ACR Appropriateness Criteria® Soft Tissue Vascular Anomalies: Vascular Malformations and Infantile Vascular Tumors (Non-CNS)-Child.

Soft tissue vascular anomalies may be composed of arterial, venous, and/or lymphatic elements, and diagnosed prenatally or later in childhood or adulthood. They are divided into categories of vascular malformations and vascular tumors. Vascular malformations are further divided into low-flow and fast-flow lesions. A low-flow lesion is most common, with a prevalence of 70%. Vascular tumors may behave in a benign, locally aggressive, borderline, or malignant manner. Infantile hemangioma is a vascular tumor that presents in the neonatal period and then regresses. The presence or multiple skin lesions in an infant can signal underlying visceral vascular anomalies, and complex anomalies may be associated with overgrowth syndromes. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Clinical Practice Guideline for the Management of Infantile Hemangiomas.

Infantile hemangiomas (IHs) occur in as many as 5% of infants, making them the most common benign tumor of infancy. Most IHs are small, innocuous, self-resolving, and require no treatment. However, because of their size or location, a significant minority of IHs are potentially problematic. These include IHs that may cause permanent scarring and disfigurement (eg, facial IHs), hepatic or airway IHs, and IHs with the potential for functional impairment (eg, periorbital IHs), ulceration (that may cause pain or scarring), and associated underlying abnormalities (eg, intracranial and aortic arch vascular abnormalities accompanying a large facial IH). This clinical practice guideline for the management of IHs emphasizes several key concepts. It defines those IHs that are potentially higher risk and should prompt concern, and emphasizes increased vigilance, consideration of active treatment and, when appropriate, specialty consultation. It discusses the specific growth characteristics of IHs, that is, that the most rapid and significant growth occurs between 1 and 3 months of age and that growth is completed by 5 months of age in most cases. Because many IHs leave behind permanent skin changes, there is a window of opportunity to treat higher-risk IHs and optimize outcomes. Early intervention and/or referral (ideally by 1 month of age) is recommended for infants who have potentially problematic IHs. When systemic treatment is indicated, propranolol is the drug of choice at a dose of 2 to 3 mg/kg per day. Treatment typically is continued for at least 6 months and often is maintained until 12 months of age (occasionally longer). Topical timolol may be used to treat select small, thin, superficial IHs. Surgery and/or laser treatment are most useful for the treatment of residual skin changes after involution and, less commonly, may be considered earlier to treat some IHs.

A retrospective analysis of pediatric patients with lichen sclerosus treated with a standard protocol of class I topical corticosteroid and topical calcineurin inhibitor.

BACKGROUND: Lichen sclerosus (LS) is a chronic, inflammatory condition of the skin, affecting primarily the anogenital region potentially leading to changes in vaginal architecture and vulvar squamous cell carcinoma. Current recommended treatment for LS is high-potency corticosteroids. Calcineurin inhibitors may also have a role. OBJECTIVE: The objective of this study is to introduce a treatment regimen involving clobetasol to induce remission, then tacrolimus to maintain remission in pediatric females with LS. METHODS: As a retrospective case series, we report 14 pediatric females between 2 and 10 years of age with LS treated with clobetasol 0.05% topical ointment and systematically bridged to tacrolimus 0.1% topical ointment. For each patient, gender, age at disease onset, and clinical symptoms and features were noted. Time in weeks to 75% clearance and to complete clearance were recorded. RESULTS: Thirteen patients showed complete clearance. One patient showed significant clearance of the disease. The time to complete clearance averaged 43.1 weeks, with a range of 4-156 weeks. CONCLUSIONS: The use clobetasol to induce remission and tacrolimus to maintain remission can be used to treat LS in pediatric females. This regimen may minimize side effects associated with long-term, high-potency corticosteroid use and reduce the risk of changes to genital architecture secondary to LS.

Common use of prescription off-label acne therapy in children younger than 12 years old.

Acne is occurring more frequently in younger age groups, but most available treatments are considered off-label in young children. As the epidemiology of acne has changed to include younger children over the past 20 years, neither regulators, pharmaceutical companies, nor clinicians have understood the need or value of obtaining regulatory sanctions for problems physicians have managed using clinical judgment. The objective of this study was to analyze the frequency of off-label acne treatment according to age and other demographic factors. We searched the National Ambulatory Medical Care Survey from 1993 to 2010 for visits in children younger than 12 years of age for the diagnosis of International Classification of Diseases, Ninth Revision, code 706.1. We tabulated leading acne treatments and assessed factors associated with off-label prescribing. Off-label but appropriate acne treatments were used in 29% of acne visits for children younger than 12 years of age. Dermatologists were more likely than pediatricians to prescribe off-label treatment (p < 0.001). The most frequently used off-label treatments were topical retinoids, followed by oral antibiotics. There was no significant trend in the rate of off-label prescribing over time (p = 0.40). Off-label treatment is well within the standard of care for young children with acne. More data on the use of topical retinoids in young children will improve our understanding of their use, which may help optimize treatment outcomes for children with acne.

Prescriptions for a toxic combination: use of methotrexate plus trimethoprim-sulfamethoxazole in the United States.

OBJECTIVES: To determine the frequency of using the potentially toxic combination of methotrexate and trimethoprim-sulfamethoxazole (TMP-SMX) in outpatient practice in the United States. METHODS: Data from the National Ambulatory Medical Care Survey for 1993-2010 were used to assess the frequency of using methotrexate with TMP-SMX and associated physician specialties and diagnoses. RESULTS: TMP-SMX was coprescribed in 22,000 methotrexate visits per year (1.0% of methotrexate visits). Pediatricians prescribed the combination most frequently, and the most common diagnosis was acute lymphoblastic leukemia. There was no significant change over time in coprescription of TMP-SMX with methotrexate (P = 0.4). CONCLUSIONS: Low-dose TMP-SMX with methotrexate chemotherapy appears to be standard for patients with acute lymphoblastic leukemia; however, other uses appear questionable, and clinicians should be cognizant of the risk for fatal interactions, especially when medications are prescribed by multiple providers.

Factors associated with topical retinoid prescriptions for acne.

BACKGROUND: Topical retinoids are recommended as the main therapy for most acne patients. OBJECTIVE: To examine the factors associated with topical retinoid prescriptions for acne. METHODS: Retrospective analyses used data from the 2005-2010 National Ambulatory Medical Care Survey (NAMCS) and the 2004-2007 Marketscan Medicaid Database. Multivariate logistic regression models were used to assess the impact of patient and physician factors on the probability of getting a topical retinoid prescription. RESULTS: Results from analyzing the NAMCS data showed that topical retinoids were prescribed in 40.9% of acne-related physician visits. Older age, male gender, and having Medicaid insurance were associated with a lower likelihood of getting a topical retinoid prescription. Moreover, we found in the Medicaid dataset that seeing a pediatrician or family doctor was associated with lower odds of getting a topical retinoid prescription than seeing a dermatologist (OR = 0.24, 95% CI: 0.23, 0.25). LIMITATIONS: The available databases do not provide an assessment of the severity of the lesions either at baseline or over time. CONCLUSION: The frequency of receiving a topical retinoid prescription among acne patients was low and it was associated with age, gender, insurance type and physician specialty.

Linear morphea: a case series with long-term follow-up of young, methotrexate-treated patients.

BACKGROUND: Linear morphea can lead to significant morbidity and functional disability in young patients. Methotrexate (MTX), with or without a short initiation with prednisone therapy, has been used and documented as a well-tolerated, effective treatment regimen. PURPOSE: To evaluate the long-term efficacy of MTX therapy in patients with linear morphea. METHODS: A retrospective chart review was performed for pediatric and young adult patients with linear morphea and evaluated in the Dermatology Clinic at Wake Forest University School of Medicine treated with MTX. RESULTS: Seventeen patients met inclusion criteria and were followed for an average of 6.6 years. All patients improved with MTX therapy, with an average of 2.1 months to disease inactivity, and 19.6 months to discontinuation of MTX. Seven patients (41%) required a second course of MTX, following an average remission of 21 months. One patient (6%) required a third course, following 6.9 years of remission. LIMITATIONS: Retrospective chart review with a small patient sample size, and several patients were lost to follow-up. CONCLUSIONS: MTX is effective for achieving disease inactivity in pediatric and young adult patients with linear morphea. MTX is also effective in achieving disease remission off of therapy. However, many patients eventually required more than one course of MTX.

A 6-year-old girl with fever, rash, and increased intracranial pressure.

BACKGROUND: Rocky Mountain spotted fever (RMSF) is a well-described, potentially lethal, tick-borne zoonotic infection and has very effective therapy. However, the diagnosis might not be made early enough, often leading to worse outcomes. OBJECTIVE: Our aim was to discuss the diagnostic dilemmas facing the physician when evaluating patients with suspected RMSF. METHODS: We report a case of RMSF in a 6-year-old girl who presented to our hospital with a 7-day history of fever, headache, and a petechial rash. After blood cultures were obtained, the patient was treated empirically with doxycycline, vancomycin, and ceftriaxone. During the next 24 h, her clinical status worsened, with acute onset of altered mental status, posturing, and fixed and dilated pupils. A computed tomography scan of the brain demonstrated diffuse cerebral edema with evidence of tonsillar herniation. She died 24 h after admission. A serum specimen tested positive for immunoglobulin G to Rickettsia rickettsii at a titer of 128 dilutions, confirming recent infection. CONCLUSIONS: We present this case to raise awareness of RMSF in patients who present with a nonspecific febrile illness in tick-endemic areas in the United States. Early diagnosis and treatment with doxycycline before day 5 of illness is essential and can prevent morbidity and mortality.

Treatment of impetigo: oral antibiotics most commonly prescribed.

BACKGROUND: Impetigo is a highly contagious, superficial skin disease that is frequently seen in children. While data support the use of topical antibiotics for treatment, the medications actually prescribed in practice are not well documented. OBJECTIVES: To determine the prescribing pattern of dermatologists and nondermatologists when treating impetigo and the demographics of the patients treated. METHODS: National Ambulatory Medical Care Survey data on office visits for impetigo were analyzed from 1997 to 2007. Patient demographics and the treatments for impetigo were recorded. RESULTS: During this 10-year period, dermatologists managed an estimated 274,815 impetigo visits and nondermatologists an estimated 3,722,462 visits. Both dermatologists and nondermatologists most frequently prescribed oral antibiotics to treat impetigo. Topical antibiotics were second most common, and a variety of combination treatments were used. CONCLUSIONS: Oral antibiotics are the most common class of medications used to treat impetigo. There is an opportunity for physicians to take advantage of the equally efficacious topical antibiotics for treating impetigo. A shift towards topical antibiotics would likely decrease morbidity (resulting from adverse effects) associated with use of oral agents.

Febrile ulceronecrotic Mucha-Habermann disease (pityriasis lichenoides et varioliformis acuta fulminans) presenting as Stevens-Johnson syndrome.

We present two pediatric patients with pityriasis lichenoides et varioliformis acuta fulminans whose admitting diagnosis was Stevens Johnson Syndrome. The patients were successfully treated with methotrexate and prednisone. These cases highlight the importance of early recognition and treatment of this disease to prevent further morbidity and a potentially fatal prognosis.

Changing age of acne vulgaris visits: another sign of earlier puberty?

The objective of the current study was to assess changes in the onset of pubertal maturation by determining whether acne is occurring at an earlier age. We assessed the age at which acne is occurring by assessing trends in the age of people seeking medical attention for acne. The National Ambulatory Medical Care Survey database was used to analyze physician visits for acne vulgaris in children aged 6 to 18 from 1979 to 2007. The data were used to assess trends in the mean age of children with acne and to compare these trends according to race and sex. Regression analysis revealed a significant decrease in the mean age of children seeking treatment for acne over this 28-year period (p < 0.001). There was no significant change in the mean age of black children seeking treatment for acne. Black girls had the lowest mean age whereas white boys had the highest mean age. There has been a decrease in the average age of children seeking treatment for acne that may be indicative of earlier acne onset. This finding provides supporting evidence of the increasingly earlier onset of puberty in girls.

Medication adherence among acne patients: a review.

BACKGROUND: Acne is a chronic disease often requiring the use of medications for extended periods of time. In general, adherence decreases over time in patients with chronic diseases, and adherence to topical medications is poor compared to adherence to oral medications, placing individuals using topical medications at increased risk for nonadherence and treatment failure. Poor adherence may also be a common cause of treatment failure in teens with acne. PURPOSE: We reviewed the current literature on medication adherence in teenagers with acne to assess adherence levels and predictors of adherence. We hope to provide a foundation for further research into medication adherence in acne patients. METHODS: A Medline search was conducted using the key words "acne" and "adherence" or "compliance." Studies reporting adherence were included in the analysis. RESULTS: A positive correlation was found between quality of life of patients with acne and medication adherence. Weaker predictors of adherence include increased age, female gender, and employment. The most commonly reported reason for nonadherence was inadequate time to use the treatment medication. Patients taking medications requiring less frequent dosing had better adherence, and medication adherence correlated with better health status among acne patients. A longer duration between office visits may be associated with decreased compliance. Limitations Few studies investigating the prevalence and causes of nonadherence in acne patients were identified. CONCLUSIONS: Adherence to medications is difficult to measure and rates reported by patients often overestimate actual adherence. Patients cite lack of time as a common reason for nonadherence to topical medications.

Physicians' perceptions of an eczema action plan for atopic dermatitis.

BACKGROUND: Poor adherence to topical medications in atopic dermatitis may lead to exposure to more costly and potentially toxic systemic agents. Written action plans (WAPs) improve adherence and treatment outcomes in asthma patients and may be useful for children with atopic dermatitis. OBJECTIVE: To assess physicians' perceptions of a WAP for atopic dermatitis and their openness to using it. METHODS: An Eczema Action Plan (EAP) was modeled from those used in pediatric asthma. A brief survey to assess the perceived practicality and usefulness of the EAP was sent to 48 pediatricians in our local area and to 17 pediatric dermatologists nationally. Survey items included layout, graphics, readability, accuracy, and utility. Qualitative analyses were performed due to small sample sizes. RESULTS: Seventeen pediatricians from five community practices and eight pediatric dermatologists responded (response rates of 35% and 41%, respectively). Layout was rated as excellent by 59% of pediatricians and 43% of pediatric dermatologists, the graphics were rated good (60% and 70%), the readability as good to excellent (100% and 86%), the accuracy as excellent or good (83% and 86%), and usefulness as good to excellent (100% of both groups). Most (71%) of the pediatric dermatologists reported already having their own patient education materials for atopic dermatitis, but none of the pediatricians did. All pediatricians and 60% of pediatric dermatologists reported they were likely to use the EAP in their clinical practices. Limitations included the sample size being small, but it still provided for qualitative assessment of generalists and sub-specialists. We did not assess how the EAP would be perceived by patients or their families. The practice settings of the community and academic physicians are not identical, which may make for weakened comparisons. CONCLUSIONS: Pediatricians are open to using an EAP for atopic dermatitis. If an EAP were effective at improving adherence and outcomes in atopic dermatitis, widespread implementation should be feasible.

Guidelines of care for acne vulgaris management.

DISCLAIMER: Adherence to these guidelines will not ensure successful treatment in every situation. Furthermore, these guidelines should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific therapy must be made by the physician and the patient in light of all the circumstances presented by the individual patient.

Successful treatment of a therapy-resistant pyogenic granuloma with topical imiquimod 5% cream.

A 58-year-old man was referred to our department for evaluation and treatment of a therapy-resistant pyogenic granuloma on his right third digit. This biopsy-confirmed lesion was unsuccessfully treated with shave excision and base electrocautery on two separate occasions before the patient presented to our clinic. After completing a 14-week course of twice-weekly imiquimod 5% topical application, this patient's pyogenic granuloma completely resolved. A satisfactory cosmetic outcome was also achieved, with virtually no scarring.

Healthcare utilization for acute and chronic diseases of young, school-age children in the rural and non-rural setting.

To determine the most frequently diagnosed conditions among rural and non-rural children age 5 to 9 and assess for environmental influences, data from the National Ambulatory Medical Care Survey (1996-2001) were used to examine frequencies of diagnoses in children age 5 to 9. Separately, we examined rural and non-rural outpatient physician visits in weighted multivariate logistic regression models. Overall, the most frequent diagnosis was routine health check, followed by several acute conditions. When analyzed separately, non-rural children were significantly more likely to visit a physician for routine health check (P = 0.002), asthma (P = 0.005), and acute upper respiratory infection (P = 0.037). Rural counterparts were significantly more likely to be seen for attention deficit disorder (P = 0.000), otitis media (P = 0.017), chronic rhinitis (P = 0.017) and influenza (P = 0.037). Children age 5 to 9 are healthy overall. When illness occurs, it is usually acute. Rural and non-rural, young, school-aged children exhibit many similarities in healthcare utilization, but differences occur. Most surprising is the difference in the diagnosis frequency of attention deficit disorder.