Tollefson, Megha M.

AbstractBackground/ObjectivesThe COVID‐19 pandemic has raised questions about the approach to management of systemic immunosuppressive therapies for dermatologic indications in children. Change to: Given the absence of data to address concerns related to SARS‐CoV‐2 infection and systemic immunosuppressive therapies in an evidence‐based manner, a Pediatric Dermatology COVID‐19 Response Task Force (PDCRTF) was assembled to offer time‐sensitive guidance for clinicians.MethodsA survey was distributed to an expert panel of 37 pediatric dermatologists on the PDCRTF to assess expert opinion and current practice related to three primary domains of systemic therapy: initiation, continuation, and laboratory monitoring.ResultsNearly all respondents (97%) reported that the COVID‐19 pandemic had impacted their decision to initiate immunosuppressive medications. The majority of pediatric dermatologists (87%) reported that they were pausing or reducing the frequency of laboratory monitoring for certain immunosuppressive medications. In asymptomatic patients, continuing therapy was the most popular choice across all medications queried. The majority agreed that patients on immunosuppressive medications who have a household exposure to COVID‐19 or test positive for new infection should temporarily discontinue systemic and biologic medications, with the exception of systemic steroids, which may require tapering.ConclusionsThe ultimate decision regarding initiation, continuation, and laboratory monitoring of immunosuppressive therapy during the pandemic requires careful deliberation, consideration of the little evidence available, and discussion with families. Consideration of an individual's adherence to COVID‐19 preventive measures, risk of exposure, and the potential severity if infected must be weighed against the dermatological disease, medication, and risks to the patient of tapering or discontinuing therapies.

AbstractBackgroundTinea capitis is a common pediatric dermatophyte infection. Its main pathogen in the United States is Trichophyton tonsurans accounting for greater than 95% of the infections. Other pathogens including Trichophyton violaceum and Trichophyton soudanense are common in Africa. Although rare in the United States, their prevalence is increasing, possibly because of immigration patterns. We evaluated the demographic characteristics, treatments, and resolution among pediatric patients with T. violaceum and T. soudanense infections.MethodsRetrospective chart review of patients from Mayo Clinic in Rochester, Minnesota, United States, with cultures positive for T. violaceum and T. soudanense from 1997 to 2014. Age at presentation, ethnic background, date and location of culture, and treatment were extracted.ResultsIn total, 81 children (age <18 years) were identified as positive for T. violaceum and T. soudanense (mean [range] age, 6.0 [1–17] years). Race/ethnicity of 67 patients (82.7%) was African; four, African‐American; three, white; two, Asian; and five, unknown. After culture identification, 64 patients (79.0%) received griseofulvin; five, terbinafine; and three, itraconazole; nine patients had no documented oral antifungal therapy. Of 28 patients not lost to follow‐up, median time to clinical cure was 2.3 months (interquartile range, 2.8 months).ConclusionT. violaceum and T. soudanense are tinea capitis pathogens, most common among patients of African descent. The pathogens may be underrecognized because such tinea capitis causes are rare in the United States. Most patients had direct contact with persons who had similar symptoms, suggesting contagious nature. Griseofulvin and terbinafine appear to be acceptable treatments against these organisms.

AbstractObese children are at higher risk of developing psoriasis, and obesity severity is correlated with psoriasis severity. The relationship between obesity and pediatric psoriasis was explored in a well‐defined population. Obesity and psoriasis coexist at diagnosis, but it is likely that obesity commonly precedes psoriasis in children.

AbstractAcquired progressive lymphangioma (benign lymphangioendothelioma) is a rare lymphatic anomaly of unclear pathogenesis. Excision is generally advised for local disease, although other therapies have been tried. This report describes a unique case of extensive acquired progressive lymphangioma involving the abdomen, genitalia, and lower extremity of a 1‐year‐old boy. Rapid progression and multisite involvement required exploration of nonsurgical options for management.

AbstractAtopic dermatitis is the most common chronic skin disease, and it primarily affects children. Although atopic dermatitis (AD) has the highest effect on burden of skin disease, no high‐level studies have defined optimal therapy for severe disease. Corticosteroids have been used to treat AD since the 1950s and remain the only systemic medication with Food and Drug Administration approval for this indication in children, despite published guidelines of care that recommend against this option. Several clinical trials with level 1 evidence have supported the use of topical treatments for mild to moderate atopic dermatitis in adults and children, but these trials have had little consistency in protocol design. Consensus recommendations will help standardize clinical development and trial design for children. The Food and Drug Administration issues guidance documents for industry as a source for “the Agency's current thinking on a particular subject.” Although they are nonbinding, industry considers these documents to be the standard for clinical development and trial design. Our consensus group is the first to specifically address clinical trial design in this population. We developed a draft guidance document for industry, Developing Drugs for Treatment of Atopic Dermatitis in Children (≥3 months to <18 years of age). This draft guidance has been submitted to the Food and Drug Administration based on a provision in the Federal Register (Good Guidance Practices).

Abstract: Vascular tumors in infants present a diagnostic and treatment dilemma for both clinicians and pathologists. Infantile hemangioma, the most common vascular tumor in infants, can be confused for other less common vascular tumors in infants. Correct and timely diagnosis is important, as some vascular tumors can be associated with life-threatening coagulopathy. We present the cases of 5 vascular tumors that have clinical and histologic overlap: infantile hemangioma, pyogenic granuloma, noninvoluting congenital hemangioma, tufted angioma, and kaposiform hemangioendothelioma. Typical clinical and histopathologic features of each lesion are summarized. We review the utility and characteristic immunohistochemistry including CD31, CD34, GLUT-1, D2-40, LYVE-1, Prox-1, and WT-1. Collaboration between the clinician and the dermatopathologist correlating the clinical history and histopathologic features can lead to the correct diagnosis, whereas the utility of immunohistochemistry remains in question.

AbstractBackgroundErythema multiforme (EM) is an acute condition characterized by distinctive target lesions of the skin often accompanied by mucosal ulcers. A subset of individuals experience frequent episodes of recurrent EM, which is rare and poorly understood, especially in children.ObjectiveTo characterize clinical features, laboratory findings, and treatment responses of pediatric recurrent EM.MethodsA retrospective chart review was conducted at the Children's Hospital of Wisconsin in Milwaukee, Wisconsin (2000‐2015) and the Mayo Clinic in Rochester, Minnesota (1990‐2015). Inclusion criterion was a diagnosis before age 18 years with recurrent EM, defined as a symmetrically distributed, fixed eruption, including target lesions, with or without mucous membrane involvement, occurring on at least three occasions. A literature review was conducted to include individuals who met the inclusion criterion.ResultsTwenty‐six patients were included, of whom 16 (62%) were male. The median age of onset was 9.1 years (range 0‐15.7 years). Nine patients (35%) required hospitalization. Herpes simplex virus testing was positive in 9 of 17 (65%) patients. Remission was achieved in 5 of 16 (31%) patients while taking suppressive antivirals. Eight patients received continuous anti‐inflammatory treatment, two (25%) of whom experienced remission.ConclusionThis study of pediatric recurrent EM found a greater male predominance, more hospitalizations, fewer cases caused by herpes simplex virus, and a lower response to immunosuppression in children than in the general population.

AbstractBackground/ObjectivesStudies describing treatment efficacy in pediatric morphea are lacking. Subspecialists have reached no consensus on how to optimally treat pediatric morphea. The objective of the current study was to describe the most common treatment practices of pediatric dermatologists worldwide who care for children with morphea.MethodsA survey regarding topical treatment practices of pediatric morphea, with representative case‐based scenarios, was distributed to pediatric dermatologists and results were tallied.ResultsThe survey response rate was 13.4%, with 110 respondents in the final analysis. The majority of respondents agreed on red violaceous rim (99%), increased local warmth (75%), raised borders (69%), and dermal thickening (64%) as signs of disease activity. Respondents had less agreement on sclerotic lesions (41%), scaling (43%), dyspigmentation (19%), and atrophy (13%) as signs of disease activity. Ninety‐two percent of respondents used primary therapy or monotherapy with topical medications, including 45% in linear morphea of the limbs and 37% in linear morphea of the head or neck. High‐potency topical corticosteroids were most commonly used (80%), although respondents did not agree on specific regimens. Sixteen different treatment regimens were selected as first‐line therapy for one case scenario of active disease.ConclusionThe survey found large variation in how pediatric dermatologists treat pediatric morphea. Consensus treatment guidelines developed by pediatric dermatologists and pediatric rheumatologists are urgently needed regarding the efficacy of therapies for pediatric morphea. Prospective studies of treatment efficacy in pediatric morphea are urgently needed as well.

AbstractBackgroundIn recent years propranolol has become the treatment of choice for infantile hemangiomas (IHs). There is broad variation in the approach to propranolol initiation in clinical practice. This retrospective study explored the effectiveness of routine pre‐treatment ECG in screening infants being considered for systemic treatment with propranolol.MethodsAll patients seen in the outpatient pediatric dermatology clinics at Oregon Health and Sciences University (OHSU) and The Mayo Clinic Rochester (MCR), as well as those seen in multidisciplinary vascular anomalies clinics, who had ECGs obtained prior to planned initiation of propranolol for treatment of IH from 2008 to 2013, were identified. A total of 162 patients were included in the study.ResultsWe found that 43% (69) of routine ECGs were read as abnormal, leading to 28 formal consultation appointments with pediatric cardiologists. After either formal consultation or informal discussion with cardiology, no patients with initially “abnormal” ECGs were ultimately excluded from treatment with propranolol based on routine ECG findings. Additionally no patients in our cohort experienced an adverse effect during treatment that could have been predicted or prevented by ECG prior to initiation of the propranolol.ConclusionOur findings suggest that routine ECG may not be necessary or helpful in the vast majority of patients treated with propranolol for IHs.