Allergic contact dermatitis in children: a practical approach to management

Allergic contact dermatitis (ACD) may account for at least 20% of all childhood dermatitis. Clinically, its morphology is identical to other forms of dermatitis in acute, subacute and chronic forms. A persistent or unusual and localized pattern is often the key to diagnosis. Treatment has centered around the use of corticosteroids, with the adjunct of antihistamines, wet dressings, and emollients for alleviation of symptoms. The newer topical immunosuppressives, tacrolimus and pimecrolimus, may also hold promise as alternative therapies, although they have not been well-studied in this regard. Allergen identification, sometimes through patch testing and allergen avoidance are the keys to preventing recurrences of this disease.

Kwashiorkor in the United States: fad diets, perceived and true milk allergy, and nutritional ignorance

BACKGROUND

Kwashiorkor is the edematous form of protein-energy malnutrition. It is associated with extreme poverty in developing countries and with chronic malabsorptive conditions such as cystic fibrosis in developed countries. Rare cases of kwashiorkor in affluent countries unrelated to chronic illness have been reported. We present 12 cases of kwashiorkor unrelated to chronic illness seen over 9 years by pediatric dermatologists throughout the United States, and discuss common causative themes in this easily preventable condition.

OBSERVATIONS

Twelve children were diagnosed as having kwashiorkor in 7 tertiary referral centers throughout the United States. The diagnoses were based on the characteristic rash and the overall clinical presentation. The rash consisted of an erosive, crusting, desquamating dermatitis sometimes with classic "pasted-on" scale-the so-called flaky paint sign. Most cases were due to nutritional ignorance, perceived milk intolerance, or food faddism. Half of the cases were the result of a deliberate deviation to a protein-deficient diet because of a perceived intolerance of formula or milk. Financial and social stresses were a factor in only 2 cases, and in both cases social chaos was more of a factor than an absolute lack of financial resources. Misleading dietary histories and the presence of edema masking growth failure obscured the clinical picture in some cases.

CONCLUSIONS

Physicians should consider the diagnosis of kwashiorkor in children with perceived milk allergies resulting in frequent dietary manipulations, in children following fad or unorthodox diets, or in children living in homes with significant social chaos. The presence of edema and "flaky paint" dermatitis should prompt a careful dietary investigation.

Unsuspected sporotrichosis in childhood

We report 10 prepubertal girls with sporotrichosis who were misdiagnosed because they had solitary ulcerative skin nodules, rather than a "sporotrichoid" pattern of multiple linear nodules. All had positive cultures for Sporothrix schenckii. We urge clinicians to consider sporotrichosis in the differential diagnosis of a solitary skin nodule.

Cutaneous manifestations of neonatal lupus without heart block: characteristics of mothers and children enrolled in a national registry

OBJECTIVE

To extend the information base on cutaneous manifestations of neonatal lupus erythematosus (NLE) with regard to maternal disease, sex of child, onset, localization, influence of UV light, prognosis, and recurrence rates in subsequent pregnancies.

METHODS

Review of records from the Research Registry for Neonatal Lupus.

RESULTS

The cohort includes 47 mothers (83% white) whose sera contain anti-SSA/Ro, anti-SSB/La, and/or anti-U1-ribonucleoprotein antibodies and their 57 infants (20 boys and 37 girls) diagnosed with cutaneous NLE (absent heart disease) between 1981 and 1997. At detection of the child's rash, 13 mothers were asymptomatic, 11 had an undifferentiated autoimmune syndrome (UAS), 9 had systemic lupus erythematosus (SLE), 7 Sjögren's syndrome (SS), 6 SLE/SS, and 1 rheumatoid arthritis/SS; 20 reported photosensitivity. Within 5 years, 7 asymptomatic mothers experienced disease progression: 1 developed photosensitivity, 2 SLE, 3 SS, 1 SLE/SS; in 2 mothers UAS progressed to SLE; and 2 mothers with SS developed SLE. The infant's rash often followed UV light exposure; mean age at detection was 6 weeks, and mean duration was 17 weeks. All had facial involvement (periorbital region most common) followed by the scalp, trunk, extremities, neck, and intertriginous areas. In 37, the rash resolved without sequelae, 43% of which were untreated. A quarter had residual sequelae that included telangiectasia and dyspigmentation. One child developed Hashimoto's thyroiditis, and 2 developed systemic-onset juvenile rheumatoid arthritis. Of 20 subsequent births, 7 children were healthy, 2 had congenital heart block (CHB) only, 4 CHB and skin rash, and 7 skin rash only.

CONCLUSIONS

Future pregnancies should be monitored by serial echocardiograms, given the substantial risk for heart block. Affected children should be observed for later development of a rheumatic disease.

Allergic contact dermatitis

Allergic contact dermatitis (ACD) in children is underrecognized. It is often confused with antibody-mediated allergies such as urticaria or allergic rhinitis, but the mechanism in ACD involves T lymphocytes and not antibody. Surprisingly, sensitization to common allergens is likely to occur in infancy. All contact allergens are weak allergens requiring repeated exposure over long periods of time. Detection of specific allergens is by epicutaneous (patch) testing and will provide the basis for allergen avoidance therapeutic strategies.

Benign cephalic histiocytosis with diabetes insipidus

Benign cephalic histiocytosis is a rare skin condition consisting of small tan papules on the face and upper trunk that is believed not to be associated with internal organ involvement. The infiltrating histiocytes are not Langerhans' cells (LCs). We report a 5-year-old girl who presented with diabetes insipidus 1 year after developing multiple small brown asymptomatic skin papules. Histologic examination revealed a non-LC histiocytic proliferation in the dermis without epidermal invasion. She had infiltration of the pituitary stalk on brain imaging. Diabetes insipidus has heretofore been associated with LC histiocytosis and xanthoma disseminatum but not benign cephalic histiocytosis.

Childhood pernio and cryoproteins

Childhood pernio is an uncommon condition described mainly through isolated case reports. We examined the cutaneous spectrum, clinical associations, presence of cryoproteins, and evolution of the condition in children, and performed a retrospective case series evaluation of children with pernio seen at a single ambulatory care university center over a 10-year period. Cases were drawn from a population of 3.2 million. Follow-up was at least 3 years. We found four boys and four girls with pernio. Distribution of skin lesions was on the fingers, toes, and ears. Four children had cryoglobulins or cold agglutinins, two had a positive rheumatoid factor, and none had a positive ANA or ANA profile. All eight cleared within 3 months and did not recur over at least a 3-year period. We concluded that childhood pernio is uncommon and may be associated with the presence of cryoproteins.

Examination of the oral mucosa and peripheral blood cells of patients with recurrent aphthous ulceration for human herpesvirus DNA

OBJECTIVE

The purpose of this study was to exam the oral mucosa and peripheral blood cells of patients with recurrent aph-thous ulceration (RAU) for the presence of the following human herpesviruses: herpes simplex viruses 1 and 2, varicella zoster virus, Epstein-Barr virus, cytomegalovirus, human herpesvirus-6, and human herpesvirus-7.

STUDY DESIGN

Fifty-eight subjects with RAU and 10 control subjects were recruited at an academic referral center and enrolled in this prospective, nonrandomized, case-controlled study. Each of the subjects with RAU was seen during an acute episode, and swab specimens from lesional (RAU-acute/lesion) and clinically normal (RAU-acute/normal) oral mucosa were obtained. Each of 2 subjects with RAU was evaluated during more than one acute episode. Three subjects with RAU were seen between active episodes, and swab specimens were taken from clinically normal (RAU-convalescent) oral mucosa. Swab specimens from clinically normal (control/normal) oral mucosa were obtained from the control subjects. Peripheral blood specimens were obtained from subjects with RAU and control subjects at the time the swab specimens were performed. Through use of polymerase chain reaction, all swab and peripheral blood specimens were examined for the presence of human herpesvirus DNA. Statistical significance was determined by means of chi(2) analysis.

RESULTS

Herpes simplex virus and human herpesvirus-6 were found in a higher percentage of mucosal specimens from the control subjects (herpes simplex virus, 4/10; human herpesvirus-6, 5/9) than from the subjects with RAU (RAU-acute/lesion: 3/45 herpes simplex virus, 13/53 human herpesvirus-6; RAU-acute/normal: 7/48 herpes simplex virus, 9/53 human herpesvirus-6). No difference was demonstrated between RAU-acute/lesion, RAU-acute/normal, and RAU-convalescent mucosal specimens for any of the human herpesviruses. Different human herpesviruses were identified from individual subjects with RAU during subsequent episodes of disease. Epstein-Barr virus (6/35), human herpesvirus-6 (3/40), and human herpesvirus-7 (7/43) were detected in the peripheral blood mononuclear cells during acute RAU but not in RAU-convalescent or control peripheral blood mononuclear cells.

CONCLUSIONS

The detection of human herpesvirus DNA from the oral mucosa and peripheral blood mononuclear cells of patients with RAU appears to represent normal viral shedding rather than a direct causal mechanism in this disorder.

Does sensitization to contact allergens begin in infancy?

OBJECTIVE

Because previous studies have found allergic contact sensitization common in children by 5 years of age, our aim was to determine the prevalence of positive epicutaneous test results in children <5 years of age and to determine whether sensitization to contact allergens was as common in infancy.

METHODS

We recruited 95 asymptomatic children 6 months to 5 years of age from well-child visits at Denver area pediatric practices for epicutaneous patch testing using the T.R.U.E. Test system. Allergens were placed on the skin for 48 hours, and at a later follow-up visit, positive reactions were evaluated.

RESULTS

A total of 85 patients completed the study. Of these, 20 (24.5%) had 1 or more positive reactions to the tested allergens. Positive reactors ranged from 6 to 65.5 months of age, with an average of 30.4 months of age. Of the children, 16 reacted to 1 allergen, and 4 reacted to 2. Eleven positive reactions were observed to nickel, followed by 8 to thimerosal. Other positive reactions were to neomycin, cobalt, and kathon CG.

CONCLUSIONS

Children as young as 6 months of age may be sensitized to contact allergens. Within this pediatric population, the prevalence of sensitization is 24.5%. Sensitization to contact allergens may occur in infants.

Steroid rosacea in prepubertal children

OBJECTIVE

To examine clinical associations, family history of rosacea, and response to treatment in prepubertal children with steroid rosacea.

DESIGN

Retrospective case-series evaluation of children younger than 13 years with steroid rosacea seen over an 8-year period (1991-1998).

SETTING

Ambulatory care university hospital.

PATIENTS

Referral patients from pediatricians serving a population of 3.4 million.

INTERVENTIONS

Abrupt cessation of topical corticosteroid use and initiation of treatment with oral erythromycin stearate for 4 weeks.

MAIN OUTCOME MEASURES

Age at onset, class of topical corticosteroid used, family history of rosacea, location of lesions, treatment, and weeks to clearing.

RESULTS

We evaluated 106 (46 boys and 60 girls) who developed steroid rosacea. Preceding steroids used were predominantly (54% of children) class 7 agents including 1% hydrocortisone and over-the-counter hydrocortisone preparations. Only 3% of children had used superpotent (class 1) topical corticosteroids. The mean age at onset was 7.04 years (range, 6 months to 13 years). Twenty-nine children were younger than 3 years. A family history of rosacea was found for 20% of the children. After abruptly stopping topical steroid use and starting treatment with oral erythromycin, 86% of children had complete clearing within 4 weeks and 100% by 8 weeks. Clearing within 3 weeks was observed in 22% of children.

CONCLUSIONS

Abrupt discontinuation of topical corticosteroids and institution of oral antibiotics resulted in clearing within 4 weeks. This finding does not support the concept that prepubertal children with steroid rosacea need to continue low-strength steroids in a gradual withdrawal strategy. This conclusion is supported by the finding that 54% developed the steroid rosacea while being treated with the lowest-strength (class 7) topical corticosteroids. Even over-the-counter hydrocortisone preparations induced steroid rosacea in susceptible children. Susceptibility may be genetic as 20% of children had a first-degree relative with rosacea.

Overexpression of mutant ras in human melanoma increases invasiveness, proliferation and anchorage-independent growth in vitro and induces tumour formation and cachexia in vivo

Malignant melanoma is the deadliest form of skin cancer. Previous studies have shown that the incidence of ras mutation increases with progression of melanoma, but that such mutations may not be present in the earliest radial growth phase melanomas. Recently it has been proposed that introduction of ras mutations into cells deficient in tumour suppressor genes such as p16 (INK4a) is sufficient to induce characteristics of cellular transformation such as anchorage-independent growth and tumour formation in vivo. To test this hypothesis in human melanoma, mutant N-ras, mutant H-ras or wild-type H-ras genes were transfected by electroporation into WM35 cells, a p16-deficient human melanoma cell line of low invasive potential. Increased expression of mutant ras p21 enhanced anchorage-dependent cell growth on tissue culture plastic. In addition, overexpression of mutant N-ras and H-ras, but not of wild-type H-ras, increased the experimental invasive potential, inducing anchorage-independent growth in soft agar, increasing cell motility measured by time-lapse video microscopy, and increasing invasiveness through reconstituted basement membranes. Finally, overexpression of mutant H-ras in melanoma cells was shown to increase tumorigenicity and to induce cachexia when H-ras transfected cell lines were injected subcutaneously in severe combined immunodeficiency (SCID) mice. Thus the addition of activating ras mutations to a melanoma cell line already deficient in p16 leads to enhanced proliferation, survival and migration in vitro and to enhanced subcutaneous tumour formation in vivo. This phenotype is typical of the behaviour of vertical growth phase (VGP) melanoma, and we propose that activation of the ras signalling pathway in the presence of deletions in p16 or related tumour suppressors can induce the VGP melanoma phenotype.

Childhood immunobullous disease following a second organ transplant

Immunobullous diseases are quite unusual in children. We report two children who developed immunobullous disease shortly after a second solid organ transplantation. One child had IgA pemphigus vegetans, the other bullous pemphigoid. We hypothesize that the repeat organ transplantation served as a "booster" immunization for autoantibody production. Both children developed their immunobullous condition while being treated with immunosuppressive drugs that are used to treat immunobullous disorders.

The clinical spectrum of anti-Ro-positive cutaneous neonatal lupus erythematosus

BACKGROUND

Cutaneous neonatal lupus erythematosus (NLE) is an uncommon disease described mainly through isolated case reports.

OBJECTIVE

Our purpose was to examine the cutaneous spectrum, clinical associations, and course of disease in babies with anti-Ro-positive NLE.

METHODS

This is a retrospective case series evaluation of newborns with anti-Ro-positive NLE seen at a single ambulatory care university center over a 20-year period. Cases were drawn from a population of 3.2 million. Follow-up was at least 3 years.

RESULTS

Four boys and 14 girls were included in our evaluation. Distribution of skin lesions in 18 babies was as follows: face, 17; periorbital "owl-eye" or "eye mask" facial rash, 14; scalp, 15; arms and legs, 13; trunk and groin, 6. Crusted lesions were predominant in 3. Photosensitivity was seen in 12, and features of cutis marmorata telangiectasia congenita were observed in 4. In 17 neonatal lupus was not suspected until the dermatology consultation. Noncutaneous manifestations included thrombocytopenia in 4, cholestatic hepatitis in 3, and congenital heart block in 3. Four patients had residual telangiectasia that persisted for 3 or more years but eventually cleared in 2 patients. Three babies had dyspigmentation that spontaneously cleared within 22 months. None had atrophy or scarring.

CONCLUSION

Periorbital, scalp, and extremity lesions are common in cutaneous NLE. Crusted lesions predominated in male infants. In children selected by cutaneous involvement, thrombocytopenia and hepatic disease were present as frequently as cardiac disease and occurred more frequently in male babies with crusted skin lesions. Children with cutaneous NLE should be evaluated for hematologic and hepatic as well as cardiac involvement.

Fixed drug eruptions in children

To determine the anatomic location and offending drug in fixed drug eruptions (FDE) in children, we performed a 5-year retrospective analysis. Thirty-five children with FDE were evaluated. The most common cause of FDE was the combination drug trimethoprim-sulfamethoxazole.

Elevated levels of interferon gamma, tumor necrosis factor alpha, interleukins 2, 4, and 5, but not interleukin 10, are present in recurrent aphthous stomatitis

OBJECTIVE

To investigate our hypothesis that recurrent aphthous stomatitis (RAS), an inflammatory disease of the oral mucosa, is the result of an abnormal oral mucosal cytokine cascade leading to an enhanced cell-mediated immune response directed toward focal areas of the oral mucosa.

DESIGN

Prospective nonrandomized case-control study.

SETTING

Academic referral center

PATIENTS

For part 1, 21 patients with RAS and 7 control patients; for part 2, 6 patients with RAS and 6 control patients.

INTERVENTION

For study part 1, lesional and clinically normal oral mucosal biopsy specimens were obtained during an acute episode (within 72 hours of onset of ulcer) from 21 patients with RAS. Normal oral mucosal biopsy specimens were obtained from 7 healthy individuals, who served as controls. In study part 2, oral mucosal biopsy specimens were obtained from 6 RAS and 6 control patients at 24 and 48 hours after surgical trauma to those sites.

MAIN OUTCOME MEASURES

Detection of the following messenger RNA (mRNA) types by use of semiquantitative reverse transcriptase polymerase chain reaction. For part 1, interleukins (IL) 2, 4, 5, and 10, interferon gamma, and tumor necrosis factor alpha were measured. For study part 2, IL-10 and interferon gamma were measured.

RESULTS

In part 1, elevated levels of IL-2, interferon gamma, and tumor necrosis factor alpha mRNAs were detected in RAS lesions, consistent with a cell-mediated immune response. The IL-10 mRNA was not increased in RAS lesions. In addition, lower resting levels of IL-10 mRNA were detected in the clinically normal mucosa from patients with RAS, as compared with levels seen in the healthy controls. In part 2, at both 24 and 48 hours following trauma to the oral mucosa, the levels of mucosal IL-10 mRNA remained lower in patients with RAS than those observed in healthy controls, while interferon gamma mRNA levels were higher.

CONCLUSION

Failure to suppress the inflammatory reaction initiated by trauma or other external stimuli, likely involving a functional deficiency of IL- 10 in the oral mucosa, appears to be important in the pathogenesis of RAS.

Newly recognized infectious exanthems

An exanthem is defined as any rash which is associated with an infectious agent. During the past 6 years, molecular techniques have produced a revolution in clinical dermatology including the exanthems. The infectious agents responsible for many exanthems of previously unknown causes have been uncovered. Included in this review is an update of the rapidly changing spectrum of exanthems, and 10 examples of new viral etiologies of exanthems and two new bacterial exanthems that were recognized during the past 5 years.

Autoimmune-associated congenital heart block: demographics, mortality, morbidity and recurrence rates obtained from a national neonatal lupus registry

OBJECTIVES

The present study describes the demographics, mortality, morbidity and recurrence rates of autoimmune-associated congenital heart block (CHB) using information from the Research Registry for Neonatal Lupus.

BACKGROUND

Isolated CHB detected at or before birth is strongly associated with maternal autoantibodies to 48-kD SSB/La, 52-kD SSA/Ro and 60-kD SSA/Ro ribonucleoproteins and is a permanent manifestation of the neonatal lupus syndromes (NLS). Available data are limited by the rarity of the disease.

RESULTS

The cohort includes 105 mothers whose sera contain anti-SSA/Ro or anti-SSB/La antibodies, or both, and their 113 infants diagnosed with CHB between 1970 and 1997 (56 boys, 57 girls). Of 87 pregnancies in which sufficient medical records were available, bradyarrhythmia confirmed to be CHB was initially detected before 30 weeks of gestation in 71 (82%) (median time 23 weeks). There were no cases in which major congenital cardiac anatomic defects were considered causal for the development of CHB; in 14 there were minor abnormalities. Twenty-two (19%) of the 113 children died, 16 (73%) within 3 months after birth. Cumulative probability of 3-year survival was 79%. Sixty-seven (63%) of 107 live-born children required pacemakers: 35 within 9 days of life, 15 within 1 year, and 17 after 1 year. Forty-nine of the mothers had subsequent pregnancies: 8 (16%) had another infant with CHB and 3 (6%) had a child with an isolated rash consistent with NLS.

CONCLUSIONS

Data from this large series substantiate that autoantibody-associated CHB is not coincident with major structural abnormalities, is most often identified in the late second trimester, carries a substantial mortality in the neonatal period and frequently requires pacing. The recurrence rate of CHB is at least two- to three-fold higher than the rate for a mother with anti-SSA/Ro-SSB/La antibodies who never had an affected child, supporting close echocardiographic monitoring in all subsequent pregnancies, with heightened surveillance between 18 and 24 weeks of gestation.

Inflammatory nevus comedonicus in children

More than 100 years has passed since the first report of a nevus comedonicus. The earliest reports emphasized the inflammatory aspect of the nevus comedonicus as being the most significant problem. In the past 30 years, publications have ignored the inflammatory aspect of nevus comedonicus while emphasizing a variety of associated malformations. In this review, we describe five prepubertal children with prominent and persistent inflammatory changes limited to areas within a nevus comedonicus. In our experience, inflammation can be severe and resistant to treatment. Ultimately, surgical removal of the involved skin was required in two children.

Facial port wine stains in childhood: prediction of the rate of improvement as a function of the age of the patient, size and location of the port wine stain and the number of treatments with the pulsed dye (585 nm) laser

In this study we examined the rate of decrease in size of facial port wine stains (PWS) as a function of number of treatments, lesion size, lesion location and patients' age. This study was performed at the University of Colorado Hospital Outpatient Dermatology Center, Denver, U.S.A. A consecutive sample of 91 patients 18 years of age or younger with facial PWS in which the entire lesion was treated at each visit were studied. Included were all patients who had a minimum of five treatments or complete clearance of their lesion in fewer than five treatments. Patients were evaluated following one, five and 10 treatments with the pulsed (450 s) dye (585 nm) laser. Improvement was defined as the percentage decrease in the size of the PWS. For all patients, the first five treatments resulted in a mean decrease in size of 55% while the second five treatments (38 patients) only improved the mean decrease in size by 18%. Grouped by location, the mean decreases in size from the first five and the second five treatments were as follows: central forehead = 100%, 0%; peripheral face = 58%, 28%; central face = 48%, 14%; and mixed (combination of peripheral and central face) = 21%, 9%. All central forehead PWS completely cleared within five treatments while none of the mixed PWS did so even with an average of 14 treatments. Grouped by size, mean decrease in size was highest for small lesions; < 20 cm2 = 67%, 21%; 20 to < 40 cm2 = 45%, 8%; and > 40 cm2 = 23%, 29%. Grouped by age, mean decrease in size was highest for young children: < 1-year-old = 63%, 33%; 1 to < 6 years = 48%, 15%; and older than 6 years = 54%, 10%. For all patients studied, maximal improvement was obtained in the first five treatments. Major determinants of treatment response in order of decreasing importance are PWS location, size and patients' age. The most successful responses are seen in young patients (less than 1 year old) with small PWS (under 20 cm2) that are located over bony areas of the face such as the central forehead. These three determinants may be useful tools to guide patient expectations and to predict the rate of improvement of PWS to pulsed dye laser treatment.

Target lesions on the lips: childhood herpes simplex associated with erythema multiforme mimics Stevens-Johnson syndrome

Erythema multiforme and Stevens-Johnson syndrome are both characterized by areas of epithelial necrosis. An important clinical feature that distinguishes the two is the extensive mucosal necrosis in Stevens-Johnson syndrome but not in erythema multiforme. Because significant and serious complications may develop with Stevens-Johnson syndrome and not with erythema multiforme, it is important to differentiate between the conditions. We describe three boys with herpes simplex virus-associated erythema multiforme who had severe necrosis of the lips develop and were initially diagnosed with Stevens-Johnson syndrome. The lip lesions were large target lesions of erythema multiforme rather than the extensive necrosis seen in Stevens-Johnson syndrome and all three had a benign course.

Herpes simplex virus-associated erythema multiforme in prepubertal children

OBJECTIVE

To examine clinical associations, evolution of the condition, and response to treatment of erythema multiforme (EM) in prepubertal children.

DESIGN

A retrospective case series evaluation of children younger than 13 years with EM.

SETTING

Ambulatory care university hospital.

PATIENTS

Referral patients from pediatricians serving a population of 3.2 million.

INTERVENTIONS

Results of treatment of each EM episode with topical acyclovir or oral acyclovir at a dose of 25 mg/kg per day and 6-month prophylaxis with oral acyclovir at a dose of 20 mg/kg per day were evaluated.

OUTCOMES

Age at EM onset, preceding illness, and number and duration of episodes during a 3-year period were recorded.

RESULTS

Twelve children (7 boys and 5 girls) in whom herpes simplex virus (HSV)-associated EM developed were evaluated. Preceding lesions were herpes labialis in 8 children and herpes facialis in 2 children. Two children had no obvious HSV lesion. The mean age at onset of disease was 8.1 years, and the mean time from the preceding HSV to the onset of skin lesions was 3.9 days (range, 0-11 days). Episodes of EM lasted a mean of 10.6 days. In 9 children, the EM was recurrent, with a mean of 2.6 episodes per year. All 12 children, including those with negative viral cultures for HSV or no HSV history had HSV detected in their target lesions by polymerase chain reaction amplification of DNA obtained from skin biopsy specimens. Six of 12 children were treated with oral acyclovir at a dose of 25 mg/kg per day for 1 or more individual episodes, without reduction in the episode. Three children underwent 6-month prophylaxis with oral acyclovir at a dose of 20 mg/kg per day and remained disease free during treatment. After discontinuation of the prophylactic treatment with acyclovir, 1 child relapsed at 4 months. The other 2 children had no further episodes during a 3-year period.

CONCLUSIONS

The HSV-associated EM is a recurrent disease that can be precipitated by sun exposure and does not progress to Stevens-Johnson syndrome. Childhood HSV-associated EM may be unresponsive to treatment with oral steroids or oral or topical acyclovir. Frequent recurrences of EM may be abrogated by prophylactic treatment with acyclovir.

"Painful and disabling granuloma annulare": a case of Munchausen by proxy

We report the unusual case of a child who from age 6 received fourteen excisions and four grafting procedures in an attempt to control "painful and disabling granuloma annulare." Although the lesions were considered disabling by the mother, they were nontender on repeated examinations. A careful investigation revealed that the mother was falsely describing symptoms necessitating surgery so she could receive public housing and other benefits for parents with a disabled child. We believe this case should alert the clinician as to the extreme measures imposed on children in Munchausen syndrome by proxy.

Contact dermatitis in children

Allergic contact dermatitis affects 20% of children at some time during childhood. Diagnosis is based upon the distribution of eczematous lesions rather than the appearance of individual lesions. There are many instances where the allergen are not found by history and epicutaneous testing is required. The clinician should know the 10 most common childhood contact allergens. Children who are considered "atopic" do not have more contact allergy. Treatment requires moderately potent topical steroid ointments. Allergen avoidance is the mainstay of prevention.

Misdiagnosis, treatments, and outcomes in the immunobullous diseases in children

As a group, the immunobullous diseases are very uncommon in childhood. We analyzed all cases of immunobullous diseases in individuals under age 18 years which we had evaluated at the University of Colorado and examined their age of onset, diagnostic difficulties, treatments, and outcomes. This was considered to be a representative North American population within a single referral area which contained a diverse ethnic population mixture. Further, we believe this study to be uniquely uniform in that all the patients were examined by us using the same diagnostic strategy and the immunofluorescent (IF) diagnostic tests were performed by the same individual (J.C. Huff) using uniform diagnostic criteria and consistent IF techniques.

Treatment of pyogenic granuloma in children with the flashlamp-pumped pulsed dye laser

OBJECTIVE

Pyogenic granuloma is a common, acquired, vascular tumor of the skin in children, often ulcerates or bleeds, and is commonly localized to the face. The treatment of choice has been surgical removal, either by excision or shave, followed by electrocautery. The site, young age of the patient, and the inherent nature of surgical removal or electrocautery often make this procedure a traumatic experience. Also, surgical treatment usually leads to permanent scarring. Owing to the pulsed dye laser's ability to cause selective destruction of superficial capillary-sized cutaneous blood vessels, its ease of operation, and its lack of scarring, we evaluated its use in the treatment of pyogenic granuloma in children.

METHODS

Twenty-two children with solitary pyogenic granulomas were treated with a vascular-specific (585 nm), pulsed (450 microseconds) dye laser using a 5-mm spot size with a laser energy of 6 to 7 J/cm2 without anesthesia. Retreatments were administered every 2 weeks if necessary until the lesion cleared. Posttreatment care consisted of twice-a-day application of bacitracin ointment.

RESULTS

In 20 patients (91%), laser treatment was successful. Five patients (25%) required one treatment for resolution, eight patients (40%) required two treatments, and six patients (30%) required three treatments for clearing. One patient required six treatments before the lesion resolved. There was no correlation with the duration, or site of the lesion, with respect to the number of laser treatments required. Lesions in all 20 children healed without scarring and with excellent cosmetic results. In two patients (9%), laser treatment failed in that there was no response to the initial laser treatment on follow-up 2 weeks later. Both had large pyogenic granulomas (1 cm and .5 cm in diameter, respectively) which were elevated over .5 cm above the surface of the skin. These lesions were surgically removed. None of the patients had a recurrence during the follow-up period of 6 months to 3 years.

CONCLUSION

Pulsed dye lasers are effective and safe for the treatment of small pyogenic granulomas in children and should be considered a treatment option.

Childhood paraneoplastic pemphigus associated with Castleman's tumour

Paraneoplastic pemphigus (PNP) is a rare condition virtually always seen in adults. We report a 13-year-old boy who developed PNP associated with Castleman's tumour. His condition mimicked Stevens-Johnson syndrome and responded to tumour resection and immunosuppressive therapy.

Cutaneous lupus erythematosus during the neonatal and childhood periods

Cutaneous lupus erythematosus may be related to maternal autoantibody production in the neonatal lupus syndrome, or may occur later in childhood, with or without findings of systemic lupus erythematosus (SLE). In the first section, we will discuss the transient, passively transferred neonatal disease, and in the second, we will discuss the persistent, actively acquired forms of lupus erythematosus in childhood.

Epidermal nevus syndrome: association with central precocious puberty and woolly hair nevus

The epidermal nevus syndrome is characterized by the association of epidermal nevi with abnormalities of the skin, skeletal system, central nervous system, eyes, and cardiovascular system, as well as with malignant conditions. We describe a 2-year-old girl with an extensive epidermal nevus involving the left side of the body (nevus unius lateris) and associated with a woolly hair nevus on the left parietal area of the scalp and multiple acquired melanocytic nevi. Idiopathic central precocious puberty characterized by premature breast and public hair development and advanced bone age developed at the age of 20 months. A sharp increase in serum gonadotropins after a luteinizing hormone releasing hormone (LHRH) stimulation test confirmed the presence of central precocious puberty. This is the third reported case of precocious puberty associated with the epidermal nevus syndrome.

Mycoplasma pneumoniae infection is associated with Stevens-Johnson syndrome, not erythema multiforme (von Hebra)

A review of the English-language medical literature revealed at least 70 cases of well-documented Mycoplasma pneumoniae infections associated with the Stevens-Johnson syndrome. There were no cases associated with erythema multiforme (von Hebra). Most of the patients were children and young adults, and male patients were more commonly affected. Most patients had prodromal symptoms of an upper respiratory tract infection before the onset of the eruption and an underlying pneumonia. Although the clinical course may be severe and prolonged, the prognosis is uniformly good with complete recovery in nearly all patients. Treatment is largely supportive and the use of antibiotics or steroids (or both) appears to have little effect on the course of the illness. We conclude that M. pneumoniae is the most common infectious agent associated with the Stevens-Johnson syndrome. It is not associated with erythema multiforme of von Hebra.