PEDIATRIC DERMATOLOGY

Jun
2010
Vol. 29. No. 2

Introduction

Pediatric dermatology lends itself beautifully to application of both the science and the art of medicine. Pediatric patients often present a unique set of challenges apart from complex cutaneous diseases. This subset of patients demands both sophisticated knowledge of medical dermatology and skillful delivery of care to newborns accompanied by anxious parents, wiggly 2 year-olds, delightful but terrified toddlers, and occasionally ambivalent adolescents. The diversity of ages, diseases, and family dynamics faced by dermatologists caring for children requires both intellectual and emotional engagement in the pursuit of practical, safe, and effective diagnostic and management strategies. Evidence-based medicine, which aims to apply the best available evidence to medical decision making, is lacking for most pediatric skin disorders. When quality evidence is not available, expert consensus often serves as the gold standard of care. This group of articles represents that reality. Within the following pages, you will find a compelling combination of state-of-the-art, evidence-based reviews admixed with expert opinion from leaders in the field of pediatric dermatology. True to the mission of Seminars in Cutaneous Medicine and Surgery, this edition delivers the most current information on diagnosis and management as well as application of the latest scientific advances in the vibrant and rapidly evolving field of pediatric dermatology. It has been an honor and a privilege to assemble and collaborate with the group of passionate and knowledgeable authors whose intellectually rigorous work fills these pages. The pieces are presented in no particular order and include thorough discussions of challenging pediatric topics, such as the true role of food allergy in atopic dermatitis, state-of-the-art management of infantile hemangiomas, autoimmune blistering diseases, and hyperhidrosis. In addition, you will find in-depth reviews of large congenital melanocytic nevi, graft-versus-host disease, phototherapy in children, genetics for the dermatologist, and the difficult issue of compliance in pediatric patients. I invite you to enjoy the material presented herein. The ultimate beneficiaries of this work are our patients and their families.

Autoimmune Blistering Diseases in Children

Elena Pope, MD, MSc | Irene Lara-Corrales, MD, MSc

Autoimmune blistering disorders comprise a series of conditions in which autoantibodies
target components of the skin and mucous membranes, leading to blister and bullae
formation. Most conditions in the spectrum of autoimmune blistering disorders are uncommonly
seen in the pediatric population, even the most common ones, such as chronic
bullous disease of childhood and dermatitis herpetiformis; however, they often come into
the differential diagnosis of other more common pediatric entities. In addition, prompt
recognition and treatment avoids unnecessary morbidity and improves ultimate outcome.
Semin Cutan Med Surg 29:85-91 © 2010 Published by Elsevier Inc.

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Clinical Update on Graft- Versus-Host Disease in Children

Biljana N. Horn, MD | Deborah S. Goddard, MD | Kelly M. Cordoro, MD | Timothy H. McCalmont, MD

The last decade has yielded many significant advances in hematopoietic transplantation
techniques, immunomodulatory prophylaxis, and diagnostic and treatment approaches to
acute and chronic graft-versus-host disease (GVHD). Unfortunately, GVHD remains the
cardinal complication in allogeneic hematopoietic stem cell transplantation, with significant
associated rates of morbidity and mortality. In this review, we highlight the numerous
strides that have been made in making hematopoietic transplantation more successful and
provide an update on the clinical and histopathological features of both acute and chronic
GVHD in the pediatric population. It is critical for dermatologists to be aware of the
characteristic features of cutaneous acute and chronic GVHD and to remain up to date on
the evolving spectrum of these conditions. We discuss 5 cases with clinico-pathologic
correlation to illustrate the key concepts and principles underlying the diagnosis and
management of both acute and chronic GVHD.
Semin Cutan Med Surg 29:92-105 © 2010 Published by Elsevier Inc.

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Current Management of Infantile Hemangiomas

Ilona J. Frieden, MD | Sheilagh M. Maguiness, MD

During the past several years, there have been new advancements in the management of
infantile hemangiomas (IHs). In many patients, no treatment is ever necessary—because
IHs are well known for their natural history of spontaneous involution. However, a significant
minority of hemangiomas do require treatment. Moreover, they are very heterogeneous,
making the decision of when, how, and why to intervene quite variable. The least
common but most important rationale for intervention is the presence of a life- or functionthreatening
complication, where prompt therapeutic intervention is a necessity. A much
more common scenario is ulceration, where appropriate management is needed to expedite
healing and control pain. Increasingly, the life-altering aspects of hemangioma are being
recognized as a rationale for treatment because permanent scarring and disfigurement can
result even if involution is complete. Treatments for IHs currently include topical, intralesional,
and systemic therapies. Laser and surgical modalities are also sometimes used
depending on the clinical scenario. In the absence of rigorous evidence-based studies,
clinicians must carefully weigh the risks and benefits of medical or surgical treatments
versus observation alone in tailoring management to the specific clinical situation at hand.
Semin Cutan Med Surg 29:106-114 © 2010 Elsevier Inc. All rights reserved.

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Diagnosis and Treatment of Primary Focal Hyperhidrosis in Children and Adolescents

Jane Sanders Bellet, MD

Primary focal hyperhidrosis is a disorder of excessive sweating that occurs in the axillae,
palms, soles, and craniofacial region in amounts greater than needed for thermal regulation.
Although the etiology is unknown, this disorder can cause significant emotional and
social distress. The focus of this paper is the diagnosis and treatment of primary focal
hyperhidrosis in children and adolescents.
Semin Cutan Med Surg 29:121-126 © 2010 Published by Elsevier Inc.

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Food Allergy and Atopic Dermatitis: Separating Fact from Fiction

Ki-Young Suh, MD

The relationship between food and atopic dermatitis (AD) is complex. A common misunderstanding
is that food allergies have a significant impact on the course of AD, resulting
in uncontrolled attempts at elimination diets and undertreatment of the skin itself. Studies
have shown that only a small portion of cutaneous reactions to food in the form of late,
eczematous eruptions will directly exacerbate AD in young infants who have moderate-tosevere
AD. Given the low frequency of food allergies actually inducing flares of AD, the
focus should return to appropriate skin therapy, and identification of true food allergies
should be reserved for recalcitrant AD in children in whom the suspicion for food allergy is
high. A different relationship between food and AD involves delaying or preventing AD in
high-risk infants by exclusive breastfeeding during the first 4 months of life. Finally, the skin
barrier defect in AD may allow for easier and earlier sensitization of food and airborne
allergens; therefore, exposure of food proteins on AD skin may act as a risk factor for
development of food allergies.
Semin Cutan Med Surg 29:72-78 © 2010 Published by Elsevier Inc.

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