[Autoimmune encephalitis in pediatric population]. / Encefalitis autoinmune en población pediátrica.

Autoimmune encephalitis can be defined as central nervous system inflammation, secondary to multiple causes, where we can possibly identify the formation of auto-antibody against neurotransmitter receptors or neuronal surface proteins. Approximately 50% of patients are seropositive; the auto-antibody against N-methyl-D-aspartate receptor (NMDAR) are the most common. In the pediatric population, the clinical presentation is characterized by movement disorders and seizures, psychiatric manifestations are more commonly found in young adults. An early intervention is associated with a better prognosis in these patients. In contrast to the seropositive group, seronegative autoimmune encephalitis is linked with less movement alterations and is related with a worse cognitive outcome. Much remains to be discovered about possible etiologies, molecular processes, detection, and interaction of yet undescribed antibodies,as well as increasing our knowledge about clinical manifestations in early disease and new diagnostic techniques that could improve the diagnosis of autoimmune encephalitis. The main goal of this document is to review the updates of the molecular field about the antibody against GluK2 and its clinical presentation in pediatric population; COVID-19 as a possible cause of autoimmune encephalitis; recognize the importance of psychiatric manifestation in early disease, especially catatonia as a marker of severity; additionally consider new imaging diagnostic method such as positron emission tomography (PET), which has shown to be more sensible than MRI (goal standard).

La encefalitis autoinmune se puede definir como el proceso inflamatorio del sistema nervioso central, secundario a múltiples causas donde se consigue identificar o no, la creación de auto-anticuerpos contra receptores de neurotransmisores o proteínas de la superficie neuronal. Aproximadamente un 50% de pacientes son seropositivos, el anticuerpo contra el receptor N-metil-D-aspartato (NMDAR) es encontrado con mayor frecuencia. La presentación clínica característica en la población pediátrica es la alteración del movimiento, seguido por episodios convulsivos; en edades más avanzadas, priman las manifestaciones psiquiátricas. Muestra buen pronóstico si se impone un pronto tratamiento. En la encefalitis autoinmune seronegativa, se observa una menor alteración de movimiento, la cual, contrario al grupo seropositivo, se asocia con peor pronóstico cognitivo. Falta mucho por conocer sobre las posibles etiologías, procesos moleculares, la interacción y detección de anticuerpos aún no descritos,al igual que es necesario incrementar nuestro conocimiento sobre las manifestaciones clínicas en etapa temprana de la enfermedad e investigar propuestas que podrían mejorar el diagnóstico de la encefalitis autoinmune. El objetivo de este documento es revisar las actualizaciones en el ámbito molecular sobre el nuevo anticuerpo descrito (GluK2) y su presentación clínica en la población pediátrica; COVID-19 como posible causa del desarrollo de encefalitis autoinmune; reconocer la importancia de las manifestaciones psiquiátricas en etapa temprana, en especial la catatonia como marcador de gravedad, de igual manera, considerar nuevas propuestas para el diagnóstico de encefalitis autoinmune como: tomografía por emisión de positrones (PET), que ha mostrado mayor sensibilidad al detectar anomalías cerebrales que la RMN (estudio de elección).

[Pediatric therapeutic options in autoimmune neurologic diseases]. / Opciones terapéuticas para enfermedades neurológicas autoinmunes en pediatría.

The pediatric neuroimmunology field has made significant progress in the last decade. Now, is possible to recognize primary demyelinating diseases, paraneoplastic syndromes, inflammatory (vasculitis), and granulomatous disorders that affect the central nervous system; at the same time, it is important to exclude neurologic manifestations caused by infections, toxic agents, and metabolic problems. An early diagnosis is imperative to institute treatment as soon as possible, improving outcomes. Treatment may include both, specific drugs if the etiology has been established, as well as drugs to treat potential complications, for example anticonvulsants, anti-inflammatory drugs, transfusions, or albumin replenishment within others. The main objective of this review is to provide guidance about the therapeutic options in pediatric autoimmune neurological diseases. We review the evidence and recommendations for the use of steroids in autoimmune demyelinating diseases, acute disseminated encephalomyelitis, optic neuritis, neuromyelitis optica, multiple sclerosis, among others. We will focus on current therapies, including high doses of intravenous methylprednisolone, followed by its progressive reduction, as well as intravenous immunoglobulin or plasmapheresis as second line therapies. Early institution of these treatments can save the patient's life and decrease their risk of permanent disability.

El campo de la pediatría neuro-inmunológica ha progresado significativamente en la última década. Ahora es posible reconocer con prontitud enfermedades desmielinizantes primarias, síndromes para-neoplásicos, enfermedades inflamatorias, autoinmunes y granulomatosas, que afectan el sistema nervioso central. Excluir con gran rapidez posibles causas infecciosas, agentes tóxicos, problemas metabólicos que se presenten con manifestaciones neurológicas es imperativo, ya que al hacer un diagnóstico preciso y temprano del paciente se puede instituir un tratamiento lo más pronto posible e incrementar las probabilidades de éxito. El tratamiento puede ser dirigido a la etiología específica, si se conoce. Adicionalmente, es importante tratar las complicaciones relacionadas a la propia enfermedad o efectos secundarios de los tratamientos que se impongan. El tratamiento puede incluir tanto fármacos específicos si se ha establecido la etiología, así como medicamentos para tratar posibles complicaciones, por ejemplo, anticonvulsivos, antiinflamatorios, transfusiones, o reposición de albúmina dentro de otros. El objetivo principal de esta revisión es brindar una guía sobre las opciones terapéuticas en enfermedades neurológicas autoinmunes en fase aguda. Revisamos la evidencia y recomendaciones acerca del uso de esteroides en enfermedades autoinmunes desmielinizantes, encefalomielitis aguda diseminada, neuritis óptica, neuromielitis óptica, esclerosis múltiple, entre otras, donde altas dosis de metilprednisolona, seguida por su disminución progresiva son esenciales, así como el uso de inmunoglobulina humana intravenosa y plasmaféresis, como tratamiento de segunda línea. La institución temprana de estos tratamientos puede salvar la vida del paciente y disminuir su discapacidad permanente.

Childhood pertussis is still here: An Asian city's perspectives.

INTRODUCTION: Pertussis, or whooping cough, is a highly contagious respiratory infection that is caused by the bacterium Bordetella pertussis. It is one of the most common causes of death in childhood. It is also a frequent cause of chronic cough in children, adolescents, and adults. METHODS: Global and Hong Kong perspectives of childhood pertussis were described. RESULTS: Hong Kong has prided herself in the city's childhood immunization program. There appear to be no major outbreaks of pertussis since the 1960s. Nevertheless, pediatricians may see isolated cases of pertussis or pertussis-like cases from time to time. Occasionally, infants are severely affected with apneas and managed with ventilator supports in the PICU. Outbreaks of the notifiable disease continue to occur despite a reasonable surveillance system and vaccination program in Hong Kong. Vaccination of mothers, adolescents, and adults are efficacious methods to further reduce the risks of pertussis. Macrolides remain efficacious antibiotics especially used early during the infectious phase. Infants with pertussis may require intensive care support and morbidity is high. CONCLUSIONS: Physicians should be reminded from time to time that outbreaks of pertussis still exist in Hong Kong and in many cities globally.

Self-perceived disease control in childhood eczema.

BACKGROUND: Atopic eczema (AE) is a common relapsing inflammatory skin disease in children which is often associated with chronicity and poor quality of life. Unlike atopic asthma, control of AE is seldom assessed in therapeutics. AIM: To investigate the utility of a Traffic Light Control (TLC) system as a measurement/assessment of self-perceived eczema control. METHODS: This is a prospectively study of all Chinese children (aged 6-18 years old) with eczema attending the pediatric dermatology clinic of a tertiary hospital from January to June 2020. Eczema control, eczema severity, quality of life and biophysical skin condition of consecutive patients at the pediatric dermatology clinic of a teaching hospital were evaluated with the validated Chinese versions of Depressive, Anxiety, Stress Scales (DASS-21), Patient Oriented Eczema Measure (POEM), transepidermal water loss (TEWL), and stratum corneum skin hydration (SH), respectively. With a visual TLC analogy, patients were asked if their eczema is under control (green light), worsening (yellow) or in flare-up (red light). RESULTS: Among AE patients (n = 36), self-perceived TLC as green (under control), amber (worsening) and red (flare up) reflected acute and chronic severity (SCORAD, NESS, POEM) and quality of life (CDLQI) (p < .0001), but not SH, TEWL or Depression, anxiety and stress. CONCLUSIONS: Eczema control can be semi-quantified with a child-friendly TLC self-assessment system. AE patients reporting worse eczema control have worse acute and chronic eczema severity, more impairment of quality of life; but not the psychologic symptoms of depression, anxiety and stress or skin hydration or transepidermal water loss. TLC can be linked to an eczema action plan to guide patient management.

Medications and Recent Patents for Status Asthmaticus in Children.

BACKGROUND: Status asthmaticus is an acute exacerbation of asthma that is persistent and intractable and remains unresponsive to initial treatment with bronchodilators and systemic corticosteroids and that the condition can result in hypoxemia, hypercarbia, and secondary respiratory failure. OBJECTIVE: To review treatment and recent patents on management of status asthmaticus. METHOD: A PubMed search was completed in Clinical Queries using the key term "status asthmaticus". The search included meta-analyses, randomized controlled trials, clinical trials, reviews and pertinent references. Patents were searched using the key term status "asthmaticus" from www.google.com/patents, www.uspto.gov, and www.freepatentsonline.com. RESULTS: Supplemental oxygen should be given to maintain an oxygen saturation of ≥ 92% in room air. Mainstay of pharmacologic treatment of status asthmaticus includes short-acting, ß2 agonists such as salbutamol (albuterol) administered by metered-dose inhaler with spacer or, preferably, by nebulizer and oral corticosteroids. There is no advantage to intravenous corticosteroids unless the child cannot tolerate oral corticosteroids (e.g., protracted vomiting), or unable to take oral corticosteroid (e.g., intubated or unconscious). Inhaled ipratropium bromide and intravenous magnesium sulfate should be considered in children with severe asthma exacerbations not responsive to conventional therapy. Subcutaneous and intramuscular ß2 agonists such as terbutaline and epinephrine may be considered for children with severe asthma exacerbation who have poor air entry, are uncooperative with nebulized therapy, or have poor response to nebulized therapy. Monoclonal anti-IgE antibody (omalizumab) and humanized monoclonal antibodies targeting interleukin pathway have shown great promise in severe refractory eosinophilic asthma. Failing therapeutic interventions necessitate non-invasive or invasive ventilation support. Severe exhaustion, deteriorating consciousness, poor air entry, worsening hypoxemia, hypercapnia, and cardiopulmonary arrest are indications for mechanical ventilation and intubation. For chronic treatment of asthma, inhaled corticosteroids, bronchodilator, and oral montelukasts are the mainstay. Some formulations of herbal medicine are efficacious but evidence of other modalities of complementary and alternative medicine are generally lacking. This review also discusses recent patents related to the management of asthma. These recent patents describe a few immunomodulating medications useful for the treatment of chronic severe asthma. There have been no recent patents for the management of status asthmaticus. CONCLUSION: Inhaled bronchodilators and systematic corticosteroids are the mainstay of therapy in the management of severe and status asthmaticus.

Complementary and alternative medicine for childhood asthma: an overview of evidence and patents.

Asthma is a prevalent childhood atopic disease associated with significant impairment of quality of life. Management relies on avoidance of triggers such as food and aeroallergens, the use of inhaled bronchodilators/corticosteroids and anti-allergic or immune-modulating therapies. Inhaled corticosteroids (ICSs) and bronchodilators have been the mainstay of treatment. In China as well as throughout Asia, myths and misconceptions on western medicine and corticosteroids are prevalent and result in non-adherence of treatment. A wide variety of complementary and alternative medicines (CAM) are available. Some of these have undergone extensive clinical trials and have been documented to have some therapeutic effects on asthma. Nevertheless, the majority of these treatment modalities is not efficacious and may even be detrimental. This article overviews the evidence for the clinical efficacy of all major CAM modalities. Despite CAM modalities are extensively used by the patients with asthma, very few CAM patents are available. This article also discusses recent patents pertinent to asthma. Only a few patents on herbal medicine for asthma have been evaluated but therapeutic efficacy is not substantially documented. Parents seeking CAM for asthma must consult qualified registered practitioners before using it.

Cardiopulmonary morbidity of streptococcal infections in a PICU.

AIM: The streptococci are important bacteria that cause serious childhood infections. We investigated cardiopulmonary morbidity associated with streptococcal infection and pediatric intensive care unit (PICU) admission. METHODS: A retrospective study between 2002 and 2013 of all children with a laboratory isolation of streptococcus. RESULTS: There were 40 (2.3%) PICU patients with streptococcal isolations including Streptococcus pyogenes (Group A streptococcus, GAS, n = 7), Streptococcus agalactiae (Group B streptococcus, GBS, n = 5), Streptococcus pneumoniae (SP, n = 20), alpha-hemolytic (n = 4), beta-hemolytic (n = 2) and gama-hemolytic (n = 2) streptococci. Comparing among GAS, GBS and SP, respiratory isolates were more likely positive for GAS or SP (P = 0.033), whereas cerebrospinal fluid was more likely positive for GBS (P = 0.002). All GAS and GBS, and the majority of SP (90%) were sensitive to penicillin. All SP specimens were sensitive to cefotaxime and vancomycin. These infections were associated with high PICU mortality of 43%, 20% and 25%, respectively. Isolation of streptococci was associated with a 30% mortality and high rates of need for mechanical ventilatory and inotropic supports. Patients with GAS, SP or any streptococcal isolation had relative risks [95% confidence interval (CI), P value] of PICU deaths of 7.5 (CI 3.1-18.1, P < 0.0001), 4.5 (CI 2.0-9.8, P < 0.0002) and 5.7 (CI 3.4-9.5, P < 0.0001), respectively. In SP, older children had significantly higher prevalence of premorbid conditions such as malignancy, mental retardation/cerebral palsy ± seizure disorders, chromosomal or genetic disorders (P = 0.003) than children <5 years of age. Serotypes were available for some of these specimens that included 19A, 6B, 3 and 6C. There were four SP deaths with multiorgan system failure and hemolytic uremic syndrome (two 19A and two serotype 3). CONCLUSIONS: Severe streptococcal infections are associated with significant morbidity and mortality despite treatment with systemic antibiotics and intensive care unit support. GAS and SP affect the lungs of children, whereas GBS more likely causes meningitis in infants. The expanded coverage of newer polyvalent pneumococcal vaccines can probably prevent infections by serotypes 19A, 19F, 6B and 3.

Specific IgG and IgA of common foods in Chinese children with eczema: friend or foe.

BACKGROUND: Specific immunoglobulins G and A (IgG and IgA) for common food items have been extensively measured as surrogate markers of food allergy, and dietary avoidance based on the test results advocated. AIM: We reviewed the prevalence of specific food IgG and IgA in children with eczema and evaluated outcome of dietary avoidance in these children. METHODS: Specific immunoglobulins of 96 food items were measured for 30 consecutive atopic dermatitis (AD) patients and disease severity [SCORing atopic dermatitis (SCORAD) and Nottingham eczema severity score (NESS)], Children Dermatology Life Quality Index (CDLQI), skin hydration (SH), transepidermal water loss (TEWL), topical corticosteroid and oral antihistamine usage were evaluated. Twenty seven of these patients received dietary avoidance advice based on IgG and IgA data. General acceptability of treatment (GAT) was documented at the end of 3 months. RESULTS: There were generally no correlations among levels of IgG or IgA of the 96 food items and disease severity, quality of life, SH or TEWL. Two-third patients reported very good or good and one-third reported fair or poor GAT following dietary avoidance advice. There was no difference in any clinical parameters between the two groups following dietary avoidance. Patient with lower sunflower seed IgA (p = 0.043), casein IgG (p = 0.041), milk IgG (p = 0.037) or whey IgG (p = 0.014) had improved SCORAD and objective SCORAD following dietary advice. CONCLUSION: Children with AD are sensitized to many food allergens via IgG and IgA mechanisms. Levels of food IgG or IgA do not seem to correlate with any clinical parameters in AD. Subjectively, two third of patients accepted dietary manipulations as very good or good for their AD. Objectively, dietary avoidance had few clinical effects on the clinical parameters. Sensitization should not be generalized to mean allergy to common food.

Prolonged non-survival in PICU: does a do-not-attempt-resuscitation order matter.

BACKGROUND: Etiologies of pediatric intensive care unit (PICU) mortality are diverse. This study aimed to investigate the pattern of PICU mortality in a regional trauma center, and explore factors associated with prolonged non-survival. METHODS: Demographic data of all PICU deaths in a regional trauma center were analyzed. Factors associated with prolonged nonsurvival (length of stay) were investigated with univariate log rank and multivariate Cox-Regression forward stepwise tests. RESULTS: There were 88 deaths (males 61%; infants 23%) over 10 years (median PICU stay = 3.5 days, interquartile range: 1 and 11 days). The mean annual mortality rate of PICU admissions was 5.8%. Septicemia with gram positive, gram negative and fungal pathogens were present in 13 (16%), 13 (16%) and 4 (5%) of these patients, respectively. Viruses were isolated in 25 patients (28%). Ninety percent of these 88 patients were ventilated, 75% required inotropes, 92% received broad spectrum antibiotic coverage, 32% received systemic corticosteroids, 56% required blood transfusion and 39% received anticonvulsants. Thirty nine patients (44%) had a DNAR (Do-Not-Attempt-Resuscitation) order with their deaths at the PICU. Comparing with non-trauma category, trauma patients had higher mortality score, no premorbid disease, suffered asystole preceding PICU admission and subsequent brain death. Oncologic conditions were the most prevalent diagnosis in the non-trauma category. There was no gunshot or asthma death in this series. Prolonged non-survival was significantly associated with DNAR, fungal infections, and mechanical ventilation but negatively associated with bacteremia. CONCLUSIONS: Death in the PICU is a heterogeneous event that involves infants and children. Resuscitation was not attempted at the time of their deaths in nearly half of the patients in honor of parents' wishes. Parents often make DNAR decision when medical futility becomes evident. They could be reassured that DNAR did not mean "abandoning" care. Instead, DNAR patients had prolonged PICU stay and received the same level of PICU supports as patients who did not respond to cardiopulmonary resuscitation.

Cupping Therapy May be Harmful for Eczema: A PubMed Search.

Eczema is a common childhood atopic condition and treatment is with emollients, topical corticosteroids, and avoidance of possible triggers. S. aureus colonization is a common complication. As there is no immediate cure, many parents seek alternative therapies that claim unproven therapeutic efficacy. We report a girl with long history of treatment noncompliance. After practicing a long period of dietary avoidance and supplementation, the grandparents took her to an alternative medicine practitioner. Following cupping therapy and acupuncture, the child developed blistering and oozing over her back the next day, which rapidly evolved to two large irregular-edge deep ulcers. She was treated with intravenous antibiotics and received multidisciplinary supportive intervention. Using search words of "cupping," "eczema," and "atopic dermatitis," only two reports were found on PubMed. Therapeutic efficacy was claimed but not scientifically documented in these reports. Childhood eczema is an eminently treatable atopic disease. Extreme alternative therapy seems not to be efficacious and may even be associated with serious undesirable sequelae. Physicians should be aware of various alternative treatment modalities and be prepared to offer evidence-based advice to the patients with eczema and their families.

Seasonal allergic rhinitis.

Seasonal allergic rhinitis is characterized by seasonal rhinorrhea, nasal congestion/stuffiness, nasal and ocular pruritus, and paroxysmal sneezing. Allergen avoidance is the first step in the management. Symptomatic relief and improved quality of life can be achieved in the majority of patients by the appropriate use of pharmacotherapy. Mild to moderate cases can be managed with either an oral/intranasal second generation antihistamine or an intranasal corticosteroid alone. More severe cases may require treatment with an intranasal corticosteroid in combination with various agents. Patients who require medications for more than 6 months per year, two or more seasons of unacceptable pollinosis, or have intolerable side effects from pharmacotherapy, especially those with co-morbid conditions are candidates for immunotherapy. This review article also discusses recent patents related to the field.

Paradoxical use of oral and topical steroids in steroid-phobic patients resorting to traditional Chinese medicines.

BACKGROUND: Childhood-onset eczema is a common condition associated with pruritus, sleep disturbance and disrupted quality of life. The mainstay of treatment is usage of emollients and topical corticosteroid (CS). Nevertheless, many steroid-phobic parents are very skeptical about western medicine that may contain CS. Furthermore, complementary and alternative medicine (CAM) is popular among Chinese patients in Asia and many citizens idolize CAM and believe that traditional Chinese medicine and herbs are without any side effects. Pressed by public's quest for efficacious and safe treatment, and lucrative profits, CAM practitioners may take the risks of prescribing steroids and "western medicine" in the name of traditional Chinese herbal medicine. METHODS: We report a series of illustrative cases of uninformed systemic and topical corticosteroid usage for eczema by steroid-phobic parents to alert the public of this risk. The drugs were detected by high-performance liquid chromatography with diode-array detection, liquid chromatography-tandem mass spectrometry, gas chromatography mass spectrometry, or liquid chromatography ion trap time-of-flight mass spectrometry. RESULTS: Five cases of uninformed corticosteroid usage for moderate-to-severe eczema by steroid-phobic parents were reported. CONCLUSIONS: The physician caring for children with skin disease should also be aware that even steroid-phobic parents might indeed be using potent CS without awareness. The patient usually suffers chronic relapsing eczema of moderate-to-severe degree. The steroid-phobic parent is usually non-compliant in following advice on usage of emollient, topical CS, and avoidance of triggers in accordance with western doctors. The CAM practitioner, when confronted by an anxious steroidophobic parent who demands efficacious topical and/or systemic treatment, may knowingly or unknowingly be forced into prescribing potent albeit illegal products containing corticosteroids in the name of traditional Chinese herbal medicine.

Adverse Drug Reactions in Children--International Surveillance and Evaluation (ADVISE): a multicentre cohort study.

BACKGROUND: A previous meta-analysis reported that 9.5% of hospitalized children suffered from an adverse drug reaction (ADR); however, reported incidences among studies varied. OBJECTIVE: To enhance the knowledge of ADRs in paediatric hospitalized patients at a global level we investigated the incidence and characteristics of ADRs in hospitalized children in European and non-European countries. METHODS: A prospective observational cohort study was conducted in academic and non-academic hospitals in five countries: Australia, Germany, Hong Kong, Malaysia and the UK. Children aged 0-18 years admitted during a 3-month period (between 1 October 2008 and 31 December 2009) were recruited. The main outcome measures were incidence, causality and outcome of ADRs. RESULTS: A total of 1278 patients (1340 admissions) were included [Australia n = 146 (149 admissions), Germany n = 376 (407), Hong Kong n = 143 (149), Malaysia n = 300 (314) and the UK n = 313 (321)]. The median age was 2 years (interquartile range [IQR] 0-7). Patients received a total of 5367 drugs (median 3; IQR 2-5) and median length of hospital stay was 4 days (IQR 3-7). A total of 380 ADRs were identified in 211 patients. The resultant ADR incidence of 16.5% (95% CI 14.5, 18.7) varied significantly between countries (p < 0.001). The highest incidences were observed in Malaysia and the UK. 65.3% (n = 248) of ADRs were found to be probable, and 24% of the ADRs were serious, with one being fatal. CONCLUSIONS: By comparing data from five countries in Europe, Asia and Australia we have shown that the incidence of ADRs in hospitalized children is at least as high as incidences published in adults. However, the variation between countries was mainly due to different populations and treatment strategies. Particular attention should be given to opioid use in hospitalized children.

The atopic march: from skin to the airways.

Many patients with atopic eczema (AE) would "march" to develop allergic rhinitis (AR) and asthma. Physicians, patients and their families often do not appreciate the significance of these diseases as co-morbidities of atopy.The aim of this study was to evaluate the prevalence and severity of airway atopies in patients with AE. AR and asthma severity were assessed in consecutive AE patients seen at a pediatric dermatology clinic by ARS (allergic rhinitis score) and ACT (asthma control test). Eczema severity (SCORAD and Nottingham Eczema Severity Score: NESS) were recorded.110 patients with AE and 42 patients without AE were recruited. Allergic rhinitis and asthma were significantly more prevalent in patients with AE [odds ratio for AR was 2.9 (CI: 1.3 - 6.5) and for asthma 4.3 (CI: 1.3 - 16.10)]. 23 (45%) of the AE patients with AR reported that they were currently on oral antihistamine whereas none of the non-AE group reported such usage. Both groups reported relatively higher sneezing and nasal congestion scores and low "eye watering" score. Comparing mild with moderate-to-severe AE, there was essentially no difference between the prevalence of allergic rhinitis and asthma, or severity of symptoms by ARS and ACT, but females reported more severe symptoms of sneezing and itching nose.We conclude that allergic disorders of airway are very common among AE patients independent of the eczema severity. Most of the patients have mild-to-moderate AR and asthma. There is a lot of room for parent/patient education, and childhood eczema may prompt early awareness of these airway co-morbidities of atopy.

Alopecia areata.

Alopecia aerata (AA) is an autoimmune disease that presents as well defined patches of nonscarring hair loss with no overt epidermal changes. The life-time risk of AA in the general population is approximately 1.7%. As many as 60% of patients with AA have disease onset before 20 years of age. AA most commonly manifests as sudden loss of hair in well demarcated, localized area in the scalp. The hair loss is usually limited to a single patch. The lesion is usually round or oval. "Exclamation point hairs" are frequently seen at the periphery of the lesion. Because of the high rate of spontaneous recovery especially in those with small areas of hair loss or with a recent onset, not all patients require pharmacological treatment. A "watch-and-wait" approach is often recommended. Psychological support may be offered if necessary. For patients who actively desire treatment, topical corticosteroids and/or minoxidil are the treatment of choice. Interleukin (IL)-31 antibodies and 308-nm Excimer laser as novel treatment modalities appear promising in the armamentarium against this distressing disease. The review also outlined recent patents on the treatment of alopecia.

Serum levels of heavy metals in childhood eczema and skin diseases: friends or foes.

The incidence of eczema has been increasing in developed countries. Environmental and hygiene factors have been incriminated. Although air and food pollution with heavy metals have been considered as possible culprits, these factors have never been investigated in Hong Kong. To evaluate if quality of life and eczema severity are associated with abnormal serum levels of six common heavy metals, namely, cadmium, lead, mercury, selenium, copper and zinc. Serum or whole blood was taken for measurement of six heavy metals from patients referred to the pediatric dermatology clinic. Eczema severity (SCORAD and NESS) and quality of life (CDLQI) were recorded. A total of 110 patients with eczema and 41 patients with miscellaneous skin conditions were recruited. Serum levels of the six heavy metals were generally within the upper limits of local reference ranges. Zinc levels were below the lower reference limit of 9.4 mum in 66 patients with eczema (60%) and 22 non-eczema patients (53%). Forty-four patients with eczema (40%) and 24 (58%) in non-eczema group had low copper levels. In eczema patients, lead levels were generally within normal limits but their levels were positively correlated with poor quality of life (CDLQI: r = 0.22 and p < 0.05), disease severity (objective SCORAD: r = 0.33 and p < 0.005; NESS: 0.20, p < 0.05), eosinophil count and log-transformed IgE. Copper/zinc ratio also correlated with NESS and CDLQI and was generally higher than non-eczema skin diseases. Our findings help reassure parents that levels of heavy metals generally do not exceed the local reference ranges for toxicity. However, lead levels have significant correlations with disease severity, quality of life and atopy. Low zinc and copper levels are commonly found in pediatric skin diseases and their significance needs to be determined.

Efficacy and tolerability at 3 and 6 months following use of azathioprine for recalcitrant atopic dermatitis in children and young adults.

INTRODUCTION: Recalcitrant childhood atopic dermatitis (AD) causes significant morbidity and may necessitate systemic treatment with immunomodulating agents such as azathioprine. We reviewed the clinical and biochemical effects of this agent in children and adolescents receiving this treatment between November 2005 and December 2007. METHODS: The clinical efficacy of azathioprine, and its hematological and biochemical effects (serum IgE level, liver and renal function), were assessed at 3 months and 6 months in 17 cases of recalcitrant AD. Disease severity was evaluated with the SCORing Atopic Dermatitis (SCORAD) score which has two components, namely (1) the objective SCORAD which measures the extent (percentage of body surface area involved) and intensity of the lesions, and (2) visual analog scales which measure the subjective symptoms of pruritus and sleep loss. RESULTS: There were nine males and eight females with a mean (SD) age of 16.1 (3.9) years. Compared with baseline, significant improvements were observed at 3 months (n = 17) and 6 months (n = 16) in SCORAD (p = 0.002; p < 0.001), objective SCORAD (p = 0.002; p = 0.001), extent (p = 0.001; p < 0.001), pruritus (p = 0.004; p = 0.001) and dryness (p = 0.033 at 6 months). Compared with males, objective SCORAD was significantly lower in females (p = 0.009) at 6 months. Azathioprine was stopped in one female after 4 months due to lack of efficacy. Serum total IgE (p = 0.006) was significantly lower at 6 months. The frequency of oral antihistamine usage and Staphylococcus aureus carriage were also significantly reduced (p = 0.031 and p = 0.016, respectively). Mild transient elevation of glutamic-pyruvic transaminase in one patient which became normalized on cessation of the drug, and mild elevation of serum bilirubin in two other patients were observed. CONCLUSIONS: Azathioprine reduced the disease severity of AD within 3 months of use in these children. Better efficacy was observed in females at 6 months. Adverse hematologic and biochemical effects appeared acceptable but longer-term monitoring is desirable.