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Holm A, Mulliken JB, Bischoff J. Infantile hemangioma: the common and enigmatic vascular tumor. J Clin Invest 2024; 134:e172836. [PMID: 38618963 PMCID: PMC11014660 DOI: 10.1172/jci172836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024] Open
Abstract
Infantile hemangioma (IH) is a benign vascular tumor that occurs in 5% of newborns. The tumor follows a life cycle of rapid proliferation in infancy, followed by slow involution in childhood. This unique life cycle has attracted the interest of basic and clinical scientists alike as a paradigm for vasculogenesis, angiogenesis, and vascular regression. Unanswered questions persist about the genetic and molecular drivers of the proliferating and involuting phases. The beta blocker propranolol usually accelerates regression of problematic IHs, yet its mechanism of action on vascular proliferation and differentiation is unclear. Some IHs fail to respond to beta blockers and regrow after discontinuation. Side effects occur and long-term sequelae of propranolol treatment are unknown. This poses clinical challenges and raises novel questions about the mechanisms of vascular overgrowth in IH.
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Affiliation(s)
- Annegret Holm
- Vascular Biology Program and Department of Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University Hospital Freiburg, VASCERN-VASCA European Reference Center, Freiburg, Germany
| | - John B. Mulliken
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
- Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Joyce Bischoff
- Vascular Biology Program and Department of Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
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Adams L, Ryan E. Immediate possible adverse event rates in infants treated with oral propranolol for infantile haemangiomas at an Australian urban tertiary hospital between 2016 and 2019. Australas J Dermatol 2022; 63:473-478. [PMID: 35938573 DOI: 10.1111/ajd.13906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 06/29/2022] [Accepted: 07/17/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES Infantile haemangiomas (IH) are common benign tumours of childhood. The current guideline recommended treatment is oral propranolol, the use of which for IH is relatively recent and there are no safety audits in Australian children published. As a result, it is a primarily inpatient initiated treatment. The aim of this study was to examine the short-term complication rates in infants treated with oral propranolol for IH. METHODS Retrospective case note review of IH patients initiated on oral propranolol admitted to the day-unit of tertiary metropolitan hospital in an Australia capital city, from January 2016 to December 2019. RESULTS Overall, 72 children were included in the study. Mean age at time of admission was 3.8 ± 2 months. Eight patients (11.1%) experienced complications during their initiation admission. Pulmonary complications (oxygen desaturation, wheeze, increased respiratory rate) was the most common type. No children required high-dependency or intensive care unit admission. The children who experienced complications had a mean age of 2.4 ± 1.2 months; t-test of equality of means found a relationship between propranolol-associated complication rate and age (p = 0.007). All other patient or admission characteristics were not associated with complication events (all p > 0.05). CONCLUSIONS Propranolol is a safe, effective and well-tolerated treatment in Australian children with IH. This study demonstrates younger infants will most likely benefit from inpatient initiation. More research needs to be done to characterise the risk profile of propranolol initiation for IH.
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Affiliation(s)
- Lucinda Adams
- Division of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Emma Ryan
- Division of Medicine, University of Adelaide, Adelaide, South Australia, Australia.,Dermatology Department, Women's and Children's Hospital, Adelaide, South Australia, Australia
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Abstract
Infantile hemangioma (IH) is the most common benign vascular tumor of infancy, affecting about 5% of infants. It has a characteristic growth pattern of early rapid proliferation followed by progressive involution. Although most IH evolve favorably, complications are observed in 10-15% of cases, justifying treatment. For over 10 years now, propranolol has become the first-line therapy for complicated IH, revolutionizing their management and their prognosis. In this article, we review the clinical features, associations, complications/sequelae and therapeutic approaches for IH, focusing on current medical therapy. Indications for treatment and various treatment options, including propranolol and other oral β-blockers, topical timolol, and corticosteroids are presented. Current controversies regarding oral propranolol such as pre-treatment screening, in- vs out-patient initiation of treatment, early and potential long-term side effects and recommended monitoring are discussed.
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Affiliation(s)
- Caroline Colmant
- Division of Pediatric Dermatology, Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal, QC, Canada.
| | - Julie Powell
- Division of Pediatric Dermatology, Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal, QC, Canada
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Sebaratnam DF, Rodríguez Bandera AL, Wong LCF, Wargon O. Infantile hemangioma. Part 2: Management. J Am Acad Dermatol 2021; 85:1395-1404. [PMID: 34419523 DOI: 10.1016/j.jaad.2021.08.020] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/25/2021] [Accepted: 08/03/2021] [Indexed: 12/18/2022]
Abstract
The majority of infantile hemangiomas (IH) can be managed conservatively, but for those requiring active treatment, management has been revolutionized in the last decade by the discovery of propranolol. Patients that may require active intervention should receive specialist review, ideally before 5 weeks of age to mitigate the risk of sequelae. Propranolol can commence for most infants in the outpatient setting and the most frequently employed dosing regimen is 1 mg/kg twice daily. In the future, β-blockers with a more-selective mechanism of action, such as atenolol, show some promise. In recalcitrant lesions, systemic corticosteroids or sirolimus may be considered. For small, superficial IHs, topical timolol maleate or pulsed dye laser may be considered. Where the IH involutes with cutaneous sequelae, a range of interventions have been reported, including surgery, laser, and embolization. IHs have a well-described clinical trajectory and are readily diagnosed and managed via telemedicine. Algorithms have been constructed to stratify those patients who can be managed remotely from those who warrant in-person review during the COVID-19 pandemic.
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Affiliation(s)
- Deshan F Sebaratnam
- The Children's Hospital at Westmead, Sydney, Australia; Liverpool Hospital, Sydney, Australia.
| | | | | | - Orli Wargon
- Sydney Children's Hospital, Sydney, Australia
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Satterfield KR, Chambers CB. Current treatment and management of infantile hemangiomas. Surv Ophthalmol 2019; 64:608-618. [PMID: 30772366 DOI: 10.1016/j.survophthal.2019.02.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 01/27/2019] [Accepted: 02/04/2019] [Indexed: 12/19/2022]
Abstract
Infantile hemangiomas, otherwise known as infantile capillary hemangiomas, strawberry hemangiomas, or strawberry nevi, are nonmalignant vascular tumors that commonly affect children. The natural disease course typically involves growth for up to a year, followed by regression without treatment over a period of years with no cosmetic or functional sequelae. Less commonly, however, infantile hemangiomas can become a threat to vision or even life depending on location and size of the lesion. In addition, infantile hemangiomas, particularly those involving the face, may be disfiguring and result in lifelong sequelae. β-blockers have become a mainstay of therapy given their relatively low-risk profile and efficacy. Other treatment modalities previously described in the literature include corticosteroids (both intralesional and systemic), imiquimod, vincristine, bleomycin A5, and interferon α. More recently, angiotensin-converting enzyme inhibitors such as captopril have been used. Laser therapy and, less commonly, surgical excision are also available treatment options. We review current recommended management and treatment of capillary hemangiomas and discuss the benefits and risks of all previously reported treatment modalities.
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Affiliation(s)
- Kellie R Satterfield
- Department of Medicine, Scripps Mercy Hospital, San Diego, California, USA; Department of Ophthalmology, University of Washington, Seattle, Washington DC, USA
| | - Christopher B Chambers
- Department of Ophthalmology, University of Washington, Seattle, Washington DC, USA; Department of Oculoplastic and Reconstructive Surgery, University of Washington, Seattle, Washington DC, USA.
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Krowchuk DP, Frieden IJ, Mancini AJ, Darrow DH, Blei F, Greene AK, Annam A, Baker CN, Frommelt PC, Hodak A, Pate BM, Pelletier JL, Sandrock D, Weinberg ST, Whelan MA. Clinical Practice Guideline for the Management of Infantile Hemangiomas. Pediatrics 2019; 143:peds.2018-3475. [PMID: 30584062 DOI: 10.1542/peds.2018-3475] [Citation(s) in RCA: 195] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Infantile hemangiomas (IHs) occur in as many as 5% of infants, making them the most common benign tumor of infancy. Most IHs are small, innocuous, self-resolving, and require no treatment. However, because of their size or location, a significant minority of IHs are potentially problematic. These include IHs that may cause permanent scarring and disfigurement (eg, facial IHs), hepatic or airway IHs, and IHs with the potential for functional impairment (eg, periorbital IHs), ulceration (that may cause pain or scarring), and associated underlying abnormalities (eg, intracranial and aortic arch vascular abnormalities accompanying a large facial IH). This clinical practice guideline for the management of IHs emphasizes several key concepts. It defines those IHs that are potentially higher risk and should prompt concern, and emphasizes increased vigilance, consideration of active treatment and, when appropriate, specialty consultation. It discusses the specific growth characteristics of IHs, that is, that the most rapid and significant growth occurs between 1 and 3 months of age and that growth is completed by 5 months of age in most cases. Because many IHs leave behind permanent skin changes, there is a window of opportunity to treat higher-risk IHs and optimize outcomes. Early intervention and/or referral (ideally by 1 month of age) is recommended for infants who have potentially problematic IHs. When systemic treatment is indicated, propranolol is the drug of choice at a dose of 2 to 3 mg/kg per day. Treatment typically is continued for at least 6 months and often is maintained until 12 months of age (occasionally longer). Topical timolol may be used to treat select small, thin, superficial IHs. Surgery and/or laser treatment are most useful for the treatment of residual skin changes after involution and, less commonly, may be considered earlier to treat some IHs.
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Affiliation(s)
- Daniel P Krowchuk
- Departments of Pediatrics and Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina;
| | - Ilona J Frieden
- Departments of Dermatology and Pediatrics, School of Medicine, University of California, San Francisco, San Francisco, California
| | - Anthony J Mancini
- Departments of Pediatrics and Dermatology, Feinberg School of Medicine, Northwestern University and Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - David H Darrow
- Departments of Otolaryngology and Pediatrics, Eastern Virginia Medical School and Children's Hospital of the King's Daughters, Norfolk, Virginia
| | - Francine Blei
- Donald and Barbara Zucker School of Medicine, Northwell Health, New York City, New York
| | - Arin K Greene
- Department of Plastic and Oral Surgery, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Aparna Annam
- Department of Radiology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado
| | - Cynthia N Baker
- Department of Pediatrics, Kaiser Permanente Medical Center, Los Angeles, California
| | - Peter C Frommelt
- Department of Pediatrics, Cardiology, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Amy Hodak
- American Board of Pediatrics, Chapel Hill, North Carolina
| | - Brian M Pate
- Department of Pediatrics, University of Kansas School of Medicine-Wichita, Wichita, Kansas
| | | | - Deborah Sandrock
- St Christopher's Hospital for Children and College of Medicine, Drexel University, Philadelphia, Pennsylvania
| | - Stuart T Weinberg
- Departments of Biomedical Informatics and Pediatrics, School of Medicine, Vanderbilt University, Nashville, Tennessee; and
| | - Mary Anne Whelan
- College of Physicians and Surgeons, Columbia University, New York City, New York
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González-Llorente N, Del Olmo-Benito I, Muñoz-Ollero N, Descalzo MA, García-Doval I, Torrelo A. Study of Cognitive Function in Children Treated with Propranolol for Infantile Hemangioma. Pediatr Dermatol 2017; 34:554-558. [PMID: 28804922 DOI: 10.1111/pde.13229] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Oral propranolol is considered the first choice for the treatment of infantile hemangiomas (IHs). There is a concern that administering propranolol in newborns and infants could induce adverse effects in learning and memory processes in the long term. The purpose of this study was to assess cognitive and memory functions in children who had been treated with propranolol for IH during their infancy. METHODS A total of 23 children between 5 and 7.5 years of age who had been treated with oral propranolol for IH during infancy were tested for cognitive functions with the Wechsler Preschool and Primary Scale of Intelligence, Fourth Edition (WPPSI-IV) test and for memory functions with the Test of Memory and Learning (TOMAL). RESULTS Comparison of our sample with a normal distribution by a Shapiro-Wilk W test showed no significant difference for any of the composite scores in the WPPSI-IV and TOMAL tests except for positive asymmetry and concentration of scores around average (p = 0.01) in the WPPSI-IV composite score (mean intelligence), due to one atypically high score. CONCLUSIONS The distribution of scores for intelligence and memory scales in our study population was similar to that in the reference general population. These results fail to support any significant disturbance in intelligence and memory development in children treated during infancy with propranolol for IH.
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Affiliation(s)
| | - Isabel Del Olmo-Benito
- Department of Learning & Speech-Language Pathology, Hospital del Niño Jesús, Madrid, Spain
| | - Natalia Muñoz-Ollero
- Department of Learning & Speech-Language Pathology, Hospital del Niño Jesús, Madrid, Spain
| | - Miguel Angel Descalzo
- Research Unit, Fundación Academia Española de Dermatología y Venereología, Madrid, Spain
| | - Ignacio García-Doval
- Research Unit, Fundación Academia Española de Dermatología y Venereología, Madrid, Spain
| | - Antonio Torrelo
- Department of Dermatology, Hospital del Niño Jesús, Madrid, Spain
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Moyakine AV, Kerstjens JM, Spillekom-van Koulil S, van der Vleuten CJM. Propranolol treatment of infantile hemangioma (IH) is not associated with developmental risk or growth impairment at age 4 years. J Am Acad Dermatol 2016; 75:59-63.e1. [DOI: 10.1016/j.jaad.2016.02.1218] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 02/19/2016] [Accepted: 02/21/2016] [Indexed: 11/19/2022]
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Techasatian L, Komwilaisak P, Panombualert S, Uppala R, Jetsrisuparb C. Propranolol was effective in treating cutaneous infantile haemangiomas in Thai children. Acta Paediatr 2016; 105:e257-62. [PMID: 26919396 DOI: 10.1111/apa.13378] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 10/29/2015] [Accepted: 02/19/2016] [Indexed: 12/28/2022]
Abstract
AIM The aim of this study was to explore the efficacy and safety of propranolol in treating infantile haemangiomas, the most common benign vascular tumours in children. METHODS We carried out a retrospective chart review of infantile haemangioma patients admitted to the Faculty of Medicine, Khon Kaen University, Thailand, from January 2009 to January 2015. RESULTS There were 53 infantile haemangioma cases treated with oral propranolol. Treatment responses occurred as early as two weeks after propranolol administration in 91.5% of the follow-up patients, with all 53 cases achieving the desired treatment responses two months after propranolol was initiated. No significant differences in treatment responses were found between propranolol as a mono-therapy or as a combination therapy with prednisolone at the two-week (p value 0.13) and one-month follow-ups (p value 0.98). Complications were documented in three cases (5.6%) when the propranolol dose was increased, and these were asymptomatic hypoglycaemia in two cases and one case of hypotension. CONCLUSION Propranolol was effective in treating infantile haemangiomas, and combining it with prednisolone achieved no significant differences in treatment outcome. Cases should be monitored for hypoglycaemia and hypotension. More data on using propranolol for infantile haemangiomas are needed, including long-term follow-up studies.
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Affiliation(s)
- Leelawadee Techasatian
- Division of Dermatology; Department of Pediatric; Faculty of Medicine; Khon Kaen University; Khon Kaen Thailand
| | - Patcharee Komwilaisak
- Department of Pediatric; Faculty of Medicine; Khon Kaen University; Khon Kaen Thailand
| | - Sunee Panombualert
- Department of Pediatric; Faculty of Medicine; Khon Kaen University; Khon Kaen Thailand
| | - Rattapon Uppala
- Department of Pediatric; Faculty of Medicine; Khon Kaen University; Khon Kaen Thailand
| | - Charoon Jetsrisuparb
- Division of Dermatology; Department of Pediatric; Faculty of Medicine; Khon Kaen University; Khon Kaen Thailand
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Moyakine AV, Vleuten CJMVD. Propranolol for infantile hemangioma: Current state of affairs. World J Dermatol 2016; 5:4-16. [DOI: 10.5314/wjd.v5.i1.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 10/19/2015] [Accepted: 12/14/2015] [Indexed: 02/06/2023] Open
Abstract
Infantile hemangioma (IH) is the most common benign tumor seen in infancy. This review provides up-to-date information on the pathophysiology, variations in clinical presentation, and natural history of IH, elaborating on associated anomalies, such as PHACE(S) syndrome and LUMBAR syndrome. Because of the benign and self-limiting characteristics seen in more than 90% of cases of IH, a conservative approach is usually chosen. However, some circumstances, such as ulceration, vision loss, breathing difficulties, or potential disfigurement, will require treatment during the proliferative phase. For decades, treatment of IH has primarily consisted of corticosteroids or surgery. Since 2008, propranolol has become the treatment of first choice. In this article, we bring to light the crucial changes in the treatment of IH over the past years. To date, there is still a lack of data on the possible long-term effects of propranolol treatment in young infants. A theoretical probability of the central nervous system being affected (that is, impairment of short- and long-term memory, psychomotor function, sleep quality, and mood) has recently been suggested. This review highlights research topics concerning these long-term adverse effects. Finally, information is provided on the potential instruments to measure IH severity and activity in clinical trials and/or in clinical practice and the recently developed and first-validated IH-specific quality-of-life questionnaire.
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Raphael MF, Breur JMPJ, Vlasveld FAE, Elbert NJ, Liem YTB, Kon M, Breugem CC, Pasmans SGMA. Treatment of infantile hemangiomas: therapeutic options in regard to side effects and adverse events – a review of the literature. Expert Opin Drug Saf 2016; 15:199-214. [DOI: 10.1517/14740338.2016.1130125] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Martine F. Raphael
- Department of Pediatric Dermatology and Allergology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Johannes M. P. J. Breur
- Department of Pediatric Cardiology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Florine A. E. Vlasveld
- Department of Pediatric Dermatology and Allergology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Niels J. Elbert
- Department of Pediatric Dermatology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Yves T. B. Liem
- Department of Clinical Pharmacy, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Moshe Kon
- Department of Pediatric Plastic Surgery, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Corstiaan C. Breugem
- Department of Pediatric Plastic Surgery, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Suzanne G. M. A. Pasmans
- Department of Pediatric Dermatology and Allergology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Pediatric Dermatology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
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