Describing skin health and disease in urban-living Aboriginal children: co-design, development and feasibility testing of the Koolungar Moorditj Healthy Skin pilot project.

BACKGROUND: Indigenous children in colonised nations experience high rates of health disparities linked to historical trauma resulting from displacement and dispossession, as well as ongoing systemic racism. Skin infections and their complications are one such health inequity, with the highest global burden described in remote-living Australian Aboriginal and/or Torres Strait Islander (hereafter respectfully referred to as Aboriginal) children. Yet despite increasing urbanisation, little is known about the skin infection burden for urban-living Aboriginal children. More knowledge is needed to inform service provision, treatment guidelines and community-wide healthy skin strategies. In this pilot study, we aimed to test the feasibility and design of larger multi-site observational studies, provide initial descriptions of skin disease frequency and generate preliminary hypotheses of association. METHODS: This project has been co-designed with local (Noongar) Elders to provide an Australian-first description of skin health and disease in urban-living Aboriginal children. In collaboration with an urban Aboriginal Community Controlled Health Organisation (Derbarl Yerrigan Health Service), we conducted a week-long cross-sectional observational cohort study of Aboriginal children (0-18 years) recruited from the waiting room. Participants completed a questionnaire, skin examination, clinical photos, and swabs and received appropriate treatment. We assessed the feasibility and impact of the pilot study. RESULTS: From 4 to 8 October 2021, we recruited 84 Aboriginal children of whom 80 (95%) were urban-living. With a trusted Aboriginal Health Practitioner leading recruitment, most parents (or caregivers) who were approached consented to participate. Among urban-living children, over half (45/80, 56%) of parents described a current concern with their child's skin, hair and/or nails; and one-third (26/80, 33%) reported current itchy skin. Using a research-service model, 27% (21/79) of examined urban-living participants received opportunistic same-day treatment and 18% (14/79) were referred for later review. CONCLUSIONS: This co-designed pilot study to understand skin health in urban-living Aboriginal children was feasible and acceptable, with high study participation and subsequent engagement in clinical care observed. Co-design and the strong involvement of Aboriginal people to lead and deliver the project was crucial. The successful pilot has informed larger, multi-site observational studies to more accurately answer questions of disease burden and inform the development of healthy skin messages for urban-living Aboriginal children.

Pruritus as an early sign of abnormal scarring in the re-epithelialising phase of Toxic Epidermal Necrolysis.

We present a 28-year-old remote-living male who presented to our dermatology clinic with increasing pruritus over his torso and limbs in the context of a recent admission for Toxic Epidermal Necrolysis (TEN) secondary to paliperidone depot. Our case demonstrates that pruritus in the re-epithelialising phase of TEN may be a sign of abnormal scarring. Early assessment and measurement for compression garments is recommended.

The burden of atopic dermatitis and bacterial skin infections among urban-living Indigenous children and young people in high-income countries: A systematic review.

BACKGROUND: A high burden of bacterial skin infections (BSI) is well documented in remote-living Indigenous children and young people (CYP) in high-income countries (HIC). Atopic dermatitis (AD) is the most common chronic inflammatory skin condition seen in CYP and predisposes to BSI. Despite the rate of urbanization for Indigenous people increasing globally, research is lacking on the burden of AD and BSI for urban-living Indigenous CYP in HIC. Indigenous people in HIC share a history of colonization, displacement and subsequent ongoing negative impacts on health. OBJECTIVE: To provide a global background on the burden of AD and BSI in urban-living Indigenous CYP in HIC. METHODS: A systematic review of primary observational studies on AD and BSI in English containing epidemiologic data was performed. MEDLINE, EMBASE, EMCARE, Web of Science, and PubMed databases were searched for articles between January 1990 and December 2021. RESULTS: From 2278 original manuscripts, 16 were included: seven manuscripts documenting eight studies on AD; and nine manuscripts documenting nine studies on BSI. Current and severe symptoms of AD were more common in urban-living Indigenous CYP in HIC compared with their non-Indigenous peers, with children having a higher prevalence than adolescents. Urban-living Indigenous CYP in HIC had a higher incidence of all measures of BSI compared with their non-Indigenous peers, and were over-represented for all measures of BSI compared with their proportion of the background population. Limitations include incomplete representation of all Indigenous populations in HIC. CONCLUSION: A significant burden of AD and BSI exists in urban-living Indigenous CYP in HIC.

The burden of bacterial skin infection, scabies and atopic dermatitis among urban-living Indigenous children in high-income countries: a protocol for a systematic review.

BACKGROUND: Bacterial skin infections and scabies disproportionately affect children in resource-poor countries as well as underprivileged children in high-income countries. Atopic dermatitis is a common childhood dermatosis that predisposes to bacterial skin infection. In Australia, at any one time, almost half of all Aboriginal and Torres Strait Islander children living remotely will have impetigo, and up to one-third will also have scabies. Yet, there is a gap in knowledge of the skin infection burden for urban-living Australian Aboriginal and Torres Strait Islander children, as well as atopic dermatitis which may be a contributing factor. The objective of this study is to provide a global background on the burden of these disorders in Indigenous urban-living children in high-income countries. These countries share a similar history of colonisation, dispossession and subsequent ongoing negative impacts on Indigenous people. METHODS: This protocol follows the Preferred Reporting Items for Systematic Review and Meta-Analyses Protocols statement. Observational studies reporting incidence and/or prevalence data on bacterial skin infection, scabies and/or atopic dermatitis in urban-living Indigenous children in high-income countries will be included. Literature searches will be conducted in several international electronic databases (from 1990 onwards), including MEDLINE, Embase, EmCare, Web of Science and PubMed. Reference lists and citation records of all included articles will be scanned for additional relevant manuscripts. Two investigators will independently perform eligibility assessment of titles, abstract and full-text manuscripts, following which both investigators will independently extract data. Where there is disagreement, the senior author will determine eligibility. The methodological quality of selected studies will be appraised using an appropriate tool. Data will be tabulated and narratively synthesised. We expect there will be insufficient data to perform meta-analysis. DISCUSSION: This study will identify and evaluate epidemiological data on bacterial skin infection, scabies and atopic dermatitis in urban-living Indigenous children in high-income countries. Where available, the clinical features, risk factors, comorbidities and complications of these common childhood skin disorders will be described. The evidence will highlight the burden of disease in this population, to contribute to global burden of disease estimates and identify gaps in the current literature to provide direction for future research. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42021277288.

Toxic epidermal necrolysis in adult patients: Experience from the West Australian Collaboration.

Toxic epidermal necrolysis (TEN) is a rare and life-threatening mucocutaneous disease triggered by a reaction to a drug. Despite reported mortality of 30%, management differs between healthcare settings. Our hospital was established in February 2015 becoming the new state burns centre in Western Australia (WA). Following this, we collaborated on comprehensive multidisciplinary guidelines for the management of TEN. These guidelines are updated annually to reflect the weight of emerging evidence in managing TEN. Our aim was to review the management and outcomes of TEN patients presenting to our hospital between February 2015 and May 2021 (inclusive). We collected data for 10 patients on year, age, ethnicity, gender, medical history, culprit drug and exposure, SCORTEN, length of stay, maximum percentage of skin detachment, mucosal surface involvement, ophthalmic amniotic membrane transplant, burns unit input/admission, intensive care unit admission, weight, systemic treatment(s), complications and outcome. We excluded 7 out of 17 flagged patients who did not strictly meet the definition of TEN as greater than 30% epidermal detachment, with epidermal detachment defined as bullae, erosions, and/or positive Nikolsky. We found that the mortality rate in WA from TEN is improving compared with two previous WA studies, with a mortality rate in our study of 20% (2 deaths). Though limited by small sample size and retrospective design, our study suggests a shift towards at least one systemic therapy per patient (most commonly cyclosporine), the growing use of etanercept and the ophthalmic use of amniotic membrane transplants. It demonstrates the importance of burns unit input and the utility of comprehensive multidisciplinary guidelines. While the management and outcomes of TEN patients in WA are continuing to improve, we support calls for large registry data to facilitate evidence growth and collaboration for this rare life-threatening condition.

Allergic Contact Dermatitis to Dermabond Prineo After Elective Orthopedic Surgery.

The Dermabond Prineo skin closure system (Ethicon, Somerville, New Jersey) is a wound closure device that combines a 2-octyl cyanoacrylate liquid adhesive and a self-adhesive polyester mesh. Although cyanoacrylates traditionally have been associated with low rates of sensitization, allergic contact dermatitis (ACD) to Dermabond products is being increasingly reported after orthopedic surgery. The authors describe the first case series of ACD to Dermabond Prineo where patch testing confirmed the diagnosis in all patients. Six patients who had suspected Dermabond Prineo ACD after lower limb orthopedic surgery were assessed. Of these patients, 5 had itching within 4 days of surgery and rash within 5 days. All 5 of these patients reported previous exposure to Dermabond products. All patients had removal of the adhesive and mesh earlier than planned and were treated with corticosteroids. In addition, 4 patients received systemic antibiotics; however, only 1 had a microbiologically confirmed superficial skin infection. In all patients, the dermatitis resolved within 2 weeks of dressing removal, with no adverse effect on the orthopedic outcome. Patch testing showed positive reactions to Dermabond Prineo glue for all patients. Orthopedic surgeons should be aware of the potential for ACD to Dermabond Prineo, especially among patients with previous exposure to Dermabond products. The authors discuss the risk factors for ACD to Dermabond Prineo in the orthopedic cohort and provide recommendations for prevention and management. [Orthopedics. 2020;43(6):e515-e522.].

A case of congenital solitary Langerhans cell histiocytoma.

A newborn baby boy was referred to the Paediatric Dermatology Unit with a solitary asymptomatic nodule overlying his right nasolabial fold. Complete physical examination, full blood count, serum chemistry, liver function tests and baseline imaging were unremarkable. Histopathological examination showed an atypical dermal infiltrate of mononuclear cells that stained positive with CD1a and S100. A diagnosis of congenital solitary Langerhans cell histiocytoma was made. The lesion completely resolved by 4 months of age. The baby is now 15 months old and repeat systemic evaluation has remained normal.

Peripheral nerve field stimulation for pruritus relief in a patient with notalgia paraesthetica.

This case study is presented to exemplify the application of peripheral nerve field stimulation in the treatment of recalcitrant notalgia paraesthetica. The patient was a 60-year-old woman with severe and disabling notalgia paraesthetica. The itch persisted despite the use of several medications - topical and oral. Following a successful trial of peripheral nerve field stimulation with a temporary electrode, two subcutaneous electrodes were inserted into the affected area with a battery implanted subcutaneously in her right buttock. The patient was reviewed at 5 months post implantation. She reported a greater than 85% improvement in her itch. She also reported a major improvement in her quality of life, with particular improvement in her ability to sleep through the night. This case illustrates the possible utilization of peripheral nerve field stimulation in the treatment of notalgia paraesthetica, which is a common yet poorly understood and treated condition. Replication and controlled studies are required to determine the general applicability of this approach.

Mycobacterium abscessus infection complicating a professional tattoo.

A healthy 23-year-old man presented with a tender papular eruption confined to the grey pigment of a recently acquired professional tattoo. Atypical mycobacterial infection was suspected and culture of a tissue specimen grew Mycobacterium abscessus. He was successfully treated with minocycline and subsequently, clarithromycin. We present a brief review of M. abscessus infection, with a particular focus on its role in nosocomial infections and in the post-tattoo setting.

Physical and mental health in mothers of children with Down syndrome.

OBJECTIVE: To identify the relationship between characteristics of the child with Down syndrome and the health of their mother. STUDY DESIGN: Families with a child/young adult with Down syndrome (<25 years) provided information related to the health of the child, functioning and behavior, and the health and well-being of the mother (n = 250). RESULTS: The mean physical health score of mothers was 50.2 (SD = 9.6). Factors associated with lower mean physical health scores were as follows: child having a current heart problem (P = .036), a higher body mass index (P = .006), and higher (poorer) scores on the Developmental Behavior Checklist. Better physical health scores were seen in mothers whose children required no help/supervision in learning new skills (P = .008) and domestic tasks (P = .014). The mean mental health score of mothers was 45.2 (SD = 10.6), significantly lower than the norm of 50 (P < .0001). Associated child factors included current ear problems (P = .079), muscle/bone problems (P = .004), >4 episodes of illness in past year (P = .016), and higher scores on the DBC (P < .0001). CONCLUSIONS: The most important predictors of maternal health were children's behavioral difficulties, everyday functioning and current health status. Mothers of children with Down syndrome appear to experience poorer mental health and may require greater support and services to improve behavior management skills for their child and their own psychological well-being.