Tinea capitis in children: a systematic review of management.

BACKGROUND: Tinea capitis is the most common cutaneous fungal infection in children. OBJECTIVES: This review aims to evaluate the differences that exist between medications for the treatment of tinea capitis, to determine whether there are any significant adverse effects associated and to define the usefulness of sample collection methods. METHODS: We conducted a systematic literature search of available papers using the databases PubMed, OVID, Cochrane Libraries and ClinicalTrials.gov. Twenty-one RCTs and 17 CTs were found. RESULTS: Among the different antifungal therapies (oral and combination thereof), continuous itraconazole and terbinafine had the highest mycological cure rates (79% and 81%, respectively), griseofulvin and terbinafine had the highest clinical cure rates (46% and 58%, respectively) and griseofulvin and terbinafine had the highest complete cure rate (72% and 92%, respectively). Griseofulvin more effectively treated Microsporum infections; terbinafine and itraconazole more effectively cured Trichophyton infections. Only 1.0% of children had to discontinue medication based on adverse events. T. tonsurans was the most common organism found in North America, and hairbrush collection method is the most efficient method of sample collection. Additionally, using a hairbrush, toothbrush or cotton swab to identify the infecting organism(s) is the least invasive and most efficient method of tinea capitis sample collection in children. CONCLUSIONS: Current dosing regimens of reported drugs are effective and safe for use in tinea capitis in children.

Prospective study of infantile haemangiomas: incidence, clinical characteristics and association with placental anomalies.

BACKGROUND: The aetiology and exact incidence of infantile haemangiomas (IHs) are unknown. Prior studies have noted immunohistochemical and biological characteristics shared by IHs and placental tissue. OBJECTIVES: We investigated the possible association between placental anomalies and the development of IHs, as well as the demographic characteristics and other risk factors for IHs. PATIENTS AND METHODS: Pregnant women (n = 578) were prospectively enrolled and their offspring followed for 9 months. Placental evaluations were performed and demographic data collected on all mother-infant pairs. RESULTS: We evaluated 594 infants: 34 haemangiomas [either IH or congenital (CH)] were identified in 29 infants, yielding an incidence of 4·5% for IH (27 infants) and 0·3% for CH (two infants). Placental anomalies were noted in almost 35% of haemangioma-related pregnancies, approximately twice the incidence noted in pregnancies with unaffected infants (P = 0·025). Other risk factors for IH included prematurity (P = 0·016) and low birth weight (P = 0·028). All IHs were present by 3 months of age, and cessation of growth had occurred in all by 9 months of age. Most occurred on the trunk. Of note, 20% of identified IHs were abortive or telangiectatic in nature, small focal lesions that did not proliferate beyond 3 months of age. Only one IH required intervention. CONCLUSIONS: This is the first prospective American study to document the incidence of IHs in infants followed from birth to early infancy. The association with placental anomalies was statistically significant. The overall incidence mirrors prior estimates, but the need for treatment was lower than previously reported.

Small facial haemangioma and supraumbilical raphe--a forme fruste of PHACES syndrome?

We report two female infants with congenital midline supraumbilical raphes who subsequently developed haemangiomas on the lower lip and gingiva within the first 2 months of life. One was found to have a subglottic haemangioma during laryngoscopy. The infants were otherwise well and had normal chest X-ray, echocardiogram, cranial ultrasound, magnetic resonance imaging/angiography (head, neck, chest) and ophthalmological examination. Both received oral prednisolone 1-2 mg kg(-1) daily and four sessions of flashlamp pulsed-dye laser therapy to the lip lesions, with significant improvement. The initial presentation of these two infants with supraumbilical raphes, who were otherwise healthy and without other cutaneous stigmata, suggested the diagnosis of isolated congenital sternal malformation. However, lower lip and gingival haemangiomas developed 4-6 weeks later, consistent with the diagnosis of PHACES syndrome. Children with sternal malformation and haemangioma may also have intracranial and/or cardiovascular anomalies. All previously reported patients were females who had either craniofacial and/or multiple haemangiomas. We propose guidelines for the evaluation and management of a neonate presenting with a sternal fusion defect at birth.

Disseminated linear calcinosis cutis associated with the Koebner phenomenon in an infant with congenital acute monocytic leukaemia.

We present a unique case of an infant with acute monocytic leukaemia who presented at birth with multiple rubbery, erythematous to violaceous subcutaneous nodules secondary to leukaemia cutis. As these infiltrates regressed with chemotherapy, numerous white to yellow linear confluent papules appeared in a scratch-like pattern. These lesions were widely disseminated but were concentrated across her face, trunk and extremities with relative sparing of the napkin area and back. We propose that these lesions represent a form of dystrophic calcinosis cutis that occurred secondary to koebnerization in an infant with congenital leukaemia cutis.

Safety of fluticasone propionate cream 0.05% for the treatment of severe and extensive atopic dermatitis in children as young as 3 months.

BACKGROUND: Topical corticosteroids are useful for the treatment of pediatric dermatoses. However, concerns regarding possible systemic and topical toxicities have limited the use of moderate-potency corticosteroids in children. OBJECTIVE: Our purpose was to characterize the safety of fluticasone propionate cream in children. METHODS: Children between 3 months and 5 years 11 months (n = 32) and 3 up to 6 years of age (n = 19) with moderate to severe atopic dermatitis (> or =35% body surface area; mean body surface area treated, 64%) were treated with fluticasone propionate cream, 0.05% twice daily for 3 to 4 weeks. Serum cortisol response, fluticasone levels, skin changes, and adverse events were analyzed. RESULTS: Mean cortisol levels were similar at baseline (13.76 +/- 6.94 microg/dL prestimulation and 30.53 +/- 7.23 microg/dL poststimulation) and at end of treatment (12.32 +/- 6.92 microg/dL prestimulation and 28.84 +/- 7.16 microg/dL poststimulation). Only 2 of 43 children had end-treatment poststimulation values less than 18.0 microg/dL. No significant adverse cutaneous effects were noted. CONCLUSION: Fluticasone propionate cream 0.05% appears to be safe for the treatment of severe eczema for up to 4 weeks in children 3 months of age and older.

Tinea capitis update: a continuing conflict with an old adversary.

Infection with tinea capitis in childhood is a common, age-old problem that continues to plague patients and their families. As is true for most infectious diseases, the epidemiology of tinea capitis is in a constant state of flux and varies considerably with respect to geography and specific patient populations. Trichophyton tonsurans is now the most common cause of tinea capitis in the United States. A recent epidemiologic observation is a striking increase in the incidence of tinea capitis, particularly among African-Americans. Clinical studies over the past decade that have investigated the response of tinea capitis to griseofulvin, the mainstay treatment for this condition, suggest a decrease in sensitivity to this pharmacologic agent, in association with this new epidemiology. Important advances in the diagnosis and treatment of tinea capitis include a renewed interest in the use of the cotton swab method of diagnosing fungal cultures in children, and the ongoing investigation of promising new medications for the treatment of tinea capitis, including terbinafine, itraconazole, and fluconazole in this era of resistant organisms.

A prospective comparison of octyl cyanoacrylate tissue adhesive (dermabond) and suture for the closure of excisional wounds in children and adolescents.

BACKGROUND: Recent studies suggest that the use of octyl cyanoacrylate tissue adhesive for closure of both traumatic lacerations and incisional surgical wounds results in a cosmetic outcome comparable to that achieved with conventional sutures. To date, no studies have looked at the use of tissue adhesive for higher-tension wounds, such as those created during cutaneous excisional procedures. OBJECTIVE: To compare the tissue adhesive octyl cyanoacrylate with standard suture for the closure of excisional wounds in children and adolescents. DESIGN: A prospective comparison with blinded assessment of cosmetic outcome. Twenty-eight wounds were closed with monofilament suture and 24 were closed with tissue adhesive. At approximately 2 months, photographs of the incisions were evaluated by 2 dermatologists blinded to the method of skin closure. SUBJECTS: Forty-two consecutive patients undergoing excisional dermatologic procedures at Children's Hospital, San Diego, Calif. These 42 patients had a total of 52 wounds that were evaluated. MAIN OUTCOME MEASURES: The cosmetic appearance of the wounds at 2 months, based on 2 validated wound scales: the Hollander Wound Evaluation Scale and a visual analog scale. RESULTS: There were no differences in early complications between the groups. The suture group scored higher on the visual analog scale (63.3 mm for suture vs 47.8 mm for tissue adhesive), and this difference was statistically significant (P =.02). The suture group also had a higher median score on the Hollander Wound Evaluation Scale, but this difference was not statistically significant (P =.09). CONCLUSION: The cosmetic outcome of cutaneous excisional surgery wounds closed with standard suturing was found to be superior to that of wounds closed with octyl cyanoacrylate.

Superficial fungal infections in adolescence.

Cutaneous fungal infections occur frequently in the adolescent population, and are second only to acne in generating skin-related adolescent anguish. Though superficial fungal infections of the skin are rarely life-threatening, they can cause significant worrisome cutaneous findings (e.g., white spots from pityriasis versicolor, distorted nails from onychomycosis). Such changes are particularly threatening to an adolescent who wants to be just like everybody else. This article focuses on several of the more common cutaneous fungal infections in adolescence, including pityrosporum (tinea) versicolor and dermatophyte infections of the feet, groin, skin, and nails. The prevalence of each disease is discussed, along with its clinical presentation, differential diagnosis, and methods of treatment.

Diaper dermatitis and advances in diaper technology.

During the last decade, a number of technological innovations in disposable diaper designs and materials have aimed at reducing dermatological problems in the diaper area. The introduction of absorbent gelling materials led to a decrease in skin overhydration and made possible a more beneficial pH in the diaper area. A retrospective evaluation of clinical studies conducted before and after the introduction of absorbent gelling materials confirms that utilization of these materials has been associated with a marked reduction in the severity of diaper dermatitis. More recently, a novel diaper designed to deliver dermatological formulations to the skin also appears to improve the condition of diapered skin. Disposable wipes now are available that are nonirritating and suitable for use on damaged or broken skin. Ongoing innovative efforts in this area promise to further decrease the prevalence of diaper-associated dermatologic conditions.

Telangiectasia macularis eruptiva perstans.

Telangiectasia macularis eruptiva perstans (TMEP) is a form of mastocytosis. It is an uncommon condition, particularly in children. The disorder is characterized by telangiectatic macules and generally has a good prognosis, with little tendency to urticate or cause constitutional symptoms. We report a girl who presented at age 2 with a 6-month history of erythematous macules on her arms and legs. The lesions were larger and possessed a more angular configuration than classic telangiectases. They slowly spread to her torso and face; there were no associated constitutional symptoms. Histopathologic examination showed dilated capillaries and increased numbers of mast cells, consistent with TMEP. Mastocytosis should be considered in patients presenting with telangiectatic lesions that are atypical in appearance, distribution, or onset.

Rare cutaneous malignancies of childhood.

Malignant melanoma and mycosis fungoides (cutaneous T cell lymphoma) are rare malignancies in childhood. However, both are potentially fatal tumors that may be cured if detected early. The incidence of melanomas in adolescents has increased in the last 10 years. This makes it imperative that high-risk children be identified for preventive measures including sun protection as well as serial skin examinations. This review highlights the important risk factors for melanoma and comments on which risk-reducing interventions pediatricians should institute. Mycosis fungoides is a cutaneous malignancy usually found in middle-aged adults. Recently, it has been asserted that this entity is underreported in children. This occurs because it may frequently mimic other more common disorders, such as eczema. Thus, lesions clinically suspicious for mycosis fungoides, especially those that have failed chronic eczema therapies, warrant a skin biopsy for definitive diagnosis.

Use of the cotton swab method in diagnosing Tinea capitis.

OBJECTIVE: To evaluate the accuracy of the cotton swab technique for identifying fungal infections of the scalp. The purpose of the study was: 1) to compare the cotton swab technique with the toothbrush method, a popular and reliable means for obtaining specimens; and 2) to ascertain if transport of a specimen, entailing variable transport duration and conditions, impairs the sensitivity and specificity of the technique. MATERIALS AND METHODS: Part 1 consisted of a prospective, investigator-blinded comparison analysis. Fifty children with scalp findings suspicious for tinea capitis were cultured using both techniques: the toothbrush and cotton swab. Ninety-six culture results were obtained for analysis. The second part of the study consisted of a prospective comparison analysis of cotton swab culture results obtained from samples plated immediately after collection in the physician's office as compared with samples transported to outside laboratories for processing. Thirty-one children with presumed tinea capitis were cultured twice with the cotton swab technique; one sample was immediately plated onto fungal medium and the other sent to an outside lab, the selection of which was dictated by the patient's insurance plan. A total of 62 samples were obtained; 58 sample results were used for analysis. RESULTS: In part 1 of the study, 60% of the 48 children analyzed had positive fungal cultures. Eighty percent of these were Trichophyton species. There was 100% agreement in the results obtained; all patients with positive results using the toothbrush method were also positive when the cotton swab method was used. Similarly, there was complete concordance in laboratory results from the second part of the study. Fifty percent of the 28 children analyzed had positive cultures; 86% grew Trichophyton species. All patients who had positive cultures from those samples plated in-office also had positive results from the outside laboratory samples. CONCLUSIONS: The cotton swab technique is an easy, atraumatic, inexpensive, and reliable means to evaluate patients with suspected tinea capitis. The method remains sensitive and specific even when transport of these specimens is required and processing is thus delayed. This painless technique requires little technical expertise and can be rapidly performed with a standard cotton tip applicator. It should prove an invaluable aid to practitioners in evaluating patients with possible fungal infections of the scalp.

Transillumination blisters in a neonate.

Transillumination with a high-intensity fiberoptic light source is an effective means of diagnosing pneumothoraces and localizing arteries and veins for blood sampling. It has been used for these purposes in neonatal intensive care units since the 1970s. Thermal burns were reported in association with the technique initially, but this complication now occurs infrequently because of numerous safety precautions. We present a case of thermal blisters induced by transillumination in a neonate. This entity is an important addition to the differential diagnosis of vesicobullous eruptions in the neonate.

The evolving role of itraconazole, fluconazole and terbinafine in the treatment of tinea capitis.

Tinea capitis has become an increasing public health concern in the last decade. The increased incidence of the disease; its sometimes subtle, nonspecific clinical presentation; and the development of tolerance to griseofulvin therapy have led to the need for alternative safe, efficacious, inexpensive therapies that work rapidly. Itraconazole, fluconazole and terbinafine all possess pharmacologic and pharmacokinetic characteristics that theoretically would make them ideal therapies for tinea capitis. However, few randomized double blind controlled studies using these agents have been published. Thus far none have been conducted in the United States. The best available data support the utility and safety of the new antifungals in the treatment of tinea capitis. However, one must keep in mind that they are not yet approved by the Food and Drug Administration for this indication. Safety and cost considerations favor terbinafine for the treatment of T. tonsurans infections. M. canis infections may respond better to itraconazole, but good controlled studies to confirm this speculation have not been conducted. Short course and pulse dosing are particularly exciting options that may decrease cost and lower the risk of adverse side effects. Further useful information will hopefully come from future randomized double blind studies that will include patients from the United States. Studies using standardized definitions of disease, cure and appropriate follow-up evaluation of clinical and mycologic cure will best identify the optimal therapy for pediatric tinea capitis infections. The new systemic antifungals may provide more therapeutic options for fungal infections of the scalp. Note added in proof A recent trial comparing short course terbinafine and intraconazole therapy demonstrated that 2-week therapy with either drug provided good results and high cure rates (Jahangir M, et al. Br J Dermatol 1998;139:672-4).

Update on acne.

Acne is a common condition seen routinely by both primary care physicians and dermatologists. Most patients have no underlying pathology and respond to traditional treatment; others, however, require more individualized evaluation and aggressive therapy. New information regarding the pathogenesis and treatment of acne is now available. This update discusses the proper evaluation of early childhood acne, the emergence of Propionibacterium acnes resistance, and the rare but serious side effects occasionally seen with minocycline. Advances in the topical treatment of acne, the use of oral contraceptives in acne, and the use and efficacy of isotretinoin are also addressed.