Unilesional granulomatous pigmented purpuric dermatosis in a 7-year-old boy.

Granulomatous pigmented purpuric dermatoses (PPD) are rarely reported. We present a case of granulomatous PPD in a 7-year-old boy, one of only two pediatric cases with reported solitary disease. The pathogenesis of unilesional granulomatous PPD may be different from the more commonly described multifocal/widespread disease variant.

Approach to the total body skin examination in adults and children: Kids are not just little people.

The indications, evidence for, and approach to performing a total body skin examination differs for adult versus pediatric patients. To provide optimal care to all of our patients, dermatologists should recognize these differences and feel comfortable and competent in performing a total body skin examination in patients of all ages.

An age-based approach to dermatologic surgery: Kids are not just little people.

Surgical dermatologic procedures in children pose unique challenges that differ from those in adults. Child and parental anxiety, along with procedural anxiety in adults, necessitate different approaches. Special considerations are reviewed in the application of topical anesthesia and administration of local anesthesia in children as opposed to adults, and the use and safety of general anesthesia in children is highlighted. In addition, management of postprocedural analgesia differs in children, largely due to concern for safety of opioids in children.

Teledermatology: Kids are not just little people.

Teledermatology has emerged as a promising solution for pediatric and adult patients accessing dermatologic care in a health care environment fraught with barriers to access. Teledermatology has been extensively evaluated in terms of diagnostic accuracy, clinical outcomes, patient and provider satisfaction, and costs, relative to traditional health care delivery models. Current research indicates that teledermatology is effective and efficient in diagnosis and management of skin diseases. The majority of studies on the subject, however, rely on adult patient data. Pediatric patients, with their unique clinical features and challenges, may interact with telemedicine differently than their adult counterparts. Maximizing the benefits of teledermatology in pediatric dermatologic care is dependent on future research. We review and analyze the commonalities and differences between pediatric and adult patient care using teledermatology.

Putative Intravascular Myofibroma Mimicking a Vascular Malformation With Phleboliths.

Myofibroma is a rare, benign myofibroblastic tumor that commonly presents at birth or in early infancy, usually as a painless, slow-growing, solitary, nodular mass. We present a case of a 40-year-old woman with a painful, solitary, myofibroma on the right elbow. The unique features of this case include age and gender of the patient, site, pain on presentation, tumor morphology, and putative intravascular nature of the tumor.

Mast cell disorders: Kids are not just little people.

Cutaneous mastocytosis is characterized by a pathologic increase in mast cells in the skin and may also involve extracutaneous organs. Symptoms, which are triggered by mast cell degranulation, vary depending on the burden of skin disease and the presence of extracutaneous disease. The clinical presentation, risk of systemic disease, pathogenesis, prognosis, and treatment options differ, largely depending on age at presentation. In the pediatric population, spontaneous remission is typical, generally by puberty, whereas in adults, progression is observed. Extracutaneous involvement and associated hematologic disorders seldom occur in children, as opposed to adults. It is therefore important to avoid overreliance on adult-based approaches to management of cutaneous mastocytosis in the pediatric population. We focus on differences in presentation, workup, and management of pediatric- and adult-onset cutaneous mast cell disorders.

Cutaneous lymphoma: Kids are not just little people.

Cutaneous T-cell lymphomas (CTCLs) are non-Hodgkin lymphomas that predominantly affect older patients. Onset of cutaneous lymphoma in childhood is rare, but it can present as early as the first decade of life. In both adults and children, the diagnosis of cutaneous lymphoma can be challenging because inflammatory dermatoses can mimic CTCL both clinically and histologically. The clinicopathologic manifestations can be similar in adults and younger individuals; however, differences in the prevalence of certain CTCL variants among age groups exist. Whereas the classic Alibert-Bazin-type mycosis fungoides (MF) and Sézary syndrome represent the overwhelming majority of adult cutaneous T-cell lymphomas, in younger individuals, certain mycosis fungoides variants, such as hypopigmented MF, are over-represented and Sézary syndrome is extremely rare. CD30+ lymphoproliferative diseases, which include lymphomatoid papulosis (LyP) and primary cutaneous anaplastic large cell lymphoma (ALCL), represent the second most common subtype of CTCL in both adults and children; however, in the pediatric population, most of these are represented by LyP, and primary cutaneous ALCL is very rare. The prognosis is stage dependent, and the most significant prognostic factor in MF is the extent of skin involvement and the presence or absence of extracutaneous disease. The overwhelming majority of pediatric patients present with early-stage disease, and progression to more advanced stages, such as tumor stage, erythrodermic MF, and large cell transformation, which can be seen in adults, is very rare. The choice of treatment, regardless of age, is dependent on the extent of skin involvement and the presence or absence of extracutaneous disease.

Paired comparison of the sensitivity and specificity of multispectral digital skin lesion analysis and reflectance confocal microscopy in the detection of melanoma in vivo: A cross-sectional study.

BACKGROUND: Several technologies have been developed to aid dermatologists in the detection of melanoma in vivo including dermoscopy, multispectral digital skin lesion analysis (MDSLA), and reflectance confocal microscopy (RCM). To our knowledge, there have been no studies directly comparing MDSLA and RCM. OBJECTIVE: We conducted a repeated measures analysis comparing the sensitivity and specificity of MDSLA and RCM in the detection of melanoma (n = 55 lesions from 36 patients). METHODS: Study patients (n = 36) with atypical-appearing pigmented lesions (n = 55) underwent imaging by both RCM and MDSLA. Lesions were biopsied and analyzed by histopathology. RESULTS: RCM exhibited superior test metrics (P = .001, McNemar test) compared with MDSLA. Respectively, sensitivity measures were 85.7% and 71.4%, and specificity rates were 66.7% and 25.0%. LIMITATIONS: The sample size was relatively small and was collected from only one dermatologist's patient base; there was some degree of dermatopathologist interobserver variability; and only one confocalist performed the RCM image evaluations. CONCLUSION: RCM is a useful adjunct during clinical assessment of in vivo lesions suspicious for melanoma or those requiring re-excision because of high level of dysplasia or having features consistent with an atypical melanocytic nevus with severe cytologic atypia.

microRNA in situ hybridization for miR-211 detection as an ancillary test in melanoma diagnosis.

Some melanocytic tumors can be histologically ambiguous causing diagnostic difficulty, which could lead to overtreatment of benign lesions with an unwarranted psychological distress or undertreatment of malignant cancers. Previously, we demonstrated that significantly decreased miR-211 expression in melanomas compared with melanocytic nevi could accurately discriminate malignant from benign tumors. Herein we show microRNA in situ hybridization for fluorescent detection of miR-211, suitable for paraffin-embedded tissues in 109 primary melanocytic tumors. miR-211 expression was significantly lower in melanomas vs nevi (P<0.0001), and receiver operating characteristic curve (area under the curve=0.862) accurately discriminated melanomas from nevi with 90% sensitivity and 86.2% specificity. Qualitatively, all dysplastic nevi expressed miR-211 at high (86%) and low (14%) levels, independent of the degree of nuclear atypia. All 35 melanocytic tumors with Spitz morphology expressed miR-211 independent of morphological classification, where clinical follow-up of these patients showed no recurrence at the site or metastasis in mean and median of 3 (ranging 2-5) years. Moreover, a decision tree learning analysis selected age and miR-211 miRNA in situ hybridization as the predictive variables for benign or malignant outcome in 88 patients correctly classified 92% (81 out of 88) of cases as proven by receiver operating characteristic curve (area under the curve=0.9029). These results support miR-211 as a leading miRNA candidate for melanoma diagnosis and miRNA in situ hybridization as a uniquely uncomplicated ancillary test.

Laser therapy in dermatology: Kids are not just little people.

Advances in laser research and technology have led to expanded laser applications for the treatment of dermatologic disease. Lasers are viable treatment modalities for patients of any age group and offer unique treatment options for both adult and pediatric patients. While many skin diseases can be treated similarly in children and adults, differences in treatment approaches can result from varying anxiety levels, pain tolerance, psychosocial considerations of untreated disease, determination of suitable anesthesia, the use of size-appropriate safety equipment, and differences in the evolution of skin disease over time. Laser therapy can prove effective for the treatment of molluscum contagiosum unresponsive to conventional therapy. Hypertrophied vascular lesions and pigmented lesions, such as the nevus of Ota, respond more effectively to laser therapy earlier in life with fewer treatment sessions and reduced side effects. In the case of port-wine stains, the pulsed dye laser is the agent of choice in the pediatric patient, while the Q-switched alexandrite may be more effective in the adult population.

Nodular cystic fat necrosis with calcification in a patient with juvenile dermatomyositis.

Nodular cystic fat necrosis is a rare, benign form of encapsulated fat necrosis with distinct histology, characterized by cystic fat necrosis with lipomembranous changes and, in later stages, calcification. We report the case of a 7-year-old child with juvenile dermatomyositis who presented with three asymptomatic, firm, mobile nodules on the arms and neck. Histology was consistent with nodular cystic fat necrosis with prominent calcification. This is an unusual presentation of this entity because it has never been previously reported in association with juvenile dermatomyositis.

Ethics in pediatric dermatology.

The patient-parent-physician relationship is central to studying medical ethics in pediatric dermatology. The rights of children in medical decision making are ambiguous, and parents and physicians will often override the autonomy of a child when a particular treatment is deemed to be in the child's best interest. The use of physical restraint to enforce a treatment should be justified, and a reasonable attempt should be made to ensure the cooperation of the child, if possible. Medical photography is central to the practice of pediatric dermatology in that it allows for serial observation of cutaneous lesions over time. Established guidelines and standards should be followed. Pediatric dermatologists frequently prescribe medications off-label; if following established professional standards, and prescribing with good intention, off-label prescribing can be appropriate and rational.

Molecular diagnosis of a benign proliferative nodule developing in a congenital melanocytic nevus in a 3-month-old infant.

Small and intermediate congenital melanocytic nevi have a lifetime risk of developing melanoma estimated to range from 0% to 5%. Secondary benign melanocytic proliferations commonly arise in congenital melanocytic nevi; however, some are difficult to definitively distinguish from malignant melanoma based on clinical features and conventional histology. Herein, we describe the use of comparative genomic hybridization in supporting the diagnosis of a deep penetrating nevus developing within a congenital melanocytic nevus of a 3-month-old infant.