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Background Lymphatic malformations can be challenging to treat. Mainstay interventions including surgery and sclerotherapy are invasive and can result in local recurrence and complications. Objective We sought to assess the effect of 20 weeks of oral sildenafil on reducing lymphatic malformation volume and symptoms in children. Methods Seven children (4 boys, 3 girls; ages 13-85 months) with lymphatic malformations were given oral sildenafil for 20 weeks in this open-label study. The volume of the lymphatic malformation was calculated blindly using magnetic resonance imaging performed before and after 20 weeks of sildenafil. Lymphatic malformations were assessed clinically on weeks 4, 12, 20, and 32. Both the physician and parents evaluated the lymphatic malformation in comparison with baseline. Results Four subjects had a lymphatic malformation volume decrease (1.0%-31.7%). In 2 subjects, despite a lymphatic malformation volume increase (1.1%-3.7%), clinical improvement was noted while on sildenafil. One subject had a 29.6% increase in lymphatic malformation volume and no therapeutic response. Lymphatic malformations of all 6 subjects who experienced a therapeutic response on sildenafil softened and became easily compressible. Adverse events were minimal. Limitations A randomized controlled trial will be necessary to verify the effects of sildenafil on lymphatic malformations. Conclusions Sildenafil can reduce lymphatic malformation volume and symptoms in some children.

Background Our group's 2009 study of the integrity of the dermatology match revealed that some dermatology program directors violated National Resident Matching Program (NRMP) policy during their communications with applicants. Our group's article concluded with recommendations to change this behavior. Objective We repeated a survey of dermatology applicants to understand if dermatology program personnel behavior has changed since our group's 2009 study of the dermatology match. Methods We surveyed 2011 applicants to Department of Dermatology, Stanford University, Palo Alto, CA. The survey was anonymous and available online. Results Of applicants, 14% were asked to reveal how they intended to rank a program before match day. Of applicants, 32% felt pressured to reveal how they intended to rank programs. Of applicants, 90% were asked about interviews at other programs. Of applicants, 44% were asked about their marital status and 19% were asked if they had children or intended to have children. Limitations The response rate for applicants was 53%. Conclusion Although our previous study increased knowledge about the problems within the dermatology match, dermatology program personnel continue to violate NRMP policy. The most widespread violations are asking applicants where they will interview, asking applicants if they are married, and pressuring applicants to reveal how they intend to rank programs. We continue to recommend that programs avoid postinterview contact, and recommend that the NRMP create training videos for applicants and interviewers.

Background National Resident Matching Program (NRMP) policy outlines the conduct expected by both program directors and residency applicants. However, recent studies and personal experiences have introduced the possibility that NRMP policy is violated during the residency application process. Objective To investigate the communications that occur between dermatology applicants and dermatology programs during the residency application process. Methods From April to July 2009, we surveyed 2009 Stanford dermatology applicants, current US dermatology residents, and US dermatology program directors. The survey was anonymous and available online. The main outcome measures were the frequency and incidence of dermatology NRMP policy violations. Results Thirty-one percent of Stanford applicants and 19% of US dermatology residents felt pressured to reveal to programs how they ranked them before match day. Seventeen percent of Stanford applicants and 14% of US dermatology residents witnessed behavior that made them feel uncomfortable or that they thought was a possible ethical infraction of NRMP policy. Limitations Response rates were as follows: 43% of Stanford applicants, 46% of residents, and 61% of program directors. Conclusions Our data suggest that some dermatology program directors violate NRMP policy during their communications with applicants. The most widespread violation is pressuring applicants into revealing how they intend to rank programs. Other violations include apparent sexual discrimination and reserving NRMP positions for preselected applicants. Additional studies should be done in order to determine the incidence of dermatology applicants violating NRMP policy.

The biotech industry is the usual venue of new drug development, with costs estimated between $500 million and $2 billion per drug developed (Adams and Brantner, 2006). Occasionally, members of an academic medical community may choose to develop a new drug within their own institution because they are focused on an orphan disease and/or their new therapy may lack a successful financial model. The Dermatology Department at Stanford University School of Medicine has focused on creating a successful treatment for epidermolysis bullosa since 1988. Support for this process has come from philanthropy (http://www.ebkids.org) as well as federal and state funding.

Skin is a unique organ that provides protection, thermoregulation, sensation, and metabolic functions. From birth to adulthood, it serves as a barrier to the environment, protecting the body against infection, injury, and fluid loss. If skin barrier function is compromised at any time, clinically significant deleterious systemic effects could result. Many skin care products have therefore been marketed specifically for “babies.” However, even though advances in dermatology and neonatology have led to a better understanding of the development, structure, and function of neonatal and premature neonatal skin, there is limited evidence-based literature promoting the use of topical emollients for optimizing the skin health of newborns. This review discusses the uniqueness of neonatal skin and the purpose and potential side effects of topical emollients, and it briefly overviews the available evidence-based literature that focuses on the use of emollients in neonates. Copyright © 2001 by W.B. Saunders Company

Objective To test the effectiveness of an evidence-based clinical practice guideline for neonatal skin care on selected clinical outcomes for newborns in neonatal intensive-care units (NICU), special-care units (SCU), and well-baby nurseries. Design Prospective evaluation of the collaborative neonatal skin care research-based practice project of the Association of Women's Health, Obstetric and Neonatal Nurses and the National Association of Neonatal Nurses. Setting NICU and well-baby units in 51 hospitals located throughout the United States. Participants Member site coordinators (N = 51) and the neonates (N = 2,820) observed during both the pre-and post implementation phases of the project. Method Site coordinators received specialized education in neonatal skin care and implemented an evidence-based clinical practice guideline addressing 10 aspects of neonatal skin care. Baseline observations of skin condition, care practices, and environment of newly admitted neonates were collected by site coordinators. Postimplementation observations were then completed. Main Outcome Measures Skin condition was assessed with the Neonatal Skin Condition Score (NSCS), which ranges from a score of three (best condition) to a score of nine (worst condition), based on dryness, erythema, and skin breakdown. Changes in frequency of selected skin care practices were used to assess the effectiveness and feasibility of using the practice guideline in everyday clinical practice. Aspects of the care environment with potential effect on skin integrity were monitored to determine risk factors. Results Fifty-one site coordinators made 11,468 systematic assessments of 2,464 NICU and SCU newborns and 356 well newborns. Baseline skin scores were better in well newborns compared with premature newborns. After implementation of the guideline, skin condition was improved, as reflected by less visible dryness, redness, and skin breakdown in both the NICU/SCU and well newborns. The guideline was integrated into care, as evidenced by increased use of emollients, particularly with premature infants, and decreased frequency of bathing. A relationship was shown between selected aspects of the environment and alterations in skin integrity. Conclusions Use of the AWHONN/NANN Neonatal Skin Care Research-Based Clinical Practice Guideline was successfully implemented at 51 sites, and effectiveness was demonstrated by changed care practices and improved skin condition in premature and full-term newborns. The results of this project support a wider dissemination of the project's practice guideline for neonatal skin care.

Objective: To develop and evaluate an evidence-based clinical practice guideline for assessment and routine care of neonatal skin, educate nurses about the scientific basis for practices recommended in the guideline, and design procedures that facilitate implementation of the project guideline into clinical practice. Design: Descriptive report of the collaborative neonatal skin care research-based practice project of the Association of Women’s Health, Obstetric and Neonatal Nurses and the National Association of Neonatal Nurses. Setting: Neonatal intensive-care unit (NICU) and special-care nurseries and well-baby nurseries in 51 hospitals located throughout the United States. Participants: Member site coordinators (N = 51), nurses who work at the selected sites, and the neonates observed during both the pre-and postimplementation phases of the project (N = 2,820). Method: An evidence-based clinical practice guideline was developed, sites were selected from all respondents of the call for sites, site coordinator training was provided, data collection was facilitated by project-specific data collection tools, and the project was evaluated by the science team. Main Outcome Measures: Diversity and numbers of sites represented, patient representation, site coordinator knowledge of neonatal skin care pre-and postimplementation, use of project-designed implementation tools, satisfaction with project guideline and the data collection process, changes in practices and product use, and site coordinators’ experiences during guideline implementation. Results: Fifty-one sites completed the project, representing NICU, special-care, and well-baby nurseries in both academic and community hospital settings in 27 states. Registered nurses working in these sites totaled 4,754 full-time equivalent positions (FTEs) (in NICU/special-care and well-baby nurseries). Site coordinators demonstrated increased knowledge of research-based neonatal skin care and satisfaction with the implementation tools and data collection process. Product use changed, reflecting acquisition of new knowledge. Barriers to implementation of the guideline were identified. Conclusions: The AWHONN/NANN Neonatal Skin Care Research-Based Practice Project demonstrated increased knowledge among site coordinators who received training, facilitated changes in neonatal skin care as defined by the practice guideline, and thus advanced evidence-based clinical practice. JOCNN, 30, 30–40; 2001.

Mitochondrial DNA syndromes are an emerging class of diseases that can present at any age. Clinical findings are legion and may include renal tubulopathy, growth retardation, myopathy, seizures, and ophthalmoplegia. Mitochondrial DNA syndromes have presented with symmetric cervical lipomas, poikiloderma, and anhidrosis. We describe a child with a novel mitochondrial DNA syndrome who had poikiloderma on sun-exposed areas. We also reviewed 274 patients with mitochondrial DNA disorders for skin findings. Symmetric cervical lipomas were consistently associated with myoclonic epilepsy as part of 1 syndrome. With the exception of lipomas, skin findings were reported in 16 patients. (J Am Acad Dermatol 1998;39:819-23.)

Objective: Premature infants have an ineffective epidermal barrier. The aim of this study was to investigate the cutaneous and systemic effects of preservative-free topical ointment therapy in premature infants. Study design: We conducted a prospective, randomized study of 60 infants less than 33 weeks' estimated gestational age. The treated infants received therapy for 2 weeks with twice-daily preservative-free topical ointment therapy while the control group received no topical treatment or as-needed therapy with a waterin-oil emollient. Data collection included transepidermal water loss (TEWL) measurement, skin condition evaluations, fungal and quantitative bacterial skin cultures, analysis of fluid requirements, patterns of weight loss or gain, and the incidence of blood and cerebrospinal fluid cultures positive for microorganisms. Results: We found that topical ointment therapy significantly decreased TEWL during the first 6 hours after the initial application. TEWL was decreased by 67% (p = 0.0001) when measured 30 minutes after application and 34% (p = 0.001) when measured 4 to 6 hours after application. We also observed significantly superior skin condition scores in the treated group on study days 7 and 14 (p = 0.001 and 0.0004, respectively). Quantitative bacterial cultures revealed significantly less colonization of the axilla on day 2, 3, or 4 and on day 14 (p = 0.008 and 0.04, respectively). The incidence of positive findings in blood and/or cerebrospinal fluid cultures was 3.3% in the treated group of infants versus 26.7% in the control group (p = 0.02). There was no statistical difference in the fluid requirements or patterns of weight gain or loss during the 2 weeks of the study. Conclusions: Preservative-free topical ointment therapy decreased TEWL for 6 hours after application, decreased the severity of dermatitis, and decreased bacterial colonization of axillary skin. Infants treated with ointment had fewer blood and cerebrospinal fluid cultures positive for microorganisms. These data support the use of topical ointment therapy in very premature infants during the first weeks after birth.

Trichoepitheliomas commonly appear as sporadic solitary lesions or, more rarely, as multiple lesions that are often dominantly inherited. We describe an 8-year-old boy with multiple facial papules that coalesced into a large plaque. This presentation of multiple trichoepitheliomas may represent an unusual type of nevus.

A murine monoclonal antibody (ECS-1) was prepared from BALB/c mice immunized with trypsinized cultured human foreskin keratinocytes. The antibody showed a pattern suggestive of intercellular staining on the nucleated layers of normal human epidermis, adult palm, mouse lip epidermis, and cultured human keratinocytes. ECS-1 stained human fetal skin by 9 weeks estimated gestational age. ECS-1 reacted with a 35 kD protein extracted from neonatal foreskin epidermis and cultured human keratinocytes. The protein required Nonidet P-40 or sodium dodecyl sulfate and mercaptoethanol for solubilization. ECS-1 induced epidermal cell detachment which was enhanced by complement. ECS- 1 shares characteristics with human pemphigus antibodies.

Thirty-five human fetal skin (HFS) grafts were transplanted to nude mice for 7 to 70 d and evaluated histologically with 64 biopsies. The estimated gestational ages (EGS) of the grafts at the time of the transplantation ranged from 8 to 19 weeks. The maturation of the engrafted fetal skin was evaluated by assessing epidermal, dermal, and appendage development. Within the nude mouse, the HFS demonstrated progression in stratification and maturation of the epidermis. The dermis increased in depth, adding fibrovascular stroma and adipose tissue. The appendages demonstrated invagination, differentiation, and progression of organogenesis. Subcutaneously placed grafts showed the same rate of HFS development as HFS in utero. The grafts transplanted to the surface of the nude mice and exposed to air demonstrated an acceleration of development. We conclude that HFS transplanted to the nude mouse is an effective in vivo model for maintaining and altering HFS maturation.

An immune reaction to wheat protein has been previously proposed to explain the pathogenesis of dermatitis herpetiformis. In order to detect and characterize antibodies to gluten in human sera, we developed an enzyme immunoassay for class-specific antibodies. Results of this assay in 49 patients with dermatitis herpetiformis were compared with those of 38 normal control subjects, 11 patients with celiac disease, and 6 small-bowel bypass patients. IgA antibodies to gluten were significantly more frequent in dermatitis herpetiformis sera (28/49) than in normal control sera (4/38). IgG antibodies to gluten were significantly more frequent in both celiac disease (10/11) and dermatitis herpetiformis (16/49) sera than in control (5/38) sera. Dermatitis herpetiformis sera also had an increased prevalence of IgM antibodies to gluten (19/49). Small-bowel bypass patients demonstrated no antibody to gluten. Antibodies to gluten in dermatitis herpetiformis objectively mark a state of immune reactivity to wheat protein and may be involved in the genesis of the cutaneous IgA immune deposits and the skin disease.

Sulconazole nitrate 1% cream applied twice daily was compared with its vehicle in the treatment of 229 patients with chronic moccasin-type tinea pedis confirmed by positive results of a potassium hydroxide preparation. At admission in this randomized, double-blind, parallel multicenter trial, 131 patients had positive dermatophyte cultures; Trichophyton rubrum was identified in 121 (92%). After 4 weeks of treatment, patients were examined and, if necessary, were treated for an additional 2 weeks. Sulconazole cream was significantly more effective than the vehicle in the treatment of chronic T. rubrum tinea pedis; 57% of patients were cured by sulconazole, compared with 13% cured with the vehicle. Relapse rates, assessed 2 weeks after the end of treatment, were significantly lower in patients treated with sulconazole than in those receiving vehicle (27% vs 71 %). The 103 patients with moccasin-type tinea pedis whose cultures were not positive for T. rubrum achieved similar results.

The Fifth Annual Meeting of the Society for Pediatric Dermatology was held in Monterey, CA, Aug. 7-9, 1980. It was cosponsored by the Department of Dermatology, Stanford University, and organized and chaired by Drs. Alvin H. Jacobs, Abigail Thorton Givens, Lucy Schmidt, and Paul H. Jacobs. Following Dr. Alvin Jacob's opening remarks, Dr. George Muller, a veterinarian from Stanford University Medical Center who specializes in cutaneous diseases, spoke on the child, his skin, and his pets. Dr. Muller began his presentation by noting that ticks and fleas are not usually transmitted directly from animals to their human owners, but that mites are directly transferable from pet to owner. Apparently, veterinarians no longer use the term "mange" because it is too vague but prefer terms that more accurately describe the disease. Sarcoptic mange is now referred to as canine scabies. This is a common disorder among domestic pets (cats and dogs) as well as farm animals (horses, goats, sheep, and pigs), each being infested with a species-specific mite. The resultant dermatitis is both clinically symptomatic and morphologically distinct-cats and dogs are most severely affected over the distal ears, elbows, and upper back. It is usually possible to obtain a positive KOH preparation from these areas. All dogs on the premises must be treated with four weekly applications of lime-sulfur, malathion, or other acaricidal dips. The canine scabies mite produces a self-limited papular and extremely pruritic erup

Human fetal skin was evaluated for sequential and regional development of several epidermal antigens. Indirect immunofluorescent methods were used to detect laminin, bullous pemphigoid antigen, pemphigus antigen, and anchoring fibril antigens identified by monoclonal antibodies AF1 and AF2. Eighty-three human fetal skin biopsies from 32 human fetuses were examined. The fetuses examined ranged from estimated gestational age (EGA) of 7-38 weeks. Laminin was present in the basement membrane zone of all the fetal tissues examined. Bullous pemphigoid antigen developed first in the palm and sole, 9 weeks EGA, and was present in all other sites by 17 weeks EGA. Pemphigus antigen was present by 11 weeks EGA. AF1 and AF2 staining was not present until 26 weeks EGA, AF1 and AF2 stained epidermal basal cells in addition to the basement membrane zone area. Comparison of human fetal skin development with basal cell carcinoma identified similarities between basal cell carcinoma and early fetal development.

A double-blind, vehicle-controlled comparison of two glucocorticosteroid ointments demonstrated that once-daily therapy for psoriasis was effective. After 3 weeks of once-daily therapy, psoriasis subjects treated with betamethasone dipropionate (BD) ointment or diflorasone diacetate (DD) ointment showed statistically significant (p less than 0.01) improvement compared to subjects using vehicle alone.