What's new in pediatric dermatology in 2012… - CHU Sainte-Justine ...

What’s new in pediatric dermatology in
2012…
Catherine Maari, M.D.
DERMATOLOGUE
HÔPITAL SAINTE-JUSTINE et ST-LUC,
CHUM
UNIVERSITÉ DE MONTRÉAL

The selection criterias…
• Pubmed: pediatric, children, dermatology
• Around 500 articles in 2012
• Chose 20 articles of interest
• Mainly based on a general practice:
– Infection: Molluscum,warts, tinea capitis.
– Autoimmune: Vitiligo, morphea.
– Side effects: common drugs.
– Others: hyperhidrosis, keratosi pilaris
– Excluded:Atopic dermatitis,hemangiomas

INFECTIONS

Onychomycosis in the Denver Pediatrics
Population, A Retrospective Study.
Young et al, Pediatr Dermatol. 2012 May 21
• Denver
• Onychomycosis rare in pediatric population.
• 66/141 (47%) patients presenting with nail
complaints had onychomycosis.
• Highest prevalence in age 6-10
• T. rubrum most common.

Cantharidin for the Treatment of
Molluscum Contagiosum: A Prospective,
Double-Blinded, Placebo-Controlled Trial.
• Dosal et al, Pediatr Dermatol, 1-10, 2012.
• N=29, between 5-10 years old, dx MC (exclusion
if only on face).
• Cantharidine vs placebo
• Main outcome: complete clearance over two
months.
• 5 visits over 2 months (authors explained their
choice based on logistic considerations)
• Conclusion: Cantharone not better than placebo

Cantharidin for the Treatment of
Molluscum Contagiosum: A Prospective,
Double-Blinded, Placebo-Controlled Trial.
• Rando 1:1 (placebo same formulation
without cantharidine).
• Visit 1: only one lesion treated (sensitivity)
• Visit 2: up to 20 lesions treated. (4 hours
application before washing)
• Visit q1-2 weeks up to max 5 visits (in
reality 3 session of tx).
• One investigator blinded to tx.

Cantharidin for the Treatment of
Molluscum Contagiosum: A Prospective,
Double-Blinded, Placebo-Controlled Trial.
Results:
• Rando 13(2) cantharidine and 16(1) placebo
• Median lesion count:
– Placebo:
• Visit 1:24
• Visit 5:10
– Cantharone:
• Visit 1: 32
• Visit 5: 7

Cantharidin for the Treatment of
Molluscum Contagiosum: A Prospective,
Double-Blinded, Placebo-Controlled Trial.
Discussion
• 50% blistering in placebo !!!
• Cantharidine is safe
• Endpoint: not a good one on such a short
period.
• Larger sample

Treatment of pediatric molluscum
contagiosum with 10% potassium hydroxide
solution. (Turquie)
Can et al J Dermatolog Treat. 2012 Jul 25
• KOH 10 %: Strong alkali that penetrates and
destroys skin by dissolving keratin.
Methods
• N=40 (age 2-15), exclusion immunosupressed or
periorbital region.
• 10 % KOH bid by cotton swab by parents.
• Until sign of inflammation or superficial
ulceration.
• Visit:0,2,4,8,12 week and 3 months after clearance

Treatment of pediatric molluscum
contagiosum with 10% potassium
Results
hydroxide solution.
Can et al J Dermatolog Treat. 2012 Jul 25
• 37/40 patients completed study.
• Mean # of lesions: 15
• All achieved complete clearance with mean
period of 4 weeks.
• Most suffered of mild stinging sensation 1-2
minutes (2 dropped out because of severe
stinging 1 because of hypopigmentation)
• No recurrence after 3 months

Treatment of pediatric molluscum
contagiosum with 10% potassium
hydroxide solution.
Can et al J Dermatolog Treat. 2012 Jul 25
Results (side effects)
• 12/40 patients
– 5 hyperpigmentation (13 %)
– 2 hypopigmentation (5%)
– 2 severe stinging (5%)
– 2 secondary infection (5%)
– 1 hypertrophic scar (3%)

KOH and Molluscum ???
• Romini et al 1999. Brazil.
– 35 patients. KOH 10% bid (stop as soon as inflammation
mean 5-7 days)
– 32/35 complete cure after mean tx of 30 day (15-90)
– 2 stopped secondary to stinging. One giant MC.
– Most reported mild stinging sensation 1-2 minutes.
– All parents said: easy to apply and preferred treatment
– Side effets:
• Hyperpigmentation: 1
• Hypo: 5
• Hyper and Hypo: 2
• Hypertrophic scar: one on right thigh (discrete scar et 6 month)

KOH and Molluscum ???
• Romini et al 2000. Brazil.
• N=20 Patients
• KOH 5% bid
• Same efficacy
• Less irritation
• No cases of hyper or hypopigmentation
Three studies: effective,safe and low priced, non
invasive, at home technique.

Cryotherapy versus salicylic acid for the treatment
of plantar warts (verrucae): a randomised
controlled trial.
Cockayne S, Hewitt C, Hicks K et al, BMJ. 2011 Jun 7;342:d3271.
• 240 patients avec verrues plantaires (moyenne 4
verrues par patient et mosaique ds 25 %).
• Traitement 8 semaines: azote q2-3 semaines (max 4 tx)
ou acide salicylique 50% die.
• Disparition à 12 semaines
• Résultat: Aucune différence entre les deux groupes à
12 semaines (14% de disparition dans les deux
groupes). À 6 mois aucune différence 31 vs 34 %.

Cryotherapy with liquid nitrogen versus
topical salicylic acid application for
cutaneous warts in primary care:
randomized controlled trial
• 250 participants (observation, acide
salicylique et azote q 2semaines): 3 mois.
• Verrues vulgaires (nonplantaire): disparition
chez 49% dans le groupe de cryo, 15% dans
le groupe de l’acide salicylique et 8% dans
le groupe d’observation.
• Groupe de verrues plantaires: Pas de
différence statistiquement significative.
Bruggink SC, Gussekloo J, Berger MY,et al CMAJ. 2010 Oct 19;182(15):1624-30

Comparative evaluation of griseofulvin,
terbinafine and fluconazole in the
treatment of tinea capitis. (India)
Grover e al. Int J Dermatol. 2012 Apr;51(4):455-8.
• T. Violaceum (68%)
• N=75 (25 per group)
• Cure rate (no statistically difference)
– 96 % griseo (15-20 mg/kg\d bid X 6 weeks)
– 88% terbinafine (3-5 mg\kg\day X 2 weeks)
– 84% fluco (6-8 mg\kg qweek X 6 weeks)

Meta-Analysis of Randomized, Controlled
Trials Comparing Particular Doses of
Griseofulvin and Terbinafine for the
Treatment of Tinea Capitis.
• Gupta et al, Pediatr Dermatol. 2012 Sep 20.
• Genus-specific differences in efficacy are believed
to exist for the two agents.
• Analysis: comparing 8 weeks of griseofulvin (10
mg\Kg) vs 4 weeks of terbinafine (3-6 mg\Kg)
• Results:
• Microsporum species: Griseo is superior.
• Trichophyton species: Terbinafine is superior

A retrospective study of the management of
pediatric kerion in Trichophyton tonsurans
infection. (London 2003-2009)
Proudfoot et al Pediatr Dermatol. 2011 Nov-Dec;28(6):655-7
• Misdiagnosis (surgical drainage,
scarring...)
• Some authors: oral cs to speed recovery and
minimize alopecia secondary to scarring.
• 25 cases of kerions out of 372 + cultures.
– 21 tx with terbinafine (fluco or griseo)
• No cases had oral CS.
• 21/25 were examined 6 weeks after
treatment and all had complete hair

Miscellaneous

A comparative trial comparing the efficacy of
tacrolimus 0.1% ointment with Aquaphor
ointment for the treatment of keratosis pilaris.
Breithaupt et al, Pediatr Dermatol. 2011 Jul-Aug;28(4):459-60
• 30 (27 completed study) patients: spit limbs.
• Bid X 4 weeks
• Double blind
• 80 % Tacrolimus et 78 % aquaphor showed
improvement. How much improvement ???
• Around 25 % in tacrolimus group showed
75 % improvement in score vs only 4% in
Aquaphor (not statistically significative)

Oral glycopyrrolate as second-line treatment
for primary pediatric hyperhidrosis.
Paller et al, J Am Acad Dermatol. 2012 Nov;67(5):918-23
• Retrospective 10 year period.
• 31 patients (mean age dx:10)
• Mean dosage of 2 mg per day
• 90 % had improvement (70% major)
• Side effect 29% (dry mouth and eyes,
blurred vision one case of palpitation.
• Authors recommend as second line
treatment (up to 10 years in their patients)

Autoimmune

Narrowband ultraviolet B phototherapy in
childhood vitiligo: evaluation of results in
28 patients.
Percival et al, Pediatr Dermatol. 2012 Mar-Apr;29(2):160-5
• Open uncontrolled study 28 patients
• Narrow band UVB twice a week.
• Mean duration 10 months.
Results
– 14% excellent results (more 75% repigmentation)
– 28% good (50-74%)
– 25 % moderate (25-49%
– 28% mild (les 25%)
– 3% unresponsive
In 2/3 repigmentation remained 1 year post tx.

Case with « good » improvement.

Topical imiquimod 5% cream for pediatric
plaque morphea: a prospective, multiplebaseline,
open-label pilot study.
Pope et al,Dermatology. 2011;223(4):363-9.
• Prospective, open-label, double-baseline
study, using imiquimod 5% cream topically
for 9 months.
• Primary outcome: improvement in the
thickening of morphea plaques using a
visual analog scale (VAS) and the DIET
score
(dyspigmentation/induration/erythema/telan

Topical imiquimod 5% cream for pediatric
plaque morphea: a prospective, multiplebaseline,
open-label pilot study.
Pope et al,Dermatology. 2011;223(4):363-9.
• Patient: n=9 (mean age of 11)
• At 36 weeks:
– Improvement:
• in the mean VAS (48.08 (SD = 18.85) to 22.7 (SD
= 12.9) (p < 0.0001),
• In the mean DIET score from 4.38 (SD = 1.2) to
3.06 (SD = 1.39) (p = 0.23).
• Ultrasonographically measured dermis thickness
changed from 1.05 (SD = 0.34) to 0.95 (SD = 0.19)
(p = 0.001).

Psoriasiform Eruption and Oral Ulcerations as
Adverse Effects of Topical 5% Imiquimod
Treatment in Children: A Report of Four Cases.
Smith et al Pediatr Dermatol. 2012 May 21
• Approved age 12 and over for genital warts.
• Two developped localized psoriasiform
eruption
• Two developped mucosal ulcerations

ASYMMETRIC CRYING FACE IN A NEWBORN
WITH ISOTRETINOIN EMBRYOPATHY
Pediatr Dermatol. 2012 May 21Sarici
et al
• Mother exposed to 20
mg/day isotretinoin
during first month of
pregnancy.
• development of the
depressor anguli oris
muscle or the
mandibular branch of
the facial nerve.