Updates on postinfectious skin rashes in pediatric dermatology.

PURPOSE OF REVIEW: This review provides updates on postinfectious skin rashes in the pediatric population from recently published literature. RECENT FINDINGS: The COVID-19 pandemic and its sequelae remain a focus of research on pediatric infectious skin rashes. Multisystem inflammatory syndrome in children (MIS-C) and reactive infectious mucocutaneous eruption (RIME) are common complications of infection with SARS-COV-2 in the pediatric population. Most cases of MIS-C show low mortality and suggest mucocutaneous symptoms do not correlate with COVID-19 disease severity. Cases of papular acrodermatitis of childhood, also known as Gianotti-Crosti, have also been reported in association with SARS-COV-2, and can present similarly in reaction to other viral infection like molluscum contagiosum, known as a Gianotti-Crosti syndrome-like reaction (GCLR). Other relevant studies on postinfectious skin rashes include updates on the management of staphylococcal scalded skin syndrome (SSSS), with newer evidence advocating for beta-lactam monotherapy without clindamycin and reduced ancillary testing. Finally, the emergence of antifungal resistance due to Trichophyton indotinae is a growing global health concern emphasizing the need for improved antifungal stewardship. SUMMARY: It is prudent for clinicians to be informed of both common and rare diagnoses that have emerged more recently in association with the COVID-19 pandemic, in addition to other diseases with newer evidence-based recommendations to guide management.

Localized calcium oxalate crystals in primary cutaneous aspergillosis.

Select Aspergillus species can produce oxalate as a fermentation byproduct, which may react with calcium ions to produce insoluble calcium oxalate crystals in tissues. These crystals are frequently associated with pulmonary Aspergillus infections, yet are rarely described in primary cutaneous aspergillosis. Herein, we report the presence of calcium oxalate crystals detected on cutaneous specimens from primary cutaneous Aspergillus niger and Aspergillus fumigatus infections in an immunocompromised, premature infant. No metabolic sources of oxalosis were found.

SCALP syndrome with a germline heterozygous DOCK6 mutation and somatic mosaic NRAS Q61R mutation.

We present a case of SCALP syndrome, which was diagnosed in a male infant with the characteristic findings of sebaceous nevi, central nervous system malformations, aplasia cutis congenita, limbal dermoid, and giant congenital melanocytic nevi, or pigmented nevi. We identified a germline compound heterozygous DOCK6 mutation and a somatic mosaic NRAS Q61R mutation in the giant congenital melanocytic nevus. This report will increase clinician awareness of SCALP syndrome and augment the literature in characterizing this rare syndrome, including its genetic background.

Treatment of pediatric alopecia areata: A systematic review.

BACKGROUND: Alopecia areata (AA) is an autoimmune, nonscarring hair loss disorder with slightly greater prevalence in children than adults. Various treatment modalities exist; however, their evidence in pediatric AA patients is lacking. OBJECTIVE: To evaluate the evidence of current treatment modalities for pediatric AA. METHODS: We conducted a systematic review on the PubMed database in October 2019 for all published articles involving patients <18 years old. Articles discussing AA treatment in pediatric patients were included, as were articles discussing both pediatric and adult patients, if data on individual pediatric patients were available. RESULTS: Inclusion criteria were met by 122 total reports discussing 1032 patients. Reports consisted of 2 randomized controlled trials, 4 prospective comparative cohorts, 83 case series, 2 case-control studies, and 31 case reports. Included articles assessed the use of aloe, apremilast, anthralin, anti-interferon gamma antibodies, botulinum toxin, corticosteroids, contact immunotherapies, cryotherapy, hydroxychloroquine, hypnotherapy, imiquimod, Janus kinase inhibitors, laser and light therapy, methotrexate, minoxidil, phototherapy, psychotherapy, prostaglandin analogs, sulfasalazine, topical calcineurin inhibitors, topical nitrogen mustard, and ustekinumab. LIMITATIONS: English-only articles with full texts were used. Manuscripts with adult and pediatric data were only incorporated if individual-level data for pediatric patients were provided. No meta-analysis was performed. CONCLUSION: Topical corticosteroids are the preferred first-line treatment for pediatric AA, as they hold the highest level of evidence, followed by contact immunotherapy. More clinical trials and comparative studies are needed to further guide management of pediatric AA and to promote the potential use of pre-existing, low-cost, and novel therapies, including Janus kinase inhibitors.

The Use of Prompts and Precision Teaching to Address Speech Sound Disorders in a 17-Year-Old Girl With Autism.

Precision teaching is a measurement system that uses frequency as its basic data and plots those data on a standard celeration chart for practitioners to make decisions (Maloney, 1998). Kay, a 17-year-old girl with autism spectrum disorder and profound speech sound disorder, participated in this multiple-baseline across-behaviors study. The syllables "thu," "fu," and "cu" were targeted for higher frequencies of correct echoic responding in isolation. Lip-tongue-teeth position prompts, frequency building (Fabrizio & Moors, 2003, European Journal of Behavior Analysis, 4(1-2), 23-36), and feedback were used in brief timed practice trials for the first 2 skills. Priming (Cihon et al., 2017) was also added to the third syllable. The frequency of correct responses accelerated from low levels in baseline to a frequency aim of 60 per minute or higher, with intervention for all 3 targets. The accuracy of her articulation with 30 functional words with the component consonant sounds was measured and showed significant improvements from baseline to postintervention. The outcomes representing fluent performance were also achieved. The implications of training for fluency of syllables on word speech are discussed.

Transitioning ABA Services From in Clinic to Telehealth: Case Study of an Indian Organization's Response to COVID-19 Lockdown.

Due to the coronavirus (COVID-19) pandemic, around the middle of March 2020, in-clinic intervention services based in applied behavior analysis provided to children had to be stopped abruptly in India. This qualitative and quantitative case study details how Behavior Momentum India (BMI), an organisation providing ABA-based interventions, transitioned services from in clinic to telehealth while continuing to target each student's skill acquisition goals in language and communication domains. A cohort of 92 students diagnosed with autism or other learning disabilities participated in this study; 51 therapists, 9 behavior supervisors, and a doctoral-level Board Certified Behavior Analyst collaborated with parents; 78% of the students and 82% of the therapists used smartphones; and only a few used iPads and laptops. Therapists conducted direct sessions and parent-mediated sessions with 82 students. With 10 students, behavior supervisors trained parents to implement interventions with their children. The critical transition decisions, logistics, and ethical challenges were identified using qualitative methods. Despite significantly reduced session durations, all students continued to acquire targeted skills, and 52% of the students acquired more skills in telehealth compared to in clinic. A parent satisfaction survey returned high ratings onour organization's initiative, and 72% of the parents reported that their familiarity and confidence with the science of applied behavior analysis had increased.

Anogenital warts and relationship to child sexual abuse: Systematic review and meta-analysis.

BACKGROUND/OBJECTIVES: In children, distinguishing anogenital warts (AGW) acquired innocently from those acquired by child sexual abuse (CSA) is challenging. High-quality studies examining this relationship are sparse. Here, we sought to evaluate the association between AGW and sexual abuse in children 12 years of age and younger with respect to wart location, age, and gender. METHODS: A systematic review of Ovid MEDLINE, Embase, and Web of Science was performed for studies published on or before 2/16/2018. Studies were eligible for inclusion if they contained at least 10 patients 12 years old and younger and reported the number of patients who were sexually abused. The principal summary measures were the odds ratios (OR) of reported CSA with respect to subject age, wart location, and gender. RESULTS: Three hundred twenty-seven studies were identified through record search. Twenty five were included in a summary synthesis (791 subjects); 10 were included in the final statistical analysis (199 subjects). In our overall review, 102 of 468 (21%) females and 36 of 204 (18%) males with AGW were abused or probably abused. Overlapping HPV types were found in abused and non-abused subjects. Perianal location and gender were not significant predictors of abuse. Both age and genital wart location (penis, vulva) did significantly predict CSA (α = .05). The odds ratio for sexual abuse of children aged 3-4 years was 7.45; 6.52 for ages 5-8 years; and 6.93 for ages 9-12 years compared to those 0-2 years of age. Genital location was associated with an OR of CSA of 5.93. CONCLUSIONS: Our systematic review supports a significant association between AGW in a child greater than 2 years of age and odds of CSA. Genital wart location significantly predicts CSA as well. HPV typing is not a reliable method to ascertain CSA. Male family members and acquaintances were the most likely perpetrators of abuse.

Behavioral Interventions to Treat Speech Sound Disorders in Children With Autism.

Children with autism are at a higher risk of being affected by speech disorders and often require remedial intervention. Eikeseth and Nesset (Journal of Applied Behavior Analysis, 36(3), 325-337, 2003) used sufficient-response exemplar training of vocal imitation in conjunction with prompting, chaining, and shaping procedures to successfully teach 2 typically developing children to articulate several Norwegian words with blends. The present study extends and adapts these procedures to children with autism. Participants were TA, an 11-year-old boy, and KS, a 15-year-old girl, both with autism and speech sound disorders. For each participant, 3 sets of 10 words with specific blends in the initial position were targeted for training. Vocal imitation training with within-stimulus prompts was used for both participants. For KS, lip-tongue-teeth position prompts and chaining were added during the training of certain words. A multiple-baseline across-behaviors (word sets with target blends) design demonstrated improvement in the articulation of trained words and generalization of correct articulation to untrained words with both participants. The findings suggest that speech sound disorders in children with autism can be addressed with behavioral interventions.

Cushing Syndrome Induced by Topical Corticosteroids for the Treatment of Lichen Sclerosus.

BACKGROUND: Lichen sclerosus is a chronic inflammatory dermatological condition with a predilection for the anogenital area. CASE: We describe a case of iatrogenic Cushing syndrome from the administration of high-potency topical steroids for vulvar lichen sclerosus in a 6-year-old girl. Her symptoms resolved after the cessation of topical steroid treatment. SUMMARY AND CONCLUSION: This case brings attention to iatrogenic Cushing syndrome as a potential complication when using high-potency topical corticosteroids in the anogenital region.

International inter-rater agreement in scoring acne severity utilizing cloud-based image sharing of mobile phone photographs.

BACKGROUND: Cloud-based image sharing technology allows facilitated sharing of images. Cloud-based image sharing technology has not been well-studied for acne assessments or treatment preferences, among international evaluators. We evaluated inter-rater variability of acne grading and treatment recommendations among an international group of dermatologists that assessed photographs. METHODS: This is a prospective, single visit photographic study to assess inter-rater agreement of acne photographs shared through an integrated mobile device, cloud-based, and HIPAA-compliant platform. Inter-rater agreements for global acne assessment and acne lesion counts were evaluated by the Kendall's coefficient of concordance while correlations between treatment recommendations and acne severity were calculated by Spearman's rank correlation coefficient. RESULTS: There was good agreement for the evaluation of inflammatory lesions (KCC = 0.62, P < 0.0001), noninflammatory lesions (KCC = 0.62, P < 0.0001), and the global acne grading system score (KCC = 0.69, P < 0.0001). Topical retinoid, oral antibiotic, and isotretinoin treatment preferences correlated with photographic based acne severity. CONCLUSIONS: Our study supports the use of mobile phone based photography and cloud-based image sharing for acne assessment. Cloud-based sharing may facilitate acne care and research among international collaborators.

Nevoid Basal Cell Carcinoma Syndrome and Hairy Skin Patches.

We report a case of an increasing number of discrete patches of darkly pigmented terminal hair in a patient with nevoid basal cell carcinoma syndrome. This case adds to a small case series of three patients which have previously reported this observation. We report this case to highlight hairy patches as an important clinical feature associated with nevoid basal cell carcinoma syndrome.

Dietary supplementation with Bifidobacterium longum subsp. infantis (B. infantis) in healthy breastfed infants: study protocol for a randomised controlled trial.

BACKGROUND: The development of probiotics as therapies to cure or prevent disease lags far behind that of other investigational medications. Rigorously designed phase I clinical trials are nearly non-existent in the field of probiotic research, which is a contributing factor to this disparity. As a consequence, how to appropriately dose probiotics to study their efficacy is unknown. Herein we propose a novel phase I ascending dose trial of Bifidobacterium longum subsp. infantis (B. infantis) to identify the dose required to produce predominant gut colonisation in healthy breastfed infants at 6 weeks of age. METHODS/DESIGN: This is a parallel-group, placebo-controlled, randomised, double-blind ascending dose phase I clinical trial of dietary supplementation with B. infantis in healthy breastfed infants. The objective is to determine the pharmacologically effective dose (ED) of B. infantis required to produce predominant (>50 %) gut colonisation in breastfed infants at 6 weeks of age. Successively enrolled infant groups will be randomised to receive two doses of either B. infantis or placebo on days 7 and 14 of life. Stool samples will be used to characterise the gut microbiota at increasing doses of B. infantis. DISCUSSION: Probiotic supplementation has shown promising results for the treatment of a variety of ailments, but evidence-based dosing regimes are currently lacking. The ultimate goal of this trial is to establish a recommended starting dose of B. infantis for further efficacy-testing phase II trials designed to evaluate B. infantis for the prevention of atopic dermatitis and food allergies in at-risk children. TRIAL REGISTRATION: Clinicaltrials.gov # NCT02286999 , date of trial registration 23 October 2014.

A Report of Two Patients with Darier Disease and Hidradenitis Suppurativa.

We report two unique cases of patients with Darier disease and hidradenitis suppurativa. Although it is unknown whether there is a connection between the two diseases, it is possible that an interaction between sarcoendoplasmic reticulum calcium transport ATPase and Notch homolog 1, translocation-associated (Drosophila) caused both diseases in these individuals.

Atopic dermatitis: Kids are not just little people.

The approach to children and adults with atopic dermatitis is similar. In both age groups, failure to respond to conventional therapy should prompt evaluation for complicating factors such as secondary infection and secondary ACD. Immunologic, metabolic, genetic, and nutritional disorders should be considered in the differential diagnosis of refractory pediatric atopic dermatitis. Cutaneous T cell lymphoma (CTCL), cutaneous drug reactions, other spongiotic dermatoses, psoriasis, dermatomycosis, and infestations should be considered in the differential of refractory atopic dermatitis in adults. Systemic therapies prescribed to both children and adults with severe atopic dermatitis include oral corticosteroids, cyclosporine, methotrexate, azathioprine, and mycophenolate mofetil.