[Incidence of methicillin-resistant Staphylococcus aureus in community-onset paediatric skin infections: a retrospective study 2000-2005]

BACKGROUND

A dramatic increase in the incidence of methicillin-resistant Staphylococcus aureus (MRSA) in community-onset skin infections has been reported over the last 10 years in the USA. The emergence of MRSA has been recently described in France. The aims of this study were to assess the incidence of MRSA in community-onset skin infections and to analyse the characteristics of MRSA skin infections in a French paediatric population.

PATIENTS AND METHODS

This is a retrospective study covering the period January 2000 to December 2005. Patients aged under 15 years with S. aureus isolated from skin and a clinical diagnosis of skin infection were included.

RESULTS

One hundred and thirty-four children were included with a median age of 3.4 years. There were no significant differences in MRSA prevalence between the different years of the study. The overall prevalence of MRSA was 8.2% (n=11/134). None of the isolated strains presented an antimicrobial susceptibility profile suggestive of the ST80-type community-acquired MRSA described in France. Three MRSA strains were isolated from serious superantigen-mediated skin infections. The antimicrobial susceptibility and genetic profile (tst-positive agr2 MSRA) for one strain of S. aureus militated strongly in favour of an MRSA ST5 clone skin infection.

CONCLUSION

In this study we found no evidence of epidemic spread of MRSA in community-onset childhood skin infections between 2000-2005. Nevertheless, we report three cases of serious MRSA-induced superantigen-associated skin infection. This argues in favour of the presence of virulent community MRSA clones in France.

Cutaneous and ocular signs of childhood rosacea

Objectives To describe the clinical features of cutaneous and ocular manifestations of childhood rosacea, to propose diagnostic criteria, and to emphasize the possible severity of ocular complications in this age group.

DESIGN

Retrospective study.

SETTING

Tertiary referral center. Patients Children aged 1 to 15 years who had received a diagnosis of cutaneous and/or ocular rosacea and were seen between January 1, 1996, and December 31, 2005.

RESULTS

Of 20 patients, 11 had ocular and cutaneous rosacea, 6 had isolated cutaneous involvement, and 3 had isolated ocular involvement. Dermatologic examination results were sufficient to diagnose rosacea in 12 of the patients (60%). The most common presentation was a papulopustular eruption on a telangiectatic background. In 11 patients (55%), ocular involvement preceded the skin eruption. Among the ophthalmologic manifestations, chalazions and blepharoconjunctivitis were the main presenting symptoms; keratitis was observed in 4 patients and corneal ulcers in 2. Ten patients were treated with oral metronidazole. Intermittent treatment for at least 3 months was used to avoid neurologic toxic effects and to achieve complete remission. Conclusion Although rare, childhood rosacea should be recognized because of the possible severity of ocular involvement.

Epicutaneous aeroallergen sensitization in atopic dermatitis infants - determining the role of epidermal barrier impairment

BACKGROUND

Sensitization to atopens is an early phenomenon that overlaps with the onset of atopic dermatitis (AD) in infancy. Early epidermal barrier impairment may facilitate the epicutaneous penetration of atopens.

OBJECTIVE

To correlate transepidermal water loss (TEWL) and aeroallergen sensitization in infants with AD.

METHODS

In this cross-sectional study we enrolled 59 AD children and 30 controls aged 3-12 months. Transepidermal water loss in uninvolved skin, specific immunoglobulin E, atopy patch test (APT) and skin prick tests were performed with respect to seven aeroallergens, i.e., Dermatophagoides pteronyssinus, D. farinae, cat, dog, birch pollen, ambrosia, and cockroach. Environmental conditions were assessed by a questionnaire, and the house dust mite (HDM) concentration was determined in dust samples.

RESULTS

Eighty-nine percent of AD infants had a positive APT vs one out of eleven controls. AD infants had a significantly higher mean TEWL than controls (27.4 vs 11.1 g/m(2)/h, P < 0001). Children with two or more positive APT had higher TEWL than the others (31.1 vs 19.0 g/m(2)/h, P < 0.025). No correlation was found between indoor APT results and exposure to HDM, cats, and dogs at home.

CONCLUSIONS

This study confirms the high prevalence of delayed sensitization to indoor and outdoor aeroallergens in AD infants, and shows that the higher the TEWL, the higher the prevalence of sensitization to aeroallergens. These data are in favor of a major role of a constitutive epidermal barrier impairment in determining early atopen sensitization in infants with AD.

Oat sensitization in children with atopic dermatitis: prevalence, risks and associated factors

BACKGROUND

Topical treatments of atopic dermatitis (AD) may be responsible for cutaneous allergies. Percutaneous sensitization to oat used in emollients/moisturizers has already been reported. Our objectives were to measure the prevalence of oat sensitization in AD children, to assess its relevance, and to look at related parameters.

METHODS

We recruited prospectively children with AD referred for allergy testing between June 2001 and December 2004. Atopy patch tests (APT) and skin prick tests (SPT) to oat proteins (1%, 3% and 5%) and to the European standard series were performed followed by oral food challenge (OFC) and repeated open application test (ROAT) in the oat-sensitized group.

RESULTS

About 302 children were enrolled. Oat APT and SPT were positive in 14.6% and 19.2% of cases, respectively. Children under 2 years of age were more likely to have positive APT. In oat-sensitized children, OFC and ROAT were positive in 15.6% (five of 32) and 28% (seven of 25) of cases, respectively. Thirty-two percentage of oat cream users had oat-positive atopy patch test (APT) vs 0% in the nonusers group.

CONCLUSIONS

Oat sensitization in AD children seen for allergy testing is higher than expected. It may be the result of repeated applications of cosmetics with oats on a predisposed impaired epidermal barrier. We suggest avoiding topical-containing oat proteins in infants with AD.

Épidermolyse staphylococcique et impétigo bulleux chez des jumeaux nouveau-nés contaminés par le lait maternel

Staphylococcus aureus is often responsible for late septic infections, more rarely of toxinic ones, occurring in neonatal period. We report a case of staphylococcal scalded skin syndrome and bullous impetigo in newborn twins infected by breast milk from their asymptomatic mother. This transmission was confirmed by molecular biology method. This case emphasizes the potential part of the mother in staphylococcal nosocomial infections and the complexity of toxinic mechanisms.

Further documentation of spontaneous regression of infantile digital fibromatosis

Infantile digital fibromatosis is a rare benign fibromatous tumor characterized by both its location on fingers and toes and its distinctive light microscopic appearance. However, treatment modalities are not yet standardized. Surgical excision had been preferred in the past but has the disadvantage of a high recurrence rate. More recently, isolated instances of spontaneous regression have been reported with a short follow-up. We report four children with infantile digital fibromatosis, who underwent spontaneous regression after clinical monitoring and long-term follow-up. We recommend regular follow-up in order to allow for intervention in case of functional impact on the affected extremities.

Idiopathic facial aseptic granuloma: a multicentre prospective study of 30 cases

BACKGROUND

Idiopathic facial aseptic granuloma (IFAG) was recently described in a single-centre retrospective study as a skin condition that occurs specifically in childhood.

OBJECTIVES

To improve our epidemiological, clinical and pathological knowledge on IFAG, to search for an infectious aetiology, and to assess therapeutic recommendations.

METHODS

Children presenting with one or several acquired nodules on the face, lasting for at least 1 month, with no evidence of any other recognizable clinical entity such as infantile acne, pilomatrixoma, furuncle, tumour or vascular malformation, were enrolled in a prospective multicentre study from June 2001 to June 2004, involving the main French paediatric dermatology outpatient units. We recorded clinical details about the nodule and its duration, ultrasound study pattern, cultures for bacteria and mycobacteria, and Bartonella henselae and Afipia felis antibody testing.

RESULTS

Thirty children (17 boys and 13 girls, mean age 3.8 years) were enrolled. Ultrasound studies revealed a solid well-demarcated hypoechoic lesion without calcium deposit. Cultures for bacteria were negative in 70% of cases. Cultures for mycobacteria and cat scratch disease serologies were negative. Antibiotic therapy was ineffective; the lesion healed spontaneously with a mean duration of 11 months. Histological examination, performed in five cases, showed a chronic dermal lymphohistiocytic granuloma with numerous foreign body-type giant cells.

CONCLUSIONS

IFAG is characterized by a painless facial nodule, presenting as a single lesion localized on the cheek, with a prolonged course but spontaneous healing. Oral or local antibiotics are usually ineffective. Regarding the pathophysiology, our study rules out a primary infectious disease, and allows considering IFAG either as a granulomatous process appearing around an embryological residue or as a manifestation to include in the spectrum of granulomatous rosacea in childhood.

SACRAL syndrome: spinal dysraphism, anogenital, cutaneous, renal and urologic anomalies, associated with an angioma of lumbosacral localization

BACKGROUND

Publications concerning perineal infantile hemangiomas are scarce, and comprise no large series.

OBJECTIVE

Studying clinical features of hemangiomas of the perineal area, complications and associated malformations.

METHODS

Retrospective analysis of all hemangiomas localized in the perineal area, encountered at the Children's Hospital in Bordeaux from 1994.

RESULTS

Of 49 perineal hemangiomas (34 girls, 15 boys), 5 patients had accompanying malformation, mainly lipomyelomeningocele with tethered cord. The superficial hemangiomas were more represented in males and presented sooner than the nodular counterpart. The average rate of ulceration was 73%, ulcerations developed earlier in the superficial forms than their nodular counterparts (2 vs. 4 months).

CONCLUSION

Superficial perineal hemangiomas are more often complicated by ulceration, and are associated with developmental anomalies. As a counterpart for the PHACE syndrome in facial hemangioma, we propose the acronym SACRAL for perineal hemangiomas: Spinal dysraphism, Anogenital anomalies, Cutaneous anomalies, Renal and urologic anomalies, associated with Angioma of Lumbosacral localization.

Odontogenic myxoma: a diagnosis to add to the list of facial tumours in infants

The differential diagnosis of a midfacial mass in a child includes a great variety of tumours. Odontogenic myxoma is a benign tumour arising from the mesenchymal portion of the odontogenic apparatus that is usually seen in adolescents and adults.

Multiple neonatal staphylococcal cold abscesses of the large folds

BACKGROUND

We describe three neonates who presented around the tenth day of life with multiple bilateral fluctuating cold abscesses situated in the lymph node areas, with secondary fistulation but without associated fever or general symptoms.

RESULTS

In all cases, Staphylococcus aureus was found in the abscesses and the umbilicus with similar antibiograms. The evolution was good and the children remained in good health afterwards.

CONCLUSION

Disseminated neonatal staphylococcal infections with a benign evolution are not commonly described in the medical literature. Clinically, cold inflammatory abscesses of the large folds associated with omphalitis may correspond to either transient bacteriemia well controlled in an immunocompetent host or more likely a local contamination process.

[Persistant mucosal ulcerations: a rare complication of toxic epidermal necrolysis]

INTRODUCTION

Sequels can be observed in toxic epidermal necrolysis. Persistence of mucosal ulcerations is not a classical complication of this disease. We describe two case reports of mucous membrane ulcerations (oral and genital) which have remained many months after the acute phase of toxic epidermal necrolysis.

CASE REPORTS

Case 1. A little girl, 9 years old, was referred for a chronic and painful ulceration of the vulva that had appeared 9 months earlier during a toxic epidermal necrolysis. She presented a clearly crircumscribed vestibular ulceration. The mucosal biopsy was refused by the family. The genital erosion persisted more than one year after the acute phase. Case 2. A 73 year-old man was referred for a persistent and clearly circumscribed lingual ulceration, 9 cm in diameter. This chronic ulceration had appeared 3 months earlier, during the acute phase of a toxic epidermal necrolysis. The skin biopsy specimen, with histologic and direct immunofluorescence analysis, did not disclose any specific anomalies. After a period of clinical observation, intralesional injections of corticosteroids were decided and ulceration progressively decreased in 13 months.

DISCUSSION

Complications of toxic epidermal necrolysis mainly occur at the acute phase. The most well documented sequelae are ophthalmological lesions. The most frequent cutaneous sequelae are cutaneous pigmentary changes and nail dystrophy. We report two observations of persistent mucous membrane erosions many months after the acute phase of toxic epidermal necrolysis. The pathophysiology of this complication, is rarely described and still remains unclear.

Self-healing congenital verruciform hyperkeratosis

We report on an apparently previously undescribed neonatal diffuse congenital hyperkeratosis with spontaneous improvement. The child, born to consanguinous parents, presented at birth with a verrucous hyperkeratosis involving face, trunk, and limbs, but sparing palms and soles. No visceral or skeletal abnormality was associated and neurosensory status was normal. The skin condition improved dramatically during the first month of life. At age 7 years, the child was healthy with normal psychomotor development and growth. He had an abnormal curvature of nose, ulerythema ophryogenes, and large ears. The skin was moderately dry. This favorable clinical outcome led us to propose the term "regressive congenital hyperkeratosis" until further molecular characterization of this new phenotype.