Clinical practice guidelines for the diagnosis and management of atopic dermatitis.

Atopic dermatitis (AD), a chronic, relapsing dermatitis, is characterized by dry and pruritus skin in patients with a personal or family history of atopy. It affects up to 20% of children and 1-3% of adults in most countries worldwide, and leads to significant treatment costs and morbidity. These guidelines are developed in accordance with evidence-based publications and expert opinions. Following simple algorithms, the guidelines aim to assist adult and pediatric physicians in the better care of patients with AD. As with other diseases, there have been several diagnosis criteria proposed over time. Nonetheless, the classical Hanifin and Rajka criterion with no pathognomonic laboratory biomarkers is still the most widely used worldwide for the diagnosis of AD. The management of AD must be considered case by case to provide suitable care for each patient. Basic therapy is focused on avoiding specific/unspecific provoking factors and hydrating skin. Topical anti-inflammatory treatments such as glucocorticoids and calcineurin inhibitors are suggested for disease flare, and proactive therapy is best for long-term control. Other therapies, including antimicrobial agents, systemic antihistamines, systemic anti-inflammatory agents, immunotherapy, phototherapy, and psychotherapy, are reviewed in these guidelines. Crisaborole, a new topical phosphodiesterase 4 inhibitor, can be used twice daily in AD patients over three months old. Dupilumab, a biological drug for patients with moderate-to-severe AD, may be considered in patients with no improvement from other systemic treatments.

Response to propranolol in infantile hemangioma.

Propranolol, 2 mg/kg/day, is effective in the treatment of infantile hemangioma. We report the response to propranolol in infants with hemangioma at a dose of 1 mg/kg/day. Sixteen infants with newly diagnosed infantile hemangioma were given propranolol at a dose titrated from 0.5 mg/kg/day then increased to 1 or 2 mg/kg/day based on response to treatment until the lesions showed clinical stability for 3 consecutive months. Five out of 16 patients (31.2%) responded to propranolol at 1 mg/kg/day, while the remainder required 2 mg/kg/day for response. Vascular endothelial growth factor significantly decreased after treatment (median, 117.8 pg/mL; range, 35.3-468.7 pg/mL vs 59.2 pg/mL; range, 26.3-133.0 pg/mL; P = 0.016). Therefore, we recommend initiating treatment at 0.5 mg/kg/day for 2 days, then 1 mg/kg/day for 1 month. If the hemangioma has not decreased in size by 1 month follow up, the dose is subsequently increased to 2 mg/kg/day.

Clinical practice guideline for diagnosis and management of urticaria.

Urticaria is a common skin condition that can compromise quality of life and may affect individual performance at work or school. Remission is common in majority of patients with acute spontaneous urticaria (ASU); however, in chronic cases, less than 50% had remission. Angioedema either alone or with urticaria is associated with a much lower remission rate. Proper investigation and treatment is thus required. This guideline, a joint development of the Dermatological Society of Thailand, the Allergy, Asthma, and Immunology Association of Thailand and the Pediatric Dermatological Society of Thailand, is graded and recommended based on published evidence and expert opinion. With simple algorithms, it is aimed to help guiding both adult and pediatric physicians to better managing patients who have urticaria with/without angioedema. Like other recent guideline, urticaria is classified into spontaneous versus inducible types. Patients present with angioedema or angioedema alone, drug association should be excluded, acetyl esterase inhibitors (ACEIs) and non-steroidal anti-inflammatory drugs (NSAIDs) in particular. Routine laboratory investigation is not cost-effective in chronic spontaneous urticaria (CSU), unless patients have clinical suggesting autoimmune diseases. Non-sedating H1-antihistamine is the first-line treatment for 2-4 weeks; if urticaria was not controlled, increasing the dose up to 4 times is recommended. Sedating first-generation antihistamines have not been proven more advantage than non-sedating antihistamines. The only strong evidence-based alternative regimen for CSU is an anti-IgE: omalizumab; due to very high cost it however might not be accessible in low-middle income countries. Non-pharmacotherapeutic means to minimize hyper-responsive skin are also important and recommended, such as prevention skin from drying, avoidance of hot shower, scrubbing, and excessive sun exposure.

Medical students themselves as surrogate patients increased satisfaction, confidence, and performance in practicing injection skill.

BACKGROUND: Injection skill is one of procedural skills usually taught to medical students. Lack of experience and confidence in their ability creates nervousness, anxiety, and leads to poor performance in giving an injection to patient. AIMS: To evaluate the satisfaction on teaching method, perceptions of confidence and feeling of empathy to the patients, and performance in injection skill of medical students toward practicing injection skill using manikin only compared to additional training using themselves as surrogate patients. METHODS: Control group consisted of year 5 medical students, who completed studying injection skill from computer assistant instruction, demonstration, and practicing with manikin. The intervention group in addition to those conventional learning methods, directly experienced injection skill using themselves as surrogate patients and received direct feedback from their peers. Both group had a chance to perform injection to actual children and were assessed while performing the injection for their performance of injection procedures. Upon completion of the entire learning process, the students were asked to answer questionnaire presented with Likert-type scales. RESULTS: There were 57 students in the control group and 32 in the intervention group who completed the study. The intervention group reported significantly higher satisfaction on the teaching method, higher level of confidence and empathy to the children who were given injection, and had significantly better performance in preparing the children and giving injection. Both groups are not different in checking accuracy of order, preparing vaccine, selecting injection site, sterile techniques, handling of instruments and injection site, documentation, and explaining to children/parents. CONCLUSIONS: Direct experience by medical students themselves as surrogate patients is an appropriate option for learning injection skill and can enhance the student performance, and therefore should be encouraged.

A survey of birthmarks and cutaneous skin lesions in newborns.

BACKGROUND: The prevalence of birthmarks and cutaneous skin lesions in newborns vary among sex and race. There are limited reports of birthmarks and cutaneous lesions among Thai neonates. OBJECTIVE: To determine the prevalence of birthmarks and cutaneous lesions in Thai newborns and evaluate the association between age, gender maturity, route of delivery, birth weight and skin lesions. MATERIAL AND METHOD: All of the subjects were healthy newborn infants, who were born between September 2008 to September 2009. They were enrolled and examined for cutaneous lesions by two dermatologists. RESULTS: 574 neonates were included in this report. The most common pigmentary birthmarks were Mongolian spots (100%), followed by congenital melanocytic nevi (2.4%) and Cafe-au-lait spots (0.3%). The most common vascular birthmarks were salmon patch (16.6%), hemangiomas (0.30%) and vascular malformations (0.3%). Among the cutaneous lesions; the three most common skin lesions were sebaceous gland hyperplasia (78%), Epstein's pearls (71.3%), and erythema toxicum neonatorum (46.5%). CONCLUSION: Mongolian spot was the most frequent birthmark while sebaceous gland hyperplasia was the most frequent cutaneous lesions found among Thai neonates. The prevalence of the cutaneous lesions of newborns differ among countries could possibly be due to race, the age of the infants and the period of observation of the study subjects.

Randomized, double-blind, split-side, comparison study of moisturizer containing licochalcone A and 1% hydrocortisone in the treatment of childhood atopic dermatitis.

BACKGROUND: Atopic dermatitis (AD) is a common chronic inflammatory skin lesion in children. Topical corticosteroid is the mainstay of treatment. OBJECTIVE: To compare the efficacy of moisturizer containing licochalcone A (LicA) and 1% hydrocortisone for the treatment of mild to moderate childhood AD. MATERIAL AND METHOD: This was a multicenter randomized, prospective, split-side, double-blind study in 55 children between the age of three months and 14 years. Patients with AD were treated twice daily, simultaneously with either Lic A or 1% hydrocortisone on opposite sides of the lesion. The SCORAD and transepidermal water loss (TEWL) were performed at the baseline, 2-week, and 4-week visits. Lic A was used on both sides of the body for another four weeks to see the effects and TEWL. RESULTS: In a randomized period, both products were equally effective in the treatment. SCORAD decreased significantly from baseline for both treatments throughout the first four weeks (p < 0.001). There was no statistically significant difference in SCORAD between both treatments (p = 0.321 and p = 0.146 at week 2 and 4, respectively). Lic A had statistically significant decrease in TEWL (p = 0.027 and p = 0.03 at weeks 2 and 4, respectively). One patient had infection on skin lesions of both sides of the body. Forty-three patients continued to the period of using Lic A on both sides of the body. SCORAD and TEWL were comparable to the end of the randomized period and significantly lower from baseline (p < 0.001). Skin lesions flared up in three patients (7.5%). CONCLUSION: Lic A had a similar result in terms of SCORAD compared to 1% hydrocortisone for the treatment of mild and moderate AD. TEWL was significantly lower than baseline on the side that used Lic A. Continuing use of Lic A for four weeks can maintain clinical and barrier improvement.

Accuracy of three methods used for Thai children's body weight estimation.

BACKGROUND: Accurate children's weight estimation is necessary and important for emergency pediatric care, particularly for drug dosages, electrical therapy, or equipment sizes. Children's weight is difficult to measure in critically ill patients. Several methods were developed to estimate children's accurate weight. Most methods were developed from western countries. The methods used currently might not work with Thai children. OBJECTIVE: To determine the accuracy of the Broselow tape, family member estimation and the 50th percentile of national weight for height correlation graph for Thai children's weight estimation. MATERIAL AND METHOD: The authors carried out a prospective study. Children from neonate to 12 years old who presented to the emergency department and general outpatient pediatric clinic were included. The patients were studied in both overall and subgroup analysis (less than 10 kg, 10 to 25 kg, 25 to 40 kg, and over 40 kg). The primary outcome was the accuracy within 10% error of the measured weight and the mean difference of the weight. RESULTS: Five hundred ninety five patients were included in the present study. There were 333 (55.97%) boys and 262 (44.03%) girls. Family member estimation was the most accurate method with the accuracy within 10% error 85.21% and had the lowest mean difference (-0.262 kg). Family members could estimate weight accurately for all weight subgroups. The Broselow tape was the second most accurate method with the accuracy within 10% error 56.13% and the low mean difference (-0.485 kg). The accuracy within 10% error of the 50th percentile of national weight for height correlation graph was 51.43% and the mean difference was -0.648 kg. Every method had the best estimation in the weight subgroup 10 to 25 kg except the Broselow tape. CONCLUSION: Family member estimation was the most accurate method in the present study. The family member could estimate the children's weight within 10% error of the measured weight about 85% of cases. In case where family member estimation was not available, the Broselow tape was the next accurate alternative method.

Poliosis as the first clue of tuberous sclerosis.

Ash leaf hypopigment macules, until now, was known as earliest signs of tuberous sclerosis, unfortunately not always visible at birth. We reported herein a case of tuberous sclerosis presented with a tuft of white hair (poliosis) at birth for recommended poliosis as a useful earliest sign for detection of tuberous sclerosis in the newborn.

Efficacy and safety of tacrolimus ointment in pediatric Patients with moderate to severe atopic dermatitis.

BACKGROUND: Atopic dermatitis (AD) is an immunological skin disease. It is common in pediatric populations and often requires topical steroid treatment. Moderate to severe AD may not respond to topical steroids. They often require systemic steroids, which may result in growth retardation. Protopic, a non-steroid, tacrolimus based ointment which is a calcinurin inhibitor has been proved to be effective in caucacian with AD. OBJECTIVE: To evaluate safety and efficacy of 0.03% tacrolimus ointment (Protopic&) in moderate to severe AD in pediatric patients age 2-12 years. MATERIAL AND METHOD: This was a one month multicenter open-label clinical trial using tacrolimus ointment twice daily in 61 subjects with moderate to severe AD from September to December 2004. Efficacy assessments were measured by Physician's Global Evaluation of Clinical Response (PhGECR), Eczema area and Severity Index (EASI), Patient's Global Evaluation of Clinical Response (PaGECR), and Quality of Life (QOL). Safety assessment was measured by incidence rate of adverse events. RESULTS: Fifty-eight patients completed the studies. Twenty-two patients were male; thirty-nine patients were female. Twenty-nine patients had moderate AD. Thirty-two patients had severe AD. Three cases had discontinued treatment at the third week due to increase in severity. Over all PhGECR were significantly increased, 94% showed moderate improvement in PhGECR at week 4 or end of treatment (EOT)and 83% had better improvement in PaGECR at EOT Within 7 days, tacrolimus demonstrated rapid onset in reduction of EASI score and itch in patients. Mean QOL were significantly decreased at the end of the present study. Incidence of adverse events included application site burning (21%), itching (17%), pruritus (9%), infections(3%), and erythema and folliculitis (2%). Burning sensation, erythema, pruritus and itching were resolved after the first week. CONCLUSION: Topical tacrolimus ointment is effective and safe in moderate to severe AD. It significantly improved PhGECR, EASI, PaGECR, and QOL in pediatric patients after the first week of treatment and continued through the end of the study. The major adverse events were burning, itching, and pruritus, which were resolved within the first week of therapy.

Expanding the phenotypic spectrum of Lenz-Majewski syndrome: facial palsy, cleft palate and hydrocephalus.

We report a sporadic case of Lenz-Majewski syndrome (LMS) with newly recognized manifestations including facial palsy, cleft palate and hydrocephalus developing later in infancy. The clinical course of the patient and neuroimaging studies are described. Increased intracranial pressure was recognized and treated early with the aim of preventing neurological morbidity.

Congenital self-healing Langerhans cell histiocytosis with pulmonary involvement: spontaneous regression.

Congenital self-healing Langerhans cell histiocytosis (CSHLCH) is a rare condition which may present at birth or during the neonatal period. It is usually characterized by eruption of multiple, discrete and red-brown papules and nodules which may increase in size and number during the first few weeks of life with spontaneous regression. Systemic signs are usually absent except for occasional mild hepatomegaly. The authors report a case of CSHLCH associated with multiple lung cysts with spontaneous regression. A healthy full term male infant presented at birth with numerous diffuse discrete dark-red papules sized 0.2-1.0 cm scattered on the eyelids, temporal areas of the scalp, neck, palms and soles. Histologic findings were mixed inflammatory infiltration of numerous histiocytes. Immunochemistry findings were S-100 and CDla positive consistent with CSHLCH. Hepatomegaly and multiple lung cysts were detected at 1 month old. Since he was healthy, no medication was given except for close monitoring. At 2 months of age, hepatomegaly was resolved but the liver had sclerosing change. Skin lesions regressed completely at the age of 4 months. Lung cysts were markedly improved at 7 months old and completely resolved at 1 year old. Spontaneous regression in CSHLCH with lung involvement has never been reported in Thailand.

Therapeutic efficacy and safety of loratadine syrup in childhood atopic dermatitis treated with mometasone furoate 0.1 per cent cream.

Atopic dermatitis is a common skin disease in Thai children. The treatment of atopic dermatitis requires topical corticosteroids, emollients, systemic antihistamine as well as avoidance of the precipitating factors. A double blind multicenter placebo controlled study was conducted to assess the therapeutic efficacy of topical mometasone furoate 0.1 per cent cream in combination with loratadine syrup. Forty-eight patients, 23 boys and 25 girls, mean age 73.67 months, with atopic dermatitis were included in the study. The severity of the disease was measured by using the SCORAD index including the degree of erythema, dryness, edema/papulation, oozing/crusting, lichenification, and excoriation. Total area involved was measured and a target area of dermatitis was selected for specific evaluation. The degree of clinical signs and pruritic symptom was graded. The sensation of pruritus, disturbance of sleep due to pruritus, and feeling of sleepiness in the morning were recorded. Mometasone furoate 0.1 per cent cream was applied to all patients once daily. One group received loratadine syrup and another group received placebo syrup. They were followed-up on day 5, 8 and 15. The severity of atopic dermatitis and pruritus significantly decreased after 14 days of treatment in both groups (p < 0.001). There was no difference in therapeutic response between the loratadine and placebo groups (p = 0.99). All signs examined had decreased by the end of the study. The result demonstrated that 0.1 per cent mometasone therapy is very effective for treating childhood atopic dermatitis. Loratadine did not show beneficial effect when combined with good topical corticosteroid but it was safe and had no serious side effect on the children.

Drug eruptions: the value of oral rechallenge test and patch test.

All in-and out-patients, who came for drug eruption consultation at the Dermatology Clinic, Ramathibodi Hospital from December 1997 to November 1998 were included in this study. Medical histories and physical examinations were performed by one of the authors. In suspected cases, a skin biopsy was performed to confirm the diagnosis. Patch test and oral challenge test were performed in some patients who had maculopapular, fixed drug eruption and acute generalized exanthematous pustulosis, with informed consent. Among 80 patients, the most common cutaneous reaction was maculopapular rash. Antimicrobial, drugs were the most common causative agents. The patch test was positive in only one patient from 12 cases. The oral provocative test was positive in two patients from 4 cases. It is concluded that oral provocative test is still necessary to get a definite diagnosis of causative agent. The value of patch test needs further study.

Neonatal lupus erythematosus: clinical manifestations and management.

The authors report 6 cases of neonatal lupus erythematosus (NLE) who were seen at Ramathibodi Hospital from 1993 to 2000. The female to male ratio was 1:5. Cutaneous lesions were the major manifestation in all cases. Other clinical manifestations were thrombocytopenia, hepatosplenomegaly and mild elevation of liver enzymes. Skin rashes mostly erupted at 3-6 weeks old. None had a complete heart block but one had abnormal electrocardiograph (ECG) changes compatible with Wolff-Parkinson-White syndrome (WPW). Four of six patients had thrombocytopenia. All of the abnormalities resolved spontaneously except thrombocytopenia. Three of six needed blood transfusion to replace blood loss from gastrointestinal bleeding. Intravenous immunoglobulin (IVIG) 2 g/kg was given in 3 cases with good response in two of three cases. Platelets rose rapidly and maintained at a normal level within 24-48 hours. Combined therapy with corticosteroid 2 mg/kg was given to 1 case with good outcome. Telangiectasia was the most common sequelae especially in patients who had periorbital lesions resembling raccoon's eyes. The authors conclude that IVIG in the dose of 1 g/kg for 1-2 days is an effective treatment for NLE with severe thrombocytopenia especially when corticosteroid is contraindicated.

Henoch-Schonlein purpura: clinical manifestations and long-term outcomes in Thai children.

The clinical features of 47 children with Henoch-Schonlein purpura (HSP) are presented. The most common ages at presentation ranged from 3-5 years. Duration of data collection was 60 months. The peak incidence was from December to February. The organ involvements included skin (100%), gastrointestinal tract (74.5%), renal (46.8%) and joint (42.6%). Renal involvement was detected within the first 2 months in 16 cases (72.7%) but was delayed until 6 months after diagnosis in 6 cases. No risk factors for renal involvement could be identified. The mean duration of follow-up was 2.6 years (range 1-5 years). Six out of 16 (37.5%) patients had residual renal diseases but none were end stage. Recurrent episodes of abdominal pain and skin purpura were found in a few cases during the first year. Overall prognosis of HSP is good and long-term morbidity is predominantly associated with renal involvement. Patients with initially normal urinalysis should have sequential urinary examination at least for 6 months.

Sebaceous nevus syndrome as the underlying cause of intractable seizures in a one-month-old infant.

A one-month-old male infant with generalized seizures since 2 days old was evaluated at the Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand. His seizures were initially characterized as focal movement of the right upper and lower limbs followed by generalized tonic. Initially, phenobarbital was administered but failed to control his seizures. Physical examination revealed generalized mild hypotonia with a hyperpigmented brownish patch affecting the left side of his face. The initial diagnosis was sebaceous nevus syndrome which is one of the neurocutaneous syndromes. The diagnosis was confirmed by skin biopsy of the affected lesion. The literature was reviewed and discussed. The authors emphasized the importance of thorough physical examination including evaluation of specific skin lesion which would be a leading clue in making the diagnosis of symptomatic epilepsy in infants.

Antineutrophilic cytoplasmic antibody-positive systemic vasculitis associated with propylthiouracil therapy: report of 2 children with Graves' disease.

Systemic vasculitis is a rare complication of therapy with antithyroid medication. Antineutrophilic cytoplasmic antibody (ANCA)-associated vasculitis has been described in patients treated with propylthiouracil (PTU) and methimazole (MMI). The majority of cases have underlying Graves' disease. The authors report 2 children who developed ANCA-associated systemic vasculitis during PTU therapy of Graves' disease. One patient, after PTU treatment for 3 years, developed severe systemic vasculitis. After 3 weeks of arthritis, she abruptly presented with hematuria, proteinuria and edema concomitant with anemia. Her serum creatinine was elevated, to 6 mg/dl. Renal biopsy revealed crescentic glomerulonephritis. After admission, she developed intracerebral hemorrhage and pulmonary hemorrhage. She had positive perinuclear-ANCA (p-ANCA) with a titer of 1:160. Despite intensive therapy with immunosuppressive agents and plasmapheresis, as well as discontinuation of PTU, she died of the complications of severe systemic vasculitis. The other patient developed fever, arthralgia and leukocytoclastic vasculitis of the skin during treatment with PTU for about 2 years. Her symptoms and skin lesions disappeared after discontinuation of PTU. However, she has had a persistently high titer of p-ANCA 1:320 through 17 months follow-up time. Thus, patients who are treated with PTU can develop ANCA-positive vasculitis in a mild or severe form. Therefore, they should be carefully followed and monitored, not only for their thyroid status but also the serious complications of PTU.