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Objectives To compare prevalence and severity of diaper dermatitis (DD) in infants and toddlers (babies) across three countries (China, USA, and Germany), including diapered skin measures and caregiver practices. Methods A cross‐sectional study of 1791 babies (~600 from each country) was recruited at each clinical site. Based on regional toilet‐training habits, exclusively diaper‐wearing infants were recruited between ages 2‐8 months in China and 2‐18 months in the USA and Germany. DD was measured, as well as skin pH, transepidermal water loss (TEWL), and relative humidity (RH) in the diapered region. Caregiver habits were collected via a questionnaire and included information on hygienic practices. Results Diaper dermatitis was highest in the perianal area, followed by the intertriginous, genital, and buttock regions. In general, DD was significantly lower in babies in China, highest in Germany, and intermediate in the USA. This rank ordering of DD by geography was also observed in baby age 2‐8 months. The lower DD observed in China was associated with lower skin pH and TEWL on diapered skin and decreased RH in the diaper. Chinese caregivers had the highest rate of prophylactic topical product usage, the most robust cleaning of the diapered area, lack of cleansing after urine‐only diaper changes, and Chinese infants spent the least time in an overnight diaper. Conclusions These data suggest caregiver behaviors including prophylactic use of topical products, thorough cleaning after stooling and reduced time in an overnight diaper are associated with less DD, lower superficial skin pH, and enhanced skin barrier.

Collagen makes up a large proportion of the human body, particularly the skin. As the body ages, collagen content decreases, resulting in wrinkled skin and decreased wound healing capabilities. This paper presents a method of delivering type I collagen into porcine and human skin utilizing a polyvinylpyrrolidone microneedle delivery system. The microneedle patches were made with concentrations of 1, 2, 4, and 8% type I collagen (w/w). Microneedle structures and the distribution of collagen were characterized using scanning electron microscopy and confocal microscopy. Patches were then applied on the porcine and human skin, and their effectiveness was examined using fluorescence microscopy. The results illustrate that this microneedle delivery system is effective in delivering collagen I into the epidermis and dermis of porcine and human skin. Since the technique presented in this paper is quick, safe, effective and easy, it can be considered as a new collagen delivery method for cosmetic and therapeutic applications.

Pruritus is a common complication in patients with epidermolysis bullosa (EB). There is limited published data about the treatments that individuals with EB use for pruritus. The objective of the current study was to determine quantitatively which treatments individuals with EB have used for pruritus and to evaluate the perceived effectiveness of these treatments in pruritus relief. A questionnaire was developed to evaluate the treatments and therapies used for pruritus in patients of all ages and for all types of EB. Questions about bathing products, moisturizers, topical products, oral medications, dressings, and alternative therapies were included. A 5-point Likert scale (-2 = relieves itch a lot, -1 = relieves itch a little, 0 = no change, 1 = increases itch a little, 2 = increases itch a lot) was used to evaluate perceived effectiveness. Patients from seven North American EB centers were invited to participate. Greasy ointments (53.4%), lotions (45.2%), creams (40.4%), and oral hydroxyzine (39.0%) were the most frequently used treatments for pruritus. Treatments that were used frequently and perceived to be the most effective included creams (mean = -1.1), topical prescription corticosteroids (mean = -1.0), oils (mean = -0.9), oral hydroxyzine (mean = -0.9), topical diphenhydramine (mean = -0.9), and vaporizing rub (menthol, camphor, eucalyptus) (mean = -0.9). Systemic opioids (mean = 0.3), adherent bandages (mean = 0.3), and bleach baths (mean = 0.2) slightly increased pruritus. Randomized controlled trials of therapies will be necessary to develop evidence-based recommendations for control of pruritus in individuals with EB.

Qualitative data suggest that pruritus is a burdensome symptom in patients with epidermolysis bullosa (EB), but the prevalence of pruritus in children and adults with EB and factors that contribute to pruritus are unknown. The objective of the current study was to quantitatively identify and to characterize pruritus that EB patients experience using a comprehensive online questionnaire. A questionnaire was developed to evaluate pruritus in all ages and all types of EB. Questions that characterize pruritus were included and factors that aggravate symptoms were investigated. Patients from seven North American EB centers were invited to participate. One hundred forty-six of 216 questionnaires were completed (response rate 68%; 73 male, 73 female; median age 20.0 years). Using a 5-point Likert scale (1 = never, 2 = rarely, 3 = sometimes, 4 = often, 5 = always), itchiness was the most bothersome EB complication (mean 3.3). The average daily frequency of pruritus increased with self-reported EB severity. Pruritus was most frequent at bedtime (mean 3.8) and interfered with sleep. Factors that aggravated pruritus included healing wounds, dry skin, infected wounds, stress, heat, dryness, and humidity. Pruritus is common in individuals with EB and can be bothersome. Future studies will need to investigate the most effective treatments given to individuals with EB for pruritus.

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.

Epidermolysis bullosa (EB) is a genetic condition characterized by skin fragility and blistering. There is no instrument available for clinical outcome research measurements. Our aim was to develop a comprehensive instrument that is easy to use in the context of interventional studies. Item collection was accomplished using a two-step Delphi Internet survey process for practitioners and qualitative content analysis of patient and family interviews. Items were reduced based on frequency and importance using a 4-point Likert scale and were subject to consensus (>80% agreement) using the nominal group technique. Pilot data testing was performed in 21 consecutive patients attending an EB clinic. The final score, Instrument for Scoring Clinical Outcome of Research for Epidermolysis Bullosa (iscorEB), is a combined score that contains clinician items grouped in five domains (skin, mucosa, organ involvement, laboratory abnormalities, and complications and procedures; maximum score 114) and patient-derived items (pain, itch, functional limitations, sleep, mood, and effect on daily and leisurely activities; maximum score 120). Pilot testing revealed that combined (see below) and subscores were able to differentiate between EB subtypes and degrees of clinical severity (EB simplex 21.7 ± 16.5, junctional EB 28.0 ± 20.7, dystrophic EB 57.3 ± 24.6, p = 0.007; mild 17.3 ± 9.6, moderate 41.0 ± 19.4, and severe 64.5 ± 22.6, p < 0.001). There was high correlation between clinician and patient subscores (correlation coefficient = 0.79, p < 0.001). iscorEB seems to be a sensitive tool in differentiating between EB types and across the clinical spectrum of severity. Further validation studies are needed.

The relationship between food and environmental allergens in contributing to eczema risk is unclear on a multiethnic population level. Our purpose was to determine whether sensitization to specific dietary and environmental allergens as measured according to higher specific immunoglobulin E (IgE) levels is associated with eczema risk in children. National Health and Nutrition Examination Survey participants ages 1 to 17 years were asked whether they had ever received a diagnosis of eczema from a physician (n = 538). Total and specific serum IgE levels for four dietary allergens (egg, cow's milk, peanut, and shrimp) and five environmental allergens (dust mite, cat, dog, Aspergillus, and Alternaria) were measured. Logistic regression was used to examine the association between eczema and IgE levels. In the United States, 10.4 million children (15.6%) have a history of eczema. Eczema was more common in black children (p < 0.001) and in children from families with higher income and education (p = 0.01). The median total IgE levels were higher in children with a history of eczema than in those without (66.4 vs 50.6 kU/L, p = 0.004). In multivariate analysis adjusted for age, race, sex, family income, household education, and physician-diagnosed asthma, eczema was significantly associated with sensitization to cat dander (odds ratio [OR] = 1.2, 95% confidence interval [CI] 1.05, 1.4, p = 0.009) and dog dander (OR = 1.5, 95% CI, 1.2, 1.7, p < 0.001). After correction for multiple comparisons, only sensitization to dog dander remained significant. U.S. children with eczema are most likely to be sensitized to dog dander. Future prospective studies should further explore this relationship.

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.

Pilomatricoma is a benign tumor that presents as a 3-30-mm, firm, solitary, deep, dermal or subcutaneous tumor on the head, neck, or upper extremities. The clinical diagnosis is often made by the firm, sometimes rock-hard texture of the skin. The diagnosis can be confirmed by a skin biopsy or excision of the lesion. We have recently noted that pilomatricomas appear as a black mass in the skin when the lesion is transilluminated by placing the light of a fiberoptic otoscope adjacent to the skin lesion. To our knowledge, this is the first report demonstrating preoperative diagnosis of pilomatricoma by transilluminating the lesion with an otoscope.

Recent discussions regarding the burden of skin disease and patient-centered medicine highlight the profound effects skin disease can have on individuals, their families, and society as a whole. Local support groups, often connected to national patient advocacy groups, can be an invaluable resource for patients, and offer physicians the opportunity to learn more about patients' disease experiences while providing adjunctive therapy for conditions such as alopecia areata and vitiligo, for which medical options are often limited. We created a support group for children with alopecia areata and their parents as a model for other diseases such as vitiligo and epidermolysis bullosa. Herein we outline the steps involved in establishing a support group, including the many resources available for patient support, steps in the recruitment of patients, topics for discussion and goals for the group, and the logistics of running a meeting. Creating this family support group was a relatively straightforward and rewarding experience for us, and we hope that other pediatric dermatologists can utilize this model for their patients.

Dystrophic EB (DEB) is a blistering skin disease caused by mutations in the gene (COL7A1) encoding type VII collagen (C7). DEB can be inherited by either dominant (DDEB) or recessive (RDEB) mechanisms. RDEB results in severe wounds and scarring, as well as extracutaneous manifestations such as esophageal strictures, chronic anemia, and pseudosyndactyly. DDEB is generally a milder form, with fewer and less severe blisters.(1)

Recessive dystrophic epidermolysis bullosa is a severe genetic blistering skin condition resulting in chronic wounds. Nonhealing wounds were treated over 8 weeks using a reconstituted natural purified type I collagen skin substitute. Chronic wounds were defined as nonhealing wounds present for longer than 6 months. For each patient, two chronic wounds were identified and randomized into a control or treatment group. Both groups received standard-of-care wound dressings. The treatment group received an additional type I collagen skin substitute. Wound size was measured at baseline and weeks 1, 4, and 8. Pain, pruritus, and burning and stinging were assessed. Wound cultures were obtained at baseline and thereafter as was considered clinically relevant. Ten subjects were enrolled; seven completed the study. Six subjects showed a positive response to the type I collagen skin substitute. Three subjects demonstrated full wound reepithelialization. Wounds treated using the collagen skin substitute showed statistically significantly greater improvement. Average scores for pruritus and pain decreased significantly. Reconstituted natural purified type I collagen skin substitutes improved the healing of chronic wounds and may be a valuable addition to the epidermolysis bullosa wound care arsenal.

Patients with recessive dystrophic epidermolysis bullosa (RDEB) lack functional type VII collagen owing to mutations in the gene COL7A1 and suffer severe blistering and chronic wounds that ultimately lead to infection and development of lethal squamous cell carcinoma. The discovery of induced pluripotent stem cells (iPSCs) and the ability to edit the genome bring the possibility to provide definitive genetic therapy through corrected autologous tissues. We generated patient-derived COL7A1 -corrected epithelial keratinocyte sheets for autologous grafting. We demonstrate the utility of sequential reprogramming and adenovirus-associated viral genome editing to generate corrected iPSC banks. iPSC-derived keratinocytes were produced with minimal heterogeneity, and these cells secreted wild-type type VII collagen, resulting in stratified epidermis in vitro in organotypic cultures and in vivo in mice. Sequencing of corrected cell lines before tissue formation revealed heterogeneity of cancer-predisposing mutations, allowing us to select COL7A1 -corrected banks with minimal mutational burden for downstream epidermis production. Our results provide a clinical platform to use iPSCs in the treatment of debilitating genodermatoses, such as RDEB.

Lymphatic malformations are rare but can cause significant clinical problems in addition to cosmetic disfigurement. Sildenafil was used in a child whose pulmonary hypertension was caused by lymphatic malformation; the result was a marked decrease in the lymphatic malformation.

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.

Importance Describing the relationship between the availability of free prescription drug samples and dermatologists’ prescribing patterns on a national scale can help inform policy guidelines on the use of free samples in a physician’s office. Objectives To investigate the relationships between free drug samples and dermatologists’ local and national prescribing patterns and between the availability of free drug samples and prescription costs. Design, Setting, and Participants Cross-sectional study investigating prescribing practices for acne, a common dermatologic condition for which free samples are often available. The settings were, first, the offices of nationally representative dermatologists from the National Disease and Therapeutic Index (an IMS Health Incorporated database) and, second, an academic medical center clinic without samples. Participants were ambulatory patients who received a prescription from a dermatologist for a primary initial diagnosis of acne vulgaris or rosacea in 2010. Main Outcomes and Measures National trends in dermatologist prescribing patterns, the degree of correlation between the availability of free samples and the prescribing of brand-name medications, and the mean cost of acne medications prescribed per office visit nationally and at an academic medical center without samples. Results On a national level, the provision of samples with a prescription by dermatologists has been increasing over time, and this increase is correlated ( r = 0.92) with the use of the branded generic drugs promoted by these samples. Branded and branded generic drugs comprised most of the prescriptions written nationally (79%), while they represented only 17% at an academic medical center clinic without samples. Because of the increased use of branded and branded generic drugs, the national mean total retail cost of prescriptions at an office visit for acne was conservatively estimated to be 2 times higher (approximately $465 nationally vs $200 at an academic medical center without samples). Conclusions and Relevance Free drug samples can alter the prescribing habits of physicians away from the use of less expensive generic medications. The benefits of free samples in dermatology must be weighed against potential negative effects on prescribing behavior and prescription costs.

Background Diaper dermatitis is a common childhood affliction. Aiming to help reduce the prevalence of this problem, we have advanced in our development of a novel diaper that delivers dermatological formulations to help protect the skin from over-hydration and irritation. Objective To determine the clinical benefits of a novel disposable diaper designed to deliver a zinc oxide and petrolatum-based formulation continuously to the skin during use. Methods All studies were independent, blinded, randomized clinical trials. Study A was conducted to confirm transfer of the zinc oxide/petrolatum (ZnO/Pet) formulation from the diaper to the child’s skin during use. Children wore a single diaper for 3 h or multiple diapers for 24 h. After the use period, stratum corneum samples were taken from each child and analysed for ZnO/Pet. Study B evaluated the prevention of skin irritation and barrier damage from a standard skin irritant (SLS) in an adult arm model. Study C evaluated skin erythema and diaper rash in 268 infants over a 4-week usage period. One half of the infants used the ZnO/Pet diaper, while the other half used a control diaper that was identical except for the absence of the ZnO/Pet formulation. Results The ointment formulation and ZnO transferred effectively from the diaper to the child’s skin during product use. Transfer of ZnO increased from 4.2 µg/cm2 at 3 h to > 8 µg/cm2 at 24 h. Exposure to the formulations directly on adult skin prior to an irritant challenge was associated with up to a 3.5 reduction in skin barrier damage and skin erythema. Greatest reductions were seen for the ZnO containing formulations. Wearing of the formulation treated diaper was also associated with a significant reduction in skin erythema and diaper rash compared to the control product. Conclusions The results demonstrated the clinical benefits associated with continuous topical administration of a zinc oxide/petrolatum-based formulation by this novel diaper.

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

Importance Recessive dystrophic epidermolysis bullosa (RDEB) is a devastating, often fatal, inherited blistering disorder caused by mutations in the COL7A1 gene encoding type VII collagen. Support and palliation are the only current therapies. Objective To evaluate the safety and wound outcomes following genetically corrected autologous epidermal grafts in patients with RDEB. Design, Setting, and Participants Single-center phase 1 clinical trial conducted in the United States of 4 patients with severe RDEB with a measured area of wounds suitable for grafting of at least 100 cm 2 . Patients with undetectable type VII collagen keratinocyte expression were excluded. Interventions Autologous keratinocytes isolated from biopsy samples collected from 4 patients with RDEB were transduced with good manufacturing practice–grade retrovirus carrying full-length human COL7A1 and assembled into epidermal sheet grafts. Type VII collagen gene–corrected grafts (approximately 35 cm 2 ) were transplanted onto 6 wounds in each of the patients (n = 24 grafts). Main Outcomes and Measures The primary safety outcomes were recombination competent retrovirus, cancer, and autoimmune reaction. Molecular correction was assessed as type VII collagen expression measured by immunofluorescence and immunoelectron microscopy. Wound healing was assessed using serial photographs taken at 3, 6, and 12 months after grafting. Results The 4 patients (mean age, 23 years [range, 18-32 years]) were all male with an estimated body surface area affected with RDEB of 4% to 30%. All 24 grafts were well tolerated without serious adverse events. Type VII collagen expression at the dermal-epidermal junction was demonstrated on the graft sites by immunofluorescence microscopy in 9 of 10 biopsy samples (90%) at 3 months, in 8 of 12 samples (66%) at 6 months, and in 5 of 12 samples (42%) at 12 months, including correct type VII collagen localization to anchoring fibrils. Wounds with recombinant type VII collagen graft sites displayed 75% or greater healing at 3 months (21 intact graft sites of 24 wound sites; 87%), 6 months (16/24; 67%), and 12 months (12/24; 50%) compared with baseline wound sites. Conclusions and Relevance In this preliminary study of 4 patients with RDEB, there was wound healing in some type VII collagen gene–corrected grafts, but the response was variable among patients and among grafted sites and generally declined over 1 year. Long-term follow-up is necessary for these patients, and controlled trials are needed with a broader range of patients to better understand the potential long-term efficacy of genetically corrected autologous epidermal grafts. Trial Registration clinicaltrials.gov Identifier:NCT01263379

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.

Multiple Spitz nevi are rare and may occur in agminated, widespread, or dermatomal distributions. Agminated Spitz nevi usually arise in children, presenting on grossly normal, hyperpigmented, or most rarely, hypopigmented skin. We present a child with Langerhans cell histiocytosis who developed bilateral agminated Spitz nevi in the inguinal area. Unusual features included the multifocal distribution, bilateral inguinal location, and co-occurrence with Langerhans cell histiocytosis.

Objective:To review the literature addressing the care of neonatal skin.Data Sources:Computerized searches in MEDLINE and CINAHL, as well as references cited in articles reviewed. Key concepts in the searches included neonatal skin differences; neonatal skin and care practices for skin integrity; neonatal skin and toxicity; permeability; and contact irritant sensitization.Study Selection:Articles and comprehensive works relevant to key concepts and published after 1963, with an emphasis on new findings from 1993 to 1999. One hundred two citations were identified as useful to this review.Data Extraction:Data were extracted and organized under the following headings: anatomy and physiology of the skin; physiologic and anatomic differences in neonatal skin; nutritional deficiencies; skin care practices; and care of skin breakdown.Data Synthesis:Newborns’ skin is at risk for disruption of normal barrier function because of trauma. In light of available evidence about differences in neonatal skin development, clinical practice guidelines are suggested for baths, lubrication, antimicrobial skin disinfection, and adhesive removal. In addition, basic care practices are suggested for maintaining skin integrity, reducing exposure to potentially toxic substances, and promoting skin health beyond the neonatal period. Preventive care recommendations are made for reducing trauma, protecting the skin’s immature barrier function, and promoting skin integrity.Conclusions:This review generated evidence with which to create a new and comprehensive practice guideline for clinicians. Evaluation of the guideline is under way at 58 U.S. sites.

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.)

Background Atopic dermatitis (AD) affects 10–15% of children in the USA and up to 20% of children in the UK. Topical corticosteroids are the mainstay of therapy to control acute flares of AD in both children and adults. Aim In paediatric patients, it is especially important to ensure that local application of a corticosteroid used is limited to the least amount needed to produce a therapeutic response, as children are particularly prone to systemic adverse effects of these agents. The development of newer corticosteroid molecules is aimed at achieving maximum activity and minimal unwanted side effects. Review Mometasone furoate (Elocon®), a medium potency topical corticosteroid, is the only topical steroid approved for use in children in the USA. Mometasone furoate undergoes biotransformation in the liver into three different metabolites with very little intrinsic activity. Local side effects are minimal, with an atrophogenic potential comparable with that of 1% hydrocortisone ointment, and the risk of adrenal suppression is low. In clinical trials including over 300 infants and children, once-daily 0.1% mometasone furoate was found to be statistically significantly more effective than twice-daily 1% or 2.5% hydrocortisone, twice-daily 0.05% alclometasone dipropionate and twice-daily 0.05% fluticasone propionate. Conclusion The once-daily regimen of mometasone furoate is also useful in promoting compliance and reducing the potential for adverse effects.

To treat or not to treat, that is the question. Two cutaneous infections, warts and molluscum contagiosum, have evaded eradication for centuries, and the viruses continue to thrive and to expand in number despite all attempts at destruction. Meanwhile, many cases regress spontaneously. In this article, the authors review the characteristics of the viruses involved; discuss their transmission, epidemiology, and clinical manifestations; and assess the effectiveness of available therapies.

We present a method of fabricating microneedles from polyvinylpyrrolidone (PVP) that enables delivery of intact proteins (or peptides) to the dermal layers of the skin. PVP is known to self-assemble into branched hollow fibers in aqueous and alcoholic solutions; we utilized this property to develop dissolvable patches of microneedles. Proteins were dissolved in concentrated PVP solution in both alcohol and water, poured into polydimethylsiloxane templates shaped as microneedles and, upon evaporation of solvent, formed into concentric, fibrous, layered structures. This approach of making PVP microneedles overcomes problems in dosage, uniform delivery and stability of protein formulation as compared to protein-coated metallic microneedles or photopolymerized PVP microneedles. Here we characterize the PVP microneedles and measure the delivery of proteins into skin. We show that our method of fabrication preserves the protein conformation. These microneedles can serve as a broadly useful platform for delivering protein antigens and therapeutic proteins to the skin, for example for allergen skin testing or immunotherapy.

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.

Stanford University Medical School established a positive partnership with a pharmaceutical company to offer an industry-sponsored resident elective course in a way that minimizes conflict of interest and has been accepted by the ACGME. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

This article reviews in detail the pathogenesis, clinical characteristics and management of impetigo in children. Impetigo is the most common bacterial skin infection of children. Most cases of nonbullous impetigo and all cases of bullous impetigo are caused by Staphylococcus aureus. The remainder of cases of nonbullous impetigo are due to group A beta hemolytic streptococci (GABHS). GABHS colonize the skin directly by binding to sites on fibronectin that are exposed by trauma. In contrast, S. aureus colonizes the nasal epithelium first; from this reservoir, colonization of the skin occurs. Patients with recurrent impetigo should be evaluated for carriage of S. aureus. Superficial, localized impetigo may be treated successfully in more than 90% of cases with topical application of mupirocin ointment. Impetigo that is widespread or involves deeper tissues should be treated with a beta-lactamase-resistant oral antibiotic. The choice of antibiotics is affected by the local prevalence of resistance to erythromycin among strains of S. aureus, antibiotic cost and availability, and issues of compliance.

Infants of less than 32 wk gestation have a defective epidermal barrier, with increased skin permeability and transepidermal water loss (TEWL). We studied the effect of a nonadhesive semipermeable dressing on the epidermal barrier of premature infants and on fetal skin transplanted to nude mice. Fifteen infants with a mean estimated gestational age of 27.7 wk and 16 human fetal skin grafts (estimated gestational age, 23-26 wk) transplanted to eight nude mice were studied. One lower leg (or skin graft) was treated and the other left untreated as a control. In the infants, TEWL was measured on control skin and treated skin (both through the dressing and after temporary dressing removal) on d 0, 1, 2, 4, and 7. Bacterial and fungal cultures were also performed. In the mice, TEWL and skin blood flow were measured on d 0, 2, and 4. Biopsies were obtained on d 4 for a cell proliferation assay, histology, and electron microscopy. Treated infant skin showed a consistently lower bacterial number and a significantly decreased TEWL (measured through the dressing). There was also a significantly lower TEWL on the treated side, measured after temporary dressing removal, on d 1, 2, 4, and 7, documenting improved epidermal barrier function. The animal study revealed decreased TEWL and a nearly 2-fold greater d-4 keratinocyte proliferation (p = 0.01) in treated skin and decreased blood flow on d 4 in control skin (p = 0.01). There was no significant difference in the volume density of membrane coating granules or the morphology of intercorneocyte spaces.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors discuss two ethical problems encountered by applicants when applying for dermatology residency using the National Resident Matching Program (NRMP). In the first scenario, a dermatology applicant is being pressured by a program director to reveal how she plans to rank individual programs. How should she respond? The authors discuss the NRMP’s communication policy and conclude that there is no ethically satisfying way to answer a program director’s questions about rank lists. The authors suggest that a change of NRMP policy to limit the communications that occur between applicants and program directors after the interview is the best way to combat this type of pressure. In the second scenario, a dermatology applicant is being asked about her marriage and her intention to have children during an interview for dermatology residency. The authors discuss what kinds of questions regarding marriage and family can and cannot be asked by interviewers according to federal statutes. They discuss ways an applicant could reply to the program director in this situation. The authors draw from classical medical ethics, the law, and their own experience researching the integrity of the dermatology match in order to discuss these two scenarios.

Epidermolysis bullosa (EB) is one of the most severe skin conditions. Recent advances in knowledge of the basic biology of this group of diseases have lead to new options for specific therapy beyond standard wound care. Human trials with new therapies can cause severe risks in the participating research subjects including death of the participant. Guiding principles for translational research are needed and suggested which expand beyond the basic standards of respect for persons, beneficence and justice. These principles apply to other life threatening diseases.

Objective. Emollient cream moisturizers are often used on premature newborns in neonatal intensive care units without accurate knowledge of the risks or benefits to the neonate. Design. We prospectively compared premature neonates treated with a water-in-oil emollient cream for up to 16 days to untreated premature neonates. Setting. The study was completed in a neonatal intensive care unit on neonates admitted for respiratory distress and/or possible sepsis. Patients. Thirty-four neonates, between 29 and 36 weeks estimated gestational age, entered the study. Interventions. One-half of the neonates were treated twice a day with an water-in-oil emollient cream, and the other half served as controls. Outcome Measures. The skin condition of the neonates' hands, feet, and abdomen was evaluated on entering the study and twice a week. Fungal cultures and quantitative bacterial cultures were obtained from the axilla and abdomen on entering the study and twice a week. Results. The mean gestational age of the treated neonates was 32.3 weeks, whereas the mean gestational age of the control neonates was 32.5 weeks. The neonates treated with emollient cream demonstrated statistically less dermatitis of their hands (day 2 through day 11), their feet (day 2 through day 16), and their abdomen (day 7 through day 11). Fungal cultures and quantitative bacterial cultures of the abdomen and axilla were equivalent in both groups. Conclusions. These studies document that emollient cream moisturizer therapy of premature neonates decreases dermatitis without changing the microbiological flora.

Pilomatricoma is a benign tumor that presents as a 3-30-mm, firm, solitary, deep, dermal or subcutaneous tumor on the head, neck, or upper extremities. The clinical diagnosis is often made by the firm, sometimes rock-hard texture of the skin. The diagnosis can be confirmed by a skin biopsy or excision of the lesion. We have recently noted that pilomatricomas appear as a black mass in the skin when the lesion is transilluminated by placing the light of a fiberoptic otoscope adjacent to the skin lesion. To our knowledge, this is the first report demonstrating preoperative diagnosis of pilomatricoma by transilluminating the lesion with an otoscope.

In spite of advances in the molecular diagnosis of recessive dystrophic epidermolysis bullosa (RDEB), an inherited blistering disease due to a deficiency of type VII collagen at the basement membrane zone (BMZ) of stratified epithelium, current therapy is limited to supportive palliation. Gene delivery has shown promise in short-term experiments; however, its long-term sustainability through multiple turnover cycles in human tissue has awaited confirmation. To characterize approaches for long-term genetic correction, retroviral vectors were constructed containing long terminal repeat-driven full-length and epitope-tagged COL7A1 cDNA and evaluated for durability of type VII collagen expression and function in RDEB skin tissue regenerated on immune-deficient mice. Type VII collagen expression was maintained for 1 year in vivo, or over 12 epidermal turnover cycles, with no abnormalities in skin morphology or self-renewal. Type VII collagen restoration led to correction of RDEB disease features, including reestablishment of anchoring fibrils at the BMZ. This approach confirms durably corrective and noninjurious gene delivery to long-lived epidermal progenitors and provides the foundation for a human clinical trial of ex vivo gene delivery in RDEB.

Ciertos cambios cutaneos se distinguen mas por palpacion que por evaluacion visual de la morfologia. La movilidad y la elasticidad cutanea son dos cualidades que se aprecian por este metodo.

Es necesario un conocimiento solido de la estructura y la funcion de la piel normal para el reconocimiento y el tratamiento de las enfermedades cutaneas. Aquellos que prestan atencion medica a los ninos deben aplicar los principios de la biologia de la piel al paciente pediatrico y dominar los fundamentos de la embriologia y el desarrollo.

Las bacterias colonizan constantemente la superficie cutanea y en ocasiones invaden la barrera epidermica para reproducirse dentro de la piel. La mayoria de los microorganismos en la piel de los ninos sanos no son patogenos. Los dos principales patogenos encontrados en la piel de los ninos son Staphylococcus aureus y Streptococcus pyogenes 1. ; 2. ; 3. . El primero se encuentra en el 5% de los ninos; el segundo, en el 1%. Sin embargo, durante las epidemias y en las areas endemicas, cualquiera de estos organismos puede encontrarse en la piel del 50-80% de los ninos. En los climas humedos y calidos y en zonas en que se practica escasa higiene cutanea, los piodermas son habituales en la infancia 1 , 3 . Los sindromes inducidos por las toxinas bacterianas, tales como la escarlatina, el sindrome de la piel escaldada y el sindrome del shock toxico (SST), son infrecuentes en la infancia y se producen por la lesion de la piel por las toxinas circulantes mas que por invasion bacteriana directa.