. The clinical presentation of this tumor is often one of an indurated exophytic plaque or nodule; however, a rare variant can present as atrophic or sclerotic in nature. We report a case of congenital atrophic dermatofibrosarcoma protuberans of the groin in a 7-month-old boy, successfully treated with Mohs micrographic surgery.

Periorbital cutaneous neonatal lupus.

The authors report 3 infant girls with a similar periorbital eruption. A 5-month-old infant girl presented with a 3-month history of a photosensitive facial eruption that had failed to respond to topical 1% hydrocortisone cream. The otherwise healthy infant was the product of a term pregnancy. The 25-year-old mother was in good health except for occasional arthralgias. She had 2 other healthy children. Physical examination revealed a well-developed, well-nourished infant with annular, polycyclic, erythematous scaly plaques involving the cheeks and periorbital region (Figure 1). Potassium hydroxide scraping from the face was negative for dermatophyte and yeast. Laboratory studies revealed normal complete blood cell count, normal liver function tests, strongly positive anti-SSA antibody at 118 units (>80 units, strongly positive), and a negative anti-SSB antibody. Cardiac examination and electrocardiogram (ECG) were also normal. Laboratory evaluation of the mother revealed a positive anti-SSA at 158 units and mild anemia, but anti-SSB, anti-Smith, U1RNP, and anti-Scl-70 antibodies were all negative. Within 4 months the facial eruption cleared completely with the use of desonide cream 0.05% applied twice a day and sun protection. A 6-month-old girl was referred for dermatitis that began on the trunk and face at about 2 months of age. Although the truncal component resolved after 2 months, the facial dermatitis persisted. The infant was in good health and was the first-born child. The mother was known to have Sjögren syndrome. Physical examination revealed the characteristic erythematous, annular, scaling, polycyclic plaques along the forehead, periorbital cheeks, and eyelids (Figure 2). Laboratory evaluation of the infant revealed normal complete blood cell count, liver function tests, and chemistry profile. Anti-SSA antibody was positive at >6 units (reference, <1 unit) and anti-SSB antibody was positive at 2.84 units (reference, <1 unit). U1RNP antibody was negative. Cardiac examination and ECG were normal. The skin abnormalities cleared completely in 6 weeks with the topical application of tacrolimus 0.03% ointment and sun protection. A 5-month-old girl presented with a 2-month history of a persistent facial dermatitis. The infant was in good health and was the product of a healthy first pregnancy and delivery. The mother was in good health. Physical examination of the infant revealed erythematous, annular, polycyclic periorbital patches (Figure 3). Laboratory evaluation revealed positive SSA and SSB antibodies (units unavailable) and normal complete blood cell count, liver function tests, and chemistry profile. Cardiac examination and ECG were normal. The mother's laboratory results were also positive for anti-SSA and anti-SSB antibodies (units unavailable). The infant's facial eruption resolved without specific treatment.

Improved clinical outcomes with moisturization in dermatologic disease.

Controlled clinical studies have provided strong evidence that moisturizers not only enhance the efficacy of topical corticosteroids in patients with atopic dermatitis but also may prevent disease reexacerbation. Furthermore, moisturizers have been shown to have a steroid-sparing effect both in patients with atopic dermatitis and in those with psoriasis. In particular, certain lipid-dominant moisturizers have been shown to significantly (P<.05) improve the condition of the skin based on objectively assessed changes in clinical parameters when used by patients with various dermatoses. Although further research is warranted, moisturizers represent a valuable first-line treatment option for many dermatologic diseases and confer a number of important therapeutic benefits beyond mere cosmetic effects.

Heroin abuse during pregnancy: Effects on perinatal outcome and early childhood growth.

Heroin abuse during pregnancy is associated with 1) fetal growth retardation and neonatal withdrawal syndrome in infants and 2) an increased frequency of abruptio placentae, sexually transmitted diseases, and other complications in mothers. Based on the findings of several small cohort studies, postnatal growth and development of infants whose mothers were addicted to heroin during pregnancy appears to fall within normal variation. In the present study, information about use of heroin and other substances during pregnancy in relation to neonatal outcome was analyzed in 47 heroin-abusing mothers and 80 control women and their respective infants. In addition medical record information was available for postnatal growth follow-up of 28 (58%) of heroin-exposed children and 22 (27.5%) of control infants. Infants born to heroin addicts in this study were significantly (P<.01) smaller at birth but exhibited no increase in the frequency of congenital anomalies compared with controls. Similar to findings of previous investigators, postnatal development of infants born to addicts was not delayed.

Peripartum cocaine use and adverse pregnancy outcome.

The objective of the study was to analyze possible adverse effects of peripartum cocaine use on maternal and fetal outcomes. Informed consent was given by 720 (97%) of 740 women who delivered consecutively at a large urban public hospital to test an umbilical cord blood sample for the presence of non-medically administered drugs of abuse and alcohol and to be interviewed for the study. Samples were tested for the presence of a cocaine metabolite (benzoylecgonine-BZE) by radioimmunoassay. The presence of other substances of abuse (alcohol, methamphetamine, opiates) resulted in exclusion from the sample of 143 subjects. Thus, in this cohort analysis, drug-free controls (N = 469) were compared to those positive for cocaine only (N = 108). Peripartum exposure to cocaine only, and no other substances of abuse, was associated with an increased frequency of abruptio placentae (1.9% vs 0% for control, P < 0.004), thick meconium stained amniotic fluid (3.9% vs 0.7% for controls, P < 0.006), premature rupture of membranes (P < 0.02), genitourinary anomalies (OR = 3.6, P < 0.05), abdominal wall defects (OR = 4.4, P < 0.01) and increased frequency of low birth weight (OR = 2.0, P < 0.02). These are important findings because previous studies have been complicated by the confounding effects of other substances of abuse. Am. J. Hum. Biol. 11:598-602, 1999. Copyright 1999 Wiley-Liss, Inc.

Unusual and recently described cutaneous atrophic disorders.

Cutaneous atrophic conditions are typically caused by changes in the dermis or subcutaneous tissue, sometimes consisting of the loss of a single fiber type. Since a significant decrease of subepidermal tissue is necessary for these lesions to be macroscopically atrophic, many conditions may not be appreciated as atrophy in the clinical setting. Clinicians should be familiar with the common or classic disorders causing cutaneous atrophy; however, there are a few new or rarely described atrophic conditions which are more difficult to identify and may not be atrophic clinically. This paper serves to describe the salient clinical and histological features of these new or rare disorders.