Expert Recommendations on Use of Topical Therapeutics for Vitiligo in Pediatric, Adolescent, and Young Adult Patients.

Importance: Evidence-based recommendations for the treatment of vitiligo in pediatric, adolescent, and young adult patients in the US are needed. Objective: To develop evidence- and consensus-based expert recommendations on the diagnosis and treatment of vitiligo in young patients. Evidence Review: A process was developed to produce consensus recommendations addressing questions regarding pediatric vitiligo. A librarian-conducted literature review was performed using articles that met the inclusion criteria: published in English, containing primary data (including meta-analysis) and pediatric-specific data, and analysis of 6 or more patients. Included articles were graded by the Strength of Recommendation Taxonomy criteria and Oxford Centre for Evidence-based Medicine's Levels of Evidence and Grades of Recommendation. Research questions were reviewed on May 9, 2022, through a video conference. One month after the conference, participants participated in an online survey documenting their level of agreement with the generated statements, using a 5-point Likert scale. Findings: Articles on topical corticosteroids and/or topical calcineurin inhibitors (n = 50), topical Janus kinase inhibitors (n = 5), pseudocatalase (n = 2), and microdermabrasion (n = 2) met inclusion criteria. Forty-two recommendations were made on the diagnosis of vitiligo and optimal topical therapeutics, with 33 recommendations obtaining a 70% or greater composite agreement and strong agreement. Topical calcineurin inhibitors twice daily, topical corticosteroids with time limitation due to atrophy risk, and topical ruxolitinib, 1.5%, cream-used off-label for patients younger than 12 years and limited to nonsegmental vitiligo-were identified as evidence-based first-line therapies in the management of pediatric and adolescent patients, with specific guidance on age-based data, minimum therapeutic trial of 6 months or greater, prolonged therapy to prevent recurrence, and the positive benefit of coordinated use of UV therapeutic sources. Conclusions and Relevance: Evidence supports the use of topical calcineurin inhibitors, topical corticosteroids, and topical Janus kinase inhibitors as effective therapeutics for vitiligo in pediatric, adolescent, and young adult patients, with specific decisions on choice of agent based on factors such as site location, body surface area, and age.

Berdazimer gel for molluscum contagiosum in patients with atopic dermatitis.

OBJECTIVE: Controlling molluscum contagiosum (MC) infections is critical in atopic dermatitis (AD) management. This post hoc analysis assessed the efficacy and safety of berdazimer gel, 10.3% (topical, antiviral, nitric oxide-releasing medication) versus vehicle in MC patients with or without AD. METHODS: Three Phase 3, multicenter, randomized, double-blind, vehicle-controlled, parallel-group trials (B-SIMPLE[berdazimer sodium in molluscum patients with lesions]1, -2, -4) enrolled patients 6 months and older with 3-70 mollusca. Berdazimer or vehicle was applied once daily to all MC lesions for 12 weeks. Data from three Phase 3 studies were integrated for subgroup efficacy and safety assessments using several weighted meta-analysis approaches. Patients with concurrent AD or a history of AD/eczema were categorized as AD+ subgroup (AD- when absent). Primary efficacy endpoint: complete lesion clearance at Week 12. Safety endpoints included adverse events (AEs) through Week 24 and local skin reactions through Week 12. RESULTS: Of 1598 enrolled patients, 209 (13.1%) were AD+. Baseline mean lesion counts were greater in AD+ (26.4) than AD- (19.3). Complete clearance rates were higher at Week 12 for berdazimer compared with vehicle in AD+ (n = 209; 35.0% vs. 27.4%; odds ratio [OR], 1.3; 95% CI, 0.7-2.5) and AD- (n = 1389; 29.1% vs. 18.9%; OR 1.8; 95% CI 1.4-2.4) subgroups. AEs in AD+ were application-site pain (21.6% with berdazimer vs. 11.9% with vehicle), dermatitis (12.8% vs. 2.4%), and erythema (9.6% vs. 7.1%). CONCLUSIONS: Berdazimer gel showed favorable efficacy regardless of AD status. Berdazimer-induced erythema may be indistinguishable from AD symptoms or with inflammatory response upon resolution of molluscum.

The Pediatric Dermatologist's View of Pediatric Vitiligo.

BACKGROUND: No guidelines exist for pediatric vitiligo. OBJECTIVE: To identify practice patterns of pediatric dermatologists treating vitiligo. METHODS: A PeDRA survey was completed online by 56 pediatric dermatologists. RESULTS: Practitioners reported feeling most comfortable treating 13- to 17-year-olds and least comfortable treating infants. Quality of life was assessed by interview in 89.3%. Topical calcineurin inhibitors (TCIs), topical corticosteroids (TCSs), narrowband UVB, coverup makeup, topical JAK inhibitors (tJAKis), and 308-nm laser were the leading vitiligo therapeutics chosen. 94.5% of practitioners reported experiencing frustration due to difficulties procuring therapies. CONCLUSION: Pediatric vitiligo has notable effects on quality of life. Some therapeutic options exist which are preferred by pediatric dermatologists. There is a need for more data on therapeutics in infants and young children, J Drugs Dermatol. 2024;23(2): doi:10.36849/JDD.7572e.

International Dermatology Outcome Measures (IDEOM) - Report from the 2022 Annual Meeting.

BACKGROUND: The International Dermatology Outcome Measures (IDEOM) is a non-profit organization dedicated to the advancement of evidence-based, consensus-driven outcome measures in dermatological diseases. Researchers and stakeholders from various backgrounds collaborate to develop these objective benchmark metrics to further advance treatment and management of dermatological conditions. SUMMARY: The 2022 IDEOM Annual Meeting was held on June 17-18, 2022. Leaders and stakeholders from the hidradenitis suppurativa, acne, vitiligo, actinic keratosis, alopecia areata, itch, cutaneous lymphoma, and psoriatic disease workgroups discussed the progress of their respective outcome-measures research. This report summarizes each workgroup's updates from 2022 and their next steps as established during the 2022 IDEOM Annual Meeting. J Drugs Dermatol. 2023;22(12):1153-1159 doi:10.36849/JDD.7615.

Mpox Update: Clinical Presentation, Vaccination Guidance, and Management.

Following the eradication of smallpox, intermittent small outbreaks of mpox (monkeypox) have occurred with increasing frequency, primarily in endemic regions of Africa. With the rapid spread of mpox around the globe in 2022, we are approaching a second zoonotic pandemic of the 21st century. Given the predominance of cutaneous involvement in mpox, dermatologists should be prepared to recognize the clinical features and manage this increasingly prevalent disease. This article reviews a brief history of the mpox virus, clinical presentation, complications, approach to diagnosis, methods of transmission, infection control recommendations, indications for vaccination, and therapeutic options to inform dermatologists on the frontline of the mpox epidemic.

Online Health Information for Acne Keloidalis Nuchae has a Difficult Level of Readability.

BACKGROUND: Acne keloidalis nuchae (AKN) is an inflammatory disorder primarily seen in individuals of color, characterized by acneiform and keloidal lesions on the occipital scalp/nuchal region. More than 50% of patients with keloids are known to search their condition on the internet. We sought to determine the level of readability of patient education materials (PEM) available to patients. The term 'acne keloidalis nuchae' was searched and screened for the top 100 search results on the Google® search engine. For evaluation, 6 readability metrics (Flesch-Kincaid grade level, Gunning Fog index, Coleman-Liau index, SMOG index, automated readability, and Linsear Write Formula) were collected by entering text from each reference site into an automatic readability calculator for computation. Median readability scores of AKN PEMs ranged from 10.3th to 13.5th grade levels. Overall, readability median above the 8th-grade level were consistently seen across all 6 readability measures, with some median scores reaching university undergraduate levels. More readable educational tools are needed for acne keloidalis nuchae online. J Drugs Dermatol. 2023;21(2):195-196. doi:10.36849/JDD.7110.

Disparities in the Use of Teledermatology During the COVID-19 Pandemic Lockdown in a Pediatric Dermatology Practice.

Background: The COVID-19 pandemic required a rapid expansion of teledermatology services. Objective: Analyze demographic shifts in a pediatric dermatology practice session with children of color. Methods: A retrospective chart review of pediatric dermatology patients seen in the 4 practice weeks preceding the New York COVID-19 lockdown and comparable teledermatology visits during the COVID-19 pandemic lockdown. Demographic differences (e.g., race, age, gender, and household income) were analyzed. Results: A greater proportion of patients seen were White during lockdown (59.7%), compared with pre-lockdown (43.6%), with a reduction in Asian patients seen in lockdown (6.0%) compared with pre-lockdown (24.5%). A lower proportion of no-show patients (4.3%, 3/70 scheduled) were noted in lockdown compared with pre-lockdown (16%, 18/112). Preferred provider organizations (PPO) and higher-income zip codes were more common for children seen during lockdown. Limitations: The sample addresses a limited New York pediatric dermatology practice during a short time period. Conclusions: White patients and patients with PPO were more likely to access telehealth, supporting disparity in teledermatology services. These results demonstrate reduced health care access for lower-income and Asian children during the COVID-19 pandemic lockdown.

Systematic Review of Lichen Planus Pigmentosus in Children.

BACKGROUND: Pediatric lichen planus (LP) is a relatively uncommon condition, with increased presentation in children with darkly pigmented skin. OBJECTIVE: To understand the small subset of children with lichen planus (LP) manifesting as lichen planus pigmentosus (LPP), a form with thin plaques and extensive hyperpigmentation, generally in the absence of signs of inflammation Methods: This article is a systematic review of the English language literature for cases of lichen planus pigmentosus (LPP) in children. RESULTS: Twenty-one cases were identified including 2 that were linear, 3 inverse types, 1 palmoplantar. In larger series, 2–2.8% of children with lichen planus are affected by this sub-variant. One patient had reported associated oral lesions. Oral and topical corticosteroids, topical tacrolimus, and ultraviolet light have been described as successful therapies. CONCLUSIONS: LPP is an uncommon but important variant of lichen planus in children. In the presence of dark hyperpigmentation of the skin, a biopsy can help identify LPP. Clinicians should be aware that LPP can follow four patterns: common, inverse, palmoplantar, and linear.J Drugs Dermatol. 2022;21(7):850-853. doi:10.36849/JDD.6760.

International Dermatology Outcome Measures (IDEOM): Report from the 2021 Annual Meeting.

BACKGROUND: International Dermatology Outcome Measures (IDEOM) is a non-profit organization founded in 2013. It is composed of researchers and stakeholders who work to develop evidenced-based outcome measures to enhance research and treatment recommendations of dermatologic diseases. SUMMARY: The 2021 IDEOM Virtual Annual Meeting occurred from November 19-20, 2021. Contributions were made by leaders and stakeholders from the psoriasis, psoriatic arthritis, pediatric hidradenitis suppurativa, acne, vitiligo, actinic keratosis, alopecia areata, itch, and cutaneous lymphoma workgroups. The psoriasis, psoriatic arthritis, and actinic keratosis workgroups provided an overview of their respective instruments for treatment satisfaction and symptom measurement. The inaugural meetings of the itch, alopecia areata, and cutaneous lymphoma workgroups identified unmet needs of their respective diseases and future goals. The acne, vitiligo, and pediatric hidradenitis suppurativa workgroups discussed concerns of quality of life, instruments for symptom measurement, and screening tools. Additionally, a representative from the US Food and Drug Administration was in attendance and presented an update on topical drugs and generics. This report provides a summary of workgroup updates from the past year and future directions established during the meeting. KEY MESSAGES: This report summarizes progress made by each IDEOM workgroup at the 2021 IDEOM Virtual Annual Meeting. J Drugs Dermatol. 2022;21(8):867-874. doi:10.36849/JDD.6974.

Short and Long-Term Outcomes of 308-nm Laser for Pediatric Vitiligo.

Pediatric vitiligo is often challenging to treat. Children with vitiligo experience stigma, bullying, and emotional distress. The long-term outcome of therapeutics used to treat pediatric vitiligo has been poorly documented in the literature. It is, therefore, hard to counsel patients on the expected long-term results of therapy. We sought to address outcomes in pediatric vitiligo treated with a 308-nm laser. An IRB-exempt chart review was conducted in June of 2016 of children undergoing active 308-nm laser in the first half of 2016. Demographic data, location of disease, therapeutic parameters of the 308-nm laser, and outcomes were recorded at that time. In 2021, the long-term outcomes were analyzed through chart review addressing pigmentation retained at later office visits. Initial repigmentation was noted in 86.7% of the face, 80% of the body, and 61.7% of the extremities. An average of 3.38 years of follow-up was recorded. Scoring extent of vitiligo using 18 site-scoring was helpful in identifying individuals who are less likely to respond to 308-nm laser, but needs broader evaluation. During that time, repigmentation was noted to be retained in 80% of facial, 40% of the body, and 20% of extremity lesions. Pediatric vitiligo responds well to the 308-nm laser, with the best retention of repigmentation for facial lesions. Patients and parents should be counseled on the likelihood of long-term retention of repigmentation and regarding the need for the ongoing management of vitiligo even after repigmentation is initially achieved after 308-nm laser therapy. J Drugs Dermatol. 2022;21(7):773-775. doi:10.36849/JDD.6895.

The genetics and diagnosis of pediatric neurocutaneous disorders: Neurofibromatosis and tuberous sclerosis complex.

Neurofibromatosis (NF) and tuberous sclerosis complex (TSC) are the two most common neurocutaneous disorders, both transmitted as autosomal dominant or, in the case of NF, also as a mosaic condition. The causative genetic mutations in these neurocutaneous disorders can lead to benign skin changes or uninhibited growth and proliferation in multiple organ systems due to the loss of tumor suppression in mitogen-activated protein kinase and mammalian target of rapamycin signaling pathways. Common clinical features in NF include pigmented lesions, known as café au lait patches, neurofibromas, intertriginous freckles (Crowe's sign), and benign fibrous growths, such as hamartomas in multiple organ systems. Common clinical features in TSC include hypopigmented macules, known as ash leaf spots, in addition to neurologic sequelae, such as autism, seizures, and developmental delays. Advances in genetic sequencing technologies have allowed an exponential expansion in the understanding of NF and TSC. Consensus criteria have been established for both diagnoses that can be confirmed in most cases through gene testing. Once diagnosed, the clinical and diagnostic value of disease-specific surveillance include early identification of benign and malignant tumors. Genetic counseling is important for informed reproductive decision-making for patients and at-risk family members. The improvement in understanding of pathways of pathogenic disease development and oncogenesis in both conditions have produced a new series of therapeutic options that can be used to control seizures and tumor growth. Tremendous advances in life expectancy and quality of life are now a reality due to early introduction of seizure control and novel medications. While we lack cures, early institution of interventions, such as seizure control in tuberous sclerosis, appears to be disease-modifying and holds immense promise to offer patients better lives.

The genetics of pediatric cutaneous autoimmunity: The sister diseases vitiligo and alopecia areata.

Autoimmunity, the reaction of the host against self, is a complex pattern of immunologic response that allows the immune system to react to "normal" tissue. Many such diseases exist in the skin, but in particular, two stand out as visible manifestations of autoimmune cutaneous attack. These are vitiligo, the immune attack on the melanocyte, and alopecia areata, the immune attack of the hair unit. These two illnesses include the prototypes of "simple" attacks on specific components of the skin. Other such illnesses are psoriasis-a complex series of immunologic responses resulting in a characteristic pattern of keratinocyte hyperproliferation-and lichen planus, which is similarly associated with a typical cutaneous skin disease pattern, but these will not be included in this review. In comparison, autoimmune polyendocrinopathies have defined pathways of disease based on single-gene mutations that can result in a variety of autoimmune skin features including vitiligo and alopecia areata. This contribution reviews known patterns of autoimmunity in childhood skin disease with a particular focus on single-gene disorders where they exist, and the more common multifactorial genes that contribute to this breach of the immune system's regulatory checks and balances. Genetic mechanisms that will be covered include innate and adaptive immunity, major histocompatibility complex II class associations, genetic polymorphisms, and major histocompatibility complex I class associations that bridge autoinflammatory and autoimmunity states, as well as alterations in oxidative metabolism promoting tissue destruction. End-organ tissue destruction appears to occur via interferon gamma and cytotoxic mediated activity and is a promising new therapeutic target. Janus kinase inhibitors also have the benefit clinically of both affecting the immune cascade at the cytotoxic T cell level and allowing triggering of melanocyte and hair follicular activity through the signal transducer and activator of transcription pathway, representing an attractive therapeutic with dial activity, among other cytokines implicated in end-organ destruction. Transplacental autoimmunity will not be covered herein. Greater insight into mechanisms of pediatric cutaneous autoimmunity in vitiligo and alopecia areata has yielded better therapeutic options and interventions. Understanding the basis of autoimmune triggering in our patients, that is, personalized medicine, may allow for targeted therapeutics with a goal of induction of remission, regeneration, or rejuvenation of the end-organ with the least toxic side effect profile.

The potential role for phage therapy for genetic modification of cutaneous diseases.

Antimicrobial resistance has become increasingly common across the globe, claiming more than 33,000 lives annually in Europe and 35,000 lives in the United States alone. The problem lies in trying to find potential solutions capable of tackling resistance and being able to fight infections that may resist various antimicrobials. Since Alexander Fleming's discovery in 1928, every antimicrobial synthesized in the past 70 years has developed at least one or more strains of resistant bacteria. One particular alternative to antimicrobials has brought hope to many in the scientific community: the bacteriophage. Bacteriophages are viruses that can replicate within bacteria, triggering genetic alterations and changes in pathways of protein expression by encoding a few to hundreds of genes within their genomes. The bacteriophage can hijack the cell, using the cell's genetic apparatus to replicate within the bacterium until bacterial lysis occurs. This therapy has been used in the genodermatosis Netherton syndrome, which has been associated with the increased risk of Staphylococcus aureus infections. Emerging data support the potential role of bacteriophage therapy for Cutibacterium acnes in acne vulgaris, with a potential role in genetic disorders with severe acne vulgaris, including Apert syndrome. Bacteriophages hold benefits for genodermatoses associated with recurrent cutaneous infections, that is, the immunodeficiencies with distinctive cutaneous features as well as conditions such as atopic dermatitis, in which bacterial colonization plays a strong role.

Association of atopic dermatitis with delinquent behaviors in US children and adolescents.

Childhood atopic dermatitis (AD) is associated with chronic itch, pain and sleep disturbance, which may predispose children to high-risk behaviors in their school and home environments. We examined the association between AD and delinquent/high-risk behaviors in children and adolescents. Data were analyzed from The Fragile Families and Child Wellbeing Study, a longitudinal birth cohort study consisting of 4898 children born in urban cities between 1998 and 2000. A 1-year history of AD was associated with ≥ 75th percentile of mean delinquent behavior scores at age 9 (adjusted odds ratio (aOR) [95% confidence interval] 1.39 [1.14-1.68]), but not age 15 (1.05 [0.86-1.29]). At age 9, a 1-year history of AD was associated with a higher number of delinquent behaviors (adjusted risk ratio [95% CI] 1.12 [1.03-1.23]). AD at ages 5 (aOR [95%CI] 1.31 [1.04-1.64]) and 9 (1.38 [1.14-1.67]) was associated with the highest quartile of mean delinquent behavior scores at ages 9 or 15. Children with AD persisting at multiple age groups had significantly increased odds of ≥ 75th percentile of mean delinquent behavior scores at age 15 (aOR [95%CI] 1.41 [1.09-1.81]). AD was found to be associated with the following delinquent problems: damaging property (aOR [95%CI] 1.38 [1.08-1.77]), cheating on a test (1.62 [1.17-2.26]), fist fight involvement (1.47 [1.21-1.79]) and school suspension (1.36 [1.08-1.71]). This study suggests that childhood AD may precede the onset of delinquent and high-risk behaviors later in childhood and adolescence.