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Therapeutic patient education is a new way to approach atopic dermatitis
(AD) resulting from poor adherence to treatment.
The aim of TPE, a multidisciplinary approach to caring for and managing AD, is to improve patient and caregiver adherence to physician-directed treatments through education and to improve quality of life, according to several presenters who spoke at a pediatric dermatology meeting sponsored by Rady Children’s Hospital–San Diego and University of California, San Diego. They reviewed the approach to using TPE in chronic disease states, demonstrating this state-of-the-art approach to educating patients, families, and health care providers about AD management, and allowing for the exchange of ideas for best practices on AD therapeutic education programs and use in the U.S. health care environment.
Other successful meetings on TPE in Europe, Asia, and South America inspired this meeting, the first in the United States aimed to train health care professionals in TPE principles for AD. The meeting was sponsored by the Fondation Dermatite Atopique (Atopic Dermatitis Foundation for Research and Education), Rady’s Eczema and Inflammatory Skin Disease Center, and UCSD.
TPE is defined by the World Health Organization as an approach to help patients with chronic illness acquire or maintain the skills necessary to manage their life and illness in the best way possible. TPE involves patient preferences, shared decision-making, organized activities, psychosocial support, hospital organization and procedures, and health- and disease-related behaviors.
Sébastien Barbarot, MD, of the departments of dermatology and pediatric dermatology, Nantes (France) University Hospital, said that there are four main components to the TPE process:
• Assessing and understanding the patient’s knowledge and values.
• Developing age-appropriate personalized educational objectives.
• Transferring the necessary skills to the patient or caregiver.
• Assessing the effectiveness of the educational program.
Lawrence Eichenfield, MD, chief of pediatric and adolescent dermatology at Rady Children’s Hospital–San Diego and professor of dermatology and pediatrics at UCSD, discussed how to conduct the initial visit with potential candidates for TPE. At the new patient visit, the pediatric patient and their caregivers should first be presented with the concept of TPE, which includes proposing a personalized education approach. Next, explain the goals and benefits of TPE (with a time and location for the sessions), provide educational materials, allow time for questions, and establish the patient’s consent to participate.
The certain skills that patients should acquire fall under three main categories: knowledge of the disease, practical skills, and relational skills.
Alain Golay, MD, professor and chief of the department of therapeutic education in chronic diseases at the Geneva University Hospital, said that patients and caregivers should be familiar with the pathophysiology and natural history of the disease, as well as with aggravating factors and the rationale behind elements of the treatment plan – and they should understand a reasonable timeline for treatment responses.
Learning how to properly apply the treatment is among the practical skills that the patient needs to acquire. In terms of relational skills, patients should know enough about their disease to be able to explain it to others. Educational methods can include interactive presentations, case studies, roundtable meetings, workshops, and role play. Other tools that can be used as a resource include written action plans, posters, informational videos, reminders, and booklets. Nurse-led educational sessions that increase teaching time is another modality. Multidisciplinary clinics should include an allergist, dermatologist, psychologist, dietitian, and nurse. These clinics also can form workshops or teaching groups. This allows for smaller groups where ideas can be exchanged, and can be targeted specifically based on the audiences’ needs, he said.
Dr. Barbarot outlined the fourth step of TPE, which involves assessment of effectiveness. Several outcome measures can be used, including clinical outcomes, quality of life, patient global assessment, and knowledge questionnaires.
(AD) resulting from poor adherence to treatment.
The aim of TPE, a multidisciplinary approach to caring for and managing AD, is to improve patient and caregiver adherence to physician-directed treatments through education and to improve quality of life, according to several presenters who spoke at a pediatric dermatology meeting sponsored by Rady Children’s Hospital–San Diego and University of California, San Diego. They reviewed the approach to using TPE in chronic disease states, demonstrating this state-of-the-art approach to educating patients, families, and health care providers about AD management, and allowing for the exchange of ideas for best practices on AD therapeutic education programs and use in the U.S. health care environment.
Other successful meetings on TPE in Europe, Asia, and South America inspired this meeting, the first in the United States aimed to train health care professionals in TPE principles for AD. The meeting was sponsored by the Fondation Dermatite Atopique (Atopic Dermatitis Foundation for Research and Education), Rady’s Eczema and Inflammatory Skin Disease Center, and UCSD.
TPE is defined by the World Health Organization as an approach to help patients with chronic illness acquire or maintain the skills necessary to manage their life and illness in the best way possible. TPE involves patient preferences, shared decision-making, organized activities, psychosocial support, hospital organization and procedures, and health- and disease-related behaviors.
Sébastien Barbarot, MD, of the departments of dermatology and pediatric dermatology, Nantes (France) University Hospital, said that there are four main components to the TPE process:
• Assessing and understanding the patient’s knowledge and values.
• Developing age-appropriate personalized educational objectives.
• Transferring the necessary skills to the patient or caregiver.
• Assessing the effectiveness of the educational program.
Lawrence Eichenfield, MD, chief of pediatric and adolescent dermatology at Rady Children’s Hospital–San Diego and professor of dermatology and pediatrics at UCSD, discussed how to conduct the initial visit with potential candidates for TPE. At the new patient visit, the pediatric patient and their caregivers should first be presented with the concept of TPE, which includes proposing a personalized education approach. Next, explain the goals and benefits of TPE (with a time and location for the sessions), provide educational materials, allow time for questions, and establish the patient’s consent to participate.
The certain skills that patients should acquire fall under three main categories: knowledge of the disease, practical skills, and relational skills.
Alain Golay, MD, professor and chief of the department of therapeutic education in chronic diseases at the Geneva University Hospital, said that patients and caregivers should be familiar with the pathophysiology and natural history of the disease, as well as with aggravating factors and the rationale behind elements of the treatment plan – and they should understand a reasonable timeline for treatment responses.
Learning how to properly apply the treatment is among the practical skills that the patient needs to acquire. In terms of relational skills, patients should know enough about their disease to be able to explain it to others. Educational methods can include interactive presentations, case studies, roundtable meetings, workshops, and role play. Other tools that can be used as a resource include written action plans, posters, informational videos, reminders, and booklets. Nurse-led educational sessions that increase teaching time is another modality. Multidisciplinary clinics should include an allergist, dermatologist, psychologist, dietitian, and nurse. These clinics also can form workshops or teaching groups. This allows for smaller groups where ideas can be exchanged, and can be targeted specifically based on the audiences’ needs, he said.
Dr. Barbarot outlined the fourth step of TPE, which involves assessment of effectiveness. Several outcome measures can be used, including clinical outcomes, quality of life, patient global assessment, and knowledge questionnaires.
(AD) resulting from poor adherence to treatment.
The aim of TPE, a multidisciplinary approach to caring for and managing AD, is to improve patient and caregiver adherence to physician-directed treatments through education and to improve quality of life, according to several presenters who spoke at a pediatric dermatology meeting sponsored by Rady Children’s Hospital–San Diego and University of California, San Diego. They reviewed the approach to using TPE in chronic disease states, demonstrating this state-of-the-art approach to educating patients, families, and health care providers about AD management, and allowing for the exchange of ideas for best practices on AD therapeutic education programs and use in the U.S. health care environment.
Other successful meetings on TPE in Europe, Asia, and South America inspired this meeting, the first in the United States aimed to train health care professionals in TPE principles for AD. The meeting was sponsored by the Fondation Dermatite Atopique (Atopic Dermatitis Foundation for Research and Education), Rady’s Eczema and Inflammatory Skin Disease Center, and UCSD.
TPE is defined by the World Health Organization as an approach to help patients with chronic illness acquire or maintain the skills necessary to manage their life and illness in the best way possible. TPE involves patient preferences, shared decision-making, organized activities, psychosocial support, hospital organization and procedures, and health- and disease-related behaviors.
Sébastien Barbarot, MD, of the departments of dermatology and pediatric dermatology, Nantes (France) University Hospital, said that there are four main components to the TPE process:
• Assessing and understanding the patient’s knowledge and values.
• Developing age-appropriate personalized educational objectives.
• Transferring the necessary skills to the patient or caregiver.
• Assessing the effectiveness of the educational program.
Lawrence Eichenfield, MD, chief of pediatric and adolescent dermatology at Rady Children’s Hospital–San Diego and professor of dermatology and pediatrics at UCSD, discussed how to conduct the initial visit with potential candidates for TPE. At the new patient visit, the pediatric patient and their caregivers should first be presented with the concept of TPE, which includes proposing a personalized education approach. Next, explain the goals and benefits of TPE (with a time and location for the sessions), provide educational materials, allow time for questions, and establish the patient’s consent to participate.
The certain skills that patients should acquire fall under three main categories: knowledge of the disease, practical skills, and relational skills.
Alain Golay, MD, professor and chief of the department of therapeutic education in chronic diseases at the Geneva University Hospital, said that patients and caregivers should be familiar with the pathophysiology and natural history of the disease, as well as with aggravating factors and the rationale behind elements of the treatment plan – and they should understand a reasonable timeline for treatment responses.
Learning how to properly apply the treatment is among the practical skills that the patient needs to acquire. In terms of relational skills, patients should know enough about their disease to be able to explain it to others. Educational methods can include interactive presentations, case studies, roundtable meetings, workshops, and role play. Other tools that can be used as a resource include written action plans, posters, informational videos, reminders, and booklets. Nurse-led educational sessions that increase teaching time is another modality. Multidisciplinary clinics should include an allergist, dermatologist, psychologist, dietitian, and nurse. These clinics also can form workshops or teaching groups. This allows for smaller groups where ideas can be exchanged, and can be targeted specifically based on the audiences’ needs, he said.
Dr. Barbarot outlined the fourth step of TPE, which involves assessment of effectiveness. Several outcome measures can be used, including clinical outcomes, quality of life, patient global assessment, and knowledge questionnaires.
How to best evaluate children’s melanocytic lesions for melanoma
Children often present for evaluation of a melanocytic lesion that is new, evolving, or worrisome to parents and caregivers.
“In the pediatric health care system, malignant melanoma is considered an especially heinous crime. In San Diego, dedicated pediatric providers who identify this disease are members of an elite squad known as the mole patrol unit.” Dr. Sheila Fallon Friedlander opened her presentation on pediatric moles with this tongue-in-cheek statement, adapted from the popular TV show “Law and Order SVU,” at a pediatric dermatology meeting sponsored by Rady Children’s Hospital–San Diego and University of California, San Diego.
Only 104 cases were diagnosed in children aged less than 10 years, and the melanoma incidence in this age group was relatively unchanging from 1973 to 2009. Dr. Friedlander further emphasized, “Pediatric melanoma is extremely uncommon in patients less than 10 years of age, but more likely to be atypical.”
She continued by describing a group of surgical oncologists at MD Anderson Cancer Center in Houston, who conducted a retrospective review of children with cutaneous melanoma between 1988 and 2007 included in the SEER database, to determine the influence of age on disease presentation. Preadolescents younger than age 10 years were more ethnically diverse (nonwhite), more frequently presented with nontruncal primary melanocytic lesions, and increasingly were diagnosed with advanced disease, compared with their adolescent counterparts (J Pediatr Surg. 2013 Nov;48[11]:2207-13).
Congenital melanocytic nevi (CMN) may have increased risk for malignant potential, and can be challenging for pediatric providers to manage. Among all CMN, the increase in melanoma risk is estimated as less than 1%. The risk for malignant melanoma is further increased in individuals with large or giant CMN (greater than 20 cm diameter adult size), with an absolute risk of approximately 2%-5%. The number of satellite nevi also is considered in risk stratification. The presence of greater than 20 satellite nevi is associated with a greater than fivefold risk of neurocutaneous melanosis. There is no documented association between an increased quantity of satellite nevi and malignant melanoma.
“One particularly challenging pigmented lesion identified among pediatric patients is a Spitz nevus,” according to Dr. Friedlander. This lesion presents with greater cytologic atypia than other benign congenital and acquired nevi, and often clinically mimics malignant melanoma if identified in adults. There also exists a subset of atypical Spitz nevi, consisting of lesions with greater cytologic atypia than benign Spitz nevi. A retrospective review at Massachusetts General Hospital, Boston, of 157 cases of Spitz-type melanocytic lesions identified between 1987 and 2002 revealed increased melanoma risk, minimal mortality, and moderate risk of regional lymph node metastasis (Arch Dermatol. 2011;147[10]:1173-9).
“Classic pediatric Spitz nevi with typical clinical features and history may be managed conservatively with clinical monitoring alone, but those with concerning features such as bleeding, asymmetry, or ulceration should be excised with clear margins,” Dr. Friedlander emphasized. She discouraged sentinel lymph node biopsy, however, given the positive outcomes of 24 patients at Boston Children’s Hospital with atypical Spitz nevi treated with excision alone, published by Cerrato et al. (Pediatr Dermatol. 2011 Dec 30;29[4]:448-53).
“In light of the rising incidence of pediatric melanoma, we need to identify high-risk patients, educate about mole surveillance, and encourage sun protection,” Dr. Friedlander stressed. Children with phenotype of Fitzpatrick I (fair skin, blonde or red hair, and blue eye color) are at highest risk, as are those with a high density of freckles who burn easily and tan poorly. Further risk factors highlighted include excessive sun exposure, indoor tanning, use of phototoxic medications, immunosuppression, and genetics. The first and best line of defense against harmful ultraviolet radiation is covering up (clothing with a tight weave, wet suits, and hats).
The American Academy of Pediatrics encourages staying in the shade when possible, and limiting sun exposure during the peak sun intensity hours, between 10 a.m. and 4 p.m. When physical protection is not possible, the American Academy of Dermatology endorses the application of water resistant, broad spectrum SPF of greater than 30 at least every 2 hours.
Children often present for evaluation of a melanocytic lesion that is new, evolving, or worrisome to parents and caregivers.
“In the pediatric health care system, malignant melanoma is considered an especially heinous crime. In San Diego, dedicated pediatric providers who identify this disease are members of an elite squad known as the mole patrol unit.” Dr. Sheila Fallon Friedlander opened her presentation on pediatric moles with this tongue-in-cheek statement, adapted from the popular TV show “Law and Order SVU,” at a pediatric dermatology meeting sponsored by Rady Children’s Hospital–San Diego and University of California, San Diego.
Only 104 cases were diagnosed in children aged less than 10 years, and the melanoma incidence in this age group was relatively unchanging from 1973 to 2009. Dr. Friedlander further emphasized, “Pediatric melanoma is extremely uncommon in patients less than 10 years of age, but more likely to be atypical.”
She continued by describing a group of surgical oncologists at MD Anderson Cancer Center in Houston, who conducted a retrospective review of children with cutaneous melanoma between 1988 and 2007 included in the SEER database, to determine the influence of age on disease presentation. Preadolescents younger than age 10 years were more ethnically diverse (nonwhite), more frequently presented with nontruncal primary melanocytic lesions, and increasingly were diagnosed with advanced disease, compared with their adolescent counterparts (J Pediatr Surg. 2013 Nov;48[11]:2207-13).
Congenital melanocytic nevi (CMN) may have increased risk for malignant potential, and can be challenging for pediatric providers to manage. Among all CMN, the increase in melanoma risk is estimated as less than 1%. The risk for malignant melanoma is further increased in individuals with large or giant CMN (greater than 20 cm diameter adult size), with an absolute risk of approximately 2%-5%. The number of satellite nevi also is considered in risk stratification. The presence of greater than 20 satellite nevi is associated with a greater than fivefold risk of neurocutaneous melanosis. There is no documented association between an increased quantity of satellite nevi and malignant melanoma.
“One particularly challenging pigmented lesion identified among pediatric patients is a Spitz nevus,” according to Dr. Friedlander. This lesion presents with greater cytologic atypia than other benign congenital and acquired nevi, and often clinically mimics malignant melanoma if identified in adults. There also exists a subset of atypical Spitz nevi, consisting of lesions with greater cytologic atypia than benign Spitz nevi. A retrospective review at Massachusetts General Hospital, Boston, of 157 cases of Spitz-type melanocytic lesions identified between 1987 and 2002 revealed increased melanoma risk, minimal mortality, and moderate risk of regional lymph node metastasis (Arch Dermatol. 2011;147[10]:1173-9).
“Classic pediatric Spitz nevi with typical clinical features and history may be managed conservatively with clinical monitoring alone, but those with concerning features such as bleeding, asymmetry, or ulceration should be excised with clear margins,” Dr. Friedlander emphasized. She discouraged sentinel lymph node biopsy, however, given the positive outcomes of 24 patients at Boston Children’s Hospital with atypical Spitz nevi treated with excision alone, published by Cerrato et al. (Pediatr Dermatol. 2011 Dec 30;29[4]:448-53).
“In light of the rising incidence of pediatric melanoma, we need to identify high-risk patients, educate about mole surveillance, and encourage sun protection,” Dr. Friedlander stressed. Children with phenotype of Fitzpatrick I (fair skin, blonde or red hair, and blue eye color) are at highest risk, as are those with a high density of freckles who burn easily and tan poorly. Further risk factors highlighted include excessive sun exposure, indoor tanning, use of phototoxic medications, immunosuppression, and genetics. The first and best line of defense against harmful ultraviolet radiation is covering up (clothing with a tight weave, wet suits, and hats).
The American Academy of Pediatrics encourages staying in the shade when possible, and limiting sun exposure during the peak sun intensity hours, between 10 a.m. and 4 p.m. When physical protection is not possible, the American Academy of Dermatology endorses the application of water resistant, broad spectrum SPF of greater than 30 at least every 2 hours.
Children often present for evaluation of a melanocytic lesion that is new, evolving, or worrisome to parents and caregivers.
“In the pediatric health care system, malignant melanoma is considered an especially heinous crime. In San Diego, dedicated pediatric providers who identify this disease are members of an elite squad known as the mole patrol unit.” Dr. Sheila Fallon Friedlander opened her presentation on pediatric moles with this tongue-in-cheek statement, adapted from the popular TV show “Law and Order SVU,” at a pediatric dermatology meeting sponsored by Rady Children’s Hospital–San Diego and University of California, San Diego.
Only 104 cases were diagnosed in children aged less than 10 years, and the melanoma incidence in this age group was relatively unchanging from 1973 to 2009. Dr. Friedlander further emphasized, “Pediatric melanoma is extremely uncommon in patients less than 10 years of age, but more likely to be atypical.”
She continued by describing a group of surgical oncologists at MD Anderson Cancer Center in Houston, who conducted a retrospective review of children with cutaneous melanoma between 1988 and 2007 included in the SEER database, to determine the influence of age on disease presentation. Preadolescents younger than age 10 years were more ethnically diverse (nonwhite), more frequently presented with nontruncal primary melanocytic lesions, and increasingly were diagnosed with advanced disease, compared with their adolescent counterparts (J Pediatr Surg. 2013 Nov;48[11]:2207-13).
Congenital melanocytic nevi (CMN) may have increased risk for malignant potential, and can be challenging for pediatric providers to manage. Among all CMN, the increase in melanoma risk is estimated as less than 1%. The risk for malignant melanoma is further increased in individuals with large or giant CMN (greater than 20 cm diameter adult size), with an absolute risk of approximately 2%-5%. The number of satellite nevi also is considered in risk stratification. The presence of greater than 20 satellite nevi is associated with a greater than fivefold risk of neurocutaneous melanosis. There is no documented association between an increased quantity of satellite nevi and malignant melanoma.
“One particularly challenging pigmented lesion identified among pediatric patients is a Spitz nevus,” according to Dr. Friedlander. This lesion presents with greater cytologic atypia than other benign congenital and acquired nevi, and often clinically mimics malignant melanoma if identified in adults. There also exists a subset of atypical Spitz nevi, consisting of lesions with greater cytologic atypia than benign Spitz nevi. A retrospective review at Massachusetts General Hospital, Boston, of 157 cases of Spitz-type melanocytic lesions identified between 1987 and 2002 revealed increased melanoma risk, minimal mortality, and moderate risk of regional lymph node metastasis (Arch Dermatol. 2011;147[10]:1173-9).
“Classic pediatric Spitz nevi with typical clinical features and history may be managed conservatively with clinical monitoring alone, but those with concerning features such as bleeding, asymmetry, or ulceration should be excised with clear margins,” Dr. Friedlander emphasized. She discouraged sentinel lymph node biopsy, however, given the positive outcomes of 24 patients at Boston Children’s Hospital with atypical Spitz nevi treated with excision alone, published by Cerrato et al. (Pediatr Dermatol. 2011 Dec 30;29[4]:448-53).
“In light of the rising incidence of pediatric melanoma, we need to identify high-risk patients, educate about mole surveillance, and encourage sun protection,” Dr. Friedlander stressed. Children with phenotype of Fitzpatrick I (fair skin, blonde or red hair, and blue eye color) are at highest risk, as are those with a high density of freckles who burn easily and tan poorly. Further risk factors highlighted include excessive sun exposure, indoor tanning, use of phototoxic medications, immunosuppression, and genetics. The first and best line of defense against harmful ultraviolet radiation is covering up (clothing with a tight weave, wet suits, and hats).
The American Academy of Pediatrics encourages staying in the shade when possible, and limiting sun exposure during the peak sun intensity hours, between 10 a.m. and 4 p.m. When physical protection is not possible, the American Academy of Dermatology endorses the application of water resistant, broad spectrum SPF of greater than 30 at least every 2 hours.
Recognizing and treating pediatric bug infestations
Pruritic bug infestations are a common problem among school-age children, Albert C. Yan, MD, said at a pediatric dermatology meeting sponsored by Rady Children’s Hospital-San Diego and UC San Diego School of Medicine.
– and it is essential for you to be able to recognize and treat these appropriately. You also need to know resistance patterns, and how to counsel patient on full treatment protocol.
Carpet beetle dermatitis presents in children with a history of spending lots of time on a carpet, presenting with nondescript itchy patches on skin areas that were in contact with the carpet. Carpet beetle dermatitis is becoming more common on the east coast. Patients can actually find these beetles, which have tiger-striped coloring and have little prickly hairs that stick out of them, in their carpets. The beetles do not bite; rather, the rash is a reaction from exposure to insect blood or the larval hairs. The adult beetles tend to feed on carpet fabrics, wool, grains of food products, animal material, or nectar and pollen in flowers. The treatment is to get rid of the beetles. To rid the house of the beetles, it is recommended to vacuum, remove contaminated food sources, freeze stuffed animals for 10-14 days, and have an exterminator visit the home. Bringing in fresh cut flowers from the garden without rinsing them may bring the beetles into the house.
Scabies tends to be an itchy, widespread dermatosis. It is associated with extensive small skin papules scattered across the body with linear or curvilinear burrows, and tends to present from the elbows or knees distally, and especially in webbed areas, such as between the fingers. Keeping these geographic locations in mind makes it easier to differentiate scabies from hand dermatitis and eczema, said Dr. Yan, chief of pediatric dermatology at Children’s Hospital of Philadelphia and professor of pediatrics and dermatology at the University of Pennsylvania, Philadelphia.
To help diagnose this infestation, scrape the lesion and visualize the mite, the scybala or mite feces, or the oval eggs under the microscope.
The treatment is a “permethrin party.” Luckily, the scabies mite has very little documented resistance to permethrin 5% cream. However, with recurrent treatment, resistance starts to develop, he said. Proper administration is critical in controlling the infestation. For an adult, use 3 ounces or one tube, and for a child, use about 1.5 ounces for a child or one-half a tube. Apply it to the skin from neck down, leave it on for 8 hours overnight. Treat the patient and family members or close contacts. Repeat this application in 1 week. Oral ivermectin is effective and is useful in older kids who may not adhere to the permethrin.
A commonly encountered problem is apparent treatment failure. The scabies may be identified, treated, and then they appear to recur. Some patients have persistent postscabetic itch – the patients are still itchy afterward, but the lesions look excoriated and different than the original scabies lesions. The patient does not need retreatment, Dr. Yan emphasized. Rather, use topical corticosteroids or antihistamines to treat the itch.
Another explanation is improper use of medication – for instance, only certain parts of the skin were treated or all family members had not been treated. In this case, everyone needs to be retreated, he said. Reinfection is possible, but resistance is unlikely. Patients with scabies sometimes develop scabetic nodules or hypersensitivity nodules. Often, these are leftover areas of inflammation that can remain for up to 1 year. Dr. Yan recommends treating these areas with low-dose topical steroids.
The last phenomena presents with recurrent crops of pustules in the acral area, which is acropustulosis of infancy or postscabetic pustulosis. This is a variant of acropustulosis of infancy, in that it is more likely to involve the torso than is traditional acropustulosis and tends to be cyclical in that it reappears every few weeks.
Recently, the Journal of Medical Entomology published study findings in which head lice genetics were assessed, raising the concern about the development of “super lice.” However, this information has not yet brought treatment changes.
The conventional treatments include Nix, Rid, Triple X, but there can be a fair amount of resistance with these OTC treatment. Other options include mayonnaise and olive oil, however, not much data support the efficacy of this treatment. There are three prescription medications available: benzyl alcohol lotion, spinosad topical suspension, and ivermectin lotion. Start with these treatments quickly when dealing with lice that are resistant. Oral ivermectin also is effective. Dr. Yan concluded his lecture with discussion of other techniques that have been Food and Drug Administration–cleared, such as blowing drying them off the head, if one is okay with them landing in the office!
Dr. Yan reported no relevant financial disclosures.
Pruritic bug infestations are a common problem among school-age children, Albert C. Yan, MD, said at a pediatric dermatology meeting sponsored by Rady Children’s Hospital-San Diego and UC San Diego School of Medicine.
– and it is essential for you to be able to recognize and treat these appropriately. You also need to know resistance patterns, and how to counsel patient on full treatment protocol.
Carpet beetle dermatitis presents in children with a history of spending lots of time on a carpet, presenting with nondescript itchy patches on skin areas that were in contact with the carpet. Carpet beetle dermatitis is becoming more common on the east coast. Patients can actually find these beetles, which have tiger-striped coloring and have little prickly hairs that stick out of them, in their carpets. The beetles do not bite; rather, the rash is a reaction from exposure to insect blood or the larval hairs. The adult beetles tend to feed on carpet fabrics, wool, grains of food products, animal material, or nectar and pollen in flowers. The treatment is to get rid of the beetles. To rid the house of the beetles, it is recommended to vacuum, remove contaminated food sources, freeze stuffed animals for 10-14 days, and have an exterminator visit the home. Bringing in fresh cut flowers from the garden without rinsing them may bring the beetles into the house.
Scabies tends to be an itchy, widespread dermatosis. It is associated with extensive small skin papules scattered across the body with linear or curvilinear burrows, and tends to present from the elbows or knees distally, and especially in webbed areas, such as between the fingers. Keeping these geographic locations in mind makes it easier to differentiate scabies from hand dermatitis and eczema, said Dr. Yan, chief of pediatric dermatology at Children’s Hospital of Philadelphia and professor of pediatrics and dermatology at the University of Pennsylvania, Philadelphia.
To help diagnose this infestation, scrape the lesion and visualize the mite, the scybala or mite feces, or the oval eggs under the microscope.
The treatment is a “permethrin party.” Luckily, the scabies mite has very little documented resistance to permethrin 5% cream. However, with recurrent treatment, resistance starts to develop, he said. Proper administration is critical in controlling the infestation. For an adult, use 3 ounces or one tube, and for a child, use about 1.5 ounces for a child or one-half a tube. Apply it to the skin from neck down, leave it on for 8 hours overnight. Treat the patient and family members or close contacts. Repeat this application in 1 week. Oral ivermectin is effective and is useful in older kids who may not adhere to the permethrin.
A commonly encountered problem is apparent treatment failure. The scabies may be identified, treated, and then they appear to recur. Some patients have persistent postscabetic itch – the patients are still itchy afterward, but the lesions look excoriated and different than the original scabies lesions. The patient does not need retreatment, Dr. Yan emphasized. Rather, use topical corticosteroids or antihistamines to treat the itch.
Another explanation is improper use of medication – for instance, only certain parts of the skin were treated or all family members had not been treated. In this case, everyone needs to be retreated, he said. Reinfection is possible, but resistance is unlikely. Patients with scabies sometimes develop scabetic nodules or hypersensitivity nodules. Often, these are leftover areas of inflammation that can remain for up to 1 year. Dr. Yan recommends treating these areas with low-dose topical steroids.
The last phenomena presents with recurrent crops of pustules in the acral area, which is acropustulosis of infancy or postscabetic pustulosis. This is a variant of acropustulosis of infancy, in that it is more likely to involve the torso than is traditional acropustulosis and tends to be cyclical in that it reappears every few weeks.
Recently, the Journal of Medical Entomology published study findings in which head lice genetics were assessed, raising the concern about the development of “super lice.” However, this information has not yet brought treatment changes.
The conventional treatments include Nix, Rid, Triple X, but there can be a fair amount of resistance with these OTC treatment. Other options include mayonnaise and olive oil, however, not much data support the efficacy of this treatment. There are three prescription medications available: benzyl alcohol lotion, spinosad topical suspension, and ivermectin lotion. Start with these treatments quickly when dealing with lice that are resistant. Oral ivermectin also is effective. Dr. Yan concluded his lecture with discussion of other techniques that have been Food and Drug Administration–cleared, such as blowing drying them off the head, if one is okay with them landing in the office!
Dr. Yan reported no relevant financial disclosures.
Pruritic bug infestations are a common problem among school-age children, Albert C. Yan, MD, said at a pediatric dermatology meeting sponsored by Rady Children’s Hospital-San Diego and UC San Diego School of Medicine.
– and it is essential for you to be able to recognize and treat these appropriately. You also need to know resistance patterns, and how to counsel patient on full treatment protocol.
Carpet beetle dermatitis presents in children with a history of spending lots of time on a carpet, presenting with nondescript itchy patches on skin areas that were in contact with the carpet. Carpet beetle dermatitis is becoming more common on the east coast. Patients can actually find these beetles, which have tiger-striped coloring and have little prickly hairs that stick out of them, in their carpets. The beetles do not bite; rather, the rash is a reaction from exposure to insect blood or the larval hairs. The adult beetles tend to feed on carpet fabrics, wool, grains of food products, animal material, or nectar and pollen in flowers. The treatment is to get rid of the beetles. To rid the house of the beetles, it is recommended to vacuum, remove contaminated food sources, freeze stuffed animals for 10-14 days, and have an exterminator visit the home. Bringing in fresh cut flowers from the garden without rinsing them may bring the beetles into the house.
Scabies tends to be an itchy, widespread dermatosis. It is associated with extensive small skin papules scattered across the body with linear or curvilinear burrows, and tends to present from the elbows or knees distally, and especially in webbed areas, such as between the fingers. Keeping these geographic locations in mind makes it easier to differentiate scabies from hand dermatitis and eczema, said Dr. Yan, chief of pediatric dermatology at Children’s Hospital of Philadelphia and professor of pediatrics and dermatology at the University of Pennsylvania, Philadelphia.
To help diagnose this infestation, scrape the lesion and visualize the mite, the scybala or mite feces, or the oval eggs under the microscope.
The treatment is a “permethrin party.” Luckily, the scabies mite has very little documented resistance to permethrin 5% cream. However, with recurrent treatment, resistance starts to develop, he said. Proper administration is critical in controlling the infestation. For an adult, use 3 ounces or one tube, and for a child, use about 1.5 ounces for a child or one-half a tube. Apply it to the skin from neck down, leave it on for 8 hours overnight. Treat the patient and family members or close contacts. Repeat this application in 1 week. Oral ivermectin is effective and is useful in older kids who may not adhere to the permethrin.
A commonly encountered problem is apparent treatment failure. The scabies may be identified, treated, and then they appear to recur. Some patients have persistent postscabetic itch – the patients are still itchy afterward, but the lesions look excoriated and different than the original scabies lesions. The patient does not need retreatment, Dr. Yan emphasized. Rather, use topical corticosteroids or antihistamines to treat the itch.
Another explanation is improper use of medication – for instance, only certain parts of the skin were treated or all family members had not been treated. In this case, everyone needs to be retreated, he said. Reinfection is possible, but resistance is unlikely. Patients with scabies sometimes develop scabetic nodules or hypersensitivity nodules. Often, these are leftover areas of inflammation that can remain for up to 1 year. Dr. Yan recommends treating these areas with low-dose topical steroids.
The last phenomena presents with recurrent crops of pustules in the acral area, which is acropustulosis of infancy or postscabetic pustulosis. This is a variant of acropustulosis of infancy, in that it is more likely to involve the torso than is traditional acropustulosis and tends to be cyclical in that it reappears every few weeks.
Recently, the Journal of Medical Entomology published study findings in which head lice genetics were assessed, raising the concern about the development of “super lice.” However, this information has not yet brought treatment changes.
The conventional treatments include Nix, Rid, Triple X, but there can be a fair amount of resistance with these OTC treatment. Other options include mayonnaise and olive oil, however, not much data support the efficacy of this treatment. There are three prescription medications available: benzyl alcohol lotion, spinosad topical suspension, and ivermectin lotion. Start with these treatments quickly when dealing with lice that are resistant. Oral ivermectin also is effective. Dr. Yan concluded his lecture with discussion of other techniques that have been Food and Drug Administration–cleared, such as blowing drying them off the head, if one is okay with them landing in the office!
Dr. Yan reported no relevant financial disclosures.
Contact dermatitis in children: The top 10 allergens
Contact dermatitis should be suspected in patients with eczematous dermatitis atypical in location, geometric or symmetric in distribution, or unresponsive to or worsened by common therapies, Dr. Catalina Matiz emphasized.
Allergic contact dermatitis is a complex disorder characterized by a type IV delayed-type hypersensitivity reaction that occurs when a patient’s skin is exposed to a substance easily penetrates the skin barrier.
Increasingly recognized in the United States, many pediatric patients are becoming sensitized to contact allergens found in personal care products, including skin care products, topical medications, and clothing.
A study published by Hill et al. in 2016 reviewed pediatric patch test studies to determine the top contact allergens in children (Expert Rev Clin Immunol. 2016;12[5]:551-61).
Dr. Matiz presented the top 10 allergens discovered by this group, and offered practical advice for allergen avoidance.
Topping the list in descending order are the following:
- Tixocortol pivalate (a corticosteroid).
- Propylene glycol.
- Methylchloroisothiazolinone (MCI)/methylisothiazolinone (MI).
- Formaldehyde.
- Cocamidopropyl betaine.
- Lanolin.
- Benzalkonium chloride.
- Fragrance and balsam of peru.
- Neomycin.
- Nickel.
Dr. Matiz educated meeting attendees on allergen-containing products and clinical correlations suggestive of allergic sensitization to common allergens. Tixocortol pivilate is a corticosteroid present in Class A corticosteroids including hydrocortisone acetate. She highlighted the cross reactivity between class A and class D2 corticosteroids including hydrocortisone butyrate and valerate.
“Usually topical corticosteroid–contact sensitivity manifests as a failure to improve or worsening of existing dermatitis,” emphasized Dr. Matiz of departments of dermatology and pediatrics at the university.
Propylene glycol, benzalkonium chloride, and neomycin also represent top contact allergens frequently found in topical medications. Similarly, lanolin contact sensitivity often presents as refractory or worsening atopic dermatitis. “Lanolin, also known as wool alcohol, is commonly found in emollients, medications, and personal care products used by atopic dermatitis patients,” Dr. Matiz stressed.
Methylchloroisothiazolinone/methylisothiazolinone represent preservatives commonly found in wet wipes, hypoallergenic, and sensitive skin products. This was the allergen of the year in 2013 and was subsequently removed from many wet wipe formulations and products in response.
In addition to acute management of allergic contact dermatitis with corticosteroids, Dr. Matiz further emphasized the importance of preemptive avoidance of the top ten allergens.
She recommends patch testing if no clinical improvement is evident after 8 weeks of common allergen avoidance, for definitive allergen identification.
Dr. Matiz said she had no relevant financial disclosures.
Contact dermatitis should be suspected in patients with eczematous dermatitis atypical in location, geometric or symmetric in distribution, or unresponsive to or worsened by common therapies, Dr. Catalina Matiz emphasized.
Allergic contact dermatitis is a complex disorder characterized by a type IV delayed-type hypersensitivity reaction that occurs when a patient’s skin is exposed to a substance easily penetrates the skin barrier.
Increasingly recognized in the United States, many pediatric patients are becoming sensitized to contact allergens found in personal care products, including skin care products, topical medications, and clothing.
A study published by Hill et al. in 2016 reviewed pediatric patch test studies to determine the top contact allergens in children (Expert Rev Clin Immunol. 2016;12[5]:551-61).
Dr. Matiz presented the top 10 allergens discovered by this group, and offered practical advice for allergen avoidance.
Topping the list in descending order are the following:
- Tixocortol pivalate (a corticosteroid).
- Propylene glycol.
- Methylchloroisothiazolinone (MCI)/methylisothiazolinone (MI).
- Formaldehyde.
- Cocamidopropyl betaine.
- Lanolin.
- Benzalkonium chloride.
- Fragrance and balsam of peru.
- Neomycin.
- Nickel.
Dr. Matiz educated meeting attendees on allergen-containing products and clinical correlations suggestive of allergic sensitization to common allergens. Tixocortol pivilate is a corticosteroid present in Class A corticosteroids including hydrocortisone acetate. She highlighted the cross reactivity between class A and class D2 corticosteroids including hydrocortisone butyrate and valerate.
“Usually topical corticosteroid–contact sensitivity manifests as a failure to improve or worsening of existing dermatitis,” emphasized Dr. Matiz of departments of dermatology and pediatrics at the university.
Propylene glycol, benzalkonium chloride, and neomycin also represent top contact allergens frequently found in topical medications. Similarly, lanolin contact sensitivity often presents as refractory or worsening atopic dermatitis. “Lanolin, also known as wool alcohol, is commonly found in emollients, medications, and personal care products used by atopic dermatitis patients,” Dr. Matiz stressed.
Methylchloroisothiazolinone/methylisothiazolinone represent preservatives commonly found in wet wipes, hypoallergenic, and sensitive skin products. This was the allergen of the year in 2013 and was subsequently removed from many wet wipe formulations and products in response.
In addition to acute management of allergic contact dermatitis with corticosteroids, Dr. Matiz further emphasized the importance of preemptive avoidance of the top ten allergens.
She recommends patch testing if no clinical improvement is evident after 8 weeks of common allergen avoidance, for definitive allergen identification.
Dr. Matiz said she had no relevant financial disclosures.
Contact dermatitis should be suspected in patients with eczematous dermatitis atypical in location, geometric or symmetric in distribution, or unresponsive to or worsened by common therapies, Dr. Catalina Matiz emphasized.
Allergic contact dermatitis is a complex disorder characterized by a type IV delayed-type hypersensitivity reaction that occurs when a patient’s skin is exposed to a substance easily penetrates the skin barrier.
Increasingly recognized in the United States, many pediatric patients are becoming sensitized to contact allergens found in personal care products, including skin care products, topical medications, and clothing.
A study published by Hill et al. in 2016 reviewed pediatric patch test studies to determine the top contact allergens in children (Expert Rev Clin Immunol. 2016;12[5]:551-61).
Dr. Matiz presented the top 10 allergens discovered by this group, and offered practical advice for allergen avoidance.
Topping the list in descending order are the following:
- Tixocortol pivalate (a corticosteroid).
- Propylene glycol.
- Methylchloroisothiazolinone (MCI)/methylisothiazolinone (MI).
- Formaldehyde.
- Cocamidopropyl betaine.
- Lanolin.
- Benzalkonium chloride.
- Fragrance and balsam of peru.
- Neomycin.
- Nickel.
Dr. Matiz educated meeting attendees on allergen-containing products and clinical correlations suggestive of allergic sensitization to common allergens. Tixocortol pivilate is a corticosteroid present in Class A corticosteroids including hydrocortisone acetate. She highlighted the cross reactivity between class A and class D2 corticosteroids including hydrocortisone butyrate and valerate.
“Usually topical corticosteroid–contact sensitivity manifests as a failure to improve or worsening of existing dermatitis,” emphasized Dr. Matiz of departments of dermatology and pediatrics at the university.
Propylene glycol, benzalkonium chloride, and neomycin also represent top contact allergens frequently found in topical medications. Similarly, lanolin contact sensitivity often presents as refractory or worsening atopic dermatitis. “Lanolin, also known as wool alcohol, is commonly found in emollients, medications, and personal care products used by atopic dermatitis patients,” Dr. Matiz stressed.
Methylchloroisothiazolinone/methylisothiazolinone represent preservatives commonly found in wet wipes, hypoallergenic, and sensitive skin products. This was the allergen of the year in 2013 and was subsequently removed from many wet wipe formulations and products in response.
In addition to acute management of allergic contact dermatitis with corticosteroids, Dr. Matiz further emphasized the importance of preemptive avoidance of the top ten allergens.
She recommends patch testing if no clinical improvement is evident after 8 weeks of common allergen avoidance, for definitive allergen identification.
Dr. Matiz said she had no relevant financial disclosures.
Pediatric psoriasis may have a distinct presentation
Children may have a distinctive presentation of psoriasis, compared with adults, Dr. Wynnis Tom said at a pediatric dermatology meeting sponsored by Rady Children’s Hospital–San Diego and UC San Diego School of Medicine.
Infants may present with diaper involvement, also known as “napkin psoriasis,” which may be confused with irritant dermatitis or perineal infections. Moreover, guttate psoriasis, which can be preceded by infectious triggers such as Streptococcus and appears as small, salmon-pink bumps on the skin, is more frequent in children than adults, said Dr. Tom, associate professor of dermatology and pediatrics at the university.
Patients with psoriasis are at higher risk for psychiatric disorders, especially depression and anxiety. A study by Varni et al. discussed QOL ratings by 208 children aged 4-17 years with moderate to severe plaque disease. The study demonstrated a significant negative QOL impact in patients with plaque psoriasis, comparable to the impairment of QOL from arthritis or asthma (Eur J Pediatr. 2011 Sep 30;171[3]485-92).
Dr. Tom talked about other comorbidities associated with psoriasis, including psoriatic arthritis, and encouraged physicians to inquire about morning stiffness, joint pains, swelling, and gait abnormalities. “Psoriatic arthritis occurs in about 10% of children, and it is essential to detect early to prevent permanent joint damage,” she said. “Over the past decade, psoriasis has resurfaced as a systemic disorder as it may be associated with obesity, metabolic syndrome, and inflammatory bowel disease.” Psoriasis also entails an increased risk for cardiovascular disease, myocardial infarction, and stroke.
Dr. Tom emphasized, “because of these risks, we need to extend comorbidity screening to the pediatric population.”
Management of pediatric psoriasis has focused on topical and systemic therapies, in addition to phototherapies. Most systemic agents are used off-label on the basis of experience rather than evidence. Clinical trials are currently underway to extend indications for systemic therapy to the pediatric age group, she said.
Dr. Tom disclosed she is an investigator for Promius Pharma, Celgene, and Janssen.
Children may have a distinctive presentation of psoriasis, compared with adults, Dr. Wynnis Tom said at a pediatric dermatology meeting sponsored by Rady Children’s Hospital–San Diego and UC San Diego School of Medicine.
Infants may present with diaper involvement, also known as “napkin psoriasis,” which may be confused with irritant dermatitis or perineal infections. Moreover, guttate psoriasis, which can be preceded by infectious triggers such as Streptococcus and appears as small, salmon-pink bumps on the skin, is more frequent in children than adults, said Dr. Tom, associate professor of dermatology and pediatrics at the university.
Patients with psoriasis are at higher risk for psychiatric disorders, especially depression and anxiety. A study by Varni et al. discussed QOL ratings by 208 children aged 4-17 years with moderate to severe plaque disease. The study demonstrated a significant negative QOL impact in patients with plaque psoriasis, comparable to the impairment of QOL from arthritis or asthma (Eur J Pediatr. 2011 Sep 30;171[3]485-92).
Dr. Tom talked about other comorbidities associated with psoriasis, including psoriatic arthritis, and encouraged physicians to inquire about morning stiffness, joint pains, swelling, and gait abnormalities. “Psoriatic arthritis occurs in about 10% of children, and it is essential to detect early to prevent permanent joint damage,” she said. “Over the past decade, psoriasis has resurfaced as a systemic disorder as it may be associated with obesity, metabolic syndrome, and inflammatory bowel disease.” Psoriasis also entails an increased risk for cardiovascular disease, myocardial infarction, and stroke.
Dr. Tom emphasized, “because of these risks, we need to extend comorbidity screening to the pediatric population.”
Management of pediatric psoriasis has focused on topical and systemic therapies, in addition to phototherapies. Most systemic agents are used off-label on the basis of experience rather than evidence. Clinical trials are currently underway to extend indications for systemic therapy to the pediatric age group, she said.
Dr. Tom disclosed she is an investigator for Promius Pharma, Celgene, and Janssen.
Children may have a distinctive presentation of psoriasis, compared with adults, Dr. Wynnis Tom said at a pediatric dermatology meeting sponsored by Rady Children’s Hospital–San Diego and UC San Diego School of Medicine.
Infants may present with diaper involvement, also known as “napkin psoriasis,” which may be confused with irritant dermatitis or perineal infections. Moreover, guttate psoriasis, which can be preceded by infectious triggers such as Streptococcus and appears as small, salmon-pink bumps on the skin, is more frequent in children than adults, said Dr. Tom, associate professor of dermatology and pediatrics at the university.
Patients with psoriasis are at higher risk for psychiatric disorders, especially depression and anxiety. A study by Varni et al. discussed QOL ratings by 208 children aged 4-17 years with moderate to severe plaque disease. The study demonstrated a significant negative QOL impact in patients with plaque psoriasis, comparable to the impairment of QOL from arthritis or asthma (Eur J Pediatr. 2011 Sep 30;171[3]485-92).
Dr. Tom talked about other comorbidities associated with psoriasis, including psoriatic arthritis, and encouraged physicians to inquire about morning stiffness, joint pains, swelling, and gait abnormalities. “Psoriatic arthritis occurs in about 10% of children, and it is essential to detect early to prevent permanent joint damage,” she said. “Over the past decade, psoriasis has resurfaced as a systemic disorder as it may be associated with obesity, metabolic syndrome, and inflammatory bowel disease.” Psoriasis also entails an increased risk for cardiovascular disease, myocardial infarction, and stroke.
Dr. Tom emphasized, “because of these risks, we need to extend comorbidity screening to the pediatric population.”
Management of pediatric psoriasis has focused on topical and systemic therapies, in addition to phototherapies. Most systemic agents are used off-label on the basis of experience rather than evidence. Clinical trials are currently underway to extend indications for systemic therapy to the pediatric age group, she said.
Dr. Tom disclosed she is an investigator for Promius Pharma, Celgene, and Janssen.
Identifying the four key findings in patients with suspected severe drug reactions
There are four key findings in patients with suspected severe drug reactions: a high risk medication, mucosal involvement, presence of pustules, and laboratory abnormalities, especially a CBC with differential and liver function tests, James R. Treat, MD, said at a pediatric dermatology meeting sponsored by Rady Children’s Hospital–San Diego and UC San Diego School of Medicine.
Several cutaneous drug reactions that were discussed during the conference included acute generalized exanthematous pustulosis (AGEP), a drug reaction with eosinophilia and systemic symptoms (DRESS), and Stevens-Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN).
AGEP is characterized by fever and generalized pustular eruption arising swiftly after administration of the causative drug. Such drugs include antibiotics, contrast agents, antifungals, and calcium channel blockers. Withdrawal of the offending drug and optimization of fluid and electrolyte balance are warranted in the management of AGEP. Topical steroids may decrease hospital length-of-stay and help with symptomatic treatment of AGEP, said Dr. Treat, a pediatric dermatologist at Children’s Hospital of Philadelphia and an assistant professor of pediatrics and dermatology at the Perelman School of Medicine at the University of Pennsylvania.
A DRESS, also known as drug hypersensitivity syndrome, or drug-induced hypersensitivity syndrome, is a skin eruption that generally occurs 2-6 weeks after the patient starts the offending medication. Clinical signs of this condition include ill-appearance, fever (greater than 100.4° F), facial and hand edema, lymphadenopathy, and lab abnormalities, including hypereosinophilia, atypical lymphocytosis, transaminitis, and human herpesvirus 6 reactivation. DRESS may be misdiagnosed as viral infection, Kawasaki’s disease, or SJS.
Commonly implicated drugs include antiepileptic drugs, antibiotics, HIV medications, and sulfa-containing medications.
“While withdrawal of the offending drug is promptly warranted, this condition may require other therapeutics, particularly if there is significant systemic involvement,” Dr. Treat emphasized. There is evidence that systemic steroids (1-2 mg/kg/day) and cyclosporine can help improve the disease course, although their use is off-label.
SJS and TEN are other severe cutaneous adverse reactions caused by Mycoplasma infection or medications, such as anticonvulsants, antibiotics, HIV medications, and sulfa-containing drugs. “These entities are characterized by an ill-appearing, febrile patient with painful skin and mucosal membrane involvement,” Dr. Treat described.
Mucosal predominance may be seen in cases associated with Mycoplasma and have been termed “Mycoplasma-induced rash and mucositis,” although the terminology is controversial. In a case series by Darren G. Gregory, MD, treatment with amniotic membrane transplantation applied to the eyelid margins, palpebral conjunctiva, and ocular surface during the acute phases of SJS and TEN has been shown to be effective, decreasing the risk of significant oculovisual sequelae (Ophthalmol. 2011 May;118[5]:908-14).
Diagnostic criteria have been detailed to classify each of these adverse reactions. Dr. Treat concluded his lecture with a discussion of a retrospective study by Bouvresse et al. that projected AGEP, DRESS, and SJS-TEN as distinct entities (Orphanet J Rare Dis. 2012. doi: 10.1186/1750-1172-7-72).
Dr. Treat reported having no relevant financial disclosures.
There are four key findings in patients with suspected severe drug reactions: a high risk medication, mucosal involvement, presence of pustules, and laboratory abnormalities, especially a CBC with differential and liver function tests, James R. Treat, MD, said at a pediatric dermatology meeting sponsored by Rady Children’s Hospital–San Diego and UC San Diego School of Medicine.
Several cutaneous drug reactions that were discussed during the conference included acute generalized exanthematous pustulosis (AGEP), a drug reaction with eosinophilia and systemic symptoms (DRESS), and Stevens-Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN).
AGEP is characterized by fever and generalized pustular eruption arising swiftly after administration of the causative drug. Such drugs include antibiotics, contrast agents, antifungals, and calcium channel blockers. Withdrawal of the offending drug and optimization of fluid and electrolyte balance are warranted in the management of AGEP. Topical steroids may decrease hospital length-of-stay and help with symptomatic treatment of AGEP, said Dr. Treat, a pediatric dermatologist at Children’s Hospital of Philadelphia and an assistant professor of pediatrics and dermatology at the Perelman School of Medicine at the University of Pennsylvania.
A DRESS, also known as drug hypersensitivity syndrome, or drug-induced hypersensitivity syndrome, is a skin eruption that generally occurs 2-6 weeks after the patient starts the offending medication. Clinical signs of this condition include ill-appearance, fever (greater than 100.4° F), facial and hand edema, lymphadenopathy, and lab abnormalities, including hypereosinophilia, atypical lymphocytosis, transaminitis, and human herpesvirus 6 reactivation. DRESS may be misdiagnosed as viral infection, Kawasaki’s disease, or SJS.
Commonly implicated drugs include antiepileptic drugs, antibiotics, HIV medications, and sulfa-containing medications.
“While withdrawal of the offending drug is promptly warranted, this condition may require other therapeutics, particularly if there is significant systemic involvement,” Dr. Treat emphasized. There is evidence that systemic steroids (1-2 mg/kg/day) and cyclosporine can help improve the disease course, although their use is off-label.
SJS and TEN are other severe cutaneous adverse reactions caused by Mycoplasma infection or medications, such as anticonvulsants, antibiotics, HIV medications, and sulfa-containing drugs. “These entities are characterized by an ill-appearing, febrile patient with painful skin and mucosal membrane involvement,” Dr. Treat described.
Mucosal predominance may be seen in cases associated with Mycoplasma and have been termed “Mycoplasma-induced rash and mucositis,” although the terminology is controversial. In a case series by Darren G. Gregory, MD, treatment with amniotic membrane transplantation applied to the eyelid margins, palpebral conjunctiva, and ocular surface during the acute phases of SJS and TEN has been shown to be effective, decreasing the risk of significant oculovisual sequelae (Ophthalmol. 2011 May;118[5]:908-14).
Diagnostic criteria have been detailed to classify each of these adverse reactions. Dr. Treat concluded his lecture with a discussion of a retrospective study by Bouvresse et al. that projected AGEP, DRESS, and SJS-TEN as distinct entities (Orphanet J Rare Dis. 2012. doi: 10.1186/1750-1172-7-72).
Dr. Treat reported having no relevant financial disclosures.
There are four key findings in patients with suspected severe drug reactions: a high risk medication, mucosal involvement, presence of pustules, and laboratory abnormalities, especially a CBC with differential and liver function tests, James R. Treat, MD, said at a pediatric dermatology meeting sponsored by Rady Children’s Hospital–San Diego and UC San Diego School of Medicine.
Several cutaneous drug reactions that were discussed during the conference included acute generalized exanthematous pustulosis (AGEP), a drug reaction with eosinophilia and systemic symptoms (DRESS), and Stevens-Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN).
AGEP is characterized by fever and generalized pustular eruption arising swiftly after administration of the causative drug. Such drugs include antibiotics, contrast agents, antifungals, and calcium channel blockers. Withdrawal of the offending drug and optimization of fluid and electrolyte balance are warranted in the management of AGEP. Topical steroids may decrease hospital length-of-stay and help with symptomatic treatment of AGEP, said Dr. Treat, a pediatric dermatologist at Children’s Hospital of Philadelphia and an assistant professor of pediatrics and dermatology at the Perelman School of Medicine at the University of Pennsylvania.
A DRESS, also known as drug hypersensitivity syndrome, or drug-induced hypersensitivity syndrome, is a skin eruption that generally occurs 2-6 weeks after the patient starts the offending medication. Clinical signs of this condition include ill-appearance, fever (greater than 100.4° F), facial and hand edema, lymphadenopathy, and lab abnormalities, including hypereosinophilia, atypical lymphocytosis, transaminitis, and human herpesvirus 6 reactivation. DRESS may be misdiagnosed as viral infection, Kawasaki’s disease, or SJS.
Commonly implicated drugs include antiepileptic drugs, antibiotics, HIV medications, and sulfa-containing medications.
“While withdrawal of the offending drug is promptly warranted, this condition may require other therapeutics, particularly if there is significant systemic involvement,” Dr. Treat emphasized. There is evidence that systemic steroids (1-2 mg/kg/day) and cyclosporine can help improve the disease course, although their use is off-label.
SJS and TEN are other severe cutaneous adverse reactions caused by Mycoplasma infection or medications, such as anticonvulsants, antibiotics, HIV medications, and sulfa-containing drugs. “These entities are characterized by an ill-appearing, febrile patient with painful skin and mucosal membrane involvement,” Dr. Treat described.
Mucosal predominance may be seen in cases associated with Mycoplasma and have been termed “Mycoplasma-induced rash and mucositis,” although the terminology is controversial. In a case series by Darren G. Gregory, MD, treatment with amniotic membrane transplantation applied to the eyelid margins, palpebral conjunctiva, and ocular surface during the acute phases of SJS and TEN has been shown to be effective, decreasing the risk of significant oculovisual sequelae (Ophthalmol. 2011 May;118[5]:908-14).
Diagnostic criteria have been detailed to classify each of these adverse reactions. Dr. Treat concluded his lecture with a discussion of a retrospective study by Bouvresse et al. that projected AGEP, DRESS, and SJS-TEN as distinct entities (Orphanet J Rare Dis. 2012. doi: 10.1186/1750-1172-7-72).
Dr. Treat reported having no relevant financial disclosures.