Survey of common cutaneous lesions in healthy infants at the well baby clinic.

OBJECTIVE: Survey the prevalence of cutaneous disorders in infants at the well baby clinic. MATERIAL AND METHOD: This prospective study was conducted on 500 infants, aged between 1 month and 1-year-old. RESULTS: Mongolian spot and nevus simplex were the two most common congenital lesions in the present study. Seborrheic dermatitis was the most frequent skin findings arisen in infancy (apart from the neonatal period) and was on the third rank in overall cutaneous lesions. CONCLUSION: Skin infections especially tinea versicolor were easily missed.

Efficacy of pulsed dyed laser (585 nm) in the treatment of molluscum contagiosum subtype 1.

Molluscum contagiosum is a common cutaneous disease that may be difficult to treat when there are multiple lesions; especially in children. This study was conducted to determine the efficacy of pulsed dye laser (585 nm) in the treatment of molluscum contagiosum in 20 children. In the treated group, 70.5% of lesions healed after the first treatment; the remaining 10.6% after the second treatment (2 weeks later). The overall cure rate was significantly different from the control group (p< 0.01). The therapy was also well tolerated. Only mild transient hypopigmentation and erythema were observed. None encountered infectious events. In conclusion, pulsed dye laser is a good alternative treatment for molluscum contagiosum due to high efficacy and mild transient side effects.

Acute hemorrhagic edema of infancy.

The authors report a case of acute hemorrhagic edema of infancy in an 8-month-old boy with a history of recent vaccination prior to the illness. He was well in general, apart from mild fever diarrhea, and the rash compatible with acute hemorrhagic edema of infancy; though, he had unusual trunk and mucosal involvement. The diagnosis was confirmed by the histopathological findings and direct immunofluorescence of the lesion. Complete resolution spontaneously occurred within 3 weeks.

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.

Comparison of dexpanthenol and zinc oxide ointment with ointment base in the treatment of irritant diaper dermatitis from diarrhea: a multicenter study.

BACKGROUND: Severity of irritant diaper dermatitis (IDD) from diarrhea varies from patient to patient depending on the nature of feces and the number of bowel movements. The purpose of the present study was to compare the effectiveness of dexpanthenol and zinc oxide ointment with ointment base in the treatment of irritant diaper dermatitis from acute diarrhea in children by measuring transepidermal water loss (TEWL). MATERIAL AND METHOD: Forty-six children with diarrhea were prospectively, block randomized, investigator-blinded to receive dexpanthenol and zinc oxide ointment on one side and ointment base on the other side. TEWL was measured before and on days 1, 3, and 7 of treatment together with the assessment of severity score. The efficacy of treatment was defined by complete clearance of the lesion. RESULTS: TEWL in the treated and control side was not different before the application of the topical medication. In the present study, the efficacy of 5% dexpanthenol and zinc oxide ointment on D3 was 39% (18from 46 patients) compared to 32% in the ointment base side. On D7, the efficacy of the treated side was 58.7% and the ointment base side was 56%. The patients who still had skin lesions were those who had prolonged diarrhea. On the treated side, the mean of TEWL was lower than the control side on DI (p = 0.18) and had significant improvement on D3 (p = 0. 002). At the end of the present study, TEWL on the treated side was less than TEWL of the control side but it did not have statistical significance (p = 0.07). There was no rash or sign of abnormality on the treated side at the end of D7. CONCLUSION: In the treatment of lDD from acute diarrhea, 5% dexpanthenol and zinc oxide ointment significantly decreased TEWL in the treated side more than the ointment base on day 3 but the severity score was not significantly different on days 1, 3 and 7.

Purpuric-like rash as cutaneous eruptions in parvovirus B19 infection in Thai infant.

An 8-month-old girl presented with fever, rash, and diarrhea. Physical examination revealed multiple well-circumscribed, brownish-black, purpuric-like rashes on the face, arms, and legs with cervical and suboccipital lymphadenopathy. Laboratory findings showed mild anemia with thrombocytopenia and positive polymerase chain reaction for parvovirus 819 DNA in the serum. The patient recovered uneventfully with symptomatic and supportive treatment. Since the infection can manifest in many dermatological patterns, it should also be included in the differential diagnosis of febrile illness with purpuric rash in children.

Diffuse Neonatal Hemangiomatosis: report of 5 cases.

Diffuse Neonatal Hemangiomatosis (DNH) is a rare, life-threatening condition associated with a few to hundreds of small, cutaneous and visceral hemangiomas. The authors reported 5 cases of DNH in which hepatic hemangioma were the most common visceral involvement. Response to prednisolone in these cases was not good, one died and four required second line therapy. Of these four cases, one case with embolisation; one with interferon and two with vinblastine. Response to vinblastine was good, but long-term follow-up of the side effects are needed.

Malassezia furfur in infantile seborrheic dermatitis.

Our objective was to study both incidence and various strains of Malassezia in infantile seborrheic dermatitis (ISD). Sixty infants between 2 weeks and 2 years old with clinical diagnosis of ISD at the Department of Pediatrics, King Chulalongkorn Memorial Hospital from May 2002 to April 2003 were recruited. Malassezia spp. were isolated from cultured skin samples of the patients, genomic DNA was extracted and the ITS1 rDNA region was amplified. The PCR product was examined by agarose gel electrophoresis and DNA sequences were determined. The ITS1 sequences were also subjected to phylogenetic analysis and species identification. ISD is most commonly found in infants below the age of 2 months (64%), followed by those between 2 and 4 months (28%) old. Cultures yielded yeast-like colonies in 15 specimens. PCR yielded 200-bp products (Candida) in 3 patients and 300-bp products (Malassezia furfur) in 12 patients (18%). Sugar fermentation using API 20C aux performed on the three 200-bp PCR products yielded Candida species. M. furfur was the only Malassezia recovered from skin scrapings of children with ISD.

Prevalence of positive antinuclear antibodies in healthy children.

Antinuclear antibodies (ANA) frequently arise in the sera of children with connective tissue disease and is used in the diagnosis of these diseases. Therefore it is also important to know the prevalence of ANA in normal children. The main objective of the present study was to determine the prevalence of antinuclear antibody (ANA) in healthy children. Ninety-nine serum samples from a serum bank and 108 samples from patients who had attended elective surgery and whose blood had been withdrawn for other investigations, were tested for ANA by indirect immunofluorescence method using HEp-2 cells as substrate. Sera from 52 children with SLE were also tested during the same period. It was found that antinuclear antibodies were present in 32 (15%) of the 207 sera of healthy children at a dilution of 1:40 or higher. ANA were positive in 9% at a serum dilution of 1:40, in 3% at 1:80 and in 3% at 1:160. The patterns of immunofluorescence staining were as follows: homogeneous in 46.7%, speckled in 20%, and nucleolar in 10%. In SLE patients, ANA were positive in 91%; 13% at a serum dilution of 1:40, 7% at 1:80, 20% at 1:160, 15% at 1:320, 9% at 1:640, 20% at 1:1,280 and 9% at > or = 1:2,560. It was concluded that the prevalence of positive ANA using the HEp-2 cells as substrate was 15% in healthy children at dilutions of 1:40 or higher. Using the cutoff serum dilution of 1:40, the sensitivity of this test was 91%, the specificity was 85%, the positive predictive value was 57% and the negative predictive value was 97%.

Food induced urticaria in children.

We conducted a prospective study at King Chulalongkorn Memorial Hospital, from June 2001 to November 2003, to identify the contribution of food allergy to urticaria in children. During the study period, 100 children with urticaria were enrolled, 36 of whom had a history suspicious of food allergy. Fifteen of 100 patients had fever (9 from upper respiratory tract infections, 4 from diarrhea and 2 from skin infections). A skin prick test (SPT) was positive in 15 of the 36 children who were suspected of having food allergy; 5 patients out of the positive SPT group had anaphylaxis due to food (2 from cow milk, 2 from wheat and 1 from egg). Six patients in the positive SPT group had a negative food challenge test (4 from open challenges and 2 from double-blind placebo-controlled food challenges [DBPCFC]). The other 4 patients of the positive SPT group refused the food challenge test. The parents of a patient who had urticaria from egg refused the skin prick test; an oral challenge test confirmed the diagnosis of egg allergy. One of the 21 patients that had a negative SPT had shrimp allergy proven by DBPCFC. Of the 64 patients who had no history related to food, SPT was done in 27 patients and revealed a positive result in 7 patients, all of whom had a negative food challenge test (4 with open challenge and 3 with DBPCFC). Urticaria from food was found in 7% and was suspected in another 4% of the patients. Severe reactions to food like anaphylaxis may occur. SPT alone is not adequate in making the diagnosis of food allergy; it must be confirmed by a food challenge test. Thirty percent of patients that did not have a history related to food had false positive SPT. Without a history suspicious of food allergy, SPT yields only minimal benefit.

Primary congenital lymphedema involving all limbs and genitalia.

Primary congenital lymphedema is the rarest form of primary lymphedema. Lymphedema of the extremities presents at birth and rarely involves the genitalia. There has never been a reported case in Thailand. The authors herby report a case of a 6-year-old boy who presented with progressive swelling of the lower legs since birth. The edema progressed into his scrotum and his arms. There was no history of lymphangitis or cellulites. Physical examination revealed a generalized non-pitting edema of all extremities, more on the right leg than the left leg. Swelling of the scrotum and penis was also detected. A diagnosis of primary congenital lymphedema was confirmed with lymphoscintigraphy.

Mucocutaneous findings in febrile neutropenic children with acute leukemias.

Febrile neutropenia is common in children with leukemia. Mucous membrane and skin are most common portals of entry for microorganisms in these patients. The aim of the present study was to find the prevalence of mucocutaneous findings infebrile neutropenic leukemic children. The authors prospectively examined children with fever with neutropenia in acute leukemia, aged 1-15 years, who were admitted to the Department of Pediatrics, King Chulalongkorn Memorial Hospital, between September 2000 and August 2001. During the study period, 46 children had 116 admissions, 51 of which were due to febrile neutropenia. Their cancer diagnoses were ALL (76%) and ANLL (24%). The prevalence of mucocutaneous findings was 86% (61% were from infections, 22% from mucositis and 4% from chemical phlebitis). Other detected sites of infection were lower respiratory tract (36%), urinary tract (32%), upper respiratory tract (11%), septicemia (11%) and unidentified (35%). Thirty-four percent of the patients had more than one site of infection. Gram-negative septicemia was the most common infection (15cases/71%) followed by gram positive (4cases/19%) and candida (2cases/10%). The prevalence of infection was found in severe neutropenia (absolute neutrophil count, ANC less than 500 cell/cu mm), moderate neutropenia (ANC, 500-1000 cell/cu mm) and mild neutropenia (ANC, 1001-1500 cell/cu mm) was 72%, 9% and 5%, respectively. Infection in patients in the severe neutropenia group was significantly more common than in moderate mild neutropenia groups (p < 0.01). Seven patients (15%) died, all of them had severe and prolonged neutropenia, for more than 7 days. Daily physical examination of skin and mucous membrane are suggested for proper and prompt diagnosis and treatment of febrile neutropenic children with acute leukemia to reduce mortality and morbidity in these patients. A Guideline for the use of antimicrobial agents in neutropenic patients with acute leukemia is proposed In conclusion, infection was commonly found in severe neutropenia. Mucocutaneous infection was the most common site of infection infebrile neutropenia in children with leukemia.

Acute renal failure in a child with jellyfish contact dermatitis.

A 7-year-old boy suffered from jellyfish contact dermatitis and acute renal failure following a jellyfish sting. Three days before being admitted, he accidentally contacted a jellyfish on the left forearm, left thigh and trunk while wading at Pattaya beach, Eastern Thailand. Investigation revealed hemoglobinuria. Histologic findings of a renal biopsy indicated that acute tubular necrosis had caused acute renal failure in the present patient. Supportive treatments improved the dermatitis and renal function of this patient.

Human herpesvirus infection in children with fever and maculopapular rash.

Fever with maculopapular rash is a common problem in children. Infection with human herpesviruses is one of the common etiologies in fever with rash. The aim of this study has been to examine patients presenting with fever and maculopapular rash without respiratory symptoms for human herpesviruses infection by using multiplex nested-polymerase chain reaction. A descriptive and prospective study was conducted at King Chulalongkorn Memorial Hospital, Bangkok, Thailand from June 2000 to December 2001. One hundred patients, 43 boys and 57 girls, aged between 2 months and 14 years were recruited. Human herpesvirus 6 (HHV6) was the most common (24%) whereas HHV7, Epstein-Barr virus (EBV) and cytomegalovirus (CMV) were present in 9%, 3% and 2% of the patients, respectively. Four percent of the patients simultaneously harbored HHV6 and HHV7. Only one patient had CMV, HHV6 and HHV7. Patients with HHV7 had a mean age of 4.5 years, whereas those with HHV6 had a mean age of 1.6 years. HHV6 and HHV7 were commonly found as causes of fever and maculopapular rash without respiratory symptoms. Co-infection with different herpesviruses can be found in the same patient.

Varicella infection in a pediatric AIDS patient presenting as umbilicated papules.

An 8-year-old girl with acquired immunodeficiency syndrome presented with fever and alteration of consciousness. She had a history of persistent cryptococcal meningitis. She developed multiple discrete umbilicated papules that resembled cutaneous cryptococcosis on the second day of admission. Skin biopsy revealed an ulcer with a wedge-shaped necrosis of the dermis. The edge of the ulcer showed intracellular edema, margination of nucleoplasm and multinucleated cells, consistent with herpes infection. The diagnosis of varicella-zoster virus infection was confirmed by the identification of herpesvirus DNA from the lesion and differentiation from other herpesviruses by restriction fragment length polymorphism (RFLP) method. Intravenous acyclovir was given at a dose of 500 mg/m2, three times daily for 14 days which resulted in resolution of the skin lesions within 2 weeks.

Detection and differentiation of human herpesviruses 1-5 by consensus primer PCR and RFLP.

Eight human viruses of the Herpesviridae family represent a significant public health problem world-wide. Detection and typing of five of the human herpesviruses (HSV-1, HSV-2, VZV, EBV, and CMV) was performed by applying a consensus primer polymerase chain reaction (PCR). The amplified PCR products from the five human herpesviruses were typed based on their restriction enzyme digestion polymorphism with Hinf I and Alu I. Fifteen clinically suspected specimens from herpesvirus-infected patients were also evaluated. A fragment of the DNA polymerase gene from each of the five human herpesviruses was successfully amplified by the set of consensus primers. Their amplicons obtained by PCR from the template DNAs were subjected to restriction endonuclease digestion and human herpesviruses 1-5 could be clearly differentiated and typed. This method can be used to detect and differentiate between the five human herpesviruses in clinical specimens. This study demonstrates the value of testing for five human herpesviruses by consensus PCR and restricted fragment length polymorphism (RFLP). These procedures are simple and straightforward techniques for the investigation of clinical specimens.

Ulcerated hemangiomas: clinical features and management.

Hemangioma is the most common tumor of infancy and ulceration is the most frequent complication of hemangioma. The purpose of this report was to review the clinical features and management of ulcerated hemangioma. A retrospective study of ulcerated hemangioma at the outpatient pediatric dermatology clinic, King Chulalongkorn Memorial Hospital from 1992 to 2001 was performed. The medical records of 41 patients were reviewed. Twenty-eight females and 13 males were seen with a female/male ratio of 2.2: 1. Superficial hemangioma was the most common type (51%). Head and neck were the most frequently involved sites, affecting 21 cases (51%). Ulcerated hemangiomas were found on extremities, torso, and perineum of 9 patients (22%), 6 patients (15%) and 5 patients (12%), respectively. Ulceration was developed at a mean age of 3.9 months (range, 1-7 months). Conventional treatment with topical and/or systemic antibiotic was successfully used in 19 patients (46%). Oral prednisolone was used in 4 patients with large hemangiomas. The mean duration of treatment with oral prednisolone was 12 months. Flashlamp-pumped pulsed-dye laser (FPDL) was used in 16 patients who failed topical and/or systemic antibiotic. Fifteen patients (94%) healed within 1 to 3 treatments. Excision was done on a small superficial hemangioma on the cheek. In conclusion, head and neck were the most common sites of ulcerated hemangioma. Topical antibiotics and/or systemic antibiotics could be used as the first-line management of ulcerated hemangioma. FPDL was very effective in the treatment of ulcerated hemangioma.

Clinical manifestation and management of hemangiomas of infancy.

A retrospective study of hemangioma seen at the Pediatric Dermatology Clinic, Department of Pediatrics, Faculty of Medicine King Chulalongkorn Memorial Hospital from June 1991 to June 2000 was conducted. A total of 197 patients with 221 hemangiomas were followed-up from 6 months to 9 years. There were 134 girls and 63 boys (2.1:1), ranging in age from 6 months to 9 years. Twenty-two patients (11%) were premature neonates. Hemangiomas were presented at birth in 114 patients (58%), within the first month in 65 patients (33%), and after the age of 1 month in 18 patients (9%). Among the 197 patients, 18 patients (9%) had multiple locations. Types of hemangiomas were recorded as superficial, deep and combined in 84 (43%), 31 (16%) and 82 (41%), respectively. Head and neck were the most common sites of hemangiomas (65%), with 36 lesions (18%) on the trunk, 22 lesions (11%) on upper extremities, 22 lesions (11%) on lower extremities and 15 lesions (8%) on the perineum and buttock. Complications were found in 63 patients (32%) with 93 complications. Perineum and buttock had the highest rate of complication (60%), followed by the eyelid region (41%). Superficial hemangioma had the highest rate of complication (64%), followed by combined type (46%). Ulceration was the most common complication in the superficial and combined type. Obstruction was the most common complication in deep hemangioma. Management of hemangioma included observation, prednisolone, flashlamp-pumped pulsed-dye laser, topical therapy and excision in 68 per cent, 8.6 per cent, 10.7 per cent, 9.6 per cent, and 2.5 per cent, respectively. In conclusion, complications of hemangiomas are common. Close observation with regular follow-up will give better recognition and treatment of complications and associations.

Resident recruitment: what are good predictors for performance during pediatric residency training?

The authors evaluated the value of the Cumulative Grade Point Average (GPAX), letters of recommendation and personal interview in predicting performance of first year residents at the Department of Pediatrics, Faculty of Medicine, Chulalongkorn University. The pre-residency data of 25 first year pediatric residents were compared to the results of the Pediatric In-training Examination (PIE) and clinical evaluation by faculty during the first 7 months of training. The Clinical Performance Rating Score (CPRS) developed by the Royal College of Pediatricians of Thailand was used for clinical performance evaluation. GPAX correlated strongly with PIE score (r = 0.69, p < 0.001) while letters or recommendation and interview score were not predictive. For the majority of residents who graduated from Chulalongkorn University, including the undergraduate program into the regression model improved this association (r = 0.90, p < 0.001). Interview score correlated moderately (r = 0.49, p = 0.02) with clinical performance measured by CPRS which entailed the evaluator to assess a resident in 6 specific areas. GPAX and letters of recommendation showed a trend toward positive correlation with clinical performance, but these associations were weak (r = 0.32-0.39). Further analysis of letters of recommendation found a significant difference between the score given by evaluators in community hospital settings compared to the score given by medical school faculty or evaluators in large regional or provincial hospitals. The authors conclude that the cognitive function of pediatric resident candidates can be assessed reliably by GPAX. Research on how to adjust for the variability of GPAX given by an individual undergraduate program will improve the residency selection process. A structured interview may correlate better with global clinical performance than GPAX or letters of recommendation but all methods are at best moderately predictive of clinical performance. Improvement can be made by continuous evaluation and adjustment of the selection process.

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.