Present and future: Infectious tropical travel rashes and the impact of climate change.

In this article, we discuss pertinent cutaneous findings with which patients may present after travel to tropical destinations. We address arthropod-borne infectious diseases such as cutaneous leishmaniasis, Chagas disease, cutaneous larva migrans, and myiasis. We discuss other relevant diseases with cutaneous signs such as monkey pox and severe acute respiratory syndrome coronavirus 2. We provide clinicians with information regarding the background, diagnosis, treatment, and prevention of these tropical rashes. In addition, we address the impact that climate change will have on the temporal and geographic incidence of these rashes. Viral, fungal, and vector-borne diseases have seen a geographic expansion into more northern latitudes. Among these are tick-borne Lyme disease, aquatic snail-related seabather's eruption, and atopic dermatitis. As these diseases spread, we believe that the updated information within this article is significant to the practicing physician in today's warming world.

New science and treatment paradigms for atopic dermatitis.

PURPOSE OF THE REVIEW: The prevalence of atopic dermatitis is increasing in industrialized countries for unclear reasons. One theory centers on reduced exposure to microbes during infancy and childhood. Alterations in the epidermal permeability barrier, place certain patients at risk for the immunological dysfunction seen in atopic dermatitis. This review examines current research pertaining to the epidermal permeability barrier, the cutaneous microbiome, and the immunology of atopic dermatitis. New collaborative research has led to evidence-based management guidelines. RECENT FINDINGS: Increased skin barrier permeability and dysfunction of innate and adaptive immunity cause atopic dermatitis. Genetic and environmental factors leading to decreased filaggrin underlie many cases of atopic dermatitis. Defective epidermal barrier function allows for an increased density of Staphylococcus aureus and a subsequent shift in adaptive immunity to a type 2 immune response. Multiple evaluation and management guidelines have been published based on current available evidence. These guidelines highlight state of the art management of seven main areas: inflammation, infection, irritation, itch, ichthyosis (dry skin), immunological influences, and impeding (comorbid) conditions. SUMMARY: Pediatricians are central to the successful diagnosis and management of atopic dermatitis. Increased basic and clinical research and well published clinical guidelines will lead to improved outcomes for the patients and families affected by this chronic relapsing disorder.

Cutaneous manifestations of systemic viral diseases in neonates: an update.

PURPOSE OF REVIEW: Dermatologic findings may be the first signs of a neonatal viral infection. This review provides an update of the diagnostic features and therapies for selected viral illnesses [herpes simplex virus (HSV), varicella zoster virus, enterovirus, and Zika virus] that present with cutaneous manifestations in the neonate. RECENT FINDINGS: HSV DNA polymerase chain reaction of plasma and cerebrospinal fluid, routinely used in the diagnosis of neonatal HSV, may have expanded utility in assessing prognosis and acyclovir therapeutic efficacy. Maternal antiviral suppressive therapy may alter the clinical appearance of congenital HSV, resulting in delayed diagnosis and treatment. VariZIG, a varicella zoster immune globulin, is a US Food and Drug Administration approved form of prophylaxis for varicella. The Centers for Disease Control and Prevention has expanded the period of VariZIG eligibility for preterm infants, a group particularly susceptible to severe varicella infection. For severe neonatal enterovirus sepsis, the results of a randomized, double-blind, placebo-controlled trial of pleconaril, a viral capsid inhibitor, suggest that this compound is an effective therapy. Human Parechovirus type 3, a strain within a newly formed viral genus, has a similar, and potentially underestimated, clinical presentation to enterovirus sepsis. However, a distinctive erythematous palmoplantar rash may be specific to human Parechovirus type 3 infection. Perinatal Zika virus infection in the neonate may present with a nonspecific macular and papular rash. As this rash is not specific, obtaining a maternal travel history and, if appropriate, requesting additional diagnostic testing are critical for early diagnosis. SUMMARY: Neonatal rashes may be harmless and transient, whereas others may reflect the presence of a severe systemic illness. Recognizing key cutaneous features of viral-associated rashes may aid in the prompt and accurate diagnosis and treatment of neonatal viral illnesses.

Childhood skin and soft tissue infections: new discoveries and guidelines regarding the management of bacterial soft tissue infections, molluscum contagiosum, and warts.

PURPOSE OF REVIEW: Pediatric skin and soft tissue infections (SSTIs) constitute a significant number of office-based pediatric visits. With SSTIs on the rise, it is not only important to effectively treat the individual, but to do so appropriately and cost-consciously. In this article, we highlight new research related to the treatment of bacterial skin infections, molluscum contagiosum, and cutaneous warts, with the goal of guiding pediatricians in their practice against these common skin conditions. RECENT FINDINGS: Recent data supports the use of topical antibiotics for noncomplicated impetigo. Systemic antibiotics covering gram-positive cocci are recommended for complicated cases of impetigo and deeper nonpurulent SSTIs. Localized purulent bacterial SSTIs can be treated with incision and drainage alone but more systemic involvement warrants treatment with systemic antibiotics covering Staphylococcus aureus species, especially community acquired methicillin-resistant S. aureus. For the treatment of molluscum contagiosum, topical cantharidin has a high satisfaction rate among patients and providers. Potassium hydroxide solution is a potentially effective and cheap form of molluscum contagiosum treatment. Imiquimod, however, has an unfavorable efficacy and safety profile as a therapy for molluscum contagiosum. Regarding warts, high-risk human papilloma virus strains have been detected in cutaneous warts in children. SUMMARY: The high-risk human papilloma virus vaccine may play a role in treating pediatric cutaneous warts in the future, and topical squaric acid dibutylester may effectively treat recalcitrant warts. Finally, both molluscum contagiosum and warts have a high rate of resolution after an extended period of time without any intervention.

Dermal melanocytosis and associated disorders.

PURPOSE OF REVIEW: Dermal melanocytosis is commonly seen in the newborn period and is frequently a concern to parents and providers. Four clinically distinct entities are recognized: nevus of Ota, nevus of Ito, Mongolian spots, and dermal melanocyte hamartoma. This article reviews these disorders, with special emphasis on melanocyte biology and important associated systemic disorders such as rare malignant transformations and inborn errors of metabolism. RECENT FINDINGS: Recent findings have highlighted the increased risk of malignancy in patients with nevus of Ota, especially ocular, central nervous system, and cutaneous tumors. Although rarely seen, cutaneous melanoma occurs in association with nevus of Ito. Extensive, dark, and progressive Mongolian spots may be more likely than isolated lesions to be associated with inborn errors of metabolism, such as Hurler's disease and monosialotetrahexosylganglioside (GM1) gangliosidosis. New laser technology utilizing Q-switched alexandrite lasers has shown promise for the cosmetic improvement of dermal melanocytosis. SUMMARY: While most dermal melanocytosis resolves by the toddler years and does not pose long-term risks to the affected individuals, some patients may have underlying associated conditions that pose significant health concerns. Pediatric care providers must be familiar with these associated conditions and refer to a dermatologist when in doubt, to confirm the diagnosis and determine appropriate follow-up care.

What's new with common, uncommon and rare rashes in childhood.

PURPOSE OF REVIEW: Children with rashes account for many of the outpatient visits to a general pediatrician. As such, pediatricians are often the first to identify and treat these rashes. Establishing an approach to common, uncommon and rare pediatric rashes assists in accurate assessment. This review highlights newly identified clinical patterns and disease severity. RECENT FINDINGS: Group A ß-hemolytic streptococci (GABHS) have been shown to be an important cause of intertrigo and to cause more widespread disease in some instances. Superficial skin infections with GABHS have been associated with strains secreting exfoliating toxins, whereas deeper infections have been associated with superantigen toxins. Hand-foot-and-mouth disease (HFMD) outbreaks have occurred with more virulent strains, causing more widespread disease that may be confused with eczema herpeticum or varicella. Mycoplasma pneumoniae has been shown to be an important cause of common disorders such as urticaria, and less common disorders such as Stevens-Johnson syndrome and Mycoplasma-associated mucositis. Recurrent toxin-mediated erythema is a recently described entity that must be differentiated from Kawasaki disease. SUMMARY: The number of rashes acquired in childhood is vast, requiring the pediatrician to be able to identify worrisome rashes from those with a more benign course. Key clinical signs may assist in clinical diagnosis and treatment.

Cosmeceuticals for children: should you care?

PURPOSE OF REVIEW: Cosmeceuticals are substances that exert physiologic changes to the skin for aesthetic purposes and are popular alternatives to invasive cosmetic procedures for antiaging. Cosmeceuticals are being used on children; yet studies of cosmeceuticals in the pediatric population are limited. RECENT FINDINGS: Cosmeceuticals remain an unrecognized category by the US Food and Drug Administration, and therefore stringent regulatory pathways do not exist to guide research and marketing. To date, no safety and efficacy study exists on cosmeceutical use in pediatric patients. Increasing knowledge of the mechanisms underlying intrinsic and extrinsic skin aging, including reactive oxygen species formation, effects of declining hormones, and ultraviolet radiation, forms the scientific basis for common cosmeceuticals such as retinoids, botanicals such as soy isoflavones, and even moisturizers and sunscreen. Virtually all studies on cosmeceuticals have been performed in women with varying degrees of skin aging. The cosmeceuticals most likely to be used by younger children are moisturizers and sunscreens. As the popularity and availability of other antiaging cosmeceuticals grow, practitioners will encounter more and more beauty-conscious teenagers using these products for preventive rather than restorative purposes. SUMMARY: Pediatricians should be familiar with the use of common cosmeceuticals used in children, especially the use of broad-spectrum sunscreen. In the future, more children will be exposed to cosmeceuticals and may experience side effects such as contact dermatitis and skin irritation.

Core concepts in congenital melanocytic nevi and infantile hemangiomas.

PURPOSE OF REVIEW: Congenital melanocytic nevi (CMN) and infantile hemangiomas are commonly encountered in newborns and may present diagnostic and therapeutic dilemmas for medical practitioners. Herein, we review and discuss these two important clinical entities and focus on core issues and recent advances. RECENT FINDINGS: Melanoma risk for patients with CMN is greatest in infants with large CMN located on the trunk, CMN greater than 40 cm, and multiple satellite nevi. Recent histological and molecular findings have been described to assist in differentiating benign proliferative nodules arising in CMN from melanoma. Multiple CMN and associated neurological lesions have recently been shown to be due to a single postzygotic mutation in NRAS [neuroblastoma RAS viral (v-ras) oncogene homolog]. Over the last several years, numerous advancements have occurred in redefining the clinical course of infantile hemangiomas, describing clinical syndromes associated with infantile hemangiomas and treating complicated infantile hemangiomas. The nonselective ß-blocker propranolol has become first-line therapy for the treatment of complicated infantile hemangiomas. Topical timolol shows promise for the treatment of certain types of infantile hemangiomas. SUMMARY: Although most CMN and infantile hemangiomas do not require active intervention, understanding which lesions may impact the overall health of the infant assists in early intervention. This article touches on core concepts in the clinical evaluation and treatment of CMN and infantile hemangioma.

Current principles of sunscreen use in children.

PURPOSE OF REVIEW: Physicians need to be prepared to counsel patients on why and how to protect themselves from damaging ultraviolet (UV) radiation, including the proper use of sunscreens. In this article, we review the interplay between UV radiation, sunscreens and the skin, highlighting current controversies and recommendations surrounding sunscreen use. RECENT FINDINGS: An important concept is that excessive UV exposure has long-term damaging effects on the skin beyond the immediate sunburn. Recent discoveries of the role of UVA radiation in skin cancer development have set high standards for broad-spectrum coverage to be met by sunscreens. Current evidence does not support an association between sunscreen use and melanoma, systemic toxicity or vitamin D deficiency. Although sunscreen application is the most common modality for sun protection, many people do not use it correctly. Regular sunscreen use during childhood and adolescence can significantly reduce lifetime incidence of skin cancer; therefore, targeting children in pediatric offices regarding unprotected UV exposure may be a practical approach. SUMMARY: Sunscreens continue to be a major method of photoprotection among the public, offering numerous benefits that clearly outweigh potential risks; however, optimizing the use of sunscreens, especially among children and adolescents, remains a major challenge.

Effect of cat and daycare exposures on the risk of asthma in children with atopic dermatitis.

Atopic dermatitis (AD) in young children is often followed by the development of asthma (atopic march). The role of environmental exposures is unclear in this high-risk population. We aimed to determine the predictive relationship between indoor allergen exposures, particularly pets, rodents, and cockroaches, to the development of asthma in a prospective pediatric cohort. Children with AD and a family history of allergy were followed prospectively with questionnaire ascertainment of environmental exposure to cats, dogs, cockroaches, rats, and mice. Asthma was diagnosed by study physicians based on caregiver reports of symptoms continually assessed over the course of the study period. Fifty-five of the 299 children developed asthma by the end of the study. Cat exposure had a strong and independent effect to reduce the risk of developing asthma across all analyses (odds ratio [OR], 0.16; 95% confidence interval [CI], 0.05-0.53). Dog, mouse, rat, and cockroach exposures did not significantly influence the development of asthma. Daycare exposure had the largest risk reduction for the development of asthma (OR, 0.08; 95% CI, 0.03-0.19). Maternal asthma (OR, 2.93; 95% CI, 1.29-6.67), baseline body mass index (OR, 1.23; 95% CI, 1.08-1.42), and specific immunoglobulin E to house-dust mix at 3 years were each independent risk factors for the development of asthma. In children with AD, cat and daycare exposure may reduce the risk of developing early childhood asthma.

Update on topical glucocorticoid use in children.

PURPOSE OF REVIEW: This monograph reviews recent studies, examining topical glucocorticoid use in children. Emphasis is placed on mechanism of action, relative potency, cutaneous absorption, adverse affects, steroid phobia, and treatment compliance. RECENT FINDINGS: Recent literature has shown that over 80% of patients prescribed topical glucocorticoids are fearful of side effects and fail to use them appropriately. This lack of compliance leads to decreased therapeutic benefits. Despite this 'steroid phobia', multiple studies indicate that proper use of glucocorticoids in children is well tolerated and effective. Recent studies have failed to show clinically significant hypothalamic-pituitary-adrenal suppression and cutaneous atrophy in children. High-potency steroids have been shown to cause growth restriction when used during pregnancy. Steroid allergy occurs with a prevalence of 2.7% and should be considered in children who fail to respond as expected to topical glucocorticoids. SUMMARY: Topical glucocorticoids continue to be well tolerated, effective and cost-effective in the treatment of inflammatory cutaneous conditions in children.

Cosmetic procedures in children.

PURPOSE OF REVIEW: Cosmetic procedures are being performed with increased frequency in the United States and worldwide. Many of these procedures are being performed on children for aesthetic reasons and for the management of dermatological conditions such as psoriasis and vitiligo. This review serves as an overview of selected cosmetic procedures with pediatric applications. RECENT FINDINGS: Recent developments in laser technology have improved our ability to treat a large number of pediatric cutaneous disorders. The vast majority of these technologies were first developed for aesthetic dermatology in adults. Collagen-stimulatory agents such as poly-L-lactic acid were first approved for lipoatrophy associated with human immunodeficiency virus. Poly-L-lactic acid and dermal fillers have potential therapeutic applications in children with atrophic disorders such as lipoatrophy and morphea. Injection of botulinum toxin is very successful in the treatment of hyperhidrosis in adults and can be utilized to improve quality of life in children with hyperhidrosis. SUMMARY: The field of cosmetic dermatology is evolving quickly, with limited safety and efficacy studies in the pediatric age group. Children may benefit from thoughtful application of these technologies.

Spitz nevi arising in speckled lentiginous nevus: clinical, histologic, and molecular evaluation of two cases.

Spitz nevi are small dome-shaped nodules that sometimes arise in areas of preexisting hyperpigmentation, such as a speckled lentiginous nevus (nevus spilus), where they present a diagnostic dilemma. We report clinical, histopathological, and molecular findings of two cases of multiple Spitz nevi arising in a speckled lentiginous nevus. We used immunohistochemistry to assess expression of Ki-67, epidermal growth factor receptor, vascular endothelial growth factor, and RelA in two cases of Spitz nevi arising in a speckled lentiginous nevus. We observed rare staining for the proliferative marker Ki-67, but positive staining for the growth and antiapoptotic factors epidermal growth factor receptor, vascular endothelial growth factor, and RelA. Characterization of the molecular phenotype of Spitz nevi arising in speckled lentiginous nevi may provide a useful adjunct to long-term monitoring in this rare but difficult clinical presentation.

Changing the topography of acne with topical medications.

PURPOSE OF REVIEW: Acne vulgaris is a common skin condition that affects approximately 40-50 million Americans annually. The peak incidence of acne occurs during adolescence and young adulthood, with approximately 80% of persons aged 11-30 years having at least minor acne. Because the onset of acne is typically in early adolescence, pediatricians are often at the front-lines in terms of caring for patients with this chief complaint. RECENT FINDINGS: Over the last 2 years, new acne therapies have become available. These include new combination fixed-dose products, which may allow for greater flexibility in treatment and greater patient compliance. New topical antibiotics have also come to the market, providing more therapeutic options for mild to moderate inflammatory acne. Lastly, acne therapies involving the use of light sources and photosensitizers are currently being developed, which may provide a whole new modality for managing complicated patients. SUMMARY: Successful management of acne requires the physician to make a thorough assessment of the patient's acne severity, predominant lesion type, skin type, and lifestyle in order to pair each individual patient's needs with the appropriate anti-acne therapy. This article provides an overview of the pathophysiology of acne and pre-existing topical therapies. It then discusses some novel acne therapies and outlines how they might fit into a physician's treatment strategy.