Dermoscopy for the pediatric dermatologist part III: dermoscopy of melanocytic lesions.

Melanocytic nevi encompass a variety of lesions, including blue, Spitz, congenital, and acquired nevi. These nevi can occasionally manifest clinical morphologies resembling melanoma, and the presence of such nevi in children can elicit anxiety in patients, parents, and clinicians. Dermoscopy has been shown to increase the diagnostic accuracy for melanoma and to help differentiate melanoma from nevi, ultimately aiding in the decision-making process as to whether to perform a biopsy. Dermoscopy is the perfect instrument to use during the evaluation of pigmented skin lesions in children because it is painless and provides important information for the clinician that can assist in formulating appropriate management decisions. This review highlights the most common benign dermoscopic patterns encountered in nevi and discuss the 10 most common dermoscopic structures seen in melanomas. Lesions manifesting a benign dermoscopic pattern and lacking any melanoma-specific structures do not need to be excised and can safely be monitored. In contrast, melanomas will invariably deviate from the benign nevus patterns and will usually manifest at least 1 of the 10 melanoma-specific structures: atypical network, negative network, streaks, crystalline structures, atypical dots and globules, irregular blotch, blue-white veil, regression structures, peripheral brown structureless areas, and atypical vessels. It is important to be cognizant of the fact that melanomas in childhood usually do not manifest the clinical ABCD features. Instead, they are often symmetric, amelanotic, nodular lesions. Although the clinical appearance may not be alarming, with dermoscopy they will invariably manifest at least one melanoma-specific structure, the most common being atypical vascular structures and crystalline structures.

Dermoscopy for the pediatric dermatologist part I: dermoscopy of pediatric infectious and inflammatory skin lesions and hair disorders.

The dermoscope allows physicians to examine the macroscopic and microscopic primary morphology of skin lesions, identify subtle clinical clues, confirm naked-eye clinical diagnoses, and monitor treatment progress while posing little threat to the young patient. This review summarizes important dermoscopic structures seen in infectious and inflammatory skin conditions and hair disorders in children. Scabies, pediculosis, phthiriasis, molluscum contagiosum, tinea nigra, and verrucae are well characterized dermoscopically by delta-shaped structures, ovoid-shaped nits, the crab louse, red corona, brown strands or spicules, and multiple densely packed papilla with a central black dot surrounded by a whitish halo, respectively. These dermoscopic structures will be discussed, focusing on the dermoscopic morphologies and dermoscopic sensitivity for diagnosis and its utility in monitoring treatment progress. Dermoscopy has also been shown to significantly improve the clinician's diagnostic and monitoring accuracy of inflammatory skin lesions such as psoriasis, which is characterized dermoscopically by uniformly distributed dotted blood vessels, and lichen planus, which is characterized by whitish lines on a purple to reddish background. Dermoscopy of the hair and scalp (trichoscopy) facilitates the differential diagnosis of hair diseases in children, including alopecia areata, trichotillomania, and tinea capitis. It can also assist in the diagnosis of multiple genetic hair shaft disorders, such as monilethrix, trichorrhexis invaginata, trichorrhexis nodosa, pili torti, and pili annulati.

Dermoscopy for the pediatric dermatologist, part ii: dermoscopy of genetic syndromes with cutaneous manifestations and pediatric vascular lesions.

Genetic syndromes including basal cell nevus syndrome (BSNS), xeroderma pigmentosum (XP), and epidermodysplasia verruciformis (EV) predispose the individual to skin cancer. Basal cell carcinomas (BCCs) often develop in patients with BCNS and XP. One of the aims of surveillance examination in these patients is to detect BCC while the tumors are still small and easy to manage. Dermoscopy, by allowing the visualization of arborizing vessels, ovoid nests, nonaggregated blue-gray globules, and spoke-wheel and leaf-like structures, can facilitate in the early detection of BCC. Patients with XP are also at risk for developing squamous cell carcinoma (SCC). Dermoscopy can assist in the early detection of these cancers by allowing the observer to visualize focal glomerular vessels, which is a common feature seen in SCC. This feature can also assist in detecting SCC developing in other syndromes such as EV and epidermolysis bullosa (EB). In addition to helping in the detection of BCC and SCC, dermoscopy can also help detect melanoma in individuals with XP and evaluate nevi developing in those with EB. This review will discuss how dermoscopy can be used in the management of patients with BSNS, XP, EV, and EB and will discuss the dermoscopic findings of vascular lesions, including pyogenic granuloma, hemangioma, port-wine stain, and lymphangioma circumscriptum.

Management of immune-related cutaneous adverse events with dupilumab.

Immune checkpoint inhibitors (ICI) target the PD-1/PD-L1 and CTLA-4 pathways and allows the immune system to deliver antitumor effects. However, it is also associated with well-documented immune-related cutaneous adverse events (ircAEs), affecting up to 70-90% of patients on ICI. In this study, we describe the characteristics of and patient outcomes with ICI-associated steroid-refractory or steroid-dependent ircAEs treated with dupilumab. Patients with ircAEs treated with dupilumab between March 28, 2017, and October 1, 2021, at Memorial Sloan Kettering Cancer Center were included in this retrospective study, which assessed the rate of clinical response of the ircAE to dupilumab and any associated adverse events (AEs). Laboratory values were compared before and after dupilumab. All available biopsies of the ircAEs were reviewed by a dermatopathologist. Thirty-four of 39 patients (87%, 95% CI: 73% to 96%) responded to dupilumab. Among these 34 responders, 15 (44.1%) were complete responders with total ircAE resolution and 19 (55.9%) were partial responders with significant clinical improvement or reduction in severity. Only 1 patient (2.6%) discontinued therapy due to AEs, specifically, injection site reaction. Average eosinophil counts decreased by 0.2 K/mcL (p=0.0086). Relative eosinophils decreased by a mean of 2.6% (p=0.0152). Total serum immunoglobulin E levels decreased by an average of 372.1 kU/L (p=0.0728). The most common primary inflammatory patterns identified on histopathological examination were spongiotic dermatitis (n=13, 33.3%) and interface dermatitis (n=5, 12.8%). Dupilumab is a promising option for steroid-refractory or steroid-dependent immune-related cutaneous adverse events, particularly those that are eczematous, maculopapular, or pruritic. Among this cohort, dupilumab was well-tolerated with a high overall response rate. Nonetheless, prospective, randomized, controlled trials are warranted to confirm these observations and confirm its long-term safety.

Acquired zinc deficiency in full-term newborns from decreased zinc content in breast milk.

Zinc deficiency occurs in children when the demand for zinc exceeds its supply. Malnutrition, prematurity, total parenteral nutrition dependence, and burns increase the demand for zinc, whereas congenital malabsorption syndromes represent clinical situations where less zinc is supplied to the growing child. Clinical recognition of acral eczematous lesions, alopecia, and gastrointestinal tract symptoms in settings of the aforementioned medical history often lead to the diagnosis. Zinc deficiency in healthy, full-term, breast-fed infants can occur. The cause of these deficiencies has been attributed to decreased zinc levels in maternal breast milk. We present a case of acquired zinc deficiency in a healthy breast-fed infant, with a review of the English language literature of reported cases.