Can You See Me Now? Video Supplementation for Pediatric Teledermatology Cases.

BACKGROUND/OBJECTIVES: Digital video is widely available and is used sporadically in clinical settings to evaluate patients, but whether it helps improve clinical management has not been determined. The aim of this study was to assess whether recorded video in addition to still images can improve residents' diagnostic and management accuracy and confidence with pediatric teledermatology cases. METHODS: Dermatology residents from three programs were assigned alternately to an online survey with 15 pediatric teledermatology cases presented with still images only (still) or still images plus recorded video (mixed). Participants provided free-text diagnoses and management recommendations and rated their confidence and image quality. Responses were scored using a modified script concordance grading key based on reference panelists' responses. RESULTS: Thirty-one residents participated (response rate 57%). Participants in the mixed group scored significantly higher on management accuracy (87.6 ± 12.9 vs 71.7 ± 14.2; p = 0.003). Both groups performed better on more common conditions than less common conditions. The mixed group outperformed the still group on less common conditions with respect to management recommendations. CONCLUSION: This novel study suggests that supplemental recorded video may improve the management accuracy of pediatric teledermatology consultations, particularly for complex cases. Residents may benefit from training in recording and interpreting video.

Ventral midline blanching in the setting of segmental infantile hemangiomas: clinical observations and pathogenetic implications.

Areas of blanched skin in children may be seen as an independent finding or in association with vascular birthmarks. We performed a retrospective chart review to identify and describe infants with areas of ventral midline blanching in the presence of segmental infantile hemangiomas. We identified nine full-term infants with partial or full segmental hemangiomas and areas of midline ventral blanching. Additional ventral wall defects were seen in five patients. Six had cardiac anomalies and six had intracranial anomalies. Five were diagnosed with definite PHACE (posterior fossa, hemangioma, arterial, cardiac, and eye abnormalities) syndrome and three had possible PHACE syndrome. Eight were complicated by ulceration. Treatment varied according to the case. Ventral blanching, even in the absence of overt midline defects, can be seen in infants with segmental hemangiomas at risk for PHACE syndrome. We hypothesize that midline blanching may represent a minor manifestation of a developmental ventral defect.

What should primary care providers know about pediatric skin conditions? A modified Delphi technique for curriculum development.

BACKGROUND: There is limited access to pediatric dermatology in the United States, resulting in inadequate education and patient care. OBJECTIVE: This Delphi study aimed to identify important objectives for a pediatric dermatology curriculum for general practitioners. METHODS: A modified, 2-round Delphi technique was used to develop consensus on objectives developed by expert pediatric dermatologists. A panel of 20 experts (pediatric dermatologists, family practitioners, and general pediatricians) rated objectives using a 5-point Likert-type scale. Items with group medians 4.0 or greater with at least 70% agreement reached consensus. RESULTS: In round 1, the expert panel rated 231 objectives from 16 categories for inclusion in an online curriculum. In round 2, experts were given group feedback and rated 235 objectives. A total of 170 items met consensus. Generally, objectives surrounding common conditions including acne, molluscum, warts, atopic dermatitis, and newborn skin met consensus whereas objectives on rare growths, birthmarks, and inherited conditions failed to meet consensus. LIMITATIONS: The Delphi panel consisted of US-based physicians, most in urban areas with a dedicated pediatric specialist at their institution. CONCLUSIONS: The accepted objectives encompass management of common conditions and referral of potentially dangerous diseases and can be used to develop a pediatric dermatology curriculum for primary care providers.

Treatment of molluscum contagiosum with cantharidin: a practical approach.

Molluscum contagiosum is very common. In this article we discuss the use of cantharidin as a treatment option for molluscum contagiosum and give detailed information about distribution sources, how to apply it, and caveats regarding its use.Molluscum contagiosum is a common viral disease of childhood caused by a poxvirus, which presents with small, firm, dome-shaped, umbilicated papules. It is generally benign and self-limited, with spontaneous resolution within 6 months to several years. Watchful waiting can often be an appropriate management strategy; however, some patients either desire or require treatment. Reasons for actively treating molluscum contagiosum may include alleviation of discomfort and itching (particularly in patients where an eczematous eruption - the so-called "molluscum eczema" - is seen in association) or in patients with ongoing atopic dermatitis where more lesions are likely to be present. Other reasons for treatment include limitation of spread to other areas and people, prevention of scarring and superinfection, and elimination of the social stigma of visible lesions. No one treatment is uniformly effective.Treatment options include destructive therapies (curettage, cryotherapy, cantharidin, and keratolytics, among others), immunomodulators (imiquimod, cimetidine, and Candida antigen), and antivirals (cidofovir). In this article we discuss and describe our first-line treatment approach for those molluscum needing treatment - cantharidin.

Pediatric teledermatology: observations based on 429 consults.

BACKGROUND: Store-and-forward teledermatology is an emerging means of access for patients with skin disease lacking direct access to dermatologists. OBJECTIVES: We sought to examine the patient demographics, diagnostic concordance, and treatment patterns in teledermatology for patients younger than 13 years. METHODS: We conducted a descriptive retrospective cohort study involving 429 patients. RESULTS: Diagnoses were concordant in 48% of cases, partially concordant in 10%, and discordant in 42%. Management recommendations were concordant in 28% of cases, partially concordant in 36%, and discordant in 36%. Primary care providers tended to underuse topical steroids and overuse topical antifungals and systemic antibiotics. Only 1.4% and 6.0% of patients required repeated teledermatology consultation and in-person dermatology consultation, respectively. LIMITATIONS: Limitations were the inability to generalize the data from the population studied and the chances of error and bias in teledermatology diagnoses. CONCLUSIONS: Store-and-forward teledermatology can improve diagnostic and therapeutic care for skin disease in children who lack direct access to dermatologists.

A four-year-old boy with fever, rash, and arthritis.

The triad of fever, rash, and arthritis in a hospitalized child suggests an inflammatory, infectious, or postinfectious process in most cases; however, malignancy must be considered. The most common causes in this age group are inflammatory conditions, including Kawasaki disease, Henoch-Schönlein Purpura, serum sickness-like reaction, and juvenile idiopathic arthritis. Other rarer inflammatory processes can present with this triad of symptoms such as Cryopyrin-related diseases (autoinflammatory disorders), urticarial vasculitis, and systemic lupus erythematosus. We will discuss the differential diagnosis and inpatient management of fever, rash, and arthritis in a young child, focusing on inflammatory conditions. The important features which can help distinguish these conditions include the nature of the rash, associated signs or symptoms, time course of the eruption, and characteristic laboratory and/or histologic findings.

''Ectopic eyelashes'' (ectopic cilia) in a 2-year-old girl: brief report and discussion of possible embryologic origin.

Cilia, or eyelashes, are unique hair follicles normally found at the eyelid margin. The spectrum of cilial anomalies includes cilial row duplication, agenesis, and ectopic placement. Ectopic cilia are the most rare of cilial anomalies. We report a case of a 2-and-a-half-year-old girl with ectopic cilia of the anterior tarsal plate, an extremely rare, congenital anomaly that is most often not associated with other findings and likely results from an event during embryogenesis.

Clinical characteristics and management of vascular anomalies: findings of a multidisciplinary vascular anomalies clinic.

OBJECTIVE: To describe the scope of the University of California, San Francisco (UCSF), Vascular Anomalies Clinic (VAC), including the types of diagnoses, characteristics, and management of patients seen in the clinic. DESIGN: Case series. SETTING: Referral, outpatient, multidisciplinary clinic in a university system. PATIENTS: Consecutive sample of 175 patients seen in the VAC at UCSF from January 2001 to July 2003. MAIN OUTCOME MEASURES: Diagnosis before and after clinic visit, symptoms, treatment recommendations, age of onset, age at clinic visit, location of lesion, sex, and type of referring physician. RESULTS: A total of 96% of patients had cutaneous involvement, 71% of patients had vascular malformations, and 14% had infantile hemangiomas. Fifty-eight percent of patients were referred from outside the UCSF system. Of the patients who had not been previously seen by members of the VAC team or UCSF dermatologists, only 22% had been assigned correct specific diagnoses before coming to the VAC, and 13% had incorrect specific diagnoses before coming to the VAC. Fifty-six percent of vascular malformations were first noted at birth and 17% were noted at later than 10 years of age. Eighty-seven percent of patients were symptomatic from their vascular lesion. Sixty-six percent of patients underwent prior magnetic resonance imaging of their lesion. Further diagnostic workup was recommended in 43% of cases, and treatment recommendations were made in 83% of cases. CONCLUSIONS: Significant confusion still exists regarding the appropriate terminology, diagnosis, and management of vascular anomalies. Multidisciplinary clinics effectively address these complicated and troubling disorders by providing accurate diagnoses, clear treatment recommendations, and counseling from a team of specialists.