Infantile hemangioma. Part 2: Management.

The majority of infantile hemangiomas (IH) can be managed conservatively, but for those requiring active treatment, management has been revolutionized in the last decade by the discovery of propranolol. Patients that may require active intervention should receive specialist review, ideally before 5 weeks of age to mitigate the risk of sequelae. Propranolol can commence for most infants in the outpatient setting and the most frequently employed dosing regimen is 1 mg/kg twice daily. In the future, ß-blockers with a more-selective mechanism of action, such as atenolol, show some promise. In recalcitrant lesions, systemic corticosteroids or sirolimus may be considered. For small, superficial IHs, topical timolol maleate or pulsed dye laser may be considered. Where the IH involutes with cutaneous sequelae, a range of interventions have been reported, including surgery, laser, and embolization. IHs have a well-described clinical trajectory and are readily diagnosed and managed via telemedicine. Algorithms have been constructed to stratify those patients who can be managed remotely from those who warrant in-person review during the COVID-19 pandemic.

Infantile hemangioma. Part 1: Epidemiology, pathogenesis, clinical presentation and assessment.

Infantile hemangioma (IH) is the most common pediatric vascular tumor. Its pathogenesis is poorly understood but thought to represent an aberrant response of pluripotent stem cells to stimuli such as hypoxia and the renin-angiotensin system. IH usually appears during the first few weeks of life and follows a characteristic natural trajectory of proliferation and involution. Their clinical appearance depends on their depth and distribution. Classification comprises superficial, mixed, and deep IH as well as IH with minimal or arrested growth. Multifocal IHs are more likely to be associated with infantile hepatic hemangioma and, although the need for screening based on a specific number of IH has been recently debated, 5 remains the most widely acceptable cutoff point. Large facial IHs warrant investigation for posterior fossa malformations, hemangioma, arterial anomalies, cardiac defects or aortic coarctation and eye anomalies (PHACE) syndrome. Lumbar IHs warrant investigation for lower body IH and other cutaneous defects, urogenital anomalies, ulceration, myelopathy, bony deformity, anorectal malformations, arterial anomalies, and renal anomalies (LUMBAR) syndrome. Complications of IH include ulceration, obstruction or functional impairment, hypothyroidism, and cosmetic sequelae. Differential diagnoses mostly consist of other vascular tumors and vascular malformations, although IH may sometimes mimic nonvascular tumors or developmental anomalies. Diagnosis is usually clinical and biopsy is rarely indicated. High-frequency ultrasonography may help with the differential diagnosis, particularly with subcutaneous lesions. Referral to other specialists may be required in specific cases.

Metastatic neuroblastoma mimicking an infantile hemangioma.

Neuroblastoma is the most common solid tumor malignancy in the first year of life. We present a rare case of a 5-month-old girl with an infraorbital tumor that simulated an infantile hemangioma clinically but was ultimately diagnosed as metastatic neuroblastoma.

Histopathological discrepancy between biopsy and Mohs micrographic surgery in keratinocyte carcinoma: A 464 case series in an Australian population.

BACKGROUND/OBJECTIVES: Therapeutic approaches to keratinocyte carcinoma rely on the accuracy of the biopsy to correctly identify, grade or subtype the tumour. Several studies have investigated the frequency and nature of histopathological discordance between the biopsy and final excision specimen. We analysed information extracted from an Australian Mohs micrographic surgery (MMS) database and compared similar studies. METHODS: An Australian MMS database was retrospectively reviewed for a period of one year. Correlation was made between the preoperative lesion diagnosis based on the formal pathology report and the histopathological results reported at the time of MMS. A systematic PubMed review of similar articles was also performed. RESULTS: A total of 464 cancers (406 BCC and 58 SCC) in 399 patients were included. The overall discrepancy rate in the histopathological classification of keratinocyte carcinoma in our study (42.2%) and the proportion of cases in which the biopsy underestimated the aggressiveness of the tumour (12.9%) were consistent with those found in similar studies. The percentage of biopsies that failed to identify an aggressive BCC subtype (31.6%), and that of biopsy-proven superficial BCC that demonstrated an invasive component in MMS (79.3%), were higher in our study than in comparable studies. The high prevalence of mixed histopathological subtypes, especially amongst BCC with discordant histopathological results, appeared as an important contributing factor. CONCLUSIONS: Despite subtle differences, the results from this Australian study support the results from similar studies and highlight that the biopsy report should be carefully interpreted in combination with the clinical findings.

Role of colour-Doppler high-frequency ultrasonography in capillary malformation-arteriovenous malformation syndrome: a case series.

High-frequency ultrasonography (HFUS) represents a useful adjunct for dermatologists in the diagnosis of capillary malformation-arteriovenous malformation (CM-AVM) syndrome. We present a paediatric case series of 6 patients with confirmed RASA1 gene mutation in whom HFUS demonstrated AVM beneath cutaneous CM-like lesions greater than 1.5 cm.

Cutaneous ultrasound and its utility in Pediatric Dermatology: Part II-Developmental anomalies and vascular lesions.

High-frequency ultrasonography represents a promising tool for pediatric dermatologists. It is a noninvasive and harmless diagnostic technique that is especially appealing when working with children. It can be easily performed at the patient's bedside, avoiding diagnostic delays, sedation, or multiple visits. It represents a useful adjunct to clinical examination and aids our understanding of cutaneous pathology. In this second part, we describe the ultrasonographic findings of developmental anomalies and vascular lesions.

Cutaneous ultrasound and its utility in pediatric dermatology. Part I: Lumps, bumps, and inflammatory conditions.

High-frequency ultrasonography represents a promising tool for pediatric dermatologists. It is a non-invasive diagnostic technique that is particularly appealing when working with children. It can be easily performed at the patient's bedside, avoiding diagnostic delays, sedation, or multiple visits. It represents a useful adjunct to clinical examination and can enhance our understanding of cutaneous diseases. Patient cooperation and limited training and experience are the main challenges for cutaneous ultrasonography in pediatric dermatology. This review describes cutaneous ultrasonography and the nuances of its use in the pediatric setting, followed by the ultrasonographic findings of cutaneous lumps, bumps, and inflammatory dermatoses commonly encountered in pediatric patients.

Movement artifacts in pediatric cutaneous ultrasonography.

BACKGROUND: Cutaneous ultrasonography can be challenging in children. We aim to identify the most complicated cases and the best timing for assessment. METHODS: We retrospectively reviewed sonographic exams in pediatric patients from our cutaneous ultrasonography clinic over a two-year period. Movement artifacts were classified according to their consequences and their frequency was studied in relation to the age of the patient, location of the lesion, and underlying pathology. RESULTS: The overall frequency of exams affected by movement artifacts was 16.76% (91/543) and all belonged to children younger than 4 years of age. The frequency of impaired sonographies was particularly low in patients aged 0 to 4 months (12.77%; 6/47) and particularly high in children aged from 4 to 12 months (56.60%; 60/106). Regarding location, exams were more frequently disadvantaged when assessing the head and neck area (44.53%; 61/137). In relation to pathology, developmental anomalies showed a significantly higher frequency of exams damaged by movement artifacts (41.82%; 23/55). CONCLUSIONS: Cutaneous ultrasonography without sedation can be particularly difficult in children aged between 4 and 12 months, especially when lesions are located on the head and neck and a Doppler exam is required. When assessing congenital lesions, the first four months of life are ideal for a first examination.

Delayed granulomatous reaction and cutaneous fistula induced by retained electrodes from a cardiac pacemaker in a child.

Permanent epicardial pacing wires are sometimes left in place and can lead to long-term complications. We report on a case of a granulomatous reaction with a cutaneous fistula secondary to the retained epicardial pacing wires in a child and highlight the relevance of sonography as an additional tool in the diagnosis and management of dermatologic conditions.

Jellyfish-like sonographic pattern can help recognition of dermatofibrosarcoma protuberans. Report of 3 new cases and review of the literature.

High-frequency ultrasonography (HFUS) can help improve dermatofibrosarcoma protuberans (DFSP) recognition. We present three cases of DFSP in which a "jellyfish-like" sonographic pattern was a useful adjunct in formulating the diagnosis. In addition, we review all DFSP ultrasound images available in the literature.

Sirolimus in blue rubber bleb naevus syndrome: A systematic review.

The aim of this study is to review sirolimus as a treatment for blue rubber bleb naevus syndrome (BRBNS). A literature search of Medline, Embase, CINAHL, SCOPUS and Google Scholar was conducted for publications reporting treatment of patients with BRBNS with sirolimus. Of 46 articles identified, 17 studies reporting 23 patients met inclusion criteria. Sirolimus was well tolerated in all but one patient who required treatment cessation; 17/18 patients noted an improvement in gastrointestinal disease where this was reported; 21/22 patients noted an improvement in cutaneous disease where this was reported. Based on these results, sirolimus may be considered a first-line treatment of BRBNS depending on patient morbidity.

Usefulness of high-frequency ultrasonography in the assessment of cutaneous lesions in children with hematologic malignancies.

High-frequency ultrasonography is a bedside tool increasingly used for the assessment of skin lesions, but there have been few reports about its importance in children with skin signs of hematologic disease. We present three cases to highlight the usefulness of high-frequency ultrasonography in assisting with the diagnosis of these skin lesions.

Cutaneous fibrolipomatous hamartoma: Report of 2 cases with retrocalcaneal location.

Precalcaneal congenital fibrolipomatous hamartoma is an underreported benign entity that has been described in the literature under different names. We present two cases of unilateral fibrolipomatous hamartoma (FLH) appearing in a unique location: on the posterior aspect of the foot overlying the heel. We propose the term "FLH of the skin" as a more inclusive and less confusing term for this condition, thus allowing distinction with FLH arising from neural tissue. High-frequency ultrasonography appears to be a useful diagnostic tool that may avoid unnecessary biopsies for this condition.

Midline anterior neck inclusion cyst: A novel superficial congenital developmental anomaly of the neck.

BACKGROUND/OBJECTIVES: A variety of congenital developmental anomalies arise on the neck because of the many fusion planes and complex embryologic structures in this region. We describe a series of seven patients with a novel type of superficial midline congenital anomaly. METHODS: Retrospective case series. Clinical and histopathologic features were compared and used to describe this entity. RESULTS: Seven patients with nearly identical clinical findings were identified. In all cases, a small superficial cyst resembling a giant milium was observed at birth. There were no significant changes during infancy and no evidence of underlying abnormalities. The histopathologic findings were identical to those of an infundibular follicular cyst. CONCLUSION: We have termed this entity midline anterior neck inclusion cyst. We believe it is a superficial developmental anomaly, probably a forme fruste of a midline fusion developmental defect, which has not to our knowledge, previously been described.

Cutaneous embolism of an atrial myxoma.

Cardiac myxoma often presents with heterogeneous symptoms and signs and represents a challenging diagnosis. The cutaneous manifestations, if present, are often transient and non-specific and the clinician must possess a high degree of suspicion to secure the diagnosis. We present the case of a 36-year-old woman with a 6-month history of intermittent, painful, violaceous, non-blanching macules on the thumb and fingertips of the left hand and right ankle. A cutaneous embolic phenomenon was suspected and an urgent echocardiogram demonstrated an atrial mass, with subsequent histopathology confirming the clinical suspicion of atrial myxoma. Early diagnosis and excision of the tumour avoided serious complications.