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Imiquimod 5% cream is a topical immune-response modifier indicated in the treatment of multiple cutaneous conditions including actinic keratoses, superficial basal cell carcinoma, and condylomata acuminata. In children, it has been approved only for ages 12 and older in the treatment of external genital and perianal warts. It has also been used off label for a variety of pediatric skin disorders, including molluscum contagiosum (MC), trichoepitheliomas, verrucae plana, and verrucae vulgaris. Local and systemic adverse reactions have been reported, with the most frequently reported events being application site reactions including itching, burning, erythema, and erosion. Although these local reactions are well known, other rare local and systemic reactions can occur. There have been multiple case reports in adults of rare adverse cutaneous reactions occurring with imiquimod, but few have been reported in children. We present four cases of rare adverse cutaneous reactions. In all cases, the children were being treated with imiquimod 5% cream for verrucae or MC. Two of these patients developed a localized psoriasiform eruption, and two developed mucosal ulcerations., (© 2012 Wiley Periodicals, Inc.)

Background: Paediatric cutaneous lupus erythematosus (CLE) is uncommon and inadequately described in the literature. Similar to adults, children with CLE develop LE-specific and/or LE-nonspecific skin findings. Similarities and differences in demographics and clinical course between paediatric and adult CLE have not been sufficiently described., Objectives: To detail the demographic and clinical features of paediatric CLE and compare these findings with those reported in the adult literature., Methods: A retrospective chart review was performed of 53 children seen in a paediatric dermatology clinic with cutaneous manifestations of LE., Results: Patients presented with all five major subtypes of CLE, with some notable differences from adult CLE and previously published reports of paediatric CLE. Progression from discoid LE to systemic LE (SLE) did not occur in our cohort. Patients with subacute CLE were more likely than adults to have lesions below the waist as well as concomitant SLE. Sex distribution for CLE in our study was equal prior to puberty and female predominant in post-pubertal patients., Conclusions: Children with CLE have variable clinical presentations and progression to SLE that may be different from adult disease. Specifically, children with acute and subacute CLE may be more likely than adults to have systemic disease; therefore, patients with these subtypes should be monitored closely for evidence of SLE. Study limitations included small patient numbers that may limit the ability to generalize these data and relatively short follow-up intervals., (© 2013 British Association of Dermatologists.)

Background: An inverse correlation between serum 25-hydroxyvitamin D concentration and atopic dermatitis (AD) severity has been suggested., Objective: To determine if a statistically significant relationship exists between serum 25-hydroxyvitamin D concentration and AD severity., Methods: A cross-sectional study was conducted of patients with AD who were 1 to 18 years of age. An objective Severity Scoring of Atopic Dermatitis (SCORAD) and a serum 25-hydroxyvitamin D concentration were measured for each subject. Statistical analysis was performed using appropriate univariate tests and multivariable models., Results: Ninety-four of 97 enrolled subjects were included in the analysis. Vitamin D deficiency (25-hydroxyvitamin D <20 ng/mL) was present in 37 subjects (39%), insufficiency (25-hydroxyvitamin D 21-29 ng/mL) in 33 (35%), and sufficiency (25-hydroxyvitamin D ≥30 ng/mL) in 24 (26%). The correlation between 25-hydroxyvitamin D concentration and SCORAD was not significant (r = -0.001; P = .99). A multivariate model showed that a lower serum 25-hydroxyvitamin D concentration was significantly associated with age 3 years or older (P < .0001), black race (P < .0001), and winter season (P = .0084)., Limitations: Limitations of this study include the inability to control for natural sunlight exposure, vitamin D intake, and AD treatment; in addition, only a single time point was captured., Conclusions: Serum 25-hydroxyvitamin D concentration is not significantly correlated with AD severity in our pediatric population., (Copyright © 2013 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Blastomycosis is a rare fungal infection that most often initially infects the lungs and can progress to disseminated involvement of the skin, bones, and central nervous system (CNS). Pediatric blastomycosis constitutes a small portion of total cases, but delay in diagnosis may result in significant morbidity. Seventeen pediatric cases of blastomycosis were identified at Children's Hospital of Wisconsin from 1999 to 2009 through retrospective chart review; 53% had evidence of dissemination (bone, skin, or CNS) confirmed by culture. Six cases presented with cutaneous lesions, and five of these were found to have other systemic involvement. These five nonimmunosuppressed cases of primary pulmonary disease with cutaneous involvement plus dissemination to bone or the CNS are reported in detail. The diagnosis of blastomycosis in children is often delayed, and dissemination by the time of diagnosis may be more common than in adults. Cutaneous dissemination may occur in immunocompetent children, may indicate underlying systemic involvement, and can be more readily identified than symptoms of bony or neurologic involvement. These reported cases indicate the importance of dermatologists recognizing and investigating all potentially involved organ systems when a patient presents with characteristic skin lesions with or without a history of respiratory illness., (© 2012 Wiley Periodicals, Inc.)

Dermatomyositis is an autoimmune inflammatory myopathy characterized by unique cutaneous features. Gottron's papules are pathognomonic, lichenoid papules that can be found overlying the joints of the dorsal hand. Papules on the palms of the hand are less commonly seen, especially in the pediatric age group. Recognition of these inverse Gottron's papules as a sign of dermatomyositis is important as they may be the only cutaneous feature and may be a clue of underlying interstitial lung disease., (© 2011 Wiley Periodicals, Inc.)

Microcystic adenexal carcinoma is a rare, locally aggressive, malignant appendage tumor also known as sclerosing sweat duct carcinoma. Since widespread recognition of microcystic adenexal carcinoma as a distinct clinicopathologic entity, approximately 300 total cases have been reported in the literature, with only eight previous cases reported in children under the age of 18, with no reported cases in patients younger than 6 years old. Our patient is unique in that the lesion was present at birth, making this the youngest case of microcystic adenexal carcinoma reported., (© 2011 Wiley Periodicals, Inc.)

The relative risk for melanoma arising within a congenital nevus is related to the size of the lesion. The timing of and clinical presentation of development of melanoma is also related to the size of the lesion. Medical decisions are individualized taking into account the perceived risk of malignancy, psychosocial impact, and anticipated treatment outcome. In this article, the common features of congenital nevi are discussed as well as the potential individual variations and their impact on treatment recommendations., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Outpatient surgical procedures performed in medicine have been increasing, as has the use of general anesthesia. Children are more likely to require general anesthesia for procedures because of developmental constraints limiting their cooperation. Dermatology procedures are typically painful and can require time to perform and thus necessitating the use of general anesthesia. Studies evaluating safety and complication rates associated with the use of general anesthesia in children are needed to determine the safety of this practice. The purpose of this investigation was to assess whether the use of general anesthesia to perform pediatric dermatology surgical procedures was associated with any significant adverse events. A retrospective chart review was conducted for eligible patients with a procedure code in the range of 10,040-19,499 for a period of 2 years. Records were reviewed for documentation of any unplanned visits, events or complications. A total of 681 procedures were reported for 226 unique patients with 235 diagnoses. No anesthesia-related adverse events were identified in any of these patients. Eleven patients had documentation of minor complications of the wound. General anesthesia can be used safely in pediatric dermatology surgery patients without associated complications in the appropriate setting, indication, and patient population, using state-of-art technology and equipment, and experienced pediatric-trained anesthesiologists.

The Spitz nevus is a relatively common skin lesion in children and is less commonly seen in adults. The lesion is defined by the presence of distinctive-appearing spindle or epithelioid cells on light microscopy in a recognizable nevus-like pattern. Spitz lesions share features with melanoma on light microscopic examination. When Spitz features are atypical or typical features are absent, distinction from melanoma can be difficult. A spectrum of pathology of Spitz lesions can be found from lesions that are benign and typical to lesions that are atypical with melanoma-like features and frank melanoma. There is significant interobserver variation in interpretation of Spitz lesions. The lack of uniformly applied criteria for distinction of light microscopic grades and the confusion in diagnostic terminology demonstrate the difficulty in the pathologic interpretation of these lesions. Exciting progress has been made recently in ancillary testing that will likely be helpful in determining in more detail the biologic nature of these lesions, in better differentiating the benign Spitz lesions from malignant lesions, and in eventually improving treatment recommendations.

Background: The role of teledermatology in the diagnosis of pediatric skin conditions has not been studied exclusively., Objective: To determine the ability of a pediatric dermatologist to correctly diagnose rashes by history and digital images., Methods: Consecutive, new referrals to the pediatric dermatology clinic with a rash were enrolled in the study. A history, demographic data, and digital photographs were obtained from each patient. The data were reviewed by a pediatric dermatologist who made a preliminary diagnosis. The child was then seen in person and a final diagnosis was made. Concordance and kappa values were calculated. Cases of diagnostic disagreement were analyzed for their effect on management., Results: One hundred thirty-five patients were enrolled. Diagnostic concordance was 82% (95% confidence interval [CI], 73%-88%), and the kappa value was 0.80. Clinically relevant disagreement occurred in 12% of cases., Limitations: The study was performed at a single site, theoretically limiting generalizability., Conclusion: Teledermatology appears to have a useful role in the care of children with rashes.

Young children, especially toddlers, are anxious and uncooperative during skin procedures. Wrapping a sheet or blanket around the child is an effective way to restrain the child to maintain a sterile field. The wrap can be used for skin biopsies and small excisions on the midsection of the body, arms, and legs.

Physical constraints and metabolic differences in neonates require that special attention is given to performing procedures in this patient group. Neonates have a thinner dermis and a greater surface-to-weight ratio, allowing for easier invasion through the skin barrier. The enzymes for metabolism of agents and defense against organisms inside the body are not fully developed in infants. Very premature neonates also have less circulating albumin, making the effective concentration of circulating agent even greater. The infant is prone to unanticipated movement during procedures, such as rolling on the procedure table. The neonatal period is the most common time period for malformations to become manifest on the skin, and invasion of some of these lesions can produce morbidity. These and other factors affect the choice of the type of procedure used, the timing for intervention, and the approach to intervention in this age group. This article reviews the important considerations for approaching procedures and offers suggestions for safe and effective methods of reliably producing the intended outcome.

Purpose of Review: Hemangiomas are common, and most lesions are benign. Careful attention needs to be paid to these lesions; however, because their growth can be unpredictable, they can have important complications and can serve as markers of underlying malformations. The consequences of hemangiomas are extensive and can be challenging to recognize., Recent Findings: Recent knowledge of the pathogenesis and diagnosis of these lesions has helped raise awareness of their classification and clinical significance. Spitz nevi can also be a challenging lesion to diagnose and treat, although for different reasons. These are lesions composed of melanocytes with clinical and histopathological findings that we easily misdiagnosed and can have significant implications for patient care., Summary: Both of these important lesions in infants and children are reviewed in further detail with particular attention to recent trends.

A 14-year-old girl was admitted to the hospital because of persistent throat pain, fever, fatigue, 25 pound weight loss, and leukopenia. On physical examination she was thin, ill-appearing, and had necrotic papules on the face and palpable cervical lymph nodes. Presumptive differential diagnosis included occult malignancy and infection. Numerous investigative procedures failed to elucidate a source. Vasculitis was eventually appreciated after repeat skin biopsy. Numerous serologic studies were performed and were notable for a very low level of the second component of complement without direct evidence of lupus erythematosus (LE) or other autoimmune conditions. A diagnosis of C2 deficiency-associated vasculitis was made. She was treated with high-dose prednisone and cyclophosphamide with resolution of her symptoms. Two years later she returned with marked malar erythema. Antinuclear and Smith antibodies were then detected and a diagnosis of LE was made. She was treated with hydroxychloroquine and sun-avoidance measures with clearance of the malar rash.