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Journal: Pediatric dermatology

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Vascular lesions such as hemangiomas and lymphangiomas can cause significant mortality and morbidity, as well as amblyopia when located in the orbit. Oral propranolol can regress infantile hemangioma during infancy and up to 23 months of age, but its effect on lymphangioma has not been demonstrated. We present two cases of lymphatic malformations treated with oral propranolol. Patient 1 is a 2-year-old boy with macrocystic bilateral cervical lymphangioma extending to the pharynx and larynx and microcystic lymphangioma of the tongue. The patient was started on propranolol 2 mg/kg/day starting at 17 months of age, and after 3 months only a very slight decrease in tongue volume was noted. Patient 2 is a 3.5-year-old boy with magnetic resonance imaging evidence of right facial complex lymphangioma with venous malformation. The patient was placed on oral propranolol 2 mg/kg/day. After 3 months of treatment, no change in the lesion was noted except for a transient decrease in the size of the conjunctival telangiectasia. Propranolol 2 mg/kg/day was not effective in treating lymphatic malformations in two children, both older than 17 months at the time of treatment.

Concepts: Nuclear magnetic resonance, Magnetic resonance imaging, Congenital disorder, Amblyopia, Hemangioma, Congenital disorders, Dermal and subcutaneous growths, Lymphangioma

28

Standard teaching dictates that systemic therapy is required for treatment of onychomycosis. It is unknown whether topical antifungal therapy is effective for pediatric nail infections. This prospective, randomized, double-blind, vehicle-controlled study was conducted in the Pediatric Dermatology Research Unit at Rady Children’s Hospital to determine whether topical antifungal therapy is efficacious for pediatric onychomycosis. Forty patients ages 2 to 16 years with nonmatrix onychomycosis were randomized 1:3 to ciclopirox lacquer or vehicle lacquer. Ciclopirox lacquer or vehicle was applied daily for 32 weeks, with weekly removal of the lacquer and mechanical trimming. Those with poor response were crossed over to active drug at week 12. Thirty-seven patients completed the 32-week study, and follow-up data were collected 1 year after completion of the study from 24 patients. Mycologic cure, effective treatment, and complete cure were assessed, as well as adverse events and effect on quality of life. Mycologic cure was 70% in the treated group and 20% in the vehicle arm (p = 0.03) at week 12. At end of the study (week 32), 77% of treated patients achieved mycologic cure and 71% effective treatment, compared with 22% of the control group. Ninety-two percent of those who were cured and followed for 1 year remained clear. Topical antifungal lacquer (ciclopirox) can be an effective option for children with nonmatrix onychomycosis. Pediatric onychomycosis does not always require systemic therapy and responds better to topical therapy than does adult disease.

Concepts: Medicine, Hospital, Effectiveness, Efficacy, Onychomycosis, Nail, Children's hospital, Nail disease

28

Because of the low prevalence of onychomycosis in children, little is known about the efficacy and safety of systemic antifungals in this population. PubMed and Embase databases and the references of related publications were searched in March 2012 for clinical trials (CTs), retrospective analyses (RAs), and case reports (CRs) on the use of systemic antifungals for onychomycosis in children (<18 years). Twenty-six studies (5 CTs, 3 RAs, and 18 CRs) were published between 1976 and 2011. Most of these studies reported the use of systemic terbinafine and itraconazole for the treatment of onychomycosis in children. Therapy with systemic antifungals alone in children age 1 to 17 years resulted in a complete cure rate of 70.8% (n = 151), whereas combined systemic and topical antifungal therapy in one infant and 19 children age 8 and older resulted in a complete cure rate of 80.0% (n = 20). The efficacy and safety profiles of terbinafine, itraconazole, griseofulvin, and fluconazole in children were similar to those previously reported for adults. In conclusion, based on the little information available on onychomycosis in children, systemic antifungal therapies in children are safe and cure rates are similar to the rates achieved in adults.

Concepts: Medicine, Therapy, Antifungals, Antifungal drug, Onychomycosis, Athlete's foot, Fluconazole, Griseofulvin

28

  We describe an 11-month-old boy with an unusually large presternal mass present since birth. The large size, fluctuant properties, transillumination, compressibility, and imaging of this lesion were characteristic of a lymphatic malformation. Although four treatments with sclerotherapy markedly reduced its size, it was not until definitive treatment with surgical excision and the final pathology report that we arrived at the ultimate diagnosis of dermoid cyst. Dermoid cysts, although appearing along embryologic lines of closure, are rarely presternal. They are usually small, thick walled, and filled with sebaceous or keratinous fluid, which typically allows for clinical diagnosis, and show characteristic features on magnetic resonance imaging (MRI) and ultrasound. However, this case illustrates that dermoid cysts can appear in somewhat atypical locations, and imaging is not always diagnostic, so dermoid cyst should remain a part of the differential diagnosis for any lesion presenting midsternally, regardless of the size and imaging characteristics.

Concepts: Oncology, Medical imaging, Magnetic resonance imaging, Ultrasound, Cyst, Dermoid cyst, Pilonidal cyst, Teratoma

27

Histoid leprosy is extremely rare in children. Molluscum contagiosum-like lesions in the setting of histoid leprosy is a highly atypical presentation and may signify the process of “transepidermal elimination” in lesions with high bacillary load. A case of histoid leprosy with umbilicated papules and nodules mimicking molluscum contagiosum is reported in a 10-year-old Indian boy.

Concepts: Molluscum contagiosum, Leprosy, 1996 albums, Bacterium-related cutaneous conditions, Histoid leprosy

27

Ichthyosis follicularis, alopecia, and photophobia (IFAP) syndrome is an X-linked dominant condition characterized by the triad of ichthyosis follicularis, alopecia, and photophobia caused by mutations in the MBTPS2 gene. Herein we describe a proband with IFAP syndrome with mild cutaneous manifestations and a novel MBTPS2 mutation in the N-terminal transmembrane domain.

Concepts: Protein, Mutation, Point mutation, Missense mutation, Nonsense mutation, Genodermatoses, Ichthyosis, IFAP syndrome

27

Phylloid hypermelanosis is a less clearly defined pigmentary disturbance than its hypopigmented counterpart, phylloid hypomelanosis. We report the case of a 32-month-old boy who had multiple melanotic macules arranged in a typical phylloid pattern since birth. He also had an abnormal facial appearance, with macrocephaly, frontal bossing, hypertelorism, internal strabismus, and auricular deformities. Psychomotor delay, multiple cystic brain lesions, and bilateral sensorineural hearing loss were also found. A review of associated anomalies as described in this and five previously reported patients with phylloid hypermelanosis shows some vague and inconsistent similarities, such as unusual facial appearance, malformed ears, hearing loss, and mental deficiency, but it is likely that phylloid hypermelanosis represents a class of heterogeneous phenotypes. Future clinical and genetic research may show how many distinct entities can be placed in this group of disorders.

Concepts: Gene, Genetics, Cochlear implant, Ototoxicity, Ear, Tinnitus, Sensorineural hearing loss, Conductive hearing loss

26

Tinea imbricata (TI) is a geographically restricted dermatophytosis with distinctive clinical and immunologic features. We present a case of TI occurring in a native Brazilian child with previously undiagnosed human immunodeficiency virus infection. Physicians should bear in mind that diagnosis of TI may be a clinical clue to potentially serious underlying immunodeficiency.

Concepts: HIV, AIDS, Immune system, Psychology, Medicine, Infectious disease, Brazil, Tinea

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Cantharidin is a widely used treatment for molluscum contagiosum (MC) that is often favored because of its speed of application and lack of pain at the time of application. Previous studies have supported its safety and reported high parental and dermatologist satisfaction with its use. Nonetheless, a lack of safety data has contributed to ambiguous U.S. Food and Drug Administration status that has made it increasingly difficult to obtain. All children treated with cantharidin for MC at a tertiary care center between January 1, 2005, and December 31, 2011, who had at least one follow-up visit or telephone call were included in the current study. Information related to treatment with cantharidin and adverse effects was abstracted from medical records. Of 512 children identified, 405 had at least one follow-up visit or telephone call after treatment and were included in this study. Cantharidin was applied to 9,688 lesions over 1,056 visits. Fifty-seven percent of children experienced blistering, an expected effect of therapy. Eleven percent of patients experienced adverse events. The most common adverse events were pain (7%) and significant blistering (2.5%). Other side effects were rare (<1%) and included pruritus, possible mild infection, significant irritation, id reactions, and bleeding. Eighty-six percent of parents reported satisfaction with cantharidin or opted to use it again. Cantharidin is a safe treatment modality for MC and should be considered when symptomatic infection necessitates treatment. The cantharidin application protocol used in this study may serve as a model protocol with a known side-effect profile.

Concepts: Immune system, Medicine, Adverse effect, Tertiary referral hospital, Molluscum contagiosum, Iatrogenesis, Wart, Cantharidin

25

A 17-year-old boy presented with recurring severe dermatitis of the face of 5-months duration that resembled impetigo. He had been treated with several courses of antibiotics without improvement. Biopsy showed changes consistent with allergic contact dermatitis and patch testing later revealed sensitization to benzoyl peroxide, which the patient had been using for the treatment of acne vulgaris.

Concepts: Inflammation, Patient, Hypersensitivity, Eczema, Face, Acne vulgaris, Dermatitis, Contact dermatitis