Predictors of Vitamin D Insufficiency in Children and Adolescents With Alopecia Areata.

INTRODUCTION: Limited data regarding predictors of vitamin D deficiency in US children exist. We aimed to identify predictors of vitamin D insufficiency among children with alopecia areata. METHODS: The medical records of 439 pediatric patients diagnosed with alopecia areata (AA) between January 2015 and December 2017 were reviewed. Those with 25-hydroxyvitamin D levels and no documented vitamin supplementation, chronic illness, or other autoimmune comorbidities other than AA were included. Demographic data, Fitzpatrick skin type, and the month of blood collection were recorded. Monthly UV index information from Philadelphia, PA corresponding to the month of blood collection was also collected. RESULTS: Within our cohort, 60.4% of patients had insufficient vitamin D levels, of which 38.2% were deficient. The mean age was nine years old. In multivariate analyses, higher Fitzpatrick skin type, non-summer season, and non-White race were associated with vitamin D insufficiency, while the monthly UV index was inversely associated. DISCUSSION/CONCLUSION: Higher Fitzpatrick skin type, non-summer season, and non-White race may be associated with vitamin D insufficiency in US pediatric patients. Larger studies are warranted to replicate our findings and fully evaluate predictors of pediatric vitamin D deficiency in the US.

Influence of climate factors on pediatric alopecia areata flares in Philadelphia, Pennsylvania.

Patients with alopecia areata (AA) may experience episodic disease flares characterized by increasing hair loss that follow a seasonal pattern. However, no studies have examined whether specific climate factors contribute to the seasonal pattern of AA flares. Using Spearman rank correlation analyses, we assessed the association between climate variables and AA flare frequency per month in 336 children with AA in Philadelphia, Pennsylvania. Region-specific monthly values for average ambient temperature, air pressure, cloudiness, hours of sunlight, relative humidity, number of days with sun, number of days with rain, volume of precipitation, wind gust, wind speed, and UV index from January 2015 to December 2017 were obtained from World Weather Online. We found significant (P < 0.05) correlations between AA flare frequency and UV index (R = - 0.66), precipitation (R = - 0.66), number of days with rain (R = - 0.70), number of days with sun (R = 0.62), and air pressure (R = 0.80). Stratified analyses showed even stronger associations with UV index and precipitation in patients with an atopic comorbidity. New significant correlations appeared with temperature, wind speed, and UV index of the prior month. However, in patients who did not have atopic comorbidities, we generally observed weaker and non-significant correlations between climate and AA flare frequency. This study suggests that certain climate factors may mediate the seasonal pattern of AA flares and may contribute to AA pathogenesis. Atopic AA patients may be more susceptible to the influence of climate compared to those with no history of atopy.

Childhood vitiligo impacts emotional health of parents: a prospective, cross-sectional study of quality of life for primary caregivers.

BACKGROUND/OBJECTIVES: Individuals with vitiligo have an increased risk of depression, anxiety, social isolation and detrimental effects on body image/self-esteem. However, assessments of quality of life (QoL) impact have not focused on caregivers of children with vitiligo. To address this, we determined the QoL impact in parents of children with vitiligo to assess the relationship between QoL parameters and disease duration, location, and severity. METHODS: We performed a cross-sectional study involving 123 parents of children diagnosed with vitiligo for at least 3 months, and who presented to the pediatric dermatology clinic of a major United States children's hospital. Parents completed a demographics survey, Quality of Life in a Child's Chronic Disease Questionnaire (QLCCDQ) and Family Dermatology Life Quality Index (FDLQI) to assess QoL measures. The lower the QLCCDQ score and higher the FLDQI score, the more quality of life is impaired. RESULTS: Subject age ranged from 20 to 57, and 13.9% received mental health intervention. QLCCDQ emotional domain scores were most impaired, and severity and location of disease impacted these scores. FDLQI scores decreased as children age, indicating overall parent wellbeing increased as children age. CONCLUSIONS: Childhood vitiligo has great emotional impact on the quality of life of caregivers. Recognizing this will enable dermatologist who primarily care for these patients to incorporate care giver specific interventions during clinical visits. Emotional domain scores for parents of children with vitiligo were the most impaired as much or more than of those seen in parents of children with chronic stable medical disease such as type 1 diabetes and asthma.

Retrospective review of drug-induced Stevens-Johnson syndrome and toxic epidermal necrolysis cases at a pediatric tertiary care institution.

BACKGROUND/OBJECTIVES: Stevens-Johnson syndrome and toxic epidermal necrolysis represent important sources of potential mortality and morbidity in children. There is a need for more clinical data in this population to determine whether specific treatments preferentially improve outcomes. METHODS: This was a single-center retrospective review of children admitted with drug-induced Stevens-Johnson syndrome, toxic epidermal necrolysis or Stevens-Johnson syndrome/toxic epidermal necrolysis overlap at a tertiary care pediatric institution in North America from 2008 to 2018. Patients without a dermatology assessment and diagnosis were excluded. Demographic, clinical, and treatment information were abstracted and reviewed for all included patients. RESULTS: Sixteen patients were identified, 43% female (7/16), with a mean age at presentation of 10.4 ± 5.2 years. Antibiotics were implicated in 56.3% of patients (9/16) and anticonvulsants in 31.3% (5/16). Sulfamethoxazole-trimethoprim was the triggering antibiotic in 31.3% of patients. The majority of patients were treated with intravenous immunoglobulin alone (50%, 8/16) or intravenous immunoglobulin with steroids (25%, 4/16). Etanercept was added to intravenous immunoglobulin and corticosteroid in a 2-year-old patient, resulting in clinical stabilization and halting of epidermolysis. No patients died. Clinical sequelae were noted in five patients, including ocular complications (n = 4), labial adhesions (n = 1), and persistent skin dyspigmentation (n = 3). CONCLUSIONS: Our results highlight that sulfamethoxazole-trimethoprim is an important cause of Stevens-Johnson syndrome-toxic epidermal necrolysis in children. Mortality was reassuringly low, but ocular sequelae were an important cause of morbidity. More data are needed to help determine whether specific treatments including etanercept may provide mortality or morbidity benefit in pediatric populations.

Acquired port-wine stains in six pediatric patients.

BACKGROUND/OBJECTIVES: Port-wine stains, also known as capillary malformations, are due to dermal vascular ectasia and dilation and are most commonly congenital; however, acquired port-wine stains (APWS) developing later in life have been noted in the literature, most commonly in the context of trauma. METHODS/RESULTS: This case series presents 6 pediatric patients with APWS who first developed lesions between ages 3 and 11 years in the absence of a traumatic or other etiologic trigger. CONCLUSIONS: The epidemiology, clinical features, and treatment response of these patients are compared to what has been previously described in other cases in the literature.

Evaluation of a modified outpatient model for using propranolol to treat infantile hemangiomas.

BACKGROUND: For infantile hemangiomas requiring treatment, existing recommendations advise initiation of propranolol followed by a 2-hour period of blood pressure and heart rate monitoring, resulting in prolonged office visits for both families and clinicians. OBJECTIVES: In order to reduce visit times, we evaluate our current practice of at-home or in-office propranolol administration followed by in-office vital sign monitoring. METHODS: We retrospectively reviewed the medical records of 157 patients with infantile hemangiomas (IH) who initiated propranolol under this outpatient protocol. Blood pressure (BP) and heart rate (HR) were obtained at a baseline visit and 1-2 hours after initial dose administration. We identified potential risk factors for clinically significant decreases in systolic blood pressure (SBP) and HR (defined as decrease of > 20 mm Hg and > 15 bpm, respectively) using logistic regression analysis, and adverse events were recorded. RESULTS: Fifty-five individuals (35.4%) showed a decrease in HR of more than 15 bpm, and 23 individuals (14.7%) showed a decrease in SBP of more than 20 mm Hg. Multivariable logistic regression suggested that younger age, history of preterm birth, and Caucasian race may slightly increase the odds of clinically significant changes in vital signs upon propranolol initiation. However, no clinically symptomatic adverse events occurred upon initiation of propranolol. CONCLUSIONS: Vital sign monitoring may be important when starting propranolol treatment in younger or historically preterm patients. However, routine mandatory in-office vital sign monitoring may not be necessary in healthy infants more than 45 weeks postconceptional age.

Treatment of severe pediatric atopic dermatitis with methotrexate: A retrospective review.

BACKGROUND/OBJECTIVES: Severe atopic dermatitis (AD) may require systemic immunomodulatory agents to control symptoms. A lack of evidence and guidelines for systemic AD therapy in children has led to variability in agents selected and uncertainty in their comparative efficacy and safety. Evaluation of the efficacy of methotrexate in children with severe AD was performed. METHODS: We performed a retrospective chart review of 55 pediatric patients seen at Children's Hospital of Philadelphia that measured improvement using the Investigator's Global Assessment (IGA), a scale that rates AD symptoms from 0 to 5. RESULTS: About 76% of patients showed improvement with methotrexate. Mean baseline IGA of all patients was 4.18. After 6-9 months of treatment, this improved to 2.94. There was additional improvement to a mean IGA score of 2.39 after 12-15 months of treatment. At the final visit before each patient stopped methotrexate, the mean IGA score was 2.71. Approximately 50% of patients experienced minor side effects with gastrointestinal side effects the most common. CONCLUSIONS: In a diverse patient population, safety and efficacy of methotrexate was demonstrated. Significant improvement in IGA was noted for the majority after 6-9 months of therapy with further improvement when continuing treatment to 12-15 months. Methotrexate remains an important option for long-term symptom control with a favorable side effect profile and low cost.

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.